This collection of forms was part of a
previously approved collection under OMB Control Number 2900-0160.
However, it has been determined that these six forms will be
separated from the other three forms in 2900-0160, and this ICR
seeks renewal under a new OMB Control Number. Title 38, CFR Part 51
State Veterans Homes (SVH) regulations published in the Federal
Register as final rule on November 28, 2018 (RIN 2900-A088) require
the VA to ensure per diem payments are limited to facilities
providing high quality care. These six forms are presented to and
completed by SVH management and then assessed and utilized by VA
SVH Representatives designated by the Medical Center Director of VA
of jurisdiction during the annual VA survey process at each SVH
across the U.S. as a regulatory action. This collection of forms
falls under the auspices of Geriatrics and Extended Care in VA
Central Office (10NC4). As per VHA Directive 1145.01, this
collection of forms is part of the annual VA survey process. The
legal requirements that necessitate this collection of information
are found specifically at 38 CFR Parts 51.31, 51.43, and 51.210 for
all three levels of care; nursing home, domiciliary, and adult day
health care. The information required at time of the VA survey
includes the application and justification for medications for a
basic rate Veteran; records and reports which SVH management must
maintain regarding activities of residents or participants;
information relating to whether the SVH meets standards concerning
residents’ rights and responsibilities prior to admission or
enrollment, during admission or enrollment, and upon discharge; the
records and reports which SVH management and SVH health care
professionals must maintain regarding residents or participants and
employees; various types of documents pertaining to the management
of the SVH; pharmaceutical records; and staffing
documentation.
US Code:
38 USC 1710, 1712, 1720 Name of Law: Per Diem for Nursing Home,
Domiciliary, or Adult Day Health Care of Veterans in State
Homes
This collection of forms was
part of a previously approved collection under OMB Control Number
2900-0160. However, it has been determined that these six forms
will be separated from the other three forms in 2900-0160, and this
ICR seeks renewal under a new OMB Control Number. The burden
increases and decreases are due to the reduction from 9 forms to 6
forms, as well as some modifications to anticipated responses based
upon historically recorded actual responses.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form 10-0143 Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
30-day FRN_Per Diem to States for Veteran Care in State Homes_published 100419.pdf
Per Diem for Veteran Care in State Homes_Supp Statement A_revised Mar 2020.docx
Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals