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Start Preamble Census kamagra uk safe Bureau, buy kamagra over the counter Commerce. Notice of information collection. Request for kamagra uk safe comment.

The Department of Commerce, in accordance with the Paperwork Reduction Act (PRA) of 1995, invites the general public and other Federal agencies to comment on proposed, and continuing information collections, which helps us assess the impact of our information collection requirements and minimize the public's reporting burden. The purpose of this notice kamagra uk safe is to allow for an additional 60 days of public comment on a proposed new information collection, the Management and Organizational Practices Survey—Hospitals (MOPS-HP). An information collection request (ICR) for the MOPS-HP was submitted to OMB for approval on July 7, 2020 and is currently pending OMB review.

To ensure consideration, comments regarding this proposed information collection must be received on or before January 19, 2021. Interested persons are invited to kamagra uk safe submit written comments by email to Thomas.J.Smith@census.gov. Please reference Management and Organizational Practices Survey—Hospitals (MOPS-HP) in the subject line of your comments.

You may also submit comments, identified by Docket Number USBC-2020-0029, to the Federal kamagra uk safe e-Rulemaking Portal. Http://www.regulations.gov. All comments received are part of the public record.

No comments kamagra uk safe will be posted to http://www.regulations.gov for public viewing until after the comment period has closed. Comments will generally be posted without change. All Personally kamagra uk safe Identifiable Information (for example, name and address) voluntarily submitted by the commenter may be publicly accessible.

Do not submit Confidential Business Information or otherwise sensitive or protected information. You may submit attachments to electronic comments in Microsoft Word, Excel, or Adobe PDF file formats. Start Further Info Requests kamagra uk safe for additional information or specific questions related to collection activities should be directed to Edward Watkins at edward.e.watkins.iii@census.gov or 301-763-4750.

End Further Info End Preamble Start Supplemental Information I. Abstract The kamagra uk safe U.S. Census Bureau plans to conduct the Management and Organizational Practices Survey-Hospitals (MOPS-HP) for survey year 2020 as a joint project with Harvard Business School.

The MOPS-HP will utilize a subset of the Service Annual Survey mail-out sample and will collect data on management practices from Chief Nursing Officers (CNOs) at kamagra uk safe general medical and surgical hospitals to assist in studying their relationship to clinical and financial performance. A notice seeking public comment on our plans to conduct this survey was previously published in the Federal Register on February 12, 2020, on pages 4623-4624. That notice proposed collecting data for survey years 2019 and 2014, but collection has been adjusted due to the ongoing erectile dysfunction kamagra.

The kamagra has further highlighted the relevance of hospital management practices, especially as they relate to hospitals' abilities to respond to shocks to kamagra uk safe their organization and the health care system. In light of this, the Census Bureau has modified the survey proposal to collect data for reference years 2020 and 2019. This change seeks to kamagra uk safe directly measure management practices and protocols before and during the kamagra to obtain a better understanding of how hospitals have had to adjust and pivot operations during this public health emergency.

The Census Bureau also plans to include two additional questions in the MOPS-HP content to help improve measurement of hospital preparedness. These questions will provide information on two elements of responsiveness, hospitals' coordinated deployment of frontline clinical workers and hospitals' ability to quickly respond to needed changes in standardized clinical protocols. In an effort to limit respondent burden while adding this content, adjustments were made to keep the total number kamagra uk safe of questions and estimated burden per response unchanged.

The project plan, schedule, and collection strategy are being actively monitored, and adjustments will be made as necessary, as the Census Bureau is cognizant and respectful of the time, resources, and burden placed on CNOs during the kamagra. After the close of this second comment period, the Census Bureau will submit these planned changes as an amendment to the ICR, which is currently pending review at kamagra uk safe OMB. Any comments received by the close of the comment period will be summarized and included in the amendment.

Currently, no official statistics on management practices in hospitals exist. Past research shows these practices are related to health care providers' kamagra uk safe clinical and financial outcomes. This suggests that providing measures on management practices may potentially help the United States health care system, which is challenged by rising health care costs, increased demand from an aging society, and quality objectives.

These data would kamagra uk safe permit users to examine relationships between management practices and financial outcomes using Census Bureau data (e.g., revenues) and relationships with clinical outcomes using external data sources. Additionally, these data would provide hospital administrators and managers information to evaluate their practices in comparison to other hospitals at an aggregate level. The MOPS-HP content was proposed by external researchers with past experience in kamagra uk safe surveying hospitals on management practices.

Some questions are adapted from the Management and Organizational Practices Survey (MOPS), conducted in the manufacturing sector, allowing for inter-sectoral comparisons. Content for the MOPS-HP includes performance monitoring, financial and clinical targets, and incentives. The 39 kamagra uk safe questions are grouped into the following sections.

Tenure, Management Practices, Management Training, Management of Team Interactions, Staffing and Allocation of Human Resources, Standardized Clinical Protocols, Documentation of Patients' Medical Records, and Organizational Characteristics.Start Printed Page 73674 II. Method of Collection The MOPS-HP kamagra uk safe sample will consist of approximately 3,200 hospital locations for enterprises classified under General Medical and Surgical Hospitals (NAICS 6221) and sampled in the Service Annual Survey (SAS). The survey will be mailed separately from the 2020 SAS and collected electronically through the Census Bureau's Centurion online reporting system.

Respondents will be sent an initial letter with instructions detailing how to log into the instrument and report their information. These letters kamagra uk safe will be addressed to the location's CNO. In instances where the CNO is not identifiable, the letter will be addressed to the hospital's administrative office with attention to the CNO.

Collection is scheduled to begin in the kamagra uk safe initial months of 2021. III. Data OMB Control Number.

Type of Review. Regular submission, New Information Collection Request. Affected Public.

General medical and surgical hospitals. Estimated Number of Respondents. Approximately 3,200.

Estimated Time per Response. 45 minutes. Estimated Total Annual Burden Hours.

2,400. Estimated Total Annual Cost to Public. $0.

(This is not the cost of respondents' time, but the indirect costs respondents may incur for such things as purchases of specialized software or hardware needed to report, or expenditures for accounting or records maintenance services required specifically by the collection.) Respondent's Obligation. Mandatory. Legal Authority.

Title 13 U.S.C., Sections 131 and 182. IV. Request for Comments We are soliciting public comments to permit the Department/Bureau to.

(a) Evaluate whether the proposed information collection is necessary for the proper functions of the Department, including whether the information will have practical utility. (b) Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used. (c) Evaluate ways to enhance the quality, utility, and clarity of the information to be collected.

And (d) Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology. Comments that you submit in response to this notice are a matter of public record. We will include, or summarize, each comment in our request to OMB to approve this ICR.

Before including your address, phone number, email address, or other personal identifying information in your comment, you should be aware that your entire comment—including your personal identifying information—may be made publicly available at any time. While you may ask us in your comment to withhold your personal identifying information from public review, we cannot guarantee that we will be able to do so. Start Signature Sheleen Dumas, Department PRA Clearance Officer, Office of the Chief Information Officer, Commerce Department.

End Signature End Supplemental Information [FR Doc. 2020-25580 Filed 11-18-20. 8:45 am]BILLING CODE 3510-07-PStart Preamble Department of Veterans Affairs.

Interim final rule. The Department of Veterans Affairs (VA) is issuing this interim final rule to confirm that its health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. Specifically, this rulemaking confirms VA's current practice of allowing VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other State requirement, thereby enhancing beneficiaries' access to critical VA health care services.

This rulemaking also confirms VA's authority to establish national standards of practice for health care professionals which will standardize a health care professional's practice in all VA medical facilities. Effective Date. This rule is effective on November 12, 2020.

Comments. Comments must be received on or before January 11, 2021. Comments may be submitted through www.Regulations.gov or mailed to, Beth Taylor, 10A1, 810 Vermont Avenue NW, Washington, DC 20420.

Comments should indicate that they are submitted in response to [“RIN 2900-AQ94—Authority of VA Professionals to Practice Health Care.”] Comments received will be available at regulations.gov for public viewing, inspection, or copies. Start Further Info Beth Taylor, Chief Nursing Officer, Veterans Health Administration. 810 Vermont Avenue NW, Washington, DC 20420, (202) 461-7250.

(This is not a toll-free number.) End Further Info End Preamble Start Supplemental Information On January 30, 2020, the World Health Organization (WHO) declared the erectile dysfunction treatment outbreak to be a Public Health Emergency of International Concern. On January 31, 2020, the Secretary of the Department of Health and Human Services declared a Public Health Emergency pursuant to 42 United States Code (U.S.C.) 247d, for the entire United States to aid in the nation's health care community response to the erectile dysfunction treatment outbreak. On March 11, 2020, in light of new data and the rapid spread in Europe, WHO declared erectile dysfunction treatment to be a kamagra.

On March 13, 2020, the President declared a National Emergency due to erectile dysfunction treatment under sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.) and consistent with section 1135 of the Social Security Act (SSA), as amended (42 U.S.C. 1320b-5).

As a result of responding to the needs of our veteran population and other non-veteran beneficiaries during the erectile dysfunction treatment National Emergency, where VA has had to shift health care Start Printed Page 71839professionals to other locations or duties to assist in the care of those affected by this kamagra, VA has become acutely aware of the need to promulgate this rule to clarify the policies governing VA's provision of health care. This rule is intended to confirm that VA health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. In particular, it will confirm (1) VA's continuing practice of authorizing VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other requirement.

And (2) VA's authority to establish national standards of practice for health care professions via policy, which will govern their employment, subject only to State laws where the health care professional is licensed, credentialed, registered, or subject to some other State requirements that do not unduly interfere with those duties. We note that the term State as it applies to this rule means each of the several States, Territories, and possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico, or a political subdivision of such State. This definition is consistent with the term State as it is defined in 38 U.S.C.

101(20). A conflicting State law is one that would unduly interfere with the fulfillment of a VA health care professional's Federal duties. We note that the policies and practices confirmed in this rule only apply to VA health care professionals appointed under 38 U.S.C.

7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code, which does not include contractors working in VA medical facilities or those working in the community. VA has long understood its governing statutory authorities to permit VA to engage in these practices.

Section 7301(b) of title 38 the U.S. Code establishes that the primary function of the Veterans Health Administration (VHA) within VA is to provide a complete medical and hospital service for the medical care and treatment of veterans. To allow VHA to carry out its medical care mission, Congress established a comprehensive personnel system for certain VA health care professionals, independent of the civil service rules.

See Chapters 73-74 of title 38 of the U.S. Code. Congress granted the Secretary express statutory authority to establish the qualifications for VA's health care professionals, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals.

38 U.S.C. 7401-7464. Section 7402 of 38 U.S.C.

Establishes the qualifications of appointees. To be eligible for appointment as a VA employee in a health care profession covered by section 7402(b) (other than a medical facility Director appointed under section 7402(b)(4)), most individuals, after appointment, must, among other requirements, be licensed, registered, or certified to practice their profession in a State, or satisfy some other State requirement. However, the standards prescribed in section 7402(b) establish only the basic qualifications for VA health care professionals and do not limit the Secretary from establishing other qualifications or rules for health care professionals.

In addition, the Secretary is responsible for the control, direction, and management of the Department, including agency personnel and management matters. See 38 U.S.C. 303.

Such authorities permit the Secretary to further regulate the health care professions to make certain that VA's health care system provides safe and effective health care by qualified health care professionals to ensure the well-being of those veterans who have borne the battle. In this rulemaking, VA is detailing its authority to manage its health care professionals by stating that they may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other State requirements that unduly interfere with their practice. VA believes that this is necessary in order to provide additional protection for VA health care professionals against adverse State actions proposed or taken against them when they are practicing within the scope of their VA employment, particularly when they are practicing across State lines or when they are performing duties consistent with a VA national standard of practice for their health care profession.

Practice Across State Lines Historically, VA has operated as a national health care system that authorizes VA health care professionals to practice in any State as long as they have a valid license, registration, certification, or fulfill other State requirements in at least one State. In doing so, VA health care professionals have been practicing within the scope of their VA employment regardless of any unduly burdensome State requirements that would restrict practice across State lines. We note, however, that VA may only hire health care professionals who are licensed, registered, certified, or satisfy some other requirement in a State, unless the statute requires or provides otherwise (e.g., 38 U.S.C.

7402(b)(14)). The erectile dysfunction treatment kamagra has highlighted VA's acute need to exercise its statutory authority of allowing VA health care professionals to practice across State lines. In response to the kamagra, VA needed to and continues to need to move health care professionals quickly across the country to care for veterans and other beneficiaries and not have State licensure, registration, certification, or other State requirements hinder such actions.

Put simply, it is crucial for VA to be able to determine the location and practice of its VA health care professionals to carry out its mission without any unduly burdensome restrictions imposed by State licensure, registration, certification, or other requirements. This rulemaking will support VA's authority to do so and will provide an increased level of protection against any adverse State action being proposed or taken against VA health care professionals who practice within the scope of their VA employment. Since the start of the kamagra, in furtherance of VA's Fourth Mission, VA has rapidly utilized its resources to assist parts of the country that are undergoing serious and critical shortages of health care resources.

VA's Fourth Mission is to improve the Nation's preparedness for response to war, terrorism, national emergencies, and natural disasters by developing plans and taking actions to ensure continued service to veterans, as well as to support national, State, and local emergency management, public health, safety and homeland security efforts. VA has deployed personnel to support other VA medical facilities that have been impacted by erectile dysfunction treatment as well as provided support to State and community nursing homes. As of July 2020, VA has deployed personnel to more than 45 States.

VA utilized the Disaster Emergency Medical Personnel System (DEMPS), VA's main deployment program, for VA health care professionals to travel to locations deemed as national emergency or disaster areas, to help provide health care services in places such as New Orleans, Louisiana, and New York City, New York. As of June 2020, a total of 1,893 staff have been mobilized to meet the needs of our facilities and Fourth Start Printed Page 71840Mission requests during the kamagra. VA deployed 877 staff to meet Federal Emergency Management Agency (FEMA) Mission requests, 420 health care professionals were deployed as DEMPS response, 414 employees were mobilized to cross level staffing needs within their Veterans Integrated Service Networks (VISN), 69 employees were mobilized to support needs in another VISN, and 113 Travel Nurse Corps staff responded specifically for erectile dysfunction treatment staffing support.

In light of the rapidly changing landscape of the kamagra, it is crucial for VA to be able to move its health care professionals quickly across the country to assist when a new hot spot emerges without fear of any adverse action from a State be proposed or taken against a VA health care professional. We note that, in addition to providing in person health care across State lines during the kamagra, VA also provides telehealth across State lines. VA's video to home services have been heavily leveraged during the kamagra to deliver safe, quality VA health care while adhering to Centers for Disease Control and Prevention (CDC) physical distancing guidelines.

Video visits to veterans' homes or other offsite location have increased from 41,425 in February 2020 to 657,423 in July of 2020. This represents a 1,478 percent utilization increase. VA has specific statutory authority under 38 U.S.C.

1730C to allow health care professionals to practice telehealth in any State regardless of where they are licensed, registered, certified, or satisfy some other State requirement. This rulemaking is consistent with Congressional intent under Public Law 115-185, sec. 151, June 6, 2018, codified at 38 U.S.C.

1730C for all VA health care professionals to practice across State lines regardless of the location of where they provide health care. This rulemaking will ensure that VA professionals are protected regardless of how they provide health care, whether it be via telehealth or in-person. Beyond the current need to mobilize health care resources quickly to different parts of the country, this practice of allowing VA health care professionals to practice across State lines optimizes the VA health care workforce to meet the needs of all VA beneficiaries year-round.

It is common practice within the VA health care system to have primary and specialty health care professionals routinely travel to smaller VA medical facilities or rural locations in nearby States to provide care that may be difficult to obtain or unavailable in that community. As of January 14, 2020, out of 182,100 licensed health care professionals who are employed by VA, 25,313 or 14 percent do not hold a State license, registration, or certification in the same State as their main VA medical facility. This number does not include the VA health care professionals who practice at a main VA medical facility in one State where they are licensed, registered, certified, or hold some other State requirement, but also practice at a nearby Community Based Outpatient Clinic (CBOC) in a neighboring State where they do not hold such credentials.

Indeed, 49 out of the 140 VA medical facilities nationwide have one or more sites of care in a different State than the main VA medical facility. Also, VA has rural mobile health units that provide health care services to veterans who have difficulty accessing VA health care facilities. These mobile units are a vital source of health care to veterans who live in rural and medically underserved communities.

Some of the services provided by the mobile units include, but are not limited to, health care screening, mental health outreach, influenza and pneumonia vaccinations, and routine primary care. The rural mobile health units are an integral part of VA's goal of encouraging healthier communities and support VA's preventative health programs. Health care professionals who provide health care in these mobile units may provide services in various States where they may not hold a license, registration, or certification, or satisfy some other State requirement.

It is critical that these health care professionals are protected from any adverse State action proposed or taken when performing these crucial services. In addition, the practice of health care professionals of providing health care across State lines also gives VA the flexibility to hire qualified health care professionals from any State to meet the staffing needs of a VA health care facility where recruitment or retention is difficult. As of December 31, 2019, VA had approximately 13,000 vacancies for health care professions across the country.

As a national health care system, it is imperative for VA to be able to recruit and retain health care professionals, where recruitment and retention is difficult, to ensure there is access to health care regardless of where the VA beneficiary resides. Permitting VA health care professionals to practice across State lines is an important incentive when trying to recruit for these vacancies, particularly during a kamagra, where private health care facilities have greater flexibility to offer more competitive pay and benefits. This is also especially beneficial in recruiting spouses of active service members who frequently move across the country.

National Standard of Practice This rulemaking also confirms VA's authority to establish national standards of practice for health care professions. We note that this rulemaking does not create any such national standards. All national standards of practice will be created via policy.

For the purposes of this rulemaking, a national standard of practice describes the tasks and duties that a VA health care professional practicing in the health care profession may perform and may be permitted to undertake. Having a national standard of practice means that individuals from the same VA health care profession may provide the same type of tasks and duties regardless of the VA medical facility where they are located or the State license, registration, certification, or other State requirement they hold. We emphasize that VA will determine, on an individual basis, that a health care professional has the necessary education, training, and skills to perform the tasks and duties detailed in the national standard of practice.

The need for national standards of practice have been highlighted by VA's large-scale initiative regarding the new electronic health record (EHR). VA's health care system is currently undergoing a transformational initiative to modernize the system by replacing its current EHR with a joint EHR with Department of Defense (DoD) to promote interoperability of medical data between VA and DoD. VA's new EHR system will provide VA and DoD health care professionals with quick and efficient access to the complete picture of a veteran's health information, improving VA's delivery of health care to our nation's veterans.

For this endeavor, DoD and VA established a joint governance over the EHR system. In order to be successful, VA must standardize clinical processes with DoD. This means that all health care professionals in DoD and VA who practice in a certain health care profession must be able to carry out the same duties and tasks irrespective of State requirements.

The reason why this is important is because each health care profession is designated a role in the EHR system that sets forth specific privileges within the EHR that dictate allowed tasks for such profession. These tasks include, but are not limited to, dispensing and administrating medications. Prescriptive practices.

Ordering of procedures and diagnostic imaging. And required level of oversight. VA has the ability to modify these privileges within EHR, however, VA Start Printed Page 71841cannot do so on an individual user level, but rather at the role level for each health care profession.

In other words, VA cannot modify the privileges for all health care professionals in one State to be consistent with that State's requirements. Instead, the privileges can only be modified for every health care professional in that role across all States. Therefore, the privileges established within EHR cannot be made facility or State specific.

In order to achieve standardized clinical processes, VA and DoD must create the uniform standards of practice for each health care specialty. Currently, DoD has specific authority from Congress to create national standards of practice for their health care professionals under 10 U.S.C. 1094.

While VA lacks a similarly specific statute, VA has the general statutory authority, as explained above, to regulate its health care professionals and authorize health care practices that preempt conflicting State law. This regulation will confirm VA's authority to do so. Absent such standardized practices, it will be incredibly difficult for VA to achieve its goal of being an active participant in EHR modernization because either some VA health care professionals would fear potential adverse State actions or DoD and VA would need to agree upon roles that are consistent with the most restrictive States' requirements to ensure that all health care professionals are acting within the scope of their State requirements.

VA believes that agreement upon roles that are consistent with the most restrictive State is not an acceptable option because it will lead to delayed care and consequently decreased access and level of health care for VA beneficiaries. One example that impacts multiple health care professions throughout the VA system is the ability to administer medication without a provider (physician or advanced practice nurse practitioner) co-signature. As it pertains to nursing, almost all States permit nurses to follow a protocol.

However, some States, such as New York, North Carolina, and South Carolina, do not permit nurses to follow a protocol without a provider co-signature. A protocol is a standing order that has been approved by medical and clinical leadership if a certain sequence of health care events occur. For instance, if a patient is exhibiting certain signs of a heart attack, there is a protocol in place to administer potentially life-saving medication.

If the nurse is the first person to see the signs, the nurse will follow the approved protocol and immediately administer the medication. However, if the nurse cannot follow the protocol and requires a provider co-signature, administration of the medication will be delayed until a provider is able to co-sign the order, which may lead to the deterioration of the patient's condition. This also increases the provider's workload and decreases the amount of time the provider can spend with patients.

Historically, VA physical therapists (PTs), occupational therapists, and speech therapists were routinely able to determine the need to administer topical medications during therapy sessions and were able to administer the topical without a provider co-signature. However, in order to accommodate the new EHR system and variance in State requirements, these therapists would need to place an order for all medications, including topicals, which would leave these therapists waiting for a provider co-signature in the middle of a therapy session, thus delaying care. Furthermore, these therapists also routinely ordered imaging to better assess the clinical needs of the patient, but would also have to wait for a provider co-signature, which will further delay care and increase provider workload.

In addition to requiring provider co-signatures, there will also be a significant decrease in access to care due to other variances in State requirements. For instance, direct access to PTs will be limited in order to ensure that the role is consistent with all State requirements. Direct access means that a beneficiary may request PT services without a provider's referral.

However, while almost half of the States allow unrestricted direct access to PTs, over half of the States have some limitations on requesting PT services. For instance, in Alabama, a licensed PT may perform an initial evaluation and may only provide other services as delineated in specific subdivisions of the Alabama Physical Therapy Practice Act. Furthermore, in New York, PT treatment may be rendered by a licensed PT for 10 visits or 30 days, whichever shall occur first, without a referral from a physician, dentist, podiatrist, nurse practitioner, or licensed midwife.

This is problematic as VA will not be able to allow for direct access due to these variances and direct access has been shown to be beneficial for patient care. Currently, VISN 23 is completing a two-year strategic initiative to implement direct access and have PTs embedded into patient aligned care teams (PACT). Outcomes thus far include decreased wait times, improved veteran satisfaction, improved provider satisfaction, and improved functional outcomes.

Therefore, VA will confirm its authority to ensure that health care professionals are protected against State action when they adhere to VA's national standards of practice. We reiterate that this rulemaking does not establish national standards of practice for each health care profession, but merely confirms VA's authority to do so, thereby preempting any State restrictions that unduly interfere with those practices. The actual national standards of practice will be developed in subregulatory policy for each health care profession.

As such, VA will make a concerted effort to engage appropriate stakeholders when developing the national standards of practice. Preemption As previously explained, in this rulemaking, VA is confirming its authority to manage its health care professionals. Specifically, this rulemaking will confirm VA's long-standing practice of allowing its health care professionals to practice in a State where they do not hold a license, registration, certification, or satisfy some other State requirement.

The rule will also confirm that VA health care professionals must adhere to VA's national standards of practice, as determined by VA policy, irrespective of conflicting State licensing, registration, certification, or other State requirements that unduly burden that practice. We do note that VA health care professionals will only be required to perform tasks and duties to the extent of their education, skill, and training. For instance, VA would not require a registered nurse to perform a task that the individual nurse was not trained to perform.

Currently, practice in accordance with VA employment, including practice across State lines or adhering to a VA standard of practice, may jeopardize VA health care professionals' credentials or result in fines and imprisonment for unauthorized health care practice. This is because most States have restrictions that limit health care professionals' practice or have rules that prohibit health care professionals from furnishing health care services within that State without a license, registration, certification, or other requirement from that State. We note that, some States, for example Rhode Island, Utah, and Michigan, have enacted legislation or regulations that specifically allow certain VA health care professionals to practice in those States when they do not hold a State license.

Several VA health care professionals have already had actions proposed or taken against them by various States Start Printed Page 71842while practicing health care within the scope of their VA employment, while they either practiced in a State where they do not hold a license, registration, certification, or other State requirement that unduly interfered with their VA employment. In one instance, a VA psychologist was licensed in California but was employed and providing supervision of a trainee at the VA Medical Center (VAMC) in Nashville, Tennessee. California psychology licensing laws require supervisors to hold a license from the State where they are practicing and do not allow for California licensed psychologists to provide supervision to trainees or unlicensed psychologists outside the State of California.

The California State Psychology Licensing Board proposed sanctions and fines of $1,000 for violating section 1387.4(a) of the CA Code of Regulations (CCR). The VA system did not qualify for the exemption of out of State supervision requirements listed in CCR section 1387.4. In addition, a VA physician who was licensed in Oregon, but was practicing at a VAMC in Biloxi, Mississippi had the status of their license changed from active to inactive because the Oregon Medical Board determined the professional did not reside in Oregon, in violation of Oregon's requirement that a physician physically reside in the State in order to maintain an active license.

This rulemaking serves to preempt State requirements, such as the ones discussed above, that were or can be used to take an action against VA health care professionals for practicing within the scope of their VA employment. State licensure, registration, certification, and other State requirements are preempted to the extent such State laws unduly interfere with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. As explained above, Congress provided general statutory provisions that permit the VA Secretary to authorize health care practices by health care professionals at VA, which serve to preempt conflicting State laws that unduly interfere with the exercise of health care by VA health care professionals pursuant to that authorization.

Although some VA health care professionals are required by Federal statute to have a State license, see, e.g., 38 U.S.C. 7402(b)(1)(C) (providing that, to be eligible to be appointed to a physician position at the VA, a physician must be licensed to practice medicine, surgery, or osteopathy in a State), a State may not attach a condition to the license that is unduly burdensome to or unduly interferes with the practice of health care within the scope of VA employment. Under well-established interpretations of the Supremacy Clause, Federal laws and policies authorizing VA health care professionals to practice according to VA standards preempt conflicting State law.

That is, a State law that prevents or unreasonably interferes with the performance of VA duties. See, e.g., Hancock v. Train, 426 U.S.

167, 178-81 (1976). Sperry v. Florida, 373 U.S.

379, 385 (1963). Miller v. Arkansas, 352 U.S.

276, 282-84 (1899). State Bar Disciplinary Rules as Applied to Federal Government Attorneys, 9 Op. O.L.C.

71, 72-73 (1985). When a State law does not conflict with the performance of Federal duties in these ways, VA health care professionals are required to abide by the State law. Therefore, VA's policies and regulations will preempt State licensure, registration, and certification laws, rules, or other requirements only to the extent they conflict with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment.

We emphasize that, in instances where there is no conflict with State requirements, VA health care professionals should abide by the State requirement. For example, if a State license requires a health care professional to have a certain number of hours of continuing professional education per year to maintain their license, the health care professional must adhere to this State requirement if it does not prevent or unduly interfere with the exercise of VA employment. To determine whether a State requirement is conflicting, VA would assess whether the State law unduly interferes on a case-by-case basis.

For instance, if Oregon requires all licensed physicians to reside in Oregon, VA would likely find that it unduly interferes with already licensed VA physicians who reside and work for VA in the State of Mississippi. We emphasize that the intent of the regulation is to only preempt State requirements that are unduly burdensome and interfere with a VA health care professionals' practice for the VA. For instance, it would not require a State to issue a license to an individual who does not meet the education requirements to receive a license in that State.

We note that this rulemaking also does not affect VA's existing requirement that all VA health care professionals adhere to restrictions imposed by the Controlled Substances Act, 21 U.S.C. 801 et seq. And implementing regulations at 21 CFR 1300, et seq., to prescribe or administer controlled substances.

Any preemption of conflicting State requirements will be the minimum necessary for VA to effectively furnish health care services. It would be costly and time-consuming for VA to lobby each State board for each health care profession specialty to remove restrictions that impair VA's ability to furnish health care services to beneficiaries and then wait for the State to implement appropriate changes. Doing so would not guarantee a successful result.

Regulation For these reasons, VA is establishing a new regulation titled Health care professionals' practice in VA, which will be located at 38 CFR 17.419. This rule will confirm the ability of VA health care professionals to practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. Subsection (a) of § 17.419 contains the definitions that will apply to the new section.

Subsection (a)(1) contains the definition for beneficiary. We are defining the term beneficiary to mean a veteran or any other individual receiving health care under title 38 of the U.S. Code.

We are using this definition because VA provides health care to veterans, certain family members of veterans, servicemembers, and others. This is VA's standard use of this term. Subsection (a)(2) contains the definition for health care professional.

We are defining the term health care professional to be an individual who meets specific criteria that is listed below. Subsection (a)(2)(i) will require that a health care professional be appointed to an occupation in VHA that is listed or authorized under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S.

Code. Subsection (a)(2)(ii) requires that the individual is not a VA-contracted health care professional. A health care professional does not include a contractor or a community health care professional because they are not considered VA employees nor appointed under 38 U.S.C.

7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. Subsection (a)(2)(iii) lists the required qualifications for a health care professional.

We note that these qualifications do not include all general Start Printed Page 71843qualifications for appointment, such as to hold a degree of doctor of medicine. These qualifications are related to licensure, registration, certification, or other State requirements. Subsection (a)(2)(iii)(A) states that the health care professional must have an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State to practice the health care specialty identified under 38 U.S.C.

7402(b). This standard ensures that VA health care professionals are qualified to practice their individual health care specialty if the specialty requires such credential. Subsection (a)(2)(iii)(B) states that the individual has other qualifications as prescribed by the Secretary for one of the health care professions listed under 38 U.S.C.

7402(b). Some health care professionals appointed under 38 U.S.C. 7401(3) whose qualifications are listed in 38 U.S.C.

7402(b) are not required to meet State license, registration, certification, or other requirements and rely on the qualifications prescribed by the Secretary. Therefore, these individuals would be included in this subsection and required to have the qualifications prescribed by the Secretary for their health care profession. Subsection (a)(2)(iii)(C) states that the individual is otherwise authorized by the Secretary to provide health care services.

This would include those individuals who practice a health care profession that does not require a State license, registration, certification, or other requirement and is also not listed in 38 U.S.C. 7402(b), but is authorized by the Secretary to provide health care services. Subsection (a)(2)(iii)(D) includes individuals who are trainees or may have a time limited appointment to finish clinicals or other requirements prior to being fully licensed.

Therefore, the regulation will state that the individual is under the clinical supervision of a health care professional that meets the requirements listed in subsection (a)(2)(iii)(A)-(C) and the individual must meet the requirements in subsection (a)(2)(iii)(D)(i) or (a)(2)(iii)(D)(ii). Subsection (a)(2)(iii)(D)(i) states that the individual is a health professions trainee appointed under 38 U.S.C. 7405 or 7406 participating in clinical or research training under supervision to satisfy program or degree requirements.

