<table>
<colgroup>
<col style="width: 11%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 15%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="13"><strong>§58.10 VA Form 10-3567—State Home Inspection
Staffing Profile.</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="5"><p>OMB Approved No. 2900-0160</p>
<p>Estimated Burden Avg. 20 min.</p></td>
</tr>
<tr class="odd">
<td colspan="6">VA Department of Veterans Affairs</td>
<td colspan="7"><h1 id="state-home-inspection">STATE HOME
INSPECTION</h1></td>
</tr>
<tr class="even">
<td colspan="11">NAME OF HOME</td>
<td colspan="2">DATE OF INSPECTION</td>
</tr>
<tr class="odd">
<td colspan="4"><strong>PART I</strong></td>
<td colspan="3"><strong>TOTAL FACILITY</strong></td>
<td colspan="2"><strong>HOSPITAL</strong></td>
<td colspan="3"><strong>NHC</strong></td>
<td><strong>DOM</strong></td>
</tr>
<tr class="even">
<td colspan="4">OPERATING BEDS</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">AUTHORIZED APPROVALS</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">PATIENT CENSUS</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">POSITIONS AUTHORIZED</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">STAFF AVAILABLE</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>PART II</strong></td>
<td colspan="3"><strong>TOTAL FACILITY</strong></td>
<td colspan="2"><strong>HOSPITAL</strong></td>
<td colspan="3"><strong>NHC</strong></td>
<td><strong>DOM</strong></td>
</tr>
<tr class="even">
<td colspan="4">PHYSICIANS:</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>PHYSICIANS ASSISTANTS</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">DENTIST</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">SOCIAL WORK: MSW</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>BSW</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>SOCIAL WORK ASSISTANT</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">PHARMACY: REG. PHARMACIST</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">DIETETICS: REG DIETITIAN</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>FOOD SUPERVISOR</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>DIETARY ASSISTANTS</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">NURSING:</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>NURSING ADM/SUP.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>DIRECT CARE: CERT.</p>
<p>N.P./C.N.S.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>R.N.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>L.P.N./L.V.N.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>N.A.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">REHABILITATION THERAPY</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>REG. P.T./P.T. AIDES</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>REG. O.T./O.T. AIDES</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">MENTAL HEALTH: PSYCHOLOGIST</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>PSYCHIATRIST</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>PSYCHIATRIC SOCIAL WORKER</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>COUNSELOR</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">SPEECH AND AUDIOLOGY</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">OPTHALMOLOGY/OPTOMETRY</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">PODIATRY</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">RADIOLOGY/LABORATORY</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">RECREATION/ACTIVITIES</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>DIRECTOR</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><blockquote>
<p>ASSISTANTS</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>VOLUNTEERS</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">CHAPLAIN</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">ADMINISTRATION</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">ENGINEERING</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">MAINTENANCE/HOUSEKEEPING</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">MEDICAL RECORDS</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">OTHER <em>(Specify)</em></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td><p><strong>VA FORM</strong></p>
<p><strong>MAY 1998(RS)</strong></p></td>
<td colspan="2"><strong>10-3567</strong></td>
<td colspan="6"></td>
<td></td>
<td colspan="3"><h2 id="see-reverse">SEE REVERSE</h2></td>
</tr>
</tbody>
</table>

  ----------------------------------------------------- -----------------
  NAME OF HOME                                          DATE OF
                                                        INSPECTION

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

+-----------------------------------------------------------------------+
| **NURSING SERVICE STAFFING PATTERN**                                  |
|                                                                       |
| *(Four Week Average)*                                                 |
+-----------------------------------------------------------------------+

  ------------- ------------ ------------------------ --------- -------- ------------ ----- ---- ------------- ----- ---- --------------- ----- ---- -------------- ----- ---- ------------ ----- ---- -------------- ----- ----
  **PART III**               **HOSPITAL *(Average                                                                                                                                                                           
                             hours Hosp.                                                                                                                                                                                    
                             \_\_\_\_\_\_\_\_\_\_\_                                                                                                                                                                         
                             )***                                                                                                                                                                                           

                **SUNDAY**                                               **MONDAY**              **TUESDAY**              **WEDNESDAY**              **THURSDAY**              **FRIDAY**              **SATURDAY**         

  **SHIFT**     **RN**                                **LPN**   **NA**   RN           LPN   NA   RN            LPN   NA   RN              LPN   NA   RN             LPN   NA   RN           LPN   NA   RN             LPN   NA

  **DAY**                                                                                                                                                                                                                   

  **EVENING**                                                                                                                                                                                                               

  **NIGHT**                                                                                                                                                                                                                 
  ------------- ------------ ------------------------ --------- -------- ------------ ----- ---- ------------- ----- ---- --------------- ----- ---- -------------- ----- ---- ------------ ----- ---- -------------- ----- ----

  ------------- ------------ ------------------------ --------- -------- ------------ ----- ---- ------------- ----- ---- --------------- ----- ---- -------------- ----- ---- ------------ ----- ---- -------------- ----- ----
  **PART IV**                **NURSING HOME *(Average                                                                                                                                                                       
                             hours NHC                                                                                                                                                                                      
                             \_\_\_\_\_\_\_\_\_\_\_                                                                                                                                                                         
                             )***                                                                                                                                                                                           

                **SUNDAY**                                               **MONDAY**              **TUESDAY**              **WEDNESDAY**              **THURSDAY**              **FRIDAY**              **SATURDAY**         

  **SHIFT**     **RN**                                **LPN**   **NA**   RN           LPN   NA   RN            LPN   NA   RN              LPN   NA   RN             LPN   NA   RN           LPN   NA   RN             LPN   NA

  **DAY**                                                                                                                                                                                                                   

  **EVENING**                                                                                                                                                                                                               

  **NIGHT**                                                                                                                                                                                                                 
  ------------- ------------ ------------------------ --------- -------- ------------ ----- ---- ------------- ----- ---- --------------- ----- ---- -------------- ----- ---- ------------ ----- ---- -------------- ----- ----

<table style="width:100%;">
<colgroup>
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"><strong>PART III</strong></td>
<td colspan="22"><strong>DOMICILIARY <em>(Average hours Dom. ___________
)</em></strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"><strong>SUNDAY</strong></td>
<td colspan="3"><strong>MONDAY</strong></td>
<td colspan="3"><strong>TUESDAY</strong></td>
<td colspan="3"><strong>WEDNESDAY</strong></td>
<td colspan="4"><strong>THURSDAY</strong></td>
<td colspan="3"><strong>FRIDAY</strong></td>
<td colspan="3"><strong>SATURDAY</strong></td>
</tr>
<tr class="odd">
<td><strong>SHIFT</strong></td>
<td colspan="2"><strong>RN</strong></td>
<td><strong>LPN</strong></td>
<td><strong>NA</strong></td>
<td>RN</td>
<td>LPN</td>
<td>NA</td>
<td>RN</td>
<td>LPN</td>
<td>NA</td>
<td>RN</td>
<td>LPN</td>
<td>NA</td>
<td>RN</td>
<td colspan="2">LPN</td>
<td>NA</td>
<td>RN</td>
<td>LPN</td>
<td>NA</td>
<td>RN</td>
<td>LPN</td>
<td>NA</td>
</tr>
<tr class="even">
<td><strong>DAY</strong></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>EVENING</strong></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>NIGHT</strong></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p><strong>VA FORM</strong></p>
<p><strong>MAY 1998 (RS)</strong></p></td>
<td colspan="15"><strong>10-3567</strong></td>
<td colspan="8"><strong>PAGE 2</strong></td>
</tr>
</tbody>
</table>

