White Paper Changes to Form 10-3567

VHA White Paper

Changes to VA Form 10-3567, State Home Inspection

The Department of Veterans Affairs (VA) is requesting to make several non-substantive edits to VA Form 10-3567, State Home Inspection – Staffing Profile, which has not been updated since 2006. The majority of changes requested are to the instructions page. Unclear instructions are putting undue burden on those completing the form, causing them to spend more than the estimated 30 minutes to complete. Additionally, the lack of clarity in the instructions results in incomplete submissions, inconsistency in how the form is interpreted / completed, and multiple calls to VA Central Office for clarifications on how to complete the form.

Other changes being requested are to ensure that only information required in Title 38 Code of Federal Regulation (CFR) Parts 51 and 52 are listed on the form. Some of these changes will include deleting staff categories where 38 CFR Parts 51 and 52 only require that the State Veteran Home (SVH) provide services, and not necessarily employ staff. Additionally, VA is requesting some title changes so that titles listed in 38 CFR Parts 51 and 52 are mirrored on this form. While the proposed changes may alter the length of the form, the instructions will be clearer, the form will become more user friendly allowing for accurate and quicker completion, and requested information will demonstrate a direct link to the regulation requirements. Below is a description of the changes, and attached is the updated form.

1. Throughout the documents, requesting several global changes:

   1. Replace the word “Hospital” with “Adult Day Health Care.” VA is only authorized to pay per diem payments to three levels of care: Nursing Home Care; Domiciliary Care; and Adult Day Health Care. Changing “Hospital” to “Adult Day Health Care” will reflect the proper levels of care captured by the State Veteran Home program.

   2. Replace the word “position” or “staff positions” with “Full Time Employee Equivalents (FTEE)” or “FTEE.” This will help clarify what is being requested for those completing the form.

   3. Add section number to CFR citations, so those completing the form know exactly where they can turn in the regulation to understand that this form is required. At the bottom of the instructions page, “Part 51.30 and Part 52.30.”

2. In the instructions, requesting several changes that will clarify how to complete the form:

   1. Under item two, add the definitions for operating beds, authorized approvals, patient census, FTEE Authorized, FTEE Available, as there could be many different interpretations of these definitions, and we need to clarify the expectations of what to include.

   2. Under item three, delete the note and following directions. The intent of this form is to capture the FTEE count and less about if those FTEE are provided by the SVH or elsewhere. According to the 38 CFR 51.41, SVH’s are able to enter into contracts and provider agreements to provide services. There has been confusion about the definitions for Agreement, Contract, Consultant, and the differences between each of them, so argue that deleting them gives the main focus back to what services are being provided.

   3. Completely rewrite item four to provide explicit step by step directions to compute the nursing hours per patient day. As many completing the form do not regularly complete nursing staff schedules, need to be clear about the process. Also, since the SVHs are owned and operated by the States, they have different shift hours. The proposed changes, clarify the process of how to account for different shift hours as well as clarify that only direct care nursing hours should be captured in the equation.

   4. Delete item five, since that information will be combined into item four. Separating the instructions has also caused confusion and all information on how to complete should be in one item for clarity.

3. Requesting multiple minor formatting edits to Part II of the form, to include:

   1. Remove all colons and left justify all entries to edit out headers. The original intent was for various lines to serve as headers for a group of specialties, but this was not done so consistently. To fix the confusion, want to make it clear that an FTEE entry is needed on each line. Also need to delete the following words that were being used as headers: Direct Care, Mental Health, and Rehabilitation Therapy.

   2. Consistently spell out credentials or use industry norms for each staff line. This should include changing the following: Physicians should read “Physicians M.D. / D.O.”; Dentists should read “Dentists D.M.D / D.D.S.”; BSW should read “Social Work BSW”; Pharmacy Reg should read “Registered Pharmacist”; Dietetics should read “Registered Dietitian”; Food Supervisor should read “Food Service Supervisor”; Nursing ADM. /Sup should read “Nursing Administration/Supervisor”; Direct Care: Cert N.P,/C,N.S should read “Nurse Practitioner (N.P.) / Certified Nursing Specialist (C.N.S); R.N. should read “Registered Nurse (R.N.)”; L.P.N./L.V.N. should read “Licensed Practical Nurse (L.P.N) / Licensed Vocational Nurse (L.V.N.)”; N.A. should read “Certified Nursing Assistant (C.N.A.); Rehabilitation Therapy should read “Speech Therapist”; Reg. P.T./P.T. Aides should read “Physical Therapist”; Reg. O.T./O.T. Aides should read “Occupational Therapist”; Director“ should read “Therapeutic Recreation Specialist”; and Administration should read “Administrator(s)”

   3. Delete lines where FTEE are not required by 38 CFR Parts 51 and 52. In many cases, the CFR requires that certain services be provided, but that can be provided at the SVH or through a contract. That information about what services provided is captured during the annual survey, and not necessary to duplicate in this form. As a result, the following should be removed: Social Work Assistant; Psychiatric Social Worker; Counselor; Speech and Audiology: Ophthalmology/Optometry; Podiatry; Radiology/Laboratory; Recreation/Activities: Assistants: Volunteers: Chaplain; Engineering; Maintenance/Housekeeping; and Medical Records.

4. Requesting minor formatting changes to Part III through Part V to clarify information requested, including:

   1. Change “NA” to “CNA” throughout the form for consistency with Part II change requested.

   2. Delete “(Average hours Hosp./NHC/DOM___)” from the header in Parts III, IV, and V, as that language does not match the instructions. As a replacement, add a row below each table with the level of care for that table and “Direct Care Nursing Hours/Patient/Day =____.” This will help clarify to those completing that they need to fill out the table before they can calculate the direct care nursing hours per patient day.

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