SUPPORTING STATEMENT A
Per Diem to States for Care of Eligible Veterans in State Homes
VA Forms: 10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460a, and 10-3567
OMB Control Number: 2900-0883
Summary of Changes from Previously Approved Collection:
Replacement of prior form 10-0460 with a new excel spreadsheet 10-0460a
Changes in burden: Hours are reduced because the new 10-0460a spreadsheet will be submitted once per month with the information for all eligible Veterans in the State Home, rather than individually by each Veteran.
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 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, which is a one-time form that requires the signature of the Veteran or their representative. Given that the onus of regulatory compliance rests with the SVH rather than the individual Veteran, this signature is unnecessarily burdensome for the Veteran or representative. This replacement method will thus reduce burden to all Veterans/their representatives, as well as enhance ongoing regulatory compliance.
Title 38 CFR Part 51 provides for the payment of per diem to an SVH that provides nursing home care, domiciliary, or adult day health care to eligible Veterans. The intended effect of these regulations is to ensure that Veterans receive safe, high-quality care. 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 to assess compliance. The information required at the
time of the VA survey includes the application and justification for medications; SVH records and reports 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; operation and provision of services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility and staffing by disciplines necessary with 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 with Title 38 CFR Part 51 regulations to ensure that VA per diem payments is 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 complete the following forms during each VA survey:
VA Form 10-0143.The completion of this form is necessary for compliance with 38 CFR §51.210(c)(9). This form is used for the annual certification for Drug-Free Workplace Act of 1988. This form is completed and validated by the SVH management through signature and date and supplied to designated VA survey team members for review and analysis.
VA Form 10-0143A. The completion of this form is necessary for compliance with 38 CFR §51.210(c)(8). This form 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 form is completed and validated by the SVH management through signature and date and supplied to designated VA survey team members for review and analysis.
VA Form 10-0144. The completion of this form is necessary for compliance with38 CFR §51.210(c)(10). This form is used for annual certification regarding lobbying in compliance with Public Law 101-121. This form is completed and validated by the SVH management through signature and date and supplied to designated VA survey team members for review and analysis.
VA Form 10-0144A. The completion of this form is necessary for compliance with 38 CFR §51.210(c)(11). This form 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 form is completed and validated by the SVH management through signature and date and supplied to designated VA survey team members for review and analysis.
VA Form 10-0460a. The completion of this form is necessary for compliance with 38 CFR §51.43(e). This regulation specifies that, “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 10-0460a with the corresponding prescription(s) for each eligible Veteran.” This current version of this form is being replaced by an excel spreadsheet. The current form is outdated, uses a signature, and requests a social security number that can violate
privacy policy. There is no known regulation that requires a Veteran to approve location or method or delivered medications. Medications are provided based on individual Veteran
eligibility. This current form is also only completed once; given that Veterans’ medications and eligibilities can change over time, this form is thus not an effective tool for measuring ongoing regulatory compliance. The form is being replaced with a modern method of information exchange between VAMC and the SVH by method of an MS Excel data collection tool. This method will eliminate any unnecessary burden to the Veteran and will also enhance accuracy between the VA and the SVH to assure ongoing regulatory compliance.
VA Form 10-3567. The completion of this form is necessary for compliance with 38 CFR §51.31. This form is completed by SVH management during any VA survey and used to record the following information: operating beds versus recognized beds, total full-time employee equivalent (FTEE) authorized and total FTEE available to review vacancies as well as total resident census. All elements of Parts I and II must be completed by each SVH in their entirety utilizing only numbers. Parts III through V are completed by the SVH according to the applicable level of care in which the SVH receives federal per diem payment. The form under Part II must be completed in its entirety entering only numbers by the SVH management for the FTEE expended on each type of discipline listed required to provide care to residents. The completed form is evaluated by the VA-contracted vendor to assess whether the clinical staffing of the facility meets federal standards set by the Title 38 CFR Part 51 regulations in Subparts D, E or F according to discipline to ensure high quality care. This form is completed by the SVH management and supplied to the designated VA survey team members for review and analysis. Minor changes have been made to the form from a previous version to enhance instructions to SVH management in an effort to obtain accurate data, as well as reduce burden to SVH management to complete all parts of the form.
