STATE OF ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD

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1 52525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS (217) FAX: (217) DOCKET NO: BOARD MEETING: PROJECT NO: PROJECT COST: H-1 July 23-24, 212 FACILITY NAME: Advanced Eye Surgery and Laser Center CITY: Decatur Original: $1,695, Current: $ TYPE OF PROJECT: Non-substantive HSA: IV PROJECT DESCRIPTION Gailey Eye Surgery-Decatur, LLC, and Advanced Eye Surgery and Laser Center, LLC, (the applicants), propose to transfer ownership of a single-specialty ASTC in Decatur. The FMV of the facility is $1,695,. Page 1

212 FACILITY NAME: Advanced Eye Surgery and Laser Center 12-23 CITY: Decatur Original: $1,695, Current: $ TYPE OF PROJECT:

2 52525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS (217) FAX: (217) EXECUTIVE SUMMARY PROJECT DESCRIPTION: Advanced Eye Surgery and Laser Center, LLC. is proposing to transfer ownership of a single-specialty ASTC in Decatur. The FMV of the facility/transaction is $1,695,. The anticipated project completion date is August 31, 212. WHY THE PROJECT IS BEFORE THE STATE BOARD: The project proposes a change of ownership of a health care facility as defined by the Act. 2 ILCS 396/3. The applicants are seeking permission for this change of ownership because the licensed entity is changing. STATE BOARD REQUIREMENTS FOR CHANGE OF OWNERSHIP: An applicant proposing a change of ownership must provide details on any proposed changes in the beds or services currently offered, the reason for the transaction, any anticipated additions or reductions in employees, any changes in the restriction of patient admissions, and; attestation that no reductions in access to care will result from the proposed change of ownership transaction. BACKGROUND/COMPLIANCE ISSUES: State Board Staff report finding no compliance issues with either applicant. PUBLIC COMMENTS: No letters of support of opposition were received by the State Board Staff and there was no request for a public hearing. PURPOSE: The purpose of the project is to improve the health and well-being of the Decatur community and other outlying areas. The purchasing applicant proposes to provide effective and efficient ophthalmologic services. FINANCIAL AND ECONOMIC FEASIBLITY: The applicants provided a representation of project costs that was based upon the purchase price of membership units and consulting fees. The application contains a copy of the Membership Unit Purchase Agreement (application, p. 9), and the Assignment and Assumption of Membership Unit Purchase Agreement (application, p. 236). Financial statements were provided by the applicants and are included in your packet of information. CONCLUSIONS: According to the applicants the benefits of the transaction are; Page 2

WHY THE PROJECT IS BEFORE THE STATE BOARD: The project proposes a change of ownership of a health care facility as defined by the Act. 2 ILCS 396/3.

3 52525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS (217) FAX: (217) o Improve the health and well-being of the Decatur community and outlying areas, o To expand the scope of ophthalmologic services provided by the ASTC, and o Provide the community with more effective and efficient operations through the expertise and experience of an existing provider of ophthalmologic services. There will be no change in services being offered. The applicant anticipates future expansion of the ASTC through the introduction of retina and pediatric ophthalmology services. No change or the reduction in the number of employees will occur, outside of the ordinary course of business. The applicant actually anticipates the hiring of additional staff as new services are introduced. No restrictions in the admission of patients or access to care will be introduced, and the applicant anticipates the lowering of the minimum patient age, to accommodate the admission of pediatric patients. The facility will continue to operate under the existing admission policy and uninsured/self pay discount policy. The applicants have met all of the requirements of the State Board. Page 3

provided by the ASTC, and o Provide the community with more effective and efficient operations through the expertise and experience of an existing provider of ophthalmologic services.

