Preview
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
EXHIBIT LL
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Inpatient Rehab
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Executive Summary
In accordance with Section 710.1(c)(5) of 10 New York Codes, Rules and Regulations (10 NYCRR),
Mount Sinai Beth Israel (MSBI) is submitting this Service Delivery Limited Review Application that
seeks approval for the decertification of the 26 inpatient Physical Medicine & Rehabilitation (PM&R)
beds at the Hospital. MSBI is currently certified for 26 PM&R beds, among other certified bed
classifications, for a total of 825 certified inpatient beds. Upon implementation of this project, all 26
PM&R beds will be decertified, resulting in a total inpatient bed count of 799 at MSBI. MSBI is located
165
at First Avenue at Street, New York (New York County), New York 10003.
This project is part of a larger effort of Mount Sinai to create a more integrated healthcare system, and to
more effectively use system resources. In the first six (6) months of 2016, MSBI experienced 290
discharges (with 3,396 patient days) for its 26 PM&R beds, representing an occupancy rate of 71.6% and
a decrease from its 88.6%
occupancy in 2012. Currently, the Hospital care for only is providing inpatient
13 PM&R patients. Through this project, patients who would typically be seen at MSBI will now be seen
at other Mount Sinai facilities within Manhattan. At the other three (3) Mount Sinai facilities with
inpatient PM&R beds (Mount Sinai Hospital (88 beds), Mount Sinai West (25 beds) and Mount Sinai St.
Luke's (15 beds)), the overall occupancy rate in the firstsix (6) months of 2016 was 52.8%, so there is
sufficient capacity at these three (3) facilities in Manhattan to be able to serve MSBI's patients once the
PM&R unit at MSBI is closed. Although MSBI understands that some individuals may choose to seek
care outside of the Mount Sinai system, the Hospital believes that this project is in the best interest of
patients from a clinical perspective, given its plans for the transformation of the MSBI campus. Lastly,
the planned decertification of the 26 inpatient PM&R beds is the result of an industry-wide transition
from an inpatient rehabilitation model to one increasingly focused on an outpatient therapy model,
resulting in the need for fewer inpatient beds for these services.
At no point will access to Mount Sinai physicians be interrupted. Additionally, Mount Sinai does not
anticipate any job losses as a result of the closure of the inpatient rehabilitation unit at MSBI, and it has
already begun meeting and working with its union partners to ensure that the affected union employees
are retrained, if necessary, and offered other union opportunities with equal pay within the Mount Sinai
Health System.
The Total Project Cost for this project is $500, which is comprised solely of the Limited Review
Application fee, and is being submitted as part of initial submission of the Application.
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Limited Review Application
State of New York Department of Health
LRA Cover Sheet
Office of Primary Care and Health Systems Management .
Project to be Proposed/Applicant Information
This application is for those projects subject to a limited review pursuant to 10 NYCRR 710.1(c)(5)-(7). Please check the appropriate
box(es) reflective of the project being proposed by your - Some projects
facility (NOTE may involve requisite "Construction". If so,
and total project costs are below designated thresholds, then both boxes must be checked and necessary LRA Schedules submitted).
Please read the LRA Instructions to ensure submission o f an appropriate and complete application:
¡ Minor Construction - Minor construction project with total project costs of up to $6,000,000 (or up to $15,000,000, if not
to clinical space - check "Non-Clinical" box below).
relating
Necessary LRASchedules; Cover Sheet, 2, 3, 4, 5, and 6.
¡ Equipment- Project related to the acquisition, relocation, installation or modification of certain medical equipment, with
total project costs of up to $6,000,000. (NOT necessary for "1-for-1" replacement of existing equipment without
construction, pursuant to Chapter 174 of the Laws of 2011 amending Article 28 of the Public Health law to eliminate limited
review and CON review for one for one equipment replacement)
Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and S.
Service - Project to
Delivery decertify a facility's beds/services; add services which involve a total project cost under
"Construction"
$6,000,000; or convert beds within approved categories. (If construction associated, also check above.)
Necessary LRA Schedules: Cover Sheet, 7, 8, 10, and 12. *Ifproposing to decertify beds within a nursing home, provide a
description of the proposed alternative use of the space including a detailed sketch (unless the decertifìcation is being
accomplished by eliminating beds in multiple-bedded rooms).
O Health Information - Project
to purchase and implement health information or
Technology technology
other information systems, with a total project cost between $6,000,000 and $15,000,000.
Necessary LRA Schedules: Cover Sheet, 2, 3, 9, and 12. Also include Vendor Contract language (Appendix D).
¡ Cardiac - Project
Services by an appropriately certified facility to add electrophysiology (EP) services;
or add, upgrade or replace a cardiac catheterization laboratory or equipment. (Ifconstruction
"Construction"
associated also check above.)
