Source: https://www.federalregister.gov/documents/2000/06/28/00-15639/per-diem-for-adult-day-health-care-of-veterans-in-state-homes
Timestamp: 2018-03-20 06:53:01
Document Index: 734123582

Matched Legal Cases: ['art 51', 'art 58', 'art 52', '§\u200952', '§\u200952', '§\u200952', '§\u200952', '§\u200952', '§\u200952', 'art 58', 'art 58', 'art 51', 'art 52', '§\u200952', 'art 51', 'art 18', 'art 46']

A Proposed Rule by the Veterans Affairs Department on 06/28/2000
Comments must be received by VA on or before August 28, 2000.
65 FR 39835
39835-39850 (16 pages)
00-15639
Collections of Information Including Collections of Information Using Forms at 38 CFR Part 51 Already Aapproved Under OMB Control Number 2900-0160
Additional Collections of Information Under This Proposed Rule, Including Collections of Information Using Forms Published at 38 CFR Part 58
https://www.federalregister.gov/d/00-15639 https://www.federalregister.gov/d/00-15639
This document proposes to establish regulations setting forth a mechanism for paying per diem to State homes providing adult day health care to eligible veterans. The intended effect of the proposed regulations is to ensure that veterans receive high quality care in State homes.
Mail or hand-deliver written comments to: Director, Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Ave., NW, Room 1154, Washington, DC 20420; or fax comments to (202) 273-9289; or e-mail comments to “OGCRegulations@mail.va.gov”. Comments should indicate that they are submitted in response to “RIN 2900-AJ74” All comments received will be available for public inspection in the Office of Regulations Management, Room 1158, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays).
This document proposes to establish a new part 52 setting forth a mechanism for paying per diem to State homes providing adult day health care to eligible veterans. The adult day health Start Printed Page 39836care program has the following basic purposes: (a) to enable functionally impaired veterans to reside in supportive home environments; (b) to facilitate expeditious medical center discharge and to reduce risk of readmission or institutional placement, through improved provision and coordination of health care services and education of patients and caregivers about service options and their appropriate use; (c) to maximize veterans' physical and psychosocial functional level; (d) to improve the quality of life for the participants by providing a rehabilitation program in the community among their peers; and (e) to provide support and respite for the family and other caregivers to enable them to maintain veterans in the community.
Under the proposal, VA would pay per diem to a State for providing adult day health care to eligible veterans in a facility if the Under Secretary for Health recognizes the facility as a State home based on a current VA certification that the facility meets the standards set forth in proposed subpart D.
The standards in proposed subpart D are patterned after the standards of the U.S. Department of Veterans Affairs Adult Day Health Care Program and the National Council on the Aging, National Adult Day Services Association. The standards are intended to set forth minimum requirements necessary to ensure that VA pays per diem for eligible veterans only if the State homes provide high quality care.
The proposed regulations include application and inspection provisions that are designed to ensure that per diem is paid only to facilities that have been inspected and found to meet the proposed standards. Also, in order to ensure continued compliance with the standards, the proposed regulations include an ongoing review and certification program. Further, the proposed regulations contain provisions for withdrawing recognition and stopping payment of per diem if a facility fails to meet the proposed standards.
The proposed rule sets forth the statutory list of veterans for whom per diem may be paid. The per diem amount would be the amount authorized under 38 U.S.C. 1741 and Congressionally approved in the yearly budget. For fiscal year 2000 the amount is $30.25.
The proposed rule imposes requirements concerning accreditation and training by certain national entities (see definition of “Physician Assistant” at proposed § 52.2, qualifications of a social worker at proposed § 52.100(g), qualifications of a dietitian at proposed § 52.140(a)(2), and requirements for program assistants at proposed § 52.210(j)). VA will consider changing the requirements to allow accreditation or training by other national entities when warranted.
The proposed rule includes provisions regarding medical errors (see proposed § 52.120(a), (k), and (l)). This is consistent with the President's initiative on medical errors announced on December 7, 1999, and the recommendation of the Quality Interagency Coordination Task Force.
