State Home Programs for Veterans - VA Forms 10-5588, 10-5588A, 10-10SH

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-0143 Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	Form	Removed	Available
Form 10-10SH State Homes Program Application for Veterans Care Medical Certification	Form and Instruction	New	Available
Form 10-5588A Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.	Form and Instruction	New	Available
Form 10-5588 State Home Report and Statement of Federal Aid Claimed	Form	New	Available
30-day FedReg Notice_State Home Programs_10232019.pdf	Supplementary Document	Uploaded 2020-04-23	Available
60-day FedReg Notice_State Home Programs_07302019.pdf	Supplementary Document	Uploaded 2019-09-16	Available
Supp Stmnt A_State Home Programs for Veterans_2900-0160_revised Mar 2020.docx	Supporting Statement A	Uploaded 2020-04-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28394	Title 38, Parts 51 and 52, State Home Program	Form	Removed	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
237053	State Homes Program Application for Veterans Care Medical Certification	Form and Instruction	New	State Homes Program Application for Veterans Care Medical Certification
237052	Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.	Form and Instruction	New	Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.
237051	State Home Report and Statement of Federal Aid Claimed	Form	New	State Home Report and Statement of Federal Aid Claimed

ICR Details

OMB Control No: 2900-0160	ICR Reference No: 201906-2900-007
Status: Historical Active	Previous ICR Reference No: 201604-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0160
Title: State Home Programs for Veterans - VA Forms 10-5588, 10-5588A, 10-10SH
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/09/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/13/2020
Terms of Clearance: Forms removed from this collection are included in "Per Diem to States for Care of Eligible Veterans in State Homes."

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2023	36 Months From Approved
Responses	13,614	0	0
Time Burden (Hours)	4,816	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Congress passed Public Law 115-159, the State Veterans Home Adult Day Health Care Improvement Act of 2017, requiring VA to pay State homes for medical model adult day health care to certain eligible Veterans, and Title 38, CFR Part 52, which provides for the payment of per diem to State homes that provide adult day health care to eligible Veterans. It also continues to provide for the payment of per diem to State homes that provide care to eligible Veterans in accordance with Title 38, CFR Part 51. The intended effect of these provisions is to provide a safeguard that Veterans are receiving high quality care in State homes. This information collection is necessary to ensure that VA per diem payments are limited to facilities providing high quality care. To verify this level of care, VA requires those facilities providing nursing home care, domiciliary, and adult day health care programs to Veterans to supply various kinds of information. The information required includes an application/eligibility for admission and justification for payment; records and reports which facility management must maintain regarding activities of payment for eligible residents or participants; and the records and reports that facilities management and health care professionals must maintain regarding the level of care approved for residents or participants. This OMB Control Number previously included six additional forms, VA Forms 10-0460, 10-0143, 10-0143A, 10-0144, 10-0144A, and 10-3567, which have now been separated out into another information collection (to be approved under a separate OMB Control Number). This information collection, under OMB Control Number 2900-0160, now includes only three forms: VA Forms 10-5588, 10-5588A, and 10-10SH.

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Authorizing Statute(s): PL: Pub.L. 109 - 461 211(a)(5) Name of Law: Veterans Benefits, Health Care, and Information Technology - Modification to State Home Authorities
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 37016	07/30/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 56891	10/23/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.	10-5588A	Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.
State Home Report and Statement of Federal Aid Claimed	10-5588	State Home Report and Statement of Federal Aid Claimed
State Homes Program Application for Veterans Care Medical Certification	10-10SH	State Homes Program Application for Veterans Care Medical Certification
Title 38, Parts 51 and 52, State Home Program	10-5588A, 10-0144A, 10-0143, 10-0143A, 10-0144, 10-5588, 10-0460, 10-10SH, VA Form 10-3567	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	13,614	0	0	730	0	12,884
Annual Time Burden (Hours)	4,816	0	0	-2,002	0	6,818
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This OMB Control Number previously included six additional forms, VA Forms 10-0460, 10-0143, 10-0143A, 10-0144, 10-0144A, and 10-3567, which have now been separated out into another information collection (to be approved under a separate OMB Control Number). This information collection, under OMB Control Number 2900-0160, now includes only three forms: VA Forms 10-5588, 10-5588A, and 10-10SH.

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Annual Cost to Federal Government: $184,737

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/28/2020

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