As medical offices struggle to keep their doors open during COVID-19, they’re often going to their landlords to request relief.

While medical office landlords might be inclined to provide this relief rather than seeing their tenants go out of business, Allison Nelson, co-deputy chair of Akerman’s real estate group, says laws specific to the healthcare sector could open landlords up to compliance issues. The main threat is violating The Stark Law and the Anti-Kickback Statute, which is a set of federal laws that prohibit physician self-referral.

These laws may be applicable when a physician or healthcare practitioner or an immediate family member of a physician is leasing or subleasing from another healthcare provider or hospital. Making things even thornier is that there could also be state corollaries to these laws.

“The [medical office] lease has to be at fair market value, and the parties can’t give concessions to each other or remuneration outside the contract,” Nelson says. “So that’s where you could get into issues with giving rent relief, which could inadvertently be considered a kickback in exchange for referrals of patients between the parties.”

In these situations, Nelson advises landlords to get their attorney involved to determine if Sark law or the Anti-Kickback Statute governs a leasing arrangement. They should also determine if the lease or sublease provides a provision that allows for a concession.

But there are situations where Nelson thinks rent relief may be acceptable. “If the healthcare system just closes down its entire medical office building and bars a tenant from use of the space, that’s probably a pretty easy example of an instance in which a rent concession is allowed,” Nelson says. “The tenant was denied access, and the whole building was shut down.”

The Anti-Kickback Statute is generally an intent-based law, according to Nelson. So if the landlord creates a policy for all tenants, that could help establish that there was no intent.

“Under The Anti-Kickback Statute, there has to be an intent to induce referrals,” Nelson says. “So if they are creating consistent policy across the board, it’s going to help mitigate that intent to induce referrals.”

Government agencies have moved to provide relief. The Centers for Medicare & Medicaid Services offered blank waivers for arrangements governed by the Stark law if related to a COVID-19 purpose. The Office of Inspector General also issued guidance that it wouldn’t prosecute or enforce agreements subject The Anti-Kickback Statute. “Hospitals and healthcare systems are looking to those blanket waivers now to give them some means for providing written concessions or other types of relief to their tenants,” Nelson says.

Nelson advises her medical office clients to create a protocol for dealing with rent relief requests.

“Maybe the tenant has to prove that they sought loans under the Paycheck Protection Program or that not getting this relief will cause an economic hardship for them that could put them out of business,” Nelson says. “That’s important with these blanket waivers. They have to be related to a COVID-19 purpose.”

Nelson says that purpose could include a lease at a below fair market value rate so a physician could treat COVID-19 patients at a hospital. “Some argue it could include rent relief to ensure medical practices stay open to serve the community,” she says.


Source:  GlobeSt.

Limiting entries, enhancing HVAC systems, compartmentalizing spaces, and creating hot zones are some of the recommendations made by local architecture firm HKS to prepare healthcare facilities for current and future pandemics. HKS released a report with details for short and long-term strategies that will help healthcare systems prepare for a potential second wave of COVID-19.

The company organized an ER COVID-19 Design Task Force made up of design, clinical, and engineering experts to compile and review effective strategies. The Task Force analyzed news stories, successful and unsuccessful facility responses, and previous publications to list eight possible concepts to help healthcare systems combat a second wave of COVID other infectious diseases.

Enhance Entry Functions

As COVID numbers began to rise, medical facilities started limiting the number of entries. Many even implemented a single-entry control point. Besides controlling entry levels, entry portals can also be used for many screening and safety functions such as providing protective personal equipment, collecting patient information, and identifying highly infectious patients.

Some short-term considerations for enhancing entry functions include providing PPE to wear when entering the facility, the use of various technologies such as rapid testing and temperature screening, and the installation of temporary materials like dry wall, plastic, or plexiglass.

Long-term considerations include providing storage for supplies like PPE and wheelchairs, inserting hand-washing stations near the entry, creating negative pressure capabilities, and providing space for new technologies that could strengthen diagnostic and security can help facilities manage future pandemics.

Support and Reinforce Personal Protective Equipment Management

PPE is an effective way to protect not only patients but health care workers. Different circumstances require different levels of PPE and how often it needs to be changed. Some hospitals have even created policies for reusing PPE in order to conserve it.

