Adult day health care of veterans in State homes; per diem payment mechanism,
[Federal Register: June 28, 2000 (Volume 65, Number 125)]
[Proposed Rules]
[Page 39835-39850]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr28jn00-31]
DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 52
RIN 2900-AJ74
Per Diem for Adult Day Health Care of Veterans in State Homes
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
SUMMARY: This document proposes to establish regulations setting forth a mechanism for paying per diem to State homes providing adult day health care to eligible veterans. The intended effect of the proposed regulations is to ensure that veterans receive high quality care in State homes.
DATES: Comments must be received by VA on or before August 28, 2000.
ADDRESSES: Mail or hand-deliver written comments to: Director, Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Ave., NW, Room 1154, Washington, DC 20420; or fax comments to (202) 273-9289; or e-mail comments to ``OGCRegulations@mail.va.gov''. Comments should indicate that they are submitted in response to ``RIN 2900-AJ74'' All comments received will be available for public inspection in the Office of Regulations Management, Room 1158, between the hours of 8:00a.m. and 4:30 p.m., Monday through Friday (except holidays).
FOR FURTHER INFORMATION CONTACT: L. Nan Stout, Chief, State Home Per Diem Program (114), Veterans Health Administration, 202-273-8538.
SUPPLEMENTARY INFORMATION: This document proposes to establish a new part 52 setting forth a mechanism for paying per diem to State homes providing adult day health care to eligible veterans. The adult day health
[[Page 39836]]
care program has the following basic purposes: (a) to enable functionally impaired veterans to reside in supportive home environments; (b) to facilitate expeditious medical center discharge and to reduce risk of readmission or institutional placement, through improved provision and coordination of health care services and education of patients and caregivers about service options and their appropriate use; (c) to maximize veterans' physical and psychosocial functional level; (d) to improve the quality of life for the participants by providing a rehabilitation program in the community among their peers; and (e) to provide support and respite for the family and other caregivers to enable them to maintain veterans in the community.
Under the proposal, VA would pay per diem to a State for providing adult day health care to eligible veterans in a facility if the Under Secretary for Health recognizes the facility as a State home based on a current VA certification that the facility meets the standards set forth in proposed subpart D.
The standards in proposed subpart D are patterned after the standards of the U.S. Department of Veterans Affairs Adult Day Health Care Program and the National Council on the Aging, National Adult Day Services Association. The standards are intended to set forth minimum requirements necessary to ensure that VA pays per diem for eligible veterans only if the State homes provide high quality care.
The proposed regulations include application and inspection provisions that are designed to ensure that per diem is paid only to facilities that have been inspected and found to meet the proposed standards. Also, in order to ensure continued compliance with the standards, the proposed regulations include an ongoing review and certification program. Further, the proposed regulations contain provisions for withdrawing recognition and stopping payment of per diem if a facility fails to meet the proposed standards.
The proposed rule sets forth the statutory list of veterans for whom per diem may be paid. The per diem amount would be the amount authorized under 38 U.S.C. 1741 and Congressionally approved in the yearly budget. For fiscal year 2000 the amount is $30.25.
The proposed rule imposes requirements concerning accreditation and training by certain national entities (see definition of ``Physician Assistant'' at proposed Sec. 52.2, qualifications of a social worker at proposed Sec. 52.100(g), qualifications of a dietitian at proposed Sec. 52.140(a)(2), and requirements for program assistants at proposed Sec. 52.210(j)). VA will consider changing the requirements to allow accreditation or training by other national entities when warranted.
The proposed rule includes provisions regarding medical errors (see proposed Sec. 52.120(a), (k), and (l)). This is consistent with the President's initiative on medical errors announced on December 7, 1999, and the recommendation of the Quality Interagency Coordination Task Force.
The proposed rule would incorporate by reference the 1997 edition of the National Fire Protection Association Life Safety Code entitled ``NFPA 101, Life Safety Code.'' The regulations are designed to ensure that State homes meet the fire and safety provisions of the Life Safety Code.
Regulatory Flexibility Act
The Secretary hereby certifies that the adoption of this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. All of the entities that would be subject to this proposed rule are State government entities under the control of State governments. Of the 95 State homes, all are operated by State governments except for 17 that are operated by entities under contract with State governments. These contractors are not small entities. Therefore, pursuant to 5 U.S.C. 605(b), this proposed rule is exempt from the initial and final regulatory flexibility analysis requirement of sections 603 and 604.
Paperwork Reduction Act of 1995
Under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520), proposed collections of information are set forth in the provisions of Secs. 52.20, 52.30, 52.40, 52.70, 52.71, 52.80, 52.90, 52.100, 52.110, 52.120, 52.130, 52.150, 52.160, 52.180, 52.190 and 52.210 of this proposed rule. Many of these collections of information require the submission to VA of information on forms published at 38 CFR Part 58.
The information collections in this document concern various activities related to the operation of a State home providing adult day health care to eligible veterans. As required under section 3507(d) of the Act, VA has submitted a copy of this proposed rulemaking action to the Office of Management and Budget (OMB) for its review of the collections of information.
The forms in 38 CFR Part 58, which are republished at the end of this proposed rule, are intended to be used for a number of VA programs. Collections of information using these forms already have been approved by OMB for the regulations in 38 CFR Part 51 captioned ``Per Diem for Nursing Home Care of Veterans in State Homes'' under OMB approval number 2900-0160. This proposed rule also would require collections of information using these same forms. Accordingly, we are requesting that OMB approve the collections of information in this proposed rule as an amendment of the collections of information already approved under OMB control number 2900-0160.
OMB assigns control numbers to collections of information it approves. VA may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Comments on the collection of information should be submitted to the Office of Management and Budget, Attention: Desk Officer for the Department of Veterans Affairs, Office of Information and Regulatory Affairs, Washington, DC 20503, with copies to the Director, Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420. Comments should indicate that they are submitted in response to ``RIN 2900-AJ74.''
Title: Aid to States for Care of Veterans in State Homes--Adult Day Health Care Per Diem.
Summary of collection of information: VA is proposing to establish the mechanism for paying per diem to State homes providing adult day health care to eligible veterans. VA proposes to require the State homes to supply various kinds of information regarding their adult day health care programs to ensure that high quality care is furnished to veterans who are participants in such programs. The information includes an application for recognition based on certification; appeal information; application and justification for payment; records and reports which program management must maintain regarding activities of participants; to include information relating to whether the program meets standards concerning participants' rights and responsibilities prior to enrollment, during enrollment, and upon discharge; the records and reports which program management and health care professionals must maintain regarding participants and employees; various types of documentation pertaining to the management of the facility; food menu planning;
[[Page 39837]]
pharmaceutical records; and life safety documentation.
Description of need for information and proposed use of information: The collections of information contained in the proposed rule appear to be necessary to ensure that VA per diem payments are limited to facilities providing high quality care. Without access to such information VA would not be able to determine whether high quality care is being provided.
Collections of Information Including Collections of Information Using Forms at 38 CFR Part 51 Already Aapproved Under OMB Control Number 2900-0160
Description of likely respondents: State home officials who receive per diem for nursing home care for veterans.
Estimated number of respondents: 13,136.
Estimated frequency of responses: 52,872.
Estimated average burden per collection: 14 minutes.
Estimated total annual reporting and record keeping burden: 12,467 hours.
Additional Collections of Information Under This Proposed Rule, Including Collections of Information Using Forms Published at 38 CFR Part 58
Description of likely respondents: State home officials who receive per diem for adult day health care for veterans.
Estimated number of respondents: 2,200.
Estimated frequency of responses: 7,568.
Estimated average burden per collection: 13 minutes.
Estimated total annual reporting and record keeping burden: 2,733. hours.
The Department considers comments by the public on proposed collections of information in--
Evaluating whether the proposed collections of information are necessary for the proper performance of the functions of the Department, including whether the information will have practical utility;
Evaluating the accuracy of the Department's estimate of the burden of the proposed collections of information, including the validity of the methodology and assumptions used;
Enhancing the quality, usefulness, and clarity of the information to be collected; and
Minimizing the burden of the collections of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.
OMB is required to make a decision concerning the proposed collection of information contained in this proposed rule between 30 and 60 days after publication of this document in the Federal Register. Therefore, a comment to OMB is best assured of having its full effect if OMB receives it within 30 days of publication. This does not affect the deadline for the public to comment on the proposed regulation.
List of Subjects in 38 CFR Part 52
Administrative practice and procedure, Alcohol abuse, Alcoholism, Claims, Day care, Dental health, Drug abuse, Foreign relations, Government contracts, Grant programs--health, Government programs-- veterans, Health care, Health facilities, Health professions, Health records, Homeless, Medical and dental schools, Medical devices, Medical research, Mental health programs, Nursing home care, Philippines, Reporting and recordkeeping requirements, Scholarships and fellowships, Travel and transportation expenses, Veterans.
Editorial Note: This document was received at the Office of the Federal Register on June 16, 2000.
Approved: October 29, 1999. Togo D. West, Jr., Secretary of Veterans Affairs.
For the reason set forth in the preamble, 38 CFR Chapter I is proposed to be amended by adding a new part 52 to read as follows.
PART 52--PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES
Subpart A--General Sec. 52.1 Purpose. 52.2 Definitions. Subpart B--Obtaining Per Diem for Adult Day Health Care in State Homes 52.10 Per diem based on recognition and certification. 52.20 Application for recognition based on certification. 52.30 Recognition and certification. Subpart C--Per Diem Payments 52.40 Monthly payment. 52.50 Eligible veterans. Subpart D--Standards 52.60 Standards applicable for payment of per diem. 52.61 General requirements for adult day health care program. 52.70 Participant rights. 52.71 Participant and family caregiver responsibilities. 52.80 Enrollment, transfer and discharge rights. 52.90 Participant behavior and program practices. 52.100 Quality of life. 52.110 Participant assessment. 52.120 Quality of care. 52.130 Nursing services. 52.140 Dietary services. 52.150 Physician services. 52.160 Specialized rehabilitative services. 52.170 Dental services. 52.180 Administration of drugs. 52.190 Infection control. 52.200 Physical environment. 52.210 Administration. 52.220 Transportation.
Authority: 38 U.S.C. 101, 501, 1741-1743, unless otherwise noted.
Subpart A--General
Sec. 52.1 Purpose.
This part sets forth the mechanism for paying per diem to State homes providing adult day health care to eligible veterans and includes quality assurance requirements that are intended to ensure that veterans receive high quality care in State homes.
Sec. 52.2 Definitions.
For purposes of this part--
Activities of daily living (ADLs) means the functions or tasks for self-care usually performed in the normal course of a day, i.e., mobility, bathing, dressing, grooming, toileting, transferring, and eating.
Clinical nurse specialist means a licensed professional nurse with a master's degree in nursing and a major in a clinical nursing specialty from an academic program accredited by the National League for Nursing and at least 2 years of successful clinical practice in the specialized area of nursing practice following this academic preparation.
Facility means a building or any part of a building for which a State has submitted an application for recognition as a State home for the provision of adult day health care or a building or any part of a building which VA has recognized as a State home for the provision of adult day health care.
Instrumental activities of daily living (IADLs) means functions or tasks of independent living, i.e., shopping, housework, meal preparation and cleanup, laundry, taking medication, money management, transportation, correspondence, and telephoning.
Nurse practitioner means a licensed professional nurse who is currently licensed to practice in the State; who meets the State's requirements governing the qualifications of nurse practitioners; and who is currently certified as an adult, family, or
[[Page 39838]]
gerontological nurse practitioner by the American Nurses Association.
Physician means a doctor of medicine or osteopathy legally authorized to practice medicine or surgery in the State.
Physician assistant means a person who meets the applicable State requirements for physician assistant, is currently certified by the National Commission on Certification of Physician Assistants (NCCPA) as a physician assistant, and has an individualized written scope of practice that determines the authorization to write medical orders, prescribe medications and other clinical tasks under appropriate physician supervision which is approved by the primary care physician.
Primary physician or primary care physician means a designated generalist physician responsible for providing, directing and coordinating health care that is indicated for the residents.
State means each of the several States, territories, and possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico.
State home means a home approved by VA which a State established primarily for veterans disabled by age, disease, or otherwise, who by reason of such disability are incapable of earning a living. A State home may provide domiciliary care, nursing home care, adult day health care, and hospital care. Hospital care may be provided only when the State home also provides domiciliary and/or nursing home care.
VA means the U.S. Department of Veterans Affairs.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Subpart B--Obtaining Per Diem for Adult Day Health Care in State Homes
Sec. 52.10 Per diem based on recognition and certification.
VA will pay per diem to a State for providing adult day health care to eligible veterans in a facility if the Under Secretary for Health recognizes the facility as a State home based on a current certification that the facility and program management meet the standards of subpart D of this part. Also, after recognition has been granted, VA will continue to pay per diem to a State for providing adult day health care to eligible veterans in such a facility for a temporary period based on a certification that the facility and program management provisionally meet the standards of subpart D of this part.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.20 Application for recognition based on certification.
To apply for recognition and certification of a State home for adult day health care, a State must:
(a) Send a request for recognition and certification to the Under Secretary for Health (10), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420. The request must be in the form of a letter and must be signed by the State official authorized to establish the State home;
(b) Allow VA to survey the facility as set forth in Sec. 52.30(c); and
(c) Upon request from the director of the VA medical center of jurisdiction, submit to the director all documentation required under subpart D of this part.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.30 Recognition and certification.
(a)(1) The Under Secretary for Health will make the determination regarding recognition and the initial determination regarding certification, after receipt of a tentative determination from the director of the VA medical center of jurisdiction regarding whether the facility and program management meet or do not meet the standards of subpart D of this part. The Under Secretary for Health will notify the official in charge of the program, the State official authorized to oversee operations of the State home, the VA Network Director (10N 1- 22), Chief Network Officer (10N), and the Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) of the action taken.
(2) For each facility recognized as a State home, the director of the VA medical center of jurisdiction will certify annually whether the facility and program management meet, provisionally meet, or do not meet the standards of subpart D of this part (this certification should be made every 12 months during the recognition anniversary month or during a month agreed upon by the VA medical center director and officials of the State home facility). A provisional certification will be issued by the director only upon a determination that the facility or program management does not meet one or more of the standards in subpart D of this part, that the deficiencies do not jeopardize the health or safety of the residents, and that the program management and the director have agreed to a plan of correction to remedy the deficiencies in a specified amount of time (not more time than the VA medical center of jurisdiction director determines is reasonable for correcting the specific deficiencies). The director of the VA medical center of jurisdiction will notify the official in charge of the program, the State official authorized to oversee the operations of the State home, the VA Network Director (10N 1-22), Chief Network Officer (10N) and the Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) of the certification, provisional certification, or noncertification.
(b) Once a program has achieved recognition, the recognition will remain in effect unless the State requests that the recognition be withdrawn or the Under Secretary for Health makes a final decision that the facility or program management does not meet the standards of subpart D of this part. Recognition of a program will apply only to the facility as it exists at the time of recognition; any annex, branch, enlargement, expansion, or relocation must be separately recognized.
(c) Both during the application process for recognition and after the Under Secretary for Health has recognized a facility, VA may survey the facility as necessary to determine if the facility and program management comply with the provisions of this part. Generally, VA will provide advance notice to the State before a survey occurs; however, surveys may be conducted without notice. A survey, as necessary, will cover all parts of the facility, and include a review and audit of all records of the program that have a bearing on compliance with any of the requirements of this part (including any reports from State or local entities). For purposes of a survey, at the request of the director of the VA medical center of jurisdiction, the State home adult day care health program management must submit to the director a completed VA Form 10-3567, Staffing Profile, set forth at 38 CFR 58.10. The director of the VA medical center of jurisdiction will designate the VA officials to survey the facility. These officials may include physicians; nurses; pharmacists; dietitians; rehabilitation therapists; social workers; representatives from health administration, engineering, environmental management systems, and fiscal officers.
(d) If the director of the VA medical center of jurisdiction determines that the State home facility or program management does not meet the standards of this part, the director will notify the State home program manager in writing of the standards not met. The director will send a copy of this notice to the State official authorized to oversee operations of the facility, the VA Network Director (10N 1-22), the Chief Network Officer (10N), and the Chief Consultant, Geriatrics and
[[Page 39839]]
Extended Care Strategic Healthcare Group (114). The letter will include the reasons for the decision and indicate that the State has the right to appeal the decision.
(e) The State must submit an appeal to the Under Secretary for Health in writing, within 30 days of receipt of the notice of failure to meet the standards. In its appeal, the State must explain why the determination is inaccurate or incomplete and provide any new and relevant information not previously considered. Any appeal that does not identify a reason for disagreement will be returned to the sender without further consideration.
(f) After reviewing the matter, including any relevant supporting documentation, the Under Secretary for Health will issue a written determination that affirms or reverses the previous determination. If the Under Secretary for Health decides that the State home facility or program management does not meet the standards of subpart D of this part, the Under Secretary for Health will withdraw recognition and stop paying per diem for care provided on and after the date of the decision. The decision of the Under Secretary for Health will constitute a final VA decision. The Under Secretary for Health will send a copy of this decision to the State home facility and to the State official authorized to oversee the operations of the State home.
(g) In the event that a VA survey team or other VA medical center staff identifies any condition at the State home facility that poses an immediate threat to public or patient safety or other information indicating the existence of such a threat, the director of the VA medical center of jurisdiction will immediately report this to the VA Network Director (10N 1-22), Chief Network Officer (10N), Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) and State official authorized to oversee operations of the State home.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Subpart C--Per Diem Payments
Sec. 52.40 Monthly payment.
(a)(1) During fiscal year 2000, VA will pay monthly one-half of the total cost of each eligible veteran's adult day health care for each day the veteran is in a facility recognized as a State home for adult day health care, not to exceed $30.25 per diem.
(2) Per diem will be paid only for a day that the veteran is under the care of the facility at least six hours.
(3) As a condition for receiving payment of per diem under this part, the State must submit a completed VA form 10-5588, State Home Report and Statement of Federal Aid Claimed. This form is set forth in full at 38 CFR 58.11.
(4) Initial payments will not be made until the Under Secretary for Health recognizes the State home. However, payments will be made retroactively for care that was provided on and after the date of the completion of the VA survey of the facility that provided the basis for determining that the facility met the standards of this part.
(5) As a condition for receiving payment of per diem under this part, the State must submit to the VA medical center of jurisdiction for each veteran the following completed VA forms: 10-10EZ, Application for Medical Benefits, and 10-10SH, State Home Program Application for Care--Medical Certification, at the time of enrollment and with any request for a change in the level of care (nursing home, domiciliary or hospital care). These forms are set forth in full at 38 CFR 58.12 and 58.13, respectively. If the program is eligible to receive per diem payments for adult day health care for a veteran, VA will pay per diem under this part from the date of receipt of the completed forms required by this paragraph (a)(5), except that VA will pay per diem from the day on which the veteran was enrolled in the program if VA receives the completed forms within 10 days after enrollment.
(b) For determining ``the one-half of the total cost'' under paragraph (a)(1) of this section, total per diem costs for an eligible veteran's adult day health care consist of those direct and indirect costs attributable to adult day health care at the facility divided by the total number of participants enrolled in the adult day health care program. Relevant cost principles are set forth in the Office of Management and Budget (OMB) Circular number A-87, dated May 4, 1995, ``Cost Principles for State, Local, and Indian Tribal Governments'' (OMB Circulars are available at the addresses in 5 CFR 1310.3).
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.50 Eligible veterans.
A veteran is an eligible veteran under this part if VA determines that the veteran needs adult day health care and the veteran is within one of the following categories:
(a) Veterans with service-connected disabilities;
(b) Veterans who are former prisoners of war;
(c) Veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty;
(d) Veterans who receive disability compensation under 38 U.S.C. 1151;
(e) Veterans whose entitlement to disability compensation is suspended because of the receipt of retired pay;
(f) Veterans whose entitlement to disability compensation is suspended pursuant to 38 U.S.C. 1151, but only to the extent that such veterans' continuing eligibility for adult day health care is provided for in the judgment or settlement described in 38 U.S.C. 1151;
(g) Veterans who VA determines are unable to defray the expenses of necessary care as specified under 38 U.S.C. 1722(a);
(h) Veterans of the Mexican border period or of World War I;
(i) Veterans solely seeking care for a disorder associated with exposure to a toxic substance or radiation or for a disorder associated with service in the Southwest Asia theater of operations during the Persian Gulf War, as provided in 38 U.S.C. 1710(e);
(j) Veterans who agree to pay to the United States the applicable co-payment determined under 38 U.S.C. 1710(f) and 1710(g), if they seek VA (U.S. Department of Veterans Affairs) hospital, nursing home, or outpatient care.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Subpart D--Standards
Sec. 52.60 Standards applicable for payment of per diem.
The provisions of this subpart are the standards that a State home and program management must meet for the State to receive per diem for adult day health care provided at that home.
Sec. 52.61 General requirements for adult day health care program.
Adult day health care must be a therapeutically oriented outpatient day program, which provides health maintenance and rehabilitative services to participants. The program must provide individualized care delivered by an interdisciplinary health care team and support staff, with an emphasis on helping participants and their caregivers to develop the knowledge and skills necessary to manage care requirements in the home. Adult day health care is principally targeted for complex medical and/or functional needs of geriatric patients.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.70 Participant rights.
The participant has a right to a dignified existence, self- determination,
[[Page 39840]]
and communication with and access to persons and services inside and outside the facility. The program management must protect and promote the rights of each participant, including each of the following rights:
(a) Exercise of rights. (1) The participant has the right to exercise his or her rights as a participant of the program and as a citizen or resident of the United States.
(2) The participant has the right to be free of interference, coercion, discrimination, and reprisal from the program management in exercising his or her rights.
(3) The participant has the right to freedom from chemical or physical restraint.
(4) In the case of a participant determined incompetent under the laws of a State by a court of jurisdiction, the rights of the participant are exercised by the person appointed under State law to act on the participant's behalf.
(b) Notice of rights and services. (1) The program management must inform the participant both orally and in writing in a language that the participant understands of his or her rights and all rules and regulations governing participant conduct and responsibilities during enrollment in the program. Such notification must be made prior to or upon enrollment and periodically during the participant's enrollment.
(2) Participants or their legal representatives have the right--
(i) Upon an oral or written request, to access all records pertaining to them including current participant records within 24 hours (excluding weekends and holidays); and
(ii) After receipt of their records for review, to purchase, at a cost not to exceed the community standard, photocopies of the records or any portions of them upon request and with 2 working days advance notice to the facility management.
(3) Participants have the right to be fully informed in language that they can understand of their total health status.
(4) Participants have the right to refuse treatment, to refuse to participate in patient activities, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (a)(7) of this section.
(5) The program management must inform each participant before, or at the time of enrollment, and periodically during the participant's stay, of services available in the facility and of charges for those services to be billed to the participant.
(6) The program management must furnish a written description of legal rights which includes a statement that the participant may file a complaint with the State (agency) concerning participant abuse and neglect.
(7) The program management must have written policies and procedures regarding advance directives (e.g., living wills). These requirements include provisions to inform and provide written information to all participants concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law.
(8) Notification of changes. (i) Program management must immediately inform the participant; consult with the primary physician; and notify the participant's legal representative or an interested family member when there is--
(A) An accident involving the participant which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the participant's physical, mental, or psychosocial status (e.g., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the participant from the program.
(ii) The program management must also promptly notify the participant and the participant's legal representative or interested family member when there is a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section.
(iii) The program management must record and periodically update the address and phone number of the participant's legal representative or interested family member and the primary physician.
(c) Free choice. (1) The participant has the right to--
(i) Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the participant's well-being; and
(ii) Unless determined incompetent or otherwise determined to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.
(2) If the participant is determined incompetent or otherwise determined to be incapacitated under the laws of the State, the participant's legal representative or interested family member(s) has the right to participant in planning care and treatment or changes in care and treatment.
(d) Privacy and confidentiality. Participants have the right to privacy and confidentiality of their personal and clinical records.
(1) Participants have a right to privacy in their medical treatment, and personal care.
(2) Except as provided in paragraph (d)(3) of this section, participants may approve or refuse the release of personal and clinical records to any individual outside the facility.
(3) The participant's right to refuse release of personal and clinical records does not apply when--
(i) The participant is transferred to another health care institution; or
(ii) The release is required by law.
(e) Grievances. A participant has the right to--
(1) Voice grievances without discrimination or reprisal. Participants may voice grievances with respect to treatment received and not received; and
(2) Prompt efforts by facility management to resolve grievances the participant may have, including those with respect to the behavior of other participants.
