Hospice PRA 2013 CMS-10277 Supporting_Statement_Part_A 5-7-14 Final - 508 Compliant 06.04.14

Supporting Statement for the Paperwork Reduction Act Submission,
Medicare and Medicaid Programs: Conditions of Participation for Hospices

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),
eligibility requirements, and reimbursement standards and procedures that hospices must meet to
participate in the Medicare program. Portions of the collection of information requirements for the
existing conditions of participation (CoPs) were previously accounted for in OMB control number
0938-0302. We have merged these requirements into this package in order to consolidate all
hospice PRA burdens into a single request.
CMS published the conditions of participation for hospice on June 5, 2008. CMS also published a
FY 2010 Hospice Wage Index Final Rule on August 6, 2009. This final rule promulgated a
change in the physician certification and recertification requirements, which requires physicians to
include a brief narrative on or with the certification or recertification, of terminal illness, and
which synthesizes the clinical information that supports the patient’s having a life expectancy of 6
months or less.
CMS published additional hospice certification requirements in the Home Health Prospective
Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for
Home Health Agencies and Hospices final rule on November 17, 2010. This rule implemented a
provision of the Affordable Care Act. The Affordable Care Act requires that on and after January
1, 2011, a hospice physician or hospice nurse practitioner (NP) must have a face-to-face encounter
with longer-stay hospice patients prior to the 180th-day recertification, and prior to every
recertification thereafter, to determine continued eligibility for the Medicare hospice benefit. The
Affordable Care Act also requires that the physician or NP who had the face-to-face encounter
attest that such visit took place. To implement this provision of the Affordable Care Act, CMS
requires that the attestation either be a separate section of the certification or an addendum, and
that the attestation state that the physician or NP who signed and dated it had a face-to-face
encounter with the patient, and include the patient’s name and the date of the visit. We also
require that when completing the certification or recertification, the physician must sign and date
the document, and include the benefit period dates on the form. With the new statutory
requirements for a face-to-face encounter prior to the 180th-day recertification, and for every
recertification thereafter, it is important for hospices to easily identify which benefit periods
require a recertification visit.
CMS also published an additional hospice certification requirement in the FY 2012 Hospice Wage
Index Final Rule related to the hospice face-to-face encounter attestation. The FY 2012 Hospice
Wage Index Final Rule required that the attestation of a nurse practitioner or of a non-certifying
hospice physician shall state that the clinical findings of that visit were provided to the certifying
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physician for use in determining continued eligibility for hospice care.
This document represents all hospice CoPs and the physician certification and recertification
requirements, including the face-to-face encounter requirements.
B.

Justification

1 . Need and Legal Basis
The information collection requirements described herein are needed to implement the Medicare
CoPs for Medicare-participating hospices. Additionally, they are needed to implement the
certification of terminal illness requirements. We believe many of the requirements applied to
these hospices will impose no burden since a prudent institution would self-impose them in the
course of doing business. Regardless, we have made an attempt to estimate the associated burden
for a hospice to engage in these standard industry practices. Statutory requirements and our
responsibility to assure an adequate level of patient health and safety in participating hospices
require the inclusion of these requirements in standards for care provided in hospices. In addition,
these requirements help ensure that Medicare hospice eligibility requirements are being met.
Section 122 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Pub. L. 97–248,
added section 1861(dd) to the Social Security Act (the Act) to provide coverage for hospice care to
terminally ill Medicare beneficiaries who elect to receive care from a Medicare-participating
hospice. Under the authority of section 1861(dd) of the Act, the Secretary has established the
Conditions of Participation (CoPs) that a hospice must meet to participate in Medicare and/or
Medicaid, and these conditions are set forth at 42 CFR part 418, Subparts C and D. The CoPs
apply to a hospice as an entity as well as to the services furnished to each individual under hospice
care. Under section 1861(dd) of the Act, the Secretary is responsible for ensuring that the CoPs,
and their enforcement, are adequate to protect the health and safety of individuals under hospice
care. To implement this requirement, State survey agencies conduct surveys of hospices to assess
their compliance with the CoPs.
Section 122(c) of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Pub. L. 97–248,
also added section 1814(a)(7) to the Social Security Act (the Act) to outline coverage requirements
for hospice care to terminally ill Medicare beneficiaries who elect to receive care from a Medicareparticipating hospice. Under the authority of section 1814(a)(7)(A)-(C) of the Act, the Secretary
has established eligibility requirements that a hospice must meet for Medicare hospice services to
be covered and paid by Medicare, and these requirements are set forth at 42 CFR part 418, Subpart
B. Under section 1814(a)(7)(A) of the Act, hospices are required to have a certification of
terminal illness for their services to be covered and paid. To implement this requirement, CMS or
its contractors may conduct reviews of claims to assess compliance with coverage requirements.
There are several statutory changes that are incorporated in the hospice CoPs. Specifically, the
Balanced Budget Act of 1997 (BBA, Pub. L. 105–33) permitted hospices to provide physician
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services, including those of a medical director, under contract (§418.64 and §418.102 of the final
rule). It also allowed hospices located in non-urbanized areas to receive a waiver of the
requirement that physical therapy, occupational therapy, speech-language pathology , and dietary
counseling be available on a 24-hour as needed basis (§418.74 of the final rule). Additionally, the
legislation allowed hospices located in non-urbanized areas to receive a waiver of the requirement
that dietary therapy be provided by hospice employees (§418.74 of the final rule). Furthermore,
section 946 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(MMA) (Pub. L. 108–173) amended section 1861(dd) of the Act, to permit a hospice to enter into
an arrangement with another hospice to provide core hospice services or to provide the highly
specialized services of a registered professional nurse, in certain circumstances (§418.64 of the
final rule).
Section 3132 of the Affordable Care Act amended section 1814(a)(7) of the Social Security Act to
require that a hospice physician or nurse practitioner (NP) must have a face-to-face encounter with
the patient prior to the 180th-day recertification, and prior to all subsequent recertifications, to
determine continued eligibility for the hospice benefit. The Affordable Care Act also requires that
the physician or NP who had the encounter attest that such a visit took place.
2.

Information Users

The primary users of this information will be Federal and State agency surveyors for determining
whether a hospice qualifies for approval or re-approval under Medicare, CMS and its contractors
for reviewing claims as a basis for determining whether the patient is eligible for the Medicare
hospice benefit and whether the claim meets criteria for coverage and Medicare payment, and
hospices for assuring their own compliance with all requirements.
3.

Use of Information Technology

Hospices may use various information technologies to store and manage patient medical records as
long as they are consistent with the existing confidentiality in record-keeping regulations at 42
CFR 485.638. This regulation in no way prescribes how the hospice should prepare or maintain
these records. Hospices are free to take advantage of any technological advances that they find
appropriate for their needs.
4.

Duplication of Efforts

There is no duplication of information.
5.

Small Business Impact

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

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6.

Less Frequent Collection

CMS does not collect information directly from hospices on a scheduled basis. Rather, hospices
are expected to maintain their own records in a timely fashion. With less frequent collection, CMS
would not be able to ensure compliance with hospice CoPs and eligibility requirements.
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 November 29, 2013. No public comments were
received.
9.

Payments 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 associated with this information collection.
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 completing and
reviewing the collection of information.
ASSUMPTIONS AND ESTIMATES USED THROUGHOUT
# of Medicare-participating hospices nationwide, CY 2012
# of hospice patients nationwide, CY 2012
# of patients per average hospice
# of new Medicare-participating hospices per year
# of Medicare-billing hospices, from CY 2012 claims
# of Medicare hospice patients, from CY2012 claims
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3,897
1,535,919
394
110
3,727
1,274,076

# of Medicare patients per hospice
342
# of new Medicare-billing hospices per year
95
# of annual certifications & recertifications, from CY 2012
2,021,745
Medicare Enrollment Database (EDB)
# of initial certifications, CY 2012 EDB
988,630
# of recertifications for benefit period 2, CY 2012 EDB
262,806
# of annual recertifications at 180+, from CY 2012 claims,
770,309
CY 2012 EDB
# of elections, from CY 2012 claims
1,048,044
Revocations/beneficiary, based on Jul – Dec 2012 claims
.061
Hourly rate of registered nurse
$41
Hourly rate of office employee
$17
Hourly rate of administrator
$63
Hourly rate of hospice aide
$13
Hourly rate of MSW
$33
Hourly rate of pharmacist
$69
Hourly rate of clinical manager
$55
Hourly rate of QAPI coordinator
$41
Hourly rate of medical director
$107
Hourly rate of nurse practitioner
$51
Note: All salary information is from the Bureau of Labor Statistics (BLS) website at
http://www.bls.gov/oes/current/naics4_621600.htm and includes a fringe benefits package
worth 30% of the base salary. Hourly rates are based on May 2012 BLS data for each
discipline, for those providing “home health care services.” CY = Calendar Year
418.22 Certification of terminal illness
(b) Content of the Certification
Hospices develop their own form for certifications and recertifications, provided the form
conforms to the requirements in 418.22(b), including requirements related to the physician
narrative and to the face-to-face encounter. All forms would include a statement which
specifies that the individual's prognosis is for a life expectancy of 6 months or less if the
terminal illness runs its normal course, and would be signed, dated, and include the benefit
period dates to which the certification or recertification applies. Additionally, the forms
would include space for the physician’s narrative and narrative attestation or a separate
narrative addendum, and the physician or nurse practitioner’s face-to-face encounter
attestation. The burden associated with certification and recertification requirements is 1) the
time for hospices to develop their own forms; 2) the time for the physician to complete the
narrative and its attestation, 3) the time for physician or nurse practitioner to complete the
face-to-face attestation; and 4) the time for the physician to sign and date the form, and the
physician or nurse to include the benefit period dates.
Because all of these requirements have been in place since 2011, the one-time cost of form
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development only falls on new hospices that begin filing Medicare claims. The average
change in the number of hospices that filed Medicare claims from CY 2007 to CY 2012 is an
increase of 95 hospices per year. We estimate that a hospice administrator could develop a
certification or recertification form within 45 minutes. Estimating 45 minutes (0.75 hours)
per hospice to develop the form, the estimated total time burden is (0.75 x 95) = 71.25 hours.
At $63 per hour for the administrator’s time, the cost per hospice would be ($63.00 x 0.75) =
$47.25. Assuming the same growth rate in the number of hospices, the total estimated cost
burden for all new hospices ($63.00 x 0.75 x 95) = $4,489.
We also estimate that it would take a clerical staff person 15 minutes (0.25 hours) to prepare
the certification or recertification form at $17.00 per hour, for an estimated clerical burden of
$4.25 per new hospice ($17.00 x 0.25). For all new hospices each year, we estimate a total
burden of (0.25 x 95) = 23.75 hours, and ($17.00 x 0.25 x 95) = $404.
In total, the estimated annual burden for certification/recertification form development is
$51.50 per new hospice, and $4,893 for all new hospices.
(b)(3)Content of Certification
The physician must include a brief narrative explanation of the clinical findings that supports
a life expectancy of 6 months or less as part of the certification and recertification forms, or as
an addendum to the certification and recertification forms. If the narrative is part of the
certification or recertification form, then the narrative must be located immediately prior to
the physician’s signature. If the narrative exists as an addendum to the certification or
recertification form, in addition to the physician’s signature on the certification or
recertification form, the physician must also sign immediately following the narrative in the
addendum. The narrative shall include a statement directly above the physician signature
attesting that by signing, the physician confirms that he/she composed the narrative based on
his/her review of the patient’s medical record or, if applicable, his or her examination of the
patient. The narrative must reflect the patient’s individual clinical circumstances and cannot
contain check boxes or standard language used for all patients. The narrative associated with
the 3rd benefit period recertification and every subsequent recertification must include an
explanation of why the clinical findings of the face-to-face encounter support a life
expectancy of 6 months or less.
The burden associated with these requirements is the time for the physician to compose a brief
narrative which synthesizes the clinical information supporting the prognosis of a life
expectancy of 6 months or less, and to write, type, or dictate that narrative so that it is on or
attached to the certification or recertification of terminal illness. If the physician chooses to
put the narrative on an attachment, he or she must also sign that attachment, in addition to
signing the certification or recertification form itself.
Because the physician has always been required to review the clinical information needed for
deciding whether or not to certify or recertify the terminal illness, the time required to review
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that information is not included as part of the burden estimate. We estimate it will take the
physician 5 minutes to compose the narrative; write, type, or dictate it; and sign any
attachment. The Medicare Enrollment Database showed that in CY 2012 there were 988,630
initial certifications, 262,806 recertifications of beneficiaries entering the second benefit
period, and 770,309 recertifications for beneficiaries entering the 3rd or later benefit periods.
A narrative would be required on each of these certifications or recertifications, for a total of
2,021,745 narratives. At 5 minutes per narrative, the total annual burden hours for the hospice
are estimated to be 168,479 hours ([2,021,745 x 5 minutes] / 60). At $107 per hour for a
Medical Director, the total annual cost burden is estimated to be $4,837 per hospice (168,479
x $107 / 3,727), and $18,027,253 for all hospices (168,479 x $107).
(b)(4)Content of the Certification
The physician or nurse practitioner who performs the face-to-face encounter with the patient
must attest in writing that he or she had a face-to-face encounter with the patient, including
the name of the patient and the date of that visit. The attestation of a nurse practitioner or a
non-certifying hospice physician shall state that the clinical findings of that visit were
provided to the certifying physician, for use in determining whether the patient continues to
have a life expectancy of 6 months or less, should the illness run its normal course. The
attestation, its accompanying signature, and the date signed, must be a separate and distinct
section of, or an addendum to, the recertification form, and must be clearly titled.
The burden associated with these requirements also includes the time for a physician or nurse
practitioner to complete the attestation, include his or her signature and the date signed, and
include the name of the patient and the date visited. We estimate that half of the attestations
would be completed by physicians, and half by nurse practitioners. We also estimate that it
would take a physician or nurse practitioner 30 seconds to complete the attestation form.
Based on CY 2012 Medicare Enrollment Database data, there were 770,309 recertifications
for patients with lengths of stay of 180 days or longer, which would require an attestation
statement. At $107 per hour for 30 seconds of time for Medical Directors to complete
385,155 attestations (half the attestations), we estimate a burden of $92.15 per hospice ([$107
x 0.0083333 x 385,155] / 3,727). For all hospices, we estimate a burden of 3,210 hours
(0.0083333 x 385,155) at a cost of $343,429 ($107 x 0.0083333 x 385,155). Similarly, at
$51.00 per hour for 30 seconds of time for nurse practitioners to complete 385,154 attestations
(half the attestations), we estimate a burden of $43.92 per hospice ([$51.00 x 0.0083333 x
385,154] / 3,727). For all hospices, we estimate a burden of 3,210 hours (0.0083333 x
385,154) at a cost of $163,690 for all hospices ($51.00 x 0.0083333 x 385,154). Therefore we
estimate a total burden of $136.07 per hospice, and 6,420 hours at a cost of $507,119 for all
hospices to complete the attestation form.
(b)(5)Content of the Certification
All certifications and recertifications must be signed and dated by the physician. It has been
longstanding policy for hospices to have physicians sign and date the certification, so we do
not believe that making this requirement explicit in the regulatory text creates any burden for
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hospices. We also required that the certification or recertification include the benefit period
dates to which it applies, but the physician does not have to be the person to record that
information on the certification. We estimate that it would take a physician or nurse no longer
than 30 seconds, on average, to write in the benefit period dates to which a certification or
recertification applies. Based on 2012 claims data, we estimate that there are 2,021,745
certifications or recertifications completed in a year, with half the benefit period dates written
in by physicians, and half by a nurse. At 30 seconds per certification or recertification, and
using a Medical Director’s hourly rate of $107, we estimate a total burden of $241.85 per
hospice ([1,010,873 x 0.0083333 x $107] / 3,727), and a total burden of 8,424 hours
(1,010,873 x 0.0083333) at a cost of $901,358 for half of all certifications and recertifications
(1,010,873 x 0.0083333 x $107). Likewise, at 30 seconds per certification or recertification,
and using a nurse’s hourly rate of $41, we estimate a total burden of $92.67 per hospice
([1,010,872 x 0.0083333 x $41] / 3,727), and a total burden of 8,424 hours (1,010,873 x
0.0083333) at a cost of $345,380 for the remaining certifications and recertifications
(1,010,872 x 0.0083333 x $41). Therefore, in total, the estimated burden of recording period
dates on certifications and recertifications is $334.52 per hospice, and 16,848 hours at a cost
of $1,246,738 for all hospices.
§418.24 Election of Hospice Care
The individual who elects hospice care must file an election statement with the hospice. The
election statement must include the following:
(a) Identification of the particular hospice that will provide care to the individual.
(b) The individual’s or representative’s acknowledgment that he or she has been given a full
understanding of the palliative rather than curative nature of hospice care, as it relates to the
individual’s terminal illness.
(c) Acknowledgment that coverage of certain Medicare services is waived by the election.
(d) The effective date of the election.
(e) The signature of the individual or representative.
Section 1812(d) of the Act requires that an individual make an election for the period with
respect to a particular hospice program and that the individual shall then be deemed to have
waived this right to payment for certain other Medicare services.
Hospices would bear the one-time cost of developing an election form, and the time to explain
the election form to beneficiaries who are choosing to elect hospice care. Because these
election requirements have been in place since 2005 or prior, election form development
would only apply to new hospices. We expect that each hospice would design its own
election form, which will require a one-time effort of about 1 hour by the hospice
administrator. We estimate that it will take 15 minutes for the hospice nurse to explain the
election form to beneficiaries, and to ensure that they understand what they’re signing.
For form development, the total hours for the estimated 95 new hospices per year would be
(1.0 x 95) or 95 hours. At $63 per hour for the administrator’s time, the cost per hospice
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would be (1.0 x $63) = $63, and the cost for all new hospices would be ($63 x 95) = $5,985.
For explaining the form to beneficiaries, we estimate 15 minutes (0.25 hours) of time per
election. We estimate that there would be 1,048,044 elections, for a total time burden per
hospice of (0.25 x 1,048,044) = 262,011 hours. With 3,727 hospices, there would be
(262,011 / 3,727) = 70 hours per hospice. At $41 per hour for a registered nurse, we estimate
a cost per hospice of (70 x $41) =$2,870, and a total cost for all hospices of (0.25 x $41 x
1,048,044) = $10,742,541.
§418.28 Revoking the Election of Hospice Care
Election of hospice may be revoked at any time during an election period. To revoke the
election the beneficiary must complete a statement that includes the following information:
1. A signed statement that the individual or representative revokes the individual’s election
for Medicare coverage of hospice care for the remainder of the period.
2. The date that the revocation is to be effective.
The revocation provision is found in section 1812(d) of the Act. The revocation waives the
right of the individual to receive Medicare hospice care benefits made in his behalf for the
remaining time in the period. Each hospice is free to design its own form or statement.
Because these requirements have been in place since 1983, the cost to hospices would be the
one-time cost for new hospices to develop a revocation form, and the cost to explain the form
to any beneficiary who revokes hospice care.
We estimate that this would require about 15 minutes (.25 hours) of the hospice
administrator’s time at $63 per hour to develop a form. With 95 new hospices per year, the
one-time hours burden to hospices would be 95 x .25 = 23.75 hours, and the one-time cost per
new hospice would be (0.25 x $63) = $15.75. The total one-time cost for all new hospices
would be (23.75 x $63) = $1,496.
We also estimate that it would take about 5 minutes (0.083333 hours) of the hospice nurse’s
time at $41 per hour to explain the form to the beneficiary. With .061 revocations per
beneficiary and 1,274,076 beneficiaries, we estimate that there would be 77,719 revocations
in a year. At 5 minutes per revocation, we estimate there would be a total of (77,719 x
0.083333) = 6,477 hours for all hospices, and (6,477 / 3,727) = 1.74 hours per hospice to
explain the form to the beneficiaries who revoke. The cost associated with explaining the
revocation form to revoking beneficiaries would be $41 per hour for a nurse’s time, for 5
minutes per revocation, or ($41 x 0.083333 x 77,719) = $265,539, and the cost per hospice
would be ($265,539 / 3,727) = $71.25.
418.52 Patient rights.
(a) Standard: Notice of rights and responsibilities
A hospice must provide patients or their representatives with written and verbal notice of the
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patient’s rights and responsibilities, during the initial assessment visit. The notification must
be presented in a manner and language consistent with the patient’s ability to comprehend the
information. A hospice must also inform and distribute written information to the patient
regarding its policies on advance directives. A hospice must obtain the patient or
representative’s signature to confirm his or her receipt of a copy of the notice of rights and
responsibilities. The burden associated with this notification requirements is the time and
effort necessary for a hospice to: develop the notification form; provide, both verbally and in
writing, the patient or the patient’s representative with a notice of patient’s rights; inform and
distribute information pertaining to its policies on advance directives and applicable State
laws; and obtain signatures from either the patient or representative confirming receipt of a
copy of the notice of rights. We estimate that a hospice will utilize an administrator to
develop the patient right form. We estimate that it will take eight hours on a one-time basis
for a newly participating hospice to develop the form. From 2008-2013 551 new hospices
began participating in the Medicare program, for an average of 110 new Medicareparticipating hospices per year. The total one time burden for the industry is 880 hours (8
hours x 110 new hospices per year). At the average hourly rate of $63 for an administrator, it
will cost a hospice $504 to meet this requirement. The total one time burden cost for the
industry is $55,440 a year ($63 x 880 hours).
We estimate that it will take a registered nurse approximately five minutes per patient to
describe the patient rights information to each patient. We estimate that on average, each
hospice will provide 394 notifications per year and the annual burden hours for a hospice to
notify all its patients of their rights as part of the informed consent process would be 33 hours
([5 minutes x 394 patients] / 60). The total annual burden for the industry would be 127,993
hours ([5 minutes x 1,535,919 patients] / 60). At an average hourly rate of $41 for a
registered nurse, it will cost a hospice $3.42 per patient annually to meet this requirement; the
annual burden cost for a hospice is $1,347 ($3.42 x 394 patients). The total annual burden
cost for the industry is $5,252,843 ($3.42 x 1,535,919 patients).
(b) Standard: Exercise of rights and respect for property and person
As an exercise of patient rights and respect for property and person, a hospice is required to
investigate and document all allegations of abuse, unexplained injuries, and misappropriations
of patient property involving hospice employees and contractors. Hospice employees and
contractors must report alleged patient rights violations to the hospice administrator, and must
report verified violations to appropriate State and local bodies having jurisdiction. A hospice
must also take action to correct problems once they are identified. The burden associated with
the recordkeeping and reporting requirements described in §418.52(b) is the time and effort
necessary to report all alleged violations to the hospice administrator, to conduct and
document an investigation and to maintain record of the documented investigation. We
expect that a hospice administrator will investigate alleged patient rights violations. We
estimate that, in a one year period, a hospice would need to conduct investigational sessions
for alleged violations involving about 5% (20) of its patients and each session would take 1
hour to complete. The total annual burden hours per hospice would be 20 and the total annual
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burden hours for the industry are 77,940 (20 hours x 3,897 hospices) At an average hourly
rate of $63 for an administrator, the annual burden cost for a hospice to perform the
investigations is $1,260 ($63 x 20 hours) and the total annual burden cost for the industry
would be $4,910,220 ($1,260 x 3,897 hospices).
418.54 Initial and comprehensive assessments of the patient.
(a) Standard: Initial assessment; (b) Standard: Timeframe for completion of the
comprehensive assessment; (c) Standards: Content of the comprehensive assessment;
(d) Standard: Update of the comprehensive assessment
The interdisciplinary group (IDG) of a hospice must conduct, document and update, within a
defined timeframe, a patient-specific comprehensive assessment that identifies the patient’s
need for hospice care and services, and the patient’s need for physical, psychosocial,
emotional and spiritual care. While these requirements are subject to the PRA, the associated
burden is as defined in both 5 CFR 1320.3(b)(2) as the burden imposed by these requirements
are considered to be usual and customary business practice. In addition, the burden imposed
by this requirement would exist even in the absence of Federal requirements.
418.54(e) Standard: Patient outcome measures.
A hospice is required to include pre-determined data elements in the comprehensive
assessment for patient care outcome measure purposes. There are no data reporting
requirements. We believe this standard will pose a burden on the hospice provider. However,
the burden of collecting information related to these outcome measures is calculated as part of
a hospice’s quality assessment and performance improvement program (418.58).
418.56 Interdisciplinary group (IDG), care planning and coordination of services.
(a) Standard: Approach to service delivery
A hospice is required to designate an interdisciplinary group with qualified professionals to
establish policies governing the day-to-day provision of hospice care and services. The
burden associated with this requirement is the time and effort necessary to draft, implement,
and maintain the policies governing the day-to-day provision of hospice care services. While
this requirement is subject to the PRA, the burden is considered to be usual and customary,
and is exempt as stated under 5 CFR 1320.3(b)(2).
(b) Standard: Plan of care
A hospice is required to designate an interdisciplinary group with qualified professionals to
develop a plan of care for each patient. In addition, a hospice must ensure that each patient
and the primary caregiver(s) receive appropriate education and training. The burden
associated with this requirement is the time and effort associated with educating and training
the patient and patient caregiver(s). We estimate the time associated for a nurse to educate
and train the patient and caregivers is 30 minutes per patient and 197 hours per hospice ([30
minutes x 394patients] /60), at a cost of $8,077 ($41 x 197). The total annual burden hours
for the industry are 767,709 (197 x 3,897 hospices), and the total annual burden cost for the
industry would be $31,476,069 ($41 x 767,709).
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(c) Standard: Content of the plan of care; (d) Standard: Review of the plan of care
A hospice is required to develop a written, individualized, and content-specific plan of care
with for each patient. The IDG of a hospice is also required to review, revise and document
the plan of care as frequently as the patient’s condition warrants, but no less than every 15
days. Based on a 19 day median length of service, patients would likely receive one update to
their plans of care. The burden associated with these requirements is the time and effort
associated with documenting the plan of care. We estimate the average time for the plan of
care updates is 10 minutes per patient every 15 days, for a total of 65.67 hours per hospice
([10minutes x 394 patients] /60), at a cost of $2,692 ($41 x 65.67). The total annual burden
hours for the industry are 255,916 (65.67 x 3,897 hospices), at a cost of $10,492,556 ($41 x
255,916).
(e) Standard: Coordination of services
A hospice must develop and maintain a system of communication and integration of patient
care information. The burden associated with this requirement is the time and effort required
to develop and maintain the system of communication in accordance with the hospice’s
policies and procedures. While this requirement is subject to the PRA, the associated burden
is considered to be usual and customary as stated in 5 CFR 1320.3(b)(2).
418.58 Quality assessment and performance improvement
A hospice must develop, implement, and maintain an effective, ongoing, hospice-wide datadriven quality assessment and performance improvement (QAPI) program. In addition, the
hospice must maintain documentary evidence of its quality assessment and performance
improvement program. The QAPI program must be able to demonstrate measurable
improvement in indicators related to improved palliative outcomes and hospice services. A
hospice must use all relevant quality indicator data to design its QAPI program, monitor the
effectiveness and safety of services and quality of care, identify, and prioritize improvement
opportunities. A hospice must track adverse patient events, analyze their causes, and
implement preventative actions and mechanisms that include feedback and learning
throughout the hospice. A hospice must measure its success and track performance in its
performance improvement initiatives to ensure that the improvements are continuous. A
hospice is required to develop, justify, implement, and evaluate performance improvement
projects. The burden associated with the requirements contained in §418.58 is the time and
effort necessary to develop, draft, and implement a QAPI program. We estimate the burden of
this requirement in three phases that are based on our experience in implementing the QAPI
requirements of the proposed rule in the Rural Hospice Demonstration project required by
section 409 of the MMA, and from discussions with hospice industry representatives who are
active in implementing QAPI programs nationwide.
In phase one, we believe that a hospice will: 1) identify quality domains and measurements
that reflect its organizational complexity, affect palliative outcomes, patient safety, and quality
of care; focus on high risk, high volume, or problem-prone areas, and track adverse events; 2)
12

develop policies and procedures to collect, document, retrieve, and analyze data; and 3)
educate hospice employees and contractors about the QAPI program. We anticipate that a
hospice will use a hospice QAPI committee which may include a QAPI coordinator, a hospice
administrator, and a clinical manager to perform these functions. We estimate that the QAPI
committee will hold four one-hour meetings for a total of 12 hours a year to identify quality
domains and measures, and develop policies and procedures. Hospices that already
participate in Medicare have already completed this phase, and are therefore excluded from
our analysis. The total burden for the industry is 1,320 hours (12 hours x 110 new hospices
per year). At an average hourly rate of $41, $63, and $55 respectively for these committee
members, the total annual cost for an average hospice to identify the domains and measures is
$636 ([$41 + $63 + $55] x 4 hours). The total annual burden cost for the industry is $69,960
($636 x 110 hospices).
In phase two, we believe a hospice will: 1) enter data into patient records and aggregate data
from different sources; 2) analyze aggregate data to identify patterns, outliers and areas for
improvement; and 3) develop, implement, and evaluate performance improvement projects
based on data analysis. We anticipate that a hospice will use a registered nurse to collect and
enter patient-level quality data at the time of each assessment. We estimate that it will take
the nurse 4 minutes per patient per assessment to comply with this requirement. The annual
burden for each hospice is 53 hours ([4 minutes per patient assessment x 2 assessments per
patient x 394 patients] / 60); the total annual burden hours for the industry is 204,789 hours
([4 minutes per patient assessment x 2 assessments per patient x 1,535,919 patients] / 60). At
an average hourly rate of $41 for a registered nurse, the annual burden cost for a hospice will
be $2,173 ($41 x 53 hours) and the annual cost for all hospices will be $8,396,349 ($41 x
204,789 hours).
Once the data are gathered, a hospice must aggregate and organize the data regularly. We
assume that a hospice will use an office employee to perform the data aggregation and
organization, and that this activity will require four hours per month for a total of 48 hours a
year (4 hours x 12 months); the annual burden hours for the industry would be 187,056 hours
(48 hours x 3,897 hospices). At an average hourly rate of $17 for an office employee, the
cost burden for a hospice will be $816 ($17 x 48 hours) and the cost for all hospices will be
$3,179,952 ($17 x 187,056).
A hospice must analyze data to identify trends, patterns and outliers, areas of strength and
concerns. To meet these requirements, we believe the data analysis will be performed by the
QAPI committee described previously. We assume the committee will meet one hour each
quarter. The annual burden hours for each hospice would be 12 hours (3 members x 4 hours)
and for an annual cost burden of $ 636 ([$41 x 4] + [$63 x 4] + [$55 x 4] = $636). The total
annual burden for the industry to comply with this requirement would be 46,764 hours (12
hours x 3,897 hospices) and the total cost burden for the industry would be $2,478,492 ($636
x 3,897 hospices).

