Senator Moss, as you know, has sponsored the program of reduced fares for senior citizens on the airlines but we have not made much headway with it. Mr. Oriol has explored the area once before but we are continuing the efforts.

As I said, I think it is a laudable goal and I commend you for the efforts that you are making in Atlanta, particularly with regard to the transportation. We have heard the problem time and time again.

I know you have got it up your way, too, Mrs. Lowry.
Mrs. LOWRY. We have been trying, we have not succeeded yet.
Mr. HALAMANDARIS. I certainly wish you success.

Mr. PARKER. A little airline, I believe it is the Executive Airline out of Atlanta, will give reduced fares to the over 65 age group. Mr. ORIOL. Do you happen to know whether that has increased ridership?

Mr. PARKER. No, I don't.

Mr. ORIOL. Well, as we indicated before, this was an impromptu arrangement. We are certainly glad to have this for the hearing record, and I hope that you will feel free to add to that record.

You mentioned the national association before. Do you believe that they have information at this point which would be useful for the record? We would like to have that.

The subcommittee will adjourn, subject to the call of the Chair. (Whereupon, at 1:55 p.m., the subcommittee adjourned, subject to the call of the Chair.)

APPENDIXES

Appendix 1

TITLE 45-PUBLIC WELFARE

CHAPTER II-SOCIAL AND REHABILITATION SERVICE (ASSISTANCE PROGRAMS), DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PART 249 -SERVICES AND PAYMENT IN MEDICAL ASSISTANCE PROGRAMS

Standards for Payment for Skilled Nursing Home Care

Iterim policy which sets forth regulations to implement section 1902 (a) (28) of the Social Security Act with respect to standards for payment for skilled nursing home care was published in the Federal Register of June 24, 1969 (34 F.R. 9788). After consideration of views presented by interested persons, the interim regulations are hereby adopted, subject to the following changes:

1. Section 249.33(a)(1) is amended to cross reference the definition of a skilled nursing home set forth under § 249.10(b) (4) (i) of Chapter II of Title 45 of the Code of Federal Regulations.

2. The provision concerning the Fire Safety Code of the National Fire Protection Association is amended to incorporate conditions under which the State agency may waive certain requirements (§ 249.33 (a) (1) (vii)).

3. The review of personnel statements is amended to provide that such statements set forth (from payroll records) the average numbers and types of personnel during a week selected by the survey agency (§ 249.33 (a) (2) (ii) (b)).

4. The requirement for one on-site inspection during the term of an agreement is amended to provide for more frequent inspections (§ 249.33 (a) (2) (iii)).

5. The requirement prohibiting second 6-month agreements is amended to provide for two successive agreements on the basis of documented evidence that substantial effort and progress has been made in correcting prior existing deficiencies (§ 249.33 (a) (2) (iv) (a) (3)).

6. The definition of organized nursing service under § 249.33 (b) (1) (iii) (a) and (b) is revised under paragraph (b) (1) (ii) (a) of the final policy to provide that where a licensed practical nurse serving as a charge nurse is not a graduate of an approved State school of practical nursing, or its equivalent, such nurse may serve in this capacity until July 1, 1970, only if she was successfully discharging charge nurse responsibilities on July 1, 1967.

7. The requirement for a determination of equivalency by the appropriate State licensing authority is amended to provide that equivalency findings be made by the appropriate State licensing authority for nurses (§ 249.33(b)(1) (ii) (a)). 8. The definition of organized nursing service relative to the use of licensed practical (or vocational) nurses is amended to add (b) to provide for institutions for the mentally retarded which are certified as skilled nursing homes (§ 249.33 (b) (1) (ii) (b)).

9. The requirement concerning the definition and assignment of duties under § 249.33 (b) (1) (v) of the interim policy is redesignated and amended to clarify the criteria for assignment of staff (§ 249.33(b)(1) (iv)).

10. The requirement for written care policies is amended to add restorative services (§ 249.33(b) (1) (v)).

11. The definition of adequate nursing and auxiliary personnel is amended to clarify and define such personnel under separate subdivisions (§ 249.33 (b) (2) (i) and (ii)).

12. The definition of adequate nursing service is amended to incorporate Social and Rehabilitation Service guidelines for adequate nursing services (§ 249.33 (b) (3)(i)).

13. The requirement relative to written agreement provisions for other outpatient services is deleted and amended to provide written agreements for other medical services (§ 249.33(b) (8) (ii)).

14. The conditions under which single State agencies may waive environment and sanitation requirements is amended to provide for the conditions for waiver of the Fire Safety Code and to provide the waivers under this provision be made on the basis of documented evidence (§ 249.33(c) (2)).

§ 249.33 Standards for payment for skilled nursing home care.

(a) State plan requirements. A State plan for medical assistance under title XIX of the Social Security Act must:

(1) Provide that any skilled nursing home (see § 249.10(b)(4)(i) of this part) receiving payments under the plan must:

(i) Supply to the licensing agency of the State full and complete information, and promptly report any changes which would affect the current accuracy of such information, as to the identity

(a) Of each person having (directly or indirectly) an ownership interest of 10 percentum or more in such skilled nursing home,

(b) In case a skilled nursing home is organized as a corporation, of each officer and director of the corporation, and

(c) In case a skilled nursing home is organized as a partnership, of each partner;

(ii) Have and maintain an organized nursing service, as defined in paragraph (b) of this section, for its patients which is under the direction of a a professional registered nurse who is employed full-time by such skilled nursing home, and which is composed of sufficient nursing and auxiliary personnel to provide adequate and properly supervised nursing services for such patients during all hours of each day and all days of each week;

(iii) Make satisfactory arrangements, as defined in paragraph (b) of this section, for professional planning and supervision of menus and meal service for patients for whom special diets or dietary restrictions are medically prescribed; (iv) Have satisfactory policies and procedures, as defined in paragraph (b) of this section;

(a) Relating to the maintenance of medical records on each patient of the skilled nursing home;

(b) Relating to dispensing and administering of drugs and biologicals; (c) To assure that each patient is under the care of a physician;

(d) To assure that adequate provision is made for medical attention to any patient during emergencies;

(v) Have arrangements, as defined in paragraph (b) of this section, with one or more general hospitals under which such hospital or hospitals will provide needed diagnostic and other services to patients of such skilled nursing home, and under which such hospital or hospitals agree to timely acceptance, as patients thereof, of acutely ill patients of such skilled nursing home who are in need of hospital care. The single State agency, however, may waive this requirement wholly or in part with respect to any skilled nursing home which meets all other requirements and is unable to effect such an arrangement with a hospital, as provided in paragraph (c) of this section;

(vi) Meet conditions relating to environment and sanitation, as specified in paragraph (b)(9) of this section, applicable to extended care facilities under title XVIII of the Social Security Act. The single State agency, however, may waive for such periods and under such conditions as the approved plan provides any requirement imposed by paragraph (b) (9) in accordance with the regulations set forth in paragraph (c) of this section;

(vii) Meet (after December 31, 1969) such provisions of the Life Safety Code of the National Fire Protection Association (21st Edition, 1967) as are applicable to nursing homes; except that the State agency may waive in accordance with regulations set forth in paragraph (c) of this section for such periods as it deems appropriate, specific provisions of such code, which if rigidly applied, would result in unreasonable hardship upon a nursing home, but only if such agency makes a determination (and keeps a written record setting forth the basis of such determination) that such waiver will not adversely affect the health and safety of the patients of such skilled nursing home; and except that the requirements of this subdivision need not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects patients in nursing homes.

(2) Provide and specify the methods and procedures which assure that:

(i) The single State agency will, prior to execution of an agreement with any facility for provision of skilled nursing home care and making payments under the plan.

(a) Obtain sufficient evidence through survey arrangements with the State licensing authority or with the agency of the State designated pursuant to section 1864 of the Social Security Act, that the facility

(1) Meets the requirement of subparagraph (1) of this paragraph; or

(2) Is a participating provider of extended care under title XVIII of the Social Security Act, and in addition meets the requirements of subdivisions (i), (v) and (vii) of such subparagraph (1); or

(b) Otherwise obtain sufficient evidence that the facility meets the requirements of such subparagraph (1); Provided, however, That if the single State agency elects not to use the services of the State licensing authority or the agency of the State designated pursuant to section 1864 of the Social Security Act, a written justification is submitted to the Administrator, Social and Rehabilitation Service that such election is not inconsistent with efficiency and economy of administration.

(ii) The single State agency will:

(a) Review information contained in reports of medical review teams on inspections made pursuant to State plan provisions under section 1902 (a) (26) of the Social Security Act;

(b) Review statements obtained by the appropriate State agency from each skilled nursing home, on forms provided by such agency, setting forth (from payroll records) the average numbers and types of personnel (in full-time equivalents) on each shift during at least 1 week of each quarter, such week to be selected by the survey agency and to occur irregularly in each quarter of the year;

(c) Evaluate such statements to determine that requirements relating to personnel were or were not met during any quarter in which payment is being requested;

(iii) Beginning January 1, 1970, onsite inspection by qualified personnel will be made at least once during the term of an agreement, or more frequently if there is a question of compliance, and the single State agency will review the information thus obtained, except that this requirement may be deemed to be met for skilled nursing homes also certified to participate as extended care facilities under title XVIII of the Social Security Act;

(iv) The single State agency agreement with a facility for payments under the plan may not exceed a period of 1 year. Execution of a new agreement shall be contingent upon a determination of compliance with the provisions of subparagraph (1) of this paragraph except that:

(a) In the case of any skilled nursing home determined or certified to be in substantial compliance (i.e., is in compliance except for deficiencies) with the requirements of such subparagraph (1), the single State agency may enter into an agreement with such skilled nursing home for the provision of services and making of payments under the plan for a period not to exceed 6 months provided that on the basis of documented evidence derived from a survey the single State agency finds that:

(1) There is a reasonable prospect that the deficiencies can be corrected within 6 months and the skilled nursing home provides in writing a plan acceptable to the single State agency for so doing;

(2) The deficiencies noted individually or in combination, do not jeopardize the health and safety of the patients and a written justification of such a finding is maintained on file by the appropriate State agency;

And provided further, That

(3) No more than two successive agreements for 6 months are executed with any skilled nursing home having deficiencies, and no second agreement is executed if any of the deficiencies existing are the same as those which occasioned the prior agreement unless the single State agency finds on the basis of documented evidence derived from a survey that the facility has made substantial effort and progress in correcting such deficiencies;

(b) Notwithstanding the foregoing provisions, in the case of skilled nursing homes certified with deficiencies as extended care facilities under the provisions of title XVIII of the Social Security Act, the term of agreements may extend until 90 days after the next inspection scheduled, as required, for extended care facility certification.

For the purposes of this subdivision (iv), waivers granted pursuant to paragraph (a)(1) (v)−(vii) and paragraph (c) of this section are not considered deficiencies.

(v) All information and reports used in determining whether a skilled nursing home meets the requirements set forth in subparagraph (1) of this paragraph are maintained on file for a period of at least 3 years by the appropriate State agency for ready access by the Department of Health, Education, and Welfare; and

(a) Copies of reports of inspection made on or after January 1, 1970, are completed by the inspector(s) surveying the premises with notations indicating whether each requirement for which inspection is made, is or is not satisfied, with documentation of deficiencies;

(b) Copies of official notices of waiver of any requirement imposed pursuant to subparagraph (1)(vii) of this paragraph and regulations pertaining thereto are on file;

(vi) Facilities which do not qualify under this section are not recognized as skilled nursing homes for purposes of payment under title XIX of the Act.

(b) Definition of terms. For purposes of paragraph (a)(1) of this section the following definitions apply:

(1) Organized nursing service. The term "organized nursing service" means that: (i) Nursing services are under the direction of a director of nursing service who is a professional registered nurse and who:

(a) Is employed full-time in the facility, devotes her full-time to supervising the nursing service, and is on duty during the day shift;

(b) Is qualified by education, training or experience for supervisory duties;

(c) Is responsible to the administrator for the selection, assignment, and direction of the activities of nursing service personnel;

(d) Is responsible to the administrator for development of standards, policies, and procedures governing skilled nursing care and for assuring that such standards, policies and procedures are observed;

(ii) There is on duty at all times and in charge of nursing activities at least one professional registered nurse or licensed practical (or vocational) nurse who is a graduate of a State-approved school of practical nursing, or who is found by the appropriate State licensing authority for nurses on the basis of the individual's education and formal training to have background considered to be equivalent to graduation from a State's approved school of practical nursing except that: (a) In those instances in which a licensed practical nurse serving as charge nurse is not a graduate of an approved school and does not possess background determined to be equivalent but was successfully discharging the responsibilities of a charge nurse on July 1, 1967, such nurse may continue to be employed in this capacity until July 1, 1970, but after that date only if she has been found by the appropriate State licensing authority to have completed training equivalent to graduation from a State-approved school of practical nursing; and

(b) In the case of institutions for the mentally retarded or distinct parts of such institutions which are certified as skilled nursing homes, other categories of licensed personnel with special training in the care of such patients may serve as charge nurse: Provided, That such person is licensed by the State in such category following completion of a course of training which includes at least the number of classroom and practice hours in all of the nursing subjects included in the program of a State approved school of practical (or vocational) nursing as evidenced by a report to the single State agency by the agency or agencies of the State responsible for the licensure of such personnel comparing the courses in the respective curricula. (iii) Lines of administrative and supervisory responsibility are clearly established in writing, and are known to all members of the nursing staff and to appropriate personnel in other units of the facility;

(iv) Duties are clearly defined and assigned to staff members consistent with the level of education, preparation, experience, and licensing of each.

(v) There are written patient-care policies and procedures governing skilled and related services, including restorative services, and staff members are familiar with them.

(2) Nursing and auxiliary personnel. (i) Nursing personnel means professional registered nurses and licensed practical (or vocational) nurses holding valid and current licenses as required by State law and performing duties directly related to providing nursing services to patients.

(ii) Auxiliary personnel includes nurses aides, orderlies, attendants, and ward clerks performing duties not constituting the practice of nursing as defined under State law.

(3) Adequate *** nursing services. The phrase "adequate nursing services'' means that: