[Federal Register Volume 74, Number 81 (Wednesday, April 29, 2009)]
[Rules and Regulations]
[Pages 19426-19451]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-9753]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Parts 51 and 58

RIN 2900-AM97


Per Diem for Nursing Home Care of Veterans in State Homes

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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

SUMMARY: The Department of Veterans Affairs (VA) amends its regulations 
which set forth a mechanism for paying per diem to State homes 
providing nursing home care to eligible veterans. More specifically, we 
are updating the basic per diem rate, implementing provisions of the 
Veterans Benefits, Health Care, and Information Technology Act of 2006, 
and making several other changes to better ensure that veterans receive 
quality care in State homes.

DATES: Effective date: May 29, 2009. The incorporation by reference of 
certain publications listed in this rule is approved by the Director of 
the Federal Register as of May 29, 2009.

FOR FURTHER INFORMATION CONTACT: Theresa Hayes at (202) 461-6771 (for 
issues concerning per diem payments), and Christa Hojlo, PhD at (202) 
461-6779 (for all other issues raised by this document), Office of 
Geriatrics and Extended Care, Veterans Health Administration, 
Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 
20420. (The telephone numbers set forth above are not toll-free 
numbers.)

SUPPLEMENTARY INFORMATION: This document amends the regulations at 38 
CFR part 51 (referred to below as the regulations), which set forth a 
mechanism for paying per diem to State homes providing nursing home 
care to eligible veterans. Under the regulations, VA pays per diem to a 
State for providing nursing home care to eligible veterans in a 
facility if the Under Secretary for Health recognizes the facility as a 
State home based on a determination that the facility meets the 
standards set forth in subpart D of the regulations. The standards set 
forth minimum requirements that are intended to ensure that VA pays per 
diem for eligible veterans only if the State homes provide quality 
care. This document also makes corresponding changes concerning VA 
forms set forth at 38 CFR part 58.
    This final rule is based on a proposed rule published in the 
Federal Register on November 28, 2008 (73 FR 72399). The proposed rule 
called for a 30 day comment period that ended on December 29, 2008. We 
received a number of comments from eight commenters (one commenter 
provided two submissions). One commenter merely agreed with the 
proposed changes. The other comments are discussed below. Based on the 
rationale set forth in the proposed rule and this document, we have 
adopted the provisions of the proposed rule as a final rule with 
changes discussed below.

Nurse Practitioners

    Proposed Sec.  51.2 defined the term ``nurse practitioner'' as ``a 
licensed professional nurse who is currently licensed to practice in 
the State; who meets the State's requirements governing the 
qualifications of nurse practitioners; and who is currently certified 
as an adult, family, or gerontological nurse practitioner by a 
nationally recognized body that provides such certification for nurse 
practitioners, such as the American Nurses Credentialing Center or the 
American Academy of Nurse Practitioners.''
    Three commenters argued directly or implicitly that certification 
is not essential for the provision of high quality care and that 
licensure is a sufficient measure of competence. One of the commenters 
argued that national certification would create an undue burden for 
nurse practitioners (``enroll in an exam course, pay for course work, 
travel, lodging and registration fees, and sit for the exam'') and 
indicated that some may fail the exam or fail to meet renewal 
requirements. The commenter further asserted that nurse practitioners 
who are currently employed should be subject to a grandfather clause 
that allows them to work as nurse practitioners without national 
certification. We made no changes based on these comments. The proposed 
rule did not create a new certification requirement but merely 
broadened the list of certifying organizations to any nationally 
recognized certifying body because the previously listed organization 
does not provide such certification.

Recognition and Certification

    Proposed Sec.  51.30(a)(1) provided that VA would not conduct the 
recognition survey until the new facility has at least 21 residents or 
the number of residents consists of at least 50 percent of the new bed 
capacity of the facility.
    One commenter seemed to read the provisions at proposed Sec.  
51.30(a)(1) by associating the portion of the formula regarding 21 
residents with new facilities and associating the portion of the 
formula regarding 50 percent of the new bed capacity to renovations. 
This is not what was intended. Both portions of the formula were 
intended to apply to recognition surveys. Accordingly, we clarified the 
regulation to state that the recognition survey will be conducted only 
after the new facility either has at least 21 residents or has a number 
of residents that consist of at least 50 percent of the new bed 
capacity of the new facility. We also note that under

[[Page 19427]]

Sec.  51.30(b), a separate recognition is required for changes 
involving an annex, branch, enlargement, expansion, or relocation.
    Two commenters asserted that the portion of the formula concerning 
21 residents is excessive. One commenter noted that CMS (Centers for 
Medicare & Medicaid Services) only requires 3 residents to determine 
whether a facility meets the CMS standards. Another commenter asserted 
that a facility should only be required to have ten residents for an 
initial test survey and that per diem could begin after the initial 
test survey with a more detailed survey to follow. New providers/
suppliers must be in operation and providing services to patients when 
surveyed. This means that at the time of survey, the institution must 
have opened its doors to admissions, be furnishing all services 
necessary to meet the applicable provider or supplier definition, and 
demonstrate the operational capability of all facets of its operations. 
To be considered ``fully operational,'' initial applicants must be 
serving a sufficient number of patients so that compliance with all 
requirements can be determined. Centers for Medicare & Medicaid 
Services, State Operations Manual, Pub. No. 100-07, Ch. 2 sec. 2008A. 
The commenters ultimately asserted that the proposed provisions would 
place a financial burden on veterans who might be responsible for costs 
until VA begins paying per diem. We made no changes based on these 
comments. Based on our experience in conducting surveys and following 
the progress of new State homes in meeting VA standards, the criteria 
as proposed set forth the minimum requirements (21 residents or 50 
percent of new bed capacity) for conducting a survey that could 
determine whether a facility meets VA standards.
    Proposed Sec.  51.30(d), (e), and (f) sets forth the process by 
which a State may appeal a decision by a director of a VA medical 
center of jurisdiction that a State home facility or facility 
management did not meet the standards of subpart D. The appeal is made 
to the Under Secretary for Health. The proposed provisions were 
intended to allow appeals to the Under Secretary in response to 
directors' recommendations regardless of whether the recommendations 
were made prior to recognition or after recognition. One commenter 
indicated that there is no procedure to appeal the decision of the 
Under Secretary. A decision of the Under Secretary, however, may be 
appealed to the Board of Veterans' Appeals. For further information on 
this appeal process, please refer to 38 U.S.C. 7104 and 7105 and 38 CFR 
part 20. We clarified Sec.  51.30(f) to state that the decisions of the 
Under Secretary are final decisions that may be appealed to the Board 
of Veterans' Appeals. The commenter further asserted that there is no 
requirement that the Under Secretary take into account the arguments 
and evidence presented in a State's appeal. We made no changes based on 
this comment. Section 51.30(f) states that the Under Secretary will 
review any relevant supporting information. This would include the 
arguments and evidence presented by the State.

