Source: https://www.federalregister.gov/documents/2004/02/27/04-3732/medicare-and-medicaid-programs-requirements-for-long-term-care-facilities-nursing-services-posting
Timestamp: 2017-09-19 17:53:44
Document Index: 27293785

Matched Legal Cases: ['§\u2009483', '§\u2009483', '§\u2009483', '§\u2009483', '§\u2009483', '§\u2009483', '§\u2009483']

9282-9288 (7 pages)
CMS-3121-P
A. Nursing Services (§ 483.30)
B. Daily Nurse Staffing Form
I. Regulatory Impact Statement
https://www.federalregister.gov/d/04-3732 https://www.federalregister.gov/d/04-3732
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.
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.
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.
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.
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 Start Printed Page 9283nursing 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).
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.
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 Medicaid-certified nursing home in the country. Nursing Home Compare contains the following sections of detailed information:
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-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 (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.
The Phase I study found data submitted through the only national data source of nursing home staffing for Start Printed Page 9284individual 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.
An October 10, 2002 State Agency Directors letter at www.cms.hhs.gov/​Medicaid/​LTCSP/​SC0303.pdf.
A December 24, 2002 letter to nursing homes at www.cms.hhs.gov/​medicaid/​bipa/​bipanh.asp.
(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—
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 Start Printed Page 9285shift; (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.
(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 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.
(If you choose to comment on this section, please include the caption “COLLECTION OF INFORMATION REQUIREMENTS” at the beginning of your comments.)
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.
(If you choose to comment on this section, please include the caption “REGULATORY IMPACT ANALYSIS” at the beginning of your comments.)
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 Start Printed Page 9286information. 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.
(e) Posting of nurse staffing information. (1) Information requirements. The facility must—
(2) Form use and posting requirements. The facility must on a daily basis—
(3) Public access and data retention requirements. The facility must—
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