(f) Examination of survey results. A participant has the right to--
(1) Examine the results of the most recent VA survey with respect to the program. The program management must make the results available for examination in a place readily accessible to participants, and must post a notice of their availability; and
(2) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.
(g) Work. The participant has the right to--
(1) Refuse to perform services for the facility;
(2) Perform services for the facility, if he or she chooses, when--
(i) The facility has documented the need or desire for work therapy in the plan of care;
(ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid;
(iii) Compensation for (work therapy) paid services is at or above prevailing rates; and
(iv) The participant agrees to the work therapy arrangement described in the plan of care.
[[Page 39841]]
(h) Access and visitation rights. (1) The program management must provide immediate access to any participant by the following:
(i) Any representative of the Under Secretary for Health;
(ii) Any representative of the State;
(iii) The State long term care ombudsman;
(iv) Immediate family or other relatives of the participant subject to the participant's right to deny or withdraw consent at any time; and
(v) Others who are visiting subject to reasonable restrictions and the participant's right to deny or withdraw consent at any time.
(2) The program management must provide reasonable access to any participant by any entity or individual that provides health, social, legal, or other services to the participant, subject to the participant's right to deny or withdraw consent at any time.
(3) The program management must allow representatives of the State Ombudsman Program to examine a participant's clinical records with the permission of the participant or the participant's legal representative, subject to State law.
(i) Telephone. The participant has the right to reasonable access to use a telephone where calls can be made without being overheard.
(j) Personal property. The participant has the right to have at least one change of personal clothing.
(k) Self-administration of drugs. An individual participant may self-administer drugs if the interdisciplinary team has determined that this practice is safe for the individual and is a part of the care plan.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.71 Participant and family caregivers responsibilities.
The program management has a written statement of participant and family caregiver responsibilities that are posted in the facility and provided to the participant and caregiver at the time of the intake screening. The statement of responsibilities must include the following:
(a) Treat personnel with respect and courtesy;
(b) Communicate with staff to develop a relationship of trust;
(c) Make appropriate choices and seek appropriate care;
(d) Ask questions and confirm understanding of instructions;
(e) Share opinions, concerns, and complaints with the program director;
(f) Communicate any changes in the participant's condition;
(g) Communicate to the program director about medications and remedies used by the participant;
(h) Let the program director know if the participant decides not to follow any instructions or treatment; and
(i) Communicate with the adult day health care staff if the participant is unable to attend the adult day health care program.
52.80 Enrollment, transfer and discharge rights.
Participants in the adult day health care program must meet the provisions of this part that apply to participants and--
(1) Must meet at least two of the following indicators:
(i) Dependence in 2 or more activities of daily living (ADLs).
(ii) Dependence in 3 or more instrumental activities of daily living (IADLs).
(iii) Advanced age, i.e., 75 years old or over.
(iv) High use of medical services defined as 3 or more hospitalizations in past year; utilization of outpatient clinics; or Emergency Evaluation Units, 12 or more times in past year.
(v) Diagnosis of clinical depression.
(vi) Recent discharge from nursing home or hospital.
(vii) Significant cognitive impairment, particularly when characterized by multiple behavior problems;
(2) Must have a supportive living arrangement sufficient to meet their health care needs when not participating in the adult day health care program; and
(3) Must be able to benefit from the adult day health care program.
(b) Transfer and discharge. (1) Definition. Transfer and discharge includes movement of a participant to a program outside of the adult day health care program whether or not that program or facility is in the same physical plant.
(2) Transfer and discharge requirements. All participants' preparedness for discharge from adult day health care must be a part of a comprehensive care plan. The possible reasons for discharge must be discussed with the participant and family members at the time of intake screening. Program management must permit each participant to remain in the program, and not transfer or discharge the participant from the program unless--
(i) The transfer or discharge is necessary for the participant's welfare and the participant's needs cannot be met in the adult day health care setting;
(ii) The transfer or discharge is appropriate because the participant's health has improved sufficiently so the participant no longer needs the services provided in the adult day health care setting;
(iii) The safety of individuals in the program is endangered;
(iv) The health of individuals in the program would otherwise be endangered;
(v) The participant has failed, after reasonable and appropriate notice, to pay for participation in the adult day health care program; or
(vi) The adult day health care program ceases to operate.
(3) Documentation. When the facility transfers or discharges a participant under any of the circumstances specified in paragraphs (b)(2)(i) through (vi) of this section, the primary physician must document the reason for such action in the participant's clinical record.
(4) Notice before transfer. Before a facility transfers or discharges a participant, the program management must--
(i) Notify the participant and a family member or legal representative of the participant of the transfer or discharge and the reasons for the move in writing and in a language and manner they can understand;
(ii) Record the reasons in the participant's clinical record; and
(iii) Include in the notice the items described in paragraph (a)(6) of this section.
(5) Timing of the notice. (i) The notice of transfer or discharge required under paragraph (b)(4) of this section must be made by program management at least 30 days before the participant is transferred or discharged, except when specified in paragraph (b)(5)(ii) of this section.
(ii) Notice may be made as soon as practicable before transfer or discharge when--
(A) The safety of individuals in the program would be endangered;
(B) The health of individuals in the program would be otherwise endangered;
(C) The participant's health improves sufficiently so the participant no longer needs the services provided by the adult day health care program;
(D) The resident's needs cannot be met in the adult day health care program.
(6) Contents of the notice. The written notice specified in paragraph (b)(4) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the participant is transferred or discharged, if any;
[[Page 39842]]
(iv) A statement that the participant has the right to appeal the action to the State official responsible for the oversight of State Veterans Home programs; and
(v) The name, address and telephone number of the State long-term care ombudsman.
(7) Orientation for transfer or discharge. The program management must provide sufficient preparation and orientation to participants to ensure safe and orderly transfer or discharge from the program.
(c) Equal access to quality care. The program management must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services for all individuals regardless of source of payment.
(d) Enrollment policy. The program management must not require a third party guarantee of payment to the program as a condition of enrollment or expedited enrollment, or continued enrollment in the program. However, program management may require a participant or an individual who has legal access to a participant's income or resources to pay for program care from the participant's income or resources, when available.
(e) Hours of operation. Each adult day health care program must provide at least 8 hours of operation five days a week. The hours of operation must be flexible and responsive to caregiver needs.
(f) Caregiver support. The adult day health care program must develop a Caregiver Program which offers mutual support, information and education.
(Authority: U.S.C. 101, 501, 1741-1743)
Sec. 52.90 Participant behavior and program practices.
(a) Restraints. (1) The participant has a right to be free from any chemical or physical restraints imposed for purposes of discipline or convenience. When a restraint is applied or used, the purpose of the restraint is reviewed and is justified as a therapeutic intervention and documented in the participant's clinical record.
(i) Chemical restraint is the inappropriate use of a sedating psychotropic drug to manage or control behavior.
(ii) Physical restraint is any method of physically restricting a person's freedom of movement, physical activity or normal access to his or her body.
(2) The program management uses a system to achieve a restraint- free environment.
(3) The program management collects data about the use of restraints.
(4) When alternatives to the use of restraint are ineffective, restraint is safely and appropriately used.
(b) Abuse. (1) The participant has the right to be free from mental, physical, sexual, and verbal abuse or neglect, corporal punishment, and involuntary seclusion.
(i) Mental abuse includes humiliation, harassment, and threats of punishment or deprivation.
(ii) Physical abuse includes hitting, slapping, pinching, kicking or controlling behavior through corporal punishment.
(iii) Sexual abuse includes sexual harassment, sexual coercion, and sexual assault.
(iv) Neglect is any impaired quality of life for an individual because of the absence of minimal services or resources to meet basic needs. Neglect may include withholding or inadequately providing food and hydration, clothing, medical care, and good hygiene. It also includes placing the individual in unsafe or unsupervised conditions.
(v) Involuntary seclusion is a participant's separation from other participants against his or her will or the will of his or her legal representative.
(c) Staff treatment of participants. The program management must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of participants and misappropriation of participant property.
(1) The program management must--
(i) Not employ individuals who--
(A) Have been found guilty of abusing, neglecting, or mistreating individuals by a court of law; or
(B) Have had a finding entered into an applicable State registry or with the applicable licensing authority concerning abuse, neglect, mistreatment of individuals or misappropriation of their property; and
(ii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a program assistant or other program staff to the State oversight agency director and licensing authorities.
(2) The program management must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of participant property are reported immediately to the State oversight agency director and to other officials in accordance with State law through established procedures.
