[Federal Register: February 27, 2004 (Volume 69, Number 39)]
[Page 9282-9288]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr27fe04-24]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 483
[CMS-3121-P]
RIN 0938-AM55
Medicare and Medicaid Programs; Requirements for Long Term Care
Facilities; Nursing Services; Posting of Nurse Staffing Information
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would establish a new data collection and
recordkeeping requirement for skilled nursing facilities (SNFs) and
nursing facilities (NFs). We are proposing that SNFs and NFs complete a
CMS-specified form at the end of each shift, on a daily basis, to post
the full-time equivalents (FTEs) of registered nurses, licensed
practical nurses, licensed vocational nurses, and certified nurse aides
who are directly responsible for resident care. We also propose that
SNFs and NFs use this form to capture and display daily resident census
information. These facilities would also be required to make this
information available to the public upon request.
DATES: We will consider comments if we receive them at the appropriate
address, as provided below, no later than 5 p.m. on April 27, 2004.
ADDRESSES: In commenting, please refer to file code CMS-3121-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
Submit electronic comments to http://www.cms.hhs.gov/regulations/ecomments
or to www.regulations.gov. Mail written comments (one
original and two copies) to the following address ONLY: Centers for
Medicare & Medicaid Services, Department of Health and Human Services,
Attention: CMS-3121-P, P.O. Box 8010, Baltimore, MD 21244-8010.
Please allow sufficient time for mailed comments to be timely
received in the event of delivery delays.
If you prefer, you may deliver (by hand or courier) your written
comments (one original and two copies) to one of the following
addresses: Room 445-G, Hubert H. Humphrey Building, 200 Independence
Avenue, SW., Washington, DC 20201, or Room C5-14-03, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Anita Panicker, (410) 786-5646, or
Jeannie Miller, (410) 786-3164.
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on all
issues set forth in this rule to assist us in fully considering issues
and developing policies. You can assist us by referencing the file code
CMS-3121-P and the specific ``issue identifier'' that precedes the
section on which you choose to comment.
(Because access to the interior of the HHH Building is not readily
available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for persons wishing to retain a proof of filing by stamping
in and retaining an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and could be considered late.
All comments received before the close of the comment period are
available for viewing by the public, including any personally
identifiable or confidential business information that is included in a
comment. After the close of the comment period, CMS posts all
electronic comments received before the close of the comment period on
its public Web site.
Inspection of Public Comments: Comments received timely will be
available for public inspection as they are received, generally
beginning approximately 3 weeks after publication of a document, at the
headquarters of the Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of
each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view
public comments, phone (410) 786-9994.
I. Background
(If you choose to comment on issues in this section, please include
the caption ``BACKGROUND'' at the beginning of your comments.)
Approximately 3 million elderly and disabled Americans receive care
in our nation's nearly 16,500 Medicare- and Medicaid-certified nursing
homes. The care of nursing home residents is a high priority for this
Administration, the Department of Health and Human Services (HHS), and
the Centers for Medicare & Medicaid Services (CMS). Medicare- and
Medicaid-participating
[[Page 9283]]
nursing homes are regulated by sections 1819 and 1919 of the Social
Security Act (the Act), added by Title IV, subtitle C of the Omnibus
Budget Reconciliation Act of 1987 (OBRA '87) (Pub. L. 100-203, December
22, 1987).
The Congress, CMS (then the Health Care Financing Administration
(HCFA)), and the public have been debating the issue of minimum nurse
staffing for nursing homes since the passage of OBRA '87. Nursing home
resident advocates tend to believe that poor care is directly tied to
inadequate staffing. Provider associations are more likely to view
staffing problems as a series of complicated interactions involving the
short supply of nursing home workers and facility differences in
resident acuity and functional limitations.
Section 941 of the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000 (BIPA), effective January 1,
2003, requires SNFs and NFs to post daily, for each shift, the number
of licensed and unlicensed nursing staff directly responsible for
resident care in the facility. This information must be displayed in a
clearly visible place. Additionally, section 941 of BIPA requires the
Secretary of Health and Human Services (the Secretary) to specify a
``uniform manner'' for display of this information.
