Va Form 10-3567 - State Home Inspection-Staffing Profile
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3OMB Approved No. 2900-0160
Estimated Burden Avg. 30 min.
STATE HOME INSPECTION - STAFFING PROFILE
INSTRUCTIONS :
1. The Staffing Profile consists of 5 Parts.
2. Complete Part 1, noting numbers of operating beds, beds authorized for VA per diem payments, patient
census (veterans and non-veterans), staff positions authorized, and staff available at the time of the
inspection for each level of care provided by the home, i.e., nursing home, domiciliary, and/or hospital.
3. Complete Part II, by enumerating total staff 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 5 for the
hospital, 6 for the nursing home, and 1 for the domiciliary. Note: If staff positions are by agreement,
contract, or on consultation basis, specify as follows:
Number of staff, qualifications, number hours/week,
AG = Agreement, CT = Contract, CS = Consultant.
Example:
Social work: 1 MSW, 4 hours/week, CS
Dietitian: 1 RD, 8 hours/week, CS
4. Complete Parts III through V, nursing staffing patterns, for each level of care. Determine the average
number and type of nursing staff on each shift for a 4-week period selected at random to determine the
average weekly nursing staffing pattern. A separate form should be used for each separate building and
include each level of care in that building.
5. In Parts III, IV, and V, complete the average nursing care hours per patient, per day as follows:
Nursing Care hours/patient/day =
Total staff in average week X 8 hrs
Patient census (veteran + non-veteran) X 7 days
Only subtract meal times, not break times. In the case of 10-hour tours, count 9.5 hours. In the case of
12-hour tours, use the State or Union guidance for whether one or two 30-minute meals are provided.
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 and 52.
VA FORM
10-3567
EXISTING STOCK OF VA FORM 10-3567, MAY 1998, WILL BE USED.
Page # of ##
JUL 2006
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