13

In phase three, we estimate that the QAPI committee of a hospice will spend three hours a
year to identify and update new domains and quality measures. The associated annual burden
hours for a hospice will be 3 hours and the total annual burden for the industry would be
11,691 hours (3 hours x 3,897 hospices). The associated cost burden will be $159 ($41 + $63
+ $55). The total annual burden cost for the industry is $619,623 ($159 x 3,897 hospices).
A hospice is required to conduct projects to improve its performance in areas where a
weakness is identified. However, we believe that conducting performance improvement
projects is standard practice within the hospice industry. Therefore, there is no additional
burden associated with this provision.
418.60 Infection control.
A hospice must maintain and document an effective infection control program that protects
patients, families, visitors, and hospice personnel by preventing and controlling infections and
communicable diseases. We believe that the burden associated with this requirement is
exempt from the PRA as defined in 5 CFR 1320.3(b)(2). As stated in 5 CFR 1320.3(b)(2), the
burden imposed by this requirement is considered to be usual, customary and long-standing
clinical practices in the hospice care industry. In addition, the burden imposed by this
requirement would exist even in the absence of the Federal requirement.
418.64 Core services.
A hospice is allowed to contract out core services in certain extraordinary or other non-routine
circumstances. We believe that negotiating, documenting and signing a business contract is
standard business practice and does not pose a burden and is exempt from the PRA as defined
in 5 CFR 1320.3(b)(2).
A hospice is also required to offer bereavement services to appropriate residents of a SNF/NF
or ICF/MR. Residents of a facility often act as a patient’s family, support, and
companionship throughout the terminal illness. Since offering and subsequently providing
bereavement services to a patient’s family is standard practice, we do not believe that
extending such services to those who act as a patient’s family in a SNF/NF or ICF/MR
imposes an additional burden upon a hospice.
418.66 Nursing services – Waiver of requirements that substantially all nursing services be
routinely provided directly by a hospice.
CMS can waive the requirement in §418.64(b) to allow a hospice to provide nursing services
directly, if the hospice is located in a non-urbanized area. To obtain a waiver, the hospice
must provide evidence to CMS that it made good faith efforts to hire a sufficient number of
nurses to provide services. To obtain an extension for a currently approved waiver, a hospice
must submit its request to CMS prior to the expiration of the waiver period and certify that the
conditions under which the hospice originally requested the waiver have not changed. The
burden associated with this requirement is the time and effort associated with a hospice
demonstrating good faith efforts for it staffing process and submitting a certified extension
14

request to CMS stating that the circumstances that caused the original waiver request have not
changed. We believe this requirement and the associated burden is exempt from the PRA
under 5 CFR 1320.3(c)(4). We believe the requirement will affect less than 10 entities on an
annual basis.
418.70 Furnishing of non-core services
A hospice must ensure that the required non-core services are provided directly by the hospice
or under arrangements. These services must be provided in manner consistent with current
standard of practice. We believe that provision of these services is standard industry practice,
and therefore, the burden is not subject to the PRA as stipulated in 5 CFR 1320.3(b)(2).
418.72 Physical therapy, occupational therapy, occupational therapy, speech-language
pathology.
A hospice is required to have physical therapy services, occupational therapy services, and
speech-language pathology services available, and when provided, they must be offered in a
manner consistent with accepted standards of practice. We believe that provision of these
services is standard industry practice, and therefore, the burden is not subject to the PRA as
stipulated in 5 CFR 1320.3(b)(2).
418.74 Waiver of requirement – Physical therapy, occupational therapy, speech-language
pathology, and dietary counseling.
CMS can waive the requirement for providing physical therapy, occupational therapy, speechlanguage pathology, and dietary counseling services (as needed) on a 24-hour basis for
hospices located in non-urbanized areas. To obtain a waiver, a hospice must provide evidence
to CMS that it made good faith efforts to meet the requirements for the aforementioned
services prior to submitting a waiver request. To obtain an extension for a currently approved
waiver, a hospice must submit its request to CMS prior to the expiration of the waiver period
and certify that the conditions under which the hospice originally requested the waiver have
not changed. The burden associated with this requirement is the time and effort associated
with a hospice demonstrating good faith efforts for it staffing process and submitting a
certified extension request to CMS stating that the circumstances that caused the original
waiver request have not changed. We believe this requirement and the associated burden is
exempt from the PRA under 5 CFR 1320.3(c)(4). We believe the requirement will affect less
than 10 entities on an annual basis.
418.76 Hospice aide and homemaker services.
(a) Standard: Hospice aide qualifications.
(b) Standard: Content and duration of hospice aide classroom and supervised practical
training.
(c) Standard: Competency evaluation.
All hospice aide services must be provided by individuals who meet the personnel
requirements and training criteria as specified. A hospice is required to maintain
documentation that each hospice aide meets these qualifications. The burden associated with
15