+-------+--------------------------------------+---+------------------+
| NAME  |                                      |   | DATE OF          |
| OF    |                                      |   | INSPECTION       |
| HOME  |                                      |   |                  |
+-------+--------------------------------------+---+------------------+
|       |                                      |   |                  |
+-------+--------------------------------------+---+------------------+
| **The |                                      |   |                  |
| Pape  |                                      |   |                  |
| rwork |                                      |   |                  |
| Redu  |                                      |   |                  |
| ction |                                      |   |                  |
| Act   |                                      |   |                  |
| of    |                                      |   |                  |
| 1     |                                      |   |                  |
| 995** |                                      |   |                  |
| req   |                                      |   |                  |
| uires |                                      |   |                  |
| us to |                                      |   |                  |
| n     |                                      |   |                  |
| otify |                                      |   |                  |
| you   |                                      |   |                  |
| that  |                                      |   |                  |
| this  |                                      |   |                  |
| i     |                                      |   |                  |
| nform |                                      |   |                  |
| ation |                                      |   |                  |
| colle |                                      |   |                  |
| ction |                                      |   |                  |
| is in |                                      |   |                  |
| accor |                                      |   |                  |
| dance |                                      |   |                  |
| with  |                                      |   |                  |
| the   |                                      |   |                  |
| clea  |                                      |   |                  |
| rance |                                      |   |                  |
| re    |                                      |   |                  |
| quire |                                      |   |                  |
| ments |                                      |   |                  |
| of    |                                      |   |                  |
| se    |                                      |   |                  |
| ction |                                      |   |                  |
| 3507  |                                      |   |                  |
| of    |                                      |   |                  |
| the   |                                      |   |                  |
| Pape  |                                      |   |                  |
| rwork |                                      |   |                  |
| Redu  |                                      |   |                  |
| ction |                                      |   |                  |
| Act   |                                      |   |                  |
| of    |                                      |   |                  |
| 1995. |                                      |   |                  |
| We    |                                      |   |                  |
| may   |                                      |   |                  |
| not   |                                      |   |                  |
| co    |                                      |   |                  |
| nduct |                                      |   |                  |
| or    |                                      |   |                  |
| spo   |                                      |   |                  |
| nsor, |                                      |   |                  |
| and   |                                      |   |                  |
| you   |                                      |   |                  |
| are   |                                      |   |                  |
| not   |                                      |   |                  |
| req   |                                      |   |                  |
| uired |                                      |   |                  |
| to    |                                      |   |                  |
| re    |                                      |   |                  |
| spond |                                      |   |                  |
| to, a |                                      |   |                  |
| colle |                                      |   |                  |
| ction |                                      |   |                  |
| of    |                                      |   |                  |
| i     |                                      |   |                  |
| nform |                                      |   |                  |
| ation |                                      |   |                  |
| u     |                                      |   |                  |
| nless |                                      |   |                  |
| it    |                                      |   |                  |
| dis   |                                      |   |                  |
| plays |                                      |   |                  |
| a     |                                      |   |                  |
| valid |                                      |   |                  |
| OMB   |                                      |   |                  |
| nu    |                                      |   |                  |
| mber. |                                      |   |                  |
| We    |                                      |   |                  |
| antic |                                      |   |                  |
| ipate |                                      |   |                  |
| that  |                                      |   |                  |
| the   |                                      |   |                  |
| time  |                                      |   |                  |
| exp   |                                      |   |                  |
| ended |                                      |   |                  |
| by    |                                      |   |                  |
| all   |                                      |   |                  |
| i     |                                      |   |                  |
| ndivi |                                      |   |                  |
| duals |                                      |   |                  |
| who   |                                      |   |                  |
| must  |                                      |   |                  |
| com   |                                      |   |                  |
| plete |                                      |   |                  |
| this  |                                      |   |                  |
| form  |                                      |   |                  |
| will  |                                      |   |                  |
| av    |                                      |   |                  |
| erage |                                      |   |                  |
| 30    |                                      |   |                  |
| min   |                                      |   |                  |
| utes. |                                      |   |                  |
| This  |                                      |   |                  |
| inc   |                                      |   |                  |
| ludes |                                      |   |                  |
| the   |                                      |   |                  |
| time  |                                      |   |                  |
| it    |                                      |   |                  |
| will  |                                      |   |                  |
| take  |                                      |   |                  |
| to    |                                      |   |                  |
| read  |                                      |   |                  |
| ins   |                                      |   |                  |
| truct |                                      |   |                  |
| ions, |                                      |   |                  |
| g     |                                      |   |                  |
| ather |                                      |   |                  |
| the   |                                      |   |                  |
| nece  |                                      |   |                  |
| ssary |                                      |   |                  |
| facts |                                      |   |                  |
| and   |                                      |   |                  |
| fill  |                                      |   |                  |
| out   |                                      |   |                  |
| the   |                                      |   |                  |
| form. |                                      |   |                  |
+-------+--------------------------------------+---+------------------+
| **VA  | **10-3567**                          | * |                  |
| F     |                                      | * |                  |
| ORM** |                                      | P |                  |
|       |                                      | A |                  |
| **MAY |                                      | G |                  |
| 1998  |                                      | E |                  |
| (     |                                      | 3 |                  |
| RS)** |                                      | * |                  |
|       |                                      | * |                  |
+-------+--------------------------------------+---+------------------+