10-5588 State Home Report and Statement of Federal Aid Claimed

OMB Control No: 2900-0160
Estimated Burden: 30 minutes
Expiration Date: 10-31-2026

STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
SECTION 1. GENERAL INFORMATION
1. STATION NUMBER
(Required)

2. VISN
(Required)

3. MONTH/YEAR
(MM/YYYY)

5. TO:

4. REPORT QUARTER
(1st, 2nd, 3rd, 4th)

6. FROM:

7. PAY TO:
SECTION 2. CHANGE IN RESIDENCY FOR THE MONTH
LINE
NO

DOMICILIARY
(A)

ITEM

NURSING
HOME CARE
(B)

ADULT DAY
HEALTH CARE
(C)

NURSING
HOME CARE
(B)

ADULT DAY
HEALTH CARE
(C)

12.
13.
14.

LOSSES

GAINS

TOTAL VETERAN RESIDENTS PRESENT IN
8. FACILITY AT END OF PRIOR MONTH
9.
ADMISSIONS (Change of Status)
10.
ADMISSIONS (Other)
11.
RETURN FROM LEAVE OF ABSENCE
DISCHARGES (Change of Status)
DISCHARGES (Other)
DEATH

15.
LEAVE OF ABSENCE
16. TOTAL VETERAN RESIDENTS PRESENT AT END OF THE MONTH
SECTION 3. STATUS AT THE END OF THE MONTH
LINE
NO

DOMICILIARY
(A)

ITEM

TOTAL NON-ELIGIBLE VETERAN AND CIVILIAN RESIDENTS
17. REMAINING AT THE END OF THE MONTH
TOTAL VETS THAT ARE 70%-100% SC; OR HAS RATING OF TDIU;
18. OR ARE IN NEED OF NHC/ADHC FOR SC DISABLILTY
FEMALE VETERAN RESIDENTS REMAINING AT THE END OF THE
19. MONTH
SECTION 4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
LINE
NO

NURSING
HOME CARE
(B)

DOMICILIARY
(A)

ITEM

ADULT DAY
HEALTH CARE
(C)

TOTAL DAYS OF CARE FURNISHED TO NON ELIGIBLE VETERANS
20. AND CIVILIANS (including Medicare Days, if applicable)
SECTION 5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
FEDERAL AID CLAIMED
LINE UNDER
SEC 1741, TITLE
NO 38, U.S.C.,
AS AMENDED

DAYS
OF
CARE
(A)

AVERAGE
DAILY
CENSUS
(B)

DIRECT AND
INDIRECT COST
(C)

DAILY COST OF
CARE FOR THE
MONTH
(D)

PER DIEM
CLAIMED
(E)

TOTAL AMOUNT
CLAIMED
(F)

21. DOMICILIARY CARE
22. NURSING HOME CARE
23. ADULT DAY HEALTH CARE
24. TOTAL AMOUNT CLAIMED
SECTION 6. CLAIM FOR SC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
LINE
NO

DAYS
OF CARE
(A)

VETERAN CATEGORY

AVERAGE
DAILY CENSUS
(B)

PREVAILING RATE
(C)

TOTAL AMOUNT
CLAIMED
(D)

HAS SINGULAR OR COMBINED RATING OF 70%
-100% SC; OR HAS RATING OF TDIU; OR ARE IN
25. NEED OF NHC FOR SC DISABILITY
HAS SINGULAR OR COMBINED RATING OF 70%
-100% SC; OR HAS RATING OF TDIU; OR ARE IN
26. NEED OF ADHC FOR SC DISABILITY
27. TOTAL AMOUNT CLAIMED
VA FORM
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The daily cost of care is the direct cost plus the indirect cost for the month, divided by the total days of care of all enrollees or residents present in the
facility during the month regardless of the payer source. Compute the cost in accordance with the Federal Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards specified in 2 CFR 200.400 - 200.475.
SECTION 7. RECOGNIZED CAPACITY APPROVED BY THE VA
28. DOM

29. NHC

30. ADHC

SECTION 8. STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CONTINUED
I certify that this report is correct based on the documentation provided to the VA and that the recognized beds approved by the VA is correct and all residents
included in the report were physically present during the period for which Federal aid is claimed, except for authorized absences for which the VA paid per diem, and
the facility management has complied with all provisions of Title VI, Public Law 88-352, entitled Civil Rights Act of 1964.
31. SIGNATURE OF SVH
ADMINISTRATOR

Printed Name
& Title:

Date
(MM/DD/
YYYY):

Signature:

(NOTE: If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility on a fulltime, on site basis. This State employee must also certify that the information in the report is correct by signing and dating the report. If the facility is under contract,
the signature of the SVH Administrator is not required.)
32. SIGNATURE OF
STATE EMPLOYEE
WHEN APPLICABLE
33. REMARKS:

Printed Name
& Title:

Date
(MM/DD/
YYYY):

Signature:

SECTION 9. RECEIVING REPORT (FOR VA USE ONLY)
Services authorized under provisions of section 1741, 1742, 1743, and 1745, Title 38, U.S.C., have been rendered in the quantity claimed and payment is
recommended except as follows.
34. TOTAL AMOUNT APPROVED BY VA FOR PAYMENT (add blocks 24(F) and 27(D)):
Printed Name
35. SIGNATURE OF VA
& Title:
APPROVING OFFICIAL

Date
(MM/DD/
YYYY):

Signature:
Obligation Number
(A)
36. ACCOUNTING
CERTIFICATION AUDIT BLOCK

* Amount Due
(B)

ADHC
DOM
NHC BASIC
NHC PREVAILING RATE
ADHC PREVAILING RATE
TOTAL AMOUNT DUE

37. SIGNATURE OF
AUDITOR

Printed Name
& Title:
Signature:
PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT

Date
(MM/DD/
YYYY):

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the
time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the
form. Although completion of this form is voluntary, VA will be unable to provide reimbursement for services rendered without a completed form. Failure to complete the form will have
no effect on any other benefits to which you may be entitled. This information is collected under the authority of Title 38 CFR Parts 51. The information requested on this form is solicited
under the authority of Title 38, U.S.C., Sections 1741, 1742, 1743, and 1745. It is being collected to enable us to determine your eligibility for medical benefits in the State Home Program
and will be used for that purpose. The income and eligibility you supply may be verified through a computer matching program at any time and information may be disclosed outside the
VA as permitted by law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in the
Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary; however, the information is required in order for us to determine your eligibility for the medical
benefit for which you have applied. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled. Disclosure of Social Security
number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of
veterans' benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title 38, U.S.C.,
and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.

