Supp Stmnt A_2900-0160_State Home Programs for Veterans_final Aug 2023

SUPPORTING STATEMENT A

STATE HOME PROGRAMS FOR VETERANS

VA Forms 10-10SH, 10-5588 and 10-5588A
OMB CONTROL NUMBER: 2900-0160

Summary of Changes from Previously Approved Collection:

• Updates to electronic version of VA Form 10-10SH for increased functionality and usage (screen shots are included)

• No changes in burden hours

A. JUSTIFICATION

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

Authority for this information collection can be found in two public laws affecting State homes: Public Law 115-159, the State Veterans Home Adult Day Health Care Improvement Act of 2017, which requires VA to pay State Veteran Homes (SVHs) for medical model adult day health care provided to certain eligible Veterans; and Public Law 116-315, Section 3007, Waiver of Requirements of Department of Veterans Affairs for Receipt of Per Diem Payments for Domiciliary Care at State Homes and Modification of Eligibility for such Payments​. This information collection also enables 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 create a safeguard that Veterans are receiving a high quality of care in SVHs.

To ensure that high quality care is furnished to Veterans, VA requires those facilities providing nursing home care, domiciliary care, and adult day health care programs to Veterans to supply various kinds of information. The information required includes an application and justification for payment; records and reports that facility management must maintain regarding payment activities of residents or participants; and records and reports that facilities management and health care professionals must maintain regarding eligible residents or participants. The following three forms are included in this information collection: 10-5588, 10-5588A, and 10-10SH. [VA Forms 10-10EZ/EZR (OMB approval 2900-0091) are used in conjunction with the VA Form 10-10SH.]

VHA has utilized the three forms under OMB control number 2900-0160 for many years. However, several current issues, researched over the past years and documented in a variety of reports support a need for automation of the 10-10SH form. In the absence of an automated system, significant reliance on manual data entry and manual verification of processing the 10-10SH negatively affected the accuracy of ensuring the form is completed as required and determining Veteran eligibility to receive per diem payments. This had placed the VA at risk for making improper payments as reported during Office of Inspector General and Improper Payments Elimination and Recovery Act audits.

In collaboration with Patient Care Services (PCS) Geriatrics and Extended Care (GEC), the State Home Per Diem (SHPD) Program automated the 10-10SH (State Home Program Application for Veteran Care Medical Certification) form. Previously, the SHPD program was required to use the 10-10SH paper form until OMB approved a non-substantive change request for the new automated form (5/29/2015). As discussed, in 2015 the 10-10SH PDF form was converted into a web-based, fillable form that can be electronically submitted from the SVH to the VAMC of jurisdiction. The form acts as a guide, asking all required information and filling out a replica of the OMB approved 10-10SH from those answers. It includes data field validation, precluding the 10-10SH from being submitted electronically unless all required fields/information have information has been filled out. It also provides for and requires an electronic signature or equivalent prior to submission. The VA portion of the application also includes business rules to assist the VA representatives in making uniform determinations, will allow the VA representative to return incomplete applications to the SVH along with a notification to them, and record the receipt of a “completed” application.

Overall, the project team has improved the language in the revised data fields, including the administrative and clinical authorization section, reducing burden hours and need for retroactive payments and the likelihood of errors leading to improper payments. When implemented nationwide, the automated 10-10SH helps improve program efficiency and reduce improper payments being made by the VA to SVHs. To date, the overall feedback/results continue to be positive. Similar to the VA Form 10-10EZ/R, this office would like the automated 10-10SH available in the same manner, to include the VA publication library.

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 that facility management must maintain regarding activities of payment for eligible residents or participants; and records and reports that facilities management and health care professionals must maintain regarding eligibility and 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 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 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 – is used 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.

In 2015 the 10-10SH PDF form was converted into a web-based, fillable form that can be electronically submitted from the SVH to the VAMC of Jurisdiction. The form acts as a guide, asking all required information and filling out a replica of the OMB approved 10-10SH from those answers. It includes data field validation, precluding the 10-10SH from being submitted electronically unless all required fields/information have information has been filled out. It also provides for and requires an electronic signature or equivalent prior to submission. The automated 10-10SH was updated in 2018, and again in 2022.

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 Information Collection Activity was published in the Federal Register on June 21, 2023 (Vol. 88, No. 118, pages 40402-40403). VA received one comment in response to this notice. The program office made no changes to the collection in response to the comment.

The 30-day notice of Agency Information Collection Activity Under OMB review was published in the Federal Register on August 29, 2023 (Vol. 88, No. 166, pages 59573-59574).

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 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:

Total annual burden = 4,816 hours

Total annual responses = 13,614

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 (12x)	1,668	30	834 hrs

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 (12x)	540	20	180 hrs

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 hrs

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 2021 Occupational Wage Code Median Hourly, the mean hourly wage is $28.01 based on the BLS wage code – “00-0000 All Occupations.”  This information was taken from the following website: https://www.bls.gov/oes/tables.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 $134,896.16 (4,816 burden hours x $28.01 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: $212,184.20

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

a. Review by VAMC officials - $10,949.40

Items 12.a. (2)

[180 hours x $60.83 (FY 2023) (average GS-13 step 5 hourly salary)]

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

b. Clerical support - $145,244.80

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

[834 hours x $42.68 (average GS-11 step 5 hourly salary) = $35,595.12]

[3,802 hours x $28.84 (average GS-7 step 5 hourly salary) = $109,649.68]

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

c. VA Headquarters oversight review - $55,990

10/Hours/Week = 500 per year x $60.83= $30,415 (average GS- 13 step 5)

10/Hours/Week = 500 per year x $51.15 = $25,575 (average GS- 12 step 5)

d. Printing costs - $0

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

Changes to 14 above: The cost to Federal government increased due to labor rate increases from 2019 to 2023.

VA does not project any burden hour changes since our last clearance submission.

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.

VA does not intend to publish this data.

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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