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 fillable and printable 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.
An MS Excel form with instructions, 10-0460a, is replacing VA Form 10-0460. Utilization of a MS Excel file will allow for the SVHs’ electronic monthly submission of all necessary information for the VAMC to assess and verify eligibility of each Veteran as a resident in the SVH. This ongoing eligibility assessment and verification is necessary to assure compliance to the federal regulation §51.43. In addition, given that the onus of regulatory compliance rests with the SVH rather than with the individual Veteran, this replacement form will remove the need for the signature of the Veteran or their representative. The impetus for the decision to replace VA Form 10-0460 with an MS Excel file, 10-0460a, is: to reduce the burden to Veterans; record and track Veterans’ specific eligibility for VA-furnished medications or reimbursement for medications and protect both VA and SVHs from regulatory non-compliance.
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 and MS Excel file are required by regulation.
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 and MS Excel file 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 using the forms and MS Excel data collection, the Department would be unable to assess the quality standards that are required by Title 38 CFR Part 51 regulations. Validation of each SVH’s compliance with these regulations is necessary to provide federal grant and per diem funding. Therefore, the assessment of quality care indicators is critical for the VA to document whether high quality care is being provided to eligible Veterans. If the minimum regulations are not being met, per diem payments to a SVH can be jeopardized. The information being collected at a SVH is on any VA survey.
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 August 25, 2023 (88 FR 164, pages 58439-58440). 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 30, 2023 (88 FR 208, pages 74247-74248).
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 current form VA 10-0460 requests the Veteran’s full Social Security Number on page 1. This form has been reported to VA as requested; however, the form is currently required by 38 CFR §51.43(e). Under this renewal, VA is requesting to replace VA form 10-0460 with a collection of necessary information from SVH management by means of an MS Excel file, 10-0460a. VA also will make regulatory edits through VA concurrence to modify §51.43(e). The remaining forms in this group do not contain information that needs to be protected. The forms are reviewed, retained, and filed with The Office of Geriatrics & Extended Care (12GEC) per VHA Directive 6300(1) Record Management for use in assessing and rating each Title 38 CFR Part 51 regulation on any individual SVH survey per level of care recognized by the Under Secretary for Health.
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 Office of Geriatrics & Extended Care (12GEC) in accordance with the policies of records management. There is no information collected on any of the forms that is of a sensitive nature.
12. Estimate of the hour burden of the collection of information:
a. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:
Total annual burden = 2,119 hours
Total annual responses = 2,805
(1) VA Form 10-0143, Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements For Grantees Other Than Individuals = 13.75 hours annually
Respondents |
Frequency |
Responses |
Min. Each |
Burden Hours |
165 |
1 |
165 |
5 |
13.75 ~14 hrs |
(2) VA Form 10-0143A, Statement of Assurance of Compliance with Section 504 of The Rehabilitation Act of 1973 = 13.75 hours annually
Respondents |
Frequency |
Responses |
Min. Each |
Burden Hours |
165 |
1 |
165 |
5 |
(3) VA Form 10-0144, Certification Regarding Lobbying = 13.75 hours annually
Respondents |
Frequency |
Responses |
Min. Each |
Burden Hours |
165 |
1 |
165 |
5 |
13.75 ~14 hrs |
(4) VA Form 10-0144A, Statement of
Assurance of Compliance with Equal
Opportunity Laws = 13.75
hours annually.
Respondents |
Frequency |
Responses |
Min. Each |
Burden Hours |
165 |
1 |
165 |
5 |
13.75 ~14 hrs |
(5) VA Form 10-0460a, MS Excel file for Medication Eligibility = 1980 hours annually.
Respondents |
Frequency |
Responses |
Min. Each |
Burden Hours |
165 |
12 |
1980 |
60 |
1,980 hrs |
VA Form 10-3567, State Home Inspection – Staffing Profile = 82.5 hours annually.
