Title 38, Parts 51 and 52, State Home Programs

Forms and Documents

Document Name	Status
Form 10-0143 Title 38, Parts 51 and 52, State Home Program Form	Modified
White Paper Changes to VA Form 10-3567 111815 (3).docx Supplementary Document	2015-12-10
30 Day FRN.pdf Supplementary Document	2015-12-10
2900-0160 Federal Register 60-day Notice.pdf Supplementary Document	2015-08-25
Example-State Letter.pdf Supplementary Document	2015-08-13
2900-0160 Justification_12-10-2015 kh edits (4).docx Supporting Statement A	2015-12-11

IC Document Collections

IC ID	Document Title	Status
28394	Title 38, Parts 51 and 52, State Home Program Form	Modified

ICR Details

OMB Control No: 2900-0160	ICR Reference No: 201506-2900-005
Status: Historical Active	Previous ICR Reference No: 201501-2900-013
Agency/Subagency: VA	Agency Tracking No: 2900-0160
Title: Title 38, Parts 51 and 52, State Home Programs
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/24/2016
	Date Received in OIRA: 12/11/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2019	36 Months From Approved	02/29/2016
Responses	12,884	0	47,838
Time Burden (Hours)	6,818	0	15,550
Cost Burden (Dollars)	0	0	0

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Abstract: To ensure per diem payments are limited to facilities providing high quality care. To determine eligibility for care, to determine payment due State Homes, Nursing Homes, State Hospitals, and Adult Day Health Care (ADHC) providing care to veterans.

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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:
	80 FR 50832	08/19/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 76744	12/10/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Title 38, Parts 51 and 52, State Home Program	10-5588A, 10-0144A, 10-0143, 10-0143A, 10-0144, 10-5588, 10-0460, 10-10SH, VA Form 10-3567	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals ,   Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973 ,   Certification Regarding Lobbying ,   Statement of Assurance of Compliance with Equal Opportunity Laws ,   State Homes Program Application for Veterans Care Medical Certification ,   State Home report and Statement of Federal Aid Claimed ,   Request for Prescription Drugs from an Eligible Veteran in a State Home ,   State Home Inspection Staffing Profile ,   Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.

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ICR Summary of Burden

	Total Approved	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	12,884	47,838	0	-34,954	0	0
Annual Time Burden (Hours)	6,818	15,550	0	-8,732	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: VA Form 10-5588A was developed as requested by State Homes to reduce burden hours in completing a payment claim for multiple Veterans. VA also clarified the wording for Form 10-10SH in the VA authorization for payment section. The revision to VA Form 10-10SH and addition of an instruction sheet enables the State Home Program Office to improve the language in the revised data fields of the administrative and clinical authorization section and reduces the likelihood of errors leading improper payments. Also, with inclusion of an automated 10-10SH system, significant reliance on manual data entry and manual verification of processing no longer has a negative affect on the accuracy of ensuring the form is completed as required and determining Veteran eligibility to receive per diem payments.

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Annual Cost to Federal Government: $1,054,682

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

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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: 12/11/2015

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