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

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.

The latest form for Per Diem to States for Care of Eligible Veterans in State Homes expires 2026-12-31 and can be found here.

Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals

Federal Enterprise Architecture: Health - Health Care Services

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.