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###### Department of Veterans Affairs

          - [OMB Control No. 2900-0883]

# AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

# ACTION:

Notice.

# SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Veterans Health Administration, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and it includes the actual data collection instrument.

# DATES:

                        Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to                         *www.reginfo.gov/​public/​do/​PRAMain.*                         Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function. Refer to “OMB Control No. 2900-0883.”                    

# FOR FURTHER INFORMATION CONTACT:

                        Maribel Aponte, Office of Enterprise and Integration, Data Governance Analytics (008), 810 Vermont Avenue NW, Washington, DC 20420, (202) 266-4688 or email                         *maribel.aponte@va.gov.*                         Please refer to “OMB Control No. 2900-0883” in any correspondence.                    

# SUPPLEMENTARY INFORMATION:

*Authority:*44 U.S.C. 3501-3521.                

*Title:*                     Per Diem to States for Care of Eligible Veterans in State Homes (VA Forms 10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460a, and 10-3567).                

*OMB Control Number:*                     2900-0883.                

*Type of Review:*                     Revision of a currently approved collection.                

*Abstract:*                     Authority for this information collection is from title 38 Code of Federal Regulations (CFR) part 51, Per Diem for Nursing Home, Domiciliary or Adult Day Health Care of Veterans in State Veterans Homes, requiring the VA to ensure that per diem payments are limited to facilities providing high quality care for Veterans. This collection of forms is approved under OMB Control Number 2900-0883.                

These six forms (10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460a, and 10-3567) are presented to and completed by State Veterans Homes (SVH) management under subpart B of the CFR part 51 and then assessed for compliance to applicable regulations under subparts D, E or F by VA contracted vendors during a VA survey at each State Veterans Home (SVH) across the U.S. as a regulatory action. This collection of forms falls under the auspices of The Office of Geriatrics and Extended Care in VA Central Office (12GEC). As per VHA Directive 1145.01, this collection of forms is part of the VA survey process. The legal requirements that necessitate this collection of information are found specifically at title 38 CFR 51.31, 51.43 and 51.210 for all three levels of care: nursing home, domiciliary, and adult day health care.

The information required at time of the VA survey includes the application and justification for medications for a basic rate Veteran; records and reports that SVH management must maintain regarding activities of residents or participants; information relating to whether the SVH meets standards concerning residents' rights and responsibilities prior to admission or enrollment, during admission or enrollment, and upon discharge; the records and reports which SVH management and SVH health care professionals must maintain regarding residents or participants and employees; various types of documents pertaining to the management of the SVH; pharmaceutical records; and staffing documentation.

a. VA Form 10-0143—38 CFR 51.210(c)(9)—is used for the annual certification pursuant to the Drug-Free Workplace Act of 1988.

b. VA Form 10-0143A—38 CFR 51.210(c)(8)—is used for annual certification from the responsible State Agency showing compliance with section 504 of the Rehabilitation Act of 1973 (Public Law 93-112).

c. VA Form 10-0144—38 CFR 51.210(c)(10)—is used for annual certification regarding lobbying, in compliance with Public Law 101-121.

d. VA Form 10-0144A—38 CFR 51.210(c)(11)—is used for annual certification of compliance with title VI of the Civil Rights Act of 1964, as incorporated in title 38 CFR 18.1-18.3.

e. VA Form 10-0460a—38 CFR 51.43—As a condition for receiving drugs or medicine under this section or under § 17.96 of this chapter, the State Home will submit to the VA medical center of jurisdiction a monthly completed VA Form 10-0460a with the corresponding prescription(s) for each eligible Veteran.

f. VA Form 10-3567—38 CFR 51.31—is completed by SVH management during the annual VA survey and used to record and then assess the following: operating beds versus recognized beds, total FTEE authorized and vacancies, as well as resident census.

                    An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The                     **Federal Register**                     Notice with a 60-day comment period                           ( print page 74248)                        soliciting comments on this collection of information was published at 88 FR 164 on August 25, 2023, pages 58439 and 58440.                

*Total Annual Burden:*                     2,119 hours.                

*Total Annual Responses:*                     2,805.                

## VA Form 10-0143

*Affected Public:*                     State, local, and Tribal governments.                

*Estimated Annual Burden:*                     13.75 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     165.                

## VA Form 10-0143A

*Affected Public:*                     State, local, and Tribal governments.                

*Estimated Annual Burden:*                     13.75 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     165.                

## VA Form 10-0144

*Affected Public:*                     State, local, and Tribal governments.                

*Estimated Annual Burden:*                     13.75 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     165.                

## VA Form 10-0144A

*Affected Public:*                     State, local, and Tribal governments.                

*Estimated Annual Burden:*                     13.75 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     165.                

## VA Form 10-0460a

*Affected Public:*                     State, local, and Tribal governments.                

*Estimated Annual Burden:*                     1980 hours.                

*Estimated Average Burden per Respondent:*                     60 minutes.                

*Frequency of Response:*                     Monthly.                

*Estimated Number of Respondents:*                     165.                

## VA Form 10-3567

*Affected Public:*                     State, local, and Tribal governments.                

*Estimated Annual Burden:*                     82.50 hours.                

*Estimated Average Burden per Respondent:*                     30 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     165.                

By direction of the Secretary.

Maribel Aponte,

VA PRA Clearance Officer, Office of Enterprise and Integration, Data Governance Analytics, Department of Veterans Affairs.

[FR Doc. 2023-23873 Filed 10-27-23; 8:45 am]

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