Per Diem to States for Veteran Care in State Homes_Supp Statement A_revised Mar 2020

Per Diem to States for Care of Eligible Veterans in State Homes (38 CFR Part 51)

VA Forms: 10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460 and 10-3567

OMB 2900-NEW

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

The circumstances making this collection of forms necessary for providing information to the VA are from 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). 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.

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.

Title 38, CFR Part 51 provides for the payment of per diem to State Veterans Homes (SVH) that provide nursing home care, domiciliary, or adult day health care to eligible Veterans. The intended effect of these revised regulations is to ensure that Veterans receive high quality care and safety in SVHs. VA requires SVHs recognized by the Under Secretary for Health in providing nursing home care, domiciliary care, and adult day health care programs to Veterans to supply various types of information in order to assess compliance. 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.

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 for the assessment and determination of compliance to federal regulation to ensure that VA per diem payments are limited to SVHs providing high quality care. To ensure this level of care, VA requires those SVHs providing nursing home care, domiciliary care, and adult day health care programs to Veterans to supply the following various kinds of information:

1. VA Form 10-0143 – 38 CFR 51.210(c)(9) – is used for the annual certification for Drug-Free Workplace Act of 1988. This collection is completed and validated by the SVH management and supplied to designated VA survey team members for review and analysis.

2. VA Form 10-0143A – 38 CFR 51.210(c)(8) – is used for annual certification from the responsible State Agency showing compliance with Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112). This collection is completed and validated by the SVH management and supplied to designated VA survey team members for review and analysis.

3. VA Form 10-0144 – 38 CFR 51.210(c)(10) – is used for annual certification regarding lobbying in compliance with Public Law 101-121. This collection is completed and validated by the SVH management and supplied to designated VA survey team members for review and analysis.

4. VA Form 10-0144A – 38 CFR 51.210(c)(11) – is used for annual certification of compliance with Title VI of the Civil Rights Act of 1964 as incorporated in Title 38 CFR 18.1-18.3. This collection is completed and validated by the SVH management and supplied to designated VA survey team members for review and analysis.

5. VA Form 10-0460 – 38 CFR 51.43 – As a condition for receiving drugs or medicine under this section or under § 17.96 of this chapter, the State must submit to the VA medical center of jurisdiction a completed VA Form 10-0460 with the corresponding prescription(s) for each eligible Veteran. This collection is completed by both the Veteran and SVH management and is supplied to the VAMC pharmacy of jurisdiction.

6. VA Form 10-3567 – 38 CFR 51.31 – is completed by SVH management during the annual VA survey and used to record and then assess the following: operating beds versus recognized beds, total FTEE authorized and vacancies as well as resident census. The form must be completed in its entirety by the SVH management for the FTEE expended on each type of discipline required to provide care to residents. The completed form determines whether the clinical staffing of the facility meets federal standards set by the Regulations according to discipline to ensure high quality care. This collection is created by the SVH management and supplied to the designated VA survey team members for review and analysis and then entered in the State Veterans Homes survey software for VA Central Office analysis and trending.

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.

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. The forms are regulatory in nature.

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. The forms are used only for State Veterans Homes.

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 at each SVH to provide them federal grant funding. Therefore, the assessment of quality care indicators is critical to the VA to document whether high quality care is being provided to eligible Veterans. If the minimum regulations are not being met, per diem payment to a SVH can be jeopardized. The information being collected at a SVH is on an annual basis.

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 publication 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 23, 2019 (84 FR 35453). 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 04, 2019 (84 FR 53243). 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 statue, regulation, or agency policy.

The form VA 10-0460 requests the Veteran Social Security Number on page 1. This form has been reported to 10N as requested; however, the form is required by 38 CFR 51.43. The remaining forms in this group contain information that is not protected by the Privacy Act, as it is not required. The forms are reviewed, retained, and filed at each VA Medical Center of jurisdiction per the RCS-10 for use in assessing and scoring each federal regulation on any individual SVH survey report per level of care recognized by the Under Secretary for Health. VA Form 10-0460 is submitted by fax under security from the SVH to the VAMC.

The income and eligibility information supplied by a Veteran on VA Form 10-0460 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 Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. 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 mandatory. 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.

11. Provide additional justification for any questions of a sensitive nature, 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.

The information is collected and maintained by the VA Medical Center (VAMC) of jurisdiction in accordance with the policies of patient records management. All medical records of patients are protected under the Privacy Act of 1974, VA and HIPPA regulations, and medical center policies.

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

a. We estimate 5630 total burden hours annually --

(1) VA Form 10-0143, Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements For Grantees Other Than Individuals = 13 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
156	1	156	5	13

(2) VA Form 10-0143A, Statement of Assurance of Compliance with Section 504 of The Rehabilitation Act of 1973 = 13 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
156	1	156	5	13

(3) VA Form 10-0144, Certification Regarding Lobbying = 13 hours annually

Respondents	Frequency	Responses	Min. Each	Burden Hours
156	1	156	5	13

(4) VA Form 10-0144A, Statement of Assurance of Compliance with Equal
Opportunity Laws = 13 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
156	1	156	5	13

(5) VA Form 10-0460, Request for Prescription Drugs from an Eligible Veteran in a
State Home = 5500 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
11,000	1	11,000	30	5500

(6) VA Form 10-3567, State Home Inspection - Staffing Profile = 78 hours annually.

Respondents	Frequency	Responses	Min. Each	Burden Hours
156	1	156	30	78 hours

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13.

See 12.a. 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.

VA Forms 10-3567, 10-0143, 10-0143A, 10-0144, 10-0144A, and 10-0460 will be completed by VA SVH staff (although 10-0460 must be signed by the Veteran, as well as SVH management):

Estimated cost to respondents: $156,682.90 (5630 burden hours x $27.83 per hour).

Data Source: Bureau of Labor Statistics (BLS) http://www.bls.gov/news.release/realer.t01.htm

VHA uses general wage data to estimate the respondents’ costs associated with completing the information collection.

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).

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

b. 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: $97,760.24

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

1. Review by VAMC designated SVH staff per VHA Directive 1145.01 and VAMC officials - $74,933.04

Items 12.a. (1-6)

1833 hours x $40.88 (FY 2019) (average GS-12 step 5 hourly salary)

This amount includes burden hours of the VA SVH designated Medical Facility Representatives and designated SVH VISN Liaisons to review (1) – (5) during an annual SVH survey.

2. VA Headquarters oversight review - $21,827.20

Items 12.a. (1-4),(5)

5/Hours/Week = 260 per year x $57.44 = $ 14,934.40 (average GS- 14 step 5 – Pittsburgh locality)

10/Hours/Month = 120 per year x $57.44 = $6,892.80 (average GS- 14 step 5– Pittsburgh locality)

This amount includes burden hours of the VACO GEC staff SVH to review (1) for all 156 surveys per year and then (2) - (4) for any recognition survey which is approximately 12 per year.

3. Printing costs - $1000

15. Explain the reason for any changes reported in Items 13 or 14 above.

Although this collection of forms requires a new OMB number, these forms previously were approved as part of 2900-0160. The changes in the cost to the Federal government since the previous approval are accounted for by separating out three forms from the six forms in this collection, as well as the increase in employee salaries from 2015 to 2019.

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

The reduction of 1188 burden hours and reduction of the cost to the federal government of $132,668.76 from the past submission of this collection reflects the following:

1. The collection has been split between Geriatrics & Extended Care (10NC) whom manages the SVH survey process per 38 CFR Part 51, as these submitted six forms are involved with the survey process only. The forms included in the past submission are now owned by the State Home Per Diem Program in the Office of Community Care. This was an appropriate and accurate decision in order to properly manage the national program.

2. The federal regulations no longer offer State Hospital Care in State Homes. Hospital care in the State home per diem program was discontinued in 2011.

3. RIN 1900-A088 created one collaborative set of regulations for all 3 levels of care; nursing home care, domiciliary care, and adult day health care to create consistency of external review.

4. Salary costs based on the average General Schedule 12 – step 5 position as that is generally the designated person at the VAMC of jurisdiction who conducts the annual SVH survey process and utilizes the VA Forms identified in this document 12. (a) (1-5) that were completed by State home officials. VA Form 10-0460 completed by SVH residents and staff and submitted to the VAMC pharmacy, GS 12 was considered an accurate average as well. There is no need to include any clerical staff per the past in the calculation, they play no role with these forms.

5. Estimated salary costs based on the current GS position for the VA Headquarters staff who currently reviews the State Home Forms 12. (a) (1-6).

6. VA Form 10-0460 is not completed solely by SVH facility; minimal information is completed by each basic rate SVH resident individually (a signature and checking a box), which can be potentially about 11,000 Veterans, and the rest of the form is completed by SVH staff.

7. VA Form 10-3567 was revised for improved efficiency in 2015 and significant amounts of education was given to both the VAMC employees as well as to the States and SVH Administrators for ease of completion.

8. The only printing necessary is if a SVH needs a copy during the survey and if they select to not use the fillable option.

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,” of OMB 83-I.

There are no exceptions.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

No statistical methods are used in this data collection.

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