(3) The program management must have evidence that all alleged violations are thoroughly investigated, and must prevent potential abuse while the investigation is in progress.
(4) The results of all investigations must be reported to the State oversight agency director or the designated representative and to other officials in accordance with State law within 5 working days of the incident, and appropriate corrective action must be taken if the alleged violation is verified.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.100 Quality of life.
Program management must provide an environment and provide or coordinate care that supports the quality of life of each participant by maximizing the individual's potential strengths and skills.
(a) Dignity. The program management must promote care for participants in a manner and in an environment that maintains or enhances each participant's dignity and respect in full recognition of his or her individuality.
(b) Self-determination and participation. The participant has the right to--
(1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care;
(2) Interact with members of the community both inside and outside the program; and
(3) Make choices about aspects of his or her life in the program that are significant to the participant.
(c) Participant and family concerns. The program management must document any concerns submitted to the management of the program by participants or family members.
(1) A participant's family has the right to meet with families of other participants in the program.
(2) Staff or visitors may attend participant or family meetings at the group's invitation.
(3) The program management must respond to written requests that result from group meetings.
(4) The program management must listen to the views of any participant or family group and act upon the concerns of participants and families regarding policy and operational decisions affecting participant care in the program.
(d) Participation in other activities. A participant has the right to participate in social, religious, and community activities that do not interfere with the rights of other participants in the program.
(e) Therapeutic Participant Activities. (1) The program management must
[[Page 39843]]
provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well being of each participant.
(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who--
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is certified as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body.
(3) A critical role of the adult day health care program is to build relationships and create a culture that supports, involves, and validates the participant. Therapeutic activity refers to that supportive culture and is a significant aspect of the individualized plan of care. A participant's activity includes everything the individual experiences during the day, not just arranged events. As part of effective therapeutic activity the adult day health care program must:
(i) Provide direction and support for participants, including breaking down activities into small, discrete steps or behaviors, if needed by a participant;
(ii) Have alternative programming available for any participant unable or unwilling to take part in group activity;
(iii) Design activities that promote personal growth and enhance the self-image and/or improve or maintain the functioning level of participants to the extent possible;
(iv) Provide opportunities for a variety of involvement (social, intellectual, cultural, economic, emotional, physical, and spiritual) at different levels, including community activities and events;
(v) Emphasize participants' strengths and abilities rather than impairments and contribute to participant feelings of competence and accomplishment; and
(vi) Provide opportunities to voluntarily perform services for community groups and organizations.
(f) Social services. (1) The facility management must provide medically-related social services to participants and their families.
(2) An adult day health care program must employ or contract for a qualified social worker to provide social services.
(3) Qualifications of social worker. A qualified social worker is an individual with--
(i) A bachelor's degree in social work from a school accredited by the Council of Social Work Education (Note: A master's degree social worker with experience in long-term care is preferred);
(ii) A social work license from the State in which the State home is located, if license is offered by the State; and
(iii) A minimum of one year of supervised social work experience in a health care setting working directly with individuals.
(4) The facility management must have sufficient social worker and support staff to meet participant and family social services needs. The adult day health care social services must:
(i) Provide counseling to participants and families/caregivers;
(ii) Facilitate the participant's adaptation to the adult day health care program and active involvement in the plan of care, if appropriate;
(iii) Arrange for services not provided by the adult day health care program and work with these resources to coordinate services;
(iv) Serve as participant advocate by asserting and safeguarding the human and civil rights of the participants;
(v) Assess signs of mental illness and/or dementia and make appropriate referrals;
(vi) Provide information and referral for persons not appropriate for adult day health care program;
(vii) Provide family conferences and serve as liaison between participant, family/caregiver and program staff;
(viii) Provide individual or group counseling and support to caregivers and participants;
(ix) Conduct support groups or facilitate participant or family/ caregiver participation in support groups;
(x) Assist program staff in adapting to changes in participants' behavior; and
(xi) Provide or arrange for individual, group, or family psychotherapy for participants' with significant psychosocial needs.
(5) Space for social services must be adequate to ensure privacy for interviews.
(g) Environment. The program management must provide--
(1) A safe, clean, comfortable, and homelike environment, and support the participants' ability to function as independently as possible and to engage in program activities;
(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;
(3) Private storage space for each participant sufficient for a change of clothes;
(4) Interior signs to facilitate participants' ability to move about the facility independently and safely;
(5) A clean bed available for acute illness, when indicated;
(6) A shower for resident's need, when indicated;
(7) Adequate and comfortable lighting levels in all areas;
(8) Comfortable and safe temperature levels; and
(9) Comfortable sound levels.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
52.110 Participant assessment.
The program management must conduct initially, semi-annually and as required by a change in the participant's condition a comprehensive, accurate, standardized, reproducible assessment of each participant's functional capacity.
(a) Intake screening. An intake screening must be completed to determine the appropriateness of the adult day health care program for each participant.
(b) Enrollment orders. The program management must have physician orders for the participant's immediate care and a medical assessment, including a medical history and physical examination, within a time frame appropriate to the participant's condition, not to exceed 72 hours after enrollment, except when an examination was performed within five days before enrollment and the findings were provided and placed in the clinical record on enrollment.
(c) Comprehensive assessments. (1)(i) The program management must make a comprehensive assessment of a participant's needs:
(A) Using (on and after January 1, 2000) the Health Care Financing Administration Long Term Care Resident Assessment Instrument Version 2.0; and
(B) Describing the participant's capability to perform daily life functions, strengths, performances, needs as well as significant impairments in functional capacity.
(ii) An initial home visit must be conducted by program staff or in coordination with community resources to identify home safety issues, home medication use, use of or need for adaptive equipment, and the in- home functioning of the participant and family/caregiver.
(2) Frequency. Participant assessments must be completed--
(i) No later than 14 calendar days after the date of enrollment; and
(ii) Promptly after a significant change in the participant's physical, mental, or social condition.
(3) Review of assessments. Program management must review each
[[Page 39844]]
participant no less than once every 6 months and as appropriate, revise the participant's assessment to assure the continued accuracy of the assessment.
(4) Use. The results of the assessment are used to develop, review, and revise the participant's individualized comprehensive plan of care, under paragraph (e) of this section.
(d) Accuracy of assessments.--(1) Coordination.
(i) Each assessment must be conducted or coordinated with the appropriate participation of health professionals.
(ii) Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment.
(2) Certification. Each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.
(e) Comprehensive care plans. (1) The program management must develop an individualized comprehensive care plan for each participant that includes measurable objectives and timetables to meet a participant's physical, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following--
(i) The services that are to be provided by the program and by other sources to attain or maintain the participant's highest physical, mental, and psychosocial well-being as required under Sec. 52.120;
(ii) Any services that would otherwise be required under Sec. 52.120 but are not provided due to the participant's exercise of rights under Sec. 52.70, including the right to refuse treatment under Sec. 52.70(b)(4);
(iii) Type and scope of interventions to be provided in order to reach desired, realistic outcomes;
(iv) Roles of participant and family/caregiver; and
(v) Discharge or transition plan, including specific criteria for discharge or transfer.
(2) A comprehensive care plan must be--
(i) Developed within 21 calendar days from the date of the adult day care enrollment and after completion of the comprehensive assessment;
(ii) Assigned to one team member for the accountability of coordinating the completion of the interdisciplinary plan;
(iii) Prepared by an interdisciplinary team, that includes the primary physician, a registered nurse with responsibility for the participant, social worker, recreational therapist and other appropriate staff in disciplines as determined by the participant's needs, the participation of the participant, and the participant's family or the participant's legal representative; and
(iv) Periodically reviewed and revised by a team of qualified persons after each assessment.
(3) The services provided or arranged by the facility must--
(i) Meet professional standards of quality; and
(ii) Be provided by qualified persons in accordance with each participant's written plan of care.
(f) Discharge summary. Prior to discharging a participant, the program management must prepare a discharge summary that includes--
(1) A recapitulation of the participant's care;
(2) A summary of the participant's status at the time of the discharge to include items in paragraph (c)(2) of this section; and
(3) A discharge/transition plan related to changes in service needs and changes in functional status that prompted another level of care.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
52.120 Quality of care.
Each participant must receive and the program management must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
(a) Reporting of sentinel events.--(1) Definition. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function.
