ࡱ> %` D:bjbj E̟̟f1$===8 >T`>$n.X?X?(???@@@>WLL$h^[I@@[I[I??4(KKK[Ip??K[IKK~8 ?L? `0?=I|۷X+>0n3bGJbb4 @>CKEtF@@@YK^@@@n[I[I[I[I$$H$ld5$Hl5$$$ DATE: November 4, 2008 TO: Brenda M. Harvey, Commissioner, DHHS THROUGH: Catherine Cobb, Director, Division of Licensing and Regulatory Services FROM: Phyllis Powell, Manager, Certificate of Need Unit Steven R. Keaten, Healthcare Financial Analyst Larry Carbonneau, Healthcare Financial Analyst SUBJECT: Proposal by Houlton Regional Hospital to renovate and redesign its existing Emergency Department, Nuclear Medicine, Radiology, and Cardio/Pulmonary Rehabilitation space in at an estimated capital cost of $4,016,240. ISSUE ACTIVATED BY: The referenced proposal requires Certificate of Need approval as defined in "The fb88 Certificate of Need Act of 2002," 22 MRSA Section 326 et seq., as amended. REGISTERED AFFECTED PARTIES: NONE I. BACKGROUND: Holton Regional Hospital, a Critical Access Hospital, is a not-for-profit corporation located at 20 Hartford Street, Houlton, fb88. It is licensed for 25 acute care and 28 long term care beds. Its primary service area is Southern Aroostook County. This hospital serves a mostly rural population of 20,000. The Division of Licensing and Regulatory Services, Medical Facilities Unit, confirms that Houlton Regional Hospital is a general hospital licensed in the State of fb88 and is fb88Care and Medicare certified. This hospital is not accredited by the Joint Commission. The hospital plans to fund a portion of the project using an estimated $1 million of equity with the balance financed by the issuance of tax-exempt bonds through the fb88 Health and Higher Educational Facilities Authority (MHHEFA) amortized over 30 years. The hospital has not undertaken any CON projects for several years. In December 2005 they received a Not-Subject-To-Review (NSTR) determination to expand the rural health clinic at a capital cost of $700,777. In January 2006 they received a NSTR determination for a joint venture with NEHE-MRI, L.L.C. to provide MRI services at a capital cost of $1,180,000. III. HIGHLIGHTS: Letter of Intent dated December 12, 2007 Subject to CON review letter issued December 17, 2007 Technical Assistance Meeting held February 6, 2008 Application filed and certified complete March 21, 2008 Application placed in review cycle March 21, 2008 Public informational meeting held April 15, 2008 Public hearing held June 17, 2008 Record closed July 17, 2008 Preliminary analysis released September 19, 2008 Preliminary analysis published in newspapers September 26, 2008 Record closed October 10, 2008 IV. PUBLIC COMMENTS RECEIVED IN RESPONSE TO THE PRELIMINARY ANALYSIS: Public comments were received relative to this application as follows: 1) On May 13, 2008 a request for Public Hearing was submitted by Mary McCready (citizen). This letter was signed by 31 people. The letter questioned why the hospital decided to spend money on this project rather than spending the money to become a Tier 1 hospital. 2)MSEA Local 1989 posted and distributed a flyer stating: At the public hearing listed below, please urge Houlton Regional Hospital to make the improvements necessary to become a Tier 1 hospital. They also state, in this flyer: MSEA-SEIU members who use Houlton Regional currently are ineligible for $200/$400 deductible waivers available to MSEA-SEIU members whose hospitals secured the Tier 1 designation (not dated). 3) A Public Hearing was held June 17, 2008. Three individuals spoke at this hearing. No on spoke in opposition, rather those who spoke also wanted other improvements, including Tier 1 status. One respondent (Sharon Swimm) knew of 150 members that were affected. (CONU believes this number to be much greater as other insured state employees under the plan were not considered such as state retirees, fb88 State Police and other bargaining units considered as employees under the plan not attributed to MSEA/SEIU members). It is unclear how many total state employees and retirees live within Houlton Regional Hospitals service area but a projection by CONU with help from the Bureau of Insurance conservatively estimated 5 % of HRHs insurance revenues are attributable to the plan. 4) According to the transcript of the Public Hearing, hospital staff present at the meeting explained that they are working toward Tier 1 status and would continue to do so. Barriers are the cost and that the requirements for Tier 1 status change over time. They also stated that the priorities targeted in this application are patient access, infection control, patient safety, and patient privacy. 5) CONU released a Preliminary Analysis on September 19, 2008. In this analysis there was a condition mandating that Houlton Regional Hospital attain Tier 1 status prior to this project becoming operational. A letter of support for the project and the condition to become a Tier 1 hospital was received on October 10, 2008. This letter was signed by 43 citizens. V. CONU ANALYSIS/HOUTON REGIONAL HOSPITAL RESPONSE TO PRELIMARY ANALYSIS Applicants Response The applicant, Houlton Regional Hospital, submitted a written response to the preliminary analysis dated October 10, 2008. In that response HRH speaks against the condition specified in the preliminary analysis that HRH must become a Tier 1 Hospital under the qualifications of the fb88 State Health Insurance Plan before this project can become operational. The reasons given by the applicant is Tier 1 status is (i) unrelated to this project, (ii) arbitrary and capricious, and (iii) discriminatory. The applicant states that this project is a project that relates to patient safety and privacy in the ED and Nuclear Medicine space. Tier 1 status bears no rational relationship to the needs sought to be addressed by the project. The Tier 1 initiative (i) is a voluntary program, (ii) is not required by any CON regulation or statute, and (iii) has never been a condition imposed on any other CON applicant. It is discriminatory against non-state employee patients that would lose out of care if this project was not able to go forward due to Tier 1 status. The applicant states to achieve Tier 1 status HRH would currently have to satisfy two remaining requirements: (i) acquisition and implementation of a physician order entry system, as part of Houltons existing electronic medical records system, and (ii) implementation of an after-hours, off site medication review system. The applicant feels its existing process for reviewing medication errors is exceptionally safe, reliable and efficient. Given in the past 20 months, HRH reports that only 2 errors that might have been prevented by pharmacist review of medication orders after hours. HRH is reluctant to undertake the major cost of implementing medication review process just because Tier 1 requires the prescribed process. In addition, HRH states Tier 1 status can change from year to year that would require HRH to comply with Tier 1 status or risk civil fines from CONU and loss of reimbursement. CONU Response Tier 1 hospital status is something new within the last couple years for employees that are insured under the fb88 State Employee Health Insurance Program. To CONUs knowledge no Certificate of Need has been issue to a hospital facility that was not deemed to be Tier 1 status since it was developed. As of October 1, 2008 a review of Tier 1 approved hospitals in fb88 included 27 of the 39 acute care hospitals including 8 critical care hospitals. It would not be arbitrary and capricious to attach a condition upon approval of a CON as the Commissioner has the authority under CON rules to attach conditions. Such a condition would improve access to quality care. As a critical access hospital, HRH gets an advantage on reimbursement of expenses that would allow it not to bear the costs to implement this condition. It is not known whether other patients insured by other insurance companies also require similar quality measures. Therefore HRH did not make its case that it would be discriminatory towards other insured patients. In the preliminary, CONU made the following determinations: CONU determined in the preliminary analysis that the Commissioner find that the applicant is fit, willing and able to provide services at the proper standard of care. CONU determined in the preliminary analysis that the Commissioner find that HRH has met its burden to show that the proposed project demonstrates economic feasibility. CONU determined in the preliminary analysis that the Commissioner find that HRH has met its burden to show that the proposed project demonstrates economic feasibility. CONU determined in the preliminary analysis that the Commissioner find that HRH, subject to all recommended conditions, will meet its burden and will demonstrate that the proposed project meets the public need. CONU determined in the preliminary analysis that the Commission find that HRH has met its burden by demonstrating that the proposed project is consistent with the orderly and economic development of health facilities and health resources for the State. CONU determined in the preliminary analysis that the applicant has satisfied a few of the State health Plan priorities and that the Commissioner find that the applicant has met its burden to show that this project is consistent with the State Health Plan. The priorities satisfied are: This project will directly and unambiguously protect patient safety. This project does consolidate some services. The applicant is in the process of implementing an electronic medical records system. The impact for regional insurance premiums is less than 0.5 %. CONU determined in the preliminary analysis that Commissioner find that HRH has met its burden, subject to the conditions for approval, that this project will ensure high quality outcomes and will not negatively affect the quality of care delivered by existing services providers. CONU determined in the preliminary analysis that the Commissioner find that HRH has met its burden to demonstrate that inappropriate increases in Service Utilization will not occur. CONU determined in the preliminary analysis that the Commissioner find that HRH has met its burden to demonstrate that there are sufficient funds in the Capital Investment Fund (CIF) to fund this project. CONU determined in the preliminary analysis that the Commissioner approve the application subject to the following conditions: The applicant must submit an implementation plan to meet the requirements for a Tier One Hospital that are in effect as of the date of the Commissioners decision. This plan is to be submitted prior to commencement of construction. The applicant must report for the first three full years of operation the following statistics: The hospital infection rates, slip and fall rates, ED elopement rates and ED departures against medical advice rates. The applicant will be required to state a firm commitment to introduce green technologies wherever possible when constructing the project. The applicant will be required to include negative pressure capabilities as comments on by Dora Mills, MD (MeCDC/DHHS). CONU recommends to the Commissioner that all conditions of approval stand, with one exception. CONU recommends that HRH submit an implementation plan to meet the requirements for a Tier 1 hospital that are in effect as of the date of the commissioners decision. VII. RECOMMENDATION: The Certificate of Need Unit recommends this proposal be Approved subject to the following conditions. The applicant submit an implementation plan to meet the requirements for a Tier 1 hospital that are in effect as of the date of the commissioners decision. This plan is to be submitted prior to commencement of construction. The applicant must report for the first three full years of operation the following statistics: The number of hospital infection rates, slip and fall rates, ED elopements rates and ED departures against medical advice rates. The applicant will be required to state a firm commitment to introduce green technologies wherever possible when constructing this project. The applicant will be required to include negative pressure capabilities as comments on by Dora Mills, MD (fb88 CDC/DHHS) Capital Costs $ 3,851,886Capital costs as Approved $ 192,950Contingency $ 4,044,836Total Approved Capital CostsIncremental 3rd Year Costs$ 392,569Approved Incremental Costs Capital Investment Fund $ 322,855Approved CIF FYE 2008     page2 Houlton Regional Hospital-PAGE5-ED and Nuclear Medicine Construction/Renovation  BRIEFING MEMO Houlton Regional Hospital Emergency Department and Nuclear Medicine Construction/Renovation BJKY, 5 7 < B \ ^   ȼȼȤxmeex]RhhNtCJaJhnCJaJhWuZCJaJhhvCJaJhh8CJaJhhbCJaJhh"CJaJhh<CJaJhh"5CJaJhhGgCJ\aJhh<5CJaJhhGg5CJaJhhGgCJaJh Qh QCJaJh Q5CJaJhhQ@5CJaJAB, -   ~|) )^`gd!* pp0!TTd&d P ^T`gd~:* v"^`" Tdgd<* pp0!Td^`gd<gd|]$ Tgd<d TdgdsCf9C:  "  . / 3 N + , 0 1 |    8 R s t һ޲uj__WhW}CJaJhhACJaJhhOACJaJhhQ@6CJaJhh2CJaJhh"CJaJhhm>CJaJhWCJaJhnCJaJh hm>aJhh2Z5CJaJhhbCJaJhh&?5CJaJhhGgCJaJhhGg5CJaJhhQ@CJaJ! , - 9 : ;<z!Jph^hgdgd)Ugd  & Fgd)UgdW & FgdQ@gdzz & Fgd2gdm>)t :;<w2 ɾԥynfn^SyHnf^SHhh-CJaJhhWhCJaJh CJaJhFCJaJhhHCJaJhhGgCJaJhhGg5CJaJhh2Z5CJaJh 5CJaJhCJ\]aJhhdCJ\]aJh=CJ\]aJhj2CJ\]aJh\uCJ\]aJh CJ\]aJh h CJ\]aJh\uCJaJ3@z  !"059;kloru⠶⫶̘⅘}̘}̘hJCJaJhwCJaJhhRCJaJhPCJaJhhWhCJaJhh'CJaJhhDCJaJhh1CJaJhhHCJaJhh-CJaJhFCJaJhhhlCJaJhhGgCJaJ-   UVWfFRSTUWǻzzrjbjZRZjZjbjhl0CJaJhfCJaJh>CJaJh)dgCJaJh?YCJaJhlCJaJhQpCJaJhz;CJaJhz;hz;CJaJhz;5CJaJhWh5CJaJhhWh5CJaJhh2Z5CJaJhh1CJaJhh[CJaJh[CJaJhvCJaJhPCJaJhhvCJaJ  VWTUijhi###gd-gdWh gd:23h^hgdW !hijlml;,ghi𴬤ؤؤ||qf]h3^U5CJaJhhWhCJaJhhlCJaJhIbCJaJh>CJaJhGgCJaJhfCJaJhM-~CJaJhX:CJaJhlCJaJh3 CJaJhX:h Q5CJaJhc9KCJaJh3^UCJaJhcsCJaJh&"CJaJhl0CJaJhhCJaJh8>8CJaJ";!"####$%/&=&C&W&Z&&&&&&='F''2)t)x)))++ᱩvvhv]hzzCJ\]aJhwbThwbTCJ\]aJhwbTCJ\]aJhwbTCJaJhqCJaJhnM*CJaJh QCJaJh%%CJaJhCJaJhoCCJaJh5TCJaJh8rCJaJhzzCJaJhsNCJaJh>CJaJh5Th5T>*CJaJh>5CJaJh2Z5CJaJ$#''''((1)2)**+++++++,-B----.. & FgdwbTgdwbTh^hgdwbT & FgdwbTgd-.//v0w00012B3334444A5B5#677 8 8 & F%gdq ^`gd0gdXYCgd- & F)gdsCh^hgdwbTgdwbT & FgdwbT+0333344444555@5A5B5P5n55!6 8 8 888ʿ|tlhddh]UlLh\]aJhCJaJ hGhqh QhqhqCJaJhXCJaJhq5CJaJhnM*hX5CJaJhhXCJaJhhXYCCJaJhhXYC5CJaJhh5CJaJhh2CJaJhkACJaJh QCJaJhnM*CJaJhwbTCJaJ h7hsChsChwbTCJ\]aJ 888888888888888*8+8,8!E p$If^`gdlP$E$ p$If^`a$gdf^lPgdXYC88-8.888V8W8Z8\8^8b8r8s8}8888889999 9/979]9^9e9f9g9i9j9l9m9o9p9r9s9w9x9y9z9{99赮|xhzzhzzOJQJhzzOJQJjhzzOJQJUhm`jhm`Uh hGg5aJ hX5aJh h\aJhhf^CJH*\aJh CJ\aJhqCJ\aJhZCJ\aJhhf^CJ\aJh h \]aJ,,8-898:8U8pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR ytU8V8c8d8q8pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR ytq8r8~888pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt88888pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikdC$$IflF HVbW t6    44 laR yt88888pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt888888ppNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt88888pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikdj$$IflF HVbW t6    44 laR yt88888pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd+$$IflF HVbW t6    44 laR yt88888pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt88 9999ppNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt99!9"989pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikdR$$IflF HVbW t6    44 laR yt8999:9;9<9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt<9=9>9?9@9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd$$IflF HVbW t6    44 laR yt@9A9B9C9D9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikdy $$IflF HVbW t6    44 laR ytD9E9F9G9H9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd, $$IflF HVbW t6    44 laR ytH9I9J9K9L9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd $$IflF HVbW t6    44 laR ytL9M9N9O9P9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd $$IflF HVbW t6    44 laR ytP9Q9R9S9T9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikdE $$IflF HVbW t6    44 laR ytT9U9V9W9X9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd $$IflF HVbW t6    44 laR ytX9Y9Z9[9\9pNN!E p$If^`gdlP$E$ p$If^`a$gdf^lPikd $$IflF HVbW t6    44 laR yt\9]9^9f9h9i9k9l9n9o9q9r9mkkkkkkkkE p^`gd*gE p^`gdikd^$$IflF HVbW t6    44 laR yt r9{9|99999999999zojJgdQ@ $da$gdQ@IgdQ@$[kd$$Ifl4FH$vH    4 lalf4 $$$Ifa$gdaO $$$Ifa$$$Ifd 99999999999999@:B:C:D:h hGg5aJhm`hzz5>*CJ hzz]htmHnHuhzzjhzzU hzz6 haOhzz9@:A:B:C:D:E p^`gd*g$ $dxa$gdQ@C 00h&PP:p2<0/ =!"#$% $$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W / aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt$$IfR !vh5b55W #vb#v#vW :VPl t065b55W aR yt~$$Ifl!vh55v5H#v#vv#vH:V l455v5H4alf4QH@H Normal CJOJQJ_HkHmH sH tH D@D Heading 15>*OJQJkHB@B Heading 2x5OJQJkHF@F Heading 3 h^h5OJQJkHF@F Heading 4 h^h>*OJQJkHJ@J Heading 5 ^5CJOJQJkHJ@J Heading 6 ^>*CJOJQJkHJ@J Heading 7 ^6CJOJQJkHJ@J Heading 8 ^6CJOJQJkHJ @J Heading 9 ^6CJOJQJkHDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List >@> Normal Indent ^>'> Comment ReferenceCJ88  Comment TextCJBB TOC 8 X !]^BB TOC 7 X !]^BB TOC 6 X !]^BB TOC 5 X !@ ]^@ BB TOC 4 X !p]^pBB TOC 3 X !]^BB TOC 2 X !]^:: TOC 1 X !]22 Index 7 p^p22 Index 6 ^22 Index 5 ^2 2 Index 4 8^82 2 Index 3 ^2 2 Index 2 h^h* * Index 1 .(@. Line Number6!6  Index Heading"4 @24 Footer # !4@B4 Header $ !D&QD Footnote ReferenceCJEH:b:  Footnote Text&CJ>*q> Endnote ReferenceH*ROR Norm Indent Quote(^`@O@ Intro)`d^``POP Cover,* pp0!0d^`0^O^ Quote:+ # p@ P !d^nOn IndentQuote=, & p@ P !d^2O2 IndentQuot1-(O( Quot I.HOH Findings/0^`0 OJQJkHDOD Normal10d` OJQJkHLK@L Salutation10^`0 OJQJkHLO"L in2$8dh^8`a$B*OJQJkHNO2N Normal Indent Block3^\OB\ Norm Indent Quote 6 pt4x^`PORP Normal Heading Bold 5$a$5:Ob: Normal No Space6XOrX Document78]^8OJQJ_HkHmH sH tH ,O, Document 8JOAJ Normal Quote Bullet 9p^p2Q@2 Body Text 3:HC@H Body Text Indent;hx^h@O@ Default Text< mHnHuHOH InitialStyle@B*CJOJQJkHxOx OmniPage #10)> D'(2d ]2^CJOJQJkHmHnHurOr OmniPage #11#? 2%J2d]J^2CJOJQJkHmHnHu O "6O6 singleA$a$OJQJ8O"8 norm B*$ @CJVR@2V Body Text Indent 2Chx7$8$H$^h@B@B@ Body TextDB*OJQJph84@R8 List 4E^`PP@bP Body Text 2 F[d5$7$8$9DH$^[ZT@rZ Block Text,G8dx5$7$8$9DH$]^8`S@` Body Text Indent 3"H5$7$8$9DH$^`<>< TitleI$da$ 5>*CJ FJ@F SubtitleJ$dxa$ 5>*CJ83@8 List 3K8^8`82@8 OTList 2L^`<Z@< ]> Plain TextM CJOJQJV^@V O Normal (Web)Ndd[$\$OJ PJ QJ ^J aJHH 8Kc Balloon TextOCJOJ QJ ^J aJr@r # Table Grid7:VP0POJQJD2 E20E20AB,-,-9:;<z! J p   V W T U ijhi 1!2!""#######$%B%%%%&&''v(w((()*B+++,,,,A-B-#.