The proposed rule would incorporate by reference the 1997 edition of the National Fire Protection Association Life Safety Code entitled “NFPA 101, Life Safety Code.” The regulations are designed to ensure that State homes meet the fire and safety provisions of the Life Safety Code.
The Secretary hereby certifies that the adoption of this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. All of the entities that would be subject to this proposed rule are State government entities under the control of State governments. Of the 95 State homes, all are operated by State governments except for 17 that are operated by entities under contract with State governments. These contractors are not small entities. Therefore, pursuant to 5 U.S.C. 605(b), this proposed rule is exempt from the initial and final regulatory flexibility analysis requirement of sections 603 and 604.
Under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520), proposed collections of information are set forth in the provisions of §§ 52.20, 52.30, 52.40, 52.70, 52.71, 52.80, 52.90, 52.100, 52.110, 52.120, 52.130, 52.150, 52.160, 52.180, 52.190 and 52.210 of this proposed rule. Many of these collections of information require the submission to VA of information on forms published at 38 CFR Part 58.
The information collections in this document concern various activities related to the operation of a State home providing adult day health care to eligible veterans. As required under section 3507(d) of the Act, VA has submitted a copy of this proposed rulemaking action to the Office of Management and Budget (OMB) for its review of the collections of information.
The forms in 38 CFR Part 58, which are republished at the end of this proposed rule, are intended to be used for a number of VA programs. Collections of information using these forms already have been approved by OMB for the regulations in 38 CFR Part 51 captioned “Per Diem for Nursing Home Care of Veterans in State Homes” under OMB approval number 2900-0160. This proposed rule also would require collections of information using these same forms. Accordingly, we are requesting that OMB approve the collections of information in this proposed rule as an amendment of the collections of information already approved under OMB control number 2900-0160.
Comments on the collection of information should be submitted to the Office of Management and Budget, Attention: Desk Officer for the Department of Veterans Affairs, Office of Information and Regulatory Affairs, Washington, DC 20503, with copies to the Director, Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420. Comments should indicate that they are submitted in response to “RIN 2900-AJ74.”
Title: Aid to States for Care of Veterans in State Homes—Adult Day Health Care Per Diem.
Summary of collection of information: VA is proposing to establish the mechanism for paying per diem to State homes providing adult day health care to eligible veterans. VA proposes to require the State homes to supply various kinds of information regarding their adult day health care programs to ensure that high quality care is furnished to veterans who are participants in such programs. The information includes an application for recognition based on certification; appeal information; application and justification for payment; records and reports which program management must maintain regarding activities of participants; to include information relating to whether the program meets standards concerning participants' rights and responsibilities prior to enrollment, during enrollment, and upon discharge; the records and reports which program management and health care professionals must maintain regarding participants and employees; various types of documentation pertaining to the management of the facility; food menu planning; Start Printed Page 39837pharmaceutical records; and life safety documentation.
Description of need for information and proposed use of information: The collections of information contained in the proposed rule appear to be necessary to ensure that VA per diem payments are limited to facilities providing high quality care. Without access to such information VA would not be able to determine whether high quality care is being provided.
Description of likely respondents: State home officials who receive per diem for nursing home care for veterans.
Estimated number of respondents: 13,136.
Estimated frequency of responses: 52,872.
Estimated average burden per collection: 14 minutes.
Estimated total annual reporting and record keeping burden: 12,467 hours.
Description of likely respondents: State home officials who receive per diem for adult day health care for veterans.
Estimated frequency of responses: 7,568.
Estimated average burden per collection: 13 minutes.
Estimated total annual reporting and record keeping burden: 2,733. hours.
This document was received at the Office of the Federal Register on June 16, 2000.
Approved: October 29, 1999.
For the reason set forth in the preamble, 38 CFR Chapter I is proposed to be amended by adding a new part 52 to read as follows.