these standards is the time to complete the required documentation. We estimate that it will
take five minutes a year to document the information and that an office employee will
complete this task. In addition, based on an employee turnover rate of 30% as indicated in the
2002 NHPCO National Data Set Summary Report, we assume that the average hospice would
replace 30% of its hospice aides in a given year, or roughly one hospice aide a year based on
the employment of 5 hospice aides. We estimate that there will be 325 annual burden hours
([5 minutes x 3,879 hospices] / 60) for the hospice industry. At an hourly rate of $17 for an
office employee, the annual burden cost for a hospice is $1.42 and the annual burden cost for
the industry is $5,534 ($1.42 x 3,897).
(d) Standard: In-service training
A hospice is required to maintain documentation that all hospice aides have received at least
12 hours of in-service training during each 12-month period. The burden associated with this
requirement is the time and effort necessary to document and maintain record of the required
in-service training. We estimate it will take each hospice 2 hours annually to meet this
requirement. The estimate total annual burden for this requirement is 7,794 hours (2 hours x
3,897 hospices). At an hourly rate of $17 for an office employee, the annual burden cost for a
hospice is $34 and the annual burden cost for the industry is $132,498 ($34 x 3,897).
(g) Standard: Hospice aide assignment and duties
A hospice aide is assigned to a patient by a registered nurse who is a member of that patient’s
IDG. Additionally, a hospice aide receives written patient care instructions prepared by the
registered nurse who is responsible for supervising the hospice aide. The burden associated
with this requirement is the time and effort necessary for a registered nurse responsible for
supervising a hospice aide to draft written patient care instructions for the hospice aide. We
believe that preparing patient care instructions is a usual and customary business practice, and
is hereby exempt from the PRA under 5 CFR 1320.3(b)(2).
(h) Standard: Supervision of hospice aides
A hospice is required to have a registered nurse perform a periodic on-site evaluation of a
hospice aide and evaluate the sufficiency of services ordered by the IDG. The burden
associated with this requirement is the time and effort necessary for a nurse to conduct an
onsite evaluation of aide services in the patient’s home, to document the quality of care
provided by the hospice care aide, and to evaluate the services ordered by the IDG to ensure
that they are consistent with the patient’s needs. We believe this is a usual and customary
business practice, and is thereby exempt from the PRA under 5 CFR 1320.3(b)(2).
(i) Standard: Individuals furnishing Medicaid personal care aide-only services under a
Medicaid personal care benefit
Prior to furnishing personal care services, an individual must demonstrate competency in the
services they are required to furnish. The burden associated with this requirement is the time
and effort necessary to demonstrate competency. While this requirement is subject to the
PRA, we believe the associated burden is exempt stated in 5 CFR 1320.3(b)(2). We believe
this is a usual and customary business practice.
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(j) Standard: Homemaker qualifications
(k) Standard: Homemaker supervision and duties
A hospice homemaker is required to complete a hospice orientation program addressing the
needs and concerns of patients and families. A member of the interdisciplinary group is
required to provide written instructions to the homemaker. Since all hospices usually train,
instruct, and supervise all of their employees, including homemakers, we do not believe this
standard would impose any additional regulatory burden.
Homemakers are also required to report all concerns about the patient or family to the
member of the IDG who is coordinating the homemaker’s services. The burden associated
with this requirement is the time and effort needed for the homemaker to report all concerns.
We believe the burden is exempt as stated in 5 CFR 1320.3(b)(2); this is a usual and
customary business practice.
418.78 Volunteers.
(a) Standard: Training
A hospice must document, maintain, and provide volunteer orientation and training that is
consistent with hospice industry standards. We estimate on average that a hospice would
provide orientation and training six times per year; we estimate that it will take no longer than
five minutes to document each orientation section for a total of 30 minutes year per hospice (5
minutes x 6 times per year) per. The total annual burden associated with this requirement is
1,949 hours for the industry ([30 minutes x 3,897 hospices] / 60). At an hourly rate of $17 for
an office employee, the annual burden cost for a hospice is $8.50 and the annual burden cost
for the industry is $33,125 ($8.50 x 3,897 hospices).
(c) Standard: Recruiting and retaining
A hospice is required to document and demonstrate viable and ongoing efforts to recruit and
retain volunteers. The burden associated with this requirement is the time and effort necessary
to document and demonstrate the recruitment and retention efforts. We estimate that it will
take each hospice 3 hours to document and demonstrate its recruitment and retention efforts,
for a total annual burden of 11,691 hours for the industry (3 hours x 3,897 hospices). At an
hourly rate of $17 for an office employee, the annual burden cost for a hospice is $51 and the
annual burden cost for the industry is $198,747 ($51 x 3,897 hospices).
(d) Standard: Cost saving
A hospice is required to document the cost savings achieved through the use of volunteers.
We estimate that complying with this requirement will take 3 hours per hospice per year, or
11,691 annual burden hours for the industry (3 hours x 3,897 hospices). At an hourly rate of
$63 for an administrator, the annual burden cost for a hospice is $189 and the annual burden
cost for the industry is $736,533 ($189 x 3,897 hospices).
(e) Standard: Level of activity
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A hospice is required to document and maintain records on the use of volunteers for patient
care and administrative services, including the type of services and time worked in a minimum
amount that equals 5% of the total patient care hours of all paid employees and contract staff.
The burden associated with this requirement is the time and effort necessary to document and
maintain the volunteer records. We estimate that recording these examples would take
approximately 48 hours per year per hospice for a total annual burden of 187,056 hours for the
industry (48 hours x 3,897 hospices). At an hourly rate of $17 for an office employee, the
annual burden cost for a hospice is $816 and the annual burden cost for the industry is
$3,179,952 ($816 x 3,897 hospices).
418.100 Organization and administration of services.
(e) Standard: Professional management responsibility
A hospice that has a written agreement with another agency, individual, or organization to
furnish any services under arrangements, must retain administrative and financial
management, and oversight of staff and services for all arranged services, to ensure the
provision of quality care. The written agreement serves as a contract between the hospice and
another individual or entity. The agreement protects the beneficiary, the hospice, and the
other provider. This requirement assures accountability of the hospice and the other provider.
The agreement will list the responsibilities of the hospice and the inpatient provider, as well
as the regulatory provisions. We estimate the development of the agreement will take the
administrator approximately 80 hours. Although establishing a written agreement with a
given entity is usually a one-time process, we believe that hospices change or add new
contracting partners on a routine basis. The burden associated with this requirement is the
time and effort necessary to develop, the written agreements. For purposes of this analysis, we
assume that, on average, each hospice will establish one new written agreement per year, for a
total of 311,760 hours for all hospices (80 hours x 3,897 hospices). At an hourly rate of $63
for an administrator, the annual burden cost for a hospice is $5,040 ($63 x 80 hours) and the
annual burden cost for the industry is $19,640,880 ($5040 x 3,897 hospices).
(f) Standard: Hospice multiple locations
A hospice must continually monitor and manage all services provided at all of its locations.
The burden associated with this requirement is the time and effort necessary to monitor and
manage all of the services provided at all of its locations. The burdens associated with this
requirement is considered to be usual and customary as stated in 5 CFR 1320.3(b)(2), and is
thereby exempt from the PRA.
(g) Standard: Training
A hospice is required to provide an initial orientation for each employee that addresses the
employee’s specific job duties. In addition, a hospice must have written policies and
procedures describing its method(s) of assessment of competency. Also, the hospice must
maintain a written description of the in-service training provided during the previous 12
months. The burden associated with the requirements of this section is considered to be usual
and customary under 5 CFR 1320.3(b)(2); usual and customary burdens are exempt from the
PRA.
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418.102 Medical director.
A hospice is required to designate an alternative physician as the medical director to assume
the role and responsibilities of the medical director in the absence of the latter. All hospices
routinely meet the medical needs of their patients 24 hours a day with the availability of more
than one physician. We do not believe this requirement would pose a burden to a hospice.
(a) Medical director contract
We added a provision permitting the medical director to work under a contractual
arrangement, reducing the program and hiring burden on the hospice. If a hospice chooses to
secure medical director services through a contract, this rule requires the contract to specify
the physician who will serve as the medical director. Identifying a single individual to serve
as the hospice medical director is standard practice in the hospice industry and does not
present a burden.
(b) Standard: Initial certification of terminal illness
(c) Standard: Recertification of the terminal illness
Hospice medical directors or physician designees are required to review the clinical
information for each hospice patient and provide written certification that it is anticipated that
the patient’s life expectancy is 6 months or less if the illness runs its normal course. The
burden for certifying and recertifying a patient’s life expectancy is already assessed in a
previous section of this document.
(d) Standard: Medical director responsibility
This standard re-codifies the requirement that the medical director or designee has
responsibility for the medical component of the hospice’s patient care program. It is standard
practice for the hospice medical director to lead, and thus bear responsibility for, the medical
component of the hospice’s patient care services. Therefore, this provision does not impose a
burden upon a hospice.
418.104 Clinical records associated.
(a) Standard: Content
(b) Standard: Authentication
(c) Standard: Protection of information
A hospice is required to maintain a clinical record for each patient. The clinical records must
contain specific information and must be authenticated in accordance with hospice policy.
The burden associated with the requirement is the time and effort necessary to document and
maintain the information. The maintenance of clinical records is a usual and customary
business practice; the burden associated with maintaining a clinical record is exempt form the
PRA under 5 CFR 1320.3(b)(2). Furthermore, a hospice is required to protect and retain the
information contained in the clinical record in accordance with the Department’s rules
regarding personal health information at 45 CFR parts 160 and 164. All of these requirements
reflect standard hospice practices and do not pose a burden.
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(d) Standard: Retention of records
A hospice is required to retain patients’ clinical records for 6 years after the death or discharge
of the patient, unless State law stipulates a longer period of time. If the hospice discontinues
operation, hospice policies must provide for retention and storage of clinical records. The
burden associated with these requirements is the time and effort necessary to maintain records
for 6 years after the death or discharge of the patient, and to draft, implement, and maintain
the record retention policy in the event that the hospice discontinues operation. While this
requirement is subject to the PRA, we believe the associated burden is exempt as stated in 5
CFR 1320.3(b)(2). The development and maintenance of a record retention policy is a usual
and customary business practice.
(e) Standard: Discharge or transfer of care
A hospice is required to prepare and send a comprehensive discharge summary for all patients
that are discharged alive. The discharge summary must include a summary of the patient’s
stay, the patient’s current plan of care, the most recent physician orders, and any other
documentation to aid in post-discharge care of the patient. These are standard elements for
discharge summaries in the health care industry, including the hospice industry. This rule also
requires a hospice to send a copy of the patient’s clinical record to the provider assuming care
of the patient, upon request of the provider. A comprehensive discharge summary should
remove any reason for the provider assuming care to request a copy of the patient’s clinical
record. We believe that these discharge requirements reflect standard industry practice and
add no burden to a hospice.
(f) Standard: Retrieval of clinical records
A hospice must make clinical records, whether in hard copy or electronic form, readily
available on request by an appropriate authority. The burden associated with this requirement
is the time and effort required to disclose a clinical record to an appropriate authority. While
this requirement is subject to the PRA, we believe the associated burden is exempt as stated in
5 CFR 1320.3(b)(2). Making clinical records available to the appropriate authority is part of
the survey and certification process, and imposes no additional burden as a usual and
customary business practice.
418.106 Drugs and biologicals, medical supplies, and durable medical equipment.
(a) Standard: Managing drugs and biologicals
A hospice must require its interdisciplinary group to confer with an individual with education
and training in drug management to ensure that drugs and biologicals meet patient needs. A
hospice may meet this requirement by hiring or contracting with a pharmacist(s), or
contracting with a pharmacy benefit management company, or hiring or contracting with a
physician or other clinician with the necessary education and training in drug management, or
by ensuring the appropriate education and training of one or more existing hospice employees.
The burden associated with this requirement is the time necessary to document the results of
20