Necessary LRA Schedules: Cover Sheet, 7, 8, 10, and 12.
Relocation of Extension Clinic -Project to relocate an extension clinic within the same service area.
Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and S. Also include a Closure Plan for vacating extension clinic.
O Part-Time Clinic- Project to operate, change services offered, change hours of operation or·relocate a part-time clinic
- "Construction"
site for applicants aheady certified for "part-time clinic". (If construction associated, also check
above.)
Necessary LRA Schedules: Cover Sheet, 8, 10, 11, and 12.
OPERATING CERTIFICATE NO. CERTIFIED OPERATOR TYPE OF FACILITY
7002002H Mount Sinai Beth Israel Hospital
OPERATOR ADDRESS - STREET & NUMBER PPI NAME AND TITLE OF CONTACT PERSON
16*
First Avenue at Street 1439 Frank M. Cicero, Cicero Consulting Associates
CITY COUNTY ZIP STREET AND NUMBER
New York New York 10003 701 Westchester Avenue, Suite 210W
PROJECT SITE ADDRESS " STREET & NUMBER PFI CITY STATE ZIP
16*
First Avenue at Street 1439 White Plains NY 10604
CITY COUNTY ZIP TELEPHONE NUMBER FAX NUMBER
New York New York 10003 (914) 682-8657 (914)'682-8895
TOTAL PROJECT COST: $ 500 (Application Fee only) CONTACT E-MAIL: conadmin@cicereassociates.com
(RevS/2014)
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Limited Review Application Schedule LRA 7
State of New York Department of Health/Ofnee of Health Systems Management
Proposed Operating Budget
Budget .Current Year* Year* Third Year*
First
(Projected) (Projected)
Revenues
Service Revenue $17,227,243 ($17,227,243) ($17,227,243)
Grants Funds
Foundation
Other
Fees
Other Income
(1) Total Revenues $17,227,243 ($17,227,243) ($17,227,243)
Expenses
Salaries and Wage Expense $4,166,086 ($4,166,086) ($4,166,086)
Employee Benefits
Professional Fees
Medical & Surgical Supplies $11,570 ($11,570) ($11,570)
Non-Medical Equipment
Purchased Services
Other Direct Expense $69,080 ($69,080) ($69,080)
Utilities Expense
Interest Expense
Rent Expense
Depreciation Expense
Other Expenses
(2) Total Expense $4,246,736 ($4,246,736) ($4,246,736)
Net Total - $12,980,507
(1-2) ($12,980,507), ($12,980,507)
* year 2015 for the Physical Medicine & Rehabilitation beds at MSBI. The
The Current Year represents
incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through
this project.
(Rev. 7/2015) 1
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Limited Review Application Schedule LRA 7
State ofNew York Department of Health/Office of Health SystemsManagement ..
* Various inpatient services
may be reimbursed as discharges or days. Applicant should indicate which method checkbox.
applies to this table by choosing the appropriate checkbox
PatientDays PatientDischarges
Inpatient Services Source of 'PotalCurrent Year** Fñst Year Incremental** Th rd Year Incremental**
Revenue
Patient Net Revenue* Patient Net Revenue* Patient Net Revenue*
Days or Days or % based Days or % based
discharg % Dollars ($) discharg on days or Dollars-($) discharg on days or Dollars-($)
es* es' discharges es* discharges
Commercial Feefor
Service
Managed
Care 110 16.7% $3,462,654 (110) 16.7% ($3,462,654) (110) 16.7% ($3,462,654)
Medicam Feefor
service 368 55.8% $9,579,492 (368) 55.8% ($9,579,492) (368) 55.8% ($9,579,492)
Managed
Care 112 17.0% $2,573,948 (112) 17.0% ($2,573,948) (112) 17.0% ($2,573,948)
Medicaid Feefor
service 21 3.2% $406,115 (21) 3,2% ($406,l15) (21) 3,2% ($406,115)
Managed
Care 43 6.5% $930,611 (43) 6.5% ($930,611) (43) 6.5% ($930,611)
Private Pay 3 0.5% $203,395 (3) 0.5% ($203,395) (3) 0.5% ($203,395)
OASAS
OMH
Charity Care
Bad Debt 3 0.5% $71,028 (3) 0.5% ($71,028) (3) 0.5% ($71,028)
All Other
Total 660 100.0% $17,227,243 (660) 100.0% ($17,227,243) (660) 100.0% ($17,227,243)
** The Current Year represents year 2015 for the Physical Medicine & Rehabilitation beds at MSBI. The incremental Year 1 and Year 3
operating
budget demonstrates that the beds will be decertified by MSBI th ough this project.