Subsection (a)(2)(iii)(D)(ii) states that the individual is a health care employee, appointed under title 5 of the U.S. Code, 38 U.S.C. 7401(1) or (3), or 38 U.S.C.

7405 for any category of personnel described in 38 U.S.C. 7401(1) or (3) who must obtain an active, current, full and unrestricted licensure, registration, or certification or meet the qualification standards as defined by the Secretary within the specified time frame. These individuals have a time-limited appointment to obtain credentials.

For example, marriage and family therapists require a certain number of supervised clinical post-graduate hours prior to receiving their license. Lastly, as we previously discussed in this rulemaking, we are defining the term State in subsection (a)(3) as the term is defined in 38 U.S.C. 101(20), and also including political subdivisions of such States.

This is consistent with the definition of State in 38 U.S.C. 1730C(f) which is VA's statutory authority to preempt State law when the covered health care professional is using telehealth to provide treatment to an individual under this title. We believe that it is important to define the term in the same way as it is defined for health care professionals practicing via telehealth so that way it is consistent regardless of whether the health care professional is practicing in-person or via telehealth.

Moreover, as subdivisions of a State are granted legal authority from the State itself, it makes sense to subject entities created by a State, or authorized by a State to create themselves, to be subject to the same limitations and restrictions as the State itself. Section 17.419(b) details that VA health care professionals must practice within the scope of their Federal employment irrespective of conflicting State requirements that would prevent or unduly interfere with the exercise of Federal duties. This provision confirms that VA health care professionals may furnish health care consistent with their VA employment obligations without fear of adverse action proposed or taken by any State.

In order to clarify and make transparent how VA utilizes or intends to utilize our current statutory authority, we are providing a non-exhaustive list of examples. The first example is listed in subsection (b)(1)(i). It states that a health care professional may practice their VA health care profession in any State irrespective of the State where they hold a valid license, registration, certification, or other qualification.

The second example is listed in subsection (b)(1)(ii). It states that a health care professional may practice their VA health care profession consistent with the VA national standard of practice as determined by VA. As previously explained, VA intends to establish national standards of practice via VA policy.

A health care professional's practice within VA will continue to be subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C. 801, et seq. And implementing regulations at 21 CFR 1300, et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy.

This will ensure that professionals are still in compliance with critical laws concerning the prescribing and administering of controlled substances. This requirement is stated in subsection (b)(2). Subsection (c) expressly states the intended preemptive effect of § 17.419, to ensure that conflicting State and local laws, rules, regulations, and requirements related to health care professionals' practice will have no force or effect when such professionals are practicing health care while working within the scope of their VA employment.

In circumstances where there is a conflict between Federal and State law, Federal law would prevail in accordance with Article VI, clause 2, of the U.S. Constitution. Executive Order 13132 establishes principles for preemption of State law when it is implicated in rulemaking or proposed legislation.

Where a Federal statute does not expressly preempt State law, agencies shall construe any authorization in the statute for the issuance of regulations as authorizing preemption of State law by rulemaking only when the exercise of State authority directly conflicts with the exercise of Federal authority or there is clear evidence to conclude that the Congress intended the agency to have the authority to preempt State law. In this situation, the Federal statutes do not expressly preempt State laws. However, VA construes the authorization established in 38 U.S.C.

303, 501, and 7401-7464 as authorizing preemption because the exercise of State authority directly conflicts with the exercise of Federal authority under these statutes. Congress granted the Secretary express statutory authority to establish the qualifications for VA's health care professionals, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals. 38 U.S.C.

7401-7464. Specifically, section 7402(b) states that most health care professionals, after appointment by VA, must, among other Start Printed Page 71844requirements, be licensed, registered, or certified to practice their profession in a State. To that end, VA's regulations and policies will preempt any State law or action that conflicts with the exercise of Federal duties in providing health care at VA.

In addition, any regulatory preemption of State law must be restricted to the minimum level necessary to achieve the objectives of the statute pursuant to the regulations that are promulgated. In this rulemaking, State licensure, registration, and certification laws, rules, regulations, or other requirements are preempted only to the extent such State laws unduly interfere with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. Therefore, VA believes that the rulemaking is restricted to the minimum level necessary to achieve the objectives of the Federal statutes.

The Executive Order also requires an agency that is publishing a regulation that preempts State law to follow certain procedures. These procedures include. The agency consult with, to the extent practicable, the appropriate State and local officials in an effort to avoid conflicts between State law and Federally protected interests.

And the agency provide all affected State and local officials notice and an opportunity for appropriate participation in the proceedings. For the reasons below, VA believes that it is not practicable to consult with the appropriate State and local officials prior to the publication of this rulemaking. The National Emergency caused by erectile dysfunction treatment has highlighted VA's acute need to quickly shift health care professionals across the country.

As both private and VA medical facilities in different parts of the country reach or exceed capacity, VA must be able to mobilize its health care professionals across State lines to provide critical care for those in need. As explained in the Supplementary Information above, as of June 2020, a total of 1,893 staff have been mobilized to meet the needs of our facilities and Fourth Mission requests during the kamagra. VA deployed 877 staff to meet Federal Emergency Management Agency (FEMA) Mission requests, 420 health care professionals were deployed as DEMPS response, 414 employees were mobilized to cross level staffing needs within their Veterans Integrated Service Networks (VISN), 69 employees were mobilized to support needs in another VISN, and 113 Travel Nurse Corps staff responded specifically for erectile dysfunction treatment staffing support.

Given the speed in which it is required for our health care professionals to go to these facilities and provide health care, it is also essential that the health care professionals can follow the same standards of practice irrespective of the location of the facility or the requirements of their individual State license. This is important because if multiple health care professionals, such as multiple registered nurses, licensed in different States are all sent to one VA medical facility to assist when there is a shortage of professionals, it would be difficult and cumbersome if they could not all perform the same duties and each supervising provider had to be briefed on the tasks each registered nurse could perform. In addition, not having a uniform national scope of practice could limit the tasks that the registered nurses could provide.

This rulemaking will provide health care professionals an increased level of protection against adverse State actions while VA strives to increase access to high quality health care across the VA health care system during this National Emergency. It would be time consuming and contrary to the public health and safety to delay implementing this rulemaking until we consulted with State and local officials. For these reasons, it would be impractical to consult with State and local officials prior to the publication of this rulemaking.

We note that this rulemaking does not establish any national standards of practice. Instead, VA will establish the national standards of practice via subregulatory guidance. VA will, to the extent practicable, make all efforts to engage with State and local officials when establishing the national standards of practice via subregulatory guidance.

Also, this interim final rule will have a 60-day comment period that will allow State and local officials the opportunity to provide their input on the rule. Administrative Procedures Act An Agency may forgo notice and comment required under the Administrative Procedures Act (APA), 5 U.S.C. 553, if the agency for good cause finds that compliance would be impracticable, unnecessary, or contrary to the public interest.

An agency may also bypass the APA's 30-day publication requirement if good cause exists. The Secretary of Veterans Affairs finds that there is good cause under the provisions of 5 U.S.C. 553(b)(B) to publish this rule without prior opportunity for public comment because it would be impracticable and contrary to the public interest and finds that there is good cause under 5 U.S.C.

553(d)(3) to bypass its 30-day publication requirement for the same reasons as outlined above in the Federalism section, above. In short, this rulemaking will provide health care professionals protection against adverse State actions while VA strives to increase access to high quality health care across the VA health care system during this National Emergency. In addition to the needs discussed above regarding the National Emergency, it is also imperative that VA move its health care professionals across State lines in order to facilitate the implementation of the new EHR system immediately.

VA implemented EHR at the first VA facility in October 2020 and additional sites are scheduled to have EHR implemented over the course of the next eight years. The next site is scheduled for implementation in Quarter 2 of Fiscal Year 2021 (i.e., between January to March 2021). Due to the implementation of the new EHR system, VA expects decreased productivity and reduced clinical staffing during training and other events surrounding EHR enactment.

VA expects a productivity decrease of up to 30 percent for the 60 days before implementation and the 120 days after at each site. Any decrease in productivity could result in decreased access to health care for our Nation's veterans. In order to support this anticipated productivity decrease, VA is engaging in a “national supplement,” where health care professionals from other VA medical facilities will be deployed to those VA medical facilities and VISNs that are undergoing EHR implementation.

The national supplement would mitigate reduced access during EHR deployment activities, such as staff training, cutover, and other EHR implementation activities. Over the eight-year deployment timeline, the national supplement is estimated to have full time employee equivalents of approximately 60 nurses, 3 pharmacy technicians, 5 mental health and primary care providers, and other VA health care professionals. We note that the actual number of VA health care professionals deployed to each site will vary based on need.

The national supplement will require VA health care professionals on a national level to practice health care in States where they do not hold a State license, registration, certification, or other requirement. In addition, VISNs will be providing local cross-leveling and intra-VISN staff deployments to support EHRM implementation activities. Put simply, in order to mitigate the decreased Start Printed Page 71845productivity as a result of EHR implementation, VA must transfer VA health care professionals across the country to States where they do not hold a license, registration, certification, or other requirement to assist in training on the new system as well as to support patient care.

Therefore, it would be impracticable and contrary to the public health and safety to delay implementing this rulemaking until a full public notice-and-comment process is completed. This rulemaking will be effective upon publication in the Federal Register. As noted above, this interim final rule will have a 60-day comment period that will allow State and local officials the opportunity to provide their input on the rule, and VA will take those comments into consideration when deciding whether any modifications to this rule are warranted.

Paperwork Reduction Act This final rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521). Regulatory Flexibility Act The Regulatory Flexibility Act, 5 U.S.C.

601-612, is not applicable to this rulemaking because a notice of proposed rulemaking is not required under 5 U.S.C. 553. 5 U.S.C.

601(2), 603(a), 604(a). Executive Orders 12866, 13563, and 13771 Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages. Distributive impacts.

And equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. The Office of Information and Regulatory Affairs has determined that this rule is a significant regulatory action under Executive Order 12866.

VA's impact analysis can be found as a supporting document at http://www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of the rulemaking and its impact analysis are available on VA's website at http://www.va.gov/​orpm/​, by following the link for “VA Regulations Published From FY 2004 Through Fiscal Year to Date.” This interim final rule is not subject to the requirements of E.O. 13771 because this rule results in no more than de minimis costs.

Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This interim final rule will have no such effect on State, local, and tribal governments, or on the private sector.

Congressional Review Act Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), the Office of Information and Regulatory Affairs designated this rule as not a major rule, as defined by 5 U.S.C. 804(2).

Catalog of Federal Domestic Assistance The Catalog of Federal Domestic Assistance numbers and titles for the programs affected by this document are. 64.007, Blind Rehabilitation Centers. 64.008, Veterans Domiciliary Care.

64.009, Veterans Medical Care Benefits. 64.010, Veterans Nursing Home Care. 64.011, Veterans Dental Care.

64.012, Veterans Prescription Service. 64.013, Veterans Prosthetic Appliances. 64.018, Sharing Specialized Medical Resources.

64.019, Veterans Rehabilitation Alcohol and Drug Dependence. 64.022, Veterans Home Based Primary Care. 64.039 CHAMPVA.

64.040 VHA Inpatient Medicine. 64.041 VHA Outpatient Specialty Care. 64.042 VHA Inpatient Surgery.

64.043 VHA Mental Health Residential. 64.044 VHA Home Care. 64.045 VHA Outpatient Ancillary Services.

64.046 VHA Inpatient Psychiatry. 64.047 VHA Primary Care. 64.048 VHA Mental Health Clinics.

64.049 VHA Community Living Center. And 64.050 VHA Diagnostic Care. Start List of Subjects Administrative practice and procedureAlcohol abuseAlcoholismClaimsDay careDental healthDrug abuseForeign relationsGovernment contractsGrant programs-healthGrant programs-veteransHealth careHealth facilitiesHealth professionsHealth recordsHomelessMedical and dental schoolsMedical devicesMedical researchMental health programsNursing homesReporting and recordkeeping requirementsScholarships and fellowshipsTravel and transportation expensesVeterans End List of Subjects Signing Authority The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs.

Brooks D. Tucker, Assistant Secretary for Congressional and Legislative Affairs, Performing the Delegable Duties of the Chief of Staff, Department of Veterans Affairs, approved this document on October 19, 2020, for publication. Start Signature Consuela Benjamin, Regulations Development Coordinator, Office of Regulation Policy &.

Management, Office of the Secretary, Department of Veterans Affairs. End Signature For the reasons stated in the preamble, the Department of Veterans Affairs is amending 38 CFR part 17 as set forth below. Start Part End Part Start Amendment Part1.

The authority citation for part 17 is amended by adding an entry for § 17.419 in numerical order to read in part as follows. End Amendment Part Start Authority 38 U.S.C. 501, and as noted in specific sections.

End Authority * * * * * Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). * * * * * Start Amendment Part2.

Add § 17.419 to read as follows. End Amendment Part Health care professionals' practice in VA. (a) Definitions.

The following definitions apply to this section. (1) Beneficiary. The term beneficiary means a veteran or any other individual receiving health care under title 38 of the United States Code.

(2) Health care professional. The term health care professional is an individual who. (i) Is appointed to an occupation in the Veterans Health Administration that is listed in or authorized under 38 U.S.C.

7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. (ii) Is not a VA-contracted health care professional.

And (iii) Is qualified to provide health care as follows. (A) Has an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State. (B) Has other qualifications as prescribed by the Secretary for one of Start Printed Page 71846the health care professions listed under 38 U.S.C.

7402(b). (C) Is an employee otherwise authorized by the Secretary to provide health care services. Or (D) Is under the clinical supervision of a health care professional that meets the requirements of subsection (a)(2)(iii)(A)-(C) of this section and is either.

(i) A health professions trainee appointed under 38 U.S.C. 7405 or 7406 participating in clinical or research training under supervision to satisfy program or degree requirements. Or (ii) A health care employee, appointed under title 5 of the U.S.

Code, 38 U.S.C. 7401(1) or (3), or 38 U.S.C. 7405 for any category of personnel described in 38 U.S.C.

7401(1) or (3) who must obtain an active, current, full and unrestricted licensure, registration, certification, or meet the qualification standards as defined by the Secretary within the specified time frame. (3) State. The term State means a State as defined in 38 U.S.C.

101(20), or a political subdivision of such a State. (b) Health care professional's practice. (1) When a State law or license, registration, certification, or other requirement prevents or unduly interferes with a health care professional's practice within the scope of their VA employment, the health care professional is required to abide by their Federal duties, which includes, but is not limited to, the following situations.

(i) A health care professional may practice their VA health care profession in any State irrespective of the State where they hold a valid license, registration, certification, or other State qualification. Or (ii) A health care professional may practice their VA health care profession within the scope of the VA national standard of practice as determined by VA. (2) VA health care professional's practice is subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C.

801 et seq. And implementing regulations at 21 CFR 1300 et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy. (c) Preemption of State law.

Pursuant to the Supremacy Clause, U.S. Const. Art.

IV, cl. 2, and in order to achieve important Federal interests, including, but not limited to, the ability to provide the same complete health care and hospital service to beneficiaries in all States as required by 38 U.S.C. 7301, conflicting State laws, rules, regulations or requirements pursuant to such laws are without any force or effect, and State governments have no legal authority to enforce them in relation to actions by health care professionals within the scope of their VA employment.

End Supplemental Information [FR Doc. 2020-24817 Filed 11-10-20. 8:45 am]BILLING CODE 8320-01-P.

Start Preamble can i buy kamagra online see page Census Bureau, Commerce. Notice of information collection. Request for can i buy kamagra online comment.

The Department of Commerce, in accordance with the Paperwork Reduction Act (PRA) of 1995, invites the general public and other Federal agencies to comment on proposed, and continuing information collections, which helps us assess the impact of our information collection requirements and minimize the public's reporting burden. The purpose of can i buy kamagra online this notice is to allow for an additional 60 days of public comment on a proposed new information collection, the Management and Organizational Practices Survey—Hospitals (MOPS-HP). An information collection request (ICR) for the MOPS-HP was submitted to OMB for approval on July 7, 2020 and is currently pending OMB review.

To ensure consideration, comments regarding this proposed information collection must be received on or before January 19, 2021. Interested persons are invited to submit written comments by email to can i buy kamagra online Thomas.J.Smith@census.gov. Please reference Management and Organizational Practices Survey—Hospitals (MOPS-HP) in the subject line of your comments.

You may also submit can i buy kamagra online comments, identified by Docket Number USBC-2020-0029, to the Federal e-Rulemaking Portal. Http://www.regulations.gov. All comments received are part of the public record.

No comments will be posted to http://www.regulations.gov for public viewing until after the comment period has closed can i buy kamagra online. Comments will generally be posted without change. All Personally Identifiable Information (for example, name and address) voluntarily submitted by the commenter can i buy kamagra online may be publicly accessible.

Do not submit Confidential Business Information or otherwise sensitive or protected information. You may submit attachments to electronic comments in Microsoft Word, Excel, or Adobe PDF file formats. Start Further Info Requests for additional information or can i buy kamagra online specific questions related to collection activities should be directed to Edward Watkins at edward.e.watkins.iii@census.gov or 301-763-4750.

End Further Info End Preamble Start Supplemental Information I. Abstract The can i buy kamagra online U.S. Census Bureau plans to conduct the Management and Organizational Practices Survey-Hospitals (MOPS-HP) for survey year 2020 as a joint project with Harvard Business School.

The MOPS-HP will utilize a subset of the Service Annual Survey mail-out sample and will collect data on management practices from Chief Nursing Officers (CNOs) at general medical and surgical hospitals can i buy kamagra online to assist in studying their relationship to clinical and financial performance. A notice seeking public comment on our plans to conduct this survey was previously published in the Federal Register on February 12, 2020, on pages 4623-4624. That notice proposed collecting data for survey years 2019 and 2014, but collection has been adjusted due to the ongoing erectile dysfunction kamagra.

The kamagra has further highlighted the can i buy kamagra online relevance of hospital management practices, especially as they relate to hospitals' abilities to respond to shocks to their organization and the health care system. In light of this, the Census Bureau has modified the survey proposal to collect data for reference years 2020 and 2019. This change seeks to directly measure management practices can i buy kamagra online and protocols before and during the kamagra to obtain a better understanding of how hospitals have had to adjust and pivot operations during this public health emergency.

The Census Bureau also plans to include two additional questions in the MOPS-HP content to help improve measurement of hospital preparedness. These questions will provide information on two elements of responsiveness, hospitals' coordinated deployment of frontline clinical workers and hospitals' ability to quickly respond to needed changes in standardized clinical protocols. In an effort to limit respondent burden while can i buy kamagra online adding this content, adjustments were made to keep the total number of questions and estimated burden per response unchanged.

The project plan, schedule, and collection strategy are being actively monitored, and adjustments will be made as necessary, as the Census Bureau is cognizant and respectful of the time, resources, and burden placed on CNOs during the kamagra. After the close of this second can i buy kamagra online comment period, the Census Bureau will submit these planned changes as an amendment to the ICR, which is currently pending review at OMB. Any comments received by the close of the comment period will be summarized and included in the amendment.

Currently, no official statistics on management practices in hospitals exist. Past research shows these practices are related to health care providers' clinical and financial can i buy kamagra online outcomes. This suggests that providing measures on management practices may potentially help the United States health care system, which is challenged by rising health care costs, increased demand from an aging society, and quality objectives.

These data would permit users to examine relationships between management practices and financial outcomes using Census Bureau data (e.g., revenues) and relationships with can i buy kamagra online clinical outcomes using external data sources. Additionally, these data would provide hospital administrators and managers information to evaluate their practices in comparison to other hospitals at an aggregate level. The MOPS-HP content was proposed by external researchers with can i buy kamagra online past experience in surveying hospitals on management practices.

Some questions are adapted from the Management and Organizational Practices Survey (MOPS), conducted in the manufacturing sector, allowing for inter-sectoral comparisons. Content for the MOPS-HP includes performance monitoring, financial and clinical targets, and incentives. The 39 questions are grouped into can i buy kamagra online the following sections.

Tenure, Management Practices, Management Training, Management of Team Interactions, Staffing and Allocation of Human Resources, Standardized Clinical Protocols, Documentation of Patients' Medical Records, and Organizational Characteristics.Start Printed Page 73674 II. Method of Collection The MOPS-HP sample will consist of approximately 3,200 hospital locations for enterprises classified can i buy kamagra online under General Medical and Surgical Hospitals (NAICS 6221) and sampled in the Service Annual Survey (SAS). The survey will be mailed separately from the 2020 SAS and collected electronically through the Census Bureau's Centurion online reporting system.

Respondents will be sent an initial letter with instructions detailing how to log into the instrument and report their information. These letters will can i buy kamagra online be addressed to the location's CNO. In instances where the CNO is not identifiable, the letter will be addressed to the hospital's administrative office with attention to the CNO.

Collection is scheduled to can i buy kamagra online begin in the initial months of 2021. III. Data OMB Control Number.

Type of Review. Regular submission, New Information Collection Request. Affected Public.

General medical and surgical hospitals. Estimated Number of Respondents. Approximately 3,200.

Estimated Time per Response. 45 minutes. Estimated Total Annual Burden Hours.

2,400. Estimated Total Annual Cost to Public. $0.

(This is not the cost of respondents' time, but the indirect costs respondents may incur for such things as purchases of specialized software or hardware needed to report, or expenditures for accounting or records maintenance services required specifically by the collection.) Respondent's Obligation. Mandatory. Legal Authority.

Title 13 U.S.C., Sections 131 and 182. IV. Request for Comments We are soliciting public comments to permit the Department/Bureau to.

(a) Evaluate whether the proposed information collection is necessary for the proper functions of the Department, including whether the information will have practical utility. (b) Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used. (c) Evaluate ways to enhance the quality, utility, and clarity of the information to be collected.

And (d) Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology. Comments that you submit in response to this notice are a matter of public record. We will include, or summarize, each comment in our request to OMB to approve this ICR.

Before including your address, phone number, email address, or other personal identifying information in your comment, you should be aware that your entire comment—including your personal identifying information—may be made publicly available at any time. While you may ask us in your comment to withhold your personal identifying information from public review, we cannot guarantee that we will be able to do so. Start Signature Sheleen Dumas, Department PRA Clearance Officer, Office of the Chief Information Officer, Commerce Department.

End Signature End Supplemental Information [FR Doc. 2020-25580 Filed 11-18-20. 8:45 am]BILLING CODE 3510-07-PStart Preamble Department of Veterans Affairs.

Interim final rule. The Department of Veterans Affairs (VA) is issuing this interim final rule to confirm that its health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. Specifically, this rulemaking confirms VA's current practice of allowing VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other State requirement, thereby enhancing beneficiaries' access to critical VA health care services.

This rulemaking also confirms VA's authority to establish national standards of practice for health care professionals which will standardize a health care professional's practice in all VA medical facilities. Effective Date. This rule is effective on November 12, 2020.

Comments. Comments must be received on or before January 11, 2021. Comments may be submitted through www.Regulations.gov or mailed to, Beth Taylor, 10A1, 810 Vermont Avenue NW, Washington, DC 20420.

Comments should indicate that they are submitted in response to [“RIN 2900-AQ94—Authority of VA Professionals to Practice Health Care.”] Comments received will be available at regulations.gov for public viewing, inspection, or copies. Start Further Info Beth Taylor, Chief Nursing Officer, Veterans Health Administration. 810 Vermont Avenue NW, Washington, DC 20420, (202) 461-7250.

(This is not a toll-free number.) End Further Info End Preamble Start Supplemental Information On January 30, 2020, the World Health Organization (WHO) declared the erectile dysfunction treatment outbreak to be a Public Health Emergency of International Concern. On January 31, 2020, the Secretary of the Department of Health and Human Services declared a Public Health Emergency pursuant to 42 United States Code (U.S.C.) 247d, for the entire United States to aid in the nation's health care community response to the erectile dysfunction treatment outbreak. On March 11, 2020, in light of new data and the rapid spread in Europe, WHO declared erectile dysfunction treatment to be a kamagra.

On March 13, 2020, the President declared a National Emergency due to erectile dysfunction treatment under sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.) and consistent with section 1135 of the Social Security Act (SSA), as amended (42 U.S.C. 1320b-5).

As a result of responding to the needs of our veteran population and other non-veteran beneficiaries during the erectile dysfunction treatment National Emergency, where VA has had to shift health care Start Printed Page 71839professionals to other locations or duties to assist in the care of those affected by this kamagra, VA has become acutely aware of the need to promulgate this rule to clarify the policies governing VA's provision of health care. This rule is intended to confirm that VA health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. In particular, it will confirm (1) VA's continuing practice of authorizing VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other requirement.

And (2) VA's authority to establish national standards of practice for health care professions via policy, which will govern their employment, subject only to State laws where the health care professional is licensed, credentialed, registered, or subject to some other State requirements that do not unduly interfere with those duties. We note that the term State as it applies to this rule means each of the several States, Territories, and possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico, or a political subdivision of such State. This definition is consistent with the term State as it is defined in 38 U.S.C.

101(20). A conflicting State law is one that would unduly interfere with the fulfillment of a VA health care professional's Federal duties. We note that the policies and practices confirmed in this rule only apply to VA health care professionals appointed under 38 U.S.C.

7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code, which does not include contractors working in VA medical facilities or those working in the community. VA has long understood its governing statutory authorities to permit VA to engage in these practices.

Section 7301(b) of title 38 the U.S. Code establishes that the primary function of the Veterans Health Administration (VHA) within VA is to provide a complete medical and hospital service for the medical care and treatment of veterans. To allow VHA to carry out its medical care mission, Congress established a comprehensive personnel system for certain VA health care professionals, independent of the civil service rules.

See Chapters 73-74 of title 38 of the U.S. Code. Congress granted the Secretary express statutory authority to establish the qualifications for VA's health care professionals, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals.

38 U.S.C. 7401-7464. Section 7402 of 38 U.S.C.

Establishes the qualifications of appointees. To be eligible for appointment as a VA employee in a health care profession covered by section 7402(b) (other than a medical facility Director appointed under section 7402(b)(4)), most individuals, after appointment, must, among other requirements, be licensed, registered, or certified to practice their profession in a State, or satisfy some other State requirement. However, the standards prescribed in section 7402(b) establish only the basic qualifications for VA health care professionals and do not limit the Secretary from establishing other qualifications or rules for health care professionals.

In addition, the Secretary is responsible for the control, direction, and management of the Department, including agency personnel and management matters. See 38 U.S.C. 303.

Such authorities permit the Secretary to further regulate the health care professions to make certain that VA's health care system provides safe and effective health care by qualified health care professionals to ensure the well-being of those veterans who have borne the battle. In this rulemaking, VA is detailing its authority to manage its health care professionals by stating that they may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other State requirements that unduly interfere with their practice. VA believes that this is necessary in order to provide additional protection for VA health care professionals against adverse State actions proposed or taken against them when they are practicing within the scope of their VA employment, particularly when they are practicing across State lines or when they are performing duties consistent with a VA national standard of practice for their health care profession.

Practice Across State Lines Historically, VA has operated as a national health care system that authorizes VA health care professionals to practice in any State as long as they have a valid license, registration, certification, or fulfill other State requirements in at least one State. In doing so, VA health care professionals have been practicing within the scope of their VA employment regardless of any unduly burdensome State requirements that would restrict practice across State lines. We note, however, that VA may only hire health care professionals who are licensed, registered, certified, or satisfy some other requirement in a State, unless the statute requires or provides otherwise (e.g., 38 U.S.C.

7402(b)(14)). The erectile dysfunction treatment kamagra has highlighted VA's acute need to exercise its statutory authority of allowing VA health care professionals to practice across State lines. In response to the kamagra, VA needed to and continues to need to move health care professionals quickly across the country to care for veterans and other beneficiaries and not have State licensure, registration, certification, or other State requirements hinder such actions.

Put simply, it is crucial for VA to be able to determine the location and practice of its VA health care professionals to carry out its mission without any unduly burdensome restrictions imposed by State licensure, registration, certification, or other requirements. This rulemaking will support VA's authority to do so and will provide an increased level of protection against any adverse State action being proposed or taken against VA health care professionals who practice within the scope of their VA employment. Since the start of the kamagra, in furtherance of VA's Fourth Mission, VA has rapidly utilized its resources to assist parts of the country that are undergoing serious and critical shortages of health care resources.

VA's Fourth Mission is to improve the Nation's preparedness for response to war, terrorism, national emergencies, and natural disasters by developing plans and taking actions to ensure continued service to veterans, as well as to support national, State, and local emergency management, public health, safety and homeland security efforts. VA has deployed personnel to support other VA medical facilities that have been impacted by erectile dysfunction treatment as well as provided support to State and community nursing homes. As of July 2020, VA has deployed personnel to more than 45 States.

VA utilized the Disaster Emergency Medical Personnel System (DEMPS), VA's main deployment program, for VA health care professionals to travel to locations deemed as national emergency or disaster areas, to help provide health care services in places such as New Orleans, Louisiana, and New York City, New York. As of June 2020, a total of 1,893 staff have been mobilized to meet the needs of our facilities and Fourth Start Printed Page 71840Mission requests during the kamagra. VA deployed 877 staff to meet Federal Emergency Management Agency (FEMA) Mission requests, 420 health care professionals were deployed as DEMPS response, 414 employees were mobilized to cross level staffing needs within their Veterans Integrated Service Networks (VISN), 69 employees were mobilized to support needs in another VISN, and 113 Travel Nurse Corps staff responded specifically for erectile dysfunction treatment staffing support.

In light of the rapidly changing landscape of the kamagra, it is crucial for VA to be able to move its health care professionals quickly across the country to assist when a new hot spot emerges without fear of any adverse action from a State be proposed or taken against a VA health care professional. We note that, in addition to providing in person health care across State lines during the kamagra, VA also provides telehealth across State lines. VA's video to home services have been heavily leveraged during the kamagra to deliver safe, quality VA health care while adhering to Centers for Disease Control and Prevention (CDC) physical distancing guidelines.

Video visits to veterans' homes or other offsite location have increased from 41,425 in February 2020 to 657,423 in July of 2020. This represents a 1,478 percent utilization increase. VA has specific statutory authority under 38 U.S.C.

1730C to allow health care professionals to practice telehealth in any State regardless of where they are licensed, registered, certified, or satisfy some other State requirement. This rulemaking is consistent with Congressional intent under Public Law 115-185, sec. 151, June 6, 2018, codified at 38 U.S.C.

1730C for all VA health care professionals to practice across State lines regardless of the location of where they provide health care. This rulemaking will ensure that VA professionals are protected regardless of how they provide health care, whether it be via telehealth or in-person. Beyond the current need to mobilize health care resources quickly to different parts of the country, this practice of allowing VA health care professionals to practice across State lines optimizes the VA health care workforce to meet the needs of all VA beneficiaries year-round.

It is common practice within the VA health care system to have primary and specialty health care professionals routinely travel to smaller VA medical facilities or rural locations in nearby States to provide care that may be difficult to obtain or unavailable in that community. As of January 14, 2020, out of 182,100 licensed health care professionals who are employed by VA, 25,313 or 14 percent do not hold a State license, registration, or certification in the same State as their main VA medical facility. This number does not include the VA health care professionals who practice at a main VA medical facility in one State where they are licensed, registered, certified, or hold some other State requirement, but also practice at a nearby Community Based Outpatient Clinic (CBOC) in a neighboring State where they do not hold such credentials.

Indeed, 49 out of the 140 VA medical facilities nationwide have one or more sites of care in a different State than the main VA medical facility. Also, VA has rural mobile health units that provide health care services to veterans who have difficulty accessing VA health care facilities. These mobile units are a vital source of health care to veterans who live in rural and medically underserved communities.

Some of the services provided by the mobile units include, but are not limited to, health care screening, mental health outreach, influenza and pneumonia vaccinations, and routine primary care. The rural mobile health units are an integral part of VA's goal of encouraging healthier communities and support VA's preventative health programs. Health care professionals who provide health care in these mobile units may provide services in various States where they may not hold a license, registration, or certification, or satisfy some other State requirement.

It is critical that these health care professionals are protected from any adverse State action proposed or taken when performing these crucial services. In addition, the practice of health care professionals of providing health care across State lines also gives VA the flexibility to hire qualified health care professionals from any State to meet the staffing needs of a VA health care facility where recruitment or retention is difficult. As of December 31, 2019, VA had approximately 13,000 vacancies for health care professions across the country.

As a national health care system, it is imperative for VA to be able to recruit and retain health care professionals, where recruitment and retention is difficult, to ensure there is access to health care regardless of where the VA beneficiary resides. Permitting VA health care professionals to practice across State lines is an important incentive when trying to recruit for these vacancies, particularly during a kamagra, where private health care facilities have greater flexibility to offer more competitive pay and benefits. This is also especially beneficial in recruiting spouses of active service members who frequently move across the country.

National Standard of Practice This rulemaking also confirms VA's authority to establish national standards of practice for health care professions. We note that this rulemaking does not create any such national standards. All national standards of practice will be created via policy.

For the purposes of this rulemaking, a national standard of practice describes the tasks and duties that a VA health care professional practicing in the health care profession may perform and may be permitted to undertake. Having a national standard of practice means that individuals from the same VA health care profession may provide the same type of tasks and duties regardless of the VA medical facility where they are located or the State license, registration, certification, or other State requirement they hold. We emphasize that VA will determine, on an individual basis, that a health care professional has the necessary education, training, and skills to perform the tasks and duties detailed in the national standard of practice.

The need for national standards of practice have been highlighted by VA's large-scale initiative regarding the new electronic health record (EHR). VA's health care system is currently undergoing a transformational initiative to modernize the system by replacing its current EHR with a joint EHR with Department of Defense (DoD) to promote interoperability of medical data between VA and DoD. VA's new EHR system will provide VA and DoD health care professionals with quick and efficient access to the complete picture of a veteran's health information, improving VA's delivery of health care to our nation's veterans.

For this endeavor, DoD and VA established a joint governance over the EHR system. In order to be successful, VA must standardize clinical processes with DoD. This means that all health care professionals in DoD and VA who practice in a certain health care profession must be able to carry out the same duties and tasks irrespective of State requirements.

The reason why this is important is because each health care profession is designated a role in the EHR system that sets forth specific privileges within the EHR that dictate allowed tasks for such profession. These tasks include, but are not limited to, dispensing and administrating medications. Prescriptive practices.

Ordering of procedures and diagnostic imaging. And required level of oversight. VA has the ability to modify these privileges within EHR, however, VA Start Printed Page 71841cannot do so on an individual user level, but rather at the role level for each health care profession.

In other words, VA cannot modify the privileges for all health care professionals in one State to be consistent with that State's requirements. Instead, the privileges can only be modified for every health care professional in that role across all States. Therefore, the privileges established within EHR cannot be made facility or State specific.

In order to achieve standardized clinical processes, VA and DoD must create the uniform standards of practice for each health care specialty. Currently, DoD has specific authority from Congress to create national standards of practice for their health care professionals under 10 U.S.C. 1094.

While VA lacks a similarly specific statute, VA has the general statutory authority, as explained above, to regulate its health care professionals and authorize health care practices that preempt conflicting State law. This regulation will confirm VA's authority to do so. Absent such standardized practices, it will be incredibly difficult for VA to achieve its goal of being an active participant in EHR modernization because either some VA health care professionals would fear potential adverse State actions or DoD and VA would need to agree upon roles that are consistent with the most restrictive States' requirements to ensure that all health care professionals are acting within the scope of their State requirements.

VA believes that agreement upon roles that are consistent with the most restrictive State is not an acceptable option because it will lead to delayed care and consequently decreased access and level of health care for VA beneficiaries. One example that impacts multiple health care professions throughout the VA system is the ability to administer medication without a provider (physician or advanced practice nurse practitioner) co-signature. As it pertains to nursing, almost all States permit nurses to follow a protocol.

However, some States, such as New York, North Carolina, and South Carolina, do not permit nurses to follow a protocol without a provider co-signature. A protocol is a standing order that has been approved by medical and clinical leadership if a certain sequence of health care events occur. For instance, if a patient is exhibiting certain signs of a heart attack, there is a protocol in place to administer potentially life-saving medication.

If the nurse is the first person to see the signs, the nurse will follow the approved protocol and immediately administer the medication. However, if the nurse cannot follow the protocol and requires a provider co-signature, administration of the medication will be delayed until a provider is able to co-sign the order, which may lead to the deterioration of the patient's condition. This also increases the provider's workload and decreases the amount of time the provider can spend with patients.

Historically, VA physical therapists (PTs), occupational therapists, and speech therapists were routinely able to determine the need to administer topical medications during therapy sessions and were able to administer the topical without a provider co-signature. However, in order to accommodate the new EHR system and variance in State requirements, these therapists would need to place an order for all medications, including topicals, which would leave these therapists waiting for a provider co-signature in the middle of a therapy session, thus delaying care. Furthermore, these therapists also routinely ordered imaging to better assess the clinical needs of the patient, but would also have to wait for a provider co-signature, which will further delay care and increase provider workload.

In addition to requiring provider co-signatures, there will also be a significant decrease in access to care due to other variances in State requirements. For instance, direct access to PTs will be limited in order to ensure that the role is consistent with all State requirements. Direct access means that a beneficiary may request PT services without a provider's referral.

However, while almost half of the States allow unrestricted direct access to PTs, over half of the States have some limitations on requesting PT services. For instance, in Alabama, a licensed PT may perform an initial evaluation and may only provide other services as delineated in specific subdivisions of the Alabama Physical Therapy Practice Act. Furthermore, in New York, PT treatment may be rendered by a licensed PT for 10 visits or 30 days, whichever shall occur first, without a referral from a physician, dentist, podiatrist, nurse practitioner, or licensed midwife.

This is problematic as VA will not be able to allow for direct access due to these variances and direct access has been shown to be beneficial for patient care. Currently, VISN 23 is completing a two-year strategic initiative to implement direct access and have PTs embedded into patient aligned care teams (PACT). Outcomes thus far include decreased wait times, improved veteran satisfaction, improved provider satisfaction, and improved functional outcomes.

Therefore, VA will confirm its authority to ensure that health care professionals are protected against State action when they adhere to VA's national standards of practice. We reiterate that this rulemaking does not establish national standards of practice for each health care profession, but merely confirms VA's authority to do so, thereby preempting any State restrictions that unduly interfere with those practices. The actual national standards of practice will be developed in subregulatory policy for each health care profession.

As such, VA will make a concerted effort to engage appropriate stakeholders when developing the national standards of practice. Preemption As previously explained, in this rulemaking, VA is confirming its authority to manage its health care professionals. Specifically, this rulemaking will confirm VA's long-standing practice of allowing its health care professionals to practice in a State where they do not hold a license, registration, certification, or satisfy some other State requirement.

The rule will also confirm that VA health care professionals must adhere to VA's national standards of practice, as determined by VA policy, irrespective of conflicting State licensing, registration, certification, or other State requirements that unduly burden that practice. We do note that VA health care professionals will only be required to perform tasks and duties to the extent of their education, skill, and training. For instance, VA would not require a registered nurse to perform a task that the individual nurse was not trained to perform.

Currently, practice in accordance with VA employment, including practice across State lines or adhering to a VA standard of practice, may jeopardize VA health care professionals' credentials or result in fines and imprisonment for unauthorized health care practice. This is because most States have restrictions that limit health care professionals' practice or have rules that prohibit health care professionals from furnishing health care services within that State without a license, registration, certification, or other requirement from that State. We note that, some States, for example Rhode Island, Utah, and Michigan, have enacted legislation or regulations that specifically allow certain VA health care professionals to practice in those States when they do not hold a State license.

Several VA health care professionals have already had actions proposed or taken against them by various States Start Printed Page 71842while practicing health care within the scope of their VA employment, while they either practiced in a State where they do not hold a license, registration, certification, or other State requirement that unduly interfered with their VA employment. In one instance, a VA psychologist was licensed in California but was employed and providing supervision of a trainee at the VA Medical Center (VAMC) in Nashville, Tennessee. California psychology licensing laws require supervisors to hold a license from the State where they are practicing and do not allow for California licensed psychologists to provide supervision to trainees or unlicensed psychologists outside the State of California.

The California State Psychology Licensing Board proposed sanctions and fines of $1,000 for violating section 1387.4(a) of the CA Code of Regulations (CCR). The VA system did not qualify for the exemption of out of State supervision requirements listed in CCR section 1387.4. In addition, a VA physician who was licensed in Oregon, but was practicing at a VAMC in Biloxi, Mississippi had the status of their license changed from active to inactive because the Oregon Medical Board determined the professional did not reside in Oregon, in violation of Oregon's requirement that a physician physically reside in the State in order to maintain an active license.

This rulemaking serves to preempt State requirements, such as the ones discussed above, that were or can be used to take an action against VA health care professionals for practicing within the scope of their VA employment. State licensure, registration, certification, and other State requirements are preempted to the extent such State laws unduly interfere with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. As explained above, Congress provided general statutory provisions that permit the VA Secretary to authorize health care practices by health care professionals at VA, which serve to preempt conflicting State laws that unduly interfere with the exercise of health care by VA health care professionals pursuant to that authorization.

Although some VA health care professionals are required by Federal statute to have a State license, see, e.g., 38 U.S.C. 7402(b)(1)(C) (providing that, to be eligible to be appointed to a physician position at the VA, a physician must be licensed to practice medicine, surgery, or osteopathy in a State), a State may not attach a condition to the license that is unduly burdensome to or unduly interferes with the practice of health care within the scope of VA employment. Under well-established interpretations of the Supremacy Clause, Federal laws and policies authorizing VA health care professionals to practice according to VA standards preempt conflicting State law.

That is, a State law that prevents or unreasonably interferes with the performance of VA duties. See, e.g., Hancock v. Train, 426 U.S.

167, 178-81 (1976). Sperry v. Florida, 373 U.S.

379, 385 (1963). Miller v. Arkansas, 352 U.S.

276, 282-84 (1899). State Bar Disciplinary Rules as Applied to Federal Government Attorneys, 9 Op. O.L.C.

71, 72-73 (1985). When a State law does not conflict with the performance of Federal duties in these ways, VA health care professionals are required to abide by the State law. Therefore, VA's policies and regulations will preempt State licensure, registration, and certification laws, rules, or other requirements only to the extent they conflict with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment.

We emphasize that, in instances where there is no conflict with State requirements, VA health care professionals should abide by the State requirement. For example, if a State license requires a health care professional to have a certain number of hours of continuing professional education per year to maintain their license, the health care professional must adhere to this State requirement if it does not prevent or unduly interfere with the exercise of VA employment. To determine whether a State requirement is conflicting, VA would assess whether the State law unduly interferes on a case-by-case basis.

For instance, if Oregon requires all licensed physicians to reside in Oregon, VA would likely find that it unduly interferes with already licensed VA physicians who reside and work for VA in the State of Mississippi. We emphasize that the intent of the regulation is to only preempt State requirements that are unduly burdensome and interfere with a VA health care professionals' practice for the VA. For instance, it would not require a State to issue a license to an individual who does not meet the education requirements to receive a license in that State.

We note that this rulemaking also does not affect VA's existing requirement that all VA health care professionals adhere to restrictions imposed by the Controlled Substances Act, 21 U.S.C. 801 et seq. And implementing regulations at 21 CFR 1300, et seq., to prescribe or administer controlled substances.

Any preemption of conflicting State requirements will be the minimum necessary for VA to effectively furnish health care services. It would be costly and time-consuming for VA to lobby each State board for each health care profession specialty to remove restrictions that impair VA's ability to furnish health care services to beneficiaries and then wait for the State to implement appropriate changes. Doing so would not guarantee a successful result.

Regulation For these reasons, VA is establishing a new regulation titled Health care professionals' practice in VA, which will be located at 38 CFR 17.419. This rule will confirm the ability of VA health care professionals to practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. Subsection (a) of § 17.419 contains the definitions that will apply to the new section.

Subsection (a)(1) contains the definition for beneficiary. We are defining the term beneficiary to mean a veteran or any other individual receiving health care under title 38 of the U.S. Code.

We are using this definition because VA provides health care to veterans, certain family members of veterans, servicemembers, and others. This is VA's standard use of this term. Subsection (a)(2) contains the definition for health care professional.

We are defining the term health care professional to be an individual who meets specific criteria that is listed below. Subsection (a)(2)(i) will require that a health care professional be appointed to an occupation in VHA that is listed or authorized under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S.

Code. Subsection (a)(2)(ii) requires that the individual is not a VA-contracted health care professional. A health care professional does not include a contractor or a community health care professional because they are not considered VA employees nor appointed under 38 U.S.C.

7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. Subsection (a)(2)(iii) lists the required qualifications for a health care professional.

We note that these qualifications do not include all general Start Printed Page 71843qualifications for appointment, such as to hold a degree of doctor of medicine. These qualifications are related to licensure, registration, certification, or other State requirements. Subsection (a)(2)(iii)(A) states that the health care professional must have an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State to practice the health care specialty identified under 38 U.S.C.

7402(b). This standard ensures that VA health care professionals are qualified to practice their individual health care specialty if the specialty requires such credential. Subsection (a)(2)(iii)(B) states that the individual has other qualifications as prescribed by the Secretary for one of the health care professions listed under 38 U.S.C.

7402(b). Some health care professionals appointed under 38 U.S.C. 7401(3) whose qualifications are listed in 38 U.S.C.

7402(b) are not required to meet State license, registration, certification, or other requirements and rely on the qualifications prescribed by the Secretary. Therefore, these individuals would be included in this subsection and required to have the qualifications prescribed by the Secretary for their health care profession. Subsection (a)(2)(iii)(C) states that the individual is otherwise authorized by the Secretary to provide health care services.

This would include those individuals who practice a health care profession that does not require a State license, registration, certification, or other requirement and is also not listed in 38 U.S.C. 7402(b), but is authorized by the Secretary to provide health care services. Subsection (a)(2)(iii)(D) includes individuals who are trainees or may have a time limited appointment to finish clinicals or other requirements prior to being fully licensed.

Therefore, the regulation will state that the individual is under the clinical supervision of a health care professional that meets the requirements listed in subsection (a)(2)(iii)(A)-(C) and the individual must meet the requirements in subsection (a)(2)(iii)(D)(i) or (a)(2)(iii)(D)(ii). Subsection (a)(2)(iii)(D)(i) states that the individual is a health professions trainee appointed under 38 U.S.C. 7405 or 7406 participating in clinical or research training under supervision to satisfy program or degree requirements.

