9282 Federal Register / Vol. 69, No. 39 / Friday, February 27, 2004 / Proposed Rules 

Actions Compliance Procedures 

(4) Only incorporate Cessna Accessory Kits 

identified in paragraph (d) of this AD that 

have been inspected and modified in accordance with paragraphs (f)(1), (f)(2), (f)(2)(i), 

and (f)(2)(ii) of this AD.

As of the effective date of this AD ................... Follow Cessna Single Engine Service Bulletin 

SEB86–8, Revision 1, and Cessna Multi-engine Service Bulletin MEB 86–22, Revision 

1, both dated July 28, 2003. 

(g) If you did the actions of this AD using 

Cessna Single Engine Service Bulletin 

SEB86–8 and Cessna Multi-engine Service 

Bulletin MEB86–22, both dated November 

21, 1986, no further action is required as long 

as you used shoulder harness adjuster, P/N 

443030–401. 

May I Request an Alternative Method of 

Compliance? 

(h) You may request a different method of 

compliance or a different compliance time 

for this AD by following the procedures in 14 

CFR 39.19. Unless FAA authorizes otherwise, 

send your request to your principal 

inspector. The principal inspector may add 

comments and will send your request to the 

Manager, Manager, Wichita Aircraft 

Certification Office (ACO), FAA. For 

information on any already approved 

alternative methods of compliance, contact 

Gary D. Park, Aerospace Engineer, FAA, 

Wichita Aircraft Certification Office, 1801 

Airport Road, Room 100, Mid-Continent 

Airport, Wichita, Kansas 67209; telephone: 

(316) 946–4123; facsimile: (316) 946–4107. 

(i) You may get copies of the documents 

referenced in this AD from Cessna Aircraft 

Company, Product Support P.O. Box 7706, 

Wichita, Kansas 67277; telephone: (316) 517–

5800; facsimile: (316) 942–9006. You may 

view these documents at FAA, Central 

Region, Office of the Regional Counsel, 901 

Locust, Room 506, Kansas City, Missouri 

64106. 

Issued in Kansas City, Missouri, on 

February 19, 2004. 

Dorenda D. Baker, 

Manager, Small Airplane Directorate, Aircraft 

Certification Service. 

[FR Doc. 04–4375 Filed 2–26–04; 8:45 am] 

BILLING CODE 4910–13–P 

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. 

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 CMSspecified 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 

Federal Register / Vol. 69, No. 39 / Friday, February 27, 2004 / Proposed Rules 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 www.medicare.gov. 

The primary purpose of Nursing Home 

Compare is to provide detailed 

information about the past performance 

of every Medicare- and Medicaidcertified 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 § 483.30(c) or 

§ 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-toresident 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 

(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 

(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 

9284 Federal Register / Vol. 69, No. 39 / Friday, February 27, 2004 / Proposed Rules 

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 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 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 (§ 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 § 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 

§ 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 

§ 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 § 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 × 8)+(2 × 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 

Federal Register / Vol. 69, No. 39 / Friday, February 27, 2004 / Proposed Rules 9285 

shift; (8 × 12)+(3 × 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 CMSspecific 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 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 § 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 

9286 Federal Register / Vol. 69, No. 39 / Friday, February 27, 2004 / Proposed Rules 

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: 

§ 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. 

BILLING CODE 4120–01–P 

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[FR Doc. 04–3732 Filed 2–26–04; 8:45 am] 

BILLING CODE 4120–01–C 

DEPARTMENT OF TRANSPORTATION 

National Highway Traffic Safety 

Administration 

49 CFR Part 571 

[Docket No. NHTSA–1998–4369; Notice 1] 

RIN 2127–AH75 

Federal Motor Vehicle Safety 

Standards; Rear Impact Guards; Notice 

of Proposed Rulemaking 

AGENCY: National Highway Traffic 

Safety Administration (NHTSA), 

Department of Transportation (DOT). 

ACTION: Notice of proposed rulemaking. 

SUMMARY: This document responds to a 

petition for rulemaking from Thieman 

Tailgates, Inc., concerning the Federal 

motor vehicle safety standard requiring 

trailers and semitrailers to be equipped 

with rear impact guards. The petitioner 

asked us to amend the standard so that 

it expressly excludes trailers with rearmounted liftgates that reside in or move 

through any part of the area specified in 

the standard for the horizontal member 

of the rear impact guard. Alternatively, 

the petitioner asked us to exclude rear 

impact guards on those trailers from the 

energy absorption requirements of the 

equipment standard for rear impact 

guards. 


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