Rate Based on Service Connection

    The provisions of 38 U.S.C. 1745(a), which were established by 
section 211 of the Veterans Benefits, Health Care, and Information 
Technology Act of 2006 (Pub. L. 109-461), set forth a mechanism for 
paying a higher per diem rate for certain veterans with service-
connected disabilities receiving nursing home care in State homes.
    Under this authority, the per diem rate was increased for:
    <bullet> Any veteran in need of nursing home care for a service-
connected disability, and
    <bullet> Any veteran who has a service-connected disability rated 
at 70 percent or more and is in need of nursing home care.
    Under the cited statutory authority, the new per diem rate is the 
lesser of the following:
    <bullet> The applicable or prevailing rate payable in the 
geographic area in which the State home is located, as determined by 
the Secretary, for nursing home care furnished in a non-Department 
nursing home (i.e., a public or private institution not under the 
direct jurisdiction of VA which furnishes nursing home care); or
    <bullet> A rate not to exceed the daily cost of care in the State 
home facility, as determined by the Secretary, following a report to 
the Secretary by the director of the State home.
    Several commenters seemed to be confused about the connection 
between higher per diem for certain veterans with service-connected 
disabilities and the provision of drugs and medicines to veterans in 
State homes. As more fully explained below, under the Veterans 
Benefits, Health Care, and Information Technology Act of 2006, VA does 
not have authority to provide drugs and medicines to veterans who are 
receiving care for which the higher per diem is payable.
    Proposed Sec.  51.41(a)(2) stated that the higher per diem rate for 
certain veterans with service-connected disabilities would apply to a 
veteran with a rating of total disability based on individual 
unemployability. One commenter questioned whether all veterans must 
have a rating of total disability based on individual unemployability 
as a condition for receiving the higher rate of per diem based on 
service connection. Another commenter questioned whether Sec.  
51.41(a)(2) would be applicable to an individual who is unemployable 
because of disabilities that are not service connected. We made no 
changes based on these comments. Veterans who are otherwise eligible 
for the higher per diem do not also need a rating of total disability 
based on individual unemployability from VA for the State to receive 
the higher rate of per diem on their behalf. However, the law permits 
VA to pay a higher per diem for veterans only based on their service-
connected disabilities. States thus would not receive the higher per 
diem for veterans who are unemployable based on disabilities that are 
not service connected unless these veterans also have service-connected 
disabilities that meet the requirements for payment of the higher per 
diem.
    With respect to the higher per diem rate for certain veterans in 
State homes, one commenter questioned whether a State home would 
receive different amounts based on the rating, i.e., 70 percent of the 
maximum per diem for a veteran with a rating of 70 percent, 80 percent 
of the maximum per diem for a veteran with a rating of 80 percent, and 
so on. We made no changes based on this comment. Under the statutory 
provisions of 38 U.S.C. 1745 and Sec.  51.41, the State home would 
receive the same per diem amount for these veterans.
    With respect to the calculation of the higher per diem, commenters 
objected to the methodology in the proposed rule. One commenter 
asserted that the higher per diem rate should be the actual cost of 
care as determined by the State home. The commenter also asserted that 
the amount should be not less than the Medicare amount, the Medicaid 
amount, or the amount VA pays for veterans in private nursing homes. 
One commenter argued that, compared to the population used in the 
proposed methodology, these service-connected veterans would need more 
care because they are generally older and mostly male. The commenter 
also indicated that the population used for the calculations would be 
based in large part on Medicare factors and asserted that some nursing 
homes do not take Medicare payments. The commenter further asserted 
that VA should use data from State homes. We made no changes based on 
these comments. The statutory

[[Page 19428]]

provisions at 38 U.S.C. 1745 require that the new higher per diem rate 
be the lesser of the following:
    <bullet> The applicable or prevailing rate payable in the 
geographic area in which the State home is located, as determined by 
the Secretary, for nursing home care furnished in a non-Department 
nursing home (i.e., a public or private institution not under the 
direct jurisdiction of VA which furnishes nursing home care); or
    <bullet> A rate not to exceed the daily cost of care in the State 
home facility, as determined by the Secretary, following a report to 
the Secretary by the director of the State home.
    The law thus requires VA to use the actual cost of care in State 
homes based on a report from the home in determining the higher per 
diem, and the home will receive its actual cost if it is less than the 
applicable or prevailing rate. However, as stated in the preamble to 
the proposed rule: ``VA is considering a modification to the proposed 
payment structure to be introduced after two or three years of 
experience with the [Resource Utilization Group-III (RUG III)] 
approach. In the modification, VA would use the actual case-mix of the 
individual state veteran nursing home to determine the reimbursement 
rate, rather than assuming that every nursing home has an equal number 
of veterans in each of the 53 RUG III levels. This modification will 
allow for more accurate payments, reimbursing nursing homes at a higher 
rate for treating veterans with more intensive needs.'' One commenter 
asserted that we should use the earlier time frame of two years to take 
action to modify the payment structure. We made no changes based on 
this comment. We will work as fast as possible to take any actions 
necessary to improve the payment methodology.
    One commenter asserted that there is no indication in the proposed 
rule as to how frequently adjustments would be made to payments under 
Sec.  51.41(b)(1) and further asserted that the regulations should 
include the process for adjustment. One commenter questioned whether VA 
would recalculate amounts each month for the higher per diem rate. In 
response, we note that the preamble to the proposed rule made clear 
that the adjustments would be made annually (see 73 FR 72401-72402). As 
stated in the preamble, the formula for establishing the rate includes 
CMS information that is published in the Federal Register every summer 
and is effective beginning October 1 for the entire fiscal year. We 
have added information in the note to Sec.  51.41(b)(1), explaining 
that adjustments will be made annually.
    One commenter argued that the conclusion that the physician portion 
should be based on one hour per month is too little. Another commenter 
asked how the formula would include costs for physician extenders. 
Another commenter questioned whether a facility would receive a higher 
payment ``if it is determined that each patient receives (and needs) 
substantially more than one hour of combined physician contact each 
month.'' Another commenter asserted that Texas does not use salaried 
physicians at their State homes and questioned whether Texas State 
homes would receive higher amounts to offset this practice. As an 
alternative, the commenter asserted that State homes should be allowed 
to continue to use Medicare Part B for the physician portion. We made 
no changes based on these comments. Based on our experience, we believe 
that one hour is the appropriate amount of time for the calculations 
for all of the primary care that would be provided by physicians or 
physician extenders as authorized under the regulations. The rate is 
based on averages, and it would not be administratively feasible to 
make a separate formula for each facility.
    One commenter further asserted that State homes should not be 
required to pay for outside specialist costs. We made no changes based 
on this comment. Outside specialty care is not considered a part of 
nursing home care.
    One commenter asked for VA to provide sample calculations to show 
how the formula works for VA's computation of the higher per diem. We 
made no changes based on this comment. The commenter was sent a sample 
calculation. We would be happy to provide sample per diem calculations 
to others upon request (see FOR FURTHER INFORMATION CONTACT above for 
contact information).
    One commenter asserted that the higher per diem rate should be made 
applicable to VA programs outside of the State home program. We made no 
changes based on this comment because it is not within the scope of 
this rulemaking proceeding. This rule implements only the statutory 
provisions at 38 U.S.C. 1741-1743 and 1745 regarding nursing home care 
provided in State homes.