Subsection (a)(2)(iii)(D)(ii) states that the individual is a health care employee, appointed under title 5 of the U.S. Code, 38 U.S.C. 7401(1) or (3), or 38 U.S.C.

7405 for any category of personnel described in 38 U.S.C. 7401(1) or (3) who must obtain an active, current, full and unrestricted licensure, registration, or certification or meet the qualification standards as defined by the Secretary within the specified time frame. These individuals have a time-limited appointment to obtain credentials.

For example, marriage and family therapists require a certain number of supervised clinical post-graduate hours prior to receiving their license. Lastly, as we previously discussed in this rulemaking, we are defining the term State in subsection (a)(3) as the term is defined in 38 U.S.C. 101(20), and also including political subdivisions of such States.

This is consistent with the definition of State in 38 U.S.C. 1730C(f) which is VA's statutory authority to preempt State law when the covered health care professional is using telehealth to provide treatment to an individual under this title. We believe that it is important to define the term in the same way as it is defined for health care professionals practicing via telehealth so that way it is consistent regardless of whether the health care professional is practicing in-person or via telehealth.

Moreover, as subdivisions of a State are granted legal authority from the State itself, it makes sense to subject entities created by a State, or authorized by a State to create themselves, to be subject to the same limitations and restrictions as the State itself. Section 17.419(b) details that VA health care professionals must practice within the scope of their Federal employment irrespective of conflicting State requirements that would prevent or unduly interfere with the exercise of Federal duties. This provision confirms that VA health care professionals may furnish health care consistent with their VA employment obligations without fear of adverse action proposed or taken by any State.

In order to clarify and make transparent how VA utilizes or intends to utilize our current statutory authority, we are providing a non-exhaustive list of examples. The first example is listed in subsection (b)(1)(i). It states that a health care professional may practice their VA health care profession in any State irrespective of the State where they hold a valid license, registration, certification, or other qualification.

The second example is listed in subsection (b)(1)(ii). It states that a health care professional may practice their VA health care profession consistent with the VA national standard of practice as determined by VA. As previously explained, VA intends to establish national standards of practice via VA policy.

A health care professional's practice within VA will continue to be subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C. 801, et seq. And implementing regulations at 21 CFR 1300, et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy.

This will ensure that professionals are still in compliance with critical laws concerning the prescribing and administering of controlled substances. This requirement is stated in subsection (b)(2). Subsection (c) expressly states the intended preemptive effect of § 17.419, to ensure that conflicting State and local laws, rules, regulations, and requirements related to health care professionals' practice will have no force or effect when such professionals are practicing health care while working within the scope of their VA employment.

In circumstances where there is a conflict between Federal and State law, Federal law would prevail in accordance with Article VI, clause 2, of the U.S. Constitution. Executive Order 13132 establishes principles for preemption of State law when it is implicated in rulemaking or proposed legislation.

Where a Federal statute does not expressly preempt State law, agencies shall construe any authorization in the statute for the issuance of regulations as authorizing preemption of State law by rulemaking only when the exercise of State authority directly conflicts with the exercise of Federal authority or there is clear evidence to conclude that the Congress intended the agency to have the authority to preempt State law. In this situation, the Federal statutes do not expressly preempt State laws. However, VA construes the authorization established in 38 U.S.C.

303, 501, and 7401-7464 as authorizing preemption because the exercise of State authority directly conflicts with the exercise of Federal authority under these statutes. Congress granted the Secretary express statutory authority to establish the qualifications for VA's health care professionals, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals. 38 U.S.C.

7401-7464. Specifically, section 7402(b) states that most health care professionals, after appointment by VA, must, among other Start Printed Page 71844requirements, be licensed, registered, or certified to practice their profession in a State. To that end, VA's regulations and policies will preempt any State law or action that conflicts with the exercise of Federal duties in providing health care at VA.

In addition, any regulatory preemption of State law must be restricted to the minimum level necessary to achieve the objectives of the statute pursuant to the regulations that are promulgated. In this rulemaking, State licensure, registration, and certification laws, rules, regulations, or other requirements are preempted only to the extent such State laws unduly interfere with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. Therefore, VA believes that the rulemaking is restricted to the minimum level necessary to achieve the objectives of the Federal statutes.

The Executive Order also requires an agency that is publishing a regulation that preempts State law to follow certain procedures. These procedures include. The agency consult with, to the extent practicable, the appropriate State and local officials in an effort to avoid conflicts between State law and Federally protected interests.

And the agency provide all affected State and local officials notice and an opportunity for appropriate participation in the proceedings. For the reasons below, VA believes that it is not practicable to consult with the appropriate State and local officials prior to the publication of this rulemaking. The National Emergency caused by erectile dysfunction treatment has highlighted VA's acute need to quickly shift health care professionals across the country.

As both private and VA medical facilities in different parts of the country reach or exceed capacity, VA must be able to mobilize its health care professionals across State lines to provide critical care for those in need. As explained in the Supplementary Information above, as of June 2020, a total of 1,893 staff have been mobilized to meet the needs of our facilities and Fourth Mission requests during the kamagra. VA deployed 877 staff to meet Federal Emergency Management Agency (FEMA) Mission requests, 420 health care professionals were deployed as DEMPS response, 414 employees were mobilized to cross level staffing needs within their Veterans Integrated Service Networks (VISN), 69 employees were mobilized to support needs in another VISN, and 113 Travel Nurse Corps staff responded specifically for erectile dysfunction treatment staffing support.

Given the speed in which it is required for our health care professionals to go to these facilities and provide health care, it is also essential that the health care professionals can follow the same standards of practice irrespective of the location of the facility or the requirements of their individual State license. This is important because if multiple health care professionals, such as multiple registered nurses, licensed in different States are all sent to one VA medical facility to assist when there is a shortage of professionals, it would be difficult and cumbersome if they could not all perform the same duties and each supervising provider had to be briefed on the tasks each registered nurse could perform. In addition, not having a uniform national scope of practice could limit the tasks that the registered nurses could provide.

This rulemaking will provide health care professionals an increased level of protection against adverse State actions while VA strives to increase access to high quality health care across the VA health care system during this National Emergency. It would be time consuming and contrary to the public health and safety to delay implementing this rulemaking until we consulted with State and local officials. For these reasons, it would be impractical to consult with State and local officials prior to the publication of this rulemaking.

We note that this rulemaking does not establish any national standards of practice. Instead, VA will establish the national standards of practice via subregulatory guidance. VA will, to the extent practicable, make all efforts to engage with State and local officials when establishing the national standards of practice via subregulatory guidance.

Also, this interim final rule will have a 60-day comment period that will allow State and local officials the opportunity to provide their input on the rule. Administrative Procedures Act An Agency may forgo notice and comment required under the Administrative Procedures Act (APA), 5 U.S.C. 553, if the agency for good cause finds that compliance would be impracticable, unnecessary, or contrary to the public interest.

An agency may also bypass the APA's 30-day publication requirement if good cause exists. The Secretary of Veterans Affairs finds that there is good cause under the provisions of 5 U.S.C. 553(b)(B) to publish this rule without prior opportunity for public comment because it would be impracticable and contrary to the public interest and finds that there is good cause under 5 U.S.C.

553(d)(3) to bypass its 30-day publication requirement for the same reasons as outlined above in the Federalism section, above. In short, this rulemaking will provide health care professionals protection against adverse State actions while VA strives to increase access to high quality health care across the VA health care system during this National Emergency. In addition to the needs discussed above regarding the National Emergency, it is also imperative that VA move its health care professionals across State lines in order to facilitate the implementation of the new EHR system immediately.

VA implemented EHR at the first VA facility in October 2020 and additional sites are scheduled to have EHR implemented over the course of the next eight years. The next site is scheduled for implementation in Quarter 2 of Fiscal Year 2021 (i.e., between January to March 2021). Due to the implementation of the new EHR system, VA expects decreased productivity and reduced clinical staffing during training and other events surrounding EHR enactment.

VA expects a productivity decrease of up to 30 percent for the 60 days before implementation and the 120 days after at each site. Any decrease in productivity could result in decreased access to health care for our Nation's veterans. In order to support this anticipated productivity decrease, VA is engaging in a “national supplement,” where health care professionals from other VA medical facilities will be deployed to those VA medical facilities and VISNs that are undergoing EHR implementation.

The national supplement would mitigate reduced access during EHR deployment activities, such as staff training, cutover, and other EHR implementation activities. Over the eight-year deployment timeline, the national supplement is estimated to have full time employee equivalents of approximately 60 nurses, 3 pharmacy technicians, 5 mental health and primary care providers, and other VA health care professionals. We note that the actual number of VA health care professionals deployed to each site will vary based on need.

The national supplement will require VA health care professionals on a national level to practice health care in States where they do not hold a State license, registration, certification, or other requirement. In addition, VISNs will be providing local cross-leveling and intra-VISN staff deployments to support EHRM implementation activities. Put simply, in order to mitigate the decreased Start Printed Page 71845productivity as a result of EHR implementation, VA must transfer VA health care professionals across the country to States where they do not hold a license, registration, certification, or other requirement to assist in training on the new system as well as to support patient care.

Therefore, it would be impracticable and contrary to the public health and safety to delay implementing this rulemaking until a full public notice-and-comment process is completed. This rulemaking will be effective upon publication in the Federal Register. As noted above, this interim final rule will have a 60-day comment period that will allow State and local officials the opportunity to provide their input on the rule, and VA will take those comments into consideration when deciding whether any modifications to this rule are warranted.

Paperwork Reduction Act This final rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521). Regulatory Flexibility Act The Regulatory Flexibility Act, 5 U.S.C.

601-612, is not applicable to this rulemaking because a notice of proposed rulemaking is not required under 5 U.S.C. 553. 5 U.S.C.

601(2), 603(a), 604(a). Executive Orders 12866, 13563, and 13771 Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages. Distributive impacts.

And equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. The Office of Information and Regulatory Affairs has determined that this rule is a significant regulatory action under Executive Order 12866.

VA's impact analysis can be found as a supporting document at http://www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of the rulemaking and its impact analysis are available on VA's website at http://www.va.gov/​orpm/​, by following the link for “VA Regulations Published From FY 2004 Through Fiscal Year to Date.” This interim final rule is not subject to the requirements of E.O. 13771 because this rule results in no more than de minimis costs.

Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This interim final rule will have no such effect on State, local, and tribal governments, or on the private sector.

Congressional Review Act Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), the Office of Information and Regulatory Affairs designated this rule as not a major rule, as defined by 5 U.S.C. 804(2).

Catalog of Federal Domestic Assistance The Catalog of Federal Domestic Assistance numbers and titles for the programs affected by this document are. 64.007, Blind Rehabilitation Centers. 64.008, Veterans Domiciliary Care.

64.009, Veterans Medical Care Benefits. 64.010, Veterans Nursing Home Care. 64.011, Veterans Dental Care.

64.012, Veterans Prescription Service. 64.013, Veterans Prosthetic Appliances. 64.018, Sharing Specialized Medical Resources.

64.019, Veterans Rehabilitation Alcohol and Drug Dependence. 64.022, Veterans Home Based Primary Care. 64.039 CHAMPVA.

64.040 VHA Inpatient Medicine. 64.041 VHA Outpatient Specialty Care. 64.042 VHA Inpatient Surgery.

64.043 VHA Mental Health Residential. 64.044 VHA Home Care. 64.045 VHA Outpatient Ancillary Services.

64.046 VHA Inpatient Psychiatry. 64.047 VHA Primary Care. 64.048 VHA Mental Health Clinics.

64.049 VHA Community Living Center. And 64.050 VHA Diagnostic Care. Start List of Subjects Administrative practice and procedureAlcohol abuseAlcoholismClaimsDay careDental healthDrug abuseForeign relationsGovernment contractsGrant programs-healthGrant programs-veteransHealth careHealth facilitiesHealth professionsHealth recordsHomelessMedical and dental schoolsMedical devicesMedical researchMental health programsNursing homesReporting and recordkeeping requirementsScholarships and fellowshipsTravel and transportation expensesVeterans End List of Subjects Signing Authority The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs.

Brooks D. Tucker, Assistant Secretary for Congressional and Legislative Affairs, Performing the Delegable Duties of the Chief of Staff, Department of Veterans Affairs, approved this document on October 19, 2020, for publication. Start Signature Consuela Benjamin, Regulations Development Coordinator, Office of Regulation Policy &.

Management, Office of the Secretary, Department of Veterans Affairs. End Signature For the reasons stated in the preamble, the Department of Veterans Affairs is amending 38 CFR part 17 as set forth below. Start Part End Part Start Amendment Part1.

The authority citation for part 17 is amended by adding an entry for § 17.419 in numerical order to read in part as follows. End Amendment Part Start Authority 38 U.S.C. 501, and as noted in specific sections.

End Authority * * * * * Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). * * * * * Start Amendment Part2.

Add § 17.419 to read as follows. End Amendment Part Health care professionals' practice in VA. (a) Definitions.

The following definitions apply to this section. (1) Beneficiary. The term beneficiary means a veteran or any other individual receiving health care under title 38 of the United States Code.

(2) Health care professional. The term health care professional is an individual who. (i) Is appointed to an occupation in the Veterans Health Administration that is listed in or authorized under 38 U.S.C.

7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. (ii) Is not a VA-contracted health care professional.

And (iii) Is qualified to provide health care as follows. (A) Has an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State. (B) Has other qualifications as prescribed by the Secretary for one of Start Printed Page 71846the health care professions listed under 38 U.S.C.

7402(b). (C) Is an employee otherwise authorized by the Secretary to provide health care services. Or (D) Is under the clinical supervision of a health care professional that meets the requirements of subsection (a)(2)(iii)(A)-(C) of this section and is either.

(i) A health professions trainee appointed under 38 U.S.C. 7405 or 7406 participating in clinical or research training under supervision to satisfy program or degree requirements. Or (ii) A health care employee, appointed under title 5 of the U.S.

Code, 38 U.S.C. 7401(1) or (3), or 38 U.S.C. 7405 for any category of personnel described in 38 U.S.C.

7401(1) or (3) who must obtain an active, current, full and unrestricted licensure, registration, certification, or meet the qualification standards as defined by the Secretary within the specified time frame. (3) State. The term State means a State as defined in 38 U.S.C.

101(20), or a political subdivision of such a State. (b) Health care professional's practice. (1) When a State law or license, registration, certification, or other requirement prevents or unduly interferes with a health care professional's practice within the scope of their VA employment, the health care professional is required to abide by their Federal duties, which includes, but is not limited to, the following situations.

(i) A health care professional may practice their VA health care profession in any State irrespective of the State where they hold a valid license, registration, certification, or other State qualification. Or (ii) A health care professional may practice their VA health care profession within the scope of the VA national standard of practice as determined by VA. (2) VA health care professional's practice is subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C.

801 et seq. And implementing regulations at 21 CFR 1300 et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy. (c) Preemption of State law.

Pursuant to the Supremacy Clause, U.S. Const. Art.

IV, cl. 2, and in order to achieve important Federal interests, including, but not limited to, the ability to provide the same complete health care and hospital service to beneficiaries in all States as required by 38 U.S.C. 7301, conflicting State laws, rules, regulations or requirements pursuant to such laws are without any force or effect, and State governments have no legal authority to enforce them in relation to actions by health care professionals within the scope of their VA employment.

End Supplemental Information [FR Doc. 2020-24817 Filed 11-10-20. 8:45 am]BILLING CODE 8320-01-P.