// 0 000000000000000*0+0,0-090:0U0V0c0d0q0r0~00000000000000000000000000000 11111!1"18191:1;1<1=1>1?1@1A1B1C1D1E1F1G1H1I1J1K1L1M1N1O1P1Q1R1S1T1U1V1W1X1Y1Z1[1\1]1^1f1h1i1k1l1n1o1q1r1{1|11111111111@2A2B2E20000*00000*0*0*0)0)0)00 00 00 00 00000000000000000000000000000000000000000000 00 00 00 0000000 0 0# 0# 0# 0#0 0 0 0 0 0 0 0 0) 0) 0) 0) 00000000% 0% 0% 0% 0000000000000000E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0 E0 E0 0 E0E0@0X00@0X00@0X00@0X00@0@0@$0 @$0 @$0@$0 @0 @$0@0@I0@0@J0@0@$0@0X00AB,-,-! p   hi 0,0U0q00000000181<1@1B1D1F1H1J1L1N1P1R1T1V1X1Z1\1^1E2@0@0@0@0@*0@0@0@0@0@*0@*0@*0@)0@)0@)0@0@ 0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0Z0U1V(,Z0W1X`,Z0Y1Z,Z0[1\,Z0]1^-Z0_1`@-Z0a1bx-Z0c1d-Z0e1f-Z0g1h .Z0i1jX.Z0k1l.Z0m1n.Z0o1p/Z00Z0r1Z00Z0t1Z00Z0v1Z00Z0x1Z00Z0z1Z00Z0|1Z00Z0~1@00 ooo t W+89D:!#$%'(+-D #. 8,8U8q88888888989<9@9D9H9L9P9T9X9\9r99D:"&)*,./0123456789:;<=>?@ABCEC: 168!!@  @H 0(  0(  B S  ?.  4 OJ $ LO:i /  L     LM6   01Dݭ T01 n"4D <,| \i \ (0>(TB9|,=@ !m "ܤ#Q$:@%,[8& `0'\?@(4<@)*TQBBJS %ZZnwrrzG)G)L)P)|1|1111111E2      !"$#%(&')*,+-IR[[$--lu||yK)O)X)X)11111111E2     !"$#%'(&)*,+-=+*urn:schemas-microsoft-com:office:smarttags PlaceType=-*urn:schemas-microsoft-com:office:smarttags PlaceName9.*urn:schemas-microsoft-com:office:smarttagsplace9 *urn:schemas-microsoft-com:office:smarttagsState8!*urn:schemas-microsoft-com:office:smarttagsCity:"*urn:schemas-microsoft-com:office:smarttagsStreet;#*urn:schemas-microsoft-com:office:smarttagsaddress \.--+--+.--+#"! --+ .-.-+.--+-.-+. -.-+.--+-.-+e1f1f1h1h1i1i1k1l1n1o1q1r1z111B2E2B$F$e1f1f1h1h1i1i1k1l1n1o1q1r1z111B2E23,,99+--!.!.]1]1e1f1f1h1h1i1i1k1l1n1o1q1r1z1|1111111B2E2e1f1f1h1h1i1i1k1l1n1o1q1r1B2E2)l`kx86d?LkTdrzj)zJ B UQԊ*)> zJ r1JQ F&cTtr2ǦiD`kI8s>f$%"zJ  &@qc*F&cLD`20/>7Ve^X7 "?+80, M@@q">@x%FPIzJ iTLGcyM&,>aP ?* Q<fKnXr?99YD!Ufsxh86nnptl9/r 9+]cs8_cs&,>$7cu>V#|Iv!>}D88^8`5o(hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h ^`hH)h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`OJQJo(hHh   ^ `OJQJo(oh   ^ `OJ QJ o(h xx^x`OJQJo(h HH^H`OJQJo(oh ^`OJ QJ o(h ^`OJQJo(h ^`OJQJo(oh ^`OJ QJ o(h ^`hH.h pp^p`hH.h @ L@ ^@ `LhH.h ^`hH.h ^`hH.h L^`LhH.h ^`hH.h PP^P`hH.h  L ^ `LhH.$ $ ^$ `o()   ^ `o(hH. L^`LhH. ^`hH. dd^d`hH. 4L4^4`LhH. ^`hH. ^`hH. L^`LhH.h ^`5hH)h^`OJQJo(hH$ $ ^$ `5o()h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH. hh^h`hH) ^`hH) 88^8`hH) ^`hH() ^`hH() pp^p`hH()   ^ `hH. @ @ ^@ `hH.   ^ `hH.h 88^8`hH)h ^`hH.h  L ^ `LhH.h   ^ `hH.h xx^x`hH.h HLH^H`LhH.h ^`hH.h ^`hH.h L^`LhH.h vv^v`5hH)h^`OJQJo(hH$ $ ^$ `5o()h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH)h^`OJQJo(hHh pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.$ $ ^$ `o()   ^ `hH. L^`LhH. ^`hH. dd^d`hH. 4L4^4`LhH. ^`hH. ^`hH. L^`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJ QJ o(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJ QJ o(hHh FF^F`5hH)h^`5OJQJo(hHh   ^ `5hH)h   ^ `hH.h ^`hH.h VLV^V`LhH.h &&^&`hH.h ^`hH.h L^`LhH.88^8`5o(hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h vv^v`5hH)h^`OJQJo(hH$ $ ^$ `5o()h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.$ $ ^$ `o()   ^ `hH. L^`LhH. ^`hH. dd^d`hH. 4L4^4`LhH. ^`hH. ^`hH. L^`LhH. L^`L5hH. ^`hH) 88^8`hH) ^`hH() ^`hH() pp^p`hH()   ^ `hH. @ @ ^@ `hH.   ^ `hH.^`o() ^`hH. ~L~^~`LhH. N N ^N `hH. ^`hH. L^`LhH. ^`hH. ^`hH. ^L^^^`LhH.h hh^h`hH)h ^`hH)h 88^8`hH)h ^`hH()h ^`hH()h pp^p`hH()h   ^ `hH.h @ @ ^@ `hH.h   ^ `hH.h^`OJQJo(hHh ^`o(hH.hpp^p`OJ QJ o(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJ QJ o(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJ QJ o(hHh ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH)h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`5hH)h^`OJQJo(hH$ $ ^$ `5o()h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.$ $ ^$ `o()88^8`5o(hH. L^`LhH. ^`hH. dd^d`hH. 4L4^4`LhH. ^`hH. ^`hH. L^`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH)h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`OJQJo(hHh ^`o(hH.hpp^p`OJ QJ o(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJ QJ o(hH^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h FF^F`5hH)h^`5OJQJo(hHh   ^ `5hH)h   ^ `hH.h ^`hH.h VLV^V`LhH.h &&^&`hH.h ^`hH.h L^`LhH.h ^`hH)h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.^`o() ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJ QJ o(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJ QJ o(hHh ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h ^`hH)h ^`hH.h$ $ ^$ `OJQJo(hHh @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJ QJ o(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJ QJ o(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJ QJ o(hH)d?LfKnX^X7M|>/rLD`2BxhI8s*)> x!Uf2V#|?* Qr1">@cyM8_cs &, M@+]cs!>}pT>7iTLc*PI) riDl$%"nnpTd99YaP"?<$7cuU))                           u >q                        AΌ                 Nv:\}T                          D~v;AΌ                                                    P                                                      %;fC[zJ0Na$I;}k Yhl8r7is& 7 HN  . k z & KB pt  ^d)'i> PN07Ozz_t=HaOc)Xk!m>m~~0s(c9A"$7ZCy{F -!("W"xb"x#QP$|]$%%+%T3%>%8r889%9-:7:;|; <<)Q<Z<8=d=j=%>Uo>~> ?&?0?J}i}~}M-~j~>/_V "[-02=+Km7 yF+d8&lqU{Rl5Aw[a:^Ub&"0sNt"09dFmm9UPU!27A{ @(DX|O)1?2ACX]|fyN< R>FJY\~-'E- /VQ22)[ z$d:I)VazH<>N 9*9&9IU\#3 #ETn'8M ScsH?'~$RQp8mZh+e]uKO`d;+ ZsR/F_DR`4rovd|:N&QT'tYF<Kw@3(wKW}>kO9~:Hn 3l0\Ct)*7Nxf)C>& 2S5]>^Ce [A~"9dJ6#/2M&I-gd eMdQWmv)btj -8v_7rt*vKH[^#l+6w"A%Am25E`q+P8K?<@w"1Tb@8X:2kA0J= ?]-X/l{Dd9Q)UrSV LOs(sN`y P Sf}EPYQRY W?Y+pkt))+kzr 1?1@1A1B1C1D1E1F1G1H1I1J1K1L1M1N1O1P1Q1R1S1T1U1V1W1X1Y1Z1[1\1]1f1|11111E2y@front-by-RaeNe09:HP Business Inkjet 2800 PCL 6front-by-Raefront-by-RaepC od,,LetterDINU"4<`b6<IUPH dLetter [none] [none]Arial4Pd?LEAH.SMITH<Automatic>300dpidx t m WINWORD.EXEfront-by-RaepC od,,LetterDINU"4<`b6<IUPH dLetter [none] [none]Arial4Pd?LEAH.SMITH<Automatic>300dpidx t m WINWORD.EXE,D2@Unknown Gz Times New Roman5Symbol3& z Arial71 CourierW5 MS LineDrawCourier NewcCG Times (W1)Times New RomanM" Univers (W1)Arial9Palatino?5 z Courier NewI& ??Arial Unicode MS5& zaTahoma;Wingdings"Vh+f+fo$F_*Y_*Y!V4dM1M1 2qVHX ?KB 2uC:\Documents and Settings\Phyllis.Powell\Local Settings\Temporary Internet Files\OLK1D\2008 EMMC Briefing Memo FD.dot BRIEFING MEMOPhyllis.Powell Leah.Smith)                           ! " # $ % & ' ( Oh+'0 0< \ h t BRIEFING MEMOPhyllis.Powell 2008 EMMC Briefing Memo FD.dot Leah.Smith2Microsoft Office Word@F#@l?>@b@?@b@?_*՜.+,0 hp|  YM1' BRIEFING MEMO Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFHIJKLMNPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FpH>1?Data G1TableOWordDocumentESummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q