1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
VA Forms 10-1170 and 10-2407 are necessary for the non-Federal nursing home or the residential care home to qualify to provide care to veteran patients. This information is collected under the authority of Title 38, Part II, Sections 1720 and 1730. VA has suggested changes to VA Form 10-1170, reducing the amount of information provided on the form (this information is available elsewhere) and adding information on prices. The form is now intended to cover more community providers. The form will cover community nursing homes (CNHs already use the form), Home Health and Hospice Care agencies and community adult day health care centers. At the suggestion of OMB, VA Form 10-1170 was revised in 2004 to include a statement that the signature of the Administrator certifies that the information provided is accurate, to provide the printed name of the administrator in case they need to be contacted (and the signature is illegible), to indicate whether the facility is part of a chain (so we have more information on the reputation of the facility, their procedures and safeguards).
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.
The forms will be utilized by administrative staff at the Department of Veterans Affairs (VA) medical centers and VA Central Office to assure that there is no attempt to defraud the government and that the agencies comply with regulations. The application forms the basis of VA’s review of long-term care agencies. It is the provider’s opportunity to describe its capacity, leadership and prices. VA uses this information in conjunction with “CMS’ Nursing Home (NH) Compare” and “Home Health Compare” information. The “NH Compare” reviews the status of deficiencies found by the State Survey Agency. State, regional and national comparisons of deficiencies are available. Staffing, patient characteristics and quality measures are also listed in both “Compare” databases. Provider-suggested prices will be analyzed in comparison to Medicare rates. This will allow VA to better manage the cost of care. The combination of the VAF 10-1170 and “Compare” databases provides VA staff with a comprehensive picture of the community agency. Without these forms, VA staff would have to make individual site visits.
The VA Form 10-1170 is an application used by community agencies wishing to provide long-term care to veterans who receive VA benefits. The prospective provider contacts the local Veterans Affairs Medical Center (VAMC) of jurisdiction to request the application form. Often the nursing home will initially contact the VAMC Geriatrics or Social Work office and is referred to the appropriate program coordinator. The coordinator will perform an initial screening to ensure that the community agency is eligible before providing the application form. Not every agency that applies will be approved to provide veterans care. The VA may not need more long-term care providers in a particular area, or may need only specific types of care. Currently, this is explained to the agency administrator during the initial request for information. If appropriate, the agency home fills out the application form and submits it by mail or fax. The coordinator receives the completed application and forwards it to the appropriate VAMC Review Team to initiate the review. VA Form 10-1170 will serve as the only signed "agreement" between some providers and the VA indicating their intent to participate in the program, comply with CMS standards, and agreeing to a price structure.
The VA Form 10-2407 is an application used by a residential care facility or home that wishes to provide residential home care to veterans. It serves as the agreement between the VA and the residential care home that the home will submit to an initial inspection and comply with VA requirements for residential care. The prospective residential care home contacts the local Veterans Affairs Medical Center (VAMC) of jurisdiction to request the application form. Not every residential home that applies will be approved to provide Veterans residential home care. Some homes may not meet strict VHA standards or wish to submit to inspections. Information concerning application requirements is provided before the application form is sent and the review process is initiated to avoid wasted time with applications that are later withdrawn. The VAMC will perform an initial screening to ensure that the residential care home is eligible before providing the application form. The Handbook (Section 8, Voluntary nature of facility operator participation) states that "facility operators who apply for participation in the CRC program must accept the VA conditions of participation. VA Form 10-2407 is the only signed "agreement" between the home operator and the VA indicating their intent to participate in the program, allow inspections, comply with standards, and others listed on the form. The handbook (Section 9, Selection of Homes, a. application) identifies this form as the way to comply with the requirement to apply in writing for participation in the program. All of the additional information about the home is gathered at the time of inspection(s) and is not documented on a routine numbered form. This information is maintained in the VHA CRC files. The potential home operators are asked to give a reference of at least one neighbor who is preferably not a relative but this is not spelled out as a regulation.
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.
In accordance with the Government Paperwork Elimination Act, VA investigated the possibility of optional electronic transmission of this data. It was the Contractor’s recommendation that neither form be converted to electronic transmission. Both forms have low returns on investment as a result of low transaction frequency and would not pay for their conversions in five years. Additionally, since private citizens as well as nursing homes with a variety of levels of automation will submit the data on these forms, it will be difficult to automate this data collection. However, VA has posted a fillable version of these forms on the Intranet (at http://vaww.va.gov/vaforms/) and on the Internet (at http://www.va.gov/vaforms/) for fill, save and print submissions.
4. Describe effort 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.
The information requested by VA Forms 10-1170 and 10-2407 is not available from any other source.
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 has been kept to an absolute minimum. The questions are only those required to verify the Home's/Agency’s adequacy to render care to veterans.
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.
VA Forms 10-1170 and 10-2407 are completed only once.
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 December 21, 2006 (Volume 71, Number 245, Pages 76727-76728). We received no comments 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. No additional consultation has been necessary as the information is simple, straightforward and is readily available.
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.
As this information is not protected by the Privacy Act, no assurance of confidentiality is provided.
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.
There are no questions of a sensitive nature.
12. Estimate of the hour burden of the collection of information:
a. The total annual burden is 125 hours
Form |
Respondents |
Minutes |
Divided by 60 |
Annual Burden Hours |
10-1170 |
500 |
10 |
60 |
83 |
10-2407 |
500 |
5 |
60 |
42 |
Total |
1,000 |
|
|
125 |
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 83-1.
See Subparagraph 12a above or the 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.
The annualized cost to respondents is estimated at $1,875.
VA Form 10-1170 |
83 hours |
x |
$15 per hour |
|
$1.245 |
VA Form 10-2407 |
42 hours |
x |
$15 per hour |
|
$630 |
|
|
|
|
$1,875 |
|
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 are 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 is no additional recordkeeping burden.
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.
Cost to the Federal Government is estimated at $8,136. We do not anticipate printing these forms because the usage is so low.
VA Form 10-1170 |
500 forms x $25.08/hour (GS 11/5) x 30 min. |
$ 6,270 |
VA Form 10-2407 |
500 forms x $12.23/hour (GS 4/5) x 6 min. |
$... 612 |
|
500 forms x $25.08/hour (GS 11/5) x 6 min. |
$ 1,254 |
|
TOTAL |
$ 8,136 |
15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I
The 41 hour Adjustment is due to a smaller number of sponsors applying for the Residential Care Home Program. The 84 hour Program decrease is a result of simplifying VA Form 10-1170 and utilizing the “CMS’ Nursing Home (NH) Compare” and “Home Health Compare” databases.
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 the information collected. VA Medical Centers conduct these reviews, as described above. It allows VA to contract with the best local Nursing Homes available that are interested in contracting with the Department.
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. The VA Form may be reproduced by the respondents and veterans service organizations from the Internet and then stocked. 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.
No statistical methods are used in this data collection.
Page
| File Type | application/msword |
| File Title | Justification for 2900-0160 |
| Subject | 10-1170, 5588 and 2407 |
| Last Modified By | Denise McLamb |
| File Modified | 2007-03-12 |
| File Created | 2007-02-13 |