The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists. The purpose of this publication is to keep our members updated on the NACNS headquarters news; connect our members with fast-breaking clinical news; and update clinical nurse specialists on state and federal legislative actions.

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Featured Articles

  1. Marilyn Tavenner Confirmed as CMS Administrator

Headquarters News

  1. New Partnerships for NACNS – Government Affairs and Public Relations
  2. NACNS Summit Planned for July 2013
  3. 2013 Annual Conference a Success
  4. Never Too Early to Plan – NACNS 2014 Annual Meeting
  5. Women’s Health Competencies Move to Validation Panel

CNS Foundation

  1. CNS Foundation Coffee a Day Campaign

Clinical Headlines

  1. U.S. Preventive Services Task Force Recommends Wide HIV Testing
  2. The “Cinnamon Challenge” – A Dangerous Trend
  3. FDA Warning for Pregnant Women on Migraine Prevention Medication
  4. Q Fever – A CDC report
  5. Suicide Trends Reported in MMWR
  6. Resources on Chronic Conditions

Association News

  1. NLN Announces Plan for New Accreditation Arm
  2. ANA Staffing Conference – November 2013

Federal and State Policy News

  1. Affordable Care Act and the Marketplace
  2. NACNS Opposes National Nurse Legislation
  3. Transitional Care Management (TCM) Services
  4. Federal Grant for Veteran’s Into Nursing
  5. PCORI Building a National Data Infrastructure to Advance Patient Centered Comparative Effectiveness Research
  6. CMS Issues Proposed Inpatient Payment Regulation for FY 2014

Featured Articles

11. Marilyn Tavenner is Confirmed as CMS Administrator

Marilyn Tavenner, RN, MHA ,FACHE was confirmed by the Senate on May 15, 2013 as the Administrator of the Centers for Medicare and Medicaid Services by a vote of 91-7. Ms. Tavenner is the first nurse to hold this position. Ms. Tavenner was serving as the Acting Administrator for CMS. Previously, Ms. Tavenner was Principal Deputy Administrator for CMS. As the Principal Deputy Administrator, Ms. Tavenner served as the agency’s second-ranking official overseeing policy development and implementation as well as management and operations. Ms. Tavenner a nurse and hospital administrator has compiled a distinguished record of service in the public and private sectors. Prior to her entry into federal service, Ms. Tavenner serve in a key leadership posts with the major hospital system HCA. She also chaired the Virginia hospital association.

NACNS joined the Nursing Community in support of Ms. Tavenner. Her warm support from the Senate will allow help smooth her path to success in this important position.

Headquarters News

2. New Partnerships for NACNS

In response to an NACNS membership survey on the association’s Mission and Goals, the membership articulated its interest in increasing the visibility of the clinical nurse specialist role and NACNS to a variety of audiences. In order to meet this acknowledged need, the NACNS Board of Directors has contracted with two cutting-edge firms to assist with messaging and representation.

For Government Affairs work, NACNS is working with KAR Associates, Inc. This firm was founded in 1997 and is a full service government relations firm. They have the resources to be able to work with NACNS to execute our advocacy and external relations agenda. They will be focusing on federal government affairs work, and specifically will represent NACNS before Congress, regulatory agencies, and with DC-based advocacy coalitions.

NACNS has contracted with PR Solutions -- a women-owned public relations firm that specializes in working with nonprofit organizations on health, education, women’s and similar issues -- to conduct a communications audit. That audit includes interviews with NACNS members, staff and leadership, as well as representatives of allied organizations. The auditors are also reviewing NACNS’ communications processes and vehicles, and will develop a series of recommendations which they will present in a report along with their findings and a communications plan for the association. While working on the audit, PR Solutions is also providing media support to NACNS.

3. NACNS 2013 Summit Planned for July 23, 2013

Plans are being finalized for the NACNS 2013 Summit to be held on July 23, 2013 in Washington, DC. The location for the Summit will be the conference room at One Dupont Circle, NW. NACNS has historically used the Summit as a meeting to discuss key issues of concern to the Clinical Nurse Specialist. This year’s Summit will be focused on key implementation issues with the APRN Consensus Model, particularly grandfathering of current CNSs and the need for population-based certification exams for licensure. The issue and importance of maintenance of specialty will be discussed as well. In the past, this meeting was by invitation only.  In the last few years, NACNS has invited key partners to the meeting and opened the Summit to interested NACNS members for attendance. If you are interested in attending this meeting, please contact Jason Harbonic at We will open a limited number of seats for general attendance. There will be a modest fee for this meeting to cover the cost of catering.

4. 2013 NACNS Annual Meeting in San Antonio a Success!

NACNS’ Annual Meeting on the Riverwalk in San Antonio was a big success. Focusing on the evolution in the role of the clinical nurse specialist (CNS), the meeting allowed NACNS members to meet with colleagues and network. Standing room only was seen at presentations that focused on CNS working in transition of care environments. A record-breaking 541 participants attended this meeting.

5. Never Too Early to Plan – 2014 Annual Meeting in Orlando Florida

Save the date! The NACNS 2014 Annual Conference will be held at the Orlando World Center Marriott in Orlando, Florida. The dates are March 6-8, 2014. Abstract submission will open in July with a due date of September 11. The call for abstracts will be available shortly on the NACNS homepage.

6. AWHONN/NACNS Women’s Health/Gender Specific Clinical Nurse Specialist Competencies Move to Validation Panel

On May 15, 2013 AWHONN and NACNS held the first call to assemble the validation panel to review and comment on the Women’s Health/Gender Specific Clinical Nurse Specialist Competencies. These competencies were developed by and expert panel with representatives from NACNS, AWHONN, ACNM and NPWH. The validation panel was comprised of individuals who responded to a public call for women’s health experts interested in serving on this important work group. The validation panel work will be followed by a public comment period and organizational endorsement. 

CNS Foundation

7. CNS Foundation Coffee a Day Campaign

The CNS Foundation is requesting that you participate in our Planned Giving Campaign. We are asking that you donate the price of a cup of coffee per week (about $20 a month) to help us continue the Foundation work. We appreciate any amount of money you could donate though as a one-time donation or through regular planned giving.

Clinical Headlines

38. The U.S. Preventive Services Task Force HIV Screening

The U.S. Preventive Services Task Force recommends that all patients ages 15 to 65 undergo HIV screening regardless of whether they are at risk. An estimated 1.2 million persons in the United States are currently living with HIV infection, and the annual incidence of the disease is approximately 50,000 cases. Since the first cases of AIDS were reported in 1981, more than 1.1 million persons have been diagnosed and nearly 595,000 have died from the condition. Approximately 20% to 25% of individuals living with HIV infection are unaware of their positive status. The task force stated in updated guidelines that identifying and addressing HIV in asymptomatic individuals may benefit the general public. The task force has also renewed its call for the screening of all pregnant women to help prevent mother-to-child transmission.

9. “Cinnamon Challenge” Leads to Hospitalizations

The "Cinnamon Challenge," made popular by YouTube has resulted in a number of emergency room visits. The Challenge involves daring someone to swallow a spoonful of ground cinnamon in 60 seconds without water. But the spice can cause complications. Trying to gulp it down can cause choking, throat irritation, breathing trouble. Collapsed lung has also been reported. It is particularly dangerous for individuals with asthma or other respiratory issues. It is important to get information out to adolescents and teens about the dangers of this prank.

10. FDA Warns Pregnant Women to not use Certain Migraine Prevention Medicines

The U.S. Food and Drug Administration is alerting health care providers and patients that medications including and related to valproate sodium can cause decreased IQ scores in children whose mothers took the medication during pregnancy. Therefore, these drugs are being contraindicated for (should never be used by) pregnant women for the prevention of migraine headaches. Valproate products include valproate sodium (Depacon), divalproex sodium (Depakote, Depakote CP, and Depakote ER), valproic acid (Depakene and Stavzor), and their generics. Valproate products have several FDA-approved uses including: prevention of migraine headaches; treatment of epilepsy (seizures); and treatment of manic episodes associated with bipolar disorder (manic-depressive disorder).
 Medicines that contain valproate already have a boxed warning for fetal risk, including birth defects. The recently published Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study found further evidence of the IQ risk, leading to today’s strengthened warnings. “Valproate medications should never be used in pregnant women for the prevention of migraine headaches because we have even more data now that show the risks to the children outweigh any treatment benefits for this use,” said Russell Katz, M.D., director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research. For its other approved uses — bipolar disorder and seizures — valproate may have some value in pregnant women, but it should only be taken if other medications have not controlled the symptoms or are otherwise unacceptable. Women who can become pregnant should not use valproate unless it is essential to managing their medical condition.

Women who are pregnant, or who become pregnant while taking one of these medications, should talk to their health care professional immediately. Women should not stop taking their medication without talking to their health care professional because stopping treatment suddenly can cause serious and life-threatening medical problems for the woman or the developing fetus. Women of childbearing age taking valproate products should use effective birth control.  It is not known if there is a certain time period during pregnancy when valproate exposure can result in decreased IQ. The women in the NEAD study were exposed to antiepileptic drugs throughout their pregnancies.

 The FDA’s strengthened recommendations are based on the final results of the NEAD study, which showed that children exposed to valproate products in utero had decreased IQ at age 6 when compared to children who were exposed to other antiepileptic drugs. The difference in average IQ between the children who had been exposed to valproate and the children who had been exposed to other antiepileptic drugs varied between 8 and 11 points depending on the antiepileptic drug. In a June 2011 alert, the FDA released interim results from the NEAD study that showed reduced cognitive test scores in these valproate-exposed children at age 3, and at that time the drug labels were updated. 

11. Q Fever – MMWR Report

Q fever, a zoonotic disease caused by the bacterium Coxiella burnetii, can cause acute or chronic illness in humans. Transmission occurs primarily through inhalation of aerosols from contaminated soil or animal waste. No licensed vaccine is available in the United States.

Q fever, first described in 1937, is a worldwide zoonosis that has long been considered an underreported and underdiagnosed illness because symptoms frequently are nonspecific, making diagnosis challenging. The causative organism, Coxiella burnetii, is an intracellular bacterium that tends to infect mononuclear phagocytes but can infect other cell types as well. Infection in humans usually occurs by inhalation of bacteria from air that is contaminated by excreta of infected animals. Other modes of transmission to humans, including tick bites, ingestion of unpasteurized milk or dairy products, and human-to-human transmission, are rare. Laboratory diagnosis relies mainly on serology, and doxycycline is the most effective treatment for acute illness. No vaccine is available commercially in the United States. Q fever was designated a nationally notifiable disease in the United States in 1999. A report on the identification and treatment of Q fever had been reported in the Center for Disease Control and Prevention’s (CDC) MMWR.

12. Suicide Trends in the United States as Reported by the CDC

The May issue of MMWR reports changes in the suicide trends in the United States. In 2009, the number of deaths from suicide surpassed the number of deaths from motor vehicle crashes in the United States. Traditionally, suicide prevention efforts have been focused mostly on youths and older adults, but recent evidence suggests that there have been substantial increases in suicide rates among middle-aged adults in the United States. To investigate trends in suicide rates among adults aged 35–64 years over the last decade, CDC analyzed National Vital Statistics System (NVSS) mortality data from 1999–2010. Trends in suicide rates were examined by sex, age group, race/ethnicity, state and region of residence, and mechanism of suicide. The results of this analysis indicated that the annual, age-adjusted suicide rate among persons aged 35–64 years increased 28.4%, from 13.7 per 100,000 population in 1999 to 17.6 in 2010. Among racial/ethnic populations, the greatest increases were observed among American Indian/Alaska Natives (AI/ANs) (65.2%, from 11.2 to 18.5) and whites (40.4%, from 15.9 to 22.3). By mechanism, the greatest increase was observed for use of suffocation (81.3%, from 2.3 to 4.1), followed by poisoning (24.4%, from 3.0 to 3.8) and firearms (14.4%, from 7.2 to 8.3). The findings underscore the need for suicide preventive measures directed toward middle-aged populations.

13. Resources Available on Chronic Conditions

A new Medicare Chronic Conditions Dashboard is available from the Centers for Medicare & Medicaid Services (CMS). The dashboard is a tool to get current data on where multiple chronic conditions occur, which services they require, and how much Medicare spends helping beneficiaries with multiple chronic conditions. The Dashboard helps users find, analyze, and apply summarized data from CMS’ Chronic Conditions Data Warehouse. See resources below.

Also available is the Silver Book®, which is an almanac of thousands of facts, statistics, graphs, and data from hundreds of agencies, organizations, and experts. It is a searchable database, produced and updated by the Alliance for Aging Research that provides free and easy access to the latest information on the burden of chronic diseases that disproportionately impact older Americans, and the value of investing in medical research.

The Agency for Healthcare Research and Quality (AHRQ) has developed a Quality Tool, a collection of innovations in the care of those with chronic diseases. It includes self-reports from patients with diabetes to generate intervention options, a self-assessment for patients with mental illness that improves communication with providers, and a smartphone application that allows patients with Crohn's disease to track health information and share it with providers. There is a pre-visit questionnaire for asthma patients, a quality-of-life assessment for diabetes patients, and a tool to help patients track and monitor their blood pressure, cholesterol, blood glucose, diet, and physical activity. The innovation profiles, related to the use of technology and patient reporting to improve chronic disease care, are available on the Innovations Exchange Web site, which contains more than 775 searchable innovations and 1,525 Quality Tools.

See website addresses for the resources below.

CMS’s Medicare Chronic Conditions Chartbooks and other reports may be accessed at

Information on HHS’s Initiative on Multiple Chronic Conditions may be viewed at

Association News

14. NLN Announces Plan for New Accreditation Arm

At the end of February, the National League for Nursing leadership announced plans for a new accreditation department in response to the needs of the nursing education community and the nursing profession. On February 19, 2013, the NLN Board of Governors reaffirmed the intent to move forward with the development of this critical initiative.

"The NLN's mission to advance the health of the nation cannot be achieved without a commitment to the best nursing education possible," said NLN president Judith Halstead, PhD, RN, FAAN, ANEF. "The League's new accreditation department will help achieve that goal."

Added NLN CEO Beverly Malone, PhD, RN, FAAN, "This transformative initiative is another facet of the NLN's upcoming move to Washington, DC. It is essential that our new NLN Home for Transformative Excellence encompasses the full spectrum of nursing education and includes accreditation services that are permeated with the League's core values of caring, integrity, diversity, and excellence."

15. ANA Staffing Conference November 8-9, 2013 in Washington, DC

The American Nurses Association will hosting a conference to bring together recognized leaders and executives from a variety of organizations to share their most successful staffing ideas and proven strategies. Be there to leverage their latest thinking on innovative staffing models, leading practices, strategies and practical solutions. Come pick their minds. Share your thoughts. Then take all that you learn and put it into practice at your own hospital. Learn more

Federal and State Policy

16. Resources for the Affordable Care Act and the Marketplace

The Affordable Care Act increases access to health insurance coverage and health services for all Americans. Everyone involved in health care in the U.S. has a role to play, including clinical nurse specialists, nursing organizations, nurses and those they serve.

As full implementation of the law approaches, it is important to be aware of the new options for obtaining health insurance that will be available starting in 2014, and how these new options will work. To help ensure the nursing community has the information they need; HRSA has created a new webpage, which offers information and resources for HRSA stakeholders on Health Insurance Marketplaces, Essential Health Benefits, Essential Community Providers and more.

The federal government’s website is the place consumers will find information about how the coming Health Insurance Marketplace works, what the benefits will be, and what key deadlines and milestones are yet to come.

The CMS Health Insurance Marketplace is the place to find the latest resources to help people apply, enroll and get coverage in 2014.

17. NACNS Continues Position Against National Nurse Legislation 

The idea for creation of a position for a National Nurse was introduced in a May, 2005 New York Times op-ed authored by Teri Mills, MS, RN, ANP, a faculty member at Portland Community College. The op-ed generated the third highest number of emails in response to all stories published in the Times that day and was subsequently published in the Oregonian and read into the Congressional Record. In response, Representative Lois Capps introduced the National Nurse Act of 2006 (H.R.4903) which would amend the Public Health Service Act to establish an Office of the National Nurse. The 2006 Congress took no action as the bill was administratively referred to a committee. The bill has been reintroduced in the current Congress as the National Nurse Act of 2013 (H.R. 485) by Congresswoman Eddie Bernice Johnson (D-TX) and Congressman Peter King (R-NY) on February 4, 2013. This legislation is steadily garnering support and co-sponsorships in the 113th Congress.

After review of the proposed legislation in 2011 the NACNS Board took a position in opposition to the proposal for reasons stated below. The current NACNS Board has reaffirmed this position and agreed to support the Nursing Community's position to oppose this legislation. The Nursing Community is a coalition of national nursing organizations that collaborate on analysis and response to Federal issues. Several Nursing Community organizations have been contacted and urged to support the legislation by Teri Mills, who is leading the effort to create the Office of National Nurse. While there are some Nursing Community organizations that support this legislation, many member organizations, including the public health focused members, do not.

Taken at face value, the proposal is very well intentioned as it would heighten the visibility of nurses’ already significant contributions to promoting public health. The concerns underlying its genesis are valid as is the intent of shifting American health care toward a preventive model. What it does not address is how this proposal would affect the current structure and function of the Public Health Service and existing state and local health department initiatives and whether limited resources would be shifted away from the country’s already weakened public health infrastructure to support implementation should the bill become law.

Concerns being expressed with the nursing community include the intent of the legislation, including that it is ambiguous, creates un-mandated funding, and dilutes the title and role of the Chief Nursing Officer for the Public Health Service. Other expressed concerns include redundancy of effort with existing public health entities and systems, the possible dilution of already stressed resources, the use of volunteers to address complex public health issues, and the need for both the content & mode of health education to be population and evidence based. Key groups are calling for support of the existing Public Health Service including strengthening the role of the Chief Nurse Officer (CNO), acknowledging the key role public health nurses already play in health promotion and prevention, strengthening the public health nursing workforce and funding for public health education efforts that go beyond simple messages to incorporate population sensitive, evidence based interventions.

18. CMS Pays for Transitional Care Management (TCM) Services

Effective January 1, 2013, Medicare pays for two new Current Procedural Terminology (CPT) codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner, including CNSs, care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization.

  • Code 99495 TCM Services has the following required elements:
    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
    • Medical decision making of at least moderate complexity during the service period.
    • Face-to-face visit, within 14 calendar days of discharge.
  • Code 99496 TCM Services with the following required elements:
    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
    • Medical decision making of high complexity during the service period.
    • Face-to-face visit, within 7 calendar days of discharge.

The TCM services would be billable billed only once per patient and only at 30 days post-discharge or thereafter. For further information about TCM services see CMS’s FAQs. 

19. HRSA Offers New Grant Program to Translate Veteran’s Medical Skills into Nursing Careers

On April 29, 2013 at the White House Forum on Military Credentialing and Licensing, Health and Human Services (HHS) Secretary Kathleen Sebelius announced a new program to help military veterans with health care experience or training, such as medics, pursue nursing careers. The program is designed to help veterans get bachelor’s degrees in nursing by building on their unique skills and abilities.

Administered by the Health Resources and Services Administration (HRSA) at HHS, the Veterans’ Bachelor of Science in Nursing Program will fund up to nine cooperative agreements, of up to $350,000 a year. Funding of $3 million is expected to be awarded by the end of fiscal year 2013 (September 30).

“The Veterans’ Bachelor of Science in Nursing Program recognizes the skills, experience and sacrifices of our veterans, while helping to grow our nursing workforce,” Secretary Sebelius said. “It helps veterans formalize their skills to get jobs, while strengthening Americans’ access to care.”

Program funding will go to accredited schools of nursing to increase veterans’ enrollment in and completion of baccalaureate nursing programs, and to explore ways to award academic credit for prior military health care experience or training. The institutions will also train faculty to provide mentorships and other supportive services.

“Through this innovative program, veterans with valuable medical expertise can now help fill the ranks of nurses across the nation,” said HRSA Administrator Mary K. Wakefield, Ph.D., R.N. This new program is an important step forward in addressing needs identified in the February 2013 White House report, “The Fast Track to Civilian Employment: Streamlining Credentialing and Licensing for Service Members, Veterans, and Their Spouses.”

20. PCORI Building a National Data Infrastructure to Advance Patient Centered Comparative Effectiveness Research

The Patient-Centered Outcomes Research Institute (PCORI) issued recently two funding announcements for up to $68 million to support development of a National Patient-Centered Clinical Research Network.  The two funding announcements will support Clinical Data Research Networks (CDRNs) and Patient-Powered Research Networks (PPRNs).

PCORI will fund up to $56 million to support up to eight new or existing CDRNs that will develop the capacity to conduct randomized comparative effectiveness studies using data from clinical practice in large, defined populations. PCORI also will fund up to $12 million to support up to 18 new or existing PPRNs and their progression toward a reusable, scalable, and sustainable research network.

Two innovative features of this initiative are PCORI’s expectation that health systems, clinicians and patients will play key roles in governing the direction and uses of the networks that this funding will support, and that the interests of patients will be central to decision-making about the network’s structure, function, and uses. Patient-Powered Research Networks (PPRNs) will govern clinical research data and make decisions about what the right approach is for the research.

21. CMS Issues Proposed Inpatient Payment Regulation for FY 2014

On April 26 CMS issued the proposed rule, which would apply to acute care hospitals and Long Term Care Hospitals (LTCHs), for discharges occurring on or after October 1, 2013. Under the proposed rule, operating rates for inpatient stays in general acute care hospitals paid under the Inpatient Prospective Payment System (IPPS) that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program would be increased by 0.8 percent. Those that do not successfully participate in the IQR Program, which is fewer than 1% of all hospitals, would receive a 2.0 percentage point reduction in the proposed increase. Medicare payments to LTCHs in FY 2014 are projected to increase by 1.1 percent as compared to FY 2013 Medicare payments. 

The proposed rule proposes a framework for implementation of the new Hospital-Acquired Condition Reduction Program, which would begin in FY 2015. There will be a decrease in hospital payments for those that do not reduce hospital-acquired conditions. The proposed rule would update the measures and financial incentives in the Hospital Value-Based Purchasing (VBP) and Readmissions Reduction programs. It would also revise measures for the Inpatient Psychiatric Facility Quality Reporting, Long-Term Care Hospital (LTCH) Quality Reporting and PPS-Exempt Cancer Hospital Quality Reporting programs. 

It includes CMS’ proposals for implementation of an Affordable Care Act provision that changes the disproportionate share methodology for calculating payments to hospitals that serve a large proportion of low-income people and will result in a reduction in payment.

New Hospital-Acquired Condition Reduction Program
The Affordable Care Act directs CMS to implement a program aimed at improving patient safety in hospitals. Beginning in FY 2015, hospitals that rank among the lowest-performing 25 percent with regard to hospital-acquired conditions will be paid 99 percent of what they would otherwise be paid under the IPPS. The proposed rule proposes the criteria and methodology CMS would use to rank hospitals with a high rate of hospital-acquired conditions. Two years ago CMS announced it would add data about “potentially life-threatening” mistakes made in hospitals to a website people can search to check on safety performance. However on May 2nd CMS stated it is planning to strip the site of the eight hospital-acquired conditions, which include infections and mismatched blood transfusions, while it comes up with a different set. The agency said it’s taking the step because some of the eight are redundant and because an advisory panel created by the 2010 Affordable Care Act recommended regulators use other gauges.

Hospital Readmissions Reduction Program 
The maximum reduction in payments under the Hospital Readmissions Reduction program will increase from one to two percent as required by law. First time knee and hip implants and chronic obstructive pulmonary disorders will be added to the 30-day readmissions penalty program for FY 2015.

Quality Reporting Programs 
The proposed rule would update the measures in the Hospital Inpatient Quality Reporting (IQR) program, Inpatient Psychiatric Facility Quality Reporting program, Long-Term Care Hospital (LTCH) Quality Reporting program, and the PPS-Exempt Cancer Hospital Quality Reporting program. It proposes to align the quality measure-reporting requirement with Medicare Electronic Health Record (EHR) Incentive Program policies with certain measures in the Hospital IQR Program.
For more information on the payment and quality provisions in the proposed IPPS/LTCH PPS rule, go to:

CMS will accept comments on the proposed rule until June 25, 2013, and will respond to comments in a final rule to be issued by August 1, 2013.  The proposed rule is available at

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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.
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