Clinical nurse specialist means a licensed professional nurse with a master's degree in nursing and a major in a clinical nursing specialty from an academic program accredited by the National League for Nursing and at least 2 years of successful clinical practice in the specialized area of nursing practice following this academic preparation.
Facility means a building or any part of a building for which a State has submitted an application for recognition as a State home for the provision of adult day health care or a building or any part of a building which VA has recognized as a State home for the provision of adult day health care.
Instrumental activities of daily living (IADLs) means functions or tasks of independent living, i.e., shopping, housework, meal preparation and cleanup, laundry, taking medication, money management, transportation, correspondence, and telephoning.
Nurse practitioner means a licensed professional nurse who is currently licensed to practice in the State; who meets the State's requirements governing the qualifications of nurse practitioners; and who is currently certified as an adult, family, or Start Printed Page 39838gerontological nurse practitioner by the American Nurses Association.
VA will pay per diem to a State for providing adult day health care to eligible veterans in a facility if the Under Secretary for Health recognizes the facility as a State home based on a current certification that the facility and program management meet the standards of subpart D of this part. Also, after recognition has been granted, VA will continue to pay per diem to a State for providing adult day health care to eligible veterans in such a facility for a temporary period based on a certification that the facility and program management provisionally meet the standards of subpart D of this part.
(a) Send a request for recognition and certification to the Under Secretary for Health (10), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420. The request must be in the form of a letter and must be signed by the State official authorized to establish the State home;
(a)(1) The Under Secretary for Health will make the determination regarding recognition and the initial determination regarding certification, after receipt of a tentative determination from the director of the VA medical center of jurisdiction regarding whether the facility and program management meet or do not meet the standards of subpart D of this part. The Under Secretary for Health will notify the official in charge of the program, the State official authorized to oversee operations of the State home, the VA Network Director (10N 1-22), Chief Network Officer (10N), and the Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) of the action taken.
(2) For each facility recognized as a State home, the director of the VA medical center of jurisdiction will certify annually whether the facility and program management meet, provisionally meet, or do not meet the standards of subpart D of this part (this certification should be made every 12 months during the recognition anniversary month or during a month agreed upon by the VA medical center director and officials of the State home facility). A provisional certification will be issued by the director only upon a determination that the facility or program management does not meet one or more of the standards in subpart D of this part, that the deficiencies do not jeopardize the health or safety of the residents, and that the program management and the director have agreed to a plan of correction to remedy the deficiencies in a specified amount of time (not more time than the VA medical center of jurisdiction director determines is reasonable for correcting the specific deficiencies). The director of the VA medical center of jurisdiction will notify the official in charge of the program, the State official authorized to oversee the operations of the State home, the VA Network Director (10N 1-22), Chief Network Officer (10N) and the Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) of the certification, provisional certification, or noncertification.
(c) Both during the application process for recognition and after the Under Secretary for Health has recognized a facility, VA may survey the facility as necessary to determine if the facility and program management comply with the provisions of this part. Generally, VA will provide advance notice to the State before a survey occurs; however, surveys may be conducted without notice. A survey, as necessary, will cover all parts of the facility, and include a review and audit of all records of the program that have a bearing on compliance with any of the requirements of this part (including any reports from State or local entities). For purposes of a survey, at the request of the director of the VA medical center of jurisdiction, the State home adult day care health program management must submit to the director a completed VA Form 10-3567, Staffing Profile, set forth at 38 CFR 58.10. The director of the VA medical center of jurisdiction will designate the VA officials to survey the facility. These officials may include physicians; nurses; pharmacists; dietitians; rehabilitation therapists; social workers; representatives from health administration, engineering, environmental management systems, and fiscal officers.
(d) If the director of the VA medical center of jurisdiction determines that the State home facility or program management does not meet the standards of this part, the director will notify the State home program manager in writing of the standards not met. The director will send a copy of this notice to the State official authorized to oversee operations of the facility, the VA Network Director (10N 1-22), the Chief Network Officer (10N), and the Chief Consultant, Geriatrics and Start Printed Page 39839Extended Care Strategic Healthcare Group (114). The letter will include the reasons for the decision and indicate that the State has the right to appeal the decision.
(e) The State must submit an appeal to the Under Secretary for Health in writing, within 30 days of receipt of the notice of failure to meet the standards. In its appeal, the State must explain why the determination is inaccurate or incomplete and provide any new and relevant information not previously considered. Any appeal that does not identify a reason for disagreement will be returned to the sender without further consideration.
(g) In the event that a VA survey team or other VA medical center staff identifies any condition at the State home facility that poses an immediate threat to public or patient safety or other information indicating the existence of such a threat, the director of the VA medical center of jurisdiction will immediately report this to the VA Network Director (10N 1-22), Chief Network Officer (10N), Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) and State official authorized to oversee operations of the State home.
(a)(1) During fiscal year 2000, VA will pay monthly one-half of the total cost of each eligible veteran's adult day health care for each day the veteran is in a facility recognized as a State home for adult day health care, not to exceed $30.25 per diem.
(2) Per diem will be paid only for a day that the veteran is under the care of the facility at least six hours.
(3) As a condition for receiving payment of per diem under this part, the State must submit a completed VA form 10-5588, State Home Report and Statement of Federal Aid Claimed. This form is set forth in full at 38 CFR 58.11.
(5) As a condition for receiving payment of per diem under this part, the State must submit to the VA medical center of jurisdiction for each veteran the following completed VA forms: 10-10EZ, Application for Medical Benefits, and 10-10SH, State Home Program Application for Care—Medical Certification, at the time of enrollment and with any request for a change in the level of care (nursing home, domiciliary or hospital care). These forms are set forth in full at 38 CFR 58.12 and 58.13, respectively. If the program is eligible to receive per diem payments for adult day health care for a veteran, VA will pay per diem under this part from the date of receipt of the completed forms required by this paragraph (a)(5), except that VA will pay per diem from the day on which the veteran was enrolled in the program if VA receives the completed forms within 10 days after enrollment.
A veteran is an eligible veteran under this part if VA determines that the veteran needs adult day health care and the veteran is within one of the following categories:
The provisions of this subpart are the standards that a State home and program management must meet for the State to receive per diem for adult day health care provided at that home.
Adult day health care must be a therapeutically oriented outpatient day program, which provides health maintenance and rehabilitative services to participants. The program must provide individualized care delivered by an interdisciplinary health care team and support staff, with an emphasis on helping participants and their caregivers to develop the knowledge and skills necessary to manage care requirements in the home. Adult day health care is principally targeted for complex medical and/or functional needs of geriatric patients.
The participant has a right to a dignified existence, self-determination, Start Printed Page 39840and communication with and access to persons and services inside and outside the facility. The program management must protect and promote the rights of each participant, including each of the following rights:
(ii) After receipt of their records for review, to purchase, at a cost not to exceed the community standard, photocopies of the records or any portions of them upon request and with 2 working days advance notice to the facility management.
(iii) The program management must record and periodically update the address and phone number of the participant's legal representative or interested family member and the primary physician.
(2) If the participant is determined incompetent or otherwise determined to be incapacitated under the laws of the State, the participant's legal representative or interested family member(s) has the right to participant in planning care and treatment or changes in care and treatment.
(1) Participants have a right to privacy in their medical treatment, and personal care.
(iv) The participant agrees to the work therapy arrangement described in the plan of care. Start Printed Page 39841
(iii) The State long term care ombudsman;
Participant and family caregivers responsibilities.
52.80 Enrollment, transfer and discharge rights.
(i) Dependence in 2 or more activities of daily living (ADLs).
(ii) Dependence in 3 or more instrumental activities of daily living (IADLs).
(iv) High use of medical services defined as 3 or more hospitalizations in past year; utilization of outpatient clinics; or Emergency Evaluation Units, 12 or more times in past year.