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INSTRUCTIONS FOR STATE HOME REPORT
AND STATEMENT OF FEDERAL AID CLAIMED
The VA Form 10-5588 consists of several parts. This report is a monthly statement of gains and losses, days of care, average daily census,
allowable cost, total per diem cost, per diem claimed and total amount claimed for nursing home, domiciliary, and adult day health care. Monthly
payments will be made to the State Home only after the State submits a completed VA Form 10-5588 and required supporting documentation.
SECTION 1. GENERAL INSTRUCTIONS
1. Station Number: Enter the station number where the VA Medical Center of jurisdiction is located.
2. VISN: Enter the Veteran Integrated Service Network (VISN) number where the VA Medical Center of jurisdiction is located.
3. Month/Year: Enter the calendar month and year covered by the report. (for example: 05/2020).
4. Report Quarter: Enter the number for the fiscal quarter report is claimed (for example: enter 1 for October to December; enter 2 for January
to March; enter 3 for April to June; enter 4 for July to September).
5. To: Enter Name, City, and State of the VA Medical Center of Jurisdiction (not the Health Care System).
6. From: Enter Level of Care, State Home Name, City, and State. For example: Level of Care for Nursing Home Care, use abbreviation “NHC."
7. Pay To: Enter the Name, City, and State where the payment is to be sent.
SECTION 2. CHANGE IN RESIDENCY FOR THE MONTH
8. Enter the Total Veteran Residents Present in the Facility at the end of the prior month.
Column A. Domiciliary: Enter the number of eligible domiciliary Veteran residents present and remaining on the rolls as of midnight on the
last day of the prior month. When a Veteran overstays an approved absence of 96 hours, no portion of the leave may be
claimed for VA payment. (Note: Present means any eligible Veteran that is physically in the SVH facility at midnight or on an
approved paid VA leave of absence.)
Column B. Nursing Home: Enter the number of eligible nursing home Veteran residents present and remaining on the rolls as of midnight
on the last day of the prior month. (Note: Present means any eligible Veteran that is physically in the SVH facility at midnight or
on an VA approved absence. See instructions for 15 regarding absences.)
Column C. Adult Day Health Care: Enter the number of eligible adult day health care occupants on the rolls for receiving adult day health
care services as of midnight the last day of the prior month. Per diem will be paid only for a day that the Veteran is under the care
of the facility at least six hours. For purposes of this paragraph a day means six hours or more in one calendar day or any two
periods of at least 3 hours each (but each less than six hours) in any two calendar days in a calendar month.
Entries on this line will be the same as those shown on line 16 for the prior month.
9. Admissions (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer from one level of care to
another within the State Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health
care. The entries on lines 9 and 12 for the month will be the same.
10. Admission (Other). Enter the number of eligible Veterans admitted to the State Home nursing home, domiciliary during the report month
and/or enrolled in the adult day health care.
11. Return From Leave of Absence. Enter eligible Veterans returning from a non-VA paid overnight absence in a VA hospital or other hospital
and for Veterans returning from an overnight absence for non-hospital leave and for domiciliary residents returning from absences of
greater than 96 hours. Applicable when a Veteran is absent from the home on a non-VA paid absence and/or does not return to the home.
DO NOT report leave of absence for which the VA paid per diem. (Not applicable to Adult Day Health Care.)
12. Discharges (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer to another level of care within
the State Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health care. The entries
on lines 9 and 12 for the month will be the same.
13. Discharges (Other). Enter the number of eligible Veterans who were discharged from the State Home or dropped from the rolls, except for
deaths. Do not count discharges for hospitalizations. Applicable when a Veteran on a VA-paid bed hold for overnight hospital stays or nonhospital leave, does not return to the nursing home. The effective date of discharge will be the date the home is notified the Veteran will
not return.
14. Deaths. Enter the number of eligible Veterans who died while enrolled in the State Home Per Diem program during the report month.
15. Leave of Absence. For Nursing Home and Domiciliary Care beds, enter the number of eligible Veterans who have a non-VA per diem
payment overnight stay in a hospital or who are absent for reasons other than hospital care. DO NOT report an authorized absence for
which the VA paid per diem. For Domiciliary absences that are not interrupted by at least 24 hours of continuous residence in the State
home are considered one continuous absence. See instructions for section 5 (Claim for Basic Per Diem Payments for Eligible Veterans)
for paid days of care. (Not applicable to Adult Day Health Care.)
16. Total Veteran Residents Present at End of Month. Enter the number of eligible Veteran residents present as of midnight on the last day of
the report month. Additionally, count eligible nursing home care Veterans who are on VA paid leave of absence for hospitalization and for
non-hospital absences and count domiciliary Veterans who are absent from the facility on a VA paid pass of 96 hours or less. This entry will
be equal to the sum of lines 8, 9, 10 and 11 minus lines 12, 13, 14 and 15 in each column.

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INSTRUCTIONS-CONTINUED FOR STATE HOME REPORT
AND STATEMENT OF FEDERAL AID CLAIMED
SECTION 3. STATUS AS OF THE END OF THE MONTH
17. Non-Eligible Veterans And Civilians Remaining End Of Month. Enter the number of nursing home, domiciliary residents, and adult day
health care enrollees not eligible for payment from VA who was present on the last day of the report month. DO NOT REPORT eligible
Veteran residents in this cell.
18. Total Veterans that are 70%-100% SC; or has rating of TDIU; or are in need of NHC/ADHC for SC disability. Enter the total number of
eligible Veterans who are 70% to 100% Service Connected (SC); or has rating of Total Disability rating based upon Individual
Unemployability (TDIU); or are in need of NHC for SC disability in column 18B and in column 18C for ADHC SC Veterans.
19. Eligible Female Veteran Residents Remaining At The End Of The Month. Enter the number of eligible female Veteran residents present
and remaining in the facility at the end the month.
SECTION 4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
20. Total Days of Care Furnished to Non-Eligible Veterans and Civilians (including Medicare Days, if applicable). Enter all days of care
provided to non-eligible Veterans and civilians for domiciliary care, nursing home care and adult day health care in blocks 20A, 20B, and
20C respectively. This includes Medicare Days paid for Veteran's stay in the Facility.
SECTION 5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
Lines 21, 22, 23 and 24:
Column A. Days of Care: A day of care for Domiciliary and Nursing Home is counted when an eligible Veteran has an overnight stay in the
facility. Enter total domiciliary days of care on line 21, nursing home care on line 22 and adult day health care on line 23. For
domiciliary: A day of care is counted when an eligible Veteran is present or on authorized absent from the facility up to 96
hours for purposes other than receiving hospital care at VA expense. If a Veteran is absent more than 96 hours, no portion of
the absence is counted as a day of care. For nursing home: A day of care is counted when the VA pays per diem for an
eligible Veteran resident on bed hold for 10 consecutive overnight hospital stays or non-hospital leave. For adult day health
care, a day of care is credited when the Veteran is under the care of the facility to include transportation for at least six hours in
one calendar day or any two periods of at least 3 hours each (but each less than six hours) in any two calendar days in a
calendar month. The day of admission is counted as a day of care. For all three levels of care, an admission and loss on the
same day is counted as a day of care; day of discharge (removed from the rolls) is not counted as a day of care.
Column B. Average Daily Census: Enter the average daily census computed by dividing the days of care in column A by the number of
calendar days in the month, carried to one decimal place for each level of care.
Column C. Direct and Indirect Cost (Allowable Cost): Enter the total of direct and indirect cost (allowable cost) for providing care to all
residents in the home for the month regardless of the payer source.
Column D. Daily Cost of Care for the Month: The daily cost of care for the month is column C (direct and indirect cost), divided by ALL
residents' days of care. Compute cost in accordance with cost principles set forth in the Office of Management and Budget
(OMB), "Uniform Administrative Requirements, Cost Principles, and Audit Requirement in Federal Awards" (2 CFR Part
200.400 to 475 for cost principles). To calculate the daily cost of care, divide the direct and indirect cost for the month in
column C by the sum of days of care for each level of care for all residents (line 20 non-eligible Veterans and Civilians, and
columns A of 21 through 26). For Dom - add 20A and 21A; for NHC - add 20B, 22A, and 25A; and for ADHC - add 20C, 23A,
and 26A to obtain the figure to divide the direct and indirect cost for the calculation of the daily cost of care for the month.
Column E. Per Diem Claimed: Enter the current fiscal year per diem rate or one-half the daily cost of care shown in column D carried to
two decimal places, whichever is the lesser, for each level of care. VA will pay monthly one-half of the cost of each eligible
Veteran's care (domiciliary, nursing home, or adult day health care) for each day the Veteran is in a facility recognized as a
State Veteran Home, not to exceed the approved per diem rate for that level of care.
Column F. Total Amount Claimed: Enter the product of columns A and E for each level of care on lines 21, 22, and 23. On line 24, sum
the totals for each level of care.

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INSTRUCTIONS-CONTINUED FOR STATE HOME REPORT
AND STATEMENT OF FEDERAL AID CLAIMED
SECTION 6. CLAIM FOR SC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
Items 25 and 26:
Column A. Enter the days of care for eligible Veteran residents who have a singular or combined SC disability rating of 70% to 100%; or
has VA rating of TDIU; or are in need of NHC for SC disability. Days of care for NHC (line 25) follows the same rules as noted
in 22A and on line 26, follow the rules for ADHC from line 23A
Column B. Average Daily Census: Enter the average daily census computed by dividing the days of care in column A for each level of
care by the number of calendar days in the month, carried to one decimal place.
Column C. Prevailing Rate: Enter the VA prevailing rate for Fiscal Year as published by SHPDP Office.
Column D. Total Amount Claimed: Using the VA prevailing rate methodology, multiply the days of care from line 25 and 26 in column A by
the prevailing rate in column C.
Line 27(D) total amount claimed: sum lines 25 and 26.
SECTION 7. RECOGNIZED CAPACITY APPROVED BY THE VA
At the end of each month, State home management will enter the recognized beds approved by the VA during the latest recognition survey
for domiciliary, nursing home and adult day health care in blocks 28, 29 and 30 respectively.
SECTION 8. STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CERTIFICATION
31. Signature of SVH Administrator: Print name and title of SVH Administrator, sign and date.
(Note: If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the
operations of the facility on a full-time, on site basis. This State employee must also certify that the information in the report is correct
by signing and dating the report. If the facility is under contract, the signature of the SVH Administrator is not required.)
32. Signature of State Employee When Applicable: If the facility is managed by a contractor, a State Employee must print name and title, sign
and date. If the facility is under contract, the signature of the SVH Administrator is not required.
33. Remarks: Enter any information needed to clarify and support invoice data.
SECTION 9. RECEIVING REPORT
34. Total Amount Approved by VA for Payment: Sum the totals of blocks 24 and 27.
35. Signature of VA Approving Official - Print name and title of VA Approving Official, then sign and date.
36. Accounting Certification - Audit Block: In column (A) enter obligation numbers for each level of payment claimed and in column (B) enter
amount due for each level of payment claimed. Total Amount Due: Sum the amount due in column (B) and enter in the Total Amount Due.
This sum should equal the amount entered on line 34.
37. Signature of Auditor: Print name and title of auditor, sign and date.
(Note: If the receiving report is not completed in its entirety, it could result in an improper payment.)

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