Form 10-5588 State Home Report and Statement of Federal Aid Claimed

OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
Expires: 02-28-2019

VA FORM 10-5588
STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
1. GENERAL INFORMATION
1. STATION
NUMBER

3. MONTH/
YEAR

2. VISN

5. TO:

4. REPORT
QUARTER

6. FROM:

7. PAY TO:
2. CHANGE IN RESIDENCY FOR THE MONTH
LINE
NO

ITEM

NURSING
HOME CARE
(B)

DOMICILIARY
(A)

GAINS

TOTAL VETERAN RESIDENTS PRESENT IN
8. FACILITY AT END OF PRIOR MONTH
ADMISSIONS (Change of Status)
9.
ADMISSIONS (Other)
10.
11.
RETURN FROM LEAVE OF ABSENCE
LOSSES

12.
13.
14.
15.

ADULT DAY
HEALTH CARE
(C)

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DISCHARGES (Change of Status)
DISCHARGES (Other)
DEATH
LEAVE OF ABSENCE

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16. TOTAL VETERAN RESIDENTS PRESENT AT END OF THE MONTH
3. STATUS AT THE END OF THE MONTH
LINE
NO

ITEM

NURSING
HOME CARE
(B)

DOMICILIARY
(A)

ADULT DAY
HEALTH CARE
(C)

TOTAL NON-ELIGIBLE VETERAN AND CIVILIAN RESIDENTS
17. REMAINING AT THE END OF THE MONTH
TOTAL VETS THAT ARE 70%-100% SC; OR HAS RATING OF TDIU;
18. OR ARE IN NEED OF NHC/ADHC FOR SC DISABLILTY

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FEMALE VETERAN RESIDENTS REMAINING AT THE END OF THE
19. MONTH
4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
LINE
NO

ITEM

NURSING
HOME CARE
(B)

DOMICILIARY
(A)

ADULT DAY
HEALTH CARE
(C)

TOTAL DAYS OF CARE FURNISHED TO NON ELIGIBLE VETERANS
20. AND CIVILIANS (including Medicare Days, if applicable)
5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
LINE
NO
21.
22.
23.
24.

DAILY COST OF
FEDERAL AID CLAIMED UNDER DAYS OF
AVERAGE
DIRECT AND
CARE FOR THE
SEC 1741, TITLE 38, U.S.C.,
CARE
DAILY CENSUS INDIRECT COST
MONTH
AS AMENDED
(A)
(B)
(C)
(D)
DOMICILIARY CARE
NURSING HOME CARE
ADULT DAY HEALTH CARE
TOTAL AMOUNT CLAIMED
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6. CLAIM FOR SC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS

LINE
NO

VETERAN CATEGORY

25.

HAS SINGULAR OR COMBINED RATING OF 70% -100% SC; OR HAS
RATING OF TDIU; OR ARE IN NEED OF NHC FOR SC DISABILITY

26.

HAS SINGULAR OR COMBINED RATING OF 70% -100% SC; OR HAS
RATING OF TDIU; OR ARE IN NEED OF ADHC FOR SC DISABILITY

27.

TOTAL AMOUNT CLAIMED

VA FORM
JAN 2020

10-5588

PER DIEM
CLAIMED
(E)

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DAYS
OF CARE
(A)

AVERAGE DAILY
CENSUS
(B)

PREVAILING
RATE
(C)

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SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.

TOTAL AMOUNT
CLAIMED
(F)

TOTAL AMOUNT
CLAIMED
(D)

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OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
The daily cost of care is the direct cost plus the indirect cost for the month, divided by the total days of care of all enrollees or residents present in the
facility during the month regardless of the payer source. Compute the cost in accordance with the Federal Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards specified in 2 CFR 200.400 - 200.475.
7. RECOGNIZED CAPACITY APPROVED BY THE VA
28. DOM

29. NHC

30. ADHC

8. STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CONTINUED
I certify that this report is correct based on the documentation provided to the VA and that the recognized beds approved by the VA is correct and all
residents included in the report were physically present during the period for which Federal aid is claimed, except for authorized absences for which
the VA paid per diem, and the facility management has complied with all provisions of Title VI, Public Law 88-352, entitled Civil Rights Act of 1964.
31. SIGNATURE OF SVH
ADMINISTRATOR

Printed Name
& Title:
Signature:

Date:

(Note: If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility
on a full-time, on site basis. This State employee must also certify that the information in the report is correct by signing and dating the report. If the
facility is under contract, the signature of the SVH Administrator is not required.)
32. SIGNATURE OF
STATE EMPLOYEE
WHEN APPLICABLE

Printed Name
& Title:
Signature:

Date:

33. REMARKS:

9. RECEIVING REPORT (FOR VA USE ONLY)
Services authorized under provisions of section 1741, 1742, 1743, and 1745, Title 38, U.S.C., have been rendered in the quantity claimed and payment is
recommended except as follows.
34. TOTAL AMOUNT APPROVED BY VA FOR PAYMENT (add blocks 24(F) and 27(D)):
Printed Name
35. SIGNATURE OF
& Title:
STATE HOME
APPROVING OFFICIAL
Signature:
36. ACCOUNTING CERTIFICATION - AUDIT BLOCK
Obligation Number
(A)

Date:
* Amount Due
(B)

ADHC
DOM
NHC BASIC
NHC PREVAILING RATE
ADHC PREVAILING RATE
TOTAL AMOUNT DUE

37. SIGNATURE OF
AUDITOR

Printed Name
& Title:
Signature:
PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT

Date:

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the
time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the
form. Although completion of this form is voluntary, VA will be unable to provide reimbursement for services rendered without a completed form. Failure to complete the form will have
no effect on any other benefits to which you maybe entitled. This information is collected under the authority Of Title 38 CFR Parts 51. The information requested on this form is
solicited under the authority of Title 38, U.S.C., Sections 1741, 1743 and 1745 and 1743. It is being collected to enable us to determine your eligibility for medical benefits in the State
Home Program and will be used for that purpose. The income and eligibility you supply may be verified through a computer matching program at any time and information may be
disclosed outside the VA as permitted by law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136, Patient Medical RecordVA, published in the Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary; however, the information is required in order for us to determine your
eligibility for the medical benefit for which you have applied. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled. Disclosure
of Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the
administration of veterans' benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized
by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
VA FORM
JAN 2020

10-5588

SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.

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OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.

VA FORM 10-5588
INSTRUCTIONS FOR
STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
The VA Form 10-5588 consists of several parts. This report is a monthly statement of gains and losses, days of care, average daily census,
allowable cost, total per diem cost, per diem claimed and total amount claimed for nursing home, domiciliary, and adult day health care. Monthly
payments will be made to the State Home only after the State submits a completed VA Form 10-5588 and required supporting documentation.
1. GENERAL INSTRUCTIONS
1. Station Number: Enter the station number where the VA Medical Center of jurisdiction is located.
2. VISN: Enter the Veteran Integrated Service Network (VISN) number where the VA Medical Center of jurisdiction is located.
3. To Month/Year: Enter the calendar month and year covered by the report. (example: May 2018).
4. Report Quarter: Enter the number for the quarter report is claimed (for example, enter 1 for October to December; enter 2 for January to
March; enter 3 for April to June; enter 4 for July to September).
5. To: Enter the VA Facility this report is submitted to.
6. From: Enter Name and Address of State Veterans' Home for this report.
7. Pay To: Enter to who the payment is to be made.
2. CHANGE IN RESIDENCY FOR THE MONTH
8. Enter the Total Veteran Residents Present in the Facility at the end of the prior month.
Column a. Domiciliary: Enter the number of eligible domiciliary Veteran residents present and remaining on the rolls as of midnight on
the last day of the prior month. When a Veteran overstays an approved absence of 96 hours, no portion of the leave may
be claimed for VA payment. (Note: Present means any eligible Veteran that is physically in the SVH facility at midnight or
on an approved paid VA leave of absence.)
Column b. Nursing Home: Enter the number of eligible nursing home Veteran residents present and remaining on the rolls as of
midnight on the last day of the prior month, as well as, the number of Veterans who were on a VA approved bed hold for
overnight hospital stays or non-hospital leave and eligible for VA nursing home payments on the last day of the prior month.
Column c. Adult Day Health Care: Enter the number of eligible adult day health care occupants on the rolls for receiving adult day health
care services as of midnight the last day of the prior month. Per diem will be paid only for a day that the Veteran is under the
care of the facility at least six hours. For purposes of this paragraph a day means six hours or more in one calendar day or
any two periods of at least 3 hours each (but each less than six hours) in any two calendar days in a calendar month.
Entries on this line will be the same as those shown on line 16 for the prior month.
9. Admissions (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer from one level of care to
another within the State Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health
care. The entries on lines 9 and 12 for the month will be the same.
10. Admission (Other). Enter the number of eligible Veterans admitted to the State Home nursing home, domiciliary during the report month
and/or enrolled in the adult day health care.
11. Return From Leave of Absence. Enter eligible Veterans returning from a non-VA paid overnight absence in a VA hospital or other hospital
and for Veterans returning from an overnight absence for non-hospital leave and for domiciliary residents returning from absences of
greater than 96 hours. Applicable when a Veteran is absent from the home on a non-VA paid absence and/or does not return to the home.
DO NOT report leave of absence for which the VA paid per diem.
12. Discharges (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer to another level of care within
the State Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health care. The entries
on lines 9 and 12 for the month will be the same.
13. Discharges (Other). Enter the number of eligible Veterans who were discharged from the State Home or dropped from the rolls, except for
deaths. Do not count discharges for hospitalizations. Applicable when a Veteran on a VA-paid bed hold for overnight hospital stays or nonhospital leave, does not return to the nursing home. The effective date of discharge will be the date the home is notified the Veteran will
not return.
14. Deaths. Enter the number of eligible Veterans who died while enrolled in the State Home Per Diem program during the report month.
15. Leave of Absence. For Nursing Home Care beds, enter the number of eligible Veterans who have a non-VA per diem payment overnight
stay in a hospital or who are absent for reasons other than hospital care. DO NOT report leave of absence for which the VA paid per diem
(i.e. bed holds), for State Home with an occupancy rate of 90% or higher, for first 10 consecutive days of leave for hospitalization or 12
days for non-hospital leave granted to nursing home residents in a calendar year.

VA FORM
JAN 2020

10-5588

SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.

Page 3

OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.

VA FORM 10-5588
INSTRUCTIONS-CONTINUED
FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
(Note: Per diem payments for bed holds are authorized when the nursing home occupancy rate is 90% or higher: In those instances
where the nursing home daily occupancy rate falls below 90%, the State Home is not eligible for bed hold per diem. The Veteran should
be listed as on leave of absence from the State Home facility and recorded on line 15(B). If the facility occupancy rate returns to 90% or
higher and the Veteran is still absent, this constitutes a return from leave of absence and should be noted on line 11(B) for VA to resume
VA per diem payments. A Veteran may have more than one 10 consecutive day episode of hospital leave in a calendar year, provided the
Veteran has an overnight stay in the SVH between each period of hospitalization; but no more than 12 days of non-hospital leave within a
calendar year. (Not applicable to domiciliary or adult day health care program).)
16. Total Veteran Residents Present at End of Month. Enter the number of eligible Veteran residents present as of midnight on the last day of
the report month. Additionally, count eligible nursing home care Veterans who are on VA paid leave of absence for hospitalization and for
non-hospital absences and count domiciliary Veterans who are absent from the facility on a VA paid pass of 96 hours or less. This entry will
be equal to the sum of lines 8, 9, 10 and 11 minus lines 12, 13, 14 and 15 in each column.
3. STATUS AS OF THE END OF THE MONTH
17. Non-Eligible Veterans And Civilians Remaining End Of Month. Enter the number of nursing home, domiciliary residents, and adult day
health care enrollees not eligible for payment from VA who was present on the last day of the report month. DO NOT REPORT eligible
Veteran residents in this cell.
18. Total Veterans that are 70%-100% SC; or has rating of TDIU; or are in need of NHC/ADHC for SC disability. Enter the total number of
eligible Veterans who are 70% to 100% Service Connected (SC); or has rating of Total Disability rating based upon Individual
Unemployability (TDIU); or are in need of NHC for SC disability in column 18B and in column 18C for ADHC SC Veterans.
19. Eligible Female Veteran Residents Remaining At The End Of The Month. Enter the number of eligible female Veteran residents present
and remaining in the facility at the end the month.
4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
20. Total Days of Care Furnished to Non-Eligible Veterans and Civilians (including Medicare Days, if applicable). Enter all days of care
provided to non-eligible Veterans and civilians for domiciliary care, nursing home care and adult day health care in blocks 20A, 20B, and
20C respectively. This includes Medicare Days paid for Veteran's stay in the Facility.
5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
Lines 21, 22, 23 and 24:
Column A. Days of Care: A day of care is counted when an eligible Veteran has an overnight stay in the facility. Enter total domiciliary
days of care on line 21, nursing home care on line 22 and adult day health care on line 23. For nursing home beds: A day
of care is counted when the VA pays per diem for an eligible Veteran resident on bed hold for 10 consecutive overnight
hospital stays or non-hospital leave. For domiciliary beds: A day of care is counted when an eligible Veteran is present or
on authorized absent from the facility up to 96 hours. If a Veteran is absent more than 96 hours, no portion of the absence
is counted as a day of care. For adult day health care, a day of care is credited when the Veteran is under the care of the
facility at least six hours in one calendar day or any two periods of at least 3 hours each (but each less than six hours) in
any two calendar days in a calendar month. The day of admission is counted as a day of care. For all three levels of care,
an admission and loss on the same day is counted as a day of care; day of discharge (removed from the rolls) is not
counted as a day of care.
Column B. Average Daily Census: Enter the average daily census computed by dividing the days of care in column A by the number of
calendar days in the month, carried to one decimal place for each level of care.
Column C. Direct and Indirect Cost (Allowable Cost): Enter the total of direct and indirect cost (allowable cost) for providing care to all
residents in the home for the month regardless of the payer source.
Column D. Daily Cost of Care for the Month: The daily cost of care for the month is column C (direct and indirect cost), divided by ALL
residents' days of care. Compute cost in accordance with cost principles set forth in the Office of Management and Budget
(OMB), "Uniform Administrative Requirements, Cost Principles, and Audit Requirement in Federal Awards" (2 CFR Part
200.400 to 475 for cost principles). To calculate the daily cost of care, divide the direct and indirect cost for the month in
column C by the sum of days of care for each level of care for all residents (line 20 non-eligible Veterans and Civilians, and
columns A of 21 through 26). For Dom - add 20A and 21A; for NHC - add 20B, 22A, and 25A; and for ADHC - add 20C,
23A, and 26A to obtain the figure to divide the direct and indirect cost for the calculation of the daily cost of care for the
month.
Column E. Per Diem Claimed: Enter the current fiscal year per diem rate or one-half the daily cost of care shown in column D carried
to two decimal places, whichever is the lesser, for each level of care. VA will pay monthly one-half of the cost of each
eligible Veteran's care (domiciliary, nursing home, or adult day health care) for each day the Veteran is in a facility
recognized as a State Veteran Home, not to exceed the approved per diem rate for that level of care.
Column F. Total Amount Claimed: Enter the product of columns A and E for each level of care on lines 21, 22, and 23. On line 24, sum
the totals for each level of care.
VA FORM
JAN 2020

10-5588

SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.

Page 4

OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.

VA FORM 10-5588
INSTRUCTIONS-CONTINUED
FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
6. CLAIM FOR PAYMENTS FOR SERVICE CONNECTED VETERANS IN STATE NURSING HOME SECTION UNDER A PROVIDER
AGREEMENT or CONTRACT
Items 25 and 26:
Column A. Enter the days of care for eligible Veteran residents who have a singular or combined SC disability rating of 70% to 100%;
or has VA rating of TDIU; or are in need of NHC for SC disability. Days of care for NHC (line 25) follows the same rules as
noted in 22A and on line 26, follow the rules for ADHC from line 23A
Column B. Average Daily Census: Enter the average daily census computed by dividing the days of care in column A for each level of
care by the number of calendar days in the month, carried to one decimal place.
Column C. Prevailing Rate: Enter the VA prevailing rate for Fiscal Year as published by SHPDP Office.
Column D. Total Amount Claimed: Using the VA prevailing rate methodology, multiply the days of care from line 25 and 26 in column A
by the prevailing rate in column C.
Line 27(D) total amount claimed: sum lines 25 and 26.
7. RECOGNIZED CAPACITY APPROVED BY THE VA
At the end of each month, State home management will enter the recognized beds approved by the VA during the latest recognition survey
for domiciliary, nursing home and adult day health care in blocks 28, 29 and 30 respectively.
8. STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CERTIFICATION
31. Signature of SVH Administrator: Print name and title of SVH Administrator, sign and date.
(Note: If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the
operations of the facility on a full-time, on site basis. This State employee must also certify that the information in the report is correct
by signing and dating the report. If the facility is under contract, the signature of the SVH Administrator is not required.)
32. Signature of State Employee When Applicable: If the facility is managed by a contractor, a State Employee must print name and title, sign
and date. If the facility is under contract, the signature of the SVH Administrator is not required.
33. Remarks
9. RECEIVING REPORT
34. Total Amount Approved by VA for Payment: Sum the totals of blocks 24 and 27.
35. Signature of the VA State Home Approving Official: Print name and title of approving official, sign and date.
36. Accounting Certification - Audit Block: In column (A) enter obligation numbers for each level of payment claimed and in column (B) enter
amount due for each level of payment claimed. Total Amount Due: Sum the amount due in column (B) and enter in the Total Amount Due.
This sum should equal the amount entered on line 34.
37. Signature of Auditor: Print name and title of auditor, sign and date.
(Note: If the receiving report is not completed in its entirety, it could result in an improper payment.)

VA FORM
JAN 2020

10-5588

SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.

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