Respondents |
Frequency |
Responses |
Min. Each |
Burden Hours |
165 |
1 |
165 |
30 |
82.50 ~83 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 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 10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460a, and 10-3567 will be completed by SVH Management and provided to the VA Survey Team members. The MS Excel file for medication eligibility will be shared between SVH management and VA Medical Center of jurisdiction monthly, or more often, if necessary, to validate Veteran compliance of eligibility.
Estimated cost to respondents: $70,689.84 (2119 burden hours x $33.36 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 SVH Management 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: $138,403.20
Data Source: http://www.fedsdatacenter.com/gs-pay-calculator/
Review by national contracted vendor who performs the survey and supplies forms to VA is based by contract on firm fixed price.
VA Central Office Geriatrics & Extended Care oversight review - $138,403.20
Items 12.a. (1-4)
4/Hours/Week with 4 POD Managers = 832 hours per year x $55.45 = $46,134.40 (GS- 13 step 5 – Pittsburgh locality)
Items 12.a. (5-6)
8/Hours/week with 4 Pod Managers = 1,664 hours per year x $55.45 = $92,268.80 (GS- 13 step 5– Pittsburgh locality)
This amount includes burden hours of the VACO GEC staff SVH to review all forms and excel file (1) for all 165 surveys per year and then any VA recognition surveys which is approximately 12 per year.
SALARY TABLE 2023-PIT (LEO) (opm.gov)
15. Explain the reason for any changes reported in Items 13 or 14 above.
The changes in the cost to the Federal government since the previous approval are accounted for by the implementation of SVH Modernization approved by the VHA Under Secretary for Health and implemented January 2022. As requested by Congress and supported by VHA, VA SVH oversight transitioned from the former state wherein a combination of a national contracted vendor and designated individuals from the VA Medical Center of jurisdiction completing the VA survey to the current state wherein a national contracted vendor and four GEC Program Managers complete the VA survey. This centralization of SVH oversight and survey responsibilities assures that GEC reviews the accuracy of all VA forms and assesses SVHs’ completed MS Excel files to determine SVHs’ regulatory compliance with eligibility criteria outlined in §51.43.
The respondent burden and federal government cost reduction is the result of the following:
The reduction of 3,511 burden hours to the SVH management and increase cost to the federal government of $40,642.96 from the past submission of this collection reflects the following:
GEC implemented SVH Modernization in January 2022 whereby the VA Medical Centers of jurisdiction are no longer a part of the VA’s SVH survey process or included in VA’s quality oversight of SVHs. All VA SVH survey oversight functions are now centralized under GEC.
Salary costs are based on the average General Schedule 13 –Step 5 position description as that is designated Pod Manager in GEC who receives the completed VA forms from the contracted vendor following completion of a VA survey identified in this document 12. (a) (1-4) that were completed by SVH management. VA Form 10-3567 is submitted to the VA-contracted national survey vendor for evaluation. The MS Excel file on medication eligibility is completed by SVH management and submitted to the VAMC throughout the year and to GEC for evaluation during any VA survey.
Estimated salary costs based on the current GS 13 position for the VA GEC staff who currently reviews the Forms 12. (a) (1-6) utilized and recorded in 14.
VA Form 10-0460 is being replaced with a data collection utilizing a defined standard MS Excel file template, 10-0460a, for Veteran medication eligibility. This process is different from the last form’s collection.
VA Form 10-3567 is being revised from previous form dated 2015 to enhance the instructions to SVH management, with the goal of reducing errors and burden. Since the last form’s submission, multiple presentations and significant amounts of educational material have been provided to the VA-contracted national survey vendor, States, and SVH Management for ease of completion.
The only printing necessary is if a SVH needs a copy during the survey and if they select to not use the fillable option or create a printed copy.
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.
No statistical methods are used in this data collection.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Bold black = OMB questions |
| Author | vhacobickoa |
| File Modified | 0000-00-00 |
| File Created | 2023-11-01 |