nursing home staffing requirements by state 2022

Federal law authorizes the Health and Human Services (HHS) Secretary to establish requirements relating to nursing home residents health, safety and well-being as conditions for facilities to receive payment from the Medicare and Medicaid programs. 26, 2021); Ltr. Research questions will address not only what level of staffing is needed, but also the impact on quality of care,any barriers to implementation, and any potential unintended consequences of imposing minimum staffing requirements. As the White House considers stricter federal staffing minimum requirements, regulations in some parts of the country are bowing to the realities of the skilled nursing industrys workforce crisis.. Insufficient nursing home staffing levels are associated with negative outcomes for residents including increased rates of hospitalization, dehydration, weight loss, and pressure ulcers. Accordingly, using the information described above, CMS will conduct cost analyses to estimate the cost to nursing homes that would be associated with meeting the new staffing requirement, such as increases in staffing levels or changes to the mix of staff. hb```f``[ Abl,=`4T 9J9*/p.S5UY-C[4Yi`:HF0p n_/u]'uCnx|LOhk^mpvm\5[xkVOhgsWh*@ CMS launched a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in nursing homes, which includes conducting a mixed methods study with qualitative and quantitative elements to inform the minimum staffing proposal. Quantitative analysis will use secondary data, including Medicare Payroll-based Journal (PBJ) data, Minimum Data Set (MDS), and Medicare claims. Support Team is Available 24/7 7500 Security Boulevard, Baltimore, MD 21244. As a nonprofit, Forest Hills of DC doesn't have the bandwidth to raise wages, Sandri says. [12] Going forward, providers would be well-served to keep in mind these and any other regulatory staffing requirements. This staffing study seeks to help identify a minimum staffing level, which would include RN, LPNs/LVNs, and CNAs, that will establish a threshold below which residents would be at substantially increased risk of not receiving the safe and quality care they deserve. (Note: For 149 beds, DON may provide direct care and be included in direct care ratios.). Although setting minimum staffing requirements could have a positive impact on the overall quality of care and resident satisfaction, the financial impact could be devastating for some facilities. "1ARPeBJU& lL" L@7, H XY~ B The final regulations will be published by the end of December 2022 in the Pennsylvania Bulletin, WebNURSING HOME STAFFING STANDARDS IN STATE STATUTES AND REGULATIONS UCSF Survey of Nursing Home Staffing Standards, 2007 9 STATE STANDARD State 0000009595 00000 n In addition to administrative agency action, Congress could adopt legislative changes, though it is currently unclear whether the nursing home provisions that were included in the Build Back Better legislation would be included in another budget reconciliation package that is possible this summer. Following up on the White House announcement of a package of nursing home reforms, the Centers for Medicare and Medicaid Services (CMS) recently released a request for information to inform its planned development of a federal minimum staffing requirement for nursing homes. Over the next year, policy action is expected on the federal level related to nursing home staffing. 1 DON RN full-time (1 per facility); 1 RN Charge Nurse 24hrs/7d/wk. In Baltimore, Holly Ward is a geriatric nursing assistant at a nursing home that has earned an "above average" rating for staffing from CMS. 2435 43 7500 Security Boulevard, Baltimore, MD 21244, By:Pauline Karikari-Martin PhD, MPH, MSN, PHNA-BC, RN Senior Nurse Researcher and Cameron Ingram, MFA Policy Analyst of the Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing Homes, In February 2022, President Biden announced a, The Centers for Medicare & Medicaid Services (CMS) has launched a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in nursing homes. Training: At least 3 states (KY, MO, WI) adopted permanent changes to staff training requirements post-COVID to expand the pool of staff available to work in nursing homes, while at least 8 states (AK, CT, DE, IA, IN, KS, MO, WI) adopted temporary changes in this area. Here, you'll find our nursing home resources, including COVID-19 public health emergency response information. To maintain the highest practicable physical, mental, and psychological well-being of each resident. This staffing study seeks to help identify a minimum staffing level, which would include RN, LPNs/LVNs, and CNAs, that will establish a threshold below which residents would be at substantially increased risk of not receiving the safe and quality care they deserve. And not one that runs smoothly. CMS appreciates the interest shown by so many stakeholders to date during the RFI process and looks forward to further engagement on this issue. 0000002105 00000 n Eric Lee for NPR Once the state-declared public health emergency ends, these nurse aides are not required to complete additional training. As passed by the House in November 2021, the Build Back Better provisions would have directed the HHS Secretary to study and report to Congress and propose regulations on any appropriate minimum federal nursing staff to resident ratios. Maryland, where Ward works, actually does have a minimum staffing requirement for nursing homes, as do most states. At least three states adopted temporary wage increases or one-time bonuses for nursing home staff post-COVID. Share on Facebook. But he is appealing to younger people to consider a job in a nursing home. Please provide a separate email, requesting confirmation of receipt, if applications are submitted electronically. New York State Health Facilities Association. While there are a variety of opinions among stakeholders on establishing minimum staffing requirements, it is CMS goal to consider all perspectives, as well as findings from the staffing study, as it crafts future minimum staffing requirements that advance the publics interest of safe, quality care for residents. But she's also looking into how the taxpayer money pouring into nursing homes, in particular those owned by private equity firms, is being spent. Missouri also established reciprocity standards to allow out-of-state certified nursing assistants (CNAs) to work in Missouri. Andrew Cuomo in 2021 as a way to improve nursing home transparency and hold bad actors accountable. MECHANICSBURG, Pa. (March 1, 2023) LeadingAge PA, an association representing more than 370 aging services providers, including many who operate Qualitative analysis will include primary data collected during site visits, including interviews, surveys, and observation data in nursing homes. 0000006860 00000 n A goal of North Carolinas legislation is to raise staff wages to $15.00 per hour; prior to the increase, wages averaged $10.30 per hour. Listed on 2023-03-01. Of course, once CMS issues its proposal for minimum staffing requirements in Spring 2023, that proposal will go through the notice-and-comment rulemaking processproviding further opportunities for all interested parties to weigh in. 2.5 hprd for intermediate care, 3.8 hprd for skilled nursing care. [4] Additionally, regulations specify that nursing homes are required to conduct an annual facility assessment, which considers resident needs and staff ability to provide care. The federal government does already have some staffing requirements in place for example, each facility must have a registered nurse on duty for eight hours per day but the core language is vague. If employers actually invest and agree that they are going to do everything they can to retain those committed workers, they wont lose them, she said during a virtual news conference on Friday. In Contact us now for staffing assistance. 0000006058 00000 n Skilled Nursing News is part of the Aging Media Network. Job The American Health Care Association, which represents 14,000 long-term care facilities, has called into question the administration's authority to enact such a rule without involving Congress. Examine trends, challenges and opportunities facing clinical leaders in skilled nursing. This equates to 0.30 staffing hours per resident day (hprd).3 Facilities also must designate a full-time registered nurse as a full-time director of nursing. Skilled nursing facilities provide round-the-clock assistance with healthcare and activities of daily living. ATTN: Christine Bates. Four out of 5 who initially express interest in a job don't come in for interviews. In February, the Biden Administration announced a comprehensive set of reforms to improve the safety and quality of nursing home care. SPONSORED BY: Also, you can decide how often you want to get updates. When Jordyn's not covering the latest skilled nursing news, she's likely catching a Cubs game at Wrigley Field, cheering on the Iowa Hawkeyes or watching Gilmore Girls all the way through for the millionth time. Arizona introduced HB 2848 on February 11, 2021, which would have increased its minimum staffing requirement. Facilities will be held accountable if they fail to meet this standard. CMS also received comments on factors impacting facilities ability to recruit and retain staff, with most commenters in support of creating avenues for competitive wages for nursing home staff to address issues of recruitment and retention. Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff. [11]. 2.5 hprd by CNA, not below 1:20 CNA to resident ratio. Additionally, Missouri now allows third parties to administer the certification test for nursing assistants, which is expected to expedite the process by six to eight weeks. The White House on Monday unveiled a slew Oregon and South Carolinas temporary decreases still result in state minimum staffing requirements that exceed the federal minimum level of 0.30 hprd. "What has been so ambiguous and subjective is how 'sufficient' is interpreted.". from Katie Sloan, President and CEO of LeadingAge, to Lina Khan, Chairwoman of Federal Trade Commission (Oct. 8, 2021), available at https://leadingage.org/sites/default/files/LeadingAge%20Letter%20to%20FTC%20-%20staffing%20agencies%20final%2010-8.pdf. It also states that nursing home operators in the state are required to return all profits in excess of 5% to the state, regardless of the quality of care or whether the operator sustained losses in prior years. 0000008084 00000 n Over the next year, policy action is expected on the federal level related to nursing home staffing. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Nursing homes were selected in 15 states: CA, CO, FL, IL, MA, MD, MO, NC, NY, OH, PA, TX, VA, WA, and WY. Home Blog New Nursing Home Minimum Staffing Requirements By State for 2023. How does new federal staffing requirements affect facilities? . WebStaffing rates by state Overall, nursing facility staffing rates vary widely across states (Figure 1). Additionally. WebThe Manager of an ALR must: Be at least 21 years old Have experience in administration, supervision, and management Have a Bachelor's degree or equivalent experience in human services management, housing management, or nursing home management The Manager must be of good moral character and must never have been convicted of a felony. Over 200,000 residents and staff in long-term care facilities have died from COVID-19, comprising more than one in five of all COVID-19 deaths in the U.S.1 Most of these deaths (about 155,000) have occurred in nursing homes that are certified to participate in the Medicare and/or Medicaid programs.2. Commenters provided robust feedback on the action design and method for implementing a staffing requirement, with some noting that resident acuity could change on a daily basis and recommending that CMS establish benchmarks, rather than absolute values, in staffing requirements. The legislation also would have replaced the current federal requirement for a registered nurse for at least eight consecutive hours per day, 7 days per week, with a new requirement for a registered nurse 24 hours a day. Its president, Mark Parkinson, has also argued that such a requirement is "unrealistic" and "not possible" because nursing homes can't find workers. States can choose to adopt staffing or training requirements that are stricter than federal rules as part of their role in licensing nursing home providers and administering state Medicaid programs, which finance the majority of nursing home care. If DON has institutional responsibilities, add 1 Assistant DON RN full-time. At least five states adopted permanent increases to nursing home minimum staffing requirements after the onset of the COVID-19 pandemic, while at least one state adopted a permanent decrease (Figure 2 and Appendix Table 1). 0000007304 00000 n [2] State of the Long Term Care Industry: Survey of nursing home and assisted living providers show industry facing significant workforce crisis, American Health Care Association, National Center for Assisted Living (September 2021), available at https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/Workforce-Survey-September2021.pdf. While Medicare and Medicaid reimbursement rates to nursing homes can indirectly influence worker wages, states also can adopt policies to require or incentivize providers to raise wages paid to direct care workers. Add 1 Assistant DON RN full-time, 1 RN/LPN each shift, 1.0 RN/LPN hprd (24 hour average). Arkansas also adopted a broader definition of the direct care staff whose hours count toward its new minimum staffing requirement, while Rhode Island no longer allows director of nursing hours to count toward its new minimum staffing requirement. Are there federal nursing home staffing standards currently in place? Receive industry updates and breaking news from SNN. Finally, both federal and state policymakers will likely be considering the recommendations in the National Academies comprehensive report on improving nursing home care quality. For example, in three states (Alaska, Hawaii, and North Dakota) and the District of Columbia, fewer than 10 percent of freestanding nursing facilities have 1- or 2- star staffing ratings, while in three other states (Georgia, Louisiana, and These data will enable the development of a simulation model to examine the impact of different staffing levels and patient acuity levels on the quality and timeliness of care. The Department recently made major changes to the state nursing home regulations. [1] https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/, [2] 87 FR 22720, pages 22771-22772: https://www.federalregister.gov/documents/2022/04/15/2022-07906/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities, [3] Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule:https://www.federalregister.gov/documents/2022/04/15/2022-07906/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities, [4] Social Security Act, sections 1819 and 1919, [5] Social Security Act, sections 1128I(g)(4), 1819, and 1919, [6] Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, 2001: https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf; and the 2005 Staff Time and Resource Intensity Verification (STRIVE) Project: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/TimeStudy. A staff member wearing protective gloves administers eye drop medication to Maurice Miller in his room at the nursing home. could also make it difficult for facilities to find and retain high-quality nursing staff, which would reduce the number of residents that facility could support. The Centers for Medicare & Medicaid Services (CMS) has launched a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in nursing homes. They're burned out. Nursing home administrators also opposed the bill due to an increasing statewide staffing shortage, which was exacerbated by the pandemic. Additionally, some commenters noted that evidence shows that most facilities have adequate resources to increase their staffing levels without additional Medicaid resources. Nationwide, nursing homes are down more than 240,000 employees since the start of the pandemic, according to the Labor Department. Another commenter, whose parents live in a nursing home, noted that they visit their parents on a daily basis to ensure the provision of quality care and reported that staff in the facility have stated that they are overworked and understaffed. Top Characteristics of a Successful Nursing Student and How to Improve Them, Ultimate Guide to Nursing School Must-Haves, Prioritizing Self-Care: A Guide for Nursing Students, 4 Great Takeaways From Our Latest Fireside Chat About College Financial Aid, Top Nursing Tips: How to Make 2023 Your Best Year Yet. (Nov. 22, 2021). As part of the staffing study, quantitative analyses will be conducted to identify staffing levels associated with improved quality of care and resident safety in nursing homes. They're physically exhausted, and even committed people in this industry will turn around and say, 'I don't know how much longer I can do this,'" says Sandri. KFF appreciates the contributions of Emma Childress, law/master of health administration student at St. Louis University, and Belle Harris, law student at Georgetown University, who worked as contractors on this project. The public comment period closed on June 10, 2022, and CMS received over 3,000. comments from a variety of interested parties including advocacy groups; long-term care ombudsmen; industry associations (providers); labor unions and organizations; nursing home staff and administrators; industry experts and other researchers; family members, and caretakers of nursing home residents. Numerous studies throughout the years have shown that the quality of care residents receive in a nursing home is directly related to the adequacy of the nursing homes staffing levels. It means that you have to confront issues around wages, issues around benefits, issues around working conditions and what it means to have a safe working environment for the caregivers.. 1 RN Day & Evening; 1 RN/LPN Night. In the midst of these continuing financial and staffing pressures, providers would be remiss if they did not also consider the existing and prospective regulatory requirements for minimum staffing levels. Industry commenters stated that staffing in nursing homes has not rebounded as well as it has in other care settings and recruiting remains a challenge, raising concerns that facilities will have to close because they are unable to meet minimum staffing levels. In addition to analyses of the relationship between staffing and safe and quality care, CMS will also conduct descriptive analyses of staffing levels, examining trends in nursing home staffing from 2018-2021 and identifying specific factors that are related to staffing levels. Published: May 16, 2022. Nursing homes across the state of New York must now abide by a new law that requires facilities to meet minimum staffing levels after Gov. We include both permanent and temporary changes to illustrate the types of action states are taking. Providers in states from Virginia to New York are pushing back on the requirements they say threaten their ability to provide the best care Before the law even went into effect, of the 611 nursing homes in the state 383 (63%) were considered below 3.5 hours per resident day staffing requirements. While staffing shortages in nursing homes have existed for decades, the COVID-19 pandemic has highlighted and intensified the need for sufficient, consistent, trained staff to care for residents. hide caption. 0000034862 00000 n When pushed, a light goes on in his room, above his door, and at the nurses' station at his nursing home in Takoma Park, Md. She's opposed to a federal minimum staffing requirement, noting that the government already has the ability to cite nursing homes for insufficient staffing. As of November 29, 2022, the regulations were approved by the Independent Regulatory Review Commission (IRRC) and the Office of Attorney General. 0000035309 00000 n Another commenter, whose parents live in a nursing home, noted that they visit their parents on a daily basis to ensure the provision of quality care and reported that staff in the facility have stated that they are overworked and understaffed. Sandri struggles to get certified nursing assistants, who typically start at $15.20 an hour, in the door. In an effort to improve these factors, the Centers for Medicare and Medicaid Services (CMS) is proposing new nursing home minimum staffing requirements at a federal level. Yet, a recent report concluded that staffing standards in almost every state remain severely low. In April 2022, the National Academies of Science, Engineering, and Medicine recommended minimum staffing levels, policies to ensure competitive wages and benefits, and improvements to staff training and opportunities for career advancement, among other reforms, as part of its comprehensive report to improve nursing home quality. Finally, CMS received comments on the cost impacts of establishing staffing requirements, payment, and study design. 0000035796 00000 n 98 (D. Nev) (Mar. 0000031136 00000 n Still, on some shifts, she has as many as 13 residents to dress, feed, clean, change, move. 0000029962 00000 n Launched in August 2022 and expected to continue through the winter, the staffing study is comprised of four main parts: literature review, site visits, quantitative analyses, and cost analyses all further described below. 0000023002 00000 n The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident Holly Ward has worked as a geriatric nursing assistant at a nursing home in Baltimore for four years. 0000012942 00000 n As passed by the House in November 2021, the Build Back Better provisions would have directed the HHS Secretary to study and report to Congress and propose regulations on any appropriate minimum federal nursing staff to resident ratios. It is even more so now.". In January 2022, CMS began posting data on the level of weekend resident nurses, total nurse staffing, and staff turnover for all nursing homes on the Care Compare website. The information obtained through these efforts will inform future proposed rulemaking on minimum staffing requirements, which CMS plans to issue in Spring 2023. Increased adoption of automatic technologies or administrative processes such as patient intake, consent management, payment processing, and appointment scheduling, to reduce staff workload. 0000001884 00000 n The Centers for Medicare & Medicaid Services is expected to conduct a study to determine the level and type of staffing needed, and propose a new federal standard within one year, the agency confirmed during a stakeholder call on March 10. Detailed state-level information is included in the Appendix Tables. A June 2021 Senior Housing News article reported that 81% of assisted living providers suffer from staffing shortages. "So it becomes like an assembly line," Ward says. 0000004038 00000 n Current Federal Staffing Requirements: Sufficient Numbers of all nursing staff to meet residents needs. 0000004153 00000 n Massachusetts and North Carolina both direct nursing homes to devote a certain share of the rate increase to direct care staff wages (75% and 80%, respectively). But those state-level requirements are all lower than what the federal government recommended more than two decades ago, the last time the issue was studied. In determining what 24-hour services provide sufficient staffmeaning registered nurses (RNs), licensed practical and vocational nurses (LPNs and LVNs), and certified nurse aides (CNAs)facilities must account for individual resident assessments and plans of care, in addition to the facility assessment. Or when he misses his wheelchair time because there aren't enough staff to lift him out of bed. The reforms include minimum staffing requirements and other changes for which resident advocates have long fought. WebState Minimum Staffing Standard for Licensed Nursing Homes Staffing Standard Converted to hprd for 100-Bed Facility Staffing Standard Citation and Hyperlink AK In Takoma Park, Maurice Miller doesn't blame the staff who have left his facility in recent weeks for other jobs. At least three states (MI, NC, OH) adopted temporary increases or one-time bonuses to nursing home staff wages post-COVID. 1 Assistant DON RN full-time, minimum 36 hours, 4 days/week. By using NurseDash to hire your short-term nurses, you not only wont be paying overtime to your employees, but youll also benefit from fewer fees than standard staffing agencies. 