this consultation in each patient’s clinical record. For purposes of our analysis only, we
assume that an average hospice will confer with a pharmacist, and that the pharmacist will
document the results of his/her consultation. We estimate that it requires 5 minutes to
document the initial review of a patient’s drug and biologicals. Additionally, we estimate that
it requires 5 minutes of the pharmacist’s time to document a review of updates to the patient’s
drug profile. Based on a 19 day median length of service, patients would likely receive one
update to their plans of care. At an average hourly rate of $69 for a pharmacist, we estimate
that it would cost a hospice $12 per patient ($69 x [5 minutes for initial + 5 minutes for 1
update]) and an annual cost of $4,728 ($12 x 394 patients). The total annual burden hours for
all hospices are 255,987 hours ([1,535,919 patients x 10 minutes per patient] / 60), and the
total annual burden cost for all hospices is $18,431,028 ($12 per patient x 1,535,919 patients).
(b) Standard: Ordering of drugs
Under the hospice final rule, the individual receiving a drug order must record and sign it
immediately and have the prescribing person sign it in accordance with State and Federal
regulations. The burden associated with this requirement is the time and effort necessary for
the recipient of the order record and sign the order and to have the prescribing person sign the
prescription. The burden associated with this requirement is exempt under both 5 CFR
1320.3(b)(2) and 5 CFR 1320.3(b)(3). As defined in 5 CFR 1320.3(b)(2), this process is a
usual and customary business practice. As defined in 5 CFR 1320.3(b)(3), a State
requirement would exist even in the absence of the Federal requirement. The associated
burden is thereby exempt from the PRA.
(c) Standard: Dispensing of drugs and biologicals
A hospice that provides inpatient care directly in its own facility must have a written policy in
place that promotes dispensing accuracy. Additionally, a hospice that provides inpatient care
directly must maintain current and accurate records of the receipt and disposition of all
controlled drugs. The burden associated with this requirement is the time and effort necessary
to develop, draft, implement, and maintain a written policy that promotes dispensing accuracy
and to maintain controlled drug records. The existence of this type of policy and these records
are usual and customary business practices. The burden associated with this section is exempt
from the PRA under 5 CFR 1320.3(b)(2).
(e) Standard: Labeling, disposing and storing of drugs and biologicals
A hospice must have a written policy for the management and disposal of controlled drugs in
a patient’s home. A hospice must educate the patient or his/her representative and family in
the safe use and disposal of controlled drugs when a controlled is first ordered. A hospice
must document in a patient’s clinical record that the written policy for managing controlled
drugs was provided and discussed. A hospice must maintain current and accurate records of
the receipt and disposition of all controlled drugs. The burden associated with these
requirements is the time and effort necessary to document a written copy of the policy on the
management and disposal of controlled drugs in the patient’s home was given to the patient
representative and family. We estimate that it will take a registered nurse five minutes to
21

complete the patient education documentation at a cost of $3 for each patient (5 minutes/60 x
$41). The total annual burden hours for a hospice to meet this requirement would be 33 hours
([5 minutes x 394 patients] / 60) at a cost of $1,353 (33 hours x $41 per hour), and the total
annual burden hours for the industry would be 127,993 ([5 minutes x 1,535,919 patients] /
60). The total annual burden cost for the industry is $4,607,757 ($3 per patient x 1,535,919
patients).
Furthermore, the pharmacist and the administrator of a hospice program that provides
inpatient care directly in its own facility must investigate discrepancies involving controlled
drugs and to document an account of the investigation. Of the 1,510 deficiencies issued by
State surveyors 2012, only two were related to controlled drug discrepancies. Thus, we do not
believe that investigating drug discrepancies and documenting the results of those
investigations occurs on a regular basis. Therefore, while this requirement is subject to the
PRA, we believe the burden is exempt under 5 CFR §1320.3(c)(4), as it would affect less than
10 entities.
(f) Standard: Use and maintenance of equipment and supplies
A hospice must ensure that manufacturer recommendations for routine and preventive
maintenance of equipment are followed. A hospice must ensure that repair and routine
maintenance policies are developed in situations when a manufacturer’s recommendation for a
piece of equipment is nonexistent. The burden associated with this requirement is the time
and effort necessary to develop, draft, implement, and maintain repair and routine
maintenance policies. However, proper maintenance of equipment is standard practice.
A hospice is required to contract only with a durable medical equipment supplier that meets
the Medicare DMEPOS Supplier Standards at 42 CFR 424.57. The vast majority of hospices
provide durable medical equipment and supplies under contract with one or more vendors.
All vendors with Medicare supplier numbers must meet the DMEPOS Standards, per separate
CMS rulemaking. Since all Medicare-participating suppliers must already meet the standards,
we do not believe that this requirement will compromise a hospice’s ability to secure a
contract or impose a burden.
In addition, a hospice must ensure that the patient, family, and other caregivers receive
instruction in the safe use of durable medical equipment and supplies. After providing
instruction, the patient, family, and/or caregiver must be able to demonstrate the appropriate
use of durable medical equipment. As defined in 5 CFR 1320.3(b)(2), providing proper
instruction on the use of durable medical equipment to patient, family members, and
caregivers is a usual and customary business.
418.108 Short term inpatient care.
(c) Standard: Inpatient care provided under arrangement
A hospice is required to include specific provisions in a written agreement if it has an
arrangement with a facility to provide short-term inpatient care. The burden associated with
this requirement is the time and effort necessary to develop, draft, execute, and maintain the
22

