PBS’s ‘This Emotional Life’: The Hospital Menu in the Modern Age

Thomas Edison wrote: “The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.”

Medical technology has made dramatic leaps in the past 150 years. From the invention of the X-ray and the introduction of vaccines to the mind-blowing capabilities of high-tech 64 slice CT scanners that allow physicians to view the inner workings of the human form, the ways in which we practice medicine today seem light years ahead of our predecessors. And yet, oddly, one aspect of the hospital stay has remained surprisingly constant — the menu.

Until recently, that is. Today’s hospitals are learning how important a tool the menu can be when it comes to promoting healing, increasing nutritional awareness and improving their patients’ emotional well-being. The twenty-first century has brought with it new ideas and sound philosophies relating to the bond between what we eat and how we feel, and nowhere is that link more dramatically felt than when one is forced to dine from a hospital bed. In the past the focus of hospital food was primarily somatic, although the lackluster fare did not always provide the much-needed healthy boost of vitamins and minerals. Today’s hospitals have come to recognize not only the value of well prepared, fresh food in bolstering the immune system, but the benefits choice can have on a patient’s psychological outlook during trying times. Food, it seems, is powerful medicine not only for the body, but also for the mind.

Since study after study continues to stress the influence proper nutrition has on rates of healing and overall health, many of today’s hospitals have begun to address the tired stereotype befitting Jell-O cubes and ice chips, striving instead to serve fare that is both varied and enjoyable. In doing so, both patients and hospitals benefit. By allowing patients to choose their meals, they are given a degree of control over their situations, albeit small, which can go a long way toward reducing the stress of waiting for test results, exams or procedures.

Over time, it has become clear that the old methods of serving patients are no longer a match for the needs of the modern hospital or those it serves. Since the average age of the hospital patient continues to rise as Baby Boomers find themselves entering their sixties and demanding a standard of quality that they have grown to expect, many hospital administrators have opted to outsource food services in an effort to provide patients with quality meals that are prepared without taxing the hospital infrastructure itself.

Today, nearly 20 percent of American hospitals employ food service outsourcing in one form or another, and the trend is on the rise. By doing so, hospitals are able to focus solely on the task of ministering to patients, freeing up staff members who once doubled as waiters and providing patients with food prepared by culinary experts who take pride in conjuring up a variety of nutritious dishes guaranteed to surprise if not delight the most curmudgeonly gourmand. This not only increases efficiency, it results in improved service, better food, greater selection and higher patient satisfaction. To keep up with the modern patient’s need to be pampered, many outsourcing companies have even begun to offer room service dining, which is in many ways similar to a hotel experience. When hungry, patients simply place an order with the kitchen, and their request is brought up in a timely fashion after having been vetted by the hospital dietitian. Food is freshly prepared and the menus are extensive.

Whether outsourced or not, many modern hospitals have committed to improving the quality and scope of their menus in an effort to capitalize on the link between healthy eating and psychological well-being. With greater variety comes better nutrition, as patients are not only eating healthier food free of excess sugars, starches and preservatives, they are eating more of it. The concept of food as preventive medicine has resulted in some leading hospitals offering primarily organic and chemical free food, including hormone free milk, antibiotic free chicken and beef and locally grown fruits and vegetables.

This stands as an excellent example of the way in which hospitals are beginning to regard education as a key factor in the continued health of their patients. Most American hospitals employ registered dietitians to ensure that patients eat healthy, well-balanced meals during their stay and receive the necessary education to continue such patterns at home. In this way, hospitals can do their part to proactively treat patients before they become sick as a result of obesity or lack of nutrition.

Understanding the full impact of a proper diet is no easy task for anyone, hospital patient or not. Modern times can often blur the lines between healthy or unhealthy, too thin or too heavy, without even addressing nutrition. Whether the focus is on obesity-associated morbidity or orthorexia nervosa (an antiphrastic oxymoron which is used to describe an unhealthy obsession with eating healthy), a hospital stay can help patients recalibrate their eating habits and promote greater combined mental and physical health in the future.

If you or a loved one find yourself in a hospital for any length of time, consider using your stay to familiarize yourself with the basics of nutritional healing and overall healthy eating. This will help you not only during your visit, but as you return to your regular lifestyle.

Get to Know Your Dietitian. Dietitians create menus that meet healthy eating guidelines set by the American Dietetic Association, as well as satisfying regional tastes (foods that are familiar to a large immigrant community, for example) and addressing specific patient related health needs such as those exhibited by diabetics, breast-feeding moms, wheat-allergy sufferers, etc. Your hospital dietitian will gladly provide advice and information on ways to improve your dining habits and cooking preparation, taking into account any health-related issues.

Shop Around. If you are not in the hospital as a result of an emergency situation, take a few minutes to find out what each of your neighboring hospitals have to offer in the way of dietary education, menu preparation, and room service dining. While medical expertise should always be the primary concern, you might be surprised at the quality of food service now being offered by medical centers in your area.

Use Your Down Time. While no one ever wants to be in a hospital, the periods of waiting between tests or while healing do provide many people with the opportunity to think about their health and reflect on ways to improve their quality of life once they are discharged. Ask questions and use the experts around you. By thinking long-term, you may be surprised to see just how easy it is to adopt healthier patterns once you are back to your normal routine.

By bringing the menu into the twenty-first century, today’s hospitals hope to educate their patients in the ways in which proper nutrition can bolster not only the body, but the mind and spirit as well. As always, the evolution of medicine continues to take its cue from Hippocrates, who must have thought holistically when he said, “Let food be thy medicine and medicine be thy food.”

This Emotional Life is a two-year campaign to foster awareness, connections and solutions around emotional wellness. Join our community at www.pbs.org/thisemotionallife.

PBS’s ‘This Emotional Life’: Rethinking ‘Medical Miracles’

Saint Augustine wrote: “Miracles are not contrary to nature, but only contrary to what we know about nature.”

A phenomena within health care, often applied when no rational scientific explanation can be given, preexists medicine itself. Be it via the Internet, urban legends or contemporary television and cinema, we have all marveled at the thought of the teen who lived 118 days without a heart, or the paraplegic man who was once again able to walk after being bitten by a brown recluse spider, or the window washer who fell 47 stories and awoke from his coma on Christmas Day. Sometimes, medical degree or no, the only way to explain the reasoning behind such patient outcomes is to use that often overburdened word — miracle.

From the outset, medicine and religion have been begrudgingly forced to spar in their attempts to provide relief. As the two have evolved, they have constantly found ways to overlap, each jockeying for position as the times around them changed. One point of mutual interest and competition has always dealt with diagnosis. For example, thanks to advances in modern medical technology, we now know Tourette’s Syndrome to be a rare neurological disorder. In its more aggressive stages, Tourette’s presents itself with facial tics and expressions, the perception of the eyes rolling upwards, and involuntary, often guttural sounds. Though contemporary physicians are capable of recognizing this disease for what it is, it is interesting to note that Tourette’s was once widely understood to be a form of demonic possession, and dealt with accordingly.

On the flip side, take the curious phenomenon of Lazarus Syndrome. Since 1982, there have been 25 documented cases of a deceased patient coming back to life without any medical intervention whatsoever, due to a spontaneous and unexplained restarting of the heart muscle after death. The name comes from the biblical tale of Lazarus, who was raised from the dead by Jesus after four days. Though medical science has put forth several possible theories for such an occurrence, it remains a widely debated mystery to this day, from both a scientific and religious standpoint.

Whether or not a patient believes in miracles, there can be no dispute that certain advances in medicine are nothing short of miraculous. In 1944, doctors performed heart surgery for the first time. In 1952, Jonas Salk took the first step toward eradicating the dreaded polio virus. Today, scientists can administer vaccines to cure many diseases, some even after infection. These same scientists believe they can also inject a patient with his or her own cells to help repair vital organs, thereby allowing the patient’s body to essentially heal itself without any outside, invasive intervention. More and more, the gulf between miracles and modern technologies continues to widen.

At their core, both medicine and religion seek to heal. To support this objective, modern medicine began to focus its attention on shortening the list of any diagnosis that could be classified as a “terminal illness” (an illness from which, despite treatment, death is certain). At the turn of the twentieth century, as patients began to realize that modern medicine was advancing quickly and achieving previously unheard of results, the role of medicine itself started to change. Patients began to expect not only treatment of symptoms, but cures. With this understanding came a new feature formerly the exclusive jurisdiction of religion, the possibility of hope.

To a certain degree, the medical miracles of yesterday have slowly become the miraculous advances of today. Many previously unexplained situations are now seen clearly from a scientific standpoint, a sure sign of progress. But to hospital patients and their loved ones who must face incurable disease, this temporal distinction weighs in as little more than semantics. Looking in from the outside, it appears that most families do not care whether comfort comes from a modern miracle or medical breakthrough, so long as it eases the pain.

No matter how far science advances, however, one should never discount religious faith within the medical arena. In fact, it is just such conviction that has always pointed the way to medical success. Study after study has shown that the act of having faith — be it in an afterlife, an all knowing creator, or a CT scanner — can have a dramatic effect on both the condition and quality of life during a loved one’s final days, for the patient and family alike. Modern medicine still has a long way to go in its quest to unravel definitively the mysteries of the human body, and when its efforts fail us, faith is the only remaining foundation.

Should you find yourself in the unenviable position of comforting a loved one when time is short, faith may prove to be your most powerful tool. In such times, communication and honesty are of utmost importance. Ask questions of the patient, and respect his or her needs and convictions. Some people insist upon continued care until the end, while others want only to be checked up on. Many want an ear that is willing to listen. Certain patients continually search for clinical trials or secret elixirs to keep their faith alive, while others take comfort in resigning themselves to what is to come. Respect the viewpoint of the patient and do your best not to superimpose your own desires or beliefs on top of theirs. Remember, this is their time, not yours.

As technology continues to discover new ways to push the limits of our understanding of the workings of the human body, faith in the unknown becomes ever more important, standing as a beacon to highlight the next step in a series of challenges. Not only must medicine and religion be allowed to coexist within a hospital, they must be able to complement one another. Most modern hospitals are big places. Surely there is room for both.

This Emotional Life is a two-year campaign to foster awareness, connections and solutions around emotional wellness. Join our community at www.pbs.org/thisemotionallife.

Charting Changes in the Doctor-Patient Relationship

Hippocrates wrote: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”

Part science and part art, the practice of medicine has changed drastically in the 6,000 years since Hippocrates first uttered his famous oath. This evolution in recent decades, as seen both in its practice by physicians and the expectations thrust upon it by patients, has influenced a shift away from the hands-on study of the body as a primary means of diagnosis to a more clinical approach, due to both the advances of modern medical technology and the wealth of health care related data accessible to all via the Internet.

A Little History

Thousands of years ago, medicine offered little more than diagnosis and prognosis. The doctor’s role was not to heal, but to predict. Over time, advances in both the understanding of human anatomy and the power of medical technology combined to revolutionize the medical expert’s ability to identify and treat a variety of illnesses. As physicians learned more about the interplay between each of the body’s organs, scientific discoveries began to shed new light on the mysteries hidden beneath the skin. The physician’s exam, once lauded as the cornerstone of diagnostic science, gave rise to the X-Ray, which led to the CT scan, to be followed by magnetic resonance imaging (MRI). In truth, such technological breakthroughs are the reason so many diseases once considered death sentences are now routine and treatable.

There is no question that these modern scientific marvels have greatly increased the twenty-first century physician’s ability to diagnose and treat his or her patients. But there is a cost. Initially intended as practical tools to gather additional data upon which to base a diagnosis, these new tests and procedures have become the central focus for many medical practitioners. The art of the physical examination, once so essential to both the diagnostic process and the emotional well-being of the patient, is becoming obsolete.

What Television and the Movies Can Teach Us About Attitudes Toward Medicine

These improvements in modern technology are in large part responsible for the transition that has taken place in the modern doctor’s bedside manner and overall attitude toward the patient. Nowhere is this trend more apparent than in the changing role of television doctors throughout recent decades. In the seventies, for example, Robert Young portrayed the kindly and world-wise general practitioner Marcus Welby, M.D., a man who struggled to treat his patients with compassion in a profession trending steadily toward specialized, impersonal care.

Such struggles were in vain, it seems, as Welby’s contemporary counterpart, Gregory House, M.D., uses his diagnostic brilliance as a means to keep himself always at arm’s length from his patients. No longer is a doctor thought of as a kindly old man who makes house calls and listens to his patients’ troubles and aches, he is now instead a young physician who hardly handles his patients while computing a checklist of ailments from which to order the proper panel of tests.

While the discussion of Drs. Welby and House above may portray two extremes in the doctor-patient relationship, the range of combinations in between has also appeared in television and film alike. In The Exorcist, Chris McNeil is a very concerned mother who desperately wants to identify the medical condition responsible for altering the behavior of her daughter Regan. The treating physician, relying upon early 1970s medical technology, offers his explanation:

“It’s a symptom of a type of disturbance in the chemical-electrical activity of the brain. In the case of your daughter in the temporal lobe, up here in the lateral part of the brain. It’s rare, but it does cause bizarre hallucinations.”

Late in the film, Regan’s physician returns to the McNeil Household during one of Regan’s more memorable performances. Though scientifically baffled, the physician is determined to hold firm to his instincts:

“Pathological states can induce abnormal strength, accelerated motor performance. For example, a 90-pound woman sees her child pinned under the wheel of a truck, runs out and lifts the wheels half a foot up off the ground. You know the story, same thing here.”

With no knowledge of the reasons for her daughter’s illness, Regan’s mother, like most people, was unable to engage in any meaningful debate about the accuracy of her daughter’s diagnosis. Armed with years of medical education and training, the ordinary doctor circa 1973 could strong arm just about anyone with his opinion. All this has changed, however, with the advent of websites such as WebMD, MedicineNet and WrongDiagnosis.com.

The rise of the Internet has made advances in medical science more accessible to patients, granting them new depth and scope, medically speaking. With such a wealth of knowledge literally at their fingertips, patients now want information immediately when it relates to the science of medicine, often researching both disease and cure on their own. For better or worse, doctors have to some degree lost the unquestioned sanctity that has historically accompanied their “mysterious” profession.

Rebuilding the Doctor-Patient Relationship

Though the benefits of modern technology are not to be overlooked, the changes they have instilled make it increasingly important for both medical practitioners and their patients to maintain an objective approach to one another. A well-rounded doctor would do well to incorporate newfound scientific resources with renewed emphasis on the physical exam and patient history, in an effort to once again personalize the medical experience. A wise patient must keep in mind that the Internet, while a practical educational tool, is no substitute for a medical degree and in-field experience.

Perhaps most important to improving the doctor-patient relationship is the need for communication. To get the most out of your doctor’s visit, it is essential that you express yourself while at the same time understanding the often complex issues and instructions your physician presents to you. Following is a set of guidelines to assist patients in their effort to communicate quickly and effectively, so that doctors have the information necessary to do their job and patients feel their needs have been addressed:

  • Be thorough. Your role is to provide the details on how you are feeling. The doctor will decide what is relevant.
  • Be honest. Your doctor has seen it all, and he or she is not there to judge you, but to heal you. Telling the truth about lifestyle choices, symptoms and concerns marks the fastest route on the road to recovery.
  • Ask questions. If something your doctor says about your condition or treatment is unclear, ask him or her to repeat it or put it in simpler terms.
  • Bring lists. The better prepared you are for your visit, the more relaxed you will be when questioned, and the more you will benefit from your doctor’s instruction.

With all the benefits provided by modern medical technology, it is clear that the clinical emphasis on diagnostic medicine is here to stay. As the relationship between physicians and their patients continues to shift, it is important for both sides to remember that the practice of health care is a partnership as well as a profession. By effectively opening up a dialogue in which information and concerns can be shared, the doctor is better able to assess the situation, while the patient is made to take a more active role in the course of treatment, leading to a more relaxed, balanced and satisfying experience for all involved.

The Visitor / Reducing Stress in a Hospital Stay

Aeschylus wrote: “What is there more kindly than the feeling between host and guest?”

The hospital stay is often a time of great stress for patients and their families alike. Recently, President Obama issued a directive for the creation of rules ensuring that hospitals protect the rights of patients to designate visitors, stating in part: “There are few moments in our lives that call for greater compassion and companionship than when a loved one is admitted to the hospital.” While the President’s comments have been widely debated, his underlying sentiment emphasizes the importance of reducing stress in a hospital setting for all those involved.

Let’s face it, no one wants to be in a hospital. Whether visiting a loved one or being visited yourself, the hospital stay poses a unique set of problems in that the presence of illness tends to tilt the scales of any relationship. Lying in a hospital bed surrounded by tubes and monitors, the patient is in a vulnerable state both mentally and physically. Separated from his or her natural environment, the patient is not only in unfamiliar territory but in the process of coming to grips with the fact that he or she is ill. Such a one-two punch often forces patients into crisis mode, leaving them feeling frightened and confused. In such a situation, the mere sight of a loved one is often enough to greatly reduce stress levels by assuring them that they are not alone in the situation.

But this burden must go somewhere, and it usually makes its way to the shoulders of the loved ones who come to visit. Family members, too, must navigate the shifting roles brought on by illness, as the physical and emotional toll of caring for a sick loved one can have a dramatic effect on everyday life. Such seemingly simple tasks as eating healthy, getting enough sleep, and addressing work responsibilities and personal commitments often fall by the wayside as time is sacrificed for the good of the patient. To make matters worse, stress is often increased by having to wrestle with concerns about the patient’s care, complex medical information, financial anxiety, questions of insurance and the possibility of long term issues after the patient’s discharge.

As difficult as it may be for people to watch a family member battle illness, for some groups the emotional distress brought about by grief or concern is further compounded by the struggle they must undertake to simply gain admittance to see their loved one. Though the President’s recent directive is a step in the right direction, the rights of gays, lesbians and unmarried partners both to visit and make decisions with respect to their loved ones’ care have historically fallen short, forcing them to watch from the sidelines as the patient battles his or her disease without the support of the partner. In addition, the elderly, who are often balancing the aforementioned stressors with additional feelings of grief and impending loss, must allow for issues deriving from potentially weakened immune systems, limited mobility and lapses in cognition, factors which can impede their ability to offer support. Children, too, can have trouble when trying to see those closest to them, as many hospitals have strict regulations prohibiting visitation by those under seventeen.

In the event that you are allowed to visit your loved one, good communication skills and a positive outlook are essential when providing comfort. The stress level of a patient can be either reduced or increased by the visitor, so it is important to remember that ultimately the needs of the patient come first. Following are guidelines to assist the family member so that his or her visit serves to calm the patient, rather than add to an already stressful situation.

● Ask permission to visit. While many patients enjoy company, some do not like for others to see them infirm or tired, or simply do not feel up to having guests. If you suspect you are intruding, politely ask if another day would suit them better. The key is to let the patient know that you are thinking about them.

● Gauge the effect of your visit. A family illness can sometimes force interaction between estranged members. However, this is no time to address old wounds. What matters now is to offer support in a time of need.

● Stay positive. Though your loved one’s hospital stay may be taking its toll on you, it is important to keep the patient’s thoughts on the task of getting better. Complaining about the situation or introducing feelings of guilt or resentment will only increase the overall stress level.

● Keep your visit short. No matter how much your loved one may enjoy your company, he or she needs plenty of rest. The fact that you have taken the time to see them is what matters, not the length of your visit. The simple act of seeing a friendly face can work wonders.

● Don’t visit when you are ill. Though you’d like to show your support, visiting a loved one while sick is never a good idea. Patients in hospitals often have compromised immune systems which can cause additional complications during treatment. Instead, feel free to call or write until you are feeling better and are no longer contagious.

● Participate in the treatment. Should your loved one approve, it may be a good idea to get involved in the process by familiarizing yourself with the patient’s condition, symptoms, and outlook. You may also want to introduce yourself to all related medical staff. This is a great way to remind your loved one that he or she is not alone, and that someone who cares is looking out for their best interest.

● Take care of yourself. While your primary focus may be on your loved one, it is important to note that you cannot be of help to him or her if you get sick yourself. Spend a few minutes every day doing something you enjoy, and try to eat well and get as much sleep as possible. The stronger you remain during this experience, the more you will be able to provide your loved one with the support he or she needs during this trying time.

This Emotional Life is a two-year campaign to foster awareness, connections and solutions around emotional wellness. Join our community at www.pbs.org/thisemotionallife.

340B and Hospital Systems0

The Department of Health and Human Services (“HHS”) responded to comments published in the Federal Register that a hospital  enrolled in the 340B program as a Covered Entity may treat its off-campus clinics and satellite hospitals as part of the Covered Entity, provided the off-campus clinic or satellite hospital is included on the Covered Entity’s Medicare Cost Report.[1]  HHS also declared that off-campus clinics and satellite hospitals may be properly included on the Covered Entity’s Cost Report where they meet Medicare’s tests for provider based status, as outlined at 42 C.F.R. § 413.65(d-e).[2]

(1)        Criteria For All Facilities

42 C.F.R. § 413.65(d) outlines the criteria for all facilities to receive provider-based status.  The requirements are divided into five main categories, with two categories in particular that typically affect hospital systems: (a) licensure and (b) clinical services.

(a)        Licensure

With respect to licensure, as stated above, “the satellite facility and the main provider are operated under the same license, except in area where the State requires a separate license for the . . . satellite facility.”[3]  One example of a state with this requirement is Nevada as Nevada law requires all hospitals and clinics, among other providers, to be licensed by the Nevada State Health Division[4].

(b)       Clinical Services

With respect to clinical services, the two entities need to be integrated such that (i) the professional staff of the off-campus clinic must have clinical privileges at the Covered Entity’s main campus; (ii) the Covered Entity provides the same monitoring and oversight as it does for any department; (iii) the medical director of the off-campus facility needs to maintain a reporting relationship with the CMO of the Covered Entity and be supervised and accountable to the CMO; (iv) the Covered Entity’s staff committees are responsible for the off-campus clinic’s medical activities, including, quality assurance, utilization review, and coordination and integration of services; (v) the entities have integrated medical records; and (vi) the off-campus clinic and the Covered Entity are integrated such that patients treated off-campus have full access to facilities and services of the covered entity.[6]

(2)       Criteria For Off-Campus Facilities

42 C.F.R. § 413.65(e) outlines the criteria for off-campus facilities to receive provider-based status.  The requirements are divided into three categories: (a) ownership and control, (b) administration and supervision, and (c) location.

(a)        Ownership and Control

With respect to ownership and control, the Covered Entity’s control of the off-campus clinic must be evidenced by: (i) 100% ownership; (ii) accountability to the same governing body; (iii) organization under the same governing documents and bylaws; (iv) and final administrative responsibility laying with the Covered Entity.[7]

(b)       Administration and Supervision

With respect to ownership and control, the Covered Entity must hold the off-campus clinic accountable as evidenced by: (i) direct supervision of the off-campus clinic; (ii) accountability to the Covered Entity’s governing body, and (iii) integrated billing, records, human resources, payroll, employee benefits, salary structure, and purchasing services.[8]

(c)        Location

With respect to location, the Covered Entity and the off-campus clinic must meet one of the following: (i) located within a 35 mile radius of each other; (ii) the Covered Entity is disproportionate share adjustment of greater than 11.75% and is owned either by the state or local government, is a nonprofit corporation granted governmental powers by the state, or is a private hospital with a State contract to provide clinic services to low-income individuals; (iii) the off-campus clinic has at least 75% of its patients from the same zip code as the Covered Entity or 75% of the off-campus clinic’s patients were treated at the Covered Entity; (iv) 75% of patients in the off-campus facility’s zip code receive treatment at Covered Entity; or (v) the off-campus facility is a children’s hospital and meets 6 other criteria.



[1] 59 Fed. Reg. 47884, 47885 (Sep. 19, 1994).

[2] Id.  The response in the Federal Register directs the reader to “Provider Certification, State Operation Manual, section 2024.”  Section 2024 in turn directs that, “all non-hospital providers of service under Medicare that state they are part of a single hospital must meet the criteria for provider-based designation in §2004 in order to be treated as a single hospital for payment purposes.”  Next, Section 2004 directs the reader to 42 C.F.R. § 413.65 for the criteria used to determine provider-based status.  Finally, the Federal Register cited above enumerated several criteria as examples, all of which are found in C.F.R. § 413.65.  Thus, while the Federal government (surprisingly) was less than clear on the test for determining whether an off-campus clinic or satellite hospital may be treated as part of a Covered Entity, I am confident that the provider-based status test is the applicable test to make such a determination.

[3] 42 C.F.R. § 413.65(d)(1) (2012).

[4] See Nevada Revised Statues § 449.030 (2012).

[5] 42 C.F.R. § 413.65(d)(1) (2012).

[6] 42 C.F.R. § 413.65(d)(2) (2012).

[7] 42 C.F.R. § 413.65(e)(1) (2012).

[8] 42 C.F.R. § 413.65(e)(2) (2012).