Red Line instructions

OMB Approval No. 2900-0160Estimated Burden: Avg. 30 min.

State Veteran Home Employees:

1. USE OF VA FORM 10-5588, STATE VETERAN 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 costs, total per diem cost, per diem claimed and total amount claimed for hospital, nursing home, domiciliary, and adult day health care. The State Veteran hHome will be paid monthly. Payments will be made only after the State submits a completed VA Form 10-5588 and required supporting documentation

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a. One copy of the monthly statement of account will be submitted by each State Veteran hHome to VA medical center of jurisdiction by the end of the 5th workday after the close of each monthly report period.

b. VA medical center of jurisdiction staff will review each monthly report for accuracy, resolve any discrepancies with the State Veteran hHome, make payment by electronic fund transfer and file the report. A report should not be accepted by a VA medical center staff if the report is incomplete (i.e., all appropriate blanks are complete and report is signed by the State homeState Veteran Home administrator and State employee when under management contract arrangement).

c. The original monthly statement will be verified and signed by the VA medical center staff person assigned as the point of contact for oversight of the State Veteran Home Program and forwarded in duplicate to the Business Office for audit and payment. On completion of VA accounting certification, one copy of each report will be sent to VA Central Office, not later than the 15th workday after the month ends. This information is used to prepare the quarterly program reports of expenditures that are the basis or long range budget projections. The VACentral Office copy will be addressed to: Chief Consultant/Chief State Home Per Diem Program, Office of Geriatrics and Extended Care(114), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420.

2. GENERAL INSTRUCTIONS

VA Employees:

a. Station Number. Enter the station number where the VA Medical Center of Jurisdiction is located.

b. VISN. Enter the VISN number where the VA Medical Center of Jurisdiction is located.

c. For Month Ending. Enter the month and year for the report e.g., Oct 2013

d. Report Quarter. Enter the Federal fiscal quarter the report is for. The Federal fiscal year starts October 1^st, which is the first day of the 1^st quarter

e. TO. Enter the name and address of the VA Medical Center of Jurisdiction.

f. FROM. Enter the name of State Veteran Home Address

g. PAY TO. Enter the name and address where the payment is sent.

2. INSTRUCTIONS FOR CHANGES IN RESIDENCY OR OCCUPANCY FOR THE MONTH SECTION

a. Enter line entries for domiciliary, in column A; nursing home, in column B; and adult day health care , in column C.

b. Lines 1 through 12 are to be completed for each level of care. Lines 1-9 will be completed to validate each eligible Veterans monthly residency or occupancy. (the term occupancy applies to Veterans enrolled in the adult day health care program as they are not residents of the State Veteran Home) Lines 10-12 will be completed to validate end of moth residency or occupancy

(1) a. Enter the last day of the calendar month covered by the report in the box labeled "For Month Ending."b.Line 1, Total Eligible Veterans Present in the Facility at the End of the Prior Month.

Enter line entries for domiciliary, column A; nursing home, column B; hospital, column C; or adult day health care, column D inappropriate columns.

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 and who were receiving domiciliary care and who had an overnight stay. When a Veteran overstays an approved absence of 96 hours, no portion of the leave may be claimed for VA payment.

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 and who were receiving nursing home care and who had an overnight stay, as well as the number of Veterans who were on a VA approved bed hold (paid) for overnight hospital stays or non-hospital leave and eligible for VA nursing home payments on the last day of the prior month.

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 and who are receiving adult day health care services. 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 9 for the prior month.

c. Lines 1 through 13 are to be completed for each level of care. Lines 1-9 will be completed as a monthly veteran residents accountability.Lines 10- 13 will be completed as the end of month resident accountability.(1) Line 1, Total Veteran Residents Remaining End of Prior Month. Enter the number of veteran eligible residents present and remaining onthe rolls of the State home as of midnight on the last day of the prior month. Entries on this line will be the same as those shown on line 9 forthe prior month.(2) Line 2, 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 Veteran Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health care. The total entries on line 2 and 5 for the month will be the same.

(3) Line 3, Admissions (Other). Enter the number of eligible veterans admitted to the State Veteran hHome nursing home or domiciliary during the report month and/or enrolled in the adult day health care.

(4) Line 4, 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. DO NOT report leave of absence for which the VA paid per diem.

(4) Line 4, Return From Leave of Absence of 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types ofovernight absences in a calendar year.

(5) Line 5, Discharges (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer to another level of care in the State Veteran Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health care. The total entries on line 2 and 5 for the month will be the same.

(5) Line 5, Discharges (Change of Status). Enter the number of eligible veterans whose status was changed by transfer to another level of carein the State home. The total entries on line 2 and 5 for the month will be the same.

(6) Line 6, Discharges (Other). Veterans not returning to the nursing home, domiciliary or discharged from the adult day health care program from a leave of absence: Enter the number of eligible Veterans who were discharged from the State Veteran Home or dropped from the rolls, except for deaths. Do not count discharges for hospitalizations or Veterans who are nonhospital leave. For Veterans on a VA-paid bed hold for overnight hospital stays or non-hospital 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.

(6) Line 6, Discharges (Others). Enter the number of eligible veterans who were discharged from the State home or dropped from the rolls,except for deaths.

(7) Line 7, Deaths. Enter the number of eligible Veterans who died during the report month regardless if the death occurs inside or outside the State Veteran facility.  It does not matter if the Veteran died in the hospital or State nursing home, domiciliary or while enrolled in the adult day health care program during the report month.  Attach a separate sheet to identify deaths by name.    

(7) Line 7, Deaths. Enter the number of eligible veterans who died during the report month. Attach a separate sheet to identify deaths byname.

(8) Line 8, Leave Of Absence.

For Nursing Home Care beds, enter the number of eligible Veterans who have an overnight stay in a VA hospital or other hospital or who are absent for reasons other than hospital care. DO NOT report leave of absence for which the VA paid per diem i.e. bed holds, 10 days of leave for hospitalization or 12 days for non-hospital leave granted to nursing home residents in a calendar year.

For Domiciliary Care beds, enter the number of eligible Veterans who have an overnight stay in a VA hospital or other hospital at VA expense or who are absent greater than 96 hours. Do not report leave of absences of Veterans who had an overnight hospital stay at a non-VA hospital and was absent less than 96 hours.

For adult day health care slots- non applicable.

Note: Per diem payments for bed holds are authorized when the nursing home occupancy rate is 90% or above: In those instances where the nursing home daily occupancy rate falls below 90%, the State Veteran Home is not eligible for bed hold per diem. The Veteran should be listed as on leave of absence from the State Veteran Home facility and recorded on line 8. If the facility occupancy rate returns to 90% or greater and the Veteran is still absent, this constitutes a return from leave of absence and should be noted on line 4 for VA to resume authorizing VA per diem payments. If a Veteran has not returned to the home after 10 consecutive days for hospital leave or 12 days for non hospital leave, count the Veteran on line 8 as being absent from the facility. Note: A Veteran may have more than one 10 day episode of hospitalization in a calendar year but no more than 12 days of non-hospital leave within a calendar year. (Not applicable to domiciliary or adult health care program).

8) Line 8, Leave of Absence of 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnightabsences in a calendar year

(9) Line 9, Total Veteran Residents Remaining End Of Month. Enter the total number of eligible Veteran residents present and remaining in the facility as of midnight who were receiving nursing home care and who had an overnight stay, as well as the number of Veterans who were on a VA approved bed hold/non-hospital leave and eligible for VA nursing home payment on the last day of the report month., This entry will be equal to the sum of lines 1, 2, 3 and 4 minus lines 5, 6, 7 and 8. Includes total number of Veteran domiciliary residents at the end of the month and total number of adult day health care residents on the rolls at the end of the month.

(9) Line 9, Total Veteran Residents Remaining End of Month. Enter the number of eligible male and female veterans present and remainingas of midnight on the last day of the report month. This entry will be equal to the sum of lines 1, 2, 3 and 4 minus lines 5, 6, 7 and 8.

(10) Line 10, Non-Eligible Veterans And Other Residents 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 were present on the last day of the report month. DO NOT REPORT eligible Veteran residents in this cell.

(10) Line 10, Non-Veteran Residents Remaining End of Month. Enter number of residents not eligible for reimbursement by VA that arepresent on the last day of the report month. DO NOT REPORT eligible veteran residents in this cell.

(11) Line 11, Total Nursing Home Care Veterans Who Are 70% to 100% Service Connected Or In Need Of Nursing Home Care For A Service Connected Condition. Enter the number of nursing home eligible Veteran residents who have a singular or combined service connection rating of 70% or greater or has a VA rating of total disability based on Individual unemployability. This also includes eligible Veteran residents who are in need of nursing home care because of a service connected condition that are 60% or below.

(11) Line 11, Total Nursing Home Care Veterans that are 70% Disabled or Admitted for a Service Connected Condition. Enter number ofresidents included on line 9, that are over 70% service connected disabled or admitted for a service connected condition.

(12) Line 12, 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. (12) Line 12, Female Veteran Residents Remaining at the end of the month.

3. INSTRUCTIONS FOR TOTAL DAYS OF CARE FURNISHED TO NON ELIGIBLE VETERANS AND OTHERS FOR THE MONTH SECTION

13) Line 13, And Line 13A, Total Days of Care Provided to Others. Enter all days of care provided to non-eligible Veterans on line 13 and to others on line 13A. Do not count any overnight absence from the facility such as private paid bed holds as a day of care. Line 13 will be completed to validate the end of the month’s total days of care provided to non-eligible Veterans (non-eligible Veterans for purposes of this form is defined as the days of care provided for eligible Veterans whose 10-10SH was not received by the VAMC of jurisdiction within 10 calendar days of admission) For example; the admission date was 1/1/13; the 10-10SH was received by VA on 1/15/13; a total of 15 days lapsed from the date of admission to receipt of 10-10SH.

Line 13A will be completed to list the total days of care provided to civilians, which represents those Veterans residing in the State Veteran Home domiciliary, nursing home beds or attending the adult day health care program as Gold Star Parents of whose child died while serving in the Armed Forces or spouses of Veterans.

CONTINUED INSTRUCTIONS FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID(13) Line 13, Total Veteran Days of Care Provided. Enter total number of days of care provided, including days of care for eligible veteranswith 10 consecutive overnight absences and for the first 12 other types of overnight absences in a calendar year. One day of care may becounted for a veteran on the day the veteran is admitted. A day of care is not counted on the day of discharge. A gain and a loss on the sameday will be reported as one day of care. When accounting for Nursing Home Care use lines 13a and 13b.(13a) Line 13a, Total Veteran Days of Care Provided for Nursing Home Care. Enter total number of days of care provided to veterans 70%or more disabled or admitted for a service connected disability, including days of care for eligible veterans with leave of absence of 10consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnight absences in a calendar year. One day ofcare may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day of discharge. A gain and a losson the same day will be reported as one day of care.

4. INSTRUCTIONS FOR CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS SECTION

a. Column D, Total Days Of Care for the Month, lines 14, 15 and 16. Enter total domiciliary days of care on line 14, nursing home care on line 15 and adult day health care on line 16. A day of care is counted when an eligible Veteran has an overnight stay in the facility. For nursing home beds: A day of care is also counted when the VA is paying per diem for an eligible Veteran resident on bed hold for 10 consecutive overnight hospital stays or 12 consecutive days for non-hospital leave. For domiciliary beds: A day of care is counted when an eligible Veteran has an overnight stay in the facility and are not absent from the facility for more than 96 hours. For adult day health care, a day of care is credited when the Veteran is under the care of the facility 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. 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.

b. Column E, Average Daily Census, lines 14, 15 and 16. Enter the average daily census computed by dividing the days of care in column D for each level of care by the number of calendar days in the month, carried to one decimal place.

c. Column F, 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.

d. Column G, Daily Cost of Care For The Month, lines 14, 15 and 16. The daily cost of care for the month is the direct cost plus the indirect (allowable) cost, divided by ALL residents or enrollees days of care. Compute cost in accordance with cost principles set forth in the Office of Management and Budget (OMB) Circular number 2 CFR 225 (A- 87), (dated, August 31, 2005), "Cost Principles for State, Local, and Indian Tribal Governments." Divide the direct and indirect (allowable) cost for the month in column F by the sum of days of care in column D provided to eligible Veterans and the days of care provided to non-eligible Veterans and civilians on line 13 for each level of care.

e. Column H, Per Diem Claimed, lines 14, 15 and 16. Enter the lesser of the authorized (VA approved per diem rate for the Fiscal Year) per diem rate or one-half the amount shown in column G for each level of care carried two decimal places. 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.

f. Column I, Total Amount Claimed, lines 14, 15, 16 and 17. Enter the product of columns D and H for each level of care on line 14, 15 and 16. On line 17, sum the totals for each level of care.

5. INSTRUCTIONS FOR CLAIM FOR PAYMENTS FOR SERVICE CONNECTED VETERANS IN STATE NURSING HOME SECTION UNDER A PROVIDER AGREEMENT or CONTRACT

a. Column J, Days of Care, Lines 19 and 20. A day of care is counted when an eligible Veteran receives nursing home care and is present at midnight in the facility. For nursing home beds: A day of care is also counted when the VA is paying per diem for an eligible Veteran resident on bed hold for 10 consecutive overnight hospital stays or 12 consecutive days for nonhospital leave.

Line 19 represents eligible nursing home Veteran residents who have a singular or combined service connection rating of 70% or greater or has a VA rating of total disability based on Individual unemployability.

Line 20 represents eligible Veteran residents who require nursing home care because of a service-connected disability rating of 60% or below. Day of admission is counted as a day of care. An admission (gain) and discharge (loss) on the same day is counted as a day of care. Day of discharge is not counted as a day of care. Sum lines 19 and 20 on line 21.

b. Column K, Average Daily Census, lines 19 and 20. Enter the average daily census computed by dividing the days of care in column J for each level of care by the number of calendar days in the month, carried to one decimal place.

c. Column L, Prevailing Rate, lines 19 and 20. Enter the VA prevailing rate for your geographical area from the chart for the current Fiscal Year.

d. Column M, Total Amount Claimed. Using the VA prevailing rate methodology, multiply the days of care from line 19 and 20 in column J by the prevailing rate in column L.

6. OPERATING BEDS or ADULT DAY HEALTH CARE PARTICIPANT SLOTS

At the end of each month, State Veteran Home management will enter the current operating bed capabilities for domiciliary, nursing homes, and adult day health care in the appropriate spaces on Page 2, State Veteran Home administrators or designee will enter bed capacities approved by VA. The approved bed capacity and the operating beds should be the same number of beds. If operating beds are closed for any reason, facility management is requested to provide the Chief Business Office approval letter by the VA Geriatrics and Extended Care Operations Office (GEC) that indicates the date of closure, expected date the beds will be operational, type of bed (domiciliary, nursing home), or slot-adult day health care, and the reason for the closure. Specify if these beds were constructed or renovated with federal funds. Along with the submission of GEC approval letter to the Chief Business Office, State Veteran Home management may also enter information related to closed beds under the "Remarks" section of this report.

