Supp Stmnt A_State Home Programs for Veterans_2900-0160_revised Mar 2020

SUPPORTING STATEMENT A

STATE HOME PROGRAMS FOR VETERANS (VA Forms 10-5588, 10-5588A, and 10-10SH)
OMB CONTROL NUMBER 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.

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 a 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; application and justification for payment; records and reports which facility management must maintain regarding payment activities of residents or participants; the records and reports which facilities management and health care professionals must maintain regarding eligible residents or participants; and various types of documents pertaining to the management of the facility. [VA Form 10-10EZ/EZR (OMB approval 2900-0091) is used in conjunction with the VA Form 10-10SH.]

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.

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 verify the provision of 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; the records and reports which facilities management and health care professionals must maintain regarding the level of care approved for residents or participants.

1. VA form 10-5588: State Home Report and Statement of Federal Aid Claimed– 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: Claim for Increased Per Diem Payment for Veterans Awarded Retroactive Service Connection – 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: State Home Program Application for Veterans Care Medical Certification – 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.

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.

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 publications 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 60-day notice of Proposed Agency Information Collection Activity was published in the Federal Register on July 30, 2019 (84 FR 37016). VA received no comments in response to this notice.

The 30-day notice of Agency Information Collection Activity under OMB Review was published in the Federal Register on October 23, 2019 (84 FR 56891). VA received no comments 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 statute, 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 (SHPDP).

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), 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 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 (SHPDP).

12. Estimate of the hour burden of the collection of information:

1. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:

We estimate 4,816 total burden hours annually:

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

Respondents	Frequency	Annual Responses	Min. Each	Burden Hours
139	Monthly	1,668	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	Annual Responses	Min. Each	Burden Hours
45	Monthly	540	20	180

3. VA Form 10-10SH -- State Home Program Application for Veteran Care Medical

Certification = 3,802 hours annually.

Program	Respondents	Frequency	Annual 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

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens.

This request for approval is for three forms -- 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.

VHA uses general wage data to estimate the respondents’ costs associated with completing the information collection.  In accordance with the Bureau of Labor Statistics (BLS) May 2018 Occupational Wage Code Median Hourly, the mean hourly wage is $24.98 based on the BLS wage code – “00-0000 All Occupations.”  This information was taken from the following website: https://www.bls.gov/oes/2018/may/oes_nat.htm.

Legally, respondents may not pay a person or business for assistance in completing the information collection, and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs. VHA estimates the total annualized cost to respondents to be $120,303.68 (4,816 burden hours x $24.98 per hour).

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).

1. There are no capital, start-up, operation or maintenance costs.

2. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

c. There is no anticipated recordkeeping burden beyond that which is considered usual and customary.

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: $184,737.36

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

a. Review by VAMC officials - $9,275.40

Items 12.a. (2)

[180 hours x $51.53 (FY 2018) (average GS-13 step 5 hourly salary)]

This amount includes burden hours to review all 10-5588A forms

b. Clerical support - $123,031.96

Items 12.a. (1),(3)

[834 hours x $36.15 (average GS-11 step 5 hourly salary) = $30,149.10]

[3,802 hours x $24.43 (average GS-7 step 5 hourly salary) = $92,882.86]

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

c. VA Headquarters oversight review - $47,430

10/Hours/Week = 500 per year x $51.53 = $25,765 (average GS- 13 step 5)

10/Hours/Week = 500 per year x $43.33 = $21,665 (average GS- 12 step 5)

d. Printing costs - $5,000

15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14.

Changes to 13 above: President Trump signed 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. Thus, VA revised invoicing form 10-5588 and 10-5588A to include a prevailing rate for adult day health care. Additionally, VA Form 10-10SH has been streamlined and burden hours reduced to assist State home and VAMC staff in completing the form and providing the prevailing rate for certain Veterans in need of adult day health care. VA also clarified and streamlined Form 10-10SH in the VA authorization for payment section. The revision to VA Form 10-10SH and revision of the instruction sheet enables the State Home Program Office to improve the language in the revised data fields of the administrative authorization section and reduces the likelihood of errors leading improper payments.

Changes to 14 above: The labor rate increased from 2015 to 2018.

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

The reduction of 5 burden hours reflects the decreased number of questions the SVH and VAMC must answer to complete the 10-10SH Form.

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.”

There are no exceptions.

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