HHA PRA Supporting Statement 2013 for existing regs v 2 - 508 compliant

Home Health Conditions of Participation (CoPs) and Supporting Regulations

A.

Background

The purpose of this package is to request Office of Management and Budget (OMB) re-approval
of the collection of information requirements for the existing conditions of participation (CoPs)
that home health agencies must meet to participate in the Medicare program (CMS-R-39, OMB
#0938-0365). On March 10, 1997, we proposed to revise the HHA conditions; however, those
revisions were not finalized. Also, on January 25, 1999 we finalized a portion of the CoPs to
require the use of the Outcome and Assessment Information Set (OASIS). That request is
approved under OMB numbers 0938-0760. This submission replaces the prior version.
Home health services are covered for the elderly and disabled under the Hospital Insurance (Part
A) and Supplemental Medical Insurance (Part B) benefits of the Medicare program, and are
described in section 1861(m) of the Social Security Act (the Act) (42 U.S.C. 1395x). These
services must be furnished by, or under arrangement with, an HHA that participates in the
Medicare program, and be provided on a visiting basis in the beneficiary's home. They may
include the following:
•
•
•
•
•
•
•

Part-time or intermittent skilled nursing care furnished by or under the supervision of a
registered nurse.
Physical therapy, speech-language pathology, or occupational therapy.
Medical social services under the direction of a physician.
Part-time or intermittent home health aide services.
Medical supplies (other than drugs and biologicals) and durable medical equipment.
Services of interns and residents if the HHA is owned by or affiliated with a hospital that
has an approved medical education program.
Services at hospitals, SNFs, or rehabilitation centers when they involve equipment too
cumbersome to bring to the home.

Section 1861(o) of the Act (42 U.S.C. 1395x) specifies certain requirements that a home health
agency must meet to participate in the Medicare program. (Existing regulations at 42 CFR
440.70(d) specify that HHAs participating in the Medicaid program must also meet the Medicare
CoPs.) In particular, section 1861(o)(6) of the Act requires that an HHA must meet the CoPs
specified in section 1891(a) of the Act and such other CoPs as the Secretary finds necessary in
the interest of the health and safety of its patients. Section 1891(a) of the Act establishes specific
requirements for HHAs in several areas, including patient rights, home health aide training and
competency, and compliance with applicable Federal, State, and local laws.

Under the authority of sections 1861(o), 1871 and 1891 of the Act, the Secretary has established
in regulations the requirements that an HHA must meet to participate in the Medicare program.
These requirements are set forth in 42 CFR Part 484 as Conditions of Participation for Home
Health Agencies. The CoPs apply to an HHA as an entity as well as the services furnished to
each individual under the care of the HHA, unless a condition is specifically limited to Medicare
beneficiaries. Under section 1891(b) of the Act, the Secretary is responsible for assuring that the
CoPs, and their enforcement, are adequate to protect the health and safety of individuals under
the care of an HHA and to promote the effective and efficient use of Medicare funds. To
implement this requirement, State survey agencies generally conduct surveys of HHAs to
determine whether they are complying with the CoPs.
B.

Justification

1.

Need and Legal Basis

The information collection requirements for which we are requesting OMB approval are listed
below. These requirements are among other requirements classified as (or known as) the CoPs
which are based on criteria prescribed in law and are standards designed to ensure that each
facility has properly trained staff to provide the appropriate safe physical environment for
patients. These particular standards reflect comparable standards developed by industry
organizations such as The Joint Commission and the Community Health Accreditation Program.
2.

Information Users

The primary users of this information will be State agency surveyors, the regional home health
intermediaries, CMS and HHAs for the purpose of ensuring compliance with Medicare CoPs as
well as ensuring the quality of care provided by HHA patients.
3.

Use of Information Technology

CMS does not require a specific format for maintaining the documentation required in this
information collection. HHAs are free to select the most efficient and effective documentation
format for their needs, including the maintenance of electronic records in accordance with their
unique technical capabilities.
4.

Duplication

There is no duplication of information.

CMS-R-39, OMB Control # 0938-0365, Page 3
5.

Small Business Impact

This information collection affects small businesses. However, the requirements are sufficiently
flexible for facilities to meet them in a way consistent with their existing operations.
6.

Less Frequent Collection

With less frequent collection, CMS would not be able to ensure timely compliance with HHA
CoPs.
7.

Special Circumstances Leading to Information Collection

There are no special circumstances for collecting this information.
8.

Federal Register Notice/Outside Consultation

The 60-day Federal Register notice published on July 12, 2013.
9.

Payment or Gift to Respondents

There are no payments or gifts to respondents.
10.

Confidentiality

We do not pledge confidentiality of aggregate data. We pledge confidentiality of patient-specific
data in accordance with the Privacy Act of 1974 (5 U.S.C. 552a).
11.

Sensitive Questions

There are no questions of a sensitive nature.
12.

Burden Estimates (Hours and Wages)

The information collection requirements are shown below with an estimate of the annual
reporting and record keeping burdens. Included in the estimates is the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and

CMS-R-39, OMB Control # 0938-0365, Page 4
completing and reviewing the collection of information.
In 2011 there were 11,930 home health agencies. Based on growth figures for the last three years,
we estimate that there will be approximately 549 agencies per year entering the program, for a
total of 13,577 home health agencies at the close of the three year PRA approval period. In 2010
7,015 freestanding HHAs had 10,729,763, for an average of 1,488 admissions per HHA. Based
on this average, we estimate that all 11,930 HHAs had 17,751,840 admissions in 2011 and that
all 13,577 projected HHAs will have a total of 20,202,576 admissions at the close of the three
year PRA approval period. We define an average-size HHA as having 1,488 admissions per
year and 56 clinicians or service providers.(based on information from the National Association
for Home Care 2010 Basic Statistics About Home Care report).
Many of the following requirements are performed only once by each agency (such as the
development of a standard patient rights disclosure), and many would normally be performed by
an agency in the normal course of responsible business practices in the absence of these
requirements (such as the maintenance of personnel records) and therefore represent a minimal, if
any, burden on home health agencies.
•

§484.10 Condition of participation: Patient rights.
The requirements under this CoP require that the HHA: (a) must provide the patient with
a written notice of the patient’s rights in advance of providing care and document that it
has complied with this requirement; (b) must document the existence and resolution of
complaints about care furnished by the agency that were made by a patient, the patient’s
family, or guardian; (c) must advise the patient in advance of the disciplines that will
furnish care and the proposed frequency of visits to provide such care as well as any
changes in the plan of care before the change is made; (d) must advise the patient of the
agency’s policies and procedures regarding disclosure of clinical records; (e) must advise
the patient of the extent to which payment for their services can be expected from any
Federally funded or aided program, as well as what costs will not be covered by Medicare
and must be paid by the individual, and must also advise the patient orally and in writing
of any changes in this information; (f) must advise the patient of the number, purpose,
and hours of operation of the State home health hotline.
New HHAs will need to develop a standard notice of rights that will fulfill the
requirements contained in paragraphs (a), (c), (d), (e) and (f). The total estimated burden
hours for developing the notice of rights is 1 hour per HHA, and 549 hours in any given
year for all new HHAs at a cost of $32,940 for an administrator earning $60/hour to
perform this task (based on salary data from the Bureau of Labor Statistics and including
a 48 percent benefits and overhead adjustment). Existing HHAs have already developed
this notice, and would therefore not be affected by this requirement. The standard notice
will contain a checklist to be completed by the HHA in a manner appropriate to each
client being admitted.

CMS-R-39, OMB Control # 0938-0365, Page 5
A copy of the signed notice will impose a minimal burden as estimated below. In the rare
circumstances to which paragraph (b) applies, it is already common practice to have this
information retained in the medical record. Therefore, the requirement under paragraph
(b) imposes no burden. The information collection requirements contained in this section
mirror those in section 4021 of OBRA ‘87, which specify the rights of patients receiving
services from Medicare certified and/or approved HHA’s. These requirements are
necessary to ensure HHA compliance with statutory responsibilities. The total estimated
annual burden hours for disclosing the notice of rights is 1,479,320 - 1,683,548 (1,488
admits/yr x 5 minutes per admit x 11,930 -13,577 HHAs / 60 minutes). Total cost
burden is estimated as $68,048,720 - 77,443,208, based on a nurse earning $46/hour to
complete this task (1,479,320- 1,683,548 hours x $46/hr, salary estimate includes 48
percent benefits and overhead adjustment). We believe that retaining the signed copy of
the notice of rights is standard business practice.
•

§484.11 Condition of participation: Reporting OASIS information
CMS-R-209: Approved by OMB (OMB Control #: 0938-0760)

•

§484.12 Condition of participation: Compliance with Federal, State and local laws,
disclosure and ownership information, and accepted professional standards and
principles.
The HHA must disclose to the State Survey Agency, at the time of the HHA's initial
request for certification, the name and address of all persons with an ownership or control
interest in the HHA, the name and address of all officers, directors, agents, and managers
of the HHA, as well as the name and address of the corporation or association responsible
for the management of the HHA and the chief executive and chairman of that corporation
or association. This requirement directly implements section 4021 of OBRA '87 and
imposes a minimal burden of the creation of a new disclosure of ownership for newly
certified HHAs. The burden imposed by the creation of a new document is estimated at 5
minutes for 549 estimated newly certified HHAs. Existing HHAs have already created
this disclosure form, and because it must only be done once, they are no longer burdened
by this requirement. The total estimated burden is 46 hours in any given year (549
estimated new HHAs x 5 minutes / 60 minutes). Total cost burden is estimated at $2,760
(46 hours x $60/hr). We believe that the act of sending information to the State Survey
Agency as part of the application process is standard business practice.

•

§484.14 Condition of participation: Organization, services and administration.
Under this CoP the HHA must organize, manage, and administer its resources to attain
and maintain the highest practicable functional capacity for each patient regarding
medical, nursing, and rehabilitative needs as indicated by the plan of care. These

CMS-R-39, OMB Control # 0938-0365, Page 6
requirements are necessary to ensure responsible management of participating HHAs as
well as an acceptable quality care for beneficiaries. Paragraphs (c), (e), (f) and (g) impose
no additional burden as they are good business or medical practices which would
otherwise be self-imposed by facilities in the absence of Federal requirements. Paragraph
(g), which requires that a written summary report for each patient be sent to the attending
physician every 62 days, imposes a burden of 3 minutes per patient. The estimated annual
burden for HHAs is 887,592 – 1,010,129 hours (3 minutes per patient x 1,488 admissions
per HHA x 11,930- 13,577 HHAs / 60 minutes) at a cost of $16,864,248 – 19,192,451 for
an office assistant to complete this task (887,592 - 1,010,129 hours x $19/hour, salary
estimate includes 48% benefits and overhead adjustment).
Paragraph (i) which relates to the HHA’s institutional planning imposes a minimal burden
and is the amount of time required to develop the initial plan and to review and revise the
existing plan. We estimate the burden for developing a new plan at 1½ hours (90
minutes) and the burden for reviewing and revising an existing plan at 30 minutes. If the
anticipated source of financing for such expenditure is Title V, Medicare, or Medicaid,
the plan must specify whether a capital expenditure proposal has been submitted to the
designated planning agency in accordance with section 1122 of the Act, and specify
whether the planning agency has approved or disapproved the proposal. The overall plan
and budget is reviewed and updated at least annually. The estimated annual burden for
existing HHAs is 5,965 – 6,514 hours (11,930 - 13,028 existing HHAs x 30 minutes / 60
minutes, Note: The estimated 13,028 existing HHAs do not include the estimated 549
new HHAs that would be joining the Medicare program in the third and final approval
year for this package). The estimated annual burden for anticipated new HHAs is 824
hours (1½ hours x 549 new HHAs) in any given year. Therefore, the annual burden for
paragraph (i) of this CoP is 6,789 – 7,338 hours (5,965 - 6,514 hours for existing HHAs +
824 hours for estimated new HHAs). The total cost for this requirement is $407,340 –
440,280 for an administrator to complete the task (6,789 - 7,338 hours x $60).
•

§484.16 Condition of participation: Group of professional personnel.
Paragraph (a) requires that a group of professional personnel will advise, assist and
evaluate the agency. The meetings of this group are documented by dated minutes. This
requirement implements statutory provisions of section 1861(o) of the Social Security
Act. The burden for this CoP is minimal and is satisfied by recording and dating the
minutes of the meeting of professional personnel. We estimate the annual burden to be
10 minutes per agency for a total annual burden of 1,988 – 2,263 hours (11,930 - 13,577
HHAs x 10 minutes / 60 minutes) at a cost of $37,772 – 42,997 (1,988 – 2,263 hours x
$19).

•

§484.18 Condition of participation: Acceptance of patients, plan of care, and medical
supervision.

CMS-R-39, OMB Control # 0938-0365, Page 7
Section §484.18 implements the statutory provisions found in sections 1835 and 1814 of
the Act, as well as section 1891(a) as amended by OBRA '87 for non-Medicare patients.
Paragraph (a) of this section requires that a plan of care be developed in consultation with
agency staff, and cover all pertinent diagnoses. Paragraph (b) requires that a plan of care
be periodically reviewed. The written plan of care is established for each patient, and
periodically reviewed, by a physician in consultation with agency staff. Paragraph (c)
requires that the nurse or therapist to immediately record and sign any verbal orders given
by the physician. Recording verbal orders reflects customary and usual medical and
business practices. Therefore, this requirement does not impose a burden.
We estimate that HHAs average 1,488 home health patient admissions per year. The
anticipated burden associated with this requirement involves at least one staff member (at
$19 per hour) who will facilitate the establishment and periodic review of plans of care by
a physician. The burden for paragraphs (a) and (b) is estimated at 5 minutes per admission
for a total estimated burden of 124 hours per HHA (1,488 admits per year x 5 minutes /
60 minutes) for a total of 1,479,320 – 1,683,548 hours (1,488 admits per year x 5 minutes
/ 60 minutes x 11,930 – 13,577 HHAs). The cost of this requirement is $28,107,080 –
31,987,412 (1,479,320 - 1,683,548 hours x $19).
•

§484.20 Condition of participation: Reporting OASIS information.
CMS-R-209: Approved by OMB (OMB Control #: 0938-0760)
The requirements under §484.30, §484.32, §484.34 and §484.38 are intended to ensure
quality of care, and are commonly accepted as good medical practice, and therefore
impose no burden on HHAs as they would be performed even in the absence of Federal
regulations.

•

§484.36 Condition of participation: Home health aide services.
The requirements in paragraphs (a) and (b) directly mirror the statutory requirements of
section 4021 of OBRA '87. The requirements of paragraph (c) implements supervisory
requirements found in section 1861(o) of the Act. Paragraph (a) imposes no additional
burden as this documentation will be included in the personnel record as required in
§484.14(e).
Paragraph (b) imposes a one-time burden (to develop competency evaluation) on any
newly certified agencies. We estimate that it will require approximately 3 hours for each
newly certified HHA to formulate this evaluation (although this figure may be much
lower in practice if agencies chose to adopt standardized evaluation forms). Maintaining
documentation that demonstrates that each aide has met the evaluation requirements
imposes no burden as this information will be retained in personnel records. Developing
the competency evaluation imposes a burden of 1,647 hours (3 hours x 549 estimated

CMS-R-39, OMB Control # 0938-0365, Page 8
new HHAs) in any given year. The cost of this requirement is $98,820 (1,647 hours x
$60)
Paragraph (c) imposes a burden of approximately 3 minutes for each newly admitted
patient that receives aide care, for a total of 887,592 – 1,010,129 hours annually. (1,488
admits/year x 3 minutes x 11,930 – 13,577 HHAs/ 60). The total annual cost burden for
this CoP is estimated at $40,829,232 – 46,465,934 (887,592 -1,010,129 hours x
$46/hour).
The total annual burden for all provisions within this CoP is 889,239 – 1,011,776 hours
(1,647 hours + 887,592 – 1,010,129 hours). The total annual cost burden is $40,928,052
– 46,564,754 ($98,820 + $40,829,232 – 46,465,934).
•

§484.48 Condition of participation: Clinical records.
This section contains provisions that are specifically required in section 1861(o) of the
Act and are necessary to the preservation of a patient’s privacy and quality of care. The
requirements of this section state that a clinical record containing pertinent past and
current findings is maintained for every patient receiving home health services. Clinical
records are retained for 5 years after the month the cost report to which the records apply
is filed with the intermediary. The HHA must have written procedures which govern the
use and removal of records and conditions for release of information. The requirement
that a clinical record be maintained is generally considered to be good medical practice,
and therefore, imposes no burden.
There is a minimal burden associated with the retention of clinical records as this merely
entails the filing of a copy of the record. The annual burden associated with this CoP is
estimated as 3 minutes per patient. Therefore the estimated annual burden for this
requirement is 887,592 – 1,010,129 hours (1,488 patients x 3 minutes x 11,930 – 13,577
HHAs / 60 minutes). The cost of this requirement is $16,773,580 – 19,192,451 (882,820 1,010,129 hours x $19).
The requirement that HHAs develop written procedures governing use of records imposes
a one time burden of 15 minutes on any newly certified HHA for an estimated burden of
137 hours (549 estimated new HHAs x 15 minutes / 60 minutes) at a cost of $8,220 (137
hours x $60) in any given year.

•

§484.52 Condition of participation: Evaluation of the agency’s program.
The HHA has a written policy requiring an overall evaluation of the agency’s total
program at least once a year by the professional group, staff, and consumers. The
evaluation consists of an overall policy, administration, and clinical record review. The
requirements of this section are necessary to ensure responsible management,

CMS-R-39, OMB Control # 0938-0365, Page 9
professional oversight, and quality of care in HHAs. The estimated burdens for this CoP
are associated with the following requirements: 1) the development of a written policy;
2) minutes kept of the annual meeting; 3) a mechanism established in writing for the
collection of data to assist in the evaluation of the agency’s program; and 4) minutes kept
of the quarterly review of clinical files when the appropriate health professionals review a
sample of open and closed clinical files to determine that established policies are
followed.
The development of a written policy governing the annual program evaluation imposes as
one-time burden of 3 hours on each newly certified HHA. The annual meeting can be
evidenced by a copy of the minutes of the meeting, which we estimate will require 10
minutes for each HHA to develop. Written mechanisms for the collection of program
information will impose a one-time burden of 30 minutes on each newly certified HHA.
The quarterly review of clinical files can be evidenced by the minutes of the meeting. We
estimate that this will impose a quarterly burden of approximately 10 minutes on each
HHA. The burden for this CoP is four-fold as indicated below.
1) Development of a written policy:
3 hours x 549 new HHAs = 1,647 hours
1,647 hours x $60 = $98,820
2) Annual meeting minutes:
11,930-13,577 HHAs x 10 minutes / 60 = 1,988 – 2,263 hours
1,988 - 2,263 hours x $19 = $37,772 – 42,997
3) Written mechanisms for the collection of program information:
30 minutes x 549 new HHAs / 60 = 275 hours
275 hours x $60 = $16,500
4) Minutes of Quarterly review of clinical files:
11,930-13,577 HHAs x 10 minutes x 4 quarters / 60 = 7,953- 9,051 hours
7,953 – 9,051 hours x $19 = $151,107 - 171,969
Total estimated burden for this CoP = 11,863 – 13,236 hours
Total estimated cost for this CoP = $304,199 – 330,286
•

§484.55 Condition of participation: Comprehensive assessment of patients.
CMS-R-245: Approved by OMB (OMB Control #: 0938-0760)

Total Burden Estimate
The total annual hourly burden for the information collection requirements under the existing

CMS-R-39, OMB Control # 0938-0365, Page 10
HHA conditions of participation is estimated to 5,644,430 - 6,422,694 hours. The differences in
the estimates (1,048,483.5 hours in the previous estimate and 5,644,430 - 6,422,694 hours in the
current estimate) are due to three main factors. An increase in the number of Medicare-certified
HHAs from 9,354 to 11,930; a steady increase in the number of HHA’s that are expected to
become certified in the next three years; and a significant increase in the number of patients using
HHA services have resulted in an overall increase in burden. For example, the Patient rights
condition of participation requires that all patients be provided with a notice of their rights and
that HHAs document compliance with this CoP. We continue to estimate that such
documentation will require 5 minutes per patient. However, the hourly burden estimate has been
increased because (1) individual HHAs are caring for more patients than estimated in the
previous PRA submission, (2) there are 2,576 more Medicare-certified HHAs than when the last
PRA was submitted, and (3) we estimate that 549 new HHAs will become Medicare certified on
a yearly basis in the next 3 years.
Second, we have adjusted the burden estimate to account for patients from all payer sources. Due
to data limitations, previous Paperwork Reduction Act calculations have only included HHA
patients who received services through the Medicare home health benefit. With improved data
we are now able to reasonably estimate the total number of HHA admissions from all payer
sources, thus increasing our estimate of the total number of patients served.
Table 1: Burden and Cost Estimates Associated with Information Collection Requirements

Regulation
Section
§484.10
§484.10

OMB
Control No.

Respondents
549
11,930-13,577

§484.12
§484.14(g)

549
11,930-13,577

§484.14(i)

11,93013,028
549
11,930-13,577

§484.14(i)
§484.16(a)
§484.18(a) &
(b)
§484.36(b)
§484.36(c)

11,930-13,577

§484.48(a)

11,930-13,577

§484.48(b)
§484.52
§484.52

549
549
11,930-13,577

§484.52(a)
§484.52(b)

549
11,930-13,577

Total

549-13,577

549
11,930-13,577

Responses
549
17,751,84020,202,576
549
17,751,84020,202,576
11,93013,028
549
11,93013,577
17,751,84020,202,576
549
17,751,84020,202,576
17,751,84020,202,576
549
549
11,93013,577
549
47,72054,308
54920,202,576

Burden
per
Response
(in hours)
1
.083

Hourly Labor
Cost of
Reporting ($)
60
46

.5

Total Annual
Burden
(in hours)
549
1,479,3201,683,548
46
887,5921,010,129
5,965- 6,514

1.5
.167

824
1,988- 2,263

60
19

.083

19

.25
3
.167

1,479,3201,683,548
1,647
887,5921,010,129
887,5921,010,129
137
1,642
1,988- 2,263

.5
.167

275
7,953- 9,051

60
19

.083
.05

3
.05
.05

5,644,4306,422,694

60
19
60

60
46
19
60
60
19

Total Cost of
Reporting ($)
32,940
68,048,72077,443,208
2,760
16,864,24819,192,451
357,900390,840
49,440
37,77242,997
28,107,08031,987,412
98,820
40,829,23246,465,934
16,864,24819,192,451
8,220
98,820
37,77242,997
16,500
151,107171,969
171,605,579195,237-759

Total
Capital/
Maintenance
Costs ($)
0
0

0

Total
Costs ($)
32,940
68,048,72077,443,208
2,760
16,864,24819,192,451
357,900- 390,840

0
0

49,440
37,772- 42,997

0

0
0
0

28,107,08031,987,412
98,820
40,829,23246,465,934
16,864,24819,192,451
8,220
98,820
37,772- 42,997

0
0

16,500
151,107- 171,969

0

171,605,579195,237-759

0
0

0
0
0

CMS-R-39, OMB Control # 0938-0365, Page 11

Total burden hours for the existing HHA CoPs = 5,644,430 - 6,422,694 hours
Total hours previously estimated = 1,048,483.5 hours
Increase of hours = 4,595,946.5 – 5,374,210.5 hours
13.

Capital Costs

There are no capital costs associated with this information collection.
14.

Cost to Federal Government

We reimburse State agencies to carry out the task of ensuring compliance with these
requirements. State agencies generally conduct surveys of home health agencies once every three
years. A survey normally requires approximately 70 hours at $138 per hour for a three person
survey team. The total potential cost to the Federal government for HHA initial and
recertification surveys is $131,153,820 every 3 years (70 hours x $138 /hour x [11,930 existing +
1,647 new HHAs]), provided that all HHAs are surveyed by CMS. However, a significant
number of HHAs are deemed providers, and responsibility for surveying these providers is that of
the accrediting bodies through which the HHAs seek their deemed status. Thus, in practice, the
total cost to the Federal government is significantly lower than the total potential cost.
15.

Changes to Burden

The total annual hourly burden for the information collection requirements under the existing
HHA conditions of participation is estimated to be 5,644,430 - 6,422,694 hours. The differences
in the estimates (1,048,483.5 hours in the previous estimate and 5,644,430 - 6,422,694 hours in
the current estimate) are due to three main factors. First, the number of Medicare-certified HHAs
increased from 9,354 to 11,930. Second, we expect a larger volume of HHA’s to become
certified in each of the next three years. And third, an improvement in our data has allowed us to
improve our estimate of the total number of HHA admissions rather than being limited to only
estimating the number of Medicare HHA admissions.
The total annual cost burden has also increased sue to these same factors. Furthermore, the total
annual cost burden has increased due to changes in both the way that the salary estimates are
calculated and increases in base salaries over time. Rather than using a single averaged salary
estimate to assess the burden for each provision, we have chosen to use specific salary amounts
for specific disciplines (e.g. nurses, administrators, and office staff) depending on the discipline
that is most likely to be responsible for implementing the requirement at hand. We have also
increased salary estimates to reflect recent Bureau of Labor Statistics wage data, and have

CMS-R-39, OMB Control # 0938-0365, Page 12
incorporated a benefits and overhead package worth 49% of base salary into our estimates to
better reflect the true costs of employment. We believe that these adjustments more accurately
reflect the impact of these requirements.

16.

Publication and Tabulation Dates

There are no publication or tabulation dates.
17.

Expiration Date

This collection does not lend itself to the displaying of an expiration date.