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Do not take Kamagra with any of the following:

• cisapride
• methscopolamine nitrate
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Kamagra may also interact with the following:

• certain drugs for high blood pressure
• certain drugs for the treatment of HIV or AIDS
• certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
• cimetidine
• erythromycin
• rifampin

This list may not describe all possible interactions. Give your health care providers a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

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Yet when she’s sought how to get kamagra in the us out professional can you buy kamagra without a prescription help, she passes her hearing test with flying colors. Alice, who now avoids crowded restaurants and parties, most likely has what’s known as “hidden hearing loss”—a brain problem hearing tests aren’t designed to catch. For this reason, it’s not a well-understood condition.

What is can you buy kamagra without a prescription hidden hearing loss?. "Hidden" hearing loss is defined as hearing loss that's not detectable on standard hearing tests, which zero in on problems within the ear, but not the nervous system. No one is sure how many people have hidden hearing gloss.

But in a study of more than 100,000 patient records from a 16-year period, about 10 percent of patients who visited the audiology clinic at Massachusetts Eye and Ear had a normal audiogram, like Alice, despite their complaints can you buy kamagra without a prescription. Signs of hidden hearing loss There is no established set of guidelines to diagnose hidden hearing loss, but some things to look out for include. A strong sense that you have hearing loss, even after passing a hearing test A preference for quiet settings for conversations Feeling easily distracted or unable to focus in noisy settings Hearing people incorrectly Testing for hidden hearing loss If you've been told that a standard "pure-tone" hearing test showed no signs of hearing loss, don't give up.

When you have can you buy kamagra without a prescription hidden hearing loss, what you likely need is more thorough testing to help root out what's going on. Sometimes, hidden hearing loss can be revealed by using a quick "words in noise" or "sentences in noise" test, which involves listening to recorded segments of speech set in increasingly noisy settings. According to an article in the Hearing Journal, all of the following tests also may be used by an audiologist to help pinpoint hidden hearing loss and rule out other causes.

otoscopy tympanometry acoustic reflexes diagnostic distortion product otoacoustic emissions extended high-frequency audiometry air, bone and speech reception testing auditory brainstem response (ABR) test What’s happening in the can you buy kamagra without a prescription brain?. When we hear, movement in the cilia, or hair cells, in the inner ear send signals to the auditory nerve, also known as the vestibulocochlear nerve, or the eighth cranial nerve. These signals must cross over synapses, which are the vital junctions between nerve cells.

Learn more about how we can you buy kamagra without a prescription hear. Ordinary hearing loss arises from damage to the hair cells or the nerve. Hidden hearing loss often arises because of loss of synapses in between.

The signal can you buy kamagra without a prescription arrives incomplete, therefore missing information we need to interpret words. Medically this is sometimes referred to as "cochlear synaptopathy"—although not everyone with invisible hearing loss has synaptopathy. "Hidden" hearing loss is defined as hearing loss that's not detectable on standard hearing tests, which zero in on problems within the ear.

Audiologists have described patients can you buy kamagra without a prescription like Alice for years. In 2009, a watershed study in mice documented that loud noises could specifically destroy synapses. In the study, mice were forced to endure a 100-decibel noise—about the same level as using a lawnmower—for two hours.

Later the team discovered that although the mice’s can you buy kamagra without a prescription hair cells had survived, half of their synapses were gone. Humans with lost synapses may still hear the beep in a hearing test even at a low volume that stumps someone with cell or nerve damage. What causes hidden hearing loss?.

Noise pollution and aging combine can you buy kamagra without a prescription to aggravate the problem. €œMost researchers feel that long exposures to even low-level noise may cause hidden hearing loss and most agree that the aging auditory system reveals this problem. We lose some synapses as we age,” said Dr.

Catherine Palmer, Director of Audiology and Hearing can you buy kamagra without a prescription Aids at the University of Pittsburgh Medical Center. Another possible cause, reported in 2017, could be problems with the cells that make myelin, a substance that insulates the neuronal axons (brain cells) in the ear. Autoimmune disorders like Guillain-Barré syndrome—linked to food poisoning, the flu, hepatitis, and the Zika kamagra—attack myelin.

Different from ADHD and auditory processing can you buy kamagra without a prescription disorder Note that hidden hearing loss can be mistaken for attention deficit hyperactivity disorder (ADHD), which happened to Alice after she took a hearing test. It’s also not the same as “central auditory processing disorder,” which is often diagnosed in children and arises at a different level of the brain. Experimental tools for detecting hidden hearing loss The team at Massachusetts Eye and Ear has developed two tests to catch hidden hearing loss.

The first measures electrical signals from the surface of the ear canal to capture how well they encode subtle and rapid fluctuations in sound waves can you buy kamagra without a prescription. For the second test, participants wear glasses that measure changes in the diameter of their pupils while listening to speech in noise. Our pupils reflect how much effort it takes to understand during a task.

When the team tried out the tests on can you buy kamagra without a prescription 23 volunteers with clinically normal hearing, their ability to follow a conversation with babbling in the background varied widely. The two tests together predicted which people would have difficulty. What it’s like to live with hidden hearing loss Alice’s story is emblematic.

She recalls can you buy kamagra without a prescription one time when she stood in a cluster of three in a room of 15 people, a reunion of her college classmates. €œI was right next to them and I couldn’t hear one word,” she said. €œI eventually asked one [of them] to go into a room with just a few people, and we were sitting but I had to move my chair closer and lean forward,” Alice explained.

€œI said, ‘I’m sorry if I seem like I’m sitting in your can you buy kamagra without a prescription lap.’” She’s dealt with the problem for years. When she was in her 20s she saw an audiologist who told her that her hearing was normal, but suggested that she might have an “attention problem.” Yet she can hear a whisper in a quiet place. She only has trouble understanding what audiologists call “speech in noise,” conversation in groups or noisy places.

As background noise in can you buy kamagra without a prescription restaurants became steadily louder, Alice looked for quiet restaurants. Large parties “lost their appeal,” she said. She became a therapist.

€œIt’s a can you buy kamagra without a prescription wonderful profession because it’s just me and another person and if I can’t hear them, I say What?. € She had her second audiogram a year ago, decades after the first. Again, her hearing was normal and the audiologist explained her difficulties as an “auditory processing problem.” Alice took her audiogram to a Costco hearing aid department, but was told that because her hearing was in the normal range, the store wouldn’t sell her an aid.

Treatment for can you buy kamagra without a prescription hidden hearing loss There is no direct treatment, although research is underway to find medications that would prompt neurons to grow new synapses. In cases where there's at least slight or mild hearing loss, people will benefit from state-of-the art hearing aids that have “speech in noise” settings. These use directional microphones to pick up the signal in front of you and reduce sound behind you or on your sides.

You can also place a microphone near the signal you need to hear, and wear a Bluetooth receiver or hearing aid in your can you buy kamagra without a prescription ear. Look for a hearing care provider where to buy cheap kamagra who is knowledgeable about hidden hearing loss. They’ll be able to help you decide whether any of the available assistive listening devices can help you, like a personal FM system or a mobile app that can caption live conversation.

Be sure to take can you buy kamagra without a prescription advantage of ADA-required assistive listening devices in theaters, places of worship, airports and other public spaces. At home and in your social life, you’ll find it easier to be in quieter places. Eat earlier in the evening when restaurants are quiet, choose restaurants with carpeting and without bars, or sit in a booth.

Arrive at lectures earlier so you can sit near the front can you buy kamagra without a prescription. At gatherings, don’t be shy about creating smaller groups and leaning in—even if you feel like you’re sitting in someone’s lap. Lastly, try not to deny the problem and withdraw.

Be aware can you buy kamagra without a prescription of how it affects your mental state. Like any kind of hearing loss, hidden hearing loss “can have an effect on your psyche, creating avoidant behavior and social anxiety,” Alice noted. €œYou might not even know it.” *To protect Alice’s privacy, we have used a different name.If you wear hearing aids or are considering making that purchase soon, be sure to ask your hearing care provider about telecoil technology.

These small copper coils have come standard in most hearing aid devices for nearly 50 years and, when can you buy kamagra without a prescription used in tandem with a hearing loop, can dramatically enhance your listening experience in public places by piping sound directly to the hearing device. €œHearing aid microphones only work for a relatively short distance,” Juliëtte Sterkens, hearing loop advocate for the Hearing Loss Association of America (HLAA), said. €œBut telecoils and hearing loops give people with hearing aids better hearing, even sometimes better than those with normal hearing.” In fact, telecoils are so useful that Sterkens considers them one of the four essentialy hearing aid must-haves that all hearing aids should come with.

What is a hearing aid can you buy kamagra without a prescription telecoil?. This Opn miniRITE T hearing aid has atelecoil. Many manufacturers use "T" inthe name to indicate a device has atelecoil.

(Image courtesy Oticon.) can you buy kamagra without a prescription Telecoils, also known as t-coils, are small copper wires coiled discreetly inside hearing aids (see image here). They can receive electromagnetic signals from a variety of sources and are generally activated easily with the touch of a button. The technology is not new.

Telecoils were originally can you buy kamagra without a prescription embedded in hearing aids to pick up electromagnetic signals from landline telephones so that the hearing aid user could hear better on the phone, Sterkens said. €œWhen the old Ma Bell telephones were in existence, they emitted lots of magnetic signals,” she explained. Today’s telephones are no longer a natural source of magnetic signals, but most still contain hearing aid compatible (HAC) equipment that generate a magnetic field to accommodate t-coil hearing aids.

How do I get a can you buy kamagra without a prescription t-coil hearing aid?. Sterkens said although some hearing aid manufacturers have removed telecoils to make the devices smaller, the feature is still standard in most hearing devices. Hearing aid wearers desiring t-coil technology should request it from their hearing healthcare practitioner, who will provide the necessary programming and education.

More about hearing aid types and styles and hearing can you buy kamagra without a prescription aid technology. What is a hearing aid loop system?. Hearing loops are assistive listening systems that exist in many public venues all over the world to assist those with hearing loss.

This inductive loop system provides a magnetic, wireless signal that is picked can you buy kamagra without a prescription up by hearing devices with telecoils. When hearing aid users are inside the loop and their t-coil setting is activated, any conversation being broadcast on the facility’s audio system — ie, a church sermon, classroom lecture, or stage performance — is sent directly to the telecoil in their hearing device. This feature not only extends the listening range of hearing devices, it also eliminates unwanted background noise, increasing listening comprehension and enjoyment.

For example, this video demonstrates can you buy kamagra without a prescription the difference a telecoil can make at a New York subway station. Which facilities have hearing loops?. Thanks in large part to Americans With Disabilities Act (ADA) guidelines, an assistive listening system (ALS) must be provided in public “assembly areas with audio amplification” such as courthouses, movie theaters, live performance theaters, and public classrooms.

The facilities can you buy kamagra without a prescription can choose which type of ALS to install. Inductive hearing loop systems transmit an audio signal directly into the hearing aid via a magnetic field. The loop, which provides a wireless, magnetic signal, is installed in the perimeter beneath the room’s carpeting or flooring in a facility.

Individuals with hearing aids can activate their device’s t-coil switch and receive the audio can you buy kamagra without a prescription signal from anywhere inside the loop. Infrared systems consist of an audio source, transmitter and receiver. Most receivers consist of a headphone or neck loop, which must be requested or checked out at the facility’s information desk.

FM systems are wireless, low power, can you buy kamagra without a prescription FM frequency radio transmissions sent from a sound system to FM receivers. Sterkens said hearing loops are being installed with greater frequency in many newly constructed or remodeled airports as well as churches, public libraries and healthcare facilities. €œThey’re much more discreet than using other hearing assistive systems in public places,” she said.

€œMaryland just passed a law that mandates hearing loops be installed in state-funded can you buy kamagra without a prescription projects. Indiana and Washington are gearing up, too. I think this is only the beginning.” New Mexico also recently signed a law requiring audiologists to educate their patients about t-coils.

How can you buy kamagra without a prescription do I find hearing loop systems near me?. Look for this logo in public places. Venues that offer hearing loop technology are identified by blue signage featuring a white ear icon and the letter “T” displayed in the lower, right-hand corner.

Many hearing loop-accessible venues can you buy kamagra without a prescription are also listed on the following websites or smartphone apps. Loopfinder.com, sponsored by the Hearing Loss Association of America, is available as an app for iOS Apple smartphones. Time2loopamerica.com displays a clickable map of the United States, with venues listed by city and town.

How do can you buy kamagra without a prescription I advocate for hearing loop technology?. Sterkens encourages people to advocate for hearing loops in their community by using the information on the HLAA website. €œThe HLAA has resources for consumers who want to advocate for hearing loops,” she said.

€œSometimes all it takes is one person to make it happen. Hearing loops beget other hearing loops. If you can help people hear that much better with the hearing aids they already have in their ears, it’s incredible.

Yet when http://mydatinghangovers.com/2010/12/choosing-a-life-partner/ she’s sought out professional help, she passes her hearing test can i buy kamagra online with flying colors. Alice, who now avoids crowded restaurants and parties, most likely has what’s known as “hidden hearing loss”—a brain problem hearing tests aren’t designed to catch. For this reason, it’s not a well-understood condition. What is hidden hearing can i buy kamagra online loss?. "Hidden" hearing loss is defined as hearing loss that's not detectable on standard hearing tests, which zero in on problems within the ear, but not the nervous system.

No one is sure how many people have hidden hearing gloss. But in a study of more than 100,000 patient records from a 16-year period, about 10 can i buy kamagra online percent of patients who visited the audiology clinic at Massachusetts Eye and Ear had a normal audiogram, like Alice, despite their complaints. Signs of hidden hearing loss There is no established set of guidelines to diagnose hidden hearing loss, but some things to look out for include. A strong sense that you have hearing loss, even after passing a hearing test A preference for quiet settings for conversations Feeling easily distracted or unable to focus in noisy settings Hearing people incorrectly Testing for hidden hearing loss If you've been told that a standard "pure-tone" hearing test showed no signs of hearing loss, don't give up. When you have hidden hearing loss, what you likely need is can i buy kamagra online more thorough testing to help root out what's going on.

Sometimes, hidden hearing loss can be revealed by using a quick "words in noise" or "sentences in noise" test, which involves listening to recorded segments of speech set in increasingly noisy settings. According to an article in the Hearing Journal, all of the following tests also may be used by an audiologist to help pinpoint hidden hearing loss and rule out other causes. otoscopy tympanometry acoustic reflexes diagnostic distortion product otoacoustic emissions extended high-frequency audiometry air, bone and speech reception testing auditory brainstem response (ABR) test can i buy kamagra online What’s happening in the brain?. When we hear, movement in the cilia, or hair cells, in the inner ear send signals to the auditory nerve, also known as the vestibulocochlear nerve, or the eighth cranial nerve. These signals must cross over synapses, which are the vital junctions between nerve cells.

Learn more about how we can i buy kamagra online hear. Ordinary hearing loss arises from damage to the hair cells or the nerve. Hidden hearing loss often arises because of loss of synapses in between. The signal can i buy kamagra online arrives incomplete, therefore missing information we need to interpret words. Medically this is sometimes referred to as "cochlear synaptopathy"—although not everyone with invisible hearing loss has synaptopathy.

"Hidden" hearing loss is defined as hearing loss that's not detectable on standard hearing tests, which zero in on problems within the ear. Audiologists have described patients like Alice can i buy kamagra online for years. In 2009, a watershed study in mice documented that loud noises could specifically destroy synapses. In the study, mice were forced to endure a 100-decibel noise—about the same level as using a lawnmower—for two hours. Later the team discovered that although the mice’s hair can i buy kamagra online cells had survived, half of their synapses were gone.

Humans with lost synapses may still hear the beep in a hearing test even at a low volume that stumps someone with cell or nerve damage. What causes hidden hearing loss?. Noise pollution and aging combine to aggravate the can i buy kamagra online problem. €œMost researchers feel that long exposures to even low-level noise may cause hidden hearing loss and most agree that the aging auditory system reveals this problem. We lose some synapses as we age,” said Dr.

Catherine Palmer, Director of Audiology can i buy kamagra online and Hearing Aids at the University of Pittsburgh Medical Center. Another possible cause, reported in 2017, could be problems with the cells that make myelin, a substance that insulates the neuronal axons (brain cells) in the ear. Autoimmune disorders like Guillain-Barré syndrome—linked to food poisoning, the flu, hepatitis, and the Zika kamagra—attack myelin. Different from ADHD and auditory processing disorder Note that can i buy kamagra online hidden hearing loss can be mistaken for attention deficit hyperactivity disorder (ADHD), which happened to Alice after she took a hearing test. It’s also not the same as “central auditory processing disorder,” which is often diagnosed in children and arises at a different level of the brain.

Experimental tools for detecting hidden hearing loss The team at Massachusetts Eye and Ear has developed two tests to catch hidden hearing loss. The first measures electrical signals from the surface of the ear canal to capture how well they encode subtle and rapid fluctuations in sound can i buy kamagra online waves. For the second test, participants wear glasses that measure changes in the diameter of their pupils while listening to speech in noise. Our pupils reflect how much effort it takes to understand during a task. When the team tried out the tests on 23 volunteers with clinically normal hearing, their ability to follow a conversation with babbling in the background varied widely can i buy kamagra online.

The two tests together predicted which people would have difficulty. What it’s like to live with hidden hearing loss Alice’s story is emblematic. She recalls one time when she stood in a can i buy kamagra online cluster of three in a room of 15 people, a reunion of her college classmates. €œI was right next to them and I couldn’t hear one word,” she said. €œI eventually asked one [of them] to go into a room with just a few people, and we were sitting but I had to move my chair closer and lean forward,” Alice explained.

€œI said, ‘I’m can i buy kamagra online sorry if I seem like I’m sitting in your lap.’” She’s dealt with the problem for years. When she was in her 20s she saw an audiologist who told her that her hearing was normal, but suggested that she might have an “attention problem.” Yet she can hear a whisper in a quiet place. She only has trouble understanding what audiologists call “speech in noise,” conversation in groups or noisy places. As background noise in restaurants became steadily louder, Alice looked for quiet restaurants can i buy kamagra online. Large parties “lost their appeal,” she said.

She became a therapist. €œIt’s a can i buy kamagra online wonderful profession because it’s just me and another person and if I can’t hear them, I say What?. € She had her second audiogram a year ago, decades after the first. Again, her hearing was normal and the audiologist explained her difficulties as an “auditory processing problem.” Alice took her audiogram to a Costco hearing aid department, but was told that because her hearing was in the normal range, the store wouldn’t sell her an aid. Treatment for hidden hearing can i buy kamagra online loss There is no direct treatment, although research is underway to find medications that would prompt neurons to grow new synapses.

In cases where there's at least slight or mild hearing loss, people will benefit from state-of-the art hearing aids that have “speech in noise” settings. These use directional microphones to pick up the signal in front of you and reduce sound behind you or on your sides. You can also place a microphone near the signal you can i buy kamagra online need to hear, and wear a Bluetooth receiver or hearing aid in your ear. Look for a hearing care provider who is knowledgeable http://theblackcatphotography.com/?page_id=59 about hidden hearing loss. They’ll be able to help you decide whether any of the available assistive listening devices can help you, like a personal FM system or a mobile app that can caption live conversation.

Be sure to take advantage of ADA-required assistive listening devices in theaters, places of worship, airports and other can i buy kamagra online public spaces. At home and in your social life, you’ll find it easier to be in quieter places. Eat earlier in the evening when restaurants are quiet, choose restaurants with carpeting and without bars, or sit in a booth. Arrive at lectures earlier can i buy kamagra online so you can sit near the front. At gatherings, don’t be shy about creating smaller groups and leaning in—even if you feel like you’re sitting in someone’s lap.

Lastly, try not to deny the problem and withdraw. Be aware of how it can i buy kamagra online affects your mental state. Like any kind of hearing loss, hidden hearing loss “can have an effect on your psyche, creating avoidant behavior and social anxiety,” Alice noted. €œYou might not even know it.” *To protect Alice’s privacy, we have used a different name.If you wear hearing aids or are considering making that purchase soon, be sure to ask your hearing care provider about telecoil technology. These small copper coils have come standard in most hearing aid devices for nearly 50 years and, when used in tandem with a hearing loop, can dramatically enhance your can i buy kamagra online listening experience in public places by piping sound directly to the hearing device.

€œHearing aid microphones only work for a relatively short distance,” Juliëtte Sterkens, hearing loop advocate for the Hearing Loss Association of America (HLAA), said. €œBut telecoils and hearing loops give people with hearing aids better hearing, even sometimes better than those with normal hearing.” In fact, telecoils are so useful that Sterkens considers them one of the four essentialy hearing aid must-haves that all hearing aids should come with. What is a hearing aid can i buy kamagra online telecoil?. This Opn miniRITE T hearing aid has atelecoil. Many manufacturers use "T" inthe name to indicate a device has atelecoil.

(Image courtesy Oticon.) Telecoils, also known can i buy kamagra online as t-coils, are small copper wires coiled discreetly inside hearing aids (see image here). They can receive electromagnetic signals from a variety of sources and are generally activated easily with the touch of a button. The technology is not new. Telecoils were originally embedded in hearing aids to pick up electromagnetic signals from can i buy kamagra online landline telephones so that the hearing aid user could hear better on the phone, Sterkens said. €œWhen the old Ma Bell telephones were in existence, they emitted lots of magnetic signals,” she explained.

Today’s telephones are no longer a natural source of magnetic signals, but most still contain hearing aid compatible (HAC) equipment that generate a magnetic field to accommodate t-coil hearing aids. How can i buy kamagra online do I get a t-coil hearing aid?. Sterkens said although some hearing aid manufacturers have removed telecoils to make the devices smaller, the feature is still standard in most hearing devices. Hearing aid wearers desiring t-coil technology should request it from their hearing healthcare practitioner, who will provide the necessary programming and education. More about hearing aid types and styles and hearing aid technology can i buy kamagra online.

What is a hearing aid loop system?. Hearing loops are assistive listening systems that exist in many public venues all over the world to assist those with hearing loss. This inductive loop system provides a magnetic, wireless signal that is can i buy kamagra online picked up by hearing devices with telecoils. When hearing aid users are inside the loop and their t-coil setting is activated, any conversation being broadcast on the facility’s audio system — ie, a church sermon, classroom lecture, or stage performance — is sent directly to the telecoil in their hearing device. This feature not only extends the listening range of hearing devices, it also eliminates unwanted background noise, increasing listening comprehension and enjoyment.

For example, can i buy kamagra online this video demonstrates the difference a telecoil can make at a New York subway station. Which facilities have hearing loops?. Thanks in large part to Americans With Disabilities Act (ADA) guidelines, an assistive listening system (ALS) must be provided in public “assembly areas with audio amplification” such as courthouses, movie theaters, live performance theaters, and public classrooms. The facilities can choose which type of ALS can i buy kamagra online to install. Inductive hearing loop systems transmit an audio signal directly into the hearing aid via a magnetic field.

The loop, which provides a wireless, magnetic signal, is installed in the perimeter beneath the room’s carpeting or flooring in a facility. Individuals with hearing aids can activate their device’s t-coil switch and receive the audio signal can i buy kamagra online from anywhere inside the loop. Infrared systems consist of an audio source, transmitter and receiver. Most receivers consist of a headphone or neck loop, which must be requested or checked out at the facility’s information desk. FM systems are wireless, low power, FM frequency radio transmissions sent from a sound can i buy kamagra online system to FM receivers.

Sterkens said hearing loops are being installed with greater frequency in many newly constructed or remodeled airports as well as churches, public libraries and healthcare facilities. €œThey’re much more discreet than using other hearing assistive systems in public places,” she said. €œMaryland just passed a law that mandates hearing loops can i buy kamagra online be installed in state-funded projects. Indiana and Washington are gearing up, too. I think this is only the beginning.” New Mexico also recently signed a law requiring audiologists to educate their patients about t-coils.

How can i buy kamagra online do I find hearing loop systems near me?. Look for this logo in public places. Venues that offer hearing loop technology are identified by blue signage featuring a white ear icon and the letter “T” displayed in the lower, right-hand corner. Many hearing loop-accessible venues are also listed on the following websites or smartphone can i buy kamagra online apps. Loopfinder.com, sponsored by the Hearing Loss Association of America, is available as an app for iOS Apple smartphones.

Time2loopamerica.com displays a clickable map of the United States, with venues listed by city and town. How do I advocate for hearing can i buy kamagra online loop technology?. Sterkens encourages people to advocate for hearing loops in their community by using the information on the HLAA website. €œThe HLAA has resources for consumers who want to advocate for hearing loops,” she said. €œSometimes all it takes is one person to make it happen.

Hearing loops beget other hearing loops. If you can help people hear that much better with the hearing aids they already have in their ears, it’s incredible.

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NCHS Data cheap kamagra oral jelly Brief No. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep is associated with an increased risk cheap kamagra oral jelly for chronic conditions such as cardiovascular disease (1) and diabetes (2). Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition. Menopause is cheap kamagra oral jelly “the permanent cessation of menstruation that occurs after the loss of ovarian activity” (3).

This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status. The age range selected for this analysis reflects the focus on midlife sleep health. In this analysis, 74.2% of women are premenopausal, 3.7% are perimenopausal, and cheap kamagra oral jelly 22.1% are postmenopausal. Keywords. Insufficient sleep, menopause, National Health Interview Survey Perimenopausal women were more likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three nonpregnant women aged 40–59 slept less than 7 cheap kamagra oral jelly hours, on average, in a 24-hour period (35.1%) (Figure 1).

Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period. Figure 1 cheap kamagra oral jelly. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, 2015image icon1Significant quadratic trend by cheap kamagra oral jelly menopausal status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer cheap kamagra oral jelly had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure cheap kamagra oral jelly 1pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble falling asleep four times cheap kamagra oral jelly or more in the past week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling asleep four times or more in the past week (19.4%) (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week. Figure 2 cheap kamagra oral jelly.

Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by cheap kamagra oral jelly menopausal status (p <. 0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cheap kamagra oral jelly cycle and their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 2pdf cheap kamagra oral jelly icon.SOURCE. NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week varied by menopausal status.More than one in four nonpregnant women aged 40–59 had trouble staying asleep four times or more in the past cheap kamagra oral jelly week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women.

Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week. Figure 3 cheap kamagra oral jelly. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend cheap kamagra oral jelly by menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and cheap kamagra oral jelly their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data cheap kamagra oral jelly table for Figure 3pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage of women in this age group who did not wake up feeling well rested 4 days or more in cheap kamagra oral jelly the past week increased from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week. Figure 4 cheap kamagra oral jelly. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status.

United States, 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle.

Access data table for Figure 4pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015. SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories. Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5). Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion.

DefinitionsMenopausal status. A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?. €. 2) “Do you still have periods or menstrual cycles?.

€. 3) “When did you have your last period or menstrual cycle?. €. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries.

Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less. Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?. €Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?.

€Trouble falling asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?. € Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis.

NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS. For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States.

The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS. Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics.

The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report. ReferencesFord ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults. J Am Heart Assoc 3(6):e001454. 2014.Ford ES, Wheaton AG, Chapman DP, Li C, Perry GS, Croft JB.

Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes. J Diabetes 6(4):338–50. 2014.American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 141.

Management of menopausal symptoms. Obstet Gynecol 123(1):202–16. 2014.Black LI, Nugent CN, Adams PF. Tables of adult health behaviors, sleep. National Health Interview Survey, 2011–2014pdf icon.

2016.Santoro N. Perimenopause. From research to practice. J Women’s Health (Larchmt) 25(4):332–9. 2016.Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al.

Recommended amount of sleep for a healthy adult. A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 11(6):591–2. 2015.Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015.

National Center for Health Statistics. Vital Health Stat 2(165). 2014.RTI International. SUDAAN (Release 11.0.0) [computer software]. 2012.

Suggested citationVahratian A. Sleep duration and quality among women aged 40–59, by menopausal status. NCHS data brief, no 286. Hyattsville, MD. National Center for Health Statistics.

2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J. Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J.

Blumberg, Ph.D., Associate Director for Science.

NCHS Data can i buy kamagra online Brief No. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep can i buy kamagra online is associated with an increased risk for chronic conditions such as cardiovascular disease (1) and diabetes (2).

Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition. Menopause is “the permanent cessation of menstruation that occurs after the loss of ovarian activity” can i buy kamagra online (3). This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status.

The age range selected for this analysis reflects the focus on midlife sleep health. In this analysis, 74.2% of women are premenopausal, 3.7% are perimenopausal, can i buy kamagra online and 22.1% are postmenopausal. Keywords.

Insufficient sleep, menopause, National Health Interview Survey Perimenopausal women were more likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three nonpregnant women aged 40–59 slept less than 7 hours, on can i buy kamagra online average, in a 24-hour period (35.1%) (Figure 1). Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period.

Figure 1 can i buy kamagra online. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, 2015image icon1Significant quadratic trend by menopausal status (p can i buy kamagra online <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle can i buy kamagra online was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table for can i buy kamagra online Figure 1pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who had trouble falling asleep four times or more in the past week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling asleep four times or can i buy kamagra online more in the past week (19.4%) (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week.

Figure 2 can i buy kamagra online. Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, can i buy kamagra online 2015image icon1Significant linear trend by menopausal status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if can i buy kamagra online they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table for Figure can i buy kamagra online 2pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged can i buy kamagra online 40–59 who had trouble staying asleep four times or more in the past week varied by menopausal status.More than one in four nonpregnant women aged 40–59 had trouble staying asleep four times or more in the past week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week.

Figure 3 can i buy kamagra online. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal can i buy kamagra online status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they can i buy kamagra online no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data can i buy kamagra online table for Figure 3pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage of women in this age group who did not wake up feeling well rested 4 days or more in the past week increased from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal can i buy kamagra online women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week.

Figure 4 can i buy kamagra online. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 4pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories.

Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5). Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion. DefinitionsMenopausal status.

A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?. €.

2) “Do you still have periods or menstrual cycles?. €. 3) “When did you have your last period or menstrual cycle?.

€. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries.

Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less. Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?.

€Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?. €Trouble falling asleep.

Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?.

€ Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis. NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone.

Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS. For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States.

The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS. Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option.

Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics. The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report.

ReferencesFord ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults. J Am Heart Assoc 3(6):e001454.

2014.Ford ES, Wheaton AG, Chapman DP, Li C, Perry GS, Croft JB. Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes. J Diabetes 6(4):338–50.

2014.American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 141.

Management of menopausal symptoms. Obstet Gynecol 123(1):202–16. 2014.Black LI, Nugent CN, Adams PF.

Tables of adult health behaviors, sleep. National Health Interview Survey, 2011–2014pdf icon. 2016.Santoro N.

Perimenopause. From research to practice. J Women’s Health (Larchmt) 25(4):332–9.

2016.Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al. Recommended amount of sleep for a healthy adult. A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society.

J Clin Sleep Med 11(6):591–2. 2015.Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015.

National Center for Health Statistics. Vital Health Stat 2(165). 2014.RTI International.

SUDAAN (Release 11.0.0) [computer software]. 2012. Suggested citationVahratian A.

Sleep duration and quality among women aged 40–59, by menopausal status. NCHS data brief, no 286. Hyattsville, MD.

National Center for Health Statistics. 2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J.

Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J.

Blumberg, Ph.D., Associate Director for Science.

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