Attachment I_ VA Form 10-3567 Staffing Profile.pdf

INSTRUCTIONS

STATE HOME INSPECTION - STAFFING PROFILE

1. The Staffing Profile consists of 5 Parts.

2. Complete Part I, noting numbers of operating beds, beds authorized for VA per diem payments, patient census (veterans and non-veterans), full time employee equivalents (FTEE) authorized, and FTEE available at the time of the inspection for each level of care provided by the home, i.e., nursing home, domiciliary, and/or adult day health care (ADHC). Please use the following definitions to complete the form:

• Operating Beds / Participant Slots - The total number of beds utilized for resident overnight stay in the SVH facility and then broken down into each level of care regardless of whether they are recognized or not. For ADHC, a bed means participant slots.

• Authorized Approvals - The total number of beds authorized or participant slots and recognized by VA for per diem payment and then broken down into each level of care.

• Patient Census - The total number of residents in the facility to include Veterans and Non-Veterans and then broken down into each level of care.

• FTEE Authorized - The total FTEE ceiling for the facility and then broken down into each level of care.

• FTEE Available - The total FTEE of staff available or working at the facility and then broken down into each level of care.

3. Complete Part II, by enumerating total FTEE positions for the facility and then breakdown the assigned FTEE for each level of care. For example, if the facility has (12) R.N's, this may breakdown to 10 for the nursing home, 1 for adult day health care and 1 for the domiciliary. Contract and agency staff shall be included in Part II.

VA FORM

DEC 2023 10-3567

OMB No. 2900-0883 Estimated Burden: 30 minutes Exp. Date: 12/31/2026

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to certify your home without a completed form. Failure to complete the form will have no effect on any other benefits to which you may be entitled. This information is collected under the authority of Title 38 CFR Parts 51.30 and 52.30.

STATE HOME INSPECTION - STAFFING PROFILE

4. Complete the tables in Parts III through V, nursing staffing patterns, for each level of care using the following instructions.

• Select 4 separate 1 week worked schedules (7 days) at random from the previous 12 months, and ensure that one week includes one holiday.

• Using the 4 worked schedules, determine the average number of hours for each type of direct care nursing staff (RN, LPN, CNA), on each shift for each day. (Note: This form is based on 8 hour shifts. If the State Home utilizes 10 hour shifts, count 8 hours in the first shift, and 2 hours in the following shift.

If the State Home utilizes 12 hour shifts, count 8 hours in the first shift, and 4 hours in the following shift.)

• To achieve the average for each box in the tables on Parts III through V, add the hours from the 4 week worked schedules, for each direct care nursing staff, by shift, by day and divide by 4.

• If the level of care has more than one building, a separate form should be used for each separate building as a pre-work to capture all buildings. The final should be an average of each of the separate buildings.

• To calculate the total direct care nursing hours for each level of care, take the sum of all direct care nursing hours from the boxes in the tables on Parts III through V. This will provide the numerator in the formula below.

• To calculate the direct nursing care hours, per patient, per day, take the total direct care nursing hours and divide by the patient census identified in Part I multiplied by seven days as displayed in the formula below.

Nursing Care hours/patient/day = Total Direct Care Nursing Hours [Patient census (veteran + non-veteran) X 7 days]

• To calculate the patient census multiply the patient census identified in Part I by seven days. This will provide the denominator in the formula below.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to certify your home without a completed form. Failure to complete the form will have no effect on any other benefits to which you may be entitled. This information is collected under the authority of Title 38 CFR Parts 51.30 and 52.30.

Page 2VA FORM 10-3567, DEC 2023

STATE HOME INSPECTION

NAME OF HOME

PART I TOTAL FACILITY ADHC NHC DOM

OPERATING BEDS /

PARTICIPANT SLOTS

AUTHORIZED APPROVALS

PATIENT CENSUS

FTEE AUTHORIZED

FTEE AVAILABLE

PART II - STAFF TOTAL FACILITY ADHC NHC DOM

PHYSICIANS M.D. / D.O.

PHYSICIANS ASSISTANTS

DENTISTS D.M.D. / D.D.S.

SOCIAL WORK MSW

SOCIAL WORK BSW

REGISTERED PHARMACIST

REGISTERED DIETITIAN

FOOD SERVICE SUPERVISOR

DIETARY ASSISTANTS

NURSING ADMINISTRATION /

SUPERVISOR

NURSE PRACTITIONER (N.P.) /

CERTIFIED NURSING

SPECIALIST (C.N.S.)

REGISTERED NURSE (R.N.)

LICENSED PRACTICAL NURSE

(L.P.N) / LISCENSE

VOCATIONAL NURSE (L.V.N.)

CERTIFIED NURSING

ASSISTANT (C.N.A.)

SPEECH THERAPIST

PHYSICAL THERAPIST

OCCUPATIONAL THERAPIST

PSYCHOLOGIST

PSYCHIATRIST

THERAPUTIC RECREATION

SPECIALIST/ACTIVITIES

DIRECTOR

ADMINISTRATOR(S)

OTHER (Specify)

Page 3VA FORM 10-3567, DEC 2023

DATE OF INSPECTION

(MM/DD/YYYY)

NURSING SERVICE STAFFING PATTERN

FOUR WEEK AVERAGE

NAME OF HOME

PART III

SHIFT

Domiciliary Direct Care Nursing Hours/Patient/Day =

SHIFT

SUNDAY

CNA

TUESDAY

CNA

THURSDAY

CNA

SATURDAY

RN LPN CNALPNRN

FRIDAY

RN LPN CNALPNRN

WEDNESDAY

RN LPN CNALPNRN

MONDAY

RN LPN CNA

DAY

EVENING

NIGHT

ADHC Direct Care Nursing Hours/Patient/Day =

ADHC

PART IV NURSING HOME

PART V DOMICILIARY

SUNDAY

CNA

TUESDAY

CNA

THURSDAY

CNA

SATURDAY

RN LPN CNALPNRN

FRIDAY

RN LPN CNALPNRN

WEDNESDAY

RN LPN CNALPNRN

MONDAY

RN LPN CNA

Nursing Home Direct Care Nursing Hours/Patient/Day =

Page 4VA FORM 10-3567, DEC 2023

TOTAL

SHIFT

DAY

EVENING

NIGHT

SUNDAY

CNA

TUESDAY

CNA

THURSDAY

CNA

SATURDAY

RN LPN CNALPNRN

FRIDAY

RN LPN CNALPNRN

WEDNESDAY

RN LPN CNALPNRN

MONDAY

RN LPN CNA

TOTAL

DAY

EVENING

NIGHT

TOTAL

DATE OF INSPECTION

(MM/DD/YYYY)

GRAND TOTAL

GRAND TOTAL

GRAND TOTAL

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs Logo.

STATE HOME INSPECTION - STAFFING PROFILE

1. The Staffing Profile consists of 5 Parts.

2. Complete Part I, noting numbers of operating beds, beds authorized for VA per diem payments, patient census (veterans and non-veterans), full time employee equivalents (FTEE) authorized, and FTEE available at the time of the inspection for each level of care provided by the home, i.e., nursing home, domiciliary, and/or adult day health care (ADHC). Please use the following definitions to complete the form:

• Operating Beds / Participant Slots - The total number of beds utilized for resident overnight stay in the SVH facility and then broken down into each level of care regardless of whether they are recognized or not. For ADHC, a bed means participant slots.

• Authorized Approvals - The total number of beds authorized or participant slots and recognized by VA for per diem payment and then broken down into each level of care.

• Patient Census - The total number of residents in the facility to include Veterans and Non-Veterans and then broken down into each level of care.

• FTEE Authorized - The total FTEE ceiling for the facility and then broken down into each level of care.

• FTEE Available - The total FTEE of staff available or working at the facility and then broken down into each level of care.

3. Complete Part II, by enumerating total FTEE positions for the facility and then breakdown the assigned FTEE for each level of care. For example, if the facility has (12) R.N's, this may breakdown to 10 for the nursing home, 1 for adult day health care and 1 for the domiciliary. Contract and agency staff shall be included in Part II.

VA FORM

DEC 2023

10-3567 OMB No. 2900-0883 Estimated Burden: 30 minutes Exp. Date: 12/31/2026 O M B Number 2900-0160.

Estimated Burden: 30 minutes.

Expiration Date: 01/31/2024.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to certify your home without a completed form. Failure to complete the form will have no effect on any other benefits to which you may be entitled. This information is collected under the authority of Title 38 CFR Parts 51.30 and 52.30.

INSTRUCTIONS

STATE HOME INSPECTION - STAFFING PROFILE

4. Complete the tables in Parts III through V, nursing staffing patterns, for each level of care using the following instructions.

• Select 4 separate 1 week worked schedules (7 days) at random from the previous 12 months, and ensure that one week includes one holiday.

• Using the 4 worked schedules, determine the average number of hours for each type of direct care nursing staff (RN, LPN, CNA), on each shift for each day. (Note: This form is based on 8 hour shifts. If the State Home utilizes 10 hour shifts, count 8 hours in the first shift, and 2 hours in the following shift. If the State Home utilizes 12 hour shifts, count 8 hours in the first shift, and 4 hours in the following shift.)

• To achieve the average for each box in the tables on Parts III through V, add the hours from the 4 week worked schedules, for each direct care nursing staff, by shift, by day and divide by 4.

• If the level of care has more than one building, a separate form should be used for each separate building as a pre-work to capture all buildings. The final should be an average of each of the separate buildings.

• To calculate the total direct care nursing hours for each level of care, take the sum of all direct care nursing hours from the boxes in the tables on Parts III through V. This will provide the numerator in the formula below.

• To calculate the direct nursing care hours, per patient, per day, take the total direct care nursing hours and divide by the patient census identified in Part I multiplied by seven days as displayed in the formula below.

Nursing Care hours/patient/day = Total Direct Care Nursing Hours [Patient census (veteran + non-veteran) X 7 days] Nursing Care hours / patient / day equals Total Direct Care Nursing Hours divided by Patient census (veteran plus non-veteran) times 7 days. This is a formula.

• To calculate the patient census multiply the patient census identified in Part I by seven days. This will provide the denominator in the formula below.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to certify your home without a completed form. Failure to complete the form will have no effect on any other benefits to which you may be entitled. This information is collected under the authority of Title 38 CFR Parts 51.30 and 52.30.

VA FORM 10-3567, DEC 2023

STATE HOME INSPECTION

PART I

TOTAL FACILITY

ADHC

NHC

DOM

OPERATING BEDS /PARTICIPANT SLOTS

AUTHORIZED APPROVALS

PATIENT CENSUS

FTEE AUTHORIZED

FTEE AVAILABLE

PART II - STAFF

TOTAL FACILITY

ADHC

NHC

DOM

PHYSICIANS M.D. / D.O.

PHYSICIANS ASSISTANTS

DENTISTS D.M.D. / D.D.S.

SOCIAL WORK MSW

SOCIAL WORK BSW

REGISTERED PHARMACIST

REGISTERED DIETITIAN

FOOD SERVICE SUPERVISOR

DIETARY ASSISTANTS

NURSING ADMINISTRATION / SUPERVISOR

NURSE PRACTITIONER (N.P.) / CERTIFIED NURSING SPECIALIST (C.N.S.)

REGISTERED NURSE (R.N.)

LICENSED PRACTICAL NURSE (L.P.N) / LISCENSE VOCATIONAL NURSE (L.V.N.)

CERTIFIED NURSING ASSISTANT (C.N.A.)

SPEECH THERAPIST

PHYSICAL THERAPIST

OCCUPATIONAL THERAPIST

PSYCHOLOGIST

PSYCHIATRIST

THERAPUTIC RECREATION SPECIALIST/ACTIVITIES DIRECTOR

ADMINISTRATOR(S)

OTHER (Specify)

VA FORM 10-3567, DEC 2023

NURSING SERVICE STAFFING PATTERN

FOUR WEEK AVERAGE

PART III

SHIFT

Domiciliary Direct Care Nursing Hours/Patient/Day =

SHIFT

SUNDAY

CNA

TUESDAY

CNA

THURSDAY

CNA

SATURDAY

RN

LPN

CNA

LPN

RN

FRIDAY

RN

LPN

CNA

LPN

RN

WEDNESDAY

RN

LPN

CNA

LPN

RN

MONDAY

RN

LPN

CNA

DAY

EVENING

NIGHT

ADHC Direct Care Nursing Hours/Patient/Day =

ADHC

PART IV

NURSING HOME

PART V

DOMICILIARY

SUNDAY

CNA

TUESDAY

CNA

THURSDAY

CNA

SATURDAY

RN

LPN

CNA

LPN

RN

FRIDAY

RN

LPN

CNA

LPN

RN

WEDNESDAY

RN

LPN

CNA

LPN

RN

MONDAY

RN

LPN

CNA

Nursing Home Direct Care Nursing Hours/Patient/Day =

VA FORM 10-3567, DEC 2023

TOTAL

SHIFT

DAY

EVENING

NIGHT

SUNDAY

CNA

TUESDAY

CNA

THURSDAY

CNA

SATURDAY

RN

LPN

CNA

LPN

RN

FRIDAY

RN

LPN

CNA

LPN

RN

WEDNESDAY

RN

LPN

CNA

LPN

RN

MONDAY

RN

LPN

CNA

TOTAL

DAY

EVENING

NIGHT

TOTAL

GRAND TOTAL

GRAND TOTAL

GRAND TOTAL

STATE HOME INSPECTION - STAFFING PROFILE.

VA Form 10-3567