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pdfOMB Control No. 2900-0883
Estimated Burden: 30 minutes
Expiration Date: 11/30/2023
STATE HOME INSPECTION - STAFFING PROFILE
INSTRUCTIONS
1. The Staffing Profile consists of 5 Parts.
2. Complete Part I, noting numbers of operating beds, beds authorized for VA per diem payments, patient
census (veterans and non-veterans), full time employee equivalents (FTEE) authorized, and FTEE
available at the time of the inspection for each level of care provided by the home, i.e., nursing home,
domiciliary, and/or adult day health care (ADHC). Please use the following definitions to complete the
form:
• Operating Beds / Participant Slots - The total number of beds utilized for resident overnight stay
in the SVH facility and then broken down into each level of care regardless of whether they are
recognized or not. For ADHC, a bed means participant slots.
• Authorized Approvals - The total number of beds authorized or participant slots and recognized
by VA for per diem payment and then broken down into each level of care.
• Patient Census - The total number of residents in the facility to include Veterans and NonVeterans and then broken down into each level of care.
• FTEE Authorized - The total FTEE ceiling for the facility and then broken down into each level
of care.
• FTEE Available - The total FTEE of staff available or working at the facility and then broken
down into each level of care.
3. Complete Part II, by enumerating total FTEE positions for the facility and then breakdown the assigned
FTEE for each level of care. For example, if the facility has (12) R.N's, this may breakdown to 10 for the
nursing home, 1 for adult day health care and 1 for the domiciliary.
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 certify your home without a completed form. Failure to complete the form will have no
effect on any other benefits to which you may be entitled. This information is collected under the authority of
Title 38 CFR Parts 51.30 and 52.30.
VA Form
NOV 2020
10-3567
10NC4
OMB Control No. 2900-0883
Estimated Burden: 30 minutes
Expiration Date: 11/30/2023
STATE HOME INSPECTION - STAFFING PROFILE
INSTRUCTIONS
4. Complete the tables in Parts III through V, nursing staffing patterns, for each level of care
using the following instructions.
• Select 4 separate 1 week worked schedules (7 days) at random from the previous 12 months,
and ensure that one week includes one holiday.
• Using the 4 worked schedules, determine the average number of hours for each type of
direct care nursing staff (RN, LPN, CNA), on each shift for each day. (Note: This form is
based on 8 hour shifts. If the State Home utilizes 10 hour shifts, count 8 hours in the first
shift, and 2 hours in the following shift. If the State Home utilizes 12 hour shifts, count 8
hours in the first shift, and 4 hours in the following shift.)
• To achieve the average for each box in the tables on Parts III through V, add the hours from
the 4 week worked schedules, for each direct care nursing staff, by shift, by day and divide
by 4.
• If the level of care has more than one building, a separate form should be used for each
separate building as a pre-work to capture all buildings. The final should be an average of
each of the separate buildings.
• To calculate the total direct care nursing hours for each level of care, take the sum of all
direct care nursing hours from the boxes in the tables on Parts III through V.
• To calculate the direct nursing care hours, per patient, per day, take the total direct care
nursing hours and divide by the patient census multiplied by seven days as displayed in the
formula below.
Nursing Care hours/patient/day = Total Direct Care Nursing Hours
_______________________________________
Patient census (veteran + non-veteran) X 7 days
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 certify your home without a completed form. Failure to complete the
form will have no effect on any other benefits to which you may be entitled. This information is collected under the
authority of Title 38 CFR Parts 51.30 and 52.30.
VA Form
NOV 2020
10-3567
10NC4
OMB Control No. 2900-0883
Estimated Burden: 30 minutes
Expiration Date: 11/30/2023
STATE HOME INSPECTION
NAME OF HOME
PART I
DATE OF INSPECTION
TOTAL FACILITY
ADHC
NHC
DOM
TOTAL FACILITY
ADHC
NHC
DOM
OPERATING BEDS /
PARTICIPANT SLOTS
AUTHORIZED APPROVALS
PATIENT CENSUS
FTEE AUTHORIZED
FTEE AVAILABLE
PART II - STAFF
PHYSICIANS M.D. / D.O.
PHYSICIANS ASSISTANTS
DENTISTS D.M.D. / D.D.S.
SOCIAL WORK MSW
SOCIAL WORK BSW
REGISTERED PHARMACIST
REGISTERED DIETITIAN
FOOD SERVICE SUPERVISOR
DIETARY ASSISTANTS
NURSING ADMINISTRATION /
SUPERVISOR
NURSE PRACTITIONER ( N.P.) /
CERTIFIED NURSING
SPECIALIST (C.N.S.)
REGISTERED NURSE (R.N.)
LICENSED PRACTICAL NURSE
(L.P.N) / LISCENSE
VOCATIONAL NURSE (L.V.N.)
CERTIFIED NURSING
ASSISTANT (C.N.A.)
SPEECH THERAPIST
PHYSICAL THERAPIST
OCCUPATIONAL THERAPIST
PSYCHOLOGIST
PSYCHIATRIST
THERAPUTIC RECREATION
SPECIALIST
ADMINISTRATOR(S)
OTHER (Specify)
VA Form
NOV 2020
10-3567
10NC4
NURSING SERVICE STAFFING PATTERN
FOUR WEEK AVERAGE
NAME OF HOME
DATE OF INSPECTION
PART III
ADHC
SUNDAY
SHIFT
OMB Control No. 2900-0883
Estimated Burden: 30 minutes
Expiration Date: 11/30/2023
RN
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
LPN CNA RN LPN CNA RN LPN CNA RN LPN CNA RN
FRIDAY
SATURDAY
LPN CNA RN LPN CNA RN LPN CNA
DAY
EVENING
NIGHT
ADHC Direct Care Nursing Hours/Patient/Day =
PART IV
NURSING HOME
SUNDAY
SHIFT
RN
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
LPN CNA RN LPN CNA RN LPN CNA RN LPN CNA RN
FRIDAY
SATURDAY
LPN CNA RN LPN CNA RN LPN CNA
DAY
EVENING
NIGHT
Nursing Home Direct Care Nursing Hours/Patient/Day =
PART V
DOMICILIARY
SUNDAY
SHIFT
RN
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
LPN CNA RN LPN CNA RN LPN CNA RN LPN CNA RN
FRIDAY
LPN CNA RN LPN CNA RN LPN CNA
DAY
EVENING
NIGHT
Domiciliary Direct Care Nursing Hours/Patient/Day =
VA Form
NOV 2020
10-3567
SATURDAY
10NC4
| File Type | application/pdf |
| File Modified | 2023-06-21 |
| File Created | 2023-06-21 |