(2) Examples of sentinel events are as follows:
(i) Any participant death, paralysis, coma or other major permanent loss of function associated with a medication error; or
(ii) Any suicide or attempted suicide of a participant, including suicides following elopement (unauthorized departure) from the program; or
(iii) Any elopement of a participant from the program resulting in a death or a major permanent loss of function; or
(iv) Any procedure or clinical intervention, including restraints, that result in death or a major permanent loss of function; or
(v) Assault, homicide or other crime resulting in a participant's death or major permanent loss of function; or
(vi) A participant's fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall; or
(vii) A serious injury requiring hospitalization.
(3) The program management must report sentinel events to the director of VA medical center of jurisdiction within 24 hours of identification. The director of VA medical center of jurisdiction must report sentinel events to VA Network Director (10N 1-22), Chief Network Officer (10N), and Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114) within 24 hours of identification and/ or notification by State home.
(4) The program management must establish a mechanism to review and analyze a sentinel event resulting in a written report no later than 10 working days following the event. The purpose of the review and analysis of a sentinel event in an adult day health care program is to prevent future injuries to residents, visitors, and personnel.
(b) Activities of daily living. Based on the comprehensive assessment of a resident, the program management must ensure that--
(1) A participant's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the participant's ability to--
(i) Bathe, dress, and groom;
(ii) Transfer and ambulate;
(iii) Toilet; and
(iv) Eat.
(2) A participant is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (b)(1) of this section.
(3) A participant who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, hydration, grooming, personal and oral hygiene, mobility, and bladder and bowel elimination.
(c) Vision and hearing. To ensure that participants receive proper treatment and assistive devices to maintain vision and hearing abilities, the program management must, if necessary, assist the participant and family--
(1) In making appointments; and
(2) Arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
(d) Pressure ulcers. Based on the comprehensive assessment of a participant, the program management must ensure that--
(1) A participant who enters the program without pressure ulcers does
[[Page 39845]]
not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(2) A participant having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing.
(e) Urinary and fecal incontinence. Based on the participant's comprehensive assessment, the program management must ensure that--
(1) A participant who enters the program without an indwelling catheter is not catheterized unless the participant's clinical condition demonstrates that catheterization was necessary;
(2) A participant who is incontinent of urine receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible; and
(3) A participant who has persistent fecal incontinence receives appropriate treatment and services to treat reversible causes and to restore as much normal bowel function as possible.
(f) Range of motion. Based on the comprehensive assessment of a participant, the program management must ensure that--
(1) A participant who enters the program without a limited range of motion does not experience reduction in range of motion unless the participant's clinical condition demonstrates that a reduction in range of motion is unavoidable; and
(2) A participant with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
(g) Mental and psychosocial functioning. Based on the comprehensive assessment of a participant, the program management must ensure that a participant who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem.
(h) Accidents. The program management must ensure that--
(1) The participant environment remains as free of accident hazards as is possible; and
(2) Each participant receives adequate supervision and assistance devices to prevent accidents.
(i) Nutrition. Based on a participant's comprehensive assessment, the program management must ensure, by working with the family, that a participant--
(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the participant's clinical condition demonstrates that this is not possible; and
(2) Receives a therapeutic diet when a nutritional deficiency is identified.
(j) Hydration. The program management must provide each participant with sufficient fluid intake during the day to maintain proper hydration and health.
(k) Unnecessary drugs.--(1) General. Each participant's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i) In excessive dose (including duplicate drug therapy); or
(ii) For excessive duration; or
(iii) Without adequate monitoring; or
(iv) Without adequate indications for its use; or
(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(vi) Any combinations of the reasons in paragraphs (k)(1)(i) through (v) of this section.
(2) Antipsychotic drugs. Based on a comprehensive assessment of a participant, the program management must ensure that--
(i) Participants who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed by the primary physician and documented in the clinical record; and
(ii) Participants who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
(l) Medication errors. The program management must ensure that--
(1) Medication errors are identified and reviewed on a timely basis; and
(2) strategies for preventing medication errors and adverse reactions are implemented.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
52.130 Nursing services.
The program management must provide an organized nursing service with a sufficient number of qualified nursing personnel to meet the total nursing care needs, as determined by participant assessment and individualized comprehensive plans of care, of all participants in the program.
(a) There must be at least one registered nurse on duty each day of operation of the adult day health care program. This nurse must be currently licensed by the State and must have, in writing, administrative authority, responsibility, and accountability for the functions, activities, and training of the nursing and program assistants. VA recommends that this nurse be a geriatric nurse practitioner or a clinical nurse specialist.
(b) The number and level of nursing staff is determined by the authorized capacity of participants and the nursing care needs of the participants.
(c) Nurse staffing must be based on a staffing methodology that uses case mix and is adequate for meeting the standards of this part.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
52.140 Dietary services.
The program management must provide each participant with a nourishing, palatable, well-balanced meal that proportionally meets the daily nutritional and special dietary needs of each participant.
(a) Food and nutritional services. The program management provides and/or contracts with a food service entity and provides and/or contracts sufficient support personnel competent to carry out the functions of the food service.
(1) The program management must employ a qualified dietitian either part-time or on a contract consultant basis to provide nutritional guidance.
(2) A qualified dietitian is one who is qualified based upon registration by the Commission on Dietetic Registration of the American Dietetic Association.
(3) The dietitian must--
(i) Conduct participant nutritional assessments and recommend nutritional intervention as appropriate.
(ii) Consult and provide nutrition education to participants, family/caregivers, and program staff as needed.
(iii) Consult and provide education and training to the food service staff.
(iv) Monitor and evaluate participants receiving enteral tube feedings and parenteral line solutions, and recommend changes as appropriate.
(b) Menus and nutritional adequacy.--(1) The participant's total dietary intake is of concern but is not the adult day health care program's responsibility.
(2) The program is responsible for the meals served in the facility.
(c) Food. Each participant receives and the program provides--
(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;
(2) Food that is palatable, attractive, and at the proper temperature;
(3) Food prepared in a form designed to meet individual needs; and
[[Page 39846]]
(4) Substitutes offered of similar nutritive value to participants who refuse food served.
(d) Therapeutic diets. (1) Therapeutic diets must be prescribed by the primary care physician.
(2) Special, modified, or therapeutic diets must be provided as necessary for participants with medical conditions or functional impairments.
(3) An adult day health care program must not admit nor continue to serve a participant whose dietary requirements cannot be accommodated by the program.
(e) Frequency of meals. (1) Each participant may receive and program management must provide at least two meals daily, at a regular time comparable to normal mealtimes in the community.
(2) The program management must offer snacks and fluids as appropriate to meet the participants' nutritional and fluid needs.
(f) Assistive devices. The program management must provide special eating equipment and utensils for participants who need them.
(g) Sanitary conditions. The program must--
(1) Procure food from sources approved or considered satisfactory by Federal, State, or local authorities;
(2) Store, prepare, distribute, and serve food under sanitary conditions; and
(3) Dispose of garbage and refuse properly.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.150 Physician services.
As a condition of enrollment in adult day health care program, a participant must obtain a written physician order for enrollment. Each participant must remain under the care of a physician.
(a) Physician supervision. The program management must ensure that--
(1) The medical care of each participant is supervised by a primary care physician;
(2) Each participant's medical record must contain the name of the participant's primary physician; and
(3) Another physician is available to supervise the medical care of participants when their primary physician is unavailable.
(b) Frequency of physician reviews.--(1) The participant must be seen by the primary physician at least annually and as indicated by a change of condition.
(2) The program management must have a policy to help ensure that adequate medical services are provided to participant.
(3) At the option of the primary physician, required reviews in the program after the initial review may alternate between personal physician reviews and reviews by a physician assistant, nurse practitioner, or clinical nurse specialist in accordance with paragraph (f) of this section.
(c) Availability of Acute Care. The program management must provide or arrange for the provision of acute care when it is indicated.
(d) Availability of physicians for emergency care. The program management must provide or arrange for the provision of physician services when the program has participants under its care, in case of an emergency.
(e) Physician delegation of tasks. (1) A primary physician may delegate tasks to:
(i) A certified physician assistant or a certified nurse practitioner; or
(ii) A clinical nurse specialist who--
(A) Is acting within the scope of practice as defined by State law; and
(B) Is under the supervision of the physician.
(2) The primary physician may not delegate a task when the provisions of this part specify that the primary physician must perform it personally, or when the delegation is prohibited under State law or by the facility's own policies.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.160 Specialized rehabilitative services.