4 52525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS (217) FAX: (217) Advanced Eye Surgery and Laser Center, Decatur Project #12-23 APPLICATION SUMMARY Applicants Gailey Eye Surgery Decatur, LLC Advanced Eye Surgery and Laser Center, LLC Facility Name Advanced Eye Surgery and Laser Center Location Decatur, Illinois Application Received March 8, 212 Application Deemed Complete March 13, 212 Scheduled Review Period Ended May 12, 212 Review Period Extended by the State No Board Staff? Public Hearing Held? No Applicants Deferred Project? No Can Applicants Request Another Deferral? Yes Applicants Modified the Project? No I. The Proposed Project Gailey Eye Surgery Decatur, LLC, and Advanced Eye Surgery and Laser Center, LLC are proposing a change of ownership of a single-specialty ASTC. The project cost is $1,695,. II. Summary of Findings A. The State Board Staff finds the proposed project appears to be in conformance with the provisions of Part 111. B. The State Board Staff finds the proposed project appears to be in conformance with the provisions of Part 112. III. General Information The applicants are Gailey Eye Surgery Decatur, LLC, and Advanced Eye Surgery and Laser Center, LLC. Advanced Eye Surgery and Laser Center is located at 646 West Pershing Road, Decatur, Illinois. Upon CON approval the facility will adopt a DBA (doing business as) name, which will be assigned after completion of the proposed transaction. The operating entity/licensee is Advanced Eye Surgery and Laser Center, LLC and the owner of the site is SSMJ, LLC. The proposed project is located in the HSA-4. Project obligation will occur after permit issuance, and the anticipated project completion date is August 31, 212. Page 4

Eye Surgery and Laser Center, LLC Facility Name Advanced Eye Surgery and Laser Center Location Decatur, Illinois Application Received March 8, 212 Application Deemed Complete March 13, 212 Scheduled

5 52525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS (217) FAX: (217) IV. Project Costs and Sources of Funds The total estimated project cost is $1,695,. The majority of this project cost is attributed to the purchase price of membership units. TABLE TWO Project Uses and Sources of Funds Uses of Funds Clinical Purchase Price of Membership Units $1,5, Consulting & Other Fees $195, Total Uses of Funds $1,695, Sources of Funds Clinical Cash & Securities $1,695, Total Sources of Funds $1,695, Safety Net Impact Statement/Charity Care The applicant notes the project is categorized as non-substantive, and a Safety Net Impact Statement is not applicable to this project. The table below shows the net patient revenue for Advanced Eye Surgery and Laser Center, LLC, for the three years prior to the application date. It appears that no charity care is reported for the previous three years. Safety Net Information per PA CHARITY CARE Charity (# of patients) Net Patient Revenue $1,122,734 $1,65, $1,139,633 Amount of Charity Care Charity (cost In dollars) $ $ $ At the conclusion of this report is the 21 Annual ASTC Questionnaire for Advanced Eye Surgery and Laser Center, Decatur. Page 5

TABLE TWO Project Uses and Sources of Funds Uses of Funds Clinical Purchase Price of Membership Units $1,5, Consulting & Other Fees $195, Total Uses of Funds $1,695, Sources of Funds Clinical Cash &

6 AMBULATORY SURGICAL TREATMENT CENTER PROFILE-21 ADVANCED EYE AND LASER CENTER, DECATUR Reference Numbers Facility Id Health Service Area 4 Planning Service Area ADVANCED EYE AND LASER CENTER, LLC 646 WEST PERSHING ROAD DECATUR, IL Number of Operating Rooms 2 Procedure Rooms Exam Rooms Number of Recovery Stations Stage 1 2 Number of Recovery Stations Stage 2 Administrator HILARE KLINGER Registered Agent SSMJ, LLC Property Owner Legal Owner Date Completed 2/14/211 Type of Ownership Limited Liability Company (RA required) HOSPITAL TRANSFER RELATIONSHIPS HOSPITAL NAME NUMBER OF PATIENTS Decatur Memorial Hospital STAFFING PATTERNS PERSONNEL FULL- EQUIVALENTS Administrator 1. Physicians. Nurse Anesthetists. Dir. of Nurses. Reg. Nurses 2. Certified Aides. Other Hlth. Profs. 1. Other Non-Hlth. Profs 1. TOTAL 5. DAYS AND HOURS OF OPERATION Monday 8 Tuesday 8 Wednesday 8 Thursday 8 Friday 8 Saturday Sunday Source:Ambulatory Surgical Treatment Center Questionnaire for 21, Illinois Department of Public Health, Health Systems Development Page 31 of 27 8/3/211

KLINGER Registered Agent SSMJ, LLC Property Owner Legal Owner Date Completed 2/14/211 Type of Ownership Limited Liability Company (RA required) HOSPITAL TRANSFER RELATIONSHIPS HOSPITAL NAME NUMBER OF

7 AMBULATORY SURGICAL TREATMENT CENTER PROFILE-21 ADVANCED EYE AND LASER CENTER, DECATUR NUMBER OF PATIENTS BY AGE GROUP AGE MALE FEMALE TOTAL Yea TOTAL ,56 NUMBER OF PATIENTS BY PRIMARY PAYMENT SOURCE PAYMENT SOURCE MALE FEMALE TOTAL Medicaid Medicare ,19 Other Public Insurance Private Pay Charity Care 1 1 TOTAL ,56 NET REVENUE BY PAYOR SOURCE FOR FISCAL YEAR Medicare Medicaid Other Public Private Insurance Private Pay TOTALS 65.9%.3%.6% 26.4% 6.7% 1.% 751,144 3,934 6,586 31,412 76,557 1,139,633 Charity Care Expense Charity Care Expense as % of Total Net Revenue % OPERATING ROOM UTILIZATION FOR THE REPORTING YEAR PREP and AVERAGE CLEAN-UP TOTAL CASE TOTAL AREA SURGERIES Cardiovascular.... Dermatology.... Gastroenterology.... General.... Laser Eye Surgery Neurology.... OB/Gynecology.... Opthalmology Oral/Maxillofacial.... Orthopedic.... Otolaryngology.... Pain Management.... Plastic Surgery.... Podiatry.... Thoracic.... Urology.... TOTAL PROCEDURE ROOM UTILIZATION FOR THE REPORTING YEAR PREP and AREA PROCEDURE ROOMS TOTAL SURGERIES CLEAN-UP TOTAL AVERAGE CASE Cardiac Catheteriza. Gastro-Intestinal. Laser Eye. Pain Management. TOTALS. Source:Ambulatory Surgical Treatment Center Questionnaire for 21, Illinois Department of Public Health, Health Systems Development Page 32 of 27 8/3/211

15 21 36 Charity Care 1 1 TOTAL 618 888 1,56 NET REVENUE BY PAYOR SOURCE FOR FISCAL YEAR Medicare Medicaid Other Public Private Insurance Private Pay TOTALS 65.9%.3%.6% 26.4% 6.7% 1.

8 12-23 Advanced Eye Surgery & Laser Center - Decatur mi Copyright and (P) Microsoft Corporation and/or its suppliers. All rights reserved. Portions InstallShield Software Corporation. All rights reserved. Certain mapping and direction data 25 NAVTEQ. All rights reserved. The Data for areas of Canada includes information taken with permission from Canadian authorities, including: Her Majesty the Queen in Right of Canada, Queen's Printer for Ontario. NAVTEQ and NAVTEQ ON BOARD are trademarks of NAVTEQ. 25 Tele Atlas North America, Inc. All rights reserved. Tele Atlas and Tele Atlas North America are trademarks of Tele Atlas, Inc.

Certain mapping and direction data 25 NAVTEQ. All rights reserved.

Changes of Ownership by Northwest Community Day Surgery

Changes of Ownership by Northwest Community Day Surgery STATE OF ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD 5 525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS 62761 (217) 782-3516 FAX: 217) 785-4111 DOCKET ITEM: BOARD MEETING: EXEMPTION NUMBER: C-01 November