Free VA Form 10-3567 - State Home Inspection - fillable - Federal

OMB 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 JUL 2006

10-3567

EXISTING STOCK OF VA FORM 10-3567, MAY 1998, WILL BE USED.

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STATE HOME INSPECTION
NAME OF HOME DATE OF INSPECTION

OPERATING BEDS PATIENT CENSUS

PART I

TOTAL FACILITY

HOSPITAL

NHC

DOM

AUTHORIZED APPROVALS POSITIONS AUTHORIZED STAFF AVAILABLE PHYSICIANS: DENTISTS SOCIAL WORK: MSW
BSW SOCIAL WORK ASSISTANT

PART II - STAFF

TOTAL FACILITY

HOSPITAL

NHC

DOM

PHYSICIANS ASSISTANTS

PHARMACY: REG. PHARMACIST DIETETICS: REG. DIETITIAN
FOOD SUPERVISOR DIETARY ASSISTANTS

NURSING:
NURSING ADM./SUP. DIRECT CARE: CERT. N.P./C.N.S. R.N. L.P.N./L.V.N. N.A.

REHABILITATION THERAPY
REG. P.T./P.T. AIDES REG. O.T./O.T. AIDES

MENTAL HEALTH: PSYCHOLOGIST
PSYCHIATRIST PSYCHIATRIC SOCIAL WORKER COUNSELOR

SPEECH AND AUDIOLOGY OPHTHALMOLOGY/OPTOMETRY PODIATRY RADIOLOGY/LABORATORY RECREATION/ACTIVITIES
DIRECTOR ASSISTANTS VOLUNTEERS

CHAPLAIN ADMINISTRATION ENGINEERING MAINTENANCE/HOUSEKEEPING MEDICAL RECORDS OTHER (Specify)
VA FORM JUL 2006

10-3567

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NAME OF HOME

DATE OF INSPECTION

NURSING SERVICE STAFFING PATTERN
(Four Week Average)

PART III
SHIFT SUNDAY MONDAY

HOSPITAL (Average hours Hosp.
TUESDAY WEDNESDAY THURSDAY

)
FRIDAY SATURDAY

RