this title, the hospital must demonstrate that prompt and diligent efforts were made to maintain required staffing levels. The Secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the exemption under this paragraph and shall establish necessary penalties for violations of this paragraph consistent with section 3406. (c) Development and reevaluation of staffing plan (1) Considerations in development of plan In developing the staffing plan, a hospital shall provide for direct care registered nurse-to-patient ratios above the minimum direct care registered nurse-to-patient ratios required under subsection (b) if appropriate based upon consideration of, at minimum, the following factors: (A) The number of patients on a particular unit on a shift-by-shift basis. (B) The acuity level and nursing care plan of patients on a particular unit on a shift-by-shift basis. (C) The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care. (D) Specialized experience required of direct care registered nurses on a particular unit. (E) Staffing levels and services provided by licensed vocational or practical nurses, licensed psychiatric technicians, certified nurse assistants, or other ancillary staff in meeting direct patient care needs not required by a direct care registered nurse. (F) The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift. (G) Obstacles to efficiency in the delivery of patient care presented by physical layout. (2) Documentation of staffing A hospital shall specify the system used to document actual staffing in each unit for each shift. (3) Annual reevaluation of plan (A) In general A hospital shall annually evaluate its staffing plan in each unit in relation to actual patient care requirements. (B) Update A hospital shall update its staffing plan to the extent appropriate based on such evaluation.