State Home Programs for Veterans - VA Forms 10-5588, 10-5588A, 10-10SH

Forms and Documents

Document Name	Status
Form 10-10SH State Homes Program Application for Veterans Care Medical Certification Form and Instruction	Modified
Form 10-5588A Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect. Form and Instruction	Modified
Form 10-5588 State Home Report and Statement of Federal Aid Claimed Form	Modified
30-Day FedRegNotice_2900-0160_State Home Programs for Veterans_published 08292023.pdf Supplementary Document	2023-08-29
Response to Public Comment_OMB Control No. 2900-0160- State Home Program for Veterans_08222023_Final.pdf Supplementary Document	2023-08-23
60-Day FedRegNotice_2900-0160_State Home Programs for Veterans_published 06212023.pdf Supplementary Document	2023-08-23
Supp Stmnt A_2900-0160_State Home Programs for Veterans_final Aug 2023.docx Supporting Statement A	2023-08-29

IC Document Collections

IC ID	Document Title	Status
237053	State Homes Program Application for Veterans Care Medical Certification Form and Instruction	Modified
237052	Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect. Form and Instruction	Modified
237051	State Home Report and Statement of Federal Aid Claimed Form	Modified

ICR Details

OMB Control No: 2900-0160	ICR Reference No: 202306-2900-010
Status: Received in OIRA	Previous ICR Reference No: 201906-2900-007
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/29/2023

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

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Abstract: Authority for this information collection can be found in two public laws affecting State homes: Public Law 115-159, the State Veterans Home Adult Day Health Care Improvement Act of 2017, which requires VA to pay State Veteran Homes (SVHs) for medical model adult day health care provided to certain eligible Veterans; and Public Law 116-315, Section 3007, Waiver of Requirements of Department of Veterans Affairs for Receipt of Per Diem Payments for Domiciliary Care at State Homes and Modification of Eligibility for such Payments. This information collection also enables 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 create a safeguard that Veterans are receiving a high quality of care in SVHs. To ensure that high quality care is furnished to Veterans, VA requires those facilities providing nursing home care, domiciliary care, and adult day health care programs to Veterans to supply various kinds of information. The information required includes an application and justification for payment; records and reports that facility management must maintain regarding payment activities of residents or participants; and records and reports that facilities management and health care professionals must maintain regarding eligibility and level of care for residents or participants. The following three forms are included in this information collection: 10-5588, 10-5588A, and 10-10SH. The State Home Per Diem (SHPD) Program made updates to the automated the 10-10SH form to increase functionality and usage. This form was converted into a web-based, fillable form that can be electronically submitted from the SVH to the appropriate VAMC. It includes data field validation, assuring that all required fields have been filled before the user can electronically submit the 10-10SH form. The VA portion of the application also includes business rules to assist the VA representatives in making uniform determinations, allow the VA representative to return incomplete applications to the SVH along with a notification to them, and record the receipt of the completed application.

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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
   PL: Pub.L. 115 - 159 2 Name of Law: State Veterans Home Adult Day Health Care Improvement Act of 2017
   PL: Pub.L. 116 - 315 3007 Name of Law: Veterans Health Care and Benefits Improvement Act of 2020
  

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:
	88 FR 40402	06/21/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 59573	08/29/2023
Did the Agency receive public comments on this ICR? Yes

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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	Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive SVC Connect.
State Home Report and Statement of Federal Aid Claimed	10-5588	State Home Report and Statement of Federal Aid Claimed
State Homes Program Application for Veterans Care Medical Certification	10-10SH, 10-10SH	State Homes Program Application for Veterans Care Medical Certification ,   Online 10-10SH - Application for State Home Care

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ICR Summary of Burden

	Total Request	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	13,614	13,614	0	0	0	0
Annual Time Burden (Hours)	4,816	4,816	0	0	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $212,184

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

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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: 08/29/2023

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