2900-0160 justification

Supporting Statement for Per Diem for Nursing Home Care of Veterans in State Homes (38 CFR Part 51) and Per Diem for Adult Day Care of Veterans in State Homes (38 CFR Part 52)

VA Forms 10-5588, 10-3567, 10-10SH, 10-0143, 10-0143a, 10-0144, 10-0144a and 10-0460

(OMB 2900-0160)

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Title 38, CFR Part 51, provides for the payment of per diem to State homes that provide nursing home care to eligible veterans. Title 38, CFR Part 52, provides for the payment of per diem to State homes that provide adult day health care to eligible veterans. The intended effect of these provisions was to ensure that veterans receive high quality care in State Homes. To ensure that high quality care is furnished veterans, VA requires those facilities providing nursing home care and adult day health care programs to veterans to supply various kinds of information. The information required includes an application for recognition based on certification; appeal information, application and justification for payment; records and reports which facility management must maintain regarding activities of residents or participants; information relating to whether the facility meets standards concerning residents’ rights and responsibilities prior to admission or enrollment, during admission or enrollment, and upon discharge; the records and reports which facilities management and health care professionals must maintain regarding residents or participants and employees; various types of documents pertaining to the management of the facility; food menu planning; pharmaceutical records; and life safety documentation. VA Form 10-10EZ (OMB approval 2900-0091) is used in conjunction with the VA Form 10-10SH.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

This information is necessary to ensure that VA per diem payments are limited to facilities providing high quality care. Without access to such information, VA would not be able to determine whether high quality care is being provided to eligible veterans.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

To comply with the Government Paperwork Elimination Act, all forms in this group now appear on the One-VA Internet website in a fill and print mode which enables the user to electronically retrieve the latest version of a form, complete the form electronically, and save the filled form in *.pdf format. Once VA has developed an effective policy for electronic signature use and pending the availability of funds, we can begin the re-engineering process to allow electronic submission. The collection of information has been automated for internal fiscal and quality survey portions of data collection.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

There is no duplication associated with this collection of information.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The impact on small businesses and other small entitles is minimized by using “standard data” or data routinely maintained by health care facilities. The collection of information has been thoroughly analyzed to ensure that all requested data is essential.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

If VA does not require this information, the Department would be unable to assess the quality standards that are being utilized and evaluated. Therefore the assessment of quality care indicators is critical to the VA to document whether high quality care is being provided to eligible veterans.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register on August 1, 2012 (Vol. 77, Number 148, Page 45719-45720). There were no comments received in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

VA Form 10-10SH collects individually identifiable information covered by the Privacy Act. Assurances of confidentiality for this form are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974. These forms are part of the system of records identified as 24VA136 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/2003.html. The other forms in this group contain information that is not protected by the Privacy Act. The forms are filed at VA Central Office for initial recognitions of the new State Homes and fiscal forms are maintained at the VA Medical Center (VAMC) of jurisdiction for the State Home Per Diem Program.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

VA Form 10-10SH contains questions that may be considered sensitive. This information is required under regulation as a minimum to determine the level of care. Disclosure is voluntary; however, the information is required to determine the eligibility for the medical benefit for which applied. The law requires that Per Diem Payments to states be made only for services provided to veterans in need of such care. The information is collected and maintained by the VA Medical Center (VAMC) of jurisdiction in accordance with the policies of patient records management. All medical records of patients are protected under the Privacy Act of 1974, VA and HIPPA regulations, and medical center policies.

12. Estimate of the hour burden of the collection of information:

a. Using 2006 data, we estimate 15,550 total burden hours annually.

(1) VA Form 10-3567, State Home Inspection - Staffing Profile = 90 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
180	1	180	30	90 hours

(2) VA Form 10-5588, State Home Report and Statement of Federal Aid Claimed = 1,080 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
180	Monthly	2,160	30	1,080

(3) VA Form 10-1OSH, State Home Program Application for Veteran Care - Medical

Certificate = 10,566 hours annually.

Program	Respondents	Frequency	Responses	Min. Each	Burden Hours
State Nursing Home	9,048	1	9,048	30	4,524
State Domiciliary	2,355	1	2,355	30	1,178
State Hospital	9,726	1	9,726	30	4,863
Adult Day Health Care (ADHC)	3	1	3	30	2
Totals:	21,132	1	21,132		10,566

(4) VA Form 10-0143, Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements For Grantees Other Than Individuals = 15 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
180	1	180	5	15

(5) VA Form 10-0143a, Statement of Assurance of Compliance with Section 504 of The Rehabilitation Act of 1973 = 15 hours annually

Respondents	Frequency	Responses s	Min. Each	Burden Hours
180	1	180	5	15

(6) VA Form 10-0144, Certification Regarding Lobbying = 15 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
180	1	180	5	15

(7) VA Form 10-0144a, Statement of Assurance of Compliance with Equal Opportunity Laws = 15 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
180	1	180	5	15

(8) VA Form 10-0460, Request for Prescription Drugs from an Eligible Veteran in a State Home = 15 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
180	1	180	5	15

(9) Section 51.20, Application for Recognition (Letter to Under Secretary for Health) = 2 hours annually.

Updated Program	Respondents	Frequency	Responses	Min. Each	Burden Hours
State Nursing Home	10	1	10	6	1
State Domiciliary	5	1	5	6	0.5
State Hospital	0
ADHC	5	1	5	6	0.5
Totals:	20		20		2

(10) Section 51.30, Recognition & Certification and Section 52.30, Recognition & Certification = 120 hours annually.

Type	Type of Facility	Respondents	Frequency	Responses	Hours Each	Burden Hours
Major Deficiency	State Nursing Homes	10	1	10	3	30
	State Domiciliary	5	1	5	3	15
	State Hospitals	0	1	0	3	0
	ADHC	0	1	0	3	0
Minor Deficiency	State Nursing Homes	50	1	50	1	50
	State Domiciliary	25	1	25	1	25
	State Hospitals	0	1	0	1	0
	ADHC	0	1	0	1	0
Totals		90		90		120

(11) Section 51.70, Residents Rights, Section 51.90, Resident Behavior & Family Practices, Section 52.70, Participant Rights & Section 52.71, Participant & Family Caregivers Responsibilities = 1,813 hours annually.

Program	Respondents	Frequency	Responses	Min. Each	Burden Hours
State Nursing Home	17,736	1	17,736	5	1,478
State Domiciliary	3,845	1	3,845	5	320
State Hospital	168	1	168	5	14
ADHC	2	1	2	5	0
Totals	21,751		21,751		1,813

(12) Section 51.80, Admission, Transfer and Discharge Rights and Section 52 80, Enrollment, Transfer and Discharge Rights --171 respondents totaling 1 hour annually (Enrollment, admission and discharge records are customary in nursing homes, domiciliary, hospitals, and adult day health care facilities.)

(13) Section 51.100, Quality of Life and Section 52.100, Quality of Life = 360 hours annually.

Program	Respondents	Frequency	Responses	Min. Each	Burden Hours
State Nursing Home	118	4	472	30	236
State Domiciliary	55	4	220	30	110
State Hospital	5	4	20	30	10
ADHC	2	4	8	30	4
Totals	180		720		360

(14) Section 51.110, Resident Assessment and Section 52.110, Participant Assessment (Clinical record keeping) --171 respondents totaling 1 hour annually (Clinical recordkeeping is a customary practice.)

(15) Section 51.120, Quality of Care and Section 52.120, Quality of Care = 0 hours annually (This is not counted in the burden estimate, as we project only three respondents.)

(16) Section 51.180, Pharmacy Services and Section 52.180, Administration of drugs –180 respondents totaling 1 hour annually (Recordkeeping for control drugs and report irregularities are a customary practice.)

(17) Section 51.190, Infection Control and Section 52.190, Infection Control --180 respondents totaling 1 hour annually (Incident reports are a customary practice in nursing homes and adult day health care facilities.)

(18) Section 51.210, Administration and Section 52.210, Administration = 1,440 hours annually (Documentation of items listed below are customary practices in State Nursing Home Programs. Recognition items are a “one time” submission; all others are surveyed and reported annually.

(a) Section 51.210(b)(1) — Disclosure of State Agency and Individual Responsible for Oversight of Facility and Section 52.2 10 (b)(1) — Disclosure of State Agency and Individual Responsible for Oversight of Facility

(b) State Law (recognition)

(c) Site Plan (recognition)

(d) Legal Title (recognition)

(e) Organization Chart and Operational Plan (recognition)

(f) Number of Staff

(g) Number of Patients

(h) Section 51,210(c)(7) — State Fire Marshall Report

(i) Credentialing and Privileging

(j) Nurse Aide Registry Verification

(k) Nurse Aide/Program Assistant Inservice

(l) CLIA # and Annual Report

(m) Quality Assessment and Assurance

(n) Disaster and Emergency Preparedness

Program	Respondents	Frequency	Responses	Hours Each	Burden Hours
State Nursing Home	118	1	118	8	944
State Domiciliary	55	1	55	8	440
State Hospital	5	1	5	8	40
Adult Day Health Care (ADHC)	2	1	2	8	16
Totals	180		180		1,440

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

See attachment to OMB Form 83-I.

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Estimated cost to respondents: $684,200 (15,550 burden hours x $44 per hour). We do not require any additional recordkeeping.

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There is no capital, start-up, operation or maintenance costs.

b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

c. There are no anticipated capital start-up cost components or requests to provide information.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

The estimated total cost to the Federal Government is $1,054,682.

a. Review by VA medical center officials -$705,984

[11,031 hours x $64.00 (average GS-14 step 10 hourly salary)]

b. Clerical support - $207,262

[777 hours x $38.00 (average GS-1l step 10 hourly salary) = $29,526]

[6,836 hours x $26.00 (average GS-7 step 10 hourly salary) = $177,736]

c. VA Headquarters oversight review - $137,936

[1,864 hours x $74.00 (clinical grades = to average GS-15 step 10 hourly salary) = $137,936]

d. Printing costs - $4,000

15. Explain the reason for any changes reported in Items 13 or 14 above.

There is no change in burden.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish the results of this information collection.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA seeks to minimize the cost to itself of collecting, processing and using the information by not displaying the expiration date. We seek an exemption that waives the displaying of the expiration date on this VA Form. If we are required to display an expiration date, it would result in unnecessary waste of existing stock of the forms stocked at the State Homes. If we are required to display an expiration date, it would result in unnecessary waste of existing stock of the forms. Inclusion of the expiration date would place an unnecessary burden on the respondent (since they would find it necessary to obtain a newer version, while VA would have accepted the old one).

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

No statistical methods are used in this data collection.

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