Per Diem to States for Care of Eligible Veterans in State Homes

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-3567 State Home Inspection Staffing Profile	Form and Instruction	Modified	Repair queued
Form 10-0460a Request for Prescription Drugs from an Eligible Veteran in a State Home	Form	Modified	Available
Form 10-0144A Statement of Assurance of Compliance with Equal Opportunity Laws	Form	Modified	Repair queued
Form 10-0144 Certification Regarding Lobbying	Form	Modified	Repair queued
Form 10-0143A Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	Form	Modified	Repair queued
Form 10-0143 Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	Form	Modified	Repair queued
30-Day FRN_2900-0883_Per Diem to States for Care of Eligible Veterans in State Homes_published 10302023.pdf	Supplementary Document	Uploaded 2023-10-30	Repair queued
60-Day FRN_2900-0883_Per Diem to States for Care of Eligible Veterans in State Homes_published 08252023.pdf	Supplementary Document	Uploaded 2023-10-20	Repair queued
Supporting Statement A_2900-0883_Per Diem to States for Care of Eligible Veterans in State Homes_updated Oct 2023.docx	Supporting Statement A	Uploaded 2023-10-30	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
242721	State Home Inspection Staffing Profile	Form and Instruction	Modified
242720	Request for Prescription Drugs from an Eligible Veteran in a State Home	Form	Modified
242719	Statement of Assurance of Compliance with Equal Opportunity Laws	Form	Modified
242717	Certification Regarding Lobbying	Form	Modified
242714	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	Form	Modified
241862	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	Form	Modified

ICR Details

OMB Control No: 2900-0883	ICR Reference No: 202306-2900-012
Status: Received in OIRA	Previous ICR Reference No: 202005-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0883
Title: Per Diem to States for Care of Eligible Veterans in State Homes
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/30/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2023
Responses	2,805	11,780
Time Burden (Hours)	2,119	5,630
Cost Burden (Dollars)	0	0

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Abstract: Authority for this information collection is from Title 38 Code of Federal Regulations (CFR) Part 51, Per Diem for Nursing Home, Domiciliary or Adult Day Health Care of Veterans in State Veterans Homes published in the Federal Register as final rule on November 28, 2018 (RIN 2900-A088). This collection of forms is approved under OMB Control Number 2900-0883. These six forms (10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460a and 10-3567) are presented to and completed by State Veterans Homes (SVH) management under Subpart B of the CFR Part 51 and then assessed for compliance to applicable regulations under Subparts D, E or F by VA contracted vendors during a VA survey at each State Veterans Home (SVH) across the U.S. as a regulatory action. This collection of forms falls under the auspices of The Office of Geriatrics and Extended Care in VA Central Office (12GEC). As per VHA Directive 1145.01, this collection of forms is part of the VA survey process. The legal requirements that necessitate this collection of information are found specifically at title 38 CFR Parts §51.31, §51.43 and §51.210 for all three levels of care: nursing home, domiciliary, and adult day health care. VA is requesting to replace VA Form 10-0460 Request for Prescription Drugs from an Eligible Veteran in a State Home with a MS Excel file, 10-0460a, that will document and record any SVH request for VA Medical Center (VAMC) furnished medications or VAMC reimbursement of medications that will identify how the Veteran meets regulatory eligibility criteria specified in §51.43. The MS Excel file will be a monthly exchange of information between the SVH and the VAMC to assure compliance with federal regulations. The MS Excel file, 10-0460a,will take the place of the current VA Form 10-0460.

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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:
	88 FR 58439	08/25/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 74247	10/30/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Certification Regarding Lobbying	10-0144	Certification Regarding Lobbying
Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	10-0143	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
Request for Prescription Drugs from an Eligible Veteran in a State Home	10-0460a	Request for Prescription Drugs from an Eligible Veteran in a State Home
State Home Inspection Staffing Profile	10-3567	State Home Inspection Staffing Profile
Statement of Assurance of Compliance with Equal Opportunity Laws	10-0144A	Statement of Assurance of Compliance with Equal Opportunity Laws
Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	10-0143A	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	2,805	11,780	0	-8,975	0	0
Annual Time Burden (Hours)	2,119	5,630	0	-3,511	0	0
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: Changing Forms

Short Statement: The 10-0460 form, which was previously submitted by every individual Veteran, is being replaced with the 10-0460a spreadsheet, which will be submitted once per month for all Veterans per State Home on one spreadsheet. This reduces the burden hours for this collection.

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Annual Cost to Federal Government: $138,403

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: 10/30/2023

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