(Rev. 7/2015) 2
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Oupatient Services To al Current Year Firs' Thir d Year Incremental
Year Incremental
Source of Revenue Net Revenue* Net Revenue*. Net Revenue*
Vih
% Dollars ($) % Dollars (3) /o Dollars ($)
Commercial Fee for
Service
Managed
Care
Medicare Fee for
Service
Managed
Care N/A N/A N/A
Medicald Fee for
Service - - -
Managed
Care Inpatient Inpatient Inpatient
Private Pay Project Project Project
OASAS Only only only
OMH
Charity Care
Bad Debt
All Other
Total
Total of Inpatient
and Outpatient
Services s17,227,243 (s17,227,243) (s17,227,243)
Title of Attachment Filename of Attachment
1. in an attachment,
provide the basis and
Revenues by payer are
based upon the
supporting calculations N/A
experience of the
for all revenues by
. Hospital.
payor.
2. In an attachment, Charity Care based on the
provide the basis for experience of the N/A
care. Hospital.
charity
* Net Deductions from Revenue
(Rev. 7/2015) 3
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
Limited R iew A PP lication
Schedule LRA 8
State of New York Depa twent of Health/Office of Health Systems Management
........... ...... ... .........
Staffing
Number of FT Es to the Nearest Tenth
Current Year* First Year of Third Year of
Staffing Categories
**** implementation implementation
**** ****
Health Providers**:
Physician 1.50 (1.50) (1.50)
Nurse Practitioner 1.00 (1.00) (1.00)
Physical Therapist & PT Assistant 8.00 (8.00) (8.00)
Occupational Therapist & OT Assistant 5.00 (5.00) (5.00)
Speech Therapist & Speech Assistant 1.00 (1.00) (1.00)
Support Staff***:
Management & Supervision 1.00 (1.00) (1.00)
Registered Nurse 17,00 (17.00) (17.00)
Aides, Orderlies & Attendants 16.00 (16.00) (16.00)
Clerical & Other Administrative 2.00 (2.00) (2.00)
Total Number of Employees 52.50 (52.50) (52.50)
* Last complete year prior to submitting application
** Providers"
"Health includes a_1]providers serving patients at the site. A Health Provider is any staff who can
provide a billable service - physician, dentist, dental hygienist, podiatrist, physician assistant, physical therapist, etc.
*** All other staff.
**** The Current Year represents vear 2015 staffing for the Physical Medicine & Rehabilitation beds at MSBL The
incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project.
Describe how the number and mix of staff were determined:
The number and mix of staff were based upon the fact that all 26 certified inpatient PM&R beds will be decertified
through this project. Nevertheless, Mount Sinai does not anticipate any job losses as a result of the closure of the
inpatient rehabilitation unit at MSBI, and it has already begun meeting and working with its union partners to ensure
that the affected union employees are retrained, if necessary, and offered other union opportunities with equal pay
within the Mount Sinai Health System.
PLEASE COMPLETE THE FOLLOWING:
1. Are staff paid and on payroll? Yes O No
2. Provide copies of contracts for any independent contractor. H/_A
3. Please attach the Medical Doctors C N. Please refer to the Schedule LRA 8 Attachment
4. Is this facility affiliated with any other facilities?
(If yes, please describe affiliation and/or agreement.) Yes O No
(Rev.7/7/2010)
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
MOUNT SINAI BETH ISRAEL
SCHEDULE LRA 8 ATTACHMENT
CURRICULUM VITAE - MEDICAL DIRECTOR
STATEMENT RE: ARTICLE 28 NETWORK
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
CURRICULUM VITAE
NAME: Joseph E. Herrera, DO, FAAPMR
Joseph.herrera@mountsinai.org
EMPLOYMENT
August 2005 - Present Icahn School of Medicine at Mount Sinai
Department of Rehabilitation Medicine
One Gustave L. Levy Place, Box 1240
New York, New York 10029
ACADEMIC APPOINTMENTS
2008- Present Program Director
July Residency
Physical Medicine and Rehabilitation
Department of Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
New York, New York
2007- Present Director
July Fellowship
Sports Medicine and Interventional Spine
Department of Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
New York, New York
2006 - Present Assistant Professor
Department of Rehabilitation Medicine
icahn School of Medicine at Mount Sinai
New York, New York
2005 - 2006 Instructor
Department of Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
New York, New York
HOSPITAL APPOINTMENTS
2005- Present Assistant Attending
Mount Sinai Medical Center
New York, NY, 10029
GAPS IN EMPLOYMENT
N/A
EDUCATION
2004 - 2005 FELLOWSHIP
Beth Israel Medical Center,
New York, New York
Interventional Spine and Sports Medicine
Fellowship,
Fellowship Program Director: Robert Gotlin, DO
1 of 20
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2001 - 2004 RESIDENCY
New York Presbyterian Hospital,
Columbia and Cornell University
Physical Medicine and Rehabilitation
New York, New York
Residency Program Director: Nancy Straus
2000 - 2001 INTERNSHIP
Saint Michaers Medical Center
Newark, New Jersey
Rotating internship
1996 - 2000 MEDICAL SCHOOL
University of Medicine and Dentistry of New Jersey
School of Osteopathic Medicine
Stratford, NJ
Doctor of Osteopathic Medicine, D.O.
