+-------------------------------------+--------------------------------+
| **Department of Veterans Affairs**  | ### VHA HANDBOOK 1140.1        |
+-------------------------------------+--------------------------------+
| **Veterans Health Administration**  | **Transmittal Sheet**          |
+-------------------------------------+--------------------------------+
| **Washington, DC 20420**            | **March 7, 2005**              |
+-------------------------------------+--------------------------------+

#### COMMUNITY RESIDENTIAL CARE PROGRAM

**1. PURPOSE.** This Veterans Health Administration (VHA) Handbook, a
complete revision of the Community Residential Care (CRC) VHA Manual
M-5, Part III, is mandated by Public Law 98-160, the Veterans Benefits
Improvement Act. ***NOTE:** Any veteran placed in a residence in the
community, other than the veteran's own domicile, is under the oversight
of the CRC Program.*

**2. SUMMARY OF CHANGES:** This Handbook:

a\. Cites statutory authority; provides key program definitions; states
goals of CRC Program; defines eligibility; and sets forth programmatic
responsibilities.

b\. Describes the process of applying for participation in the CRC
Program, the training requirements for CRC providers, staffing guidance,
record keeping, and reporting systems.

c\. Establishes CRC facility standards to be met and describes
exceptions to these standards, and the variable interval lengths of VA
approval.

d\. Describes the process of revoking Department of Veterans Affairs
(VA) approval of a facility when there is non-compliance with VA
standards that the facility will not correct.

e\. Establishes the rate structure for CRC and allowable deviations from
that structure.

f\. Describes appropriate CRC candidates; states resident placement
policy; establishes follow-up policy of residents by VA staff; and
outlines discharge policy from CRC Program.

g\. Makes provision for an expedited pension claim process that can be
utilized.

**3. RELATED ISSUES:** VHA Directive 1140 (to be published).

**4. RESPONSIBLE OFFICE:** The Office of Patient Care Services,
Geriatrics and Extended Care (114), is responsible for the contents of
this Handbook. Questions may be directed to 202-273-8537.

**5.** **RESCISSIONS**: VHA Manual M-5, Part III, Chapters 1 through 9,
are rescinded.

**6. RECERTIFICATION:** This VHA Handbook is scheduled for
recertification on or before the last working day of March 2010.

  ------------------------------- ---------------------------------------
                                  

                                  S/Jonathan B. Perlin, MD, PhD, MSHA,
                                  FACP

                                  Acting Under Secretary for Health
  ------------------------------- ---------------------------------------

  ---------------- ------ ------------------------------------------------
  DISTRIBUTION:    CO:    E-mailed 3/8/2005

                   FLD:   VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          3/8/2005
  ---------------- ------ ------------------------------------------------

#### CONTENTS

**COMMUNITY RESIDENTIAL CARE (CRC) PROGRAM**

## PARAGRAPHS PAGE

1\. Purpose 1

2\. Background 1

3\. Authority 1

4\. Definitions 1

5\. Goals of Program 3

6\. Eligibility 4

7\. Responsibilities 4

8\. Voluntary Nature of Facility Operator Participation 5

9\. Selection of Homes 5

a\. Application 5

b\. Inspection 6

c\. Notification of CRC Facility Operator 6

10\. Standards for Homes 6

a\. Health and Safety Standards 6

b\. Health Services 7

c\. Interior Plan 7

d\. Laundry Service 7

e\. Residents' Bedrooms 7

f\. Nutrition 7

g\. Activities 8

h\. Residents' Rights 8

i\. CRC Facility Records 9

j\. CRC Staff Requirement 9

k\. Exceptions to Standards 9

11\. Timetable for Reinspections and Duration of Approval 10

###### **CONTENTS** Continued

## 

## PARAGRAPHS PAGE

12\. Due Process and Request for Hearing 11

a\. Notice of Non-compliance with VA Standards 11

b\. Request for Hearing 12

c\. Notice and Conduct of Hearing 12

d\. Waiver of Opportunity for Hearing 12

e\. Written Decision Following a Hearing 12

f\. Revocation of VA Approval 13

13\. Financial Arrangements 14

a\. Cost of CRC 14

b\. Fees for CRC Care 14

14\. Selection, Placement, and Follow-Up of Residents 15

a\. Selection of Potential Residents 15

b\. Placement of Residents 15

c\. Follow-up 16

d\. Discharge from CRC Program 16

15\. Provider Knowledge, Skill, and Education 17

16\. Quality Assurance in the CRC Program 18

a\. Responsibility 18

b\. Data 18

##### 17. Availability of Information, Staffing, Records, Reporting Systems,

#####  and the Release of Patient-specific Health Information 19

a\. Availability of Information 19

b\. Staff Guidance 19

c\. VA Records 20

d\. CRC Facility Records 20

e\. Reporting System 20

f\. Release of Patient-specific Health Information 21

**APPENDIX**

A VA Form 10-2407, Residential Care Home Program -- Sponsor Application
A-1

######## 

###### **CONTENTS** (Appendices Continued)

## 

## PARAGRAPHS PAGE

######## 

######## B Initial Home Assessment Checklist B-1

C VA Form 10-2410, Agreement to Provide Home Care for Patient C-1

D VA Form 10-2409, Patient's Agreement with Hospital in Relation to a
Home

Other Than His Own D-1

E VA Form 10-2406, Recommendation for Release of Patient in Home Other

Than His Own E-1

**COMMUNITY RESIDENTIAL CARE PROGRAM**

**1. PURPOSE**

This Veterans Health Administration (VHA) Handbook is a complete
revision of the Community Residential Care (CRC) Manual M-5, Part III,
Chapters 1 through 9, and is based on the first Federal Regulations
addressing the health and safety of residents in this level of care,
mandated by Public Law 98-160, the Veterans Benefits Improvement Act.

**2. BACKGROUND**

Since 1951, the Department of Veterans Affairs' (VA) CRC Program has
provided health care supervision to eligible veterans not in need of
acute hospital care, but who, because of medical and/or psychosocial
health conditions, are not able to live independently and have no
suitable family or significant others to provide the needed supervision
and supportive care. The CRC Program is an important component in VA\'s
continuum of long-term care services. This program has evolved through
the years to encompass: Medical Foster Homes, Assisted Living, Personal
Care Homes, Family Care Homes, and Psychiatric CRC Homes.

**3. AUTHORITY**

The CRC Program is operated under the authority of Title 38 United
States Code (U.S.C.) 630. Any veteran placed in a residence in the
community, other than the veteran's own domicile, is under the oversight
of the CRC Program.

