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pdfOMB Approved No. 2900-0160
Estimated Burden Avg. 30 min.
STATE HOME INSPECTION - STAFFING PROFILE
INSTRUCTIONS :
1. The Staffing Profile consists of 5 Parts.
2. Complete Part 1, noting numbers of operating beds, beds authorized for VA per diem payments, patient
census (veterans and non-veterans), staff positions authorized, and staff available at the time of the
inspection for each level of care provided by the home, i.e., nursing home, domiciliary, and/or hospital.
3. Complete Part II, by enumerating total staff positions for the facility and then breakdown the assigned
FTEE for each level of care. For example, if the facility has (12) R.N’s, this may breakdown to 5 for the
hospital, 6 for the nursing home, and 1 for the domiciliary. Note: If staff positions are by agreement,
contract, or on consultation basis, specify as follows:
Number of staff, qualifications, number hours/week,
AG = Agreement, CT = Contract, CS = Consultant.
Example:
Social work: 1 MSW, 4 hours/week, CS
Dietitian: 1 RD, 8 hours/week, CS
4. Complete Parts III through V, nursing staffing patterns, for each level of care. Determine the average
number and type of nursing staff on each shift for a 4-week period selected at random to determine the
average weekly nursing staffing pattern. A separate form should be used for each separate building and
include each level of care in that building.
5. In Parts III, IV, and V, complete the average nursing care hours per patient, per day as follows:
Nursing Care hours/patient/day =
Total staff in average week X 8 hrs
Patient census (veteran + non-veteran) X 7 days
Only subtract meal times, not break times. In the case of 10-hour tours, count 9.5 hours. In the case of
12-hour tours, use the State or Union guidance for whether one or two 30-minute meals are provided.
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 certify your home 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 and 52.
VA FORM
JUL 2006
10-3567
EXISTING STOCK OF VA FORM 10-3567, MAY 1998, WILL BE USED.
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STATE HOME INSPECTION
NAME OF HOME
DATE OF INSPECTION
PART I
OPERATING BEDS
TOTAL FACILITY
HOSPITAL
NHC
DOM
TOTAL FACILITY
HOSPITAL
NHC
DOM
AUTHORIZED APPROVALS
PATIENT CENSUS
POSITIONS AUTHORIZED
STAFF AVAILABLE
PART II - STAFF
PHYSICIANS:
PHYSICIANS ASSISTANTS
DENTISTS
SOCIAL WORK: MSW
BSW
SOCIAL WORK ASSISTANT
PHARMACY: REG. PHARMACIST
DIETETICS: REG. DIETITIAN
FOOD SUPERVISOR
DIETARY ASSISTANTS
NURSING:
NURSING ADM./SUP.
DIRECT CARE: CERT. N.P./C.N.S.
R.N.
L.P.N./L.V.N.
N.A.
REHABILITATION THERAPY
REG. P.T./P.T. AIDES
REG. O.T./O.T. AIDES
MENTAL HEALTH: PSYCHOLOGIST
PSYCHIATRIST
PSYCHIATRIC SOCIAL WORKER
COUNSELOR
SPEECH AND AUDIOLOGY
OPHTHALMOLOGY/OPTOMETRY
PODIATRY
RADIOLOGY/LABORATORY
RECREATION/ACTIVITIES
DIRECTOR
ASSISTANTS
VOLUNTEERS
CHAPLAIN
ADMINISTRATION
ENGINEERING
MAINTENANCE/HOUSEKEEPING
MEDICAL RECORDS
OTHER (Specify)
VA FORM
JUL 2006
10-3567
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NAME OF HOME
DATE OF INSPECTION
NURSING SERVICE STAFFING PATTERN
(Four Week Average)
HOSPITAL (Average hours Hosp.
PART III
SHIFT
MONDAY
SUNDAY
RN
LPN
NA
RN
LPN
TUESDAY
NA
RN LPN
NA
WEDNESDAY
RN
LPN
NA
)
THURSDAY
RN
LPN NA
FRIDAY
RN
LPN
SATURDAY
NA
RN
LPN
NA
DAY
EVENING
NIGHT
NURSING HOME (Average hours NHC
PART IV
SUNDAY
SHIFT
RN
LPN
MONDAY
NA
RN
LPN
TUESDAY
NA
RN LPN
NA
WEDNESDAY
RN
LPN
NA
)
THURSDAY
RN
LPN
NA
FRIDAY
RN LPN
SATURDAY
NA
RN
LPN
NA
DAY
EVENING
NIGHT
DOMICILIARY (Average hours Dom.
PART V
SUNDAY
SHIFT
RN
LPN
MONDAY
NA
RN
LPN
TUESDAY
NA
RN LPN
NA
WEDNESDAY
RN
LPN
NA
)
THURSDAY
RN
LPN NA
FRIDAY
RN
LPN
SATURDAY
NA
RN
LPN
NA
DAY
EVENING
NIGHT
VA FORM
JUL 2006
10-3567
Page # of ##
| File Type | application/pdf |
| File Modified | 2006-07-19 |
| File Created | 2006-07-19 |