Form CMS-10398 (#31) CMS-10398 (#31) Sample Template for State Settings’ Analysis

OMB Control Number 0938-1148

Expiration date: 10/31/2014

SAMPLE TEMPLATE FOR STATE SETTINGS’ ANALYSIS (Optional)

CATEGORY	STANDARD (LICENSING, CERTIFICATION, REGULATION, STATE REVIEW OF SETTINGS, ETC.)	TYPE OR NAME OF SETTING AND TOTAL NUMBER OF SETTINGS	SOURCE(S) OF EVIDENCE/EVALUATION FOR PLACEMENT IN CATEGORY	REMEDIATION STRATEGY
Settings fully align with HCB setting requirements:
With changes, settings will align with HCB setting requirements:
Presumptively non-HCB settings (for which state is submitting justification/evidence to refute presumption):
Settings do not/cannot meet HCB setting requirements (including presumptively non-HCB settings for which the state does not dispute the status

PRA Disclosure Statement

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