Drugs and Medicines

    The provisions of 38 U.S.C. 1745(b) require VA to furnish 
recognized State homes with such drugs and medicines as may be ordered 
by prescription of a duly licensed physician as specific therapy in the 
treatment of illness or injury for certain veterans with service-
connected disabilities.
    One commenter questioned whether veterans for whom the higher per 
diem rate is payable would also receive drugs and medicines under 
section 1745(b). Two commenters argued that the payment of the higher 
per diem for veterans should not bar the receipt of drugs and medicines 
under 38 U.S.C. 1712(d) and corresponding VA regulations. One of the 
commenters questioned whether all veterans with a service-connected 
disability would receive drugs and medicines under proposed Sec.  
51.41. We made no changes based on these comments. Section 1745(b) 
states that drugs and medicines provided under that statutory provision 
cannot be provided to veterans who are being provided nursing home care 
for which the higher per diem is payable. In addition, section 
1745(a)(3) provides that payment by VA of the higher per diem 
constitutes payment in full to the State home for the veteran's nursing 
home care. We interpret this provision to mean that the higher per diem 
includes the cost of drugs and medicines, which provides the basis for 
the provision in Sec.  51.41 that, as a condition of receiving 
payments, the State home must agree not to accept drugs and medicines 
from VA on behalf of veterans provided under 38 U.S.C. 1712(d) and 
corresponding VA regulations. Also, section 1745(b) does not authorize 
VA to provide drugs to all veterans with a service-connected 
disability.
    One commenter questioned, for purposes of proposed Sec.  51.42, who 
would determine if drugs and medicines are needed and how fast these 
determinations would be made. We made no changes based on these 
comments. As indicated in Sec.  51.42, the physician prescribing the 
drug or medicine would make this determination. These determinations 
would be made in the normal course of business.
    One commenter questioned whether a facility would have a choice in 
how the medications sent to the facility would be packaged, e.g., punch 
cards, unit doses, stock. We made no changes based on this comment. VA 
will work with State homes and when practical meet the requests of 
State homes for packaging the drugs and medications.
    One commenter questioned how veterans would receive drugs and 
medicines that may be needed before they could be supplied by VA. Two 
commenters questioned how the State home would receive reimbursement 
for supplying such drugs and medications. We made no changes based on 
these comments. The statute at 38 U.S.C. 1745(b) does not authorize VA 
to

[[Page 19429]]

reimburse States for the cost of drugs and medicines. However, as we 
have done in the existing VA program under which VA provides drugs and 
medicines to State homes on behalf of certain service-connected 
veterans, VA will work with State homes to establish working 
relationships that will allow for the most efficient methods of 
supplying drugs and medicines.

Retroactive Payments

    Section 211(a)(5) of Public Law 109-461 required the higher per 
diem rate based on service connection to take effect on March 21, 2007 
(90 days after enactment of the law). This authority also required that 
the provision of drugs and medicines for specified veterans take effect 
on the same date. Accordingly, the preamble to the proposed rule 
indicated that VA would make retroactive payments constituting the 
difference between the basic per diem actually paid and the higher per 
diem required for care provided to specified veterans on and after 
March 21, 2007. The preamble also indicated that VA would make 
retroactive payments constituting the amount State homes paid for drugs 
and medicines for specified veterans on and after March 21, 2007 (not 
including any administrative costs) (73 FR 72401).
    The preamble to the proposed rule also asserted that VA would not 
make retroactive payments if the State home received any payment for 
such care or for such medicines and drugs from any source unless the 
amount received was returned to the payor (73 FR 72401). One commenter 
indicated that States should not be required to make refunds prior to 
receipt of VA payments because some States may not have sufficient 
funds to advance the payor. One commenter asserted that VA should 
establish a process for returning payments received under the Medicare 
and Medicaid programs. The commenter also asserted that VA should 
establish a process for reimbursing physicians who are not State 
employees and who obtained payments under Medicare Part B. One 
commenter asserted that a State should make repayments to the estate of 
a deceased veteran prior to receiving retroactive payments from VA that 
cover payments previously made by the veteran. We made no changes based 
on these comments. Regardless of whether the return of payment is made 
prior to VA's payment or immediately after VA's payment, the 
responsibility for the return of a payment rests with the State home 
that received the payment.
    One commenter questioned whether VA will make retroactive payments 
from March 2007. As stated in the preamble to the proposed rule (73 FR 
72401), VA will make retroactive payments for care provided on and 
after March 21, 2007, and for drugs and medicines provided on and after 
March 21, 2007.
    Proposed Sec.  51.43(d) provided that per diem payments would be 
made retroactively for care that was provided on and after the date of 
the completion of VA's survey of the facility that provided the basis 
for determining that the facility met VA's standards. One commenter 
asserted that VA should pay per diem payments retroactively back to the 
date the State home opened for operation. We made no changes based on 
this comment. The statutory provisions at 38 U.S.C. 1741(d) provide for 
payment of per diem to commence on the date of the completion of the 
inspection that recognized the State home as meeting VA's standards, as 
determined by the Secretary.
    One commenter essentially questioned when new VA Form 10-0460 
(captioned ``Request for Prescription Drugs from an Eligible Veteran in 
a State Home'') would be used by State homes. We made no changes based 
on this comment. The form should be used from the effective date of 
this document.

Time Limits

    One commenter asserted that a State home should be given 30 days to 
apply for retroactive payments and monthly per diem and VA should be 
given 30 days to act on applications and begin making payments. We made 
no changes based on this comment. State homes are allowed to submit 
immediately for VA retroactive payments and are allowed to submit 
requests for monthly payments as soon as they are due. The regulation 
imposes no deadline on when States must seek retroactive payments. VA 
will respond promptly to States' requests but will not establish the 
deadline suggested by the commenter because it is difficult to predict 
the availability of resources at any given time.

Compensation

    One commenter asserted that those veterans receiving VA 
compensation should not be required to use any of such funds for the 
cost of their State home care. We made no changes based on this 
comment. We know of no basis for treating VA compensation differently 
from other income or other funds of a resident except that the State 
home is prohibited from charging a veteran for nursing home care when 
VA pays the higher per diem rate based on service connection because 
VA's payment constitutes payment in full for the care provided (see 38 
U.S.C. 1745(a)(3)).

Bed Holds

    We proposed to make changes to the bed hold rule. Proposed Sec.  
51.43(c) provided that per diem would be paid for a bed hold only if 
the veteran has established residency by being in the facility for 30 
consecutive days (including overnight stays) and the facility has an 
occupancy rate of 90 percent or greater. In addition, we proposed that 
per diem for a bed hold would be paid ``only for the first 10 
consecutive days during which the veteran is admitted as a patient in a 
VA or other hospital (this could occur more than once in a calendar 
year) and only for the first 12 days in a calendar year during which 
the veteran is absent for purposes other than receiving hospital 
care.''
    One commenter argued that residency should be established by 
admission and that a transfer to an acute care facility should not 
affect residency. The commenter further asserted that the proposed rule 
failed to provide a rationale for the residency requirement. One 
commenter asserted that the regulations should allow a bed hold for at 
least 15 days for a resident who is absent due to hospitalization 
unless the nursing home documents that it has objective information 
from the hospital confirming that the patient will not return to the 
nursing home within 15 days of the hospital admission. We made no 
changes based on these comments. As we indicated in the preamble to the 
proposed rule, VA believes that State homes should receive per diem for 
bed holds only if the State would likely fill the bed without such 
payments and only if the veteran has established residency at the State 
home (73 FR 72402). We believe that 30 days is a minimal amount of time 
for demonstrating that a veteran intends to be a resident at the State 
home and that the veteran was not temporarily placed in the State home.
    With respect to hospital absences, one commenter questioned whether 
the regulations provide for VA to pay per diem ``for only 10 
consecutive overnight hospital absences or any number of overnight 
hospital absences but only up to ten consecutive days maximum period 
each time.'' We have clarified the regulations to state that VA will 
provide per diem ``only for the first 10 consecutive days during which 
the veteran is admitted as a patient for any stay in a VA or other 
hospital (a hospital stay could occur more than once in a calendar 
year).''
    One commenter asserted that the 90 percent occupancy requirement 
should not apply to a new facility for the first

[[Page 19430]]

two years of operation. The commenter asserted that this would afford 
the time to safely fill the building to the 90 percent occupancy rate. 
We made no changes based on this comment. The request is inconsistent 
with the purpose of a bed hold. As stated in the preamble to the 
proposed rule, payments for bed holds are intended to assure that 
nursing home residents who are hospitalized or who are granted leave 
for other purposes are assured a nursing home bed upon return to the 
nursing home (73 FR 72402). It is unlikely that facilities with an 
occupancy of less than 90 percent would fill the bed of an absent 
resident.
    One commenter questioned how to determine when a facility has an 
occupancy rate of 90 percent or greater. We made no changes based on 
this comment. The occupancy rate would be determined by dividing the 
number of residents by the number of beds identified in the recognition 
process. If a facility is recognized as a 100 bed facility and has 90 
residents, the occupancy rate is 90 percent.
    One commenter asserted that their facility was constructed with a 
400-bed capacity but now, because of a nurse shortage, operates at a 
maximum of 300 beds. The commenter asked whether the 90 percent 
requirement would apply to the lower amount. We made no changes based 
on this comment. The lower amount would apply only if the amount were 
based on a formal re-recognition action.

Resident Rights

    Proposed Sec.  51.70(c)(5) provided that ``[u]pon the death of a 
resident with a personal fund deposited with the facility, the facility 
management must convey within 90 calendar days the resident's funds, 
and a final accounting of those funds, to the individual or probate 
jurisdiction administering the resident's estate; or other appropriate 
individual or entity, if State law allows.'' One commenter asserted 
that the regulations should provide a waiver from the 90 day 
requirement in those cases when ``funds are inadequate, there are 
multiple creditors and relatives and the matter is tied in probate or 
no relative or creditor is located or willing to open an estate.'' We 
made no changes based on this comment. The regulations only require 
that the time limit be met when the funds can be conveyed ``to the 
individual or probate jurisdiction administering the resident's estate; 
or other appropriate individual or entity, if State law allows.'' VA 
sees no reason why funds should be retained for longer periods under 
these circumstances.

Quality of Life

    Proposed Sec.  51.100(h)(2) clarified the regulations to specify 
that a nursing home with 100 or more beds would be required to employ 
one or more qualified social workers who work for a total period that 
equals at least the work time of one full-time employee (FTE). We also 
proposed to clarify the regulations to specify that a State home must 
provide qualified social worker services in proportion to the total 
number of beds in the home, specifically one or more social worker FTE 
per 100 beds. For example, under the proposal a nursing home with 50 
beds would be required to employ one or more qualified social workers 
who work for a total period equaling at least one-half FTE and a 
nursing home with 150 beds would be required to employ qualified social 
workers who work for a total period equaling at least one and one-half 
FTE. One commenter asserted that this requirement is too onerous and 
that others could perform the social work under the supervision of a 
social worker. The commenter further asserted that a grandfather 
clause, a waiver, or a phase-in time should be allowed for those not 
meeting the requirement. The commenter also asserted that, instead of a 
1:100 ratio, VA should establish the ratio of 1:120.
    We believe that a resident must have access to a quality social 
work program to help ensure the well being of the resident. We believe 
that we could increase the ratio to 1:120, which is the CMS standard 
and still allow for sufficient availability of social workers. 
Accordingly, the final rule reflects this change. However, we made no 
further changes because we believe that only qualified social workers 
would have the skills necessary to provide this specialized help needed 
by residents.

