Attachment J_VA Form 10-3567 Staffing Profile Reference.pdf

VA Form 10-3567 State Home Inspection – Staffing Profile Tips and Hints for Completion

VA Form 10-3567, State Home Inspection – Staffing Profile is dated DEC 2023. This previous form dated NOV 2020 is rescinded.

GEC worked with VHA’s Office of Nursing Services on the calculation for direct nursing care hours per patient day. Education has been provided to NASVH, and the form instructions should be straightforward, but this document will provide some helpful tips and hints to completing this form in its entirety.

General Form Tips:

• Virtual survey: The VA Survey team will electronically send VA Form 10-3567 along with the other four VA required forms to the SVH Management

• Onsite survey: The VA Survey team is suggested to bring 2 copies of the entire VA Form 10-3567 when preparing for the onsite SVH survey. The VA Survey team may also electronically send VA Form 10-3567 along with the other four VA required forms to SVH Management.

• The VA Survey Team is reminded to not exit the survey until the team has reviewed and evaluated information entered on the form by SVH management to determine whether it is complete and accurate in relationship to the applicable regulations in Subparts D, E, and/or F.

• There should be no blank spaces, a (0) zero should be placed in each box if the SVH does not provide a staff discipline.

o There should also not be words such as “contract” included on the form.

• The State Veterans Home (SVH) management should understand the numbers documented as full-time employee equivalent (FTEE) as well as potential implications of numbers provided as it relates to the applicable 38 CFR Part 51 regulations (e.g., if a “0” is listed for Dentist, PT/OT/ST, or Psychologist/Psychiatrist fields).

• This form takes about 30 minutes on average to complete as defined by Office of Management and Budget (OMB) on VA Form 10-3567.

• The staffing profile form consists of 5 Parts (Parts I – V).

• Only one VA Form 10-3567 is required per SVH facility, regardless of whether the SVH has more than one level of care. If a SVH facility has more than one level of care, the final VA Form 10-3567 should be populated with data reflecting the appropriate levels of care. If a SVH facility has multiple buildings within a level of care, the final VA Form 10-3567 should be reflective of information aggregated across all buildings.

Helpful Hints for Instructions Part I

• Instructions and definitions are provided on page 1.

• Record the full name of the SVH and date of the survey at the top. The date should be whatever day the form is filled out.

• The SVH management generally completes this section by entering the number, in whole numbers, in the level of care columns offered by the SVH, of:

o Operating beds or participant slots, o Authorized approvals for VA per diem payments (i.e., # of recognized beds for VA per diem), o Patient (resident) census (veterans and non-veterans), o FTEE authorized by the state to employ, and o FTEE available or working at the time of the survey for each level of care provided by the home, i.e., nursing home, domiciliary, and/or adult day health care (ADHC). This is the FTEE currently in use by the SVH.

• The numbers in the TOTAL FACILITY column will automatically total. No manual entries are needed in this column.

• The SVH should use the following definitions, which are under the instructions page, to complete the form:

o 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.

o 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.

o 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.

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

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

• Please note that for operating beds / participant slots, patient census, and FTEE available, the numbers should be reflective of the day the form is filled out at the time of the survey, not an average.

Helpful Hints for Part II

• Instructions and definitions are provided on page 1.

• The SVH management generally completes this section by enumerating the total

FTEE positions for the facility and then breaking down the assigned FTEE for each level of care. This needs to be recorded as a whole number or a decimal of not more than two (2) place values in the level of care columns offered by the

SVH.

o For example, if the facility has 12 RNs and three levels of care, this may breakdown to 10 for the nursing home, 1 for the ADHC and 1 for the domiciliary. The 12 would be placed under “Total Facility,” 10 under “NHC,” 1 under “ADHC,” and 1 under “DOM.”

• The numbers in the TOTAL FACILITY column will automatically total. No manual entries are needed in this column.

• FTEE must also be broken down if there is not a full FTEE (i.e., 0.50 FTEE / 0.25

FTEE).

• Please note, the FTEE included in this count, should be any FTEE working in the facility. It does not matter if they are being employed by the SVH facility or through a sharing agreement, memorandum of understanding, contract, consultation, etc.

o Unlike the past versions of this form, there is no need to codify how the FTEE is being employed / paid by the SVH. The Total FTEE the SVH provides is all that is necessary. ONLY a number is placed into the box.

• The staff members listed by specific discipline is limited to the FTEE required by the 38 CFR Part 51.

• If the SVH would like to list any other staff disciplines, they may do so in the final “Other” category in Part II. However, they need to specify who they are counting;

this can be done on a separate page where the other disciplines are broken down. If the SVH chooses not to enter any other staff, then this box may remain blank.

• If a “0” is listed for certain disciplines, this may lead to follow up questions from a VA survey team member to SVH management to validate whether there are issues with the SVH’s compliance as it relates to requirements with regulations in Subpart D, E or F or whether the 10-3567 needs to be modified. These are examples:

o For NH: Dental Services are required per §51.170; PT/OT/ST Services are required per §51.120(a); Mental Health Services are required per §51.120(a) and §51.120(g) o For DOM: Dental Services are required per §51.350 o For ADHC: PT/OT/ST Services are required per §51.450(a); Mental

Health Services are required per §51.430(c)

Helpful Hints for Parts III through V:

• VA Form 10-3567 provides explicit step-by-step directions to compute the nursing hours per patient day on page 2. The instructions expand on how to account for different shift hours as well as clarify that only direct care nursing hours should be captured in the equation.

• Record the full name of the SVH and date of the survey at the top. As with Part I, the date should be whatever day the form is filled out.

• The SVH management should complete the following for each level of care provided (ADHC, NHC, DOM), using the following instructions:

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

The SVH can select which 4 weeks they would like to include.

o Using the 4 selected work schedules, determine the average number of hours for each type of direct care nursing staff (RN, LPN, CNA), on each shift for each day.

o Please Note: This form is based on 8-hour shifts. If the SVH 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. Please subtract mealtimes, not break times.

This should be done for each week. The SVH may need to use a copy of the form as a pre-work to get the average. The final VA form should be an average of the four weeks, not four separate documents or separate VA forms per week.

If the level of care (ADHC, NHC, DOM) 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 VA form should be reflective of information aggregated across all buildings, not separate documents or separate VA forms per building.

o To fill out the table and 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.

o All entries into the boxes should be either a whole number or one decimal point.

o A formula has been added to the form that automatically calculates the nursing care hours/patient/day as long as the census from Part I has been entered. The total will update as numbers are added to the boxes in Parts

III – V.

o The total calculated can be validated with this formula:

Grand Total / [Patient census (veteran + non-veteran) X 7 days] If nursing care hours/patient/day equals less than 2.5, refer to §51.130(d) in Subpart D.