Fillable Printable VA Form 10-3567
Fillable Printable VA Form 10-3567
VA Form 10-3567
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.
VA FORM
OCT 2015
10-3567
OMB No. 2900-0160
Estimated Burden: 30 minutes
Exp. Date: 02/28/2019
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.
• To calculate the direct nursing care hours, per patient, per day, take the total direct care nursing hours
and divide by the patient census 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
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
OCT 2015
10-3567
STATE HOME INSPECTION
NAME OF HOME DATE OF 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
ADMINISTRATOR(S)
OTHER (Specify)
VA FORM
OCT 2015
10-3567
NURSING SERVICE STAFFING PATTERN
FOUR WEEK AVERAGE
NAME OF HOME DATE OF INSPECTION
VA FORM
OCT 2015
10-3567
PART III
SHIFT
Domiciliary Direct Care Nursing Hours/Patient/Day =
SHIFT
DAY
EVENING
NIGHT
SUNDAY
CNA
TUESDAY
CNA
THURSDAY
CNA
SATURDAY
RN LPN CNA
LPNRN
FRIDAY
RN LPN CNALPNRN
WEDNESDAY
RN LPN CNALPNRN
MONDAY
RN LPN CNA
CNALPNRN
MONDAY
RN LPN CNALPNRN
WEDNESDAY
RN LPN CNALPNRN
FRIDAY
RN LPN
CNALPNRN
SATURDAY
CNA
THURSDAY
CNA
TUESDAY
CNA
SUNDAY
NIGHT
EVENING
DAY
SHIFT
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
LPNRN
FRIDAY
RN LPN CNALPNRN
WEDNESDAY
RN LPN CNALPNRN
MONDAY
RN LPN CNA
Nursing Home Direct Care Nursing Hours/Patient/Day =