(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech therapy, occupational therapy, and mental health services for mental illness are required in the participant's comprehensive plan of care, program management must--
(1) Provide the required services; or (2) Obtain the required services and equipment from an outside resource, in accordance with Sec. 52.210(h), from a provider of specialized rehabilitative services.
(b) Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.170 Dental services.
(a) Program management must, if necessary, assist the participant and family/caregiver--
(1) In making appointments; and
(2) By arranging for transportation to and from the dental services.
(b) Program management must promptly assist and refer participants with lost or damaged dentures to a dentist.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.180 Administration of drugs.
The program management must assist with the management of medication and have a system for disseminating drug information to participants and program staff.
(a) Procedures. (1) The program management must provide reminders or prompts to participants to initiate and follow though with self- administration of medications.
(2) The program management must establish a system of records to document the administration of drugs by participants and/or staff.
(3) The program management must ensure that drugs and biologicals used by participants are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
(4) The program management must store all drugs, biologicals, and controlled scheduled II drugs listed in 21 CFR 1308.12 in locked compartments under proper temperature controls, permit only authorized personnel to have access, and otherwise comply with all applicable State and Federal laws.
(b) Service consultation. The program management must employ or contract for the services of a pharmacist licensed in the State in which the program is located who provides consultation, as needed, on all the provision of drugs.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.190 Infection control.
The program management must establish and maintain an infection control program designed to prevent the development and transmission of disease and infection.
(a) Infection control program. The program management must--
(1) Investigate, control, and prevent infections in the program participants and staff; and
(2) Maintain a record of incidents and corrective actions related to infections.
(b) Preventing spread of infection. (1) The program management must prevent participants or staff, with a communicable disease or infected skin lesions from attending the adult day health care program, if direct contact will transmit the disease.
(2) The program management must require staff to wash their hands after each direct participant contact for which hand washing is indicated by accepted professional practice.
[[Page 39847]]
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.200 Physical environment.
The physical environment must be designed, constructed, equipped, and maintained to protect the health and safety of participants, personnel and the public.
(a) Life safety from fire. The facility must meet the applicable provisions of the National Fire Protection Association?s NFPA 101, Life Safety Code, 1997 edition. Incorporation by reference this document was approved by the Director of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The document incorporated by reference is available for inspection at the Office of the Federal Register, Suite 700, 800 North Capitol Street, NW., Washington, DC, and the Department of Veterans Affairs, Office of Regulations Management (02D), Room 1154, 810 Vermont Avenue, NW., Washington, DC 20420. Copies may be obtained from the National Fire Protection Association, Battery March Park, Quincy, MA 02269. (For ordering information, call toll-free 1- 800-344-3555.)
(b) Space and equipment. (1) Program management must--
(i) Provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide participants with needed services as required by these standards and as identified in each participant's plan of care; and
(ii) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.
(2) Each adult day health care program, when it is co-located in a nursing home, domiciliary, or other care facility, must have its own separate designated space during operational hours.
(3) The indoor space for an adult day health care program must be at least 100 square feet per participant including office space for staff and must be 60 square feet per participant excluding office space for staff.
(4) Each program will need to design and partition its space to meet its own needs, but a minimal number of functional areas must be available. These include:
(i) A dividable multipurpose room or area for group activities, including dining, with adequate table setting space.
(ii) Rehabilitation rooms or an area for individual and group treatments for occupational therapy, physical therapy, and other treatment modalities.
(iii) A kitchen area for refrigerated food storage, the preparation of meals and/or training participants in activities of daily living.
(iv) An examination and/or medication room.
(v) A quiet room, which functions to isolate participants who become ill or disruptive, or who require rest, privacy, or observation. It should be separate from activity areas, near a restroom, and supervised.
(vi) Bathing facilities adequate to facilitate bathing of participants with functional impairments.
(vii) Toilet facilities and bathrooms easily accessible to people with mobility problems, including participants in wheelchairs. There must be at least one toilet for every eight (8) participants. The toilets must be equipped for use by persons with limited mobility, easily accessible from all programs areas, i.e. preferably within 40 feet from that area, designed to allow assistance from one or two staff, and barrier-free.
(viii) Adequate storage space. There should be space to store arts and crafts materials, personal clothing and belongings, wheelchairs, chairs, individual handiwork, and general supplies. Locked cabinets must be provided for files, records, supplies, and medications.
(ix) An individual room for counseling and interviewing participants and family members.
(x) A reception area.
(xi) An outside space that is used for outdoor activities that is safe, accessible to indoor areas, and accessible to those with a disability. This space may include recreational space and garden area. It should be easily supervised by staff.
(c) Furnishings must be available for all participants. This must include functional furniture appropriate to the participants' needs. Furnishings must be attractive, comfortable, and homelike, while being sturdy and safe.
(d) Participant call system. The coordinator's station must be equipped to receive participant calls through a communication system from--
(1) Clinic rooms; and
(2) Toilet and bathing facilities.
(e) Other environmental conditions. The program management must provide a safe, functional, sanitary, and comfortable environment for the participants, staff and the public. The program management must--
(1) Establish procedures to ensure that water is available to essential areas if there is a loss of normal water supply;
(2) Have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two;
(3) Equip corridors, when available, with firmly-secured handrails on each side; and
(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.210 Administration.
An adult day health care program must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being of each participant.
(a) Governing body. (1) The State must have a governing body, or designated person functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the program; and
(2) The governing body or State official with oversight for the program appoints the adult day health care program administrator who is:
(i) a qualified heath care professional experienced in clinical program management and, if required by the State, certified as a Certified Administrator in Adult Day Health Care; and
(ii) Responsible for the operation and management of the program including:
(A) Documentation of current credentials for each licensed independent practitioner employed by the program;
(B) Review of the practitioner's record of experience;
(C) Assessment of whether practitioners with clinical privileges act within the scope of privileges granted; and
(iii) Awareness of local trends in community adult day health care and other services, and participation in area adult day health care organizations.
(b) Disclosure of State agency and individual responsible for oversight of facility. The State must give written notice to the Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group (114), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420, at the time of the change, if any of the following change:
(1) The State agency and individual responsible for oversight of a State home facility;
(2) The State adult day health care program administrator; or
(3) The State employee responsible for oversight of the State home adult day health care program if a contractor operates the State program.
(c) Required information. The program management must submit the following to the director of the VA
[[Page 39848]]
medical center of jurisdiction as part of the application for recognition and thereafter as often as necessary to be current:
(1) The copy of legal and administrative action establishing the State-operated facility (e.g., State laws);
(2) Site plan of facility and surroundings.
(3) Legal title, lease, or other document establishing right to occupy facility;
(4) Organizational charts and the operational plan of the adult day health care program;
(5) The number of the staff by category indicating full-time, part- time and minority designation, annually;
(6) The number of adult day health care participants who are veterans and non-veterans, the number of veterans who are minorities and the number of non-veterans who are minorities, annually;
(7) Annual State Fire Marshall's report;
(8) Annual certification from the responsible State home showing compliance with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) (VA Form 10-0143A set forth at 38 CFR 58.14);
(9) Annual certification for Drug-Free Workplace Act of 1988 (41 U.S.C. 701-707) (VA From 10-0143 set forth at 38 CFR 58.15);
(10) Annual certification regarding lobbying in compliance with 31 U.S.C. 1352 (VA Form 10-0144 set forth at 38 CFR 58.16);
(11) Annual certification of compliance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d-1) as effectuated in 38 CFR part 18 (VA Form 10-0144A located at 38 CFR 58.17);
(d) Percentage of veterans. At least 75 percent of the program participants must be eligible veterans except that the veteran percentage need only be more than 50 percent if the facility was acquired, constructed, or renovated solely with State funds. All non- veteran participants must be veteran-related family members or gold star parents of veterans.
(e) Management contract facility. If a program is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility on a full-time onsite basis.
(f) Licensure. The facility and program management must comply with applicable State and local licensure laws.
(g) Staff qualifications. (1) The program management must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements. Professional disciplines involved in participant care must include registered nurses, program assistants, physicians, social workers, rehabilitation therapist, dietitian, and therapeutic activity therapist and pharmacist. Other disciplines may be considered depending upon the participant and/or program needs.
(2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws.
