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OMB Control No: 2900-0160	ICR Reference No: 201906-2900-005
Status: Historical Inactive	Previous ICR Reference No: 201604-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-NEW
Title: Per Diem to States for Care of Eligible Veterans in State Homes
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 05/12/2020
	Date Received in OIRA: 04/28/2020
Terms of Clearance: Withdrawn at agency request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

Abstract: This collection of forms was part of a previously approved collection under OMB Control Number 2900-0160. However, it has been determined that these six forms will be separated from the other three forms in 2900-0160, and this ICR seeks renewal under a new OMB Control Number. Title 38, CFR Part 51 State Veterans Homes (SVH) regulations published in the Federal Register as final rule on November 28, 2018 (RIN 2900-A088) require the VA to ensure per diem payments are limited to facilities providing high quality care. These six forms are presented to and completed by SVH management and then assessed and utilized by VA SVH Representatives designated by the Medical Center Director of VA of jurisdiction during the annual VA survey process at each SVH across the U.S. as a regulatory action. This collection of forms falls under the auspices of Geriatrics and Extended Care in VA Central Office (10NC4). As per VHA Directive 1145.01, this collection of forms is part of the annual VA survey process. The legal requirements that necessitate this collection of information are found specifically at 38 CFR Parts 51.31, 51.43, and 51.210 for all three levels of care; nursing home, domiciliary, and adult day health care. The information required at time of the VA survey includes the application and justification for medications for a basic rate Veteran; records and reports which SVH management must maintain 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; and staffing documentation.

Authorizing Statute(s): US Code: 38 USC 1710, 1712, 1720 Name of Law: Per Diem for Nursing Home, Domiciliary, or Adult Day Health Care of Veterans in State Homes

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 35453	07/23/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 53243	10/04/2019
Did the Agency receive public comments on this ICR? No

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This collection of forms was part of a previously approved collection under OMB Control Number 2900-0160. However, it has been determined that these six forms will be separated from the other three forms in 2900-0160, and this ICR seeks renewal under a new OMB Control Number. The burden increases and decreases are due to the reduction from 9 forms to 6 forms, as well as some modifications to anticipated responses based upon historically recorded actual responses.

Annual Cost to Federal Government: $97,760

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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? No

Agency Contact: Frances O'Donnell 703 405-2449 fran.odonnell@cathexiscorp.com

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