**4. DEFINITIONS**

a\. **[CRC.]{.underline}** CRC is a form of enriched housing which
provides health care supervision to eligible veterans not in need of
acute hospital care but who, because of medical, psychiatric and/or
psychosocial limitations as determined through a statement of needed
care, are not able to live independently and have no suitable family or
significant others to provide the needed supervision and supportive
care. Examples of CRC's enriched housing may include, but are not
limited to: Medical Foster Homes, Assisted Living Homes, Group Living
Homes, Family Care Homes, and Psychiatric CRC Homes. Care must consist
of room, board, assistance with activities of daily living and
supervision as determined on an individual basis. The cost of
residential care is financed by the veteran\'s own resources. Placement
is made in residential settings inspected and approved by the
appropriate VA facility, but chosen by the veteran.

b\. **[CRC Home.]{.underline}** A CRC Home is a privately owned
residence or group living facility situated in the community. It
provides room, board, supervision and assistance in daily living
activities.

c\. **[Facility Operator (Sponsor).]{.underline}** A facility operator
assumes the management responsibility for the facility and may or may
not be the provider. ***NOTE:** Historically, the facility operator has
been called the sponsor.*

d\. **[Fiduciary.]{.underline}** A fiduciary is a person or an
institution responsible for:

\(1\) Managing money or property for another, and

\(2\) Exercising a standard of care imposed by law or contract in such
management activity.

e\. **[Provider.]{.underline}** A provider is the person responsible for
the day-to-day operations of veterans' care in the home. The provider,
or designee, is normally a full-time occupant of the home.

f\. **[Statement of Needed Care.]{.underline}** The
"Statement of Needed Care" means a written description of needed
assistance in daily living activities devised by a VA facility for each
referred veteran in CRC. This statement of needed care may also be
referred to as Treatment Plan or Plan of Care.

g\. **[Activities of Daily Living  (ADL).]{.underline}** The terms ADL
and Instrumental ADL relate to the following:

\(1\) Transfer, ambulation, and walking;

\(2\) Bathing, shaving, brushing teeth, and combing hair;

\(3\) Dressing;

\(4\) Eating and/or feeding;

\(5\) Getting in and out of bed and/or transferring from bed to chair;

\(6\) Doing laundry;

\(7\) Cleaning room;

\(8\) Managing money;

\(9\) Shopping;

\(10\) Using public transportation;

\(11\) Writing letters;

\(12\) Making telephone calls;

\(13\) Obtaining appointments;

\(14\) Managing medication;

\(15\) Recreation and leisure activities;

\(16\) Preparing food for personal use; and

\(17\) Toileting

h\. **[Approving Official.]{.underline}** The term "Approving Official"
means the Director or, if designated by the Director, the Associate
Director or Chief of Staff, of a VA medical center or Outpatient Clinic
which has jurisdiction to approve a CRC facility.

i\. **[Hearing Official.]{.underline}** The term "Hearing Official"
means the Director or, if designated by the Director, the Associate
Director or Chief of Staff, of a VA medical center or Outpatient Clinic
which has jurisdiction to approve a CRC facility.

j\. **[Home--Based Primary Care (HBPC).]{.underline}** HBPC is a program
that provides comprehensive interdisciplinary primary and palliative
care in the homes of veterans with complex medical, social, and
behavioral conditions for whom routine clinic-based care is not
effective. The focus of HBPC is long-term care.

k\. **[Program Coordinator.]{.underline}** The Program Coordinator is
that individual in the VA medical center or Outpatient Clinic who is
assigned the role of managing the CRC Program.

l\. **[Paper Hearing.]{.underline}** A Paper Hearing is a review of the
written evidence of record by the Hearing Official.

m\. **[Oral Hearing.]{.underline}** An Oral Hearing is the in-person
testimony of representatives of a CRC facility and VA before the Hearing
Official and the review of the written evidence of record by that
official.

n\. **[VA Health Care Provider.]{.underline}** The term "VA Health Care
Provider" refers to the Interdisciplinary Team responsible for providing
and/or coordinating care to veterans. The Interdisciplinary Team may
include, but is not limited to the: Physician, Advanced Practice Nurse,
Registered Nurse, Social Worker, Physical Therapist, Dietitian, and
other team members, as identified.

o\. **[VA Facility.]{.underline}** Any facility operated by VHA
including: medical centers, outpatient clinics, and community-based
outpatient clinics.

**5. GOALS OF PROGRAM**

The goals of the CRC Program are to:

a\. Provide the appropriate level of care and an improved quality of
life for veterans who do not require acute hospital care, but who are
not capable of independent living. Veterans may receive follow-up
services through a VHA facility or Community-Based Outpatient Clinic
(CBOC) or programs such as: HBPC, Primary Care, Geriatrics, Mental
Health Service, and other clinics and programs.

b\. Facilitate the most appropriate use of VA and community resources.

c\. Maintain or improve veterans\' health and social functioning in a
non-institutional, supportive environment.

d\. Support the highest level of functioning of the veteran including
discharge to independent living, when possible.

e\. Provide a home environment where the veteran may remain in comfort,
retain dignity, and have the needed support through end of life, guided
by veteran preference and feasibility.

**6.** **ELIGIBILITY**

Veterans may be self-referred to the CRC program or by VA health care
staff, if they meet the following criteria:

a\. At the time of referral:

\(1\) The veteran is receiving VA medical services on an outpatient
basis, or is a patient at a VA medical center, domiciliary, or nursing
home care unit; or

\(2\) Such care or services were furnished to the veteran within the
preceding 12 months.

[and]{.underline}

b\. The veteran is unable to live independently and has no suitable
significant others to provide needed monitoring, supervision, and
necessary assistance in activities of daily living (ADL).

**7. RESPONSIBILITIES**

a\. **[Office of Geriatrics and Extended Care at VA Central
Office.]{.underline}** The Office of Geriatrics and Extended Care at VA
Central Office is responsible for the overall program management and
policies of the CRC Program. This office coordinates the activities in
the CRC Program with other involved VHA and VA offices.

b\. **[Medical Center Director or Outpatient Clinic
Director.]{.underline}** The Medical Center Director or Outpatient
Clinic Director is responsible for:

\(1\) Local CRC program management.

\(2\) In consultation with the Chief, Social Work Service or the Social
Work Executive, is responsible for appointing a Program Coordinator who
must be a clinician with the ability to work with complex medical,
geriatric, mental health, and community programs. The Program
Coordinator has responsibility for overall operation of the program.

\(3\) Designating an interdisciplinary inspection team.