1991 - 1995 UNDERGRADUATE STUDIES
Rutgers University, Cook College,
New Brunswick, NJ
Bachelors of Science in Biological Sciences
CERTIFICATION
2011 Board Certified Sports Medicine
2005 Diplomate, American Board of Physical Medicine
and Rehabilitation
2005 Certified in Ringside Medicine, American
Association of Professional Ringside Physicians
LICENSURE
2001 New York State,
License # 222712
2012 New Jersey
License # 25MB09042200
HONORS/AWARDS/PATENTS
2012-2015 Super Doctors
Featured in The New York'Times Magazine
Top 5% of physicians in New York
5/20/2012, 5/17/2013, 5/18/2014, 5/17/2015
2014 Castle Connolly Top Doctors
Top doctor for New York Region
2008 American Association for the Improvement of
Boxing
Rocky Marciano Physician of the Year Award
2 of 20
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2004 American Pain Society, American Pain Scholar
2000 Saint Michaels Medical Center
Medical Intern of the Month (November)
1995 Rutgers University
William H. Martin Scholarship
1995 Rutgers University
Sigma Xi Grant-In-Aid of Research Award
1995 Rutgers University,
George H. Cook Honors Program
PATENTS
N/A
OTHER PROFESSIONAL APPOINTMENTS
2015 Course Program Director
Ultrasound in Education and Research
Association of Academic Physiatrist
Track C1 2015 - San Antonio Texas
Association of Academic Physiatrist 2006-Present
2014 Course Program Co-Director
Course Program Facilitator for Course A1
"ACA - - Obamacare & Implications for
Regulatory
PM&R"
Academic
Association of Academic Physiatrist
Course A1 2014 - TN
Nashville,
Association of Academic Physiatrist 2006-Present
2010 Oral Board Examiner,
American Board of Physical Medicine and
dates: 2005 - Present
Rehabilitation, Membership
2010 Musculoskeletal Council
American Association of Physical Medicine and
dates: 2001- Present
Rehabilitation, Membership
2007- 2010 Chief Physician
USA dates: 2002 -
Boxing Metro, Membership
Present
2006 - Present Chief Musculoskeletal book Humana
Editor, Series,
Press
2006 - 2010 Chief Current Reviews in Musculoskeletal
Editor,
Medicine,
Springer Press
3 of 20
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2005 - 2009 Medical Review Board
American Association for Professional Ringside
Physicians, Membership dates: 2002-2010
2004-2006 Chairman, Membership Committee
American Association for Professional Ringside
Physicians, Membership dates: 2002-2010
2004 Team Physician
New York Knicks Basketball
Team Physicals
New York, New York
2004 Team Physician
Westchester Wildfire
USBL Basketball Tournament
New York, New York
2004 Team Physician
New City Sevens
York
Rugby Tournament
New York, New York
2004 Team Physician
USA Boxing
National Championships
Colorado Springs, Colorado
2003 Medical Team Captain
New York City Triathlon
New York, New York
2002 - Present Medical Panel Physician
New York State Athletic Commission
2002 - Present Ringside Physician
Daily News
New York City Golden Gloves
New York, New York
2002 - Present Medical Team Captain
New York City Marathon
New York Road Runners Club
2002 Team Physician
Empire State Games
Syracuse, New York
2002 Team Physician
NJAIAW Tennis Tournament,
4 of 20
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NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024
MOUNT SINAI BETH ISRAEL
ARTICLE 28 NETWORK DESCRIPTION
Mount Sinai Hospitals Group, Inc. (MSHG), a not-for-profit corporation, is the active parent and
co-operator of Mount Sinai Hospital (including its division, Mount Sinai Hospital of Queens),
Mount Sinai Beth Israel, Mount Sinai Brooklyn, Mount Sinai St. Luke's, Mount Sinai Roosevelt
and the New York Eye and Ear Infirmary of Mount Sinai.
Mount Sinai Hospital(MSH) is located at One Gustave L. Levy Place, New York (New York
County), New York 10029. MSH also has a division, Mount Sinai Hospital of Queens, which is
3081
located at 25-10 Avenue, Long Island City (Queens County), New York 11102. Mount
Sinai Beth Israel is located at First Avenue at 16 Street, New York (New York County), New
York 10003. Mount Sinai Brooklyn is located at 3201 Kings Highway, Brooklyn (Kings
County), New York 11234. Mount Sinai St. Luke's is located at 1111 Arnsterdam Avenue, New
York (New York County), New York 10025. Mount Sinai Roosevelt is located at 1000 Tenth
Avenue, New York (New York County), New York 10019. New York Eye and Ear Infirmary of
Mount Sinai is located at 310 East 14 Street, New York (New York County), New York 10003.
The following table provides information on operating certificate numbers and PFI numbers for
the ab
Preview
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 EXHIBIT LL FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Inpatient Rehab FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Executive Summary In accordance with Section 710.1(c)(5) of 10 New York Codes, Rules and Regulations (10 NYCRR), Mount Sinai Beth Israel (MSBI) is submitting this Service Delivery Limited Review Application that seeks approval for the decertification of the 26 inpatient Physical Medicine & Rehabilitation (PM&R) beds at the Hospital. MSBI is currently certified for 26 PM&R beds, among other certified bed classifications, for a total of 825 certified inpatient beds. Upon implementation of this project, all 26 PM&R beds will be decertified, resulting in a total inpatient bed count of 799 at MSBI. MSBI is located 165 at First Avenue at Street, New York (New York County), New York 10003. This project is part of a larger effort of Mount Sinai to create a more integrated healthcare system, and to more effectively use system resources. In the first six (6) months of 2016, MSBI experienced 290 discharges (with 3,396 patient days) for its 26 PM&R beds, representing an occupancy rate of 71.6% and a decrease from its 88.6% occupancy in 2012. Currently, the Hospital care for only is providing inpatient 13 PM&R patients. Through this project, patients who would typically be seen at MSBI will now be seen at other Mount Sinai facilities within Manhattan. At the other three (3) Mount Sinai facilities with inpatient PM&R beds (Mount Sinai Hospital (88 beds), Mount Sinai West (25 beds) and Mount Sinai St. Luke's (15 beds)), the overall occupancy rate in the firstsix (6) months of 2016 was 52.8%, so there is sufficient capacity at these three (3) facilities in Manhattan to be able to serve MSBI's patients once the PM&R unit at MSBI is closed. Although MSBI understands that some individuals may choose to seek care outside of the Mount Sinai system, the Hospital believes that this project is in the best interest of patients from a clinical perspective, given its plans for the transformation of the MSBI campus. Lastly, the planned decertification of the 26 inpatient PM&R beds is the result of an industry-wide transition from an inpatient rehabilitation model to one increasingly focused on an outpatient therapy model, resulting in the need for fewer inpatient beds for these services. At no point will access to Mount Sinai physicians be interrupted. Additionally, Mount Sinai does not anticipate any job losses as a result of the closure of the inpatient rehabilitation unit at MSBI, and it has already begun meeting and working with its union partners to ensure that the affected union employees are retrained, if necessary, and offered other union opportunities with equal pay within the Mount Sinai Health System. The Total Project Cost for this project is $500, which is comprised solely of the Limited Review Application fee, and is being submitted as part of initial submission of the Application. FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Limited Review Application State of New York Department of Health LRA Cover Sheet Office of Primary Care and Health Systems Management . Project to be Proposed/Applicant Information This application is for those projects subject to a limited review pursuant to 10 NYCRR 710.1(c)(5)-(7). Please check the appropriate box(es) reflective of the project being proposed by your - Some projects facility (NOTE may involve requisite "Construction". If so, and total project costs are below designated thresholds, then both boxes must be checked and necessary LRA Schedules submitted). Please read the LRA Instructions to ensure submission o f an appropriate and complete application: ¡ Minor Construction - Minor construction project with total project costs of up to $6,000,000 (or up to $15,000,000, if not to clinical space - check "Non-Clinical" box below). relating Necessary LRASchedules; Cover Sheet, 2, 3, 4, 5, and 6. ¡ Equipment- Project related to the acquisition, relocation, installation or modification of certain medical equipment, with total project costs of up to $6,000,000. (NOT necessary for "1-for-1" replacement of existing equipment without construction, pursuant to Chapter 174 of the Laws of 2011 amending Article 28 of the Public Health law to eliminate limited review and CON review for one for one equipment replacement) Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and S. Service - Project to Delivery decertify a facility's beds/services; add services which involve a total project cost under "Construction" $6,000,000; or convert beds within approved categories. (If construction associated, also check above.) Necessary LRA Schedules: Cover Sheet, 7, 8, 10, and 12. *Ifproposing to decertify beds within a nursing home, provide a description of the proposed alternative use of the space including a detailed sketch (unless the decertifìcation is being accomplished by eliminating beds in multiple-bedded rooms). O Health Information - Project to purchase and implement health information or Technology technology other information systems, with a total project cost between $6,000,000 and $15,000,000. Necessary LRA Schedules: Cover Sheet, 2, 3, 9, and 12. Also include Vendor Contract language (Appendix D). ¡ Cardiac - Project Services by an appropriately certified facility to add electrophysiology (EP) services; or add, upgrade or replace a cardiac catheterization laboratory or equipment. (Ifconstruction "Construction" associated also check above.) Necessary LRA Schedules: Cover Sheet, 7, 8, 10, and 12. Relocation of Extension Clinic -Project to relocate an extension clinic within the same service area. Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and S. Also include a Closure Plan for vacating extension clinic. O Part-Time Clinic- Project to operate, change services offered, change hours of operation or·relocate a part-time clinic - "Construction" site for applicants aheady certified for "part-time clinic". (If construction associated, also check above.) Necessary LRA Schedules: Cover Sheet, 8, 10, 11, and 12. OPERATING CERTIFICATE NO. CERTIFIED OPERATOR TYPE OF FACILITY 7002002H Mount Sinai Beth Israel Hospital OPERATOR ADDRESS - STREET & NUMBER PPI NAME AND TITLE OF CONTACT PERSON 16* First Avenue at Street 1439 Frank M. Cicero, Cicero Consulting Associates CITY COUNTY ZIP STREET AND NUMBER New York New York 10003 701 Westchester Avenue, Suite 210W PROJECT SITE ADDRESS " STREET & NUMBER PFI CITY STATE ZIP 16* First Avenue at Street 1439 White Plains NY 10604 CITY COUNTY ZIP TELEPHONE NUMBER FAX NUMBER New York New York 10003 (914) 682-8657 (914)'682-8895 TOTAL PROJECT COST: $ 500 (Application Fee only) CONTACT E-MAIL: conadmin@cicereassociates.com (RevS/2014) FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Limited Review Application Schedule LRA 7 State of New York Department of Health/Ofnee of Health Systems Management Proposed Operating Budget Budget .Current Year* Year* Third Year* First (Projected) (Projected) Revenues Service Revenue $17,227,243 ($17,227,243) ($17,227,243) Grants Funds Foundation Other Fees Other Income (1) Total Revenues $17,227,243 ($17,227,243) ($17,227,243) Expenses Salaries and Wage Expense $4,166,086 ($4,166,086) ($4,166,086) Employee Benefits Professional Fees Medical & Surgical Supplies $11,570 ($11,570) ($11,570) Non-Medical Equipment Purchased Services Other Direct Expense $69,080 ($69,080) ($69,080) Utilities Expense Interest Expense Rent Expense Depreciation Expense Other Expenses (2) Total Expense $4,246,736 ($4,246,736) ($4,246,736) Net Total - $12,980,507 (1-2) ($12,980,507), ($12,980,507) * year 2015 for the Physical Medicine & Rehabilitation beds at MSBI. The The Current Year represents incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project. (Rev. 7/2015) 1 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Limited Review Application Schedule LRA 7 State ofNew York Department of Health/Office of Health SystemsManagement .. * Various inpatient services may be reimbursed as discharges or days. Applicant should indicate which method checkbox. applies to this table by choosing the appropriate checkbox PatientDays PatientDischarges Inpatient Services Source of 'PotalCurrent Year** Fñst Year Incremental** Th rd Year Incremental** Revenue Patient Net Revenue* Patient Net Revenue* Patient Net Revenue* Days or Days or % based Days or % based discharg % Dollars ($) discharg on days or Dollars-($) discharg on days or Dollars-($) es* es' discharges es* discharges Commercial Feefor Service Managed Care 110 16.7% $3,462,654 (110) 16.7% ($3,462,654) (110) 16.7% ($3,462,654) Medicam Feefor service 368 55.8% $9,579,492 (368) 55.8% ($9,579,492) (368) 55.8% ($9,579,492) Managed Care 112 17.0% $2,573,948 (112) 17.0% ($2,573,948) (112) 17.0% ($2,573,948) Medicaid Feefor service 21 3.2% $406,115 (21) 3,2% ($406,l15) (21) 3,2% ($406,115) Managed Care 43 6.5% $930,611 (43) 6.5% ($930,611) (43) 6.5% ($930,611) Private Pay 3 0.5% $203,395 (3) 0.5% ($203,395) (3) 0.5% ($203,395) OASAS OMH Charity Care Bad Debt 3 0.5% $71,028 (3) 0.5% ($71,028) (3) 0.5% ($71,028) All Other Total 660 100.0% $17,227,243 (660) 100.0% ($17,227,243) (660) 100.0% ($17,227,243) ** The Current Year represents year 2015 for the Physical Medicine & Rehabilitation beds at MSBI. The incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI th ough this project. (Rev. 7/2015) 2 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Oupatient Services To al Current Year Firs' Thir d Year Incremental Year Incremental Source of Revenue Net Revenue* Net Revenue*. Net Revenue* Vih % Dollars ($) % Dollars (3) /o Dollars ($) Commercial Fee for Service Managed Care Medicare Fee for Service Managed Care N/A N/A N/A Medicald Fee for Service - - - Managed Care Inpatient Inpatient Inpatient Private Pay Project Project Project OASAS Only only only OMH Charity Care Bad Debt All Other Total Total of Inpatient and Outpatient Services s17,227,243 (s17,227,243) (s17,227,243) Title of Attachment Filename of Attachment 1. in an attachment, provide the basis and Revenues by payer are based upon the supporting calculations N/A experience of the for all revenues by . Hospital. payor. 2. In an attachment, Charity Care based on the provide the basis for experience of the N/A care. Hospital. charity * Net Deductions from Revenue (Rev. 7/2015) 3 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 Limited R iew A PP lication Schedule LRA 8 State of New York Depa twent of Health/Office of Health Systems Management ........... ...... ... ......... Staffing Number of FT Es to the Nearest Tenth Current Year* First Year of Third Year of Staffing Categories **** implementation implementation **** **** Health Providers**: Physician 1.50 (1.50) (1.50) Nurse Practitioner 1.00 (1.00) (1.00) Physical Therapist & PT Assistant 8.00 (8.00) (8.00) Occupational Therapist & OT Assistant 5.00 (5.00) (5.00) Speech Therapist & Speech Assistant 1.00 (1.00) (1.00) Support Staff***: Management & Supervision 1.00 (1.00) (1.00) Registered Nurse 17,00 (17.00) (17.00) Aides, Orderlies & Attendants 16.00 (16.00) (16.00) Clerical & Other Administrative 2.00 (2.00) (2.00) Total Number of Employees 52.50 (52.50) (52.50) * Last complete year prior to submitting application ** Providers" "Health includes a_1]providers serving patients at the site. A Health Provider is any staff who can provide a billable service - physician, dentist, dental hygienist, podiatrist, physician assistant, physical therapist, etc. *** All other staff. **** The Current Year represents vear 2015 staffing for the Physical Medicine & Rehabilitation beds at MSBL The incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project. Describe how the number and mix of staff were determined: The number and mix of staff were based upon the fact that all 26 certified inpatient PM&R beds will be decertified through this project. Nevertheless, Mount Sinai does not anticipate any job losses as a result of the closure of the inpatient rehabilitation unit at MSBI, and it has already begun meeting and working with its union partners to ensure that the affected union employees are retrained, if necessary, and offered other union opportunities with equal pay within the Mount Sinai Health System. PLEASE COMPLETE THE FOLLOWING: 1. Are staff paid and on payroll? Yes O No 2. Provide copies of contracts for any independent contractor. H/_A 3. Please attach the Medical Doctors C N. Please refer to the Schedule LRA 8 Attachment 4. Is this facility affiliated with any other facilities? (If yes, please describe affiliation and/or agreement.) Yes O No (Rev.7/7/2010) FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 MOUNT SINAI BETH ISRAEL SCHEDULE LRA 8 ATTACHMENT CURRICULUM VITAE - MEDICAL DIRECTOR STATEMENT RE: ARTICLE 28 NETWORK FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 CURRICULUM VITAE NAME: Joseph E. Herrera, DO, FAAPMR Joseph.herrera@mountsinai.org EMPLOYMENT August 2005 - Present Icahn School of Medicine at Mount Sinai Department of Rehabilitation Medicine One Gustave L. Levy Place, Box 1240 New York, New York 10029 ACADEMIC APPOINTMENTS 2008- Present Program Director July Residency Physical Medicine and Rehabilitation Department of Rehabilitation Medicine Icahn School of Medicine at Mount Sinai New York, New York 2007- Present Director July Fellowship Sports Medicine and Interventional Spine Department of Rehabilitation Medicine Icahn School of Medicine at Mount Sinai New York, New York 2006 - Present Assistant Professor Department of Rehabilitation Medicine icahn School of Medicine at Mount Sinai New York, New York 2005 - 2006 Instructor Department of Rehabilitation Medicine Icahn School of Medicine at Mount Sinai New York, New York HOSPITAL APPOINTMENTS 2005- Present Assistant Attending Mount Sinai Medical Center New York, NY, 10029 GAPS IN EMPLOYMENT N/A EDUCATION 2004 - 2005 FELLOWSHIP Beth Israel Medical Center, New York, New York Interventional Spine and Sports Medicine Fellowship, Fellowship Program Director: Robert Gotlin, DO 1 of 20 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 2001 - 2004 RESIDENCY New York Presbyterian Hospital, Columbia and Cornell University Physical Medicine and Rehabilitation New York, New York Residency Program Director: Nancy Straus 2000 - 2001 INTERNSHIP Saint Michaers Medical Center Newark, New Jersey Rotating internship 1996 - 2000 MEDICAL SCHOOL University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine Stratford, NJ Doctor of Osteopathic Medicine, D.O. 1991 - 1995 UNDERGRADUATE STUDIES Rutgers University, Cook College, New Brunswick, NJ Bachelors of Science in Biological Sciences CERTIFICATION 2011 Board Certified Sports Medicine 2005 Diplomate, American Board of Physical Medicine and Rehabilitation 2005 Certified in Ringside Medicine, American Association of Professional Ringside Physicians LICENSURE 2001 New York State, License # 222712 2012 New Jersey License # 25MB09042200 HONORS/AWARDS/PATENTS 2012-2015 Super Doctors Featured in The New York'Times Magazine Top 5% of physicians in New York 5/20/2012, 5/17/2013, 5/18/2014, 5/17/2015 2014 Castle Connolly Top Doctors Top doctor for New York Region 2008 American Association for the Improvement of Boxing Rocky Marciano Physician of the Year Award 2 of 20 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 2004 American Pain Society, American Pain Scholar 2000 Saint Michaels Medical Center Medical Intern of the Month (November) 1995 Rutgers University William H. Martin Scholarship 1995 Rutgers University Sigma Xi Grant-In-Aid of Research Award 1995 Rutgers University, George H. Cook Honors Program PATENTS N/A OTHER PROFESSIONAL APPOINTMENTS 2015 Course Program Director Ultrasound in Education and Research Association of Academic Physiatrist Track C1 2015 - San Antonio Texas Association of Academic Physiatrist 2006-Present 2014 Course Program Co-Director Course Program Facilitator for Course A1 "ACA - - Obamacare & Implications for Regulatory PM&R" Academic Association of Academic Physiatrist Course A1 2014 - TN Nashville, Association of Academic Physiatrist 2006-Present 2010 Oral Board Examiner, American Board of Physical Medicine and dates: 2005 - Present Rehabilitation, Membership 2010 Musculoskeletal Council American Association of Physical Medicine and dates: 2001- Present Rehabilitation, Membership 2007- 2010 Chief Physician USA dates: 2002 - Boxing Metro, Membership Present 2006 - Present Chief Musculoskeletal book Humana Editor, Series, Press 2006 - 2010 Chief Current Reviews in Musculoskeletal Editor, Medicine, Springer Press 3 of 20 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 2005 - 2009 Medical Review Board American Association for Professional Ringside Physicians, Membership dates: 2002-2010 2004-2006 Chairman, Membership Committee American Association for Professional Ringside Physicians, Membership dates: 2002-2010 2004 Team Physician New York Knicks Basketball Team Physicals New York, New York 2004 Team Physician Westchester Wildfire USBL Basketball Tournament New York, New York 2004 Team Physician New City Sevens York Rugby Tournament New York, New York 2004 Team Physician USA Boxing National Championships Colorado Springs, Colorado 2003 Medical Team Captain New York City Triathlon New York, New York 2002 - Present Medical Panel Physician New York State Athletic Commission 2002 - Present Ringside Physician Daily News New York City Golden Gloves New York, New York 2002 - Present Medical Team Captain New York City Marathon New York Road Runners Club 2002 Team Physician Empire State Games Syracuse, New York 2002 Team Physician NJAIAW Tennis Tournament, 4 of 20 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 37 RECEIVED NYSCEF: 02/07/2024 MOUNT SINAI BETH ISRAEL ARTICLE 28 NETWORK DESCRIPTION Mount Sinai Hospitals Group, Inc. (MSHG), a not-for-profit corporation, is the active parent and co-operator of Mount Sinai Hospital (including its division, Mount Sinai Hospital of Queens), Mount Sinai Beth Israel, Mount Sinai Brooklyn, Mount Sinai St. Luke's, Mount Sinai Roosevelt and the New York Eye and Ear Infirmary of Mount Sinai. Mount Sinai Hospital(MSH) is located at One Gustave L. Levy Place, New York (New York County), New York 10029. MSH also has a division, Mount Sinai Hospital of Queens, which is 3081 located at 25-10 Avenue, Long Island City (Queens County), New York 11102. Mount Sinai Beth Israel is located at First Avenue at 16 Street, New York (New York County), New York 10003. Mount Sinai Brooklyn is located at 3201 Kings Highway, Brooklyn (Kings County), New York 11234. Mount Sinai St. Luke's is located at 1111 Arnsterdam Avenue, New York (New York County), New York 10025. Mount Sinai Roosevelt is located at 1000 Tenth Avenue, New York (New York County), New York 10019. New York Eye and Ear Infirmary of Mount Sinai is located at 310 East 14 Street, New York (New York County), New York 10003. The following table provides information on operating certificate numbers and PFI numbers for the ab