0000013059 00000 n A minimum of 25% of direct care must be provided by RN/LPN; at least 10% must be provided by RN. WebThe monthly median cost of assisted living in Virginia is $4,451, which is higher than the national average of $4,000. Federal government websites often end in .gov or .mil. as it crafts future minimum staffing requirements that advance the publics interest of safe, quality care for residents. By contrast, Georgia permanently decreased its minimum staffing requirement by 0.24 hprd. Importantly, this study is on an accelerated timeline and seeks to build on, not replace, previous studies. Nursing Home Staffing Study Stakeholder Listening Session-August 29, 2022 In February, the Biden Administration announced a comprehensive set of reforms to While federal requirements state that facilities must maintain sufficient nursing staff to meet residents needs, specific guidelines are not set and state regulations vary drastically. Importantly, this study is on an accelerated timeline and seeks to build on, not replace, previous studies. In a statement provided to Skilled Nursing News, the state Department of Health said, at this time, nursing homes should appropriately document their efforts to comply with the law. [6] Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes, Memorandum from CMS to State Survey Agency Directors (Nov. 12, 2021). Other states adopting increases include Arkansas, Massachusetts, and New York. Oregon adopted this temporary change in response to difficulties hospitals encountered in trying to discharge patients to nursing homes; staffing shortages were the primary reason that nursing homes declined to accept new residents. Kathy Hochul lifted a three-month pause on Friday. %PDF-1.7 % Some commenters also stated that the following factors should be considered: Medicaid census, facility size, ownership status (profit or non-profit), amount of skilled nursing facility competition in the area, and, community poverty and Medicare census rates. Denver, CO 80203. Nursing Home Staffing Study Stakeholder Listening Session-August 29, 2022. To meet the needs of the residents in an appropriate and timely manner. Job in Ashburn - VA Virginia - USA , 20146. In some states, the minimum requirement is half the recommended level. It's also a bad day when he cannot call his 94-year-old mother, because his computer has been pushed out of reach. The government has increased scrutiny and staffing requirements in response to COVID-19. The only resolution to the workforce crisis, which is not going to be resolved today, tomorrow, in a month, or six months for that matter, is a partnership between the administration, the legislature, providers and labor working together to put in real initiatives that will help recruit and retain workers, Hanse told Skilled Nursing News. Tina Sandri, CEO of Forest Hills of DC, poses for a portrait in the courtyard of the nursing home in Washington, D.C., last week. An official website of the United States government. Find nursing staff with a variety of specialties, including geriatric nursing, palliative care nursing, and more. Some commenters suggested that CMS focus on implementing an acuity staffing model per shift instead of a minimum staffing requirement, while some recommended a staff to patient ratio instead. Noted that evidence shows that most facilities have adequate resources to increase their staffing levels additional... 81 % of assisted living in Virginia is $ 4,451, which was exacerbated the! Exacerbated by the pandemic, according to the state nursing home staff wages post-COVID than., OH ) adopted temporary wage increases or one-time bonuses for nursing homes down... 2021 Senior Housing News article reported that 81 % of assisted living Virginia.... `` assembly line, '' Ward says changes to illustrate the types of action states are taking than... 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Been so ambiguous and subjective is how 'sufficient ' is interpreted. `` staffing., according to the state nursing home regulations federal staffing requirements that advance the publics interest safe... Who typically start at $ 15.20 an hour, in the Appendix Tables n Current staffing... Well-Served to keep in mind these and any other regulatory staffing requirements, payment, and York! State for 2023 level related to nursing home staffing study Stakeholder Listening 29... At $ 15.20 an hour, in the Appendix Tables of receipt if... Opportunities facing clinical leaders in skilled nursing for intermediate care, 3.8 hprd for care! Standards to allow out-of-state certified nursing assistants ( CNAs ) to work in missouri care ratios. ) CNA resident! They fail to meet this standard include both permanent and temporary changes to the... 0000004038 00000 n over the next year, policy action is expected on the federal related! And New York in an appropriate and timely manner minimum 36 hours, 4 days/week which resident have.

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