2900-0160 Justification_12-10-2015 kh edits (4)

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, 10-5588A,
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.

Several current issues, researched over the past years and documented in a variety of reports support a need for automation of the 10-10SH form. In the absence of an automated system, significant reliance on manual data entry and manual verification of processing the 10-10SH negatively affected the accuracy of ensuring the form is completed as required and determining Veteran eligibility to receive per diem payments. This had placed the VA at risk for making improper payments as reported during Office of Inspector General and Improper Payments Elimination and Recovery Act audits.

In collaboration with Chief Business Office Purchased Care (CBOPC) and CBO Systems Management (SM), the State Home Per Diem (SHPD) Program recently automated the 10-10SH (State Home Program Application for Veteran Care Medical Certification) form with VISN 12 VAMC of Jurisdiction (Iron Mountain) and SVH (Marquette) for Phase I. Until recently, the SHPD program was required to use the current 10-10SH paper form until OMB approved a Non-substantive change request for the new automated form (5/29/2015). The 10-10SH PDF form was converted into a web-based, fillable form that can be electronically submitted from the SVH to the VAMC of Jurisdiction. The form acts as a guide, asking all of the required information and filling out the actual 10-10SH from those answers. It includes data field validation, precluding the 10-10SH from being submitted electronically unless all required fields/information have information has been filled out. It also provides for and requires an electronic signature or equivalent prior to submission. The landing page of the pilot form provides a link to the 10-10EZ to remind the SVH to determine if the 10-10SH should be paired with a 10-10EZ for initial admission to an SVH and for per diem payments for domiciliaries. The VA portion of the application also includes business rules to assist the VA representatives in making uniform determinations, will allow the VA representative to return incomplete applications to the SVH along with a notification to them, and record the receipt of a “completed” application.

Thus far, VISN 12 (Marquette SVH and Iron Mountain VAMC) have processed over 70 new admissions electronically.   The project managers travelled to both facilities to provide training and to establish internal workflow process/controls to ensure documents are completed correctly and accurately.  In addition we helped key SVH employees set up their electronic signature and obtain VA Public Key Infrastructure (PKI) encryption in order to submit the electronic 10-10SH form with Personally Identifiable Information (PII) and Health Insurance Portability and Accountability (HIPAA) information to the VAMC. The SVH employees completing the form are able to electronically sign and submit the 10-10SH form to VAMC for processing.    Some minor hiccups exist since automation with VISN 12, but are being fixed along the way. For example, the project management team fixed issues with the electronic signature block and uploading attachments with submission of electronic form. Currently, the team is reviewing/validating form capability for the VAMC to send SVH receipt confirmation to assist with the 10 day rule determination. The team is also exploring an alternative solution to VA PKI encryption requirements in order to allow SVHs to send/receive encrypted data to the VAMCs. The automation was recently expanded to include two additionally VAMC and SVH facilities (Phase II). Here, the project team is currently assisting two SVHs with establishing internal workflow process and with satisfying VA PKI requirements.

Overall, the project team has improved the language in the revised data fields; including the administrative and clinical authorization section, reduce burden hours and need for retroactive payments and the likelihood of errors leading to improper payments. When implemented nationwide, the automated 10-10SH form will help improve program efficiency and reduce improper payments being made by the VA to SVHs. To date, the overall feedback/results continue to be positive.

Lessons learned thus far:

• The electronic 10-10SH form is necessarily strict, but it does not mean unworkable

  • Signed forms cannot be altered because that negates the signature

  • The individual who signed the form is the only one who can remove a signature

  • The form has a function (Comment) that can be used to make small/minor pen and ink changes while maintaining the integrity of the form.

• Working cross-agency and cross-government can be time consuming

  • The form relies on secure/encrypted email for submission

  • The VA requires certain types of proof/credentials to create an email account with encryption

  • The State has to be willing to set up the account in their domain for it to work. When completed, it is an amazing feeling to be able to send something to directly to the VA

• Attachments can be a lifesaver

  • Because it is sent by email, supporting attachments can be sent with the forms

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. To ensure this level of care, 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.

1. VA form 10-5588 – 38 CFR 51, 52 and Title 38, U.S.C., Sections 1741, 1742, 1743 and 1745 – is used to assess and provide per Diem to State Homes. This collection is used by the State Home employees and VA Staff.

2. VA form 10-5588a – 38 CFR 51, 52 and Title 38, U.S.C., Sections 1741, 1742, 1743 and 1745, is used to assess and provide per Diem to State Homes retroactively. This collection is used by the State Home employees and VA Staff.

3. VA Form 10-10SH – 38 CFR 51, 52 and Title 38, U.S.C., Sections 1741, 1742, 1743 and 1745 – provides for the collection of information to apply for the benefits of this program.

4. VA Form 10-3567 – 38 CFR 51.210 and 52.210 – is used to assess whether the staffing of the facility meets the standard set by the Regulation to ensure high quality care. This collection is used by the State home employees and VA staff.

5. VA Form 10-0143 – 38 CFR 51.210 and 52.210 – is used to certify Drug-Free workplace requirements. This collection is used by the State home employees and VA staff.

6. VA Form 10-0143a – 38 CFR 51.210 and 52.210 – is used to assure compliance with Section 504. This collection is used by the State home employees and VA staff.

7. VA Form 10-0144 – 38 CFR 51.210 and 52.210 – is used to certify lobby requirements. This collection is used by the State home employees and VA staff.

8. VA Form 10-0144a – 38 CFR 51.210 and 52.210 – is used to assure compliance with the Equal Opportunity Act. This collection is used by the State home employees and VA staff.

9. VA Form 10-0460 – 38 CFR 51.42 and 52.42 – is used to provide eligible Veterans with prescription drugs. This collection is used by the State home employees and VA staff.

10. 38 CFR 51.20 and 52.20 do not have an instrument. This collection is used to recognize a new State home or modify an existing recognition. The information is collected by a letter sent from the State home to the applicable VA Medical Center (VAMC). This collection is used by the State home employees and VA staff.

11. 38 CFR 51.30 and 52.30 do not have an instrument. This collection is used to appeal major and minor deficiencies noted by VA in the care plan or policy. The information is collected by a letter sent from the State home to the applicable VAMC. This collection is used by the State home employees and VA staff.

12. 38 CFR 51.100 and 52.100, do not have an instrument. This collection is record documenting concerns submitted to the State home management by a council of residents, as provided in 51.100(b), and concerns submitted to the day care program by participants or family members, as provided in 52.100(c). This is collected through internal records of the respective concerns. This collection is used by the State home employees and VA staff.

13. 38 CFR 51.210 and 52.210, do not have an instrument. This collection is documentation of items for either recognition or disclosure. This is collected by letter from the State. This collection is used by the State home employees and VA staff.

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.

The automated 10-10SH process will help assure compliance and fiscal integrity in the submission and management of the SVH application process. It will help provide accurate information and timely training/support to VA internal and external stakeholders in regard to the application process. This includes VAMC of Jurisdiction and SVH staff. Furthermore, it will provide the ability to improve the efficiency and timeliness of securely transmitting SVH applications, as well as provide ability to streamline/track the application approval status for SVH care online and notify the SVH in a timely manner.

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 19, 2015 (Vol. 80, Number 160, Page 50382-50383). 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 privacy, to the extent permitted by law, 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. We estimate 6818 total burden hours annually

(1) VA Form 10-5588, State Home Report and Statement of Federal Aid Claimed
= 834 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	Monthly	139	30	834

(2) VA Form 10-5588a Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive Service Connection = 180 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
45	Monthly	45	20	180

(3) VA Form 10-10SH (Automated Process), State Home Program Application for Veteran Care – Medical Certificate = 3,802 hours annually.

Automated 10-10 SH Projection:

Program	Respondents	Frequency	Responses	Min. Each	Burden Hours
State Nursing Home	9,048	1	9,048	20	3,016
State Domiciliary	2,355	1	2,355	20	785
Adult Day Health Care (ADHC)	3	1	3	20	1
Totals:	11,406	1	11,406		3,802

(4) VA Form 10-3567, State Home Inspection - Staffing Profile = 69.5 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	1	139	30	69.5 hours

(5) VA Form 10-0143, Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements For Grantees Other Than Individuals = 12 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	1	139	5	12

(6) VA Form 10-0143a, Statement of Assurance of Compliance with Section 504 of The Rehabilitation Act of 1973 = 12 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	1	139	5	12

(7) VA Form 10-0144, Certification Regarding Lobbying = 12 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	1	139	5	12

(8) VA Form 10-0144a, Statement of Assurance of Compliance with Equal
Opportunity Laws = 12 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	1	139	5	12

(9) VA Form 10-0460, Request for Prescription Drugs from an Eligible Veteran in a
State Home = 12 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
139	1	139	5	12

(10) 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
ADHC	5	1	5	6	0.5
Totals:	20		20		2

(11) 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
	ADHC	0	1	0	3	0
Minor Deficiency	State Nursing Homes	50	1	50	1	50
	State Domiciliary	25	1	25	1	25
	ADHC	0	1	0	1	0
Totals		90		90		120

(12) Section 51.100, Quality of Life and Section 52.100, Quality of Life
= 350 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
ADHC	2	4	8	30	4
Totals	175		700		350

(13) Section 51.210, Administration and Section 52.210, Administration = 1400 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
ADHC	2	1	2	8	16
Totals	175		175		1,400

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 above.

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: $230,429 (6,858 burden hours x $24 per hour x 1.4). We do not require any additional recordkeeping. The BLS has been multiplied by 1.4 to account for benefits. (Data Source : Bureau of Labor Statistics (BLS) http://www.bls.gov/news.release/realer.t01.htm

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 $232,359.48

Data Source: http://www.fedsdatacenter.com/gs-pay-calculator/

a. Review by VAMC officials - $6,386.94

Items 12.a. (1),(4),(5),(6),(7),(8).

[129.5 hours x $49.32 (FY 2015) (average GS-13 step 5 hourly salary)]

This amount includes burden hours to review all annual survey and recognition forms.

b. Clerical support - $162,192.54

Items 12.a. (2),(3)

[834 hours x $34.60 (average GS-1l step 5 hourly salary) = $28,856.40 ]

[5,703 hours x $23.38 (average GS-7 step 5 hourly salary) = $133,336.14 ]

This amount includes burden hours to review all 10-10SH and 10-5588 forms.

c. VA Headquarters oversight review - $58,280.00

10/Hours/Week = 500 per year x $58.28 = $ 29,140.00 (average GS- 14 step 5)

10/Hours/Week = 500 per year x $58.28 = $29,140.00 (average GS- 14 step 5)

d. Printing costs - $5,500

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

President Obama signed into law on August 6, 2012 Public Law 112-154, Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012 (the Act). Section 105; contracts and agreements for nursing home care apply to the VA State Home Per Diem Program. The Act required that rates of payments for certain eligible service connected Veterans be “based on a methodology, developed by the Secretary in consultation with the State home, to adequately reimburse the State home for the care provided. The law authorizes the VA to change the current payment methodology for highly service connected Veterans in need of nursing home care. VA published an interim final Rule (RIN 2900-AO57) amending 38 CFR 51.41 to implement this methodology. Thus, VA revised invoicing form 10-5588. Enhancements to VA Forms 10-10SH and 10-5588 have been made to assist State Home and VAMC staff in completing the form. Additional changes to form 10-5588 are required to account for new per diem payment methodologies that will be available for State Homes as a result of the implementation. A new form is VA Form 10-5588A, Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive Service Connection. Revisions are intended to provide clarity in completing the forms and reducing burden hours in completing the forms. VA Form 10-5588A was developed as requested by State Homes to reduce burden hours in completing a payment claim for multiple Veterans.

VA also clarified the wording for Form 10-10SH in the VA authorization for payment section. The revision to VA Form 10-10SH and addition of an instruction sheet enables the State Home Program Office to improve the language in the revised data fields of the administrative and clinical authorization section and reduces the likelihood of errors leading improper payments.

Additionally, VA made some non-significant changes on Form 10-3567. The revisions were to clarify the instructions to make it easier to complete the form and delete staff categories where 38 CFR Parts 51 and 52 only require that the State Homes provide services, and not necessarily employ staff,

The form will become more user friendly allowing for more accurate completion, and requested information will demonstrate a direct link to the regulation requirements.

The respondent burden and federal government cost reduction is the result of the following:

The reduction of 8,692 burden hours is a reflection of the number of annual survey certifications and recognitions VA Forms, admissions and invoices VA Forms completed by State Home officials and processed by VA staff.

a. With inclusion of an automated 10-10SH system, significant reliance on manual data entry and manual verification of processing no longer has a negative effect on the accuracy of ensuring the form is completed as required and determining Veteran eligibility to receive per diem payments.

The addition of an instruction sheet; improved language in the revised data fields; including the administrative and clinical authorization section, also reduces burden hours and need for retroactive payments and the likelihood of errors leading to improper payments.

When completed, the customer is able to utilize an electronic signature block and send form attachments directly to the VA, which results in burden reduction.

b. VA Form 10-5588A was developed as requested by State Homes to reduce burden hours in completing a payment claim for multiple Veterans.

c. We no longer offer State Hospital Care in State Homes. Hospital care in the State home per diem program was discontinued in 2011.

d. (14.a-b) We estimated salary costs based on the average General Schedule positions assigned to those VAMC employees responsible for processing all the various VA Forms identified in this document 12.(a)(1-8) that were completed by State home officials.

(14.c) We estimated salary costs based on the current GS position for the VA Headquarters staff who currently reviews the State Home Forms 12. (a)(1,2,4-8).

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 will include the expiration date on all forms.

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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