written agreement. While this requirement is subject to the PRA, the burden is exempt under
5 CFR 1320.2(b)(2). The use of the written agreements between providers is a usual and
customary business practice.
(c)(1) The hospice must furnish a copy of the hospice plan of care to any inpatient provider
that is furnishing inpatient hospice care under arrangements. The inpatient care must be
furnished by a facility that meets the requirements in § 418.110(b) and (e).
This requirement is an important factor in assuring that the hospice maintain professional
management responsibility for all services furnished to an individual, regardless of the
location or facility in which such services are furnished (1861(dd )(2)(A)(ii)(I) of the Act).
The plan of care is typically from two to five pages long. It is estimated that 23% of hospice
patients receive one inpatient care stay for an average of 5.5 days per stay. The average
number of hospice patients per hospice is 394 x 23% = 91 patients per hospice require
inpatient stays. This requirement may be met by providing a copy of this plan, thus the
burden is the time taken to produce a copy of the plan. We estimate it will take the hospice
office employee 10 minutes to copy and mail each plan, for a total of 15 hours per hospice
annually ([10 minutes x 91] /60)at an estimated cost of $255 per hospice ($17 x 15hours).
The total annual burden hours for the industry would be 58,455 hours for all hospices (15
hours x 3,897 hospices) at an estimated cost of $993,735 ($17 x 58,455).
(c)(3) Inpatient services and events (e.g., treatments, tests, consultations, evaluations, etc.)
furnished by the inpatient provider, and a copy of the discharge summary, are entered in the
hospice’s medical record.
This requirement implements section 1861(dd)(2)(C) of the Act, which requires the hospice to
maintain a complete clinical record. It is also designed to assure continuity of care and
professional management responsibility. This requirement will be met by including a copy of
the discharge summary prepared by the inpatient provider. We estimate that it will takes the
hospice office staff 5 minutes to place the inpatient discharge summary into the hospice
medical record, for a total of 8 hours per hospice annually ([5 minutes x 91] /60) at an
estimated burden of $136 (8 hours x $17). The total annual burden hours for the industry
would be 31,176 (8 hours x 3,897 hospices) at an estimated cost of $529,992 ($136 x 3,897
hospices).
The burden of acquiring this information is required under 418.108(c)(1), above. Retaining it
is necessary to meet the clinical record requirement in 1861(dd)(2)(C) of the Act to assure
continuity of care and professional management responsibility. The requirement that health
care providers retain medical records is also a matter of State law.
418.110 Hospices that provide inpatient care directly.
(b) Twenty-four hour nursing services
This requirement for a hospice that provides general inpatient care directly to have a registered
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nurse on each shift to provide direct patient care has been in place since the inception of the
Medicare hospice Conditions of Participation. As such, it is standard practice and does not
pose a burden.
(c) Standard: Physical environment.
A hospice must have a written disaster preparedness plan in effect to manage emergencies that
might compromise the hospice’s ability to provide care. Additionally, the plan must be
periodically reviewed. The burden associated with this requirement is the time and effort
necessary to develop, draft, implement, maintain, and periodically review the disaster
preparedness plan. A hospice is required to develop procedures for managing physical plant
issues. The burden associated with the requirement is the time and effort necessary to draft,
implement, maintain, and review the facility’s disaster preparedness plans and procedures to
address physical plant issues. While these requirements are subject to the PRA, we believe
the associated burden is exempt as stated in 5 CFR 1320.3(b)(2).
(d) Standard: Fire protection
(e) Standard: Patient areas
(f) Standard: Patient rooms
(g) Standard: Toilet and bathing
(h) Standard: Plumbing facilities
(i) Standard: Infection control
(j) Standard: Sanitary environment
(k) Standard: Linen
(l) Standard: Meal service and menu planning
A hospice is required to comply with applicable fire safety requirements, provide a home-like
atmosphere with sufficient space and amenities, maintain an adequate infection control
program, provide clean linens and properly handle soiled ones and serve meals to meet patient
needs. These requirements are standard practice in hospice-operated inpatient facilities and
pose no additional burden.
(m) Standard: Restraint or seclusion
A hospice shall implement restraint and seclusion in accordance with safe and appropriate
restraint and seclusion techniques as determined by hospice policy in accordance with State
law and the written plan of care shall be modified. The burden associated with this
requirement is the time and effort necessary to modify the plan of care in writing to include
the physician order for restraint and seclusion.
A hospice shall use restraint or seclusion in accordance with a physician’s orders per hospice
policy in accordance with State law. There is a burden associated with creating a physician’s
order. However, we believe the burden associated with the aforementioned requirements is
exempt from the PRA under 5 CFR 1320.3(b)(2), as they are part of the usual and customary
business practice for hospices.
Prior to writing a new order for the use of restraint or seclusion, a physician must see and
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assess the patient. The burden associated with this requirement is the time and effort
necessary for the ordering physician to see and assess the patient. Further, when restraint or
seclusion is used, a hospice patient’s clinical record must contain the specified documentation.
The burden associated with this requirement is the time and effort necessary to compile the
specified documentation in the patient’s clinical record. We estimate the collective burden
associated with the above requirements to be 45 minutes per event at a cost of $31 ([$41/60] x
45). There are 1,018 hospices that operate their own inpatient facilities. Based on public
comments related to the hospice CoP proposed rule and the results of hospice surveys, we
believe that the use of seclusion and restraint techniques is very rare. For purposes of this
analysis, we assume that each hospice-operated inpatient facility will need to use a seclusion
or restraint technique for one patient in a given year. Therefore, we estimate the collective
burden associated with the above requirements to be 764 hours annually at a cost of $23,684
($31 x 764).
(n) Standard: Restraint or seclusion staff training requirements
Patient care staff working in the hospice inpatient facility and who are involved in the
application of restraint or seclusion must be trained in accordance to specific requirements,
and able to demonstrate competency in the application of restraints, implementation of
seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. A
hospice must document in the personnel records that each employee successfully completed
the restraint and seclusion training and demonstrated competency.
The burden associated with this requirement is the time to develop a staff-wide training
program and to document the required training completion information in each employee’s
personnel record. We estimate that developing a staff-wide training program will require 40
hours on a one-time basis for each affected hospice, at a cost of $1,640 ($41 x 40 hours) per
newly opened hospice inpatient facility. In the past 5 years, 272 new inpatient facilities have
been opened, for an average of 54 new inpatient facilities per year. All currently existing
inpatient facilities have already incurred a burden develop a staff-wide training program, and
should be excluded from this analysis. Therefore, we will only be assessing the burden
imposed upon the 54 new inpatient facilities that are likely to open each year. As such, we
estimate a total one-time cost of $88,560 for the industry each year ($1,640 x 54). The total
associated annual burden hours for the industry are 2,160 (40 hours per hospice x 54).
A hospice is required to revise its training program annually as needed. We estimate that it
will take 4 hours a year each hospice to complete this task, and the total annual burden hours
for the industry are 4,072 hours (4 hours x 1,018 hospices with inpatient units). At an average
hourly rate of $41 for a registered nurse, the annual burden cost for each hospice is $164 ($41
x 4 hours), and the total annual burden cost for the industry are $166,952 ($164 x 1,018
hospices with inpatient units).
Additionally, a hospice is required to document in each trained individual's personnel record
that he or she has successfully completed the training. We estimate that it will take 5 minutes
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to document each participant’s training record. For purposes of this analysis only, we assume
that 16 hospice employees (12 nurses and 4 ordering physicians) will be trained and need
documentation. We estimate that it will take an office employee 1.33 hours ([5 minutes x 16
trainees] / 60) at a cost of $23 ($17 x 1.33 hours) annually to meet this requirement. For the
hospice industry, the total annual burden hours are 1,357 hours ([5 minutes x 16 employees x
1,018] / 60) and the total annual burden cost for the industry is $23,069 ($17 x 1,357 hours).
(o) Standard: Death reporting requirements
A hospice must report deaths associated with the use of restraint or seclusion. The hospice
staff must document in the decedents clinical record the date and time the death was reported
to CMS by telephone. Since the inception of this requirement, CMS has not received any
reports, which confirms our understanding that such deaths are exceedingly rare. Therefore,
while this requirement is subject to the PRA, we believe the burden is exempt under 5 CFR
§1320.3(c)(4), as it would affect less than 10 entities.
418.112 Hospices that provide hospice care to residents of a SNF/NF or ICF/MR.
(a) Standard: Resident eligibility
This standard requires that Medicare patients receiving hospice services and residing in a
SNF, NF, or ICF/MR must be subject to the Medicare hospice eligibility criteria as delineated
in the current hospice rule. The burden associated with this requirement is the time and
efforts to validate patients’ Medicare eligibility. Validating Medicare eligibility for hospice
services is already addressed in a previous section of this package; therefore we will not be reestimating the burden here.
(b) Standard: Professional management
A hospice must assume responsibility for professional management of the resident’s hospice
services provided, in accordance with the hospice plan of care and the hospice conditions of
participation, and make any arrangements necessary for hospice-related inpatient care in a
participating Medicare/Medicaid facility. The burden associated with this standard is the time
and efforts needed to ensure these responsibilities are met. We believe that in fulfilling these
requirements, a hospice will not incur any burden above and beyond its usual and customary
business practice.
(c) Standard: Written agreement
A hospice and SNF/NF or ICF/MR must have a written agreement that specifies the provision
of hospice services in the facility. The agreement must be signed by authorized
representatives of the hospices and the SNF/NF or ICF/MR prior to the provision of hospice
care services. This rule establishes the minimum content of the written agreement that a
hospice provider must have with a SNF/NF or ICF/MR if the hospice is caring for a resident
of the facility. The burden associated with this requirement is the time and effort necessary to
develop, draft, sign, and maintain the written agreement. However, the use of this type of
written agreement is a usual and customary business practice; the associated burden is exempt
from the PRA under 5 CFR §1320.3(b)(2).
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(d) Standard: Hospice plan of care
A written plan of care must be established and maintained in consultation with SNF/NF or
ICF/MR representatives. The burden associated with this requirement is discussed under our
discussion of §418.56(c).
(e)(3) Standard: Coordination of services
In the coordination of services for residents of a SNF, NF, or ICF/MR, a hospice is required to
designate an IDG member to coordinate a patient’s care with facility representatives,
including provision of specific information about the patient’s care. The specific information
includes the patient’s hospice election form, advance directives, certification forms, physician
orders, contact information for pertinent hospice personnel and hospice’s 24-hour on-call
system, patient’s medication, and physician’s orders.
With the exception of the election and advanced directives forms, certification forms, and
physician orders, all of the specified information is routinely provided to a patient’s
caregiver(s). Since the facility is the caregiver, providing this information presents no burden
to a hospice. We believe that a hospice would use an office employee to fax the required
documents to the facility and it would take 10 minutes to complete this task for each patient.
According to a 2009 Office of the Inspector General report
(https://oig.hhs.gov/oei/reports/oei-02-10-00070.pdf), 31 percent of hospice patients
nationwide resided in a SNF or other long term care facility. Therefore, we estimate that
hospices will provide forms to SNFs/NFs and ICFs/MR for hospice 476,135 patients
(1,535,919 patients x 31%) residing in those facilities. We also estimate that the average
hospice will provide care to 122 patients residing in a SNF/NF or ICF/MR (476,135 patients
nationwide / 3,897 hospices). We estimate that the total annual burden hours for each hospice
to meet this requirement are 20 hours ([10 minutes x 122 patients] / 60), and the total burden
hours for the industry are 79,356 hours ([10 minutes x 476,135 patients] / 60). At an average
hourly rate of $17 for an office employee, the cost burden cost for each hospice is $340 ($17 x
20 hours) and the total cost for the industry is $1,349,052 ($17 x 79,356 hours). The cost per
patient for a hospice to fax the forms would be $2.83 ($1,349,052 /476,135 patients).
(f) Standard: Orientation and training of staff
A hospice is required to ensure that SNF/NF and ICF/MR staffs receive orientation in caring
for hospice patients. Staff orientation must address the following topics: hospice philosophy;
hospice policies regarding patient comfort methods, pain control, and symptom management;
principles about death and dying; individual responses to death; patient rights; appropriate
forms; and record keeping requirements. We recognize that residents in a single facility may
be served by several hospices, and many hospices will rely on the orientation already provided
by another hospice. We do not know exactly how many hospices serve patients residing in a
SNF/NF or ICF/MR, or how many of those facilities are served by multiple hospices.
Therefore, we cannot estimate the number of hospices that will conduct orientation sessions
for SNF/NF and ICF/MR staff. We believe that any burden associated with orienting SNF/NF
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and ICF/MR will be minimal because hospices already orient patients and families/caregivers
about many of the topics covered in this standard (that is, hospice philosophy and principles
about death and dying). Since the SNF/NF or ICF/MR staff act as the patient’s care giver,
orienting them would be very similar to orienting the patient’s family/caregiver. Orientation
to patient families/caregivers is usual and customary practice and does not incur burden for
hospices.
418.114 Personnel qualifications.
(a) Standard: General qualifications
All hospice professionals, who furnish hospice services directly, under contract, or under
arrangement with a hospice, must be legally authorized (licensed, certified or registered) in
accordance with applicable Federal, State and local laws, and must act only within the scope
of his or her State license, or State certification, or registration. All personnel qualifications
must be kept current at all times. As defined in 5 CFR 1320.3(b)(2), these requirements is a
usual and customary business practice. As defined in 5 CFR 1320.3(b)(3), a State
requirement would exist even in the absence of the federal requirement. The associated
burden is thereby exempt from the PRA.
(b) Standard: Social worker
The social worker in a hospice program must either be a Social Worker with a master degree
(MSW) from a school of social work accredited by the Council on Social Work Education and
one year of experience in a health care setting; or a Social Worker with a baccalaureate degree
(BSW) from a school of social work accredited by the Council on Social Work Education and
one year of experience in a health care setting; or a Social Worker with a baccalaureate degree
in psychology, sociology, or other field related to social work and at least one year of social
work experience in a health care setting. If a hospice chooses to employ a social worker with
a baccalaureate degree in social work, psychology, sociology, or other field related to social
work, the services of the BSW must be provided under the supervision of a MSW. This
supervision may occur in person, over the telephone, through electronic communication, or
any combination thereof. The burden associated with this social work qualification
requirement is the time and cost to document BSW supervision by an MSW. By virtue of the
personnel qualifications for social workers in hospice that existed from the inception of the
hospice CoPs in 1983 until finalization of the new CoPs in 2008, all hospices in existence
prior to 2008 qualified for an exemption of MSW supervision described above.
In 2009 7,992 MSWs were employed by hospices throughout the country (Hospice Facts and
Statistics, Hospice Association of America, November 2010), indicating that most hospices
employ at least one MSW. For purposes of this estimate only, we assume that 33 percent of
hospices or 1,286 (3,897 x .33) hospices also use BSWs to provide social work services to
patients, and are therefore required to document MSW supervision of a BSW. Furthermore,
we estimate that a hospice MSW would spend 4 hours per month documenting supervision
activities. As such, at an average hourly rate of $33 for a MSW, we estimate that an affected
hospice would spend $1,584 annually (4 hours x 12 months x $33). Therefore, for all 1,286
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hospices to comply with this requirement would require a total of 61,728 annual burden hours
(4 hours x 12 months x 1,286 hospices) and an estimated total cost of $2,037,024 ($1,584 x
1,286 hospices).
(d) Standard: Criminal background
A hospice must obtain a background check for each employee including contract employees,
who have direct patient contact or access to patient records. We estimate that compliance
with this provision requires 10 minutes of clerical time per background check to process the
paper work, at a cost of $3 per check. According to National Association for Home Care
2010 Hospice Facts and Statistics, there are 150,629 hospice employees in 50 states. This is
an average of 3,013 employees per state (150,629 /50 states). According to a report by the
National Conference of State Legislatures titled “Safe at Home? Developing Effective
Criminal Background Checks and Other Screening Policies for Home Care Workers: State
Summaries”, 47 states required criminal background checks for at least some types of hospice
employees. For purposes of our analysis, we estimate that a hospice will replace 20% of its
staff in a given year. We also estimate that half of the replacement staff would receive a
criminal background check in accordance with State requirements in the absence of this
Federal rule. Therefore, only 10 percent of the hospice workforce in those 47 states in a given
year receives a criminal background check due to this regulation, or 301 individuals per state
(3,013 employees per state x 10 percent). Based on an estimated 20 percent turnover rate in
the 3 remaining states that do not have any criminal background check requirements, we
estimate that 603 individuals per state will receive a criminal background check in accordance
with this rule in a given year (3,013 employees per state x 20 percent). We estimate a total of
15,956 individuals will receive a criminal background check as a result of this requirement
([301 individuals in states that have criminal background check requirements x 47 states] +
[603 individuals in states that do not have criminal background check requirements x 3
states]), requiring 2,659 hours ([15,956 x 10 minutes] / 60) at a cost of $47,868 (15,956 x $3
per check).
The average hospice has 39 employees (150,629 employees/3,897 hospices). Assuming a
20% turnover rate, and assuming that half of all new employees will have a criminal
background check completed due to State-imposed requirements, we estimate that hospices in
the 47 states that require some background checks will complete checks on approximately 4
new employees per year, for a total burden of 40 minutes per hospice (4 employees x 10
minutes / 60) at a cost of $12 (40 minutes per hospice x $17 per hour). We estimate that
hospices in the 3 states that do not require background checks will complete background
checks on approximately 8 new employees per year, for a total burden of 1.33 hours per
hospice (8 employees x 10 minutes / 60) at a cost of $24 (1.33 hours per hospice x $17 per
hour).
In addition to those criminal background checks performed by existing hospice providers,
such checks will also need to be performed by new hospices that are entering the Medicare
program. From 2008-2013 551 new hospices began participating in the Medicare program,
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for an average of 110 new hospices per year, or approximately 2 new hospices per state. As
start-up businesses, we believe that these new hospices have significantly smaller staffs than
existing hospices. For purposes of this analysis only, we assume that a new hospice has 15
staff members that will need criminal background checks. For new hospices in states with
existing criminal background check requirements, we estimate that 1,410 background checks
will be completed (15 staff members per new hospice x 2 new hospices per state x 47 states),
and that this will require 235 hours ([1,410 x 10] / 60). For new hospices in states without
existing criminal background check requirements, we estimate that 120 background checks
will be completed (20 staff members per new hospice x 2 new hospices per state x 3 states),
and that this will require 20 hours ([120 x 10] / 60). In total, we estimate that 1,530
background checks will be completed for new hospices, requiring 255 hours at a cost of
$4,590 (1,530 x $3). On an individual hospice level, we estimate that it will require 1.66
hours for each new hospice in a state with existing criminal background check requirements to
complete the documentation associated with a criminal background check (10 employees x 10
minutes per check / 60) at a cost of $28 (1.66 hours x $17). For new hospices in states
without existing criminal background check requirements, we estimate that it will require 3.33
hours for each new hospice to complete the documentation associated with a criminal
background check (20 employees x 10 minutes per check / 60) at a cost of $57 (3.33 hours x
$17).
On an annual basis, we estimate that all hospices, both new and existing, will complete 17,486
background checks (1,530 new + 15,956 existing), requiring 2,914 hours (255 new + 2,659
existing) at a cost of $52,458 ($4,590 new + $47,868 existing).
Total burden hours requested = 3,300,735 hours
Total hours previously approved = 1,393,111.5 hours
Increase of hours = 1,907,624 hours
13. Capital Costs
There are no capital costs associated with this information collection.
14. Cost to Federal Government
There are minimal costs associated with these requirements that are accrued at the Federal
level and especially at the regional office (RO) levels. For example, RO staff is responsible
for acting on the information collections requirements discussed in this package as it relates to
hospice compliance. Once state survey agencies have completed their surveys and if a final
decision to terminate a hospice for noncompliance is to be made, such decisions are made by
the Central Office and the RO. The changes to coverage and payment requirements associated
with the face-to-face requirement, which were implemented in the CY 2011 home health final
rule, do not create additional federal level costs; payment contractors use the data collected as
part of their usual and customary claims processing and review activities.
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15. Changes to Burden
The total annual hourly burden for the information collection requirements is estimated to be
3,300,735 hours. The 1,907,624 hour increase is due to three main factors. First, the number
of Medicare-certified hospices has increased by 36 percent, from 2,872 to 3,897. Second, the
number of patients receiving hospice services has increased by 77 percent, from 869,201 to
1,535,919. Third, the burden hours previously accounted for in OMB control number 09380302 have been updated and moved into this package in order to consolidate all hospice PRA
burdens into a single package. However, the increase for some of the requirements is
moderated by the fact that the original burden estimates included substantial initial
compliance burdens as hospices adjusted their practices from those required by the previous
CoPs to those required by the new CoPs. Now that most hospices have completed the more
time-intensive initial phase of compliance, and have moved to the less time intensive
maintenance phase of compliance, the annual burdens have leveled-off to an extent.
The total annual cost burden has also increased due to these same factors. Additionally, we
have increased salary estimates to reflect recent Bureau of Labor Statistics wage data. We
believe that this adjustment more accurately reflects 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.

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