Resident Assessment

    Section 51.110 requires facility management to ``conduct initially, 
annually and as required by a change in the resident's condition a 
comprehensive, accurate, standardized, reproducible assessment of each 
resident's functional capacity.'' Section 51.110(b)(3) also requires 
quarterly reassessments.
    Proposed Sec.  51.110(b)(1)(i) required officials conducting such 
assessments, among other things, to use the Centers for Medicare and 
Medicaid Services (CMS) Resident Assessment Instrument Minimum Data Set 
(RAI/MDS), Version 2.0. Two commenters asserted that the version will 
be updated and that we should use a generic reference so that we could 
require compliance with the changed versions as they are adopted. We 
made no changes based on these comments. We prefer our incremental 
approach because it allows us to review each new version of the 
standard prior to making it applicable.
    Two commenters asserted that VA should clarify the purposes for 
such CMS RAI/MDS submissions. One of the commenters further questioned 
whether VA would calculate RUG scores from this information and 
questioned how differences between VA and facilities would be resolved. 
We made no changes based on these comments. The purpose for obtaining 
the information is not to challenge the data reviewed. VA uses the 
quality indicators to prepare for surveys.
    Also, we proposed to require each State home to submit each 
assessment to VA at a VA email address. Two commenters asserted that 
facilities should be able to submit the data by electronic means other 
than email. We agree that the information should be submitted 
electronically in a form other than email. Accordingly, the final rule 
requires the submission to be made electronically to the IP address 
provided by VA.

Physical Environment

    Proposed Sec.  51.200 required State home facilities to meet 
certain provisions of the National Fire Protection Association's NFPA 
101, Life Safety Code and the NFPA 99, Standard for Health Care 
Facilities. These documents are incorporated by reference in accordance 
with the provisions of 5 U.S.C. 552(a) and 1 CFR Part 51. We proposed 
to change the regulations to update these documents to refer to the 
current editions of the NFPA code and standard. One commenter asserted 
that the updates should apply only to new construction and renovation. 
The commenter further asserted that existing State homes ``should be 
grandfathered and assessed under the standards that were in place when 
the Homes were constructed and initially surveyed.'' These documents 
represent national consensus standards that are generally recognized as 
minimum standards for life and safety. Ultimately, we believe that 
State homes must work to protect residents by meeting the minimum 
consensus standards contained in these documents.
    The standards for existing facilities take into account that some 
changes may take a considerable amount of time to make, such as 
installation of sprinkler systems for existing nursing homes. The 
Centers for Medicare & Medicaid Services (CMS) has determined that

[[Page 19431]]

August 13, 2013, provides a reasonable amount of time to install 
sprinkler systems in existing nursing homes, as required by paragraph 
19.3.5.1 in the 2006 edition of NFPA 101, which specifically states 
``Buildings containing nursing homes shall be protected throughout by 
an approved, supervised automatic sprinkler system in accordance with 
Section 9.7, unless otherwise permitted by 19.3.5.4.'' We agree, and 
therefore based on the above comment we have included such a 
requirement in the final rule. We note that paragraph 13-3.5.1 in the 
1997 edition of NFPA 101 requires sprinkler protection for buildings of 
certain construction types. The requirement for sprinkler protection 
due to construction type is also found in paragraph 19.1.6 in the 2006 
edition of NFPA 101. The changes in Sec.  51.200 are not intended to 
postpone enforcement of the existing requirement for sprinkler 
protection in nursing homes due to the construction type of the 
building.
    The proposed rule indicated that we would incorporate by reference 
the 2006 edition of the standard. This was in error since the latest 
edition of the standard is the 2005 edition. Therefore, we are 
incorporating by reference the 2005 edition.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in an expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any given year. This rule will have no such effect on 
State, local, and tribal governments, or on the private sector.

Paperwork Reduction Act

    The final rule at Sec. Sec.  51.43, 58.11, 58.13, and 58.18 
contains collections of information under the Paperwork Reduction Act 
of 1995 (44 U.S.C. 3501-3521). The Office of Management and Budget 
(OMB) assigns a control number for each collection of information it 
approves. VA 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. These regulations set forth a 
mechanism for State homes to obtain per diem payments as well as drugs 
and medicines.
    The final rule at Sec.  51.110 also contains a collection of 
information. VA has already obtained OMB clearance for the use of 
Minimum Data Sets (initial, annual, significant change in condition, 
and quarterly) (OMB Control Number 2900-0160). However, the final rule 
requires such Minimum Data Sets to be electronically transmitted to VA.
    In a notice published in the Federal Register on November 28, 2008 
(73 FR 72399), we requested public comments on these collections of 
information. We did not receive any comments.
    OMB has approved those collections and a number of other 
collections in part 51 under OMB Control Numbers 2900-0160 and 2900-
0091. We are adding a statement to all of the sections in part 51 for 
which collections have been approved so that each applicable control 
number is displayed for each collection.

Executive Order 12866

    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, when regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety, 
and other advantages; distributive impacts; and equity). The Executive 
Order classifies a ``significant regulatory action'' requiring review 
by OMB, as any regulatory action that is likely to result in a rule 
that may: (1) Have an annual effect on the economy of $100 million or 
more or adversely affect in a material way the economy, a sector of the 
economy, productivity, competition, jobs, the environment, public 
health or safety, or State, local, or tribal governments or 
communities; (2) create a serious inconsistency or interfere with an 
action taken or planned by another agency; (3) materially alter the 
budgetary impact of entitlements, grants, user fees, or loan programs 
or the rights and obligations of entitlement recipients; (4) raise 
novel legal or policy issues arising out of legal mandates, the 
President's priorities, or the principles set forth in the Executive 
Order.
    The economic, interagency, budgetary, legal, and policy 
implications of this final rule have been examined and it has been 
determined to be a significant regulatory action under Executive Order 
12866 because it may result in a rule that raises novel legal or policy 
issues arising out of legal mandates, the President's priorities, or 
the principles set forth in the Executive Order.

Regulatory Flexibility Act

    The Secretary hereby certifies that this regulatory amendment will 
not have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This rulemaking will affect veterans, State homes, and 
pharmacies. The State homes that are subject to this rulemaking are 
State government entities under the control of State governments. All 
State homes are owned, operated and managed by State governments except 
for a small number that are operated by entities under contract with 
State governments. These contractors are not small entities. Also, this 
rulemaking will have only an insignificant impact on a small number of 
pharmacies that could be considered small entities. Therefore, pursuant 
to 5 U.S.C. 605(b), this amendment is exempt from the initial and final 
regulatory flexibility analysis requirements of sections 603 and 604.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.005, Grants to States for 
Construction of State Home Facilities; 64.007, Blind Rehabilitation 
Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical 
Care Benefits; 64.010, Veterans Nursing Home Care; 64.011, Veterans 
Dental Care; 64.012, Veterans Prescription Service; 64.013, Veterans 
Prosthetic Appliances; 64.014, Veterans State Domiciliary Care; 64.015, 
Veterans State Nursing Home Care; 64.016, Veterans State Hospital Care; 
64.018, Sharing Specialized Medical Resources; 64.019, Veterans 
Rehabilitation Alcohol and Drug Dependence; 64.022, Veterans Home Based 
Primary Care; and 64.026, Veterans State Adult Day Health Care.