3. INSTRUCTIONS FOR MONTHLY SUMMARY STATEMENT ACCOUNT.a. Column E, Days of Care, Lines 14, 15, 16, and 17. Enter from line 13 the data in columns A for domiciliary, C for hospital care and D foradult day health care to show the total number of days for each level of care for the month. Enter from line 13b for B for nursing home careto show the total number of day for Nursing home Care for patients less than 70% service disabled or not admitted for a service connectedcondition. One day of care may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day ofdischarge. A gain and a loss on the same day will be reported as one day of care.b. Column F, Average Daily Census, Lines 14, 15, 16, and 17. Enter the average daily census computed by dividing the appropriate entry incolumn J by the number of calendar days in the month, carried to one decimal place.c. Column G, Total Per Diem Cost, Lines 14, 15, 16, and 17. Enter on the appropriate line the total per diem costs for the month computed inaccordance with relevant cost principles set forth in the Office of Management and Budget(OMB) Circular number A-87, dated May 4,1995, "Cost Principles for State, Local, and Indian Tribal Governments." The total per diem cost will include the direct and indirect costsappropriate for each level of care.d. Column H, Per Diem Claimed, 14, 15, 16, and 17. Enter the authorized (VA approved per diem rate for the Fiscal Year) per diem rate orone-half the amount shown in column L carried to two decimal places whichever is the lesser, for the appropriate level of care. VA will paymonthly one-half of the cost of each eligible veteran's care (domiciliary, nursing home, hospital or adult day health care) for each day theveteran is in a facility recognized as a State home, not to exceed the approved per diem rate for that level of care.e. Column I, Total Amount Claimed.(1) Line 18. Verify that the total amount claimed in line 17 does not exceed one-half the sum of products of entries in columns E and I, lines14, 15, 16 and 17.

4. INSTRUCTIONS FOR CLAIM PER DIEM PAYMENTS OF 70% SC VETERANS IN STATE NURSINGHOMES.a. Column J, Days of Care, Lines 19 and 20 total number of days for each level of care for the month. Including days of care for eligibleveterans absent 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnight absences in acalendar year. One day of care may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day ofdischarge. A gain and a loss on the same day will be reported as one day of care. Total on line 21.b. Column K, Total Veterans, Lines 19 and 20. Enter the total number of eligible veterans present on the last day of the report month on line21.c. Column L, Rate Per Day of SC Vet, 19 and 20. Use prevailing rate chart or (G) 15, whichever is less.d. Column M, Amount Claimed, Lines 19 and 20. Enter the total amount by adding line 19 to line 20.

5. OPERATING BEDSa. At the end of each month, State home management will enter the current operating bed capacities for domiciliary, nursing home, hospitalor adult day health care in the appropriate spaces on Page 2 of the report form.b. Also on Page 2, facility management will enter bedcapacities approved by VA. The approved bed capacity and the operating beds should be the same number of beds. If operating beds areclosed for any reason, facility management is required to provide the date of closure, expected date the beds will be operational, type of bed(domiciliary, nursing home, hospital, or adult day health care), and the reason for the closure. Please specify if these beds were constructedwith federal funds. Information related to closed beds may be entered under "Remarks".

a. Signature and date of State Veteran Home Administrator. The State Veteran Home management must certify that the information in the report is correct by signing and dating the report.

b. Signature and date of State Veteran Home Employee When Applicable: 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.

VA Employees: TOTAL AMOUNT APPROVED BY VA FOR PAYMENT

a. Signature, title and date of VA official certifying the 10-5588 form (the State Veteran Home Per Diem Point of Contact).

b. Signature, title and date of VA State Veteran Home Contract Officer Representative or Agreement Coordinator.

Note: If the State Veteran Home Per Diem Point of Contact and either the Contract Officer Representative or Agreement Coordinator both certify the 10-5588 form then signatures, titles and dates are required are on lines . However if only one individual certifies the entire 10-5588 form for both basic per diem payments and higher per diem payments then only one of the three titles, signatures and dates listed above may be completed and the other titles, signatures and dates may be documented as non- applicable.

c. Accounting Certification Block: Enter the obligation/control number for each level of payment (i.e. ADHC, DOM, NHC Basic and NHC P1), the amount due and date. This requires a signature, title and date of the VA Auditor employed in the VAMC Finance Office.

All monthly State Veteran Home 10-5588’s will be processed electronically beginning March 1, 2013.

6. CERTIFICATIONa. The facility management must certify that the information in the report is correct by signing and dating the report.b. If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of thefacility on a full-time, on site basis. This State employee must also certify that the information in the report is correct by signing and datingthe report.

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VA FORM

10-5588

MAY 2009