(3) The staff-participant ratio must be sufficient in number and skills (at least one staff to 4 participants) to ensure compliance with the standards of this part. There must be at least two responsible persons (paid staff members) at the adult day health care center at all times when there are two or more participants in attendance.
(4) Persons counted in the staff to participant ratio must spend at least 70 percent of their time in direct service with participants.
(5) All professional team members will serve in the role of case manager for designated participants.
(6) All personnel, paid and volunteer, will be provided appropriate training to maintain the knowledge and skills required for the participant needs.
(h) Use of outside resources. (1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the program management must have that service furnished to participants by a person or agency outside the facility under a written agreement described in paragraph (h)(2) of this section.
(2) Agreements pertaining to services furnished by outside resources must specify in writing that the program management assumes responsibility for--
(i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a program; and
(ii) The timeliness of the services.
(i) Medical director. (1) The program management must provide a primary care physician to serve as medical director and a consultant to the interdisciplinary program team.
(2) The medical director is responsible for:
(i) Participating in establishing policies, procedures, and guidelines to ensure adequate, comprehensive services;
(ii) Directing and coordinating medical care in the program;
(iii) Ensuring continuous physician coverage to handle medical emergencies;
(iv) Participating in managing the environment by reviewing and evaluating incident reports or summaries of incident reports, identifying hazards to health and safety, and making recommendations to the adult day health care program administrator; and
(v) Monitoring employees' health status and advising the program administrator on employee-health policies.
(3) The medical director may also provide hands-on assessment and/ or treatment if authorized by the participant's primary care provider. In programs where a medical director is available to act as a member of the team and authorizes care, information concerning the care provided must be shared with the primary care physician who continues to provide the ongoing medical care.
(4) The program management must have written procedures for handling medical emergencies. The procedures must include, at least:
(i) Procedures for notification of the family;
(ii) Procedures for transportation arrangements;
(iii) Provision for an escort, if necessary; and
(iv) Procedures for maintaining a portable basic emergency information file for each participant that includes:
(A) Hospital preference;
(B) Physician of record and telephone number;
(C) Emergency contact (family);
(D) Insurance information;
(E) Medications/allergies;
(F) Current diagnosis and history; and
(G) Photograph for participant identification.
(j) Required training of program assistants. (1) Program assistants must have a high school diploma or the equivalent and must have at least one year of experience in working with adults in a health care setting. Program assistants also must complete the National Adult Day Services Association training course or complete equivalent training.
(2) The program management must not use any individual working in the program as a program assistant whether permanent or not unless:
(i) That individual is competent to provide appropriate services; and
(ii) That individual has completed training or is certified by the National Adult Day Services Association as a certified Program Assistant in Adult Day Services.
(3) Verification. Before allowing an individual to serve as a nurse aide or program assistant, program management
[[Page 39849]]
must verify that the individual has successfully completed a training and competency evaluation program. Facilities must follow up to ensure that such an individual actually becomes certified, if available in the State.
(4) Multi-State registry verification. Before allowing an individual to serve as a nurse aide or program assistant, program management must seek information from every State registry established under HHS regulations at 42 CFR 483.156 which the facility believes may include information on the individual.
(5) Required retraining. If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.
(6) Regular in-service education. The program management must complete a performance review of every nurse aide or program assistant at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must--
(i) Be sufficient to ensure the continuing competence of nurse aides or program assistants, but must be no less than 12 hours per year;
(ii) Address areas of weakness as determined in program assistants' performance reviews and address the special needs of participants as determined by the program staff; and
(iii) For program assistants or nurse aides providing services to individuals with cognitive impairments, address the care of the cognitively impaired.
(k) Proficiency of program assistants. The program management must ensure that program assistants or nurse aides are able to demonstrate competency in skills and techniques necessary to care for participants' needs, as identified through participant assessments, and described in the plan of care.
(l) Laboratory and radiology results. The program management must--
(1) Obtain laboratory or radiology results from the participant's primary physician to support the needs of its participants.
(2) Assist the participant and/or family/caregiver in making transportation arrangements to and from the source of laboratory or radiology services, if the participant needs assistance.
(3) File in the participant's clinical record laboratory or radiology reports that are dated and contain the name and address of the testing laboratory or radiology service.
(m) Participant records. (1) The facility management must maintain clinical records on each participant in accordance with accepted professional standards and practices that are--
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized.
(2) Clinical records must be retained for--
(i) The period of time required by State law; or
(ii) Five years from the date of discharge if there is no requirement in State law.
(3) The program management must safeguard clinical record information against loss, destruction, or unauthorized use.
(4) The program management must keep confidential all information contained in the participant's records, regardless of the form or storage method of the records, except when release is required by--
(i) Transfer to another health care institution;
(ii) Law;
(iii) A third-party payment contract;
(iv) The participant; or
(v) The participant's legal representative.
(5) The clinical record must contain--
(i) Sufficient information to identify the participant;
(ii) A record of the participant's assessments;
(iii) The plan of care and services provided;
(iv) The results of any pre-enrollment screening conducted by the State; and
(v) Progress notes.
(n) Quality assessment and assurance. (1) Program management must maintain a quality improvement program and a quality improvement committee consisting of--
(i) A registered nurse;
(ii) A medical director designated by the program; and
(iii) At least 3 other members of the program's staff.
(2) The quality improvement committee--
(i) Must implement a quality improvement plan for the evaluation of its operation and services and review and revise annually; and
(ii) Must meet at least quarterly to identify quality of care issues; and
(iii) Must develop and implement appropriate plans of action to correct identified quality deficiencies; and
(iv) Must ensure that identified quality deficiencies are corrected within an established time period.
(3) The VA Under Secretary for Health may not require disclosure of the records of such committee unless such disclosure is related to the compliance with the requirements of this section.
(o) Disaster and emergency preparedness. (1) The program management must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, bomb threats, and missing participants.
(2) The program management must train all employees in emergency procedures when they begin to work in the program, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures.
(p) Transfer procedure. (1) The program management must have in effect a written transfer procedure that reasonably assures that--
(i) Participants will be transferred from the adult day health care program to the hospital, and ensured of timely admission to the hospital when transfer is medically appropriate as determined by a physician; and
(ii) Medical and other information needed for care and treatment of participants will be exchanged between the institutions.
(2) The transfer must be with a hospital sufficiently close to the adult day health care program to make transfer feasible.
(q) Compliance with Federal, State, and local laws and professional standards. The program management must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. This includes the Single Audit Act of 1984 (31 U.S.C. 7501 et seq.) and the Cash Management Improvement Acts of 1990 and 1992 (31 U.S.C. 3335, 3718, 3720A, 6501, 6503).
(r) Relationship to other Federal regulations. In addition to compliance with the regulations set forth in this subpart, the program must meet the applicable provisions of other Federal laws and regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, national origin, handicap, or age (38 CFR part 18); protection of human subjects of research (45 CFR part 46), section 504 of the Rehabilitation Act of 1993 (29 U.S.C. 794); Drug-Free Workplace Act of 1988 (41 U.S.C. 701- 707); restrictions regarding lobbying (31 U.S.C. 1352); Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d-1). Although these regulations are not in
[[Page 39850]]
themselves considered requirements under this part, their violation may result in the termination or suspension of, or the refusal to grant or continue payment with Federal funds.
(s) Intermingling. A facility recognized as a State home for providing adult day health care may only provide adult day health care in the areas of the facility recognized as a State home for providing adult day health care.
(t) VA management of State veterans homes. Except as specifically provided by statute or regulations, VA employees have no authority regarding the management or control of State homes providing adult day health care.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
Sec. 52.220 Transportation.
Transportation of participants to and from the adult day health care facility must be a component of the overall program.
(a) The adult day health care program management must provide, arrange, or contract for transportation to enable participants, including persons with disabilities, to attend the program and to participate in facility-sponsored outings.
(b) The adult day health care program management must have a transportation policy that includes routine and emergency procedures, with a copy of the relevant procedures located in all program vehicles.
(c) All vehicles transporting participants to and from adult day health care must be equipped with a device for two-way communication and one additional staff person besides the driver.
(d) All facility-provided and contracted transportation systems must meet local, state and federal regulations.
(e) The time to transport participant to or from the facility must not be more than 60 minutes except under unusual conditions, e.g. bad weather.
(Authority: 38 U.S.C. 101, 501, 1741-1743)
[FR Doc. 00-15639Filed6-27-00; 8:45 am]
BILLING CODE 8320-01-P