\(4\) Ensuring that transportation is available to the team for
evaluation and patient follow-up.

c\. **[Interdisciplinary Inspection Team]{.underline}** At a minimum,
the team will consist of a social worker, nurse, dietitian and a fire
and safety specialist. Adjunct team members, including a physician,
rehabilitation medicine staff member and an infection control staff
member, will participate in team meetings and must be available to
assist the interdisciplinary inspection team upon consultation. The team
is responsible for:

\(1\) Conducting inspections of CRC facilities and recommending approval
or disapproval of these facilities' participation in the program.

\(2\) Providing guidance for the overall management of the program.

> \(3\) Establishing and implementing a system of monitors which
> includes re-hospitalizations and complaints to determine any deficits
> in the care provided in CRC facilities.

\(4\) Conducting sponsor and provider education.

**8. VOLUNTARY NATURE OF FACILITY OPERATOR PARTICIPATION**

Facility operators who apply for participation in the CRC Program must
accept the VA conditions of participation. VA inspects CRC facilities
with the permission of the facility operator and, if deficiencies are
found in the inspection process, the facility operator freely decides
whether to correct them so as to become or remain a part of the CRC
Program.

**9. SELECTION OF HOMES**

All CRC facilities must be inspected by a VA inspection team prior to
the placement of any veteran. Inspections must be carried out in
accordance with standards delineated in paragraphs 10 and 13. ***NOTE:**
No VA employee or member of an employee\'s household may be a CRC
facility operator, employee, or provider.*

a\. **[Application]{.underline}**

\(1\) Application for participation in the CRC Program must be made in
writing by the prospective facility operator. VA Form 10-2407,
Residential Care Home Program Sponsor Application, (see App. A) may be
used. The completed application must be forwarded to the CRC Program
Coordinator.

\(2\) The prospective CRC facility operator may informally discuss the
potential of the home for use in the CRC Program with the Program
Coordinator, or designee.

\(3\) When formal application is made it will be reviewed by the CRC
Program Coordinator, or designee, who will contact the applicant to
arrange a site visit.

\(4\) The CRC Program Coordinator, or designee, must visit the
prospective facility operator and the home to make an initial assessment
of the facility and its appropriateness for potential use and must
evaluate the operator's predictors for success, e.g., strong
interpersonal skills, good listening skills, and problem solving skills
(see App. B).

\(a\) If the recommendation is positive, a formal inspection is
scheduled. In those states requiring a license to operate a residential
care home, the facility operator must provide proof of licensure prior
to the initial assessment or Interdisciplinary Team inspection.
Additionally, a background check is required of any person who is
employed by, or provides care as a CRC operator or provider.

\(b\) If the recommendation is negative, the applicant must be notified
in writing.

b\. **[Inspection.]{.underline}** If indicated, a VA inspection is
scheduled and conducted by the interdisciplinary inspection team.
Attention needs to be given to the facility and/or home evacuation plan
and its adherence to applicable life safety codes. All reports must be
submitted to the CRC Program Coordinator for review. The Program
Coordinator must make a recommendation of approval or disapproval to the
approving official.

***NOTE:** The initial assessment and interdisciplinary team inspection
may be combined into one step.*

c\. **[Notification of CRC Facility Operator.]{.underline}** Following
the team inspection, a letter of final acceptance or rejection must be
sent to the applicant within 30 days of the inspection date.

**10. STANDARDS FOR HOMES**

The approving official may approve a CRC facility based on the report of
a VA inspection on any findings of necessary interim monitoring of the
facility, if that facility meets the following standards:

a\. **[Health and Safety Standards.]{.underline}** The facility must:

\(1\) Meet all State and local licensure requirements and regulations
including construction, fire, maintenance, and sanitation regulations.

\(2\) Meet the applicable provisions of the most current edition of the
National Fire Protection Association (NFPA) Life Safety Code, Standard
#101, subject to changes published in the
[Federal Register]{.underline}. Applicable chapter of the most current
NFPA Life Safety Code must be used. In lieu of direct compliance with
the NFPA Life Safety Code, alternative equivalent methods may be used,
in accordance with the most current NFPA Manual, [Alternative Approaches
to Life Safety]{.underline}, and are subject to approval by the facility
Safety Officer and Director.

\(3\) Have safe and functioning systems for: heating and cooling; hot
and cold water; electricity; plumbing; sewage; food preparation,
distribution and storage; laundry; artificial and natural light; and
ventilation.

b\. **[Health Services.]{.underline}** The CRC facility must agree to
assist residents as detailed in the Statement of Needed Care, and/or
Treatment Plan and/or Plan of Care developed by the VA health care
provider. The VA health care provider, veteran, and the CRC operator
collaborate to implement the stated Plan of Care. Veterans residing in
residential care facilities may receive follow-up services through
facility programs, such as: Primary Care, Geriatrics, Mental Health
Services, and HBPC for veterans requiring in-home care, and other
clinics as indicated.

c\. **[Interior Plan.]{.underline}** The CRC facility must:

\(1\) Have comfortable dining areas, adequate in size for the number of
residents.

\(2\) Comfortable living room areas, adequate in size to accommodate a
reasonable proportion of residents.

\(3\) Maintain at least one functional toilet and lavatory, and bathing
or shower facility for every six people living in the facility,
including provider and staff.

d\. **[Laundry Service.]{.underline}** The CRC facility must provide or
arrange for laundry service.

e\. **[Residents' Bedrooms]{.underline}**

\(1\) Bedrooms may contain no more than four beds. ***NOTE:** The
complex nature of certain patients may dictate the need for single
occupancy in a bedroom.*

\(2\) Bedrooms must measure, exclusive of closet space, at least 100
square feet for a single-resident room and 80 square feet for each
resident in a multi-resident room and must contain necessary equipment
and furnishings appropriate to health care needs.

\(3\) Bedrooms must contain, at a minimum, a suitable bed and
furnishings: night stand with lamp; dresser; mirror; chair; wardrobe or
closet, a secure space for personal items, and floor coverings, e.g.,
linoleum, carpet, hardwood floors, etc.

f\. **[Nutrition]{.underline}**

\(1\) The CRC facility must provide safe and sanitary food production,
distribution, and storage for residents. These practices will meet all
applicable standards set for safe food handling.

\(2\) The CRC facility must plan menus to meet currently recommended
dietary allowances for residents.

\(3\) Individual nutritional requirements must be met, taking into
consideration residents\' preferences and health status.

g\. **[Activities.]{.underline}** The facility must plan and facilitate
appropriate recreation and leisure activities to meet individual needs,
as specified in the statement of needed care.

h\. **[Residents' Rights.]{.underline}** The provider must have written
policies and procedures that ensure and inform each resident of their
following rights:

\(1\) **General.** All residents have the right to:

\(a\) Be treated with respect, dignity and consideration.

\(b\) Non-disclosure of records and information obtained or kept by the
CRC facility staff, except in accordance with the requirements of
applicable law.

\(c\) Review their own records kept by the CRC facility.

\(d\) Exercise rights as a citizen.

\(e\) Voice grievances and make recommendations concerning policies and
procedures of the CRC facility.

\(2\) **Financial Affairs.** Residents must be allowed to manage their
own personal financial affairs except when restricted in this right by
law or by the plan of needed care. If the resident requests assistance
in managing personal financial affairs, the request must be documented
and evaluated by the Program Coordinator and other persons as
appropriate.

\(3\) **Privacy.** Residents must be allowed privacy, to include:

\(a\) Access to a phone. ***NOTE:** Reasonable privacy must be
available.*

\(b\) Unopened and uncensored mail. Mail must be sorted and delivered
unopened and uncensored.

\(c\) Privacy of self and possessions.

\(4\) **Work.** No resident will perform household duties, other than
personal housekeeping tasks, unless the resident receives compensation
for these duties, or is told in advance they are voluntary and the
patient agrees to do them.

\(5\) **Freedom of Association**

\(a\) Residents may receive and associate freely with persons and groups
of their own choosing both within and outside of the facility in
accordance with the CRC facility and/or house rules, set forth in the
agreement between the resident and the CRC facility operator.

\(b\) Residents may leave and return freely to the CRC facility in
accordance with the house rules and the statement of needed care as set
forth in the agreement between the resident and the facility operator.

\(c\) Residents may practice the religion of their own choosing or
choose to abstain from religious practice.

\(6\) **Transfer or Withdraw.** A resident has the right to request a
transfer to another CRC facility or to withdraw from the program, unless
there are legal constraints.

i\. [**CRC Facility** **Records**]{.underline}

\(1\) The CRC facility must maintain resident records in a secure place.

\(2\) The CRC facility records must include the following:

\(a\) A copy of the Statement of Needed Care as well as a statement
signed by a VA provider certifying the veteran's need for residential
care.

\(b\) Emergency notification procedures.

\(c\) A copy of all signed agreements with the resident or the
resident\'s fiduciary.

\(d\) A record of all financial transactions with the resident or the
resident\'s fiduciary.

\(3\) Record maintenance must comply with State and local law.

\(4\) Records may only be disclosed with the resident\'s permission, or
when required by law.

j\. **[CRC Staff Requirements]{.underline}**

\(1\) Sufficient, qualified staff must be on duty and available to
ensure the health, safety, and care of each resident.

\(2\) The CRC provider and staff must have adequate education, training
and/or experience to maintain the facility.

k\. **[Exceptions to Standards]{.underline}**

\(1\) Facilities that participated in the CRC Program prior to June 14,
1989, may continue to be approved if all standards other than the
bathroom and bedroom standards are met and the following conditions
exist:

\(a\) There is at least one functional toilet, lavatory, and bathing or
shower facility for every eight people living in the facility including
the provider and staff; and

\(b\) The residents\' bedrooms measure, exclusive of closet space, at
least 80 square feet for a single-resident room or 65 square feet for
each resident in a multi-resident room.

\(c\) In lieu of direct compliance with the Life Safety Code,
alternative equivalent methods may be used in accordance with the most
current NFPA manual, Alternative Approaches to Life Safety, and are
subject to approval by the facility Safety Officer and the facility
Director.

\(2\) CRC facilities which do not meet the requirements for continued
approval because they do not comply with the preceding stated exceptions
may apply in writing to the Secretary of Veterans Affairs for an
exception. Requests must be reviewed by the Chief Consultant for
Geriatrics and Extended Care (114). The Chief Consultant for Geriatrics
and Extended Care (114) must notify the approving official of the
application and write a response to the application for the Secretary\'s
approval. The application must include a description of the facility,
including a description of the bathroom and/or the bedroom, and an
analysis of alternative solutions.

\(3\) In lieu of direct compliance with the NFPA Life Safety Code,
alternative equivalent methods may be used, in accordance with the most
current NFPA Manual, [Alternative Approaches to Life
Safety]{.underline}, and are subject to approval by the facility Safety
Officer and Director.

**11. TIMETABLE FOR REINSPECTIONS AND DURATION OF APPROVAL**

a\. The duration of VA\'s approval depends on a facility\'s compliance
with standards. Re-inspections, and interim monitoring, of any facility
in the CRC Program may be unannounced. ***NOTE:*** *Annual
re-inspections for quality management purposes are recommended to ensure
facility compliance with VHA regulations and this Handbook.* Public Law
98-160, and Title 38 Code of Federal Regulations (CFR) Chapter 1,
specify the following inspection timetables.

\(1\) Approval may be valid for up to 24 months, if the facility
complies with all standards during the current inspection, all previous
VA inspections, and any interim monitoring for a period of 2 years.

\(2\) Approval may be valid for up to 15 months, if VA finds the
facility has complied with all standards except the records standard set
forth in sub paragraph 10i during current inspection, all previous VA
inspections, and any interim monitoring.

\(3\) Approval may be valid for up to 12 months if VA finds that the
facility has complied with all standards except the laundry service
standards in subparagraph 10d, and the records standard during the
current inspection, all previous VA inspections, and any interim
monitoring.

\(4\) Approval may be valid for up to 9 months if VA finds that the
facility has complied with all standards except the bedroom standard in
sub paragraph 10e; the activities standard in subparagraph 10g; the
laundry service standards; and the records standard during the current
inspection, all previous VA inspections, and any interim monitoring.

**NOTE:** *A facility granted an exception, under subparagraph 10k,
relating to the bedroom standard, or under subparagraph 13b, relating to
the fees for care requirement, is in compliance with that standard or
requirement for purposes of this Handbook.*

b\. All re-inspections must be carried out by an interdisciplinary team
consisting of a social worker, nurse, dietitian, and fire safety
specialist. Adjunct team members including the physician, rehabilitation
medicine staff member, and infection control staff member must
participate in the inspection as needed.

c\. The CRC Program Coordinator is responsible for ensuring that all
deficiencies are corrected.

\(1\) The CRC Operator must be notified in writing of the identified
deficiencies within 15 days of the inspection.

**NOTE:** *At any time, if any major deficiency is found, any team
member, in conjunction with the CRC Program Coordinator, may suspend new
admissions to the facility.*

\(2\) The CRC Operator must develop and submit a corrective plan of
action within 10 days of receipt of the Letter of Deficiencies.

\(3\) Failure to comply with the proposed plan of corrective action may
lead to the procedures outlined in paragraph 12.

\(4\) The VA facility Director, or designee, must receive a copy of the
deficiencies, a proposed plan of corrective action, and a copy of the
confirmation letter that the deficiencies have been corrected.

**12. DUE PROCESS AND REQUEST FOR HEARING**

a\. **[Notice of Non-Compliance with VA Standards.]{.underline}** If the
Hearing Official (Director, or if designated by the Director, the
Associate Director or Chief of Staff for a VA medical center or
Outpatient Clinic) determines that an approved CRC facility does not
comply with standards set forth in paragraphs 10 and 13, the hearing
official must notify the CRC facility in writing:

\(1\) Which standards have not been met.

\(2\) The date by which the standards must be met in order to avoid
revocation of VA approval.

\(3\) That the CRC facility has an opportunity to request an oral or
paper hearing before VA approval is revoked.

\(4\) The date by which the Hearing Official must receive the CRC
facility\'s request for a hearing. ***NOTE**: The date by which the
hearing official must receive the request for a hearing must not be more
than 20 calendar days after the date of VA notice of non-compliance,
unless the hearing official determines that non-compliance with the
standards threatens the lives of residents, in which case the hearing
official must receive the CRC facility\'s request for an oral or paper
hearing within 36 hours of receipt of the VA notice. Nothing in this
Handbook prevents VA officials from assisting a veteran (with permission
from the veteran or the authorized representative of the veteran) who
resides in a CRC facility in finding temporary lodging if the CRC
Program Coordinator determines that CRC facility's non-compliance with
the standards in this Handbook threatens the life of the veteran.*

b\. **[Request For Hearing.]{.underline}** The CRC facility operator
must specify in writing whether an oral or paper hearing is requested.
The request must be sent to the Hearing Official within 20 calendar days
of the receipt of the notification in order to stay the revocation of
approval. The Hearing Official may accept a request for a hearing after
the time limit, if the CRC facility shows that the delay was due to
circumstances beyond its control.

c\. **[Notice and Conduct of Hearing]{.underline}**

\(1\) Upon receipt of a request for an oral hearing, the Hearing
Official must notify the CRC facility operator:

\(a\) In writing, of the date, time, and location of the hearing; and

\(b\) That written statements and other evidence for the record may be
submitted to the Hearing Official before the date of the hearing. Oral
hearings are to be informal and rules of evidence are not followed.
Witnesses must testify under oath or affirmation. A recording or
transcript of every hearing must be made by a certified Court Reporter
at the expense of the jurisdictional facility. The Hearing Official may
exclude irrelevant, immaterial, or unduly repetitious testimony.

\(2\) Upon receipt of a request for a paper hearing, the Hearing
Official must notify the CRC facility operator that written statements
and other evidence must be submitted to the Hearing Official by a
specified date in order to be considered as part of the record.

\(3\) In all hearings, the CRC facility operator and VA may be
represented by counsel.

d\. **[Waiver of Opportunity for Hearing.]{.underline}** If
representatives of a CRC facility were issued a notice of non-compliance
fail to appear at an oral hearing of which they have been notified, or
fail to submit written statements for a paper hearing (unless their
failure to appear was due to circumstances beyond their control as
determined by the hearing official), the hearing official must:

\(1\) Consider the representatives of the CRC facility to have waived
their opportunity for a hearing; and

\(2\) Revoke VA approval of the CRC facility and notify the facility of
this revocation.

e\. **[Written Decision Following a Hearing]{.underline}**

\(1\) The Hearing Official must issue a written decision within 20 days
of the completion of the hearing. An oral hearing is considered
completed when the hearing ceases to receive in-person testimony. A
paper hearing is considered complete on the day by which written
statements must be submitted to the Hearing Official in order to be
considered as part of the record.

\(2\) The Hearing Official\'s determination of a CRC facility\'s
noncompliance with VA standards must be based on the preponderance of
the evidence.

\(3\) The written decision must include:

\(a\) A statement of the facts; and,

\(b\) A determination whether the CRC facility complies with the
standards in this Handbook.

\(4\) The written decision may include a determination of the time
period the CRC facility has to remedy any noncompliance with VA
standards before revocation of VA approval occurs.

\(5\) The hearing official\'s determination of any time period shall
consider the safety and health of the residents of the CRC facility and
the length of time since the CRC facility received notice of the
noncompliance.

f\. **[Revocation of VA Approval]{.underline}**

\(1\) If the Hearing Official determines that the CRC facility does not
comply with the standards and that the facility has no further time to
remedy the noncompliance, the Hearing Official must revoke approval of
the CRC facility and notify the facility of this revocation.

\(2\) Upon revocation of approval, VA health care personnel must:

\(a\) Cease referring veterans to the CRC facility;

\(b\) Notify any veteran residing in the CRC facility of the facility\'s
disapproval and offer to assist with alternate placement plans.
***NOTE:** If the veteran has a legal representative, then that person
must be notified and offered assistance with alternate placement
planning*; and

\(c\) Offer to assist the veteran and/or the legal guardian with
alternative placement planning.

\(3\) If the Hearing Official determines that the CRC facility is to be
given additional time with which to remedy the noncompliance, the
Hearing Official must establish a new date for review. If at the end of
the time period, the CRC facility still does not comply with these or
any other standards, the Hearing Official must repeat the procedures in
subparagraphs 12a through 12e of this Handbook.

**13. FINANCIAL ARRANGEMENTS**

a\. **[Cost of CRC]{.underline}**

\(1\) The cost of care shall normally cover the following services:

\(a\) Room;

\(b\) Meals, as defined in the resident's Plan of Care;

\(c\) Laundry;

\(d\) Transportation for routine healthcare, if appropriate;

\(e\) Twenty-four-hour supervision, if indicated; and

\(f\) Care and assistance with ADLs, as defined in the Statement of
Need.

\(2\) Payment for the charges of CRC are the responsibility of the
veteran and not the responsibility of the United States Government.

\(3\) The resident or an authorized personal representative and a
representative of the CRC facility must agree upon the charge and
payment procedures for care. The agreement must be in writing and signed
by both parties and a copy of the agreement provided to each party as
well as being documented in the medical record using VA Form 10-2409,
Patient's Agreement with Hospital in Relation to a Home Other Than His
Own (see App. D).

\(4\) All financial arrangements between the facility operator and/or
provider and resident must be documented in the resident's electronic
medical record and in the CRC records. ***NOTE:** All financial
transactions and arrangements are subject to review and approval by the
CRC Coordinator, or designee.*

b\. **[Fees for CRC Care.]{.underline}** The CRC Program Coordinator
must establish and approve basic rates.

\(1\) Basic rates are to be locally established based on a variety of
indices, i.e., Medicaid, Social Security disability and Retirement
Insurance, Supplemental Security Income (SSI), Department of Human
Services, licensing agencies, State Department of Mental Health, and/or
a survey of facilities to determine local comparable residential care
rates. Subsequent increases may be tied to the National Consumer Price
Index (CPI) for other local market conditions.

\(2\) The charges for care in the CRC must be reviewed annually, or as
indicated, due to changes in care needs. This must be documented in the
medical record, in a completed VA Form 10-2410, Agreement to Provide
Care for Patient (see App. C), and in an updated VA Form 10-2409 (see
App. D).

\(3\) For special needs or additional services, the veteran or the
veteran's representative may agree to pay an increased rate. These rates
must be established conjointly with the CRC Program Coordinator, CRC
Operator, the veteran, and the veteran's representative; this must be
documented in the veteran's medical record. ***NOTE:*** *Individual
resident\'s rates will differ from a facility\'s average rate.*

**14. SELECTION, PLACEMENT, AND FOLLOW-UP OF RESIDENTS**

a\. **[Selection of Potential Residents]{.underline}**

\(1\) Candidates for CRC placement must meet the criteria found in
paragraph 6.

\(2\) A completed referral and release of information form, or VA Form
10-2406, Recommendation for Release of Patient in Home Other Than His
Own (see App. E), must be submitted to the CRC Coordinator, or designee.
It must include the following:

\(a\) Psychosocial assessment including: risk factors, strengths, and
weaknesses;

\(b\) Medical, mental, and physical functional statements;

\(c\) Goals of placement; and

\(d\) Statement of needed care.

\(3\) Candidates for CRC placement must have sufficient resources to
meet the cost of care and other incidental needs. ***NOTE:** VA Staff
may assist the veteran in accessing sufficient funds to pay the cost of
residential care, e.g., utilizing the expedited pension claims process
as it is available.*

\(4\) All potential residents must be medically and psychiatrically
stable. They must not be a danger to themselves or others and need to
demonstrate behavior that is acceptable for community living. ***NOTE:**
If veterans with complex medical conditions require more than basic
residential care, this may be provided through other VA and community
programs, i.e., HBPC.*

\(5\) All residents must agree to comply with program, house rules, and
regulations.

b\. **[Placement of Residents]{.underline}**

\(1\) The CRC Coordinator, or designee, in collaboration with the
treatment team, assists the patient in the final selection of a CRC
facility and arranges for the placement. ***NOTE:** Efforts are always
made to match the needs and preferences of the veteran with the
resources of the receiving CRC facility.*

\(2\) Pertinent medical and social data must be shared with the provider
with the written consent of the veteran or the individual legally
empowered to provide such consent for the veteran.

\(3\) The placement process must be documented in the veteran\'s medical
record.

\(4\) Placements made from one VA facility into another VA facility's
CRC Program must be accomplished by submission of the referral to the
receiving VA facility's CRC Coordinator for evaluation and placement.
All arrangements must be made prior to placement. ***NOTE:** In the
event of the placement failing, and if no alternate CRC placement is
available, the referring VA facility must receive the veteran back.*

c\. **[Follow-Up]{.underline}**

\(1\) The CRC Program Coordinator must ensure that each resident and
provider is visited at least monthly by a VA health care professional.
Residents who have special needs must be seen more frequently, as
determined in their statements of needed care, or as their care needs
change. Other team members may visit the residents or CRC facilities as
needed, or in conjunction with a special need situation.

\(2\) Veterans in the CRC Program must receive an annual physical
examination in accordance with the provisions of M-1, Part I, Chapter
17. The CRC Coordinator, in conjunction with the annual physical
examination, reviews and determines the veteran\'s need and
appropriateness for continued CRC placement and then documents this
determination in the veteran's medical record.

\(3\) Veterans in the CRC Program must be maintained on an appropriate
outpatient status.

\(4\) All veterans in the CRC Program, who require hospitalization, must
be granted expeditious readmission to the VA facility of jurisdiction,
or the most appropriate alternative facility.

\(5\) All follow-up visits to the veteran in the CRC Program require
documentation of visit and data entry into the veteran's VA medical
record.

d\. **[Discharge From the CRC Program]{.underline}**

\(1\) Veterans are to be discharged from the CRC Program under the
following conditions:

\(a\) Transfer to another level of care or independent living
arrangement.

\(b\) Voluntary Discharge occurs when the veteran no longer desires
follow-up monitoring services by VA staff, or when the veteran decides
to move to a non-VA approved facility.

\(c\) Involuntary Discharge occurs when the veteran fails to abide by
the plan of care, or fails to comply with the CRC facility rules.

\(d\) Death.

\(2\) The appropriate VA staff member must record in the patient
treatment file the type of discharge and relevant information.

**15. PROVIDER KNOWLEDGE, SKILL, AND EDUCATION**

a\. In order to meet the needs of veteran residents, each VA facility
must train providers, or ensure that CRC providers have knowledge and
skills in the following areas:

\(1\) Provision of personal care, specific to ADL.

\(2\) Medication management.

\(3\) Crisis management and re-hospitalization procedures.

\(4\) Provision of supportive and emotional care.

\(5\) Nutrition and proper food preparation, distribution and storage.

\(6\) Activity and program planning.

\(7\) Applicable VA policies.

\(8\) Protecting the resident's privacy and confidentiality.

\(9\) Local and State laws and ordinances.

\(10\) Fire and safety procedures.

b\. Ongoing training will be provided, including diversity and ethics
training on personal boundaries and conflict of interest for facility
operators and staff. Documentation of the training will be maintained in
the VA facility record.

c\. A CRC Provider's Handbook must be developed by the CRC Coordinator
and must be distributed to each CRC Operator. This Handbook must be
updated annually and reviewed with the CRC Operator at the time of the
inspection. A statement must be written and signed that this has been
accomplished and placed in the facility record. The CRC Provider's
Handbook may include, but is not limited to:

\(1\) Standards for operation of the home,

\(2\) Resident's rights and responsibilities,

\(3\) Protocol for Emergencies,

\(4\) Points of Contact, and

\(5\) The CRC Operator's Rights.

d\. CRC provider and/or operator education programs must be held at
least twice annually in order to ensure the quality of skills acquired
by the provider and/or operator and in order to address additional
issues. ***NOTE:** Training topics may be provided in addition to the
areas listed in subparagraph 15a.*

e\. Consultative education by VA staff is to be made available.

**16. QUALITY ASSURANCE IN THE CRC HOME PROGRAM**

a\. **[Responsibility.]{.underline}** The VA facility or CBOC must
integrate the CRC Program into its Quality Improvement Program.
Generally, this is the responsibility of the clinical area (service line
or care line) with program oversight.

b\. **[Quality Data.]{.underline}** CRC data must include:

\(1\) Reports of surveys conducted by Federal, State, and local
regulatory licensing agencies.

\(2\) Patient Safety Data to include:

\(a\) [Adverse Events.]{.underline} Adverse events may result from acts
of commission or omission. They include:

[1]{.underline}. Patient falls;

[2]{.underline}. Adverse drug events;

[3]{.underline}. Procedural errors and complications;

[4]{.underline}. Completed suicide;

[5]{.underline}. Para-suicidal behaviors (attempts, gestures, and/or
threats) and missing patient events;

[6]{.underline}. Incidents of suspected neglect and/or abuse and/or
assaults on or by the CRC resident;

[7]{.underline}. Incidents that result in injury with loss of function;
and

[8]{.underline}. Severe psychosocial and emotional distress.

\(b\) [Sentinel Events.]{.underline} Sentinel events associated with
Root Cause Analysis (RCA) are defined as unexpected occurrences
involving death, serious physical or psychological injury, or risk
thereof. They include:

[1]{.underline}. Death resulting from a medication error, or other
treatment--related error.

[2]{.underline}. Suicide of a patient in a setting where the patient was
receiving around-the-clock care.

[3]{.underline}. Surgery on the wrong patient or body part, regardless
of the magnitude of the operation; and

[4]{.underline}. Hemolytic transfusion reaction involving administration
of blood or blood products having major blood group incompatibilities.

***NOTE:** Adverse and Sentinel Events require investigation and
documentation. All Adverse and Sentinel Events must be reported to the
VHA Office of Geriatrics and Extended Care (114).*

\(c\) [Results.]{.underline} Results of quality assessment and
improvement activities must be used by local VA staff in suggesting
program improvements and changes, and in making decisions regarding the
continued use of any residential care home facility, including:

[1]{.underline}. Results from any patient and/or family satisfaction
reports; and

[2]{.underline}. Any CRC specific quality improvement findings that may
be established by the VA facility.

**17. AVAILABILITY OF INFORMATION, STAFFING, RECORDS, REPORTING**

**SYSTEMS, AND RELEASE OF PATIENT-SPECIFIC HEALTH INFORMATION**

a\. **[Availability of Information.]{.underline}** VA standards will be
made available to other Federal, State and local agencies charged with
the responsibility of licensing or otherwise regulating or inspecting
CRC facilities.

b\. **[Staffing Guidance]{.underline}.** In addition to the CRC Program
Coordinator, the ratio of CRC residents to one VA Full-time Equivalent
(FTE) direct case manager who provides patient follow-up, may range from
twenty to fifty depending on the following factors:

\(1\) Turnover rate of residents.

\(2\) Severity and complexity of residents\' problems.

\(3\) Geographic distance from the CRC to the VA facility of
jurisdiction.

\(4\) Number of veterans per CRC facility.

\(5\) Number of individual CRC facilities under supervision.

\(6\) Access to VA and non-VA services.

\(7\) Any special requirements of the VA program(s) providing follow-up
care to the veterans.

c\. **[VA Records]{.underline}**

a\. Procedures for recording the electronic patient treatment record are
to be consistent with VA and facility policy and procedures.

b\. Workload and data capture must be completed for each encounter, on
the date of the occurrence in real time.

c\. The CRC Program Coordinator must maintain a file on each CRC
facility. The file must contain:

\(1\) VA Form 10-2407, Residential care home program provider
application.

\(2\) Initial CRC evaluation statement.

\(3\) Inspection reports.

\(4\) All correspondence relating to the facility.

\(5\) All material relating to any hearing and decision.

d\. **[CRC Facility Records.]{.underline}** See subparagraph 10i.

e\. **[Reporting System.]{.underline}** By the 15^th^ calendar day of
each new quarter, the CRC Coordinator is responsible for reporting the
following data sets, through the VA facility Director, and the Veterans
Integrated Service Network (VISN) Geriatrics and Extended Care Director,
to the VA Central Office CRC Program Office. The CRC Coordinator must
work with local Office of Information Management staff to obtain the
data required.

  ------------------------------------------------ ----------------------
  **Data Set**                                     **Location of Data**

                                                   

  Name of CRC Coordinator                          

  If different from the CRC Coordinator, name of   
  person completing this report                    

  VISN and Station Number                          

  E-mail Address                                   

  Telephone Number                                 

  Average Monthly Rate Paid by Veteran             CRC Coordinator

  Highest Monthly Rate Paid by Veteran             CRC Coordinator

  Lowest Monthly Rate Paid by Veteran              CRC Coordinator

  Bed Days of Care                                 CRC Coordinator and
                                                   Cost Distribution
                                                   Report (CDR)

  Census on Last Day of Previous Quarter           CRC Coordinator

  Number of Unique Veterans in Program             CRC Coordinator or
                                                   Decision Support
                                                   System (DSS)
  ------------------------------------------------ ----------------------

+------------------------------------------------+---------------------+
| **Data Set**                                   | **Location of       |
|                                                | Data**              |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| Number of Encounters Utilizing Decision        | Patient Clinic      |
| Support System (DSS) Identifiers (Stop         | Encounter (PCE) and |
| Codes)\*                                       | DSS                 |
|                                                |                     |
| Number of 121 (Predominantly non-mental        |                     |
| health)                                        |                     |
|                                                |                     |
| Number of 503 (Predominantly mental health)    |                     |
+------------------------------------------------+---------------------+
| FTE allocated to Program                       | Cost Distribution   |
|                                                | Report (CDR) and/or |
|                                                | DSS                 |
|                                                |                     |
|                                                | ***NOTE:** These    |
|                                                | should match.*      |
+------------------------------------------------+---------------------+
| Personal Services Costs                        | DSS                 |
+------------------------------------------------+---------------------+
| State Licensure Required                       | CRC Coordinator     |
+------------------------------------------------+---------------------+
| How many homes were inspected during the       | CRC Coordinator     |
| previous quarter?                              |                     |
+------------------------------------------------+---------------------+
| Number of CRC Homes                            | CRC Coordinator     |
+------------------------------------------------+---------------------+
| Number of Homes with:                          | CRC Coordinator     |
+------------------------------------------------+---------------------+
| 1 -- 3 beds                                    |                     |
+------------------------------------------------+---------------------+
| 4 -- 15 beds                                   |                     |
+------------------------------------------------+---------------------+
| 16 -- 25 beds                                  |                     |
+------------------------------------------------+---------------------+
| 26 -- 100 beds                                 |                     |
+------------------------------------------------+---------------------+
| 101 beds and Over                              |                     |
+------------------------------------------------+---------------------+
| Total Number of Beds                           | CRC Coordinator     |
+------------------------------------------------+---------------------+

**\*** Focus of visit determines which DSS Identifier is used.

f\. **[Release of Patient-specific Health Information]{.underline}**.

\(1\) **Regulations.** CRC program officials, CRC staff, CRC operators,
and CRC providers may release patient-specific health information in
compliance with the following regulations:

\(a\) Title 5 U.S.C. 552, the Freedom of Information Act (FOIA).

\(b\) Title 5 U.S.C. 552a, the Privacy Act.

\(c\) Title 38 U.S.C. 5701, the VA Claims Confidentiality Statute.

\(d\) Title 38 U.S.C. 7332, Confidentiality of Drug Abuse, Alcoholism
and Alcohol Abuse, Human Immunodeficiency Virus (HIV) Infection, and
Sickle Cell Anemia Medical Records.

\(e\) Public Law 104-191, Health Information Portability Act (HIPPA).

\(f\) Title 38 U.S.C. 5705, Confidentiality of Healthcare Quality
Assurance Review Records.

\(2\) **CRC Providers.** CRC staff must consult with the VA facility
Privacy Officer and Release of Information Office when questions arise
regarding how and what patient-specific health information may be
released to CRC sponsors.

\(3\) **Business Associate Agreement (BAA).** CRC Services are
considered a continuation of treatment and provided on VHA's behalf, as
documented by the VHA health care "Statement of Needed Care, and/or
Treatment Plan, and/or Plan of Care." Accordingly, a BAA **[is
not]{.underline}** required (because of the "Treatment exemption").

**VA FORM 10-2407, RESIDENTIAL CARE HOME PROGRAM**

**SPONSOR APPLICATION**

Below is an imbedded copy of Department of Veterans Affairs (VA) Form
10-2407, Residential Care Home Program -- Sponsor Application. This form
can also be found on the Veterans Health Administration (VHA) Forms at
the Intranet web site at <http://vaww.va.gov/vaforms>*.* This is to be
used for local reproduction. Since this is a low use form, it will not
be stocked by the Hines Service and Distribution Center (formerly known
as the Forms and Publications Depot).

You should use Adobe Acrobat 5.05 or later to view this form. To print
this form, your printer must be set to "print as image" and "fit to
page."

![](media/image1.wmf)

####### INITIAL HOME ASSESSMENT CHECKLIST

An Initial Home Assessment, designed to assist the Community Residential
Care (CRC) coordinator in determining the suitability of the potential
CRC Provider and home, may include the following:

**1. Facility Description**

a\. Own, rent, apartment, other, etc.

b\. Number of baths and location.

c\. Location of bedroom(s) designed for resident(s).

d\. Source of water supply.

e\. Heating and/or cooling source.

**2. Presentation of the Facility**

a\. Adequate food preparation areas, refrigeration, and storage.

b\. Condition of facility, including: paint, rugs, woodwork, windows,
doors, foundation, roof, appliances, furnishings, lighting fixtures, and
electrical outlets.

c\. Orderliness, cleanliness, and sanitation of the home (interior and
exterior) and property.

d\. Ventilation.

e\. Safety and fire protection.

**3. Location of Facility in relation to Recreation, Shopping, and
Church.**

**4. Availability and Type(s) of Transportation.**

**5. Make-up of Household or Staff:**

a\. Relationship to provider.

b\. Attitude toward disabled veterans.

c\. Physical and mental health.

d\. Personality of applicant and household members.

e\. Level of other community involvement and/or activities and
relationship with neighbors.

**6. Surveyor's Assessment.** Surveyor's assessment of the type(s) of
patients who could use this home and recommendation to CRC Coordinator
for further evaluation.

**VA FORM 10-2410, AGREEMENT TO PROVIDE HOME CARE FOR PATIENT**

Below is an imbedded copy of Department of Veterans Affairs (VA) Form
10-2410, Agreement to provide Home Care for Patient. This form can also
be found on the Veterans Health Administration (VHA) Forms at the
Intranet web site at <http://vaww.va.gov/vaforms>*.* This is to be used
for local reproduction. Since this is a low use form, it will not be
stocked by the Hines Service and Distribution Center (formerly known as
the Forms and Publications Depot).

You should use Adobe Acrobat 5.05 or later to view this form. To print
this form, your printer must be set to "print as image" and "fit to
page."

![](media/image2.wmf)

**VA FORM 10-2409, PATIENT'S AGREEMENT WITH HOSPITAL IN RELATION TO A
HOME OTHER THAN HIS OWN**

Below is an imbedded copy of Department of Veterans Affairs (VA) Form
10-2409, Patient's Agreement with Hospital in Relation to a Home Other
Than His Own. This form can also be found on the Veterans Health
Administration (VHA) Forms at the Intranet web site at
<http://vaww.va.gov/vaforms>*.* This is to be used for local
reproduction. Since this is a low use form, it will not be stocked by
the Hines Service and Distribution Center (formerly known as the Forms
and Publications Depot).

You should use Adobe Acrobat 5.05 or later to view this form. To print
this form, your printer must be set to "print as image" and "fit to
page."

![](media/image3.wmf)

**VA FORM 10-2406, RECOMMENDATION FOR RELEASE OF PATIENT IN HOME OTHER
THAN HIS OWN**

Below is an imbedded copy of Department of Veterans Affairs (VA) Form
10-2406, Recommendation for Release of Patient in Home Other Than His
Own. This form can also be found on the Veterans Health Administration
(VHA) Forms at the Intranet web site at <http://vaww.va.gov/vaforms>*.*
This is to be used for local reproduction. Since this is a low use form,
it will not be stocked by the Hines Service and Distribution Center
(formerly known as the Forms and Publications Depot).

You should use Adobe Acrobat 5.05 or later to view this form. To print
this form, your printer must be set to "print as image" and "fit to
page."

![](media/image4.wmf)