View Information Collection Request (ICR) Package

OMB Control No: 2900-0160	ICR Reference No: 201906-2900-007
Status: Historical Active	Previous ICR Reference No: 201604-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0160
Title: State Home Programs for Veterans - VA Forms 10-5588, 10-5588A, 10-10SH
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/09/2020
	Date Received in OIRA: 05/13/2020
Terms of Clearance: Forms removed from this collection are included in "Per Diem to States for Care of Eligible Veterans in State Homes."

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2023	36 Months From Approved
Responses	13,614	0	0
Time Burden (Hours)	4,816	0	0
Cost Burden (Dollars)	0	0	0

Abstract: Congress passed Public Law 115-159, the State Veterans Home Adult Day Health Care Improvement Act of 2017, requiring VA to pay State homes for medical model adult day health care to certain eligible Veterans, and Title 38, CFR Part 52, which provides for the payment of per diem to State homes that provide adult day health care to eligible Veterans. It also continues to provide for the payment of per diem to State homes that provide care to eligible Veterans in accordance with Title 38, CFR Part 51. The intended effect of these provisions is to provide a safeguard that Veterans are receiving high quality care in State homes. This information collection is necessary to ensure that VA per diem payments are limited to facilities providing high quality care. To verify this level of care, VA requires those facilities providing nursing home care, domiciliary, and adult day health care programs to Veterans to supply various kinds of information. The information required includes an application/eligibility for admission and justification for payment; records and reports which facility management must maintain regarding activities of payment for eligible residents or participants; and the records and reports that facilities management and health care professionals must maintain regarding the level of care approved for residents or participants. This OMB Control Number previously included six additional forms, VA Forms 10-0460, 10-0143, 10-0143A, 10-0144, 10-0144A, and 10-3567, which have now been separated out into another information collection (to be approved under a separate OMB Control Number). This information collection, under OMB Control Number 2900-0160, now includes only three forms: VA Forms 10-5588, 10-5588A, and 10-10SH.

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

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 37016	07/30/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 56891	10/23/2019
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.	10-5588A
State Home Report and Statement of Federal Aid Claimed	10-5588
State Homes Program Application for Veterans Care Medical Certification	10-10SH
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

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	13,614	730	12,884
Annual Time Burden (Hours)	4,816	-2,002	6,818
Annual Cost Burden (Dollars)	0	0	0

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 OMB Control Number previously included six additional forms, VA Forms 10-0460, 10-0143, 10-0143A, 10-0144, 10-0144A, and 10-3567, which have now been separated out into another information collection (to be approved under a separate OMB Control Number). This information collection, under OMB Control Number 2900-0160, now includes only three forms: VA Forms 10-5588, 10-5588A, and 10-10SH.

Annual Cost to Federal Government: $184,737

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

View ICR - OIRA Conclusion