2012-25749. Agency Information Collection Activities (Per Diem for Nursing Home Care of Veterans in State Homes; Per Diem for Adult Day Care of Veterans in State Homes) Under OMB Review

AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Health Administration, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden; it includes the actual data collection instrument.

DATES:

Comments must be submitted on or before November 19, 2012.

ADDRESSES:

Submit written comments on the collection of information through www.Regulations.gov;​; or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 [phone]. Please refer to “OMB Control No. 2900-0160” in any correspondence.

FOR FURTHER INFORMATION CONTACT:

Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, [phone], fax [phone] or email [e-mail]. Please refer to “OMB Control No. 2900-0160.”

SUPPLEMENTARY INFORMATION:

Titles

a. Title 38, CFR Parts 51 and 52, State Home Programs.

b. State Home Inspection—Staffing Profile, VA Form 10-3567.

c. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588.

d. State Home Program Application for Veteran Care—Medical Certification, VA Form 10-10SH.

e. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143.

f. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-0143a.

g. Certification Regarding Lobbying, VA Form 10-0144.

h. Statement of Assurance of Compliance with Equal Opportunity Laws, VA Form 10-0144a.

i. Request for Prescription Drugs from an Eligible Veteran in a State Home, VA Form 10-0460.

OMB Control Number: 2900-0160.

Type of Review: Extension of a currently approved collection.

Abstract: VA pays per diem to State homes providing nursing home and adult day health services care to Veterans. VA requires facilities providing nursing home and adult day health care to furnish an application for recognition based on certification; appeal information, application and justification for payment; records and reports which facility management must maintain regarding activities of residents or participants; information relating to whether the facility meets standards concerning residents' rights and responsibilities prior to admission or enrollment, during admission or enrollment, and upon discharge; the records and reports which facilities management and health care professionals must maintain regarding residents or participants and employees; documents pertain to the management of the facilities; food menu planning; pharmaceutical records; and life safety documentation. Without access to such information, VA would not be able to determine whether high quality care is being provided to Veterans.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on August 1, 2012, at pages 45719-45720.

Affected Public: State, Local or Tribal Government.

Estimated Total Annual Burden:

a. Title 38, CFR Parts 51 and 52, State Home Programs—3,738 hours.

b. State Home Inspection Staffing Profile, VA Form 10-3567—90 hours.

c. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588—1,080 hours.

d. State Home Program Application for Veteran Care—Medical Certification, VA Form 10-10SH—10,566 hours.

e. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—15 hours.

f. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-1043a—15 hours.

g. Certification Regarding Lobbying, VA Form 10-0144—15 hours.

h. Statement of Assurance of Compliance with Equal Opportunity Laws, VA Form 10-0144a—15 hours.

i. Request for Prescription Drugs from an Eligible Veteran in a State Home, VA Form 10-0460—15 hours.

Estimated Average Burden per Respondent:

a. Title 38, CFR Parts 51 and 52, State Home Programs—7 minutes.

b. State Home Inspection Staffing Profile, VA Form 10-3567—30 minutes.

c. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588—30 minutes.

d. State Home Program Application for Veteran Care—Medical Certification, VA Form 10-10SH—30 minutes.

e. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—5 minutes.

f. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-1043a—5 minutes.

g. Certification Regarding Lobbying, VA Form 10-0144—5 minutes.

h. Statement of Assurance of Compliance with Equal Opportunity Laws, VA Form 10-0144a—5 minutes.

i. Request for Prescription Drugs from an Eligible Veteran in a State Home, VA Form 10-0460—5 minutes.

Frequency of Response: One-time.

Estimated Number of Respondents:

a. Title 38, CFR Parts 51 and 52, State Home Programs—22,926.

b. State Home Inspection Staffing Profile, VA Form 10-3567—180.

c. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588—180.

d. State Home Program Application for Veteran Care—Medical Certification, VA Form 10-10SH—21,132.

e. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—180.

f. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-1043a—180.

g. Certification Regarding Lobbying, VA Form 10-0144—180.

h. Statement of Assurance of Compliance with Equal Opportunity Laws, VA Form 10-0144a—180.

i. Request for Prescription Drugs from an Eligible Veteran in a State Home, VA Form 10-0460—180.

Estimated Total Annual Responses:

a. Title 38, CFR Parts 51 and 52, State Home Programs—23,466

b. State Home Inspection Staffing Profile, VA Form 10-3567—180.

c. State Home Report and State of Federal Aid Claimed, VA Form 10-5588—2,160.

d. State Home Program Application for Veteran Care—Medical Certification, VA Form 10-10SH—21,132.

e. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—180.

f. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-1043a—180.

g. Certification Regarding Lobbying, VA Form 10-0144—180.

h. Statement of Assurance of Compliance with Equal Opportunity Laws, VA Form 10-0144a—180.

i. Request for Prescription Drugs from an Eligible Veteran in a State Home, VA Form 10-0460—180.

Dated: October 15, 2012.

By direction of the Secretary.

William F. Russo,

Deputy Director, Office of Regulations Policy and Management, Office of the General Counsel, Department of Veterans Affairs.