In November 2001, the Secretary announced an initiative to
highlight efforts addressing quality of care improvement for nursing
homes. The Nursing Home Quality Initiative represents a broad-based
program that includes our continuing regulatory and enforcement
systems, new and improved consumer information, community-based nursing
home quality improvement programs, and partnerships, and collaborative
efforts to promote quality awareness and improvement. Working with data
measurement experts, the National Quality Forum and a diverse group of
nursing home industry stakeholders, CMS adopted a set of nursing home
quality measures. The initiative combines new information for consumers
about the quality of care provided in individual nursing homes with
important resources available to nursing homes to improve the quality
of care in their facilities.
The main components of the initiative are nursing home quality
measures derived from resident assessment data. This information is
routinely collected by nursing homes at specified intervals during a
resident's stay (the Minimum Data Set or MDS). These measures are
additional pieces of available information to help consumers make
informed decisions about nursing home care options. The measures are
also intended to motivate nursing homes to improve care delivery and
encourage discussions about quality between consumers and clinicians.
Although staffing is not an explicit part of this initiative, we
believe that our proposed requirement that all SNFs and NFs post nurse
staffing information and make the information available to the public
is essential to keeping the public informed.
Additional CMS-sponsored quality improvement information may be
found in the ``Nursing Home Compare'' section of our Web site at
http://www.medicare.gov. The primary purpose of Nursing Home Compare is to
provide detailed information about the past performance of every
Medicare- and Medicaid-certified nursing home in the country. Nursing
Home Compare contains the following sections of detailed information:
About the Nursing Home: including the number of
beds and type of ownership.
Quality Measures: providing data on quality
measures, including the percent of residents with pressure (bed) sores,
percent of residents with physical restraints, and more.
Inspection Result Information: including health
deficiencies found during the most recent State nursing home survey and
from recent complaint investigations.
Nursing Home Staff Information: including the
average number of hours worked by registered nurses, licensed practical
or vocational nurses, and certified nursing assistants per resident per
day.
Each nursing home is required to report nursing staff totals to its
State Survey Agency. CMS then receives this information from State
Survey Agencies and converts the nursing staff hours reported into the
number of staff hours per resident per day. We report the total nursing
staff hours per resident per day, and also the total nursing staff
hours per resident per day of registered nurses, licensed practical
nurses, licensed vocational nurses, and certified nursing assistants.
Currently, nursing homes are required to have enough staff to give
adequate care to all residents. There are no current plans to develop a
Federal standard for optimal nursing staff levels. SNFs and NFs must
have at least one registered nurse for at least 8 consecutive hours per
day, 7 days per week, and either a registered nurse, licensed practical
nurse/licensed vocational nurse, and other nursing personnel on duty 24
hours per day, unless a waiver has been granted in accordance with
Sec. 483.30(c) or Sec. 483.30(d). Certain States may have more
stringent nurse staffing specifications than the Federal requirements.
Section 4801(e)(17)(B) of the Omnibus Budget Reconciliation Act of
1990 (OBRA 90) (Pub. L. 101-508, November 5, 1990) required the
Secretary to report to the Congress no later than January 1, 1992 on
the appropriateness of establishing minimum caregiver-to-resident and
supervisor-to-nurse ratios for Medicare- and Medicaid-certified nursing
homes. The purpose of the study was to examine the analytic
justification for establishing minimum nurse staffing ratios for
nursing homes. The study, ``Appropriateness of Minimum Nurse Staffing
Ratios in Nursing Homes,'' (Report to Congress, July 2000) was
conducted in two phases. Phase I of the study (http://www.cms.hhs.gov/Medicaid/reports/rp700hmp.asp
) examined whether an association exists
between staffing levels in nursing homes and quality of care. Phase II
of the study (http://www.cms.hhs.gov/medicaid/reports/rp1201home.asp) examined
the cost and benefits associated with establishing staffing minimums
and expanding the data used in the multivariate analysis from three
States to a more representative national sample. It included an
exploration of more refined case mix classification methods and case
studies to validate Phase I findings, while examining related issues
affecting certified nursing assistant recruitment and retention. In
both Phase I and Phase II studies, the phrase ``nurse staffing''
referenced all three categories of nurses and nurse aides: registered
nurses, licensed practical nurses, and nurse aides/nursing assistants.
Based upon these studies, at this time, we do not believe
sufficient evidence exists to warrant minimum nurse staffing ratio
requirements. However, we do acknowledge the importance of improving
nurse staffing and making accurate information available to the public.
Consistent with our November 2001 initiative to disseminate and publish
reliable information on nursing home quality for Medicare and Medicaid
beneficiaries, our objective is to make staffing information available
to the public to assist them in making informed decisions when choosing
health care providers. With reliable information, nurse-staffing levels
may simply increase due to the market demand created by an informed
public.
The Phase I study found data submitted through the only national
data source of nursing home staffing for
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individual facilities, the Online Survey Certification and Reporting
(OSCAR) system, can be less than accurate, and as such, is misleading
when used as the sole data source for public reporting. The Phase I
study also indicated that nurse staffing could vary considerably during
the course of a year. We have concluded that accurately assessing the
situation will require a longer reporting period. The proposed BIPA
regulation will have the advantage of potentially providing consumers
staffing information on a day-to-day basis. On the other hand, we are
concerned that this self-reported information may be subject to the
same limitations as the current OSCAR system. Hence, the results of the
Phase I study as well as the BIPA provision have served as a catalyst
for CMS to develop a reliable system of public reporting of nurse
staffing.
We believe that additional study is required to develop and test
effective audit mechanisms for public and provider reporting. Some
assessment of the feasibility of collecting accurate data on the time
contributions of volunteers, and facility aides may also be warranted.
Accurate information on facility staffing is necessary but not
sufficient for informing the public. It is also essential that
information that enables the public to make informed judgments about a
facility's reported staffing levels be provided within the context of
the facility's case mix.
Although the Phase II analysis did not identify the most efficient
levels of staffing to maximize quality of care for various case mix
groups, the results did indicate that adverse outcomes were
significantly higher with similar staffing levels among facilities with
more severe case mix. The investigators concluded that higher staffing
levels are warranted for facilities with residents of more profound
acuity and functional limitations. Hence, consumers need to have not
only accurate staffing information about a nursing home they may be
considering, but also need to know how the reported staffing levels
compare to facilities of comparable case mix.
Consistent with the above objectives, we have a current contract
with Abt Associates to present us with options for: (1) Collecting more
accurate staffing data; (2) auditing the data collected; (3)
transmitting the data; and (4) configuring the data so that they can be
informative to the public when placed on our Web site.
It is important to note that the completion of this project will
not result in a self-implementing system of public reporting. On the
contrary, the final product will be a report with options for
implementing such a system.
To date, we have done the following to implement section 941 of
BIPA requirements:
An October 10, 2002 State Agency Directors
letter at http://www.cms.hhs.gov/Medicaid/LTCSP/SC0303.pdf.
Presentation of information at a national
nursing home conference.
Publication of a notice on an electronic
bulletin board used by nursing homes.
A December 24, 2002 letter to nursing homes at
http://www.cms.hhs.gov/medicaid/bipa/bipanh.asp.
II. Provisions of the Proposed Regulations
As discussed in section I of this preamble, we are proposing the
following changes:
A. Nursing Services (Sec. 483.30)
(If you choose to comment on this issue, please include the caption
``NURSING SERVICES'' at the beginning of your comment.)
We are proposing to revise Sec. 483.30 by adding a new paragraph
(e) to require nursing homes to post nurse staffing information in
accordance with section 941 of BIPA, specified as sections 1819(b)(8)
and 1919(b)(8) of the Act. Paragraph (e)(1) would read ``The facility
must, on a daily basis, at the end of each shift, calculate the number
of FTE(s) for the following licensed and unlicensed nursing staff
directly responsible for resident care: registered nurses, licensed
practical nurses or licensed vocational nurses (as defined under State
law), and certified nurse aides.'' We note that neither section
1819(b)(8) nor section 1919(b)(8) specifies what constitutes ``licensed
and unlicensed nursing staff,'' but for the purposes of this proposed
rulemaking, we have interpreted licensed and unlicensed nursing staff
to mean registered nurses, licensed practical nurses or licensed
vocational nurses (as the term(s) are defined under State law), and
certified nurse aides.
In this proposed rule, we would require that only nursing staff
assigned and directly responsible for resident care be captured on the
CMS Daily Nurse Staffing Form. This proposed regulation would not
require data collection on other staff, volunteers, or feeding
assistants. If, for example, the director of nursing also served as a
charge nurse in accordance with Sec. 483.30(b)(3), then he or she
would be counted in the information for his or her shift as a charge
nurse. Otherwise, he or she would not be included except in situations
where the director of nursing performs direct patient care during
instances of staff shortages or absence. Additionally, we are proposing
that the facility collect and display resident census for that day.
While collection of resident census information is not specifically
required under section 941 of BIPA, we believe that collection of this
information is authorized under our general supervisory authority as
defined in sections 1819(f)(1) and 1919(f)(1) of the Act. These
sections require the Secretary to ``assure that requirements which
govern the provision of care [in both SNFs and NFs] * * * and the
enforcement of such requirements, are adequate to protect the health,
safety, welfare, and rights of residents and to promote the effective
and efficient use of public moneys.'' Therefore, we believe the
addition of census information makes the nurse staffing data more
meaningful and useful to the public and is in line with our rulemaking
authority. If only nurse staffing data were presented absent resident
census information, there would be no way for the public to make
inferences regarding the nurse staffing levels in relation to the
resident population. We welcome comments on our proposing the addition
of resident census information on the form.
We are proposing to add a new Sec. 483.30(e)(1) that would specify
the contents and format of the information in accordance with statutory
authority provided by BIPA. Section 483.30(e)(1) through Sec.
483.30(e)(3) would require that the nurse staffing and census public
must--
Contain current nurse staffing numbers (FTEs)
for each shift;
Contain the daily resident census;
Be posted on the CMS Daily Nurse Staffing Form;
and
Be displayed in a prominent place readily
accessible to residents and visitors.
A full time equivalent (FTE) equals one person working full time.
For example, one person working full time (based upon an 8-hour shift)
equals one FTE as does two people each working 4 hours. To determine
FTEs, the facility would multiply the number of staff by the number of
hours worked, and then divide by the number of hours in that shift. For
example, Facility A runs on three 8-hour shifts daily. For the morning
shift, Facility A has ten 8-hour employees and two 4-hour employees;
(10 x 8)+(2 x 4)= 88 staff hours; therefore, 88/8=11 FTEs for that
shift. Facility B runs two 12-hour shifts on the weekends with eight
12-hour employees and three 4-hour employees on the first
[[Page 9285]]
shift; (8 x 12)+(3 x 4)=108 staff hours; therefore, 108/12=9 FTEs for
that shift. These instructions would also be included on the CMS Daily
Nurse Staffing form as described in Appendix A.
Additionally, we would require the SNF or NF to make the collected
information available to the public upon request. We are not proposing
to require the facility to transmit the data to CMS or to the State
Agency at this time. However, we would expect the facility to retain
this information in keeping with standard business practices and be
able to produce it if requested by us, the State Agency, or the public.
To that end, we would also require that the facility retain the Daily
Nurse Staffing Form for a minimum of 3 years, or as required by State
law, whichever is greater. We welcome comments on this proposal and any
suggestions for other timeframes.
B. Daily Nurse Staffing Form
(If you choose to comment on this issue, please include the caption
``DAILY NURSE STAFFING FORM'' at the beginning of your comment.)
We are further proposing a CMS-specific form, the ``Daily Nurse
Staffing Form'' (found in Appendix A of this proposed rule), to be used
by each facility to aid in presenting the nurse staffing information in
a uniform manner. We would expect that this form would be completed at
the end of each shift with a total FTE count of nursing staff who were
actually present and providing direct care to residents. While we would
allow the facility to photocopy a blank form or download it from our
Web site at http://www.cms.hhs.gov and store them electronically or by paper,
we would expect that the actual completion of the FTE count would not
commence until after the staff for that shift had actually worked.
Although we have not proposed a designated person to fill out the form,
we would expect a facility to appoint someone responsible for
presenting the information accurately. We welcome any comments on the
format, design, and completion of the form.
III. Collection of Information Requirements
(If you choose to comment on this section, please include the
caption ``COLLECTION OF INFORMATION REQUIREMENTS'' at the beginning of
your comments.)
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its
usefulness in carrying out the proper functions of our agency.
The accuracy of our estimate of the information
collection burden.
The quality, utility, and clarity of the
information to be collected.
Recommendations to minimize the information
collection burden on the affected public, including automated
collection techniques.
We are soliciting public comment on each of these issues for the
following sections of this document that contain information collection
requirements:
Section 483.30 Nursing Services
In summary, section 483.30(e)(2) requires that long-term care
facilities use the CMS-specified form (Daily Nurse Staffing Form) to
enter the information specified in paragraph (e)(1) of this section;
and to post the completed Daily Nurse Staffing Form in a prominent
place readily accessible to residents and visitors.
The burden associated with this requirement is the time and effort
it would take for the facility to complete the form and post it.
Currently, there are 16,473 participating nursing homes. We estimate a
total of 5 minutes to fill in the information per day. We further
estimate that it will require facilities 30.42 hours each on an annual
basis to meet these collection requirements.
Section 483.30(e)(3) requires the facility to make the information
required in Sec. 483.30(e)(1)-(2) available to the public and to
maintain documentation.
The burden associated with this requirement would be the time it
would take for the facility to retrieve the documented information
being requested. We believe this requirement to be usual and customary
business practice; therefore, the burden for this collection
requirement is exempt under 5 CFR 1320.3(b)(2)and 5 CFR 1320.3(b)(3).
If you comment on these information collection and recordkeeping
requirements, please mail copies directly to the following:
Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Regulations Development and
Issuances Group, Attn: Dawn Willinghan, CMS-3121-P, Room C5-14-03, 7500
Security Boulevard, Baltimore, MD 21244-1850; and
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington, DC
20503, Attn: Brenda Aguilar, CMS Desk Officer, baguilar@omb.eop.gov.
Fax (202) 395-6974.
IV. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents, we are not able to provide
individual responses to comments submitted. We will consider all
comments we receive by the date and time specified in the DATES section
of this preamble, and, if we proceed with a subsequent document, our
responses to all timely public comments will appear in the preamble of
that document.
I. Regulatory Impact Statement
(If you choose to comment on this section, please include the
caption ``REGULATORY IMPACT ANALYSIS'' at the beginning of your
comments.)
We have examined the impact of this rule as required by Executive
Order 12866 (September 1993, Regulatory Planning and Review), the
Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96-354),
section 1102(b) of the Act, the Unfunded Mandates Reform Act of 1995
(Pub. L. 104-4), and Executive Order 13132.
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). A regulatory impact
analysis (RIA) must be prepared for major rules with economically
significant effects ($100 million or more in any one year). This rule
does not reach the economic threshold and thus is not considered a
major rule.
The RFA requires agencies to analyze options for regulatory relief
of small entities. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and government agencies.
Most hospitals and most other providers and suppliers are small
entities, either by virtue of their nonprofit status or by having
revenues of $6 million to $29 million in any one year. Individuals and
States are not included in the definition of small entities. The only
burden associated with this rule is the information collection burden
associated with collecting and posting nurse staffing
[[Page 9286]]
information. Since this burden is minimal, as we have described in
Section III of this preamble, we are not preparing an analysis for the
RFA because we have determined that this rule would not have a
significant economic impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. We are not preparing an
analysis for section 1102(b) of the Act because we have determined that
this proposed rule would not have a significant impact on the
operations of a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule that may result in expenditure in any one year by
State, local, or tribal governments, in the aggregate, or by the
private sector, of $110 million. The only burden associated with this
rule is the information collection burden associated with collecting
and posting nurse staffing information. Since this burden is minimal,
as we have described in Section III of this preamble, this proposed
rule would have no consequential effect on the governments mentioned or
on the private sector.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. Since this regulation would not impose any costs on State
or local governments, the requirements of Executive Order 13132 are not
applicable.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 483
Grant programs-health, Health facilities, Health professions,
Health records, Medicaid, Medicare, Nursing homes, Nutrition, Reporting
and recordkeeping requirements, Safety.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR part 483 as follows:
PART 483--REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES
1. The authority citation for part 483 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 483.30 is amended by adding paragraph (e) to read as
follows:
Sec. 483.30 Nursing services.
* * * * *
(e) Posting of nurse staffing information. (1) Information
requirements. The facility must--
(i) On a daily basis, at the end of each shift, calculate the
number of FTE(s) for the following licensed and unlicensed nursing
staff directly responsible for resident care:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as
defined under State law); and
(C) Certified nurse aides.
(ii) On a daily basis, determine or verify the resident census.
(2) Form use and posting requirements. The facility must on a daily
basis--
(i) Use the CMS-specified form (Daily Nurse Staffing Form) to enter
the information specified in paragraph (e)(1) of this section; and
(ii) Post the completed Daily Nurse Staffing Form in a prominent
place readily accessible to residents and visitors.
(3) Public access and data retention requirements. The facility
must--
(i) Upon request, make the Daily Nurse Staffing Form(s) available
to the public;
(ii) Maintain the Daily Nurse Staffing Form(s) for a minimum of 3
years, or as required by State law, whichever is greater.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance.)
Dated: June 27, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
Approved: October 21, 2003.
Tommy G. Thompson,
Secretary.
The following appendix will not appear in the Code of Federal
Regulations.
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