10-0388-3 Space Program Analysis - Nursing Home & Domiciliary

OMB Number 2900-0661
Estimated Burden: 6 hours

STATE HOME CONSTRUCTION GRANT PROGRAM
SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY
PROJECT LOCA TION
FAI#

PROJECT NA M E:

1. SUPPORT FACILITIES

NUMBER OF BEDS IN PROJECT

PROPOSED BY
STATE

VA CRITERIA

ADMINISTRATOR' S OFFICE

200

ASST. ADMINISTRATOR

150

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT

150

NURSES' OFFICE AND DICTATION AREA

120

GENERAL ADMINISTRATION (each

120

office/person)

TOTAL VA
ALLOWED

120
120
120
120
120
120
120
120
120

MAY INCLUDE: MEDICAL RECORDS
SOCIAL SERVICES

120

RECEPTION / INFORMATION

120
80@

CLERICAL STAFF (Each) #
COM PUTER A REA

40

CONFERENCE ROOM / CONSULTATION AREA / IN-SERV ICE TRAINING

500
3/BED
(150 min. 600)

LOBBY/WAITING AREA

25/FIXTURE

PUBLIC TOILETS (MALE, FEMALE)
PHARMA CY
DIETETIC SERVICE

AR

AS REQUIRED

AR

AR

AS REQUIRED

AR

20/BED

DINING AREA

2/BED

CANTEEN, RETAIL SALES

1/BED
(450 max./facility)

VENDING MACHINE

25/FIXTURE

RESIDENTS TOILETS
CHILD DAYCARE
MEDICAL SUPPORT (Each)

AR

AS REQUIRED

AR

140
140
140

STAFF OFFICES (Each)

120

EXAM / TREATMENT (Each)

120

FAMILY COUNSELING (Each)

120

VA FORM
MAR 2005

10-0388-3

Page 1 of 4

PROPOSED BY
STATE

1. SUPPORT FACILITIES (Continued)

VA CRITERIA

BARBER AND / OR BEAUTY

140

MAIL ROOM

120

JANITORS CLOSET

TOTAL VA
ALLOWED

40
15/BED

MULTIPURPOSE ROOM

6/EMPLOYMENT

EMPLOYEE LOCKERS # EMPL.
LOUNGE

120

TOILETS

25/FIXTURE

CHAPEL

450

PHYSICAL THERAPY

5/BED

OFFICE, IF REQUIRED

120

OCCUPATIONAL THERAPY

5/BED

OFFICE, IF REQUIRED

120

LIBRARY

1.5/BED

BUILDING MAINTENANCE STORAGE

2.5/BED

RESIDENT STORAGE

6/BED

GENERAL WAREHOUSE STORAGE (medical,

dietary)

6/BED

GENERAL LAUNDRY

AR

AS REQUIRED

AR

SUPPORT FACILITIES SUB-TOTAL; (No "As Required" Areas)
AS REQUIRED AREAS:

AR

AS REQUIRED

AR

2. BED UNITS
ONE #

ROOMS X

@

=

150

TWO #

ROOMS X

@

=

245

LARGE 2 #

ROOMS X

@

= (2 Unit Max)

305

THREE #

ROOMS X

@

=

370

FOUR #

ROOMS X

@

=

460

LOUNGE AREAS:

RESIDENT LOUNGE W /STORA GE

RESIDENT QUIET ROOM

8/BED
3/BED

CLEAN UTILITY

120

SOILED UTILITY

105

LINEN STORAGE

150

GENERAL STORA GE

100

NURSES STATION, WARD SECRETARY

260

MEDICATION ROOM

75

EXAMINATION / TREATMENT ROOM

140

WAITING AREA

50

UNIT SUPPLY AND EQUIPMENT

50

STAFF TOILET

25 /FIXTURE

STRETCHER / WHEELCHAIR STORAGE

100

KITCHENETTE

120

VA FORM
MAR 2005

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1. SUPPORT FACILITIES

(Continued)

PROPOSED BY
STATE

JANITOR CLOSET

VA CRITERIA

TOTAL VA
ALLOWED

40

RESIDENT LAUNDRY

125

TRASH COLLECTION

60

OTHER (Justify)
UNIT SUB-TOTAL:
TIMES NO. OF UNITS:

X

X

SUB TOTAL-ALL BED UNITS:
3. BATHING AND TOILET FACILITIES
A. PRIVATE OR SHARED FACILITIES

WHEELCHAIR FACILITIES #

ROOMS X

@=

25/FIXTURE

(50% OF TOTAL, MINIMUM COMPLIANCE WITH UFAS)
STANDARD FACILITIES #

ROOMS X

25/FIXTURE
@=

15/FIXTURE
25/FIXTURE

B. FULL BATHROOM
# ROOMS X @

=

75
25/FIXTURE

C. CONGREGATE BATHING FACILITIES
FIRST TUB/SHOWER

80

EACH ADDITIONAL FIXTURE#

25
UNIT SUB-TOTAL:
TIMES NO.OF UNITS:

X

X

SUB-TOTAL-ALL UNIT TOILETS
NOTE 1: If Bed Units vary in bed numbers, program, or design, reproduce Bed Unit forms, as required (pages 2 & 3), and fill out for each
different unit type.
NOTE 2: Mechanical, electrical and other engineering/utility areas, in addition to engineering workshops and circulation space, are not
included in the Space Analysis or the Percentage of Participation calculations.
NOTE 3: All areas not shown on this form must be justified, on a programmatic medical care or state imposed regulatory basis, in order for VA
to participate in the funding of that space.
TOTALS

PROPOSED BY
STATE

VA CRITERIA

TOTAL VA
ALLOWED

COMPREHENSIVE SUB-TOTALS
SUPPORT FACILITIES - CRITERIA
SUPPORT FACILITIES - AS REQUIRED

AR

AR

AR

AR

BED UNITS
BATHING AND TOILET FACILITIES
GRAND TOTALS - CRITERIA AREAS:
GRAND TOTALS - AS REQUIRED AREAS:

If prepared by State: I certify that this accurately reflects the proposed Space Program Analysis for this project
(Signature)
VA FORM
MAR 2005

10-0388-3

(Date)
Page 3 of 4

TOTAL VA
ALLOWED

PROPOSED BY
STATE

COMPUTATIONS
ANALYSIS
CRITERIA AREAS
10% DEVIATION

+

AS REQUIRED AREAS

+

TOTAL STATE PROPOSED:
FORMULA FOR % OF VA PARTICIPATION:

AR

TOTAL VA ALLOWED:
VA ALLOWED:

+

AR

x.65
%

=
STATE PROPOSED:

%

OFFICIAL PERCENTAGE OF VA STATE PROPOSED PARTICIPATION =
CERTIFIED

DATE

State Home Grant Program, Office of Facilities Management (181A)
811 Vermont Avenue, NW, Washington, D.C. 20420

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VA FORM
MAR 2005

10-0388-3

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