“PPE for decades has really been an afterthought design, which puts nurses in the position of using mobile or makeshift solutions for storage,” Sarah Holton, Vice President at HKS, said during an online seminar about the report. “Our opportunity as a design leader is to really advance the strategic placement of PPE in the design process. By carefully integrating PPE in the design dialogue, we more effectively support the principles of infection, prevention, and its use.”

Potential strategies to be implemented now include placing PPE at key entries, creating areas for donning and doffing the equipment, designating space for cleaning reusable PPE, and installing foot-operated door pulls. Looking ahead, the Task Force suggests separating donning and doffing PPE areas away from patient care areas, installing a sink at doffing areas, creating disposal stations into rooms near exits.

Bolster Resistance to Pathogens

Implementing effective policies can help strengthen resistance to pathogen threats and reduce the risk of infecting patients and staff. The concept of bolstering resistance to pathogens strategies considers water integrity, all surfaces, and air purity. Another thing to take into account when developing resistance to pathogens is the ability to remove all items from a room. One short-term modification is to use carts.

“We consider the use of carts rather than permanent cabinetry that can be removed so the room can be fully clean. Carts could be removed if unnecessary during the particular patient course of treatment.” Holton said. “Placing equipment outside of the room when possible to limit the need to go in and out of the room is very helpful.”

Other immediate modifications include implementing temporary negative pressure with exhaust to enhance isolation areas, placing select equipment outside of the patient’s room, covering high-risk surfaces with adhesive films that can be easily cleaned, labeling high-touch surfaces with specific signals that indicate to housekeeping staff that frequent cleaning is required, and using hydrogen peroxide misting or UV light disinfection.

Health care facilities can implement strategies such as using cleanable surfaces, using high touch strip concepts to enhance cleaning, providing access to equipment from outside of the room, creating a unidirectional flow suite that separates doffing and donning areas to help reduce contamination.

Enhance Heating, Ventilation, and Air Conditioning Systems

HVAC systems in medical facilities play an important role in stopping and destroying a virus from spreading throughout the hospital. Because many diseases can spread through the air, enhancing HVAC systems is an important step in limiting the transmission of diseases to patients and medical staff.

“Being a global company, we had the ability to start getting an understanding of what other regions were doing in Asia and in Europe,” Nolan Rome, Senior Vice President at engineering firm WSP, said. “It really came down to the basic premise of all healthcare, which is that directional airflow of clean to less clean and to pull that air using negative pressure and the contaminator away from the caregiver, as they provide care to the patient.”

Potential near-term policies that could help enhance HVAC systems include upgrading filters in air handling units to include High Efficiency Particulate Air final filters, operating the air handling units serving COVID-19 areas at 100 percent outside air with full exhaust, creating temporary negative pressure rooms with direct exhaust through HEPA filtration, and installing temporary ante-rooms for negative pressure isolation rooms with HEPA filtration.

Looking ahead, healthcare systems should consider pressure monitors for all areas that require pressure compartmentalization, designing air handling units for emergency department areas to handle 100 percent air for pandemic operation, implementing purge mode that will allow the entire ED to be exhausted, and validation of directional airflow patterns.

Strategize for Compartmentalization

The strategy of compartmentalizing a department into multiple zones can be effective in caring for different groups of patients. In order to successfully compartmentalize units, health care facilities must take into account access to critical resources, equipment, and supplies as well as accessibility, stairs and elevators, existing fire safety plans, and interstitial spaces.

“Looking at the long-term considerations and essentially something we do in our Asia practices regularly is to start to look at creating areas of compartmentalization,”Rome said. “We start to give ourselves a seasonal pandemic or a seasonal flu plan where we can isolate entire parts of the body and isolate entire patient wings, so we can give ourselves a parallel path to be able to treat our acute and relatively well patients in a way that allows for revenue stream that also allows us to process the pandemic patients at the same time.”

Changes in the near future for compartmentalization include using secured interlocking double doors, using tape, sealers, and caulk to limit air leaks, stock adequate supplies and equipment in each zone, and color-coding areas to visually represent the risk/precaution level and help establish safe behavior.

Long-range considerations include designing ventilation systems to isolate cohort compartments, using air pressure gradients that match the level of disease spread, and taking advantage of fire door requirements to create compartments.

Delineate Safe Zones and Hot Zones

During a pandemic, it may be difficult to establish a completely safe zone. Nevertheless it is important to create an area where healthcare workers are able to operate with less PPE and be safe from contamination. In order for the safe zone to be effective, medical staff need to easily understand the level of safety a zone needs and the delineation of the zone.