(iii) The location to which the participant is transferred or discharged, if any; Start Printed Page 39842
(Authority: U.S.C. 101, 501, 1741-1743)
(4) The results of all investigations must be reported to the State oversight agency director or the designated representative and to other officials in accordance with State law within 5 working days of the incident, and appropriate corrective action must be taken if the alleged violation is verified.
(e) Therapeutic Participant Activities. (1) The program management must Start Printed Page 39843provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well being of each participant.
(c) Comprehensive assessments. (1)(i) The program management must make a comprehensive assessment of a participant's needs:
(A) Using (on and after January 1, 2000) the Health Care Financing Administration Long Term Care Resident Assessment Instrument Version 2.0; and
(B) Describing the participant's capability to perform daily life functions, strengths, performances, needs as well as significant impairments in functional capacity.
(ii) An initial home visit must be conducted by program staff or in coordination with community resources to identify home safety issues, home medication use, use of or need for adaptive equipment, and the in-home functioning of the participant and family/caregiver.
(3) Review of assessments. Program management must review each Start Printed Page 39844participant no less than once every 6 months and as appropriate, revise the participant's assessment to assure the continued accuracy of the assessment.
(d) Accuracy of assessments.—(1) Coordination.
(iii) Prepared by an interdisciplinary team, that includes the primary physician, a registered nurse with responsibility for the participant, social worker, recreational therapist and other appropriate staff in disciplines as determined by the participant's needs, the participation of the participant, and the participant's family or the participant's legal representative; and
Each participant must receive and the program management must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
(a) Reporting of sentinel events.—(1) Definition. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function.
(3) The program management must report sentinel events to the director of VA medical center of jurisdiction within 24 hours of identification. The director of VA medical center of jurisdiction must report sentinel events to VA Network Director (10N 1-22), Chief Network Officer (10N), and Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) within 24 hours of identification and/or notification by State home.
(1) A participant who enters the program without pressure ulcers does Start Printed Page 39845not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(k) Unnecessary drugs.—(1) General. Each participant's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(c) Nurse staffing must be based on a staffing methodology that uses case mix and is adequate for meeting the standards of this part.
(b) Menus and nutritional adequacy.—(1) The participant's total dietary intake is of concern but is not the adult day health care program's responsibility.
(3) Food prepared in a form designed to meet individual needs; and Start Printed Page 39846
(e) Frequency of meals. (1) Each participant may receive and program management must provide at least two meals daily, at a regular time comparable to normal mealtimes in the community.
(b) Frequency of physician reviews.—(1) The participant must be seen by the primary physician at least annually and as indicated by a change of condition.
(2) The program management must have a policy to help ensure that adequate medical services are provided to participant.
(3) At the option of the primary physician, required reviews in the program after the initial review may alternate between personal physician reviews and reviews by a physician assistant, nurse practitioner, or clinical nurse specialist in accordance with paragraph (f) of this section.
(d) Availability of physicians for emergency care. The program management must provide or arrange for the provision of physician services when the program has participants under its care, in case of an emergency.
(i) A certified physician assistant or a certified nurse practitioner; or
(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech therapy, occupational therapy, and mental health services for mental illness are required in the participant's comprehensive plan of care, program management must—
(1) Provide the required services; or (2) Obtain the required services and equipment from an outside resource, in accordance with § 52.210(h), from a provider of specialized rehabilitative services.
(a) Program management must, if necessary, assist the participant and family/caregiver—
(3) The program management must ensure that drugs and biologicals used by participants are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
(4) The program management must store all drugs, biologicals, and controlled scheduled II drugs listed in 21 CFR 1308.12 in locked compartments under proper temperature controls, permit only authorized personnel to have access, and otherwise comply with all applicable State and Federal laws.
(b) Preventing spread of infection. (1) The program management must prevent participants or staff, with a communicable disease or infected skin lesions from attending the adult day health care program, if direct contact will transmit the disease.
(a) Life safety from fire. The facility must meet the applicable provisions of the National Fire Protection Association?s NFPA 101, Life Safety Code, 1997 edition. Incorporation by reference this document was approved by the Director of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The document incorporated by reference is available for inspection at the Office of the Federal Register, Suite 700, 800 North Capitol Street, NW., Washington, DC, and the Department of Veterans Affairs, Office of Regulations Management (02D), Room 1154, 810 Vermont Avenue, NW., Washington, DC 20420. Copies may be obtained from the National Fire Protection Association, Battery March Park, Quincy, MA 02269. (For ordering information, call toll-free 1-800-344-3555.)
(i) A dividable multipurpose room or area for group activities, including dining, with adequate table setting space.
(v) A quiet room, which functions to isolate participants who become ill or disruptive, or who require rest, privacy, or observation. It should be separate from activity areas, near a restroom, and supervised.
(vii) Toilet facilities and bathrooms easily accessible to people with mobility problems, including participants in wheelchairs. There must be at least one toilet for every eight (8) participants. The toilets must be equipped for use by persons with limited mobility, easily accessible from all programs areas, i.e. preferably within 40 feet from that area, designed to allow assistance from one or two staff, and barrier-free.
(e) Other environmental conditions. The program management must provide a safe, functional, sanitary, and comfortable environment for the participants, staff and the public. The program management must—
(b) Disclosure of State agency and individual responsible for oversight of facility. The State must give written notice to the Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420, at the time of the change, if any of the following change:
(c) Required information. The program management must submit the following to the director of the VA Start Printed Page 39848medical center of jurisdiction as part of the application for recognition and thereafter as often as necessary to be current:
(2) Site plan of facility and surroundings.
(9) Annual certification for Drug-Free Workplace Act of 1988 (41 U.S.C. 701-707) (VA From 10-0143 set forth at 38 CFR 58.15);
(e) Management contract facility. If a program is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility on a full-time onsite basis.
(g) Staff qualifications. (1) The program management must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements. Professional disciplines involved in participant care must include registered nurses, program assistants, physicians, social workers, rehabilitation therapist, dietitian, and therapeutic activity therapist and pharmacist. Other disciplines may be considered depending upon the participant and/or program needs.
(3) The staff-participant ratio must be sufficient in number and skills (at least one staff to 4 participants) to ensure compliance with the standards of this part. There must be at least two responsible persons (paid staff members) at the adult day health care center at all times when there are two or more participants in attendance.
(v) Monitoring employees' health status and advising the program administrator on employee-health policies.
(j) Required training of program assistants. (1) Program assistants must have a high school diploma or the equivalent and must have at least one year of experience in working with adults in a health care setting. Program assistants also must complete the National Adult Day Services Association training course or complete equivalent training.
(3) Verification. Before allowing an individual to serve as a nurse aide or program assistant, program management Start Printed Page 39849must verify that the individual has successfully completed a training and competency evaluation program. Facilities must follow up to ensure that such an individual actually becomes certified, if available in the State.
(ii) A medical director designated by the program; and
(iii) At least 3 other members of the program's staff.
(r) Relationship to other Federal regulations. In addition to compliance with the regulations set forth in this subpart, the program must meet the applicable provisions of other Federal laws and regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, national origin, handicap, or age (38 CFR part 18); protection of human subjects of research (45 CFR part 46), section 504 of the Rehabilitation Act of 1993 (29 U.S.C. 794); Drug-Free Workplace Act of 1988 (41 U.S.C. 701-707); restrictions regarding lobbying (31 U.S.C. 1352); Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d-1). Although these regulations are not in Start Printed Page 39850themselves considered requirements under this part, their violation may result in the termination or suspension of, or the refusal to grant or continue payment with Federal funds.
(a) The adult day health care program management must provide, arrange, or contract for transportation to enable participants, including persons with disabilities, to attend the program and to participate in facility-sponsored outings.
(c) All vehicles transporting participants to and from adult day health care must be equipped with a device for two-way communication and one additional staff person besides the driver.
(e) The time to transport participant to or from the facility must not be more than 60 minutes except under unusual conditions, e.g. bad weather.
[FR Doc. 00-15639 Filed 6-27-00; 8:45 am]