List of Subjects in 38 CFR Parts 51 and 58

    Administrative practice and procedure, Claims, Day care, Dental 
health, Government contracts, Grant programs--health, Grant programs--
veterans, Health care, Health facilities, Health professions, Health 
records, Incorporation by reference, Mental health programs, Nursing 
homes, Reporting and recordkeeping requirements, Travel and 
transportation expenses, Veterans.

    Approved: February 27, 2009.
John R. Gingrich,
Chief of Staff, Department of Veterans Affairs.

0
For the reasons set forth in the preamble, 38 CFR parts 51 and 58 are 
amended as follows:

PART 51--PER DIEM FOR NURSING HOME CARE OF VETERANS IN STATE HOMES

0
1. The authority citation for part 51 is revised to read as follows:


[[Page 19432]]


    Authority: 38 U.S.C. 101, 501, 1710, 1741-1743, 1745.


0
2. Amend part 51 by removing the phrase ``Geriatrics and Extended Care 
Strategic Healthcare Group'' each place it appears and adding, in its 
place, ``Office of Geriatrics and Extended Care''.

Subpart A--General

0
3. Amend Sec.  51.2 by revising the definitions of the terms ``Clinical 
nurse specialist'' and ``Nurse practitioner'' to read as follows:


Sec.  51.2  Definitions.

* * * * *
    Clinical nurse specialist means a licensed professional nurse who 
has a Master's degree in nursing with a major in a clinical nursing 
specialty from an academic program accredited by the National League 
for Nursing and who is certified by a nationally recognized 
credentialing body (such as the National League for Nursing, the 
American Nurses Credentialing Center, or the Commission on Collegiate 
Nursing Education).
* * * * *
    Nurse practitioner means a licensed professional nurse who is 
currently licensed to practice in the State; who meets the State's 
requirements governing the qualifications of nurse practitioners; and 
who is currently certified as an adult, family, or gerontological nurse 
practitioner by a nationally recognized body that provides such 
certification for nurse practitioners, such as the American Nurses 
Credentialing Center or the American Academy of Nurse Practitioners.
* * * * *

Subpart B--Obtaining Per Diem for Nursing Home Care in State Homes

0
4. Amend Sec.  51.20 by revising paragraph (a) and adding a 
parenthetical statement after the authority citation, to read as 
follows:


Sec.  51.20  Application for recognition based on certification.

* * * * *
    (a) Send a request for recognition and certification to the Chief 
Consultant, Office of Geriatrics and Extended Care (114), VA Central 
Office, 810 Vermont Avenue, NW., Washington, DC 20420. The request must 
be in the form of a letter and must be signed by the State official 
authorized to establish the State home;
* * * * *

    (The Office of Management and Budget has approved the 
information collection requirements in this section under control 
number 2900-0160.)


0
5. Amend Sec.  51.30 as follows:
0
a. Revise paragraph (a)(1).
0
b. Revise paragraphs (d), (e), and (f).
0
c. Add a parenthetical statement after the authority citation.
    The revisions and addition read as follows:


Sec.  51.30  Recognition and certification.

    (a)(1) The Under Secretary for Health will make the determination 
regarding recognition and the initial determination regarding 
certification, after receipt of a recommendation from the director of 
the VA medical center of jurisdiction regarding whether, based on a VA 
survey, the facility and facility management meet or do not meet the 
standards of subpart D of this part. The recognition survey will be 
conducted only after the new facility either has at least 21 residents 
or has a number of residents that consist of at least 50 percent of the 
new bed capacity of the new facility.
* * * * *
    (d) If, during the process for recognition and certification, the 
director of the VA medical center of jurisdiction recommends that the 
State home facility or facility management does not meet the standards 
of this part or if, after recognition and certification have been 
granted, the director of the VA medical center of jurisdiction 
determines that the State home facility or facility management does not 
meet the standards of this part, the director will notify the State 
home facility in writing of the standards not met. The director will 
send a copy of this notice to the State official authorized to oversee 
operations of the facility, the VA Network Director (10N 1-22), the 
Chief Network Officer (10N), and the Chief Consultant, Geriatrics and 
Extended Care (114). The letter will include the reasons for the 
recommendation or decision and indicate that the State has the right to 
appeal the recommendation or decision.
    (e) The State must submit the appeal to the Under Secretary for 
Health in writing, within 30 days of receipt of the notice of the 
recommendation or decision regarding the failure to meet the standards. 
In its appeal, the State must explain why the recommendation or 
determination is inaccurate or incomplete and provide any new and 
relevant information not previously considered. Any appeal that does 
not identify a reason for disagreement will be returned to the sender 
without further consideration.
    (f) After reviewing the matter, including any relevant supporting 
documentation, the Under Secretary for Health will issue a written 
determination that affirms or reverses the previous recommendation or 
determination. If the Under Secretary for Health decides that the 
facility does not meet the standards of subpart D of this part, the 
Under Secretary for Health will withdraw recognition and stop paying 
per diem for care provided on and after the date of the decision (or 
not grant recognition and certification and not pay per diem if the 
appeal occurs during the recognition process). The decision of the 
Under Secretary for Health will constitute a final decision that may be 
appealed to the Board of Veterans' Appeals (see 38 U.S.C. 7104 and 7105 
and 38 CFR Part 20). The Under Secretary for Health will send a copy of 
this decision to the State home facility and to the State official 
authorized to oversee the operations of the State home.
* * * * *

    (The Office of Management and Budget has approved the 
information collection requirements in this section under control 
number 2900-0160.)

Subpart C--Per Diem Payments

0
6. Revise Sec.  51.40 to read as follows:


Sec.  51.40  Basic per diem.

    Except as provided in Sec.  51.41 of this part,
    (a) During Fiscal Year 2008 VA will pay a facility recognized as a 
State home for nursing home care the lesser of the following for 
nursing home care provided to an eligible veteran in such facility:
    (1) One-half of the cost of the care for each day the veteran is in 
the facility; or
    (2) $71.42 for each day the veteran is in the facility.
    (b) During Fiscal Year 2009 and during each subsequent Fiscal Year, 
VA will pay a facility recognized as a State home for nursing home care 
the lesser of the following for nursing home care provided to an 
eligible veteran in such facility:
    (1) One-half of the cost of the care for each day the veteran is in 
the facility; or
    (2) The basic per diem rate for the Fiscal Year established by VA 
in accordance with 38 U.S.C. 1741(c).


(Authority: 38 U.S.C. 101, 501, 1710, 1741-1744)



0
7. Amend part 51 by adding new Sec. Sec.  51.41 through 51.43, to read 
as follows:

[[Page 19433]]

Sec.  51.41  Per diem for certain veterans based on service-connected 
disabilities.

    (a) VA will pay a facility recognized as a State home for nursing 
home care at the per diem rate determined under paragraph (b) of this 
section for nursing home care provided to an eligible veteran in such 
facility, if the veteran:
    (1) Is in need of nursing home care for a VA adjudicated service-
connected disability, or
    (2) Has a singular or combined rating of 70 percent or more based 
on one or more service-connected disabilities or a rating of total 
disability based on individual unemployability and is in need of 
nursing home care.
    (b) For purposes of paragraph (a) of this section, the rate is the 
lesser of the amount calculated under the paragraph (b)(1) or (b)(2) of 
this section.
    (1) The amount determined by the following formula. Calculate the 
daily rate for the CMS RUG III (resource utilization groups version 
III) 53 case-mix levels for the applicable metropolitan statistical 
area if the facility is in a metropolitan statistical area, and 
calculate the daily rate for the CMS Skilled Nursing Prospective 
Payment System 53 case-mix levels for the applicable rural area if the 
facility is in a rural area. For each of the 53 case-mix levels, the 
daily rate for each State home will be determined by multiplying the 
labor component by the nursing home wage index and then adding to such 
amount the non-labor component and an amount based on the CMS payment 
schedule for physician services. The amount for physician services, 
based on information published by CMS, is the average hourly rate for 
all physicians, with the rate modified by the applicable urban or rural 
geographic index for physician work, and then with the modified rate 
multiplied by 12 and then divided by the number of days in the year.

    Note to paragraph (b)(1): The amount calculated under this 
formula reflects the applicable or prevailing rate payable in the 
geographic area in which the State home is located for nursing home 
care furnished in a non-Department nursing home (a public or private 
institution not under the direct jurisdiction of VA which furnishes 
nursing home care). Further, the formula for establishing these 
rates includes CMS information that is published in the Federal 
Register every summer and is effective beginning October 1 for the 
entire fiscal year. Accordingly, VA will adjust the rates annually.

    (2) A rate not to exceed the daily cost of care for the month in 
the State home facility, as determined by the Chief Consultant, Office 
of Geriatrics and Extended Care, following a report to the Chief 
Consultant, Office of Geriatrics and Extended Care under the provisions 
of Sec.  51.43(b) of this part by the director of the State home.
    (c) Payment under this section to a State home for nursing home 
care provided to a veteran constitutes payment in full to the State 
home by VA for such care furnished to that veteran. Also, as a 
condition of receiving payments under this section, the State home must 
agree not to accept drugs and medicines from VA on behalf of veterans 
provided under 38 U.S.C. 1712(d) and corresponding VA regulations 
(payment under this section includes payment for drugs and medicines).

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1744)


    (The Office of Management and Budget has approved the 
information collection requirements in this section under control 
number 2900-0160.)


Sec.  51.42  Drugs and medicines for certain veterans.

    (a) In addition to per diem payments under Sec.  51.40 of this 
part, the Secretary shall furnish drugs and medicines to a facility 
recognized as a State home as may be ordered by prescription of a duly 
licensed physician as specific therapy in the treatment of illness or 
injury for a veteran receiving care in a State home, if:
    (1) The veteran:
    (i) Has a singular or combined rating of less than 50 percent based 
on one or more service-connected disabilities and is in need of such 
drugs and medicines for a service-connected disability; and
    (ii) Is in need of nursing home care for reasons that do not 
include care for a VA adjudicated service-connected disability, or
    (2) The veteran:
    (i) Has a singular or combined rating of 50 or 60 percent based on 
one or more service-connected disabilities and is in need of such drugs 
and medicines; and
    (ii) Is in need of nursing home care for reasons that do not 
include care for a VA adjudicated service-connected disability.
    (b) VA may furnish a drug or medicine under paragraph (a) of this 
section only if the drug or medicine is included on VA's National 
Formulary, unless VA determines a non-Formulary drug or medicine is 
medically necessary.
    (c) VA may furnish a drug or medicine under paragraph (a) of this 
section by having the drug or medicine delivered to the State home in 
which the veteran resides by mail or other means determined by VA.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1744)

Sec.  51.43  Per diem and drugs and medicines--principles.

    (a) As a condition for receiving payment of per diem under this 
part, the State home must submit to the VA medical center of 
jurisdiction for each veteran a completed VA Form 10-10EZ, Application 
for Medical Benefits (or VA Form 10-10EZR, Health Benefits Renewal 
Form, if a completed Form 10-10EZ is already on file at VA), and a 
completed VA Form 10-10SH, State Home Program Application for Care--
Medical Certification. These VA Forms must be submitted at the time of 
admission and with any request for a change in the level of care 
(domiciliary, hospital care or adult day health care). In case the 
level of care has changed or contact information is outdated, VA Forms 
10-10EZ and 10-10EZR are set forth in full at Sec.  58.12 and VA Form 
10-10SH is set forth in full at Sec.  58.13. If the facility is 
eligible to receive per diem payments for a veteran, VA will pay per 
diem under this part from the date of receipt of the completed forms 
required by this paragraph, except that VA will pay per diem from the 
day on which the veteran was admitted to the facility if the completed 
forms are received within 10 days after admission.
    (b) VA pays per diem on a monthly basis. To receive payment, the 
State must submit to the VA medical center of jurisdiction a completed 
VA Form 10-5588, State Home Report and Statement of Federal Aid 
Claimed. This form is set forth in full at Sec.  58.11 of this chapter.
    (c) Per diem will be paid under Sec. Sec.  51.40 and 51.41 for each 
day that the veteran is receiving care and has an overnight stay. Per 
diem also will be paid when there is no overnight stay if the veteran 
has resided in the facility for 30 consecutive days (including 
overnight stays) and the facility has an occupancy rate of 90 percent 
or greater. However, these payments will be made only for the first 10 
consecutive days during which the veteran is admitted as a patient for 
any stay in a VA or other hospital (a hospital stay could occur more 
than once in a calendar year) and only for the first 12 days in a 
calendar year during which the veteran is absent for purposes other 
than receiving hospital care.
    (d) Initial per diem payments will not be made until the Under 
Secretary for Health recognizes the State home. However, per diem 
payments will be made retroactively for care that was provided on and 
after the date of the completion of the VA survey of the

[[Page 19434]]

facility that provided the basis for determining that the facility met 
the standards of this part.
    (e) The daily cost of care for an eligible veteran's nursing home 
care for purposes of Sec. Sec.  51.40(a)(1) and 51.41(b)(2) consists of 
those direct and indirect costs attributable to nursing home care at 
the facility divided by the total number of residents at the nursing 
home. Relevant cost principles are set forth in the Office of 
Management and Budget (OMB) Circular number A-87, dated May 4, 1995, 
``Cost Principles for State, Local, and Indian Tribal Governments.''
    (f) As a condition for receiving drugs and medicines under this 
part, the State must submit to the VA medical center of jurisdiction a 
completed VA Form 10-0460 for each eligible veteran. This form is set 
forth in full at Sec.  58.18 of this chapter. The corresponding 
prescriptions described in Sec.  51.42 also should be submitted to the 
VA medical center of jurisdiction.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1744)


    (The Office of Management and Budget has approved the 
information collection requirements in this section under control 
numbers 2900-0091 and 2900-0160.)

Subpart D--Standards

0
8. Amend Sec.  51.70, in paragraph (c)(5), by removing ``30 days'' and 
adding, in its place, ``90 calendar days'' and after the authority 
citation by adding

    ``(The Office of Management and Budget has approved the 
information collection requirements in this section under control 
number 2900-0160.)''.


0
9. Amend Sec. Sec.  51.80, and 51.90 by adding after the authority 
citation for each section

    ``(The Office of Management and Budget has approved the 
information collection requirements in this section under control 
number 2900-0160.).''


0
10. Amend Sec.  51.100, by revising paragraph (h)(2) and adding a 
parenthetical statement after the authority citation, to read as 
follows:


Sec.  51.100  Quality of life.

* * * * *
    (h) * * *
    (2) For each 120 beds, a nursing home must employ one or more 
qualified social workers who work for a total period that equals at 
least the work time of one full-time employee (FTE). A State home that 
has more or less than 120 beds must provide qualified social worker 
services on a proportionate basis (for example, a nursing home with 60 
beds must employ one or more qualified social workers who work for a 
total period equaling at least one-half FTE and a nursing home with 180 
beds must employ qualified social workers who work for a total period 
equaling at least one and one-half FTE).
* * * * *

    (The Office of Management and Budget has approved the 
information collection requirements in this section under control 
number 2900-0160.)


0
11. Amend Sec.  51.110 by:
0
a. Revising paragraph (b)(1)(i).
0
b. Removing paragraph (b)(1)(iii).

0
c. Redesignating paragraphs (d) and (e) as paragraphs (e) and (f), 
respectively.
0
d. Adding a new paragraph (d).
0
e. Adding a parenthetical statement after the authority citation. The 
revision and additions read as follows:


Sec.  51.110  Resident assessment.

* * * * *
    (b) * * *
    (1) * * *
    (i) Using the Centers for Medicare and Medicaid Services (CMS) 
Resident Assessment Instrument Minimum Data Set, Version 2.0; and
* * * * *
    (d) Submission of assessments. Each assessment (initial, annual, 
change in condition, and quarterly) using the Centers for Medicare and 
Medicaid Services (CMS) Resident Assessment Instrument Minimum Data 
Set, Version 2.0 must be submitted electronically to VA at the IP 
address provided by VA to the State within 30 days after completion of 
the assessment document.
* * * * *

(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
0160.)


0
12. Amend Sec. Sec.  51.120, 51.130, 51.150, 51.160, 51.180, and 51.190 
by adding after the authority citation for each section ``(The Office 
of Management and Budget has approved the information collection 
requirements in this section under control number 2900-0160.)''.
0
13. Amend Sec.  51.200, by:
0
a. In paragraph (a), removing the phrase, ``(1997 edition)'' and 
adding, in its place, ``(2006 edition), except that the requirement in 
paragraph 19.3.5.1 for all buildings containing nursing homes to have 
an automatic sprinkler system is not applicable until August 13, 2013, 
unless an automatic sprinkler system was previously required by the 
Life Safety Code''; removing the phrase, ``(1996 edition)'' each time 
it appears and adding, in its place, ``(2005 edition)''; and removing 
``Office of Regulations Management (02D), Room 1154,'' and adding, in 
its place ``Office of Regulation Policy and Management (02REG),'' and 
by removing ``or at'' and adding, in its place ``, call 202-461-4902, 
or at''.
0
b. In paragraph (b), removing the phrase, ``(1997 edition)'' each time 
it appears and adding, in its place, ``(2006 edition)'' and removing 
the phrase, ``(1996 edition)'' each time it appears and adding, in its 
place, ``(2005 edition)''; and

0
14. Amend Sec. Sec.  51.210 by adding after the authority citation 
``(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
0160.)''.

PART 58--FORMS

0
15. The authority citation for part 58 is revised to read as follows:

    Authority: 38 U.S.C. 101, 501, 1710, 1741-1743, 1745.


0
16. Amend Sec.  58.11 by revising VA Form 10-5588 to read as follows:


Sec.  58.11  VA Form 10-5588--State Home Report and Statement of 
Federal Aid Claimed.

BILLING CODE 8320-01-P

[[Page 19435]]

[GRAPHIC] [TIFF OMITTED] TR29AP09.140


[[Page 19436]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.141


[[Page 19437]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.142


[[Page 19438]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.143


[[Page 19439]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.144


0
17. Amend Sec.  58.12 by:
0
a. Revising the section heading.
0
b. Revising VA Form 10-10EZ.
0
c. Adding VA Form 10-10EZR.
    The revisions and addition read as follows:


Sec.  58.12  VA Forms 10-10EZ and 10-10EZR--Application for Health 
Benefits and Renewal Form.

[[Page 19440]]

[GRAPHIC] [TIFF OMITTED] TR29AP09.145


[[Page 19441]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.146


[[Page 19442]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.147


[[Page 19443]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.148


[[Page 19444]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.149


0
18. Amend Sec.  58.13 by revising VA Form 10-10SH to read as follows:


Sec.  58.13  VA Form 10-10SH--State Home Program Application for 
Veteran Care Medical Certification.

[[Page 19445]]

[GRAPHIC] [TIFF OMITTED] TR29AP09.150


[[Page 19446]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.151


[[Page 19447]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.152

0
19. Add Sec.  58.18 to read as follows:


Sec.  58.18  VA Form 10-0460--Request for Prescription Drugs from an 
Eligible Veteran in a State Home.

[[Page 19448]]

[GRAPHIC] [TIFF OMITTED] TR29AP09.153


[[Page 19449]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.154


[[Page 19450]]


[GRAPHIC] [TIFF OMITTED] TR29AP09.155


[[Page 19451]]


[FR Doc. E9-9753 Filed 4-28-09; 8:45 am]
BILLING CODE 8320-01-C