[Federal Register Volume 69, Number 39 (Friday, February 27, 2004)]
[Rules and Regulations]
[Pages 9282-9288]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-3732]


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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 
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 (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

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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 
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 (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 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, [email protected]. 
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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