“This takes a look at how you would alter the corridor going into the room in a very simplistic way. Number one, outside of the room, you would have a great area which is for donning,”Jim Lennon, an ED Specialist said.  ‘On the door and wall is a color-coded system representing various levels of infection. Similarly, you try to make your exit on the left side with hand sanitizer and some kind of PPE disposal.”

Other solutions to establish clean safe zones include using tape or stanchions in circulation areas to separate clean and potentially contaminated flows, creating color-coded floors, walls, or doors, making sure signs are simple to read across languages or creating universally recognizable icons, using portable screens to separate zones, and adding physical barriers where appropriate.

Color-coded doors, embedded LED lighting that change color to represent different conditions, the usage of different colors in flooring materials, and pass-throughs for equipment can help medical facilities establish effective safe zones in the future.

Expand and Facilitate Telemedicine Usage

During the pandemic, telemedicine became more widespread. Telemedicine prevents exposure and allows for the preservation of equipment.“We want to develop a security structure that utilizes all of these tools and establish a space that can support medical professionals providing telemedicine services and dedicated telemedicine rooms,” Holton said. “The idea is that [the telemedicine rooms] should ensure acoustic privacy, good speech clarity, adequate lighting, and clarity space expressions.”

Long-term strategies including considering a center where telemedicine can be coordinated, including a health system logo on the room or on the feed, considering on-site tele-triage, and establishing patient spaces for incoming telemedicine support.

Provide Surge Capacity

During the pandemic, ERs have been running at or beyond their capacity levels. In planning for the future waves, every space near the ER must be considered for re-purposing in order to handle the influx of patients.

Portable equipment to minimize the need for bedside electrical, rapid assembly of surge structures, using rigid structures, providing well stocked areas with high use clinical and cleaning supplies, zoning immediately adjacent surface parking areas for environmentally controlled deployable, and rapidly connecting to existing hospital sources of medical gases, water, electrical and data outlets.

When designing new facilities, features such as slightly over-sized ED treatment rooms, docking area for temporary structures, ED canopies that can be easily enclosed to become indoor spaces, pre-wire and pre-plumb common spaces with power increases a hospital’s ability to surge during a crisis.


Source:  Healthcare DMagazine

Florida officials are finalizing plans for a “super-skilled nursing facility” that will accept COVID-19 patients who don’t require critical medical care.

The 120-bed facility will be in Pinellas County, though more specific details haven’t been released, Pinellas County Administrator Barry Burton said July 16.

Last month, only eight COVID-19 patients in Pinellas County needed ventilators, but 54 patients were on ventilators July 15, said Angus Jameson, MD, medical director for Pinellas County Emergency Medical Services. Some hospitals are again halting elective surgeries, Dr. Jameson said.

“Clearly, the healthcare system is stressed at this point from a physical standpoint, but also frankly from a human standpoint,” Dr. Jameson said. “Your healthcare workers are exhausted. They’ve been at this for months. It is incredibly hard to care for patients with COVID.”

Earlier this week, Florida officials said they were focusing on expanding hospital surge capacity rather than building alternate sites to accommodate an overflow of patients due to the hurricane season, according to WUSF Public Media. 

“At this time, mobile field hospitals consisting of tents may not be the best resource to deploy during hurricane season,” Florida Division of Emergency Management communications director Jason Mahon told WUSF. “Instead, our primary support strategy is to surge staff into existing facilities — opening up additional capacity in those hospitals.”


Source:  Becker’s Hospital Review

Architecture and engineering firm Stellar has been selected by Flagler Health+ to design and build a $150 million health and wellness campus in the Durbin Park section of St. Johns County, to be sited between Interstate 95 and State Road 9B.

A recent release from Stellar, based in Jacksonville, said that the firm will be collaborating with Flagler Health+ and University of Florida Health on the project, whose conception entails medical residency programs, a hospital complex as well as educational opportunities for residents and fellows at the campus.  Furthermore, plans for down the road at the facility entail ambulatory medical services.

Architect Gresham Smith will collabrote with Stellar on the five-year, 42-acre buildout project, which is anticipated to break ground sometime this fall and be completed in 2025.

“Stellar is excited to be the design-builder for this innovative new concept in health and wellness,” Richard Lovelace, senior vice president, commercial at Stellar, said in a recent statement.  “After building two Health Villages for Flagler Health+ at Murabella and Nocatee, we are proud to continue our partnership and help bring comprehensive medical care to northern St. Johns County.”


Added Rick Bouchereau, vice president at architectural partner firm Gresham Smith, said in a statement that his firm is “honored to partner with Stellar on this transformative project for Flagler Health+ and this community. Our design for the Durbin Park campus will create a strong sense of place and embody Flagler Health+’s goals for a healthy community.”

Stellar employs nearly 800 professionals in such specialties as architecture, engineering and construction, and the firm specializes in construction management and design-build for projects around the nation.  In addition to healthcare, their portfolio entails construction in the recreation, hospitality, industrial and military sectors.

Healthcare provider Flagler Health+ maintains a healthcare presence specifically in Northeast Florida, inclusive of working with local schoolchidren to educate them about behavioral health.  Flagler Health+ falls under the umbrella of the 130-year-old Flagler Hospital, which is located in St. Augustine.


Source:  HC+O News

Catalyst Healthcare Real Estate has wrapped up construction on a 50,000-square-foot medical office building in St. Cloud, Fla. Anchored by Orlando Health St. Cloud Hospital, the development broke ground in 2019. According to Osceola County records, Ameris Bank provided nearly $10 million in construction financing. Davis Stokes Collaborative served as the project architect.

Located at 1330 Budinger Ave., at the intersection of U.S. Highway 192 and Budinger Avenue, the 84-bed facility is the first multi-specialty medical property developed on the campus of OHSCH, the former St. Cloud Regional Medical Center. Earlier this year, Orlando Health entered into an agreement to become the majority owner of the newly-built asset.

The facility provides patient access point and serves as a walk-in clinic as well. Outpatient services include cardiology, diagnostic imaging, gastroenterology, urology and primary care. Celebration Orthopaedic, Sports Medicine Institute and Eye Florida also lease space at the building, which is some 2 miles from the city center in the Medical Arts District. There are numerous dining and shopping options alongside the highway, including St. Cloud Square.


Source:  CPE

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A new report from BTIG shows that health care REITS are down nearly 26% year-to-date as opposed to the wider REITS sector, which is down about 14%.

The report states that health care “remains a sector of change.”

“The acute phase of the COVID-19 pandemic has led to different levels of operating stress across the healthcare system,” the report states…. “Potential disparities in outcomes based on insurance coverage during the pandemic could also lead increased calls for changes to government healthcare programs.”

The same report does show that medical office building REITs have held up pretty well and have been “relatively resilient.”

The report says that since April during the midst of the coronavirus pandemic, “outpatient volumes have risen to 69% of pre-COVID levels… Accordingly, our MOB (medical office building) coverage has collected 95% of second quarter rent on average, stability which is reflected in unchanging MOB dividends.”

As it pertains to senior housing trends, BTIG says senior housing facilities and their residents are taking the advice of health experts.

The numbers of seniors in such facilities who have contracted the virus has declined, BTIG says.

“Specifically, for SNR, less than 0.2% of residents and employees are positive for the virus, and the new case rate has declined 91% from peak levels in April,” the report says. “Thus, 90% of SNR properties have begun lifting restriction using a phased approach so that residents can return toward normality and new residents can begin moving in.”

The report concludes: “We expect this same-store operational and occupancy focus to remain at the forefront until REITs’ cost of capital improves enough to return to the acquisition market.”



Source:  GlobeSt.

The city’s oldest and largest hospital, Bayfront Health St. Petersburg, is set to be sold to nonprofit health care company Orlando Health, pending a vote by the City Council on July 9.

Community Health Systems Inc., the private company which currently owns the 480-bed facility, announced it had signed an agreement with Orlando Health on Thursday. The news comes about a year after city officials raised concerns about the management of the hospital, which sits on city-owned land and provides care to all, regardless of insurance status.

Orlando Health will take over operations and the long-term lease that Community Health Systems holds with the city, so long as council members approve next month, a news release said. A copy of the proposed lease obtained by the Tampa Bay Times shows it would run for 50 years.

The agreement states Orlando Health must continue to “provide charity care to needy and underserved persons” and “those who may otherwise be unable to afford or obtain care due to various possible adverse circumstances.”

City councilman Robert Blackmon, who was born at Bayfront St. Petersburg, said Friday that continuing the charity care was a “sticking point” in negotiations with Orlando Health. He said he will support the agreement, as did councilwoman Darden Rice.

After a one-on-one conversation with the company’s president and CEO David Strong a couple of months ago, Blackmon said he is confident charity care will continue at the hospital — and be even better under new management.

He pointed to a string of troubles at Bayfront under Community Health Systems, which purchased it in 2013. The hospital has seen layoffs and resignations of top executives, the ending of a partnership with the University of South Florida, and a Department of Justice investigation related to charity care finances in recent years.

Already frustrated, city officials grew more so in early 2019, when then-Bayfront CEO Joe Mullany gave council members a glowing annual report that did not align with problems playing out in public view.

“We’ve had difficult times in the last few years,” Blackmon said. “Orlando Health is the best-situated group to bring (Bayfront) back to the excellence it was once known for.”

Rice called the sale the “only reasonable solution” to the ongoing issues at the hospital.

“Ultimately, the new ownership is what is best for our community,” she said.

The city’s other six council members did not respond to requests for comment Friday. Mayor Rick Kriseman was not available for an interview.

About 15,000 patients were served at Bayfront St. Petersburg in 2018, according to hospital records. As of July 2019, the hospital employed 1,839 people and had 171 open positions.

Officials for Orlando Health declined to be interviewed, instead releasing a statement that said the sale should be final by Sept. 30.

Peter Young, a hospital consultant based in Fort Myers, said Orlando Health, which operates the only Level 1 trauma center in the Orlando area, is in an “expansion moment” of “picking up the skeletal remains” of hospitals in need of rejuvenation.

The purchase of Bayfront St. Petersburg would be the nonprofit’s debut in the Tampa Bay area, and make it so the nonprofit owns 14 total hospitals, according to the Orlando Sentinel. The sale also would mark the second Community Health Systems hospital acquired by Orlando Health, as it purchased Osceola County’s St. Cloud Regional Medical Center in April, the Sentinel reported.

Community Health Systems, based in Tennessee, has sold more than 50 hospitals since 2017 to pay off debt related to its $7.6 billion purchase of Florida’s Health Managed Associates in 2014, according to the National Business Journal.

Bayfront officials declined to be interviewed, and the company released a statement by Sharon Hayes, chief executive officer of the St. Petersburg hospital:

“Orlando Health is well-respected for their work to sustain and enhance medical services, and we are excited to partner with them to benefit our patients and communities,” she wrote. “This is an extraordinary time in health care and together we will continue to provide quality care for our neighbors, friends and family.”


Source:  Tampa Bay Times


AdventHealth plans to build a new facility near its downtown-area campus.

The Altamonte Springs-based nonprofit health system is seeking city of Orlando approval for a 12-story medical office building with a parking garage at a listed address of 225 E. Rollins St.

The project — codenamed “Project Lego” and slated to be built on 15 parcels of land — has not submitted additional project documents with the city of Orlando yet, said city spokeswoman Samantha Holsten.

AdventHealth representatives declined to comment.

The health system is being represented by Orlando-based GrayRobinson law firm for its application seeking site plan approval.

The facility would be built inside AdventHealth Health Village, a 172-acre mixed-use community surrounding AdventHealth’s downtown Orlando campus. The longterm plan for the district includes:

  • Room for up to 800 additional hospital beds
  • 600,000 square feet of medical office space
  • 100,000 square feet of general office space
  • 100,000 square feet of retail space
  • Up to 670 residential units
  • A future hotel

Some of that residential development already has kicked off in the area. Orlando-based Ustler Group of Cos. and Atlanta-based Wood Partners are underway on construction of the 285-unit Alta at Health Village apartment complex at Orange Avenue and Winter Park Street, which is expected to be completed by mid-2021.

Ustler Group of Cos. President Craig Ustler supports having a diverse mix of real estate uses there, because they help enliven the area and add to the hospital’s presence, he told Orlando Business Journal.


Source:  OBJ

Broward Health is poised to expand after purchasing vacant land in Parkland for $14.5 million.

Lucky Land Star Holdings, managed by Agustin Herran in Miami, sold seven acres at the southwest corner of University Drive and Trails End to the North Broward Hospital District, the public body that runs Broward Health.

Herran is part of the family that owns Sedano’s Supermarket. His company acquired the property in deals of $8.8 million in 2012 and $950,000 in 2017.

No development plans have been approved there, but Broward Health could look to build an outpatient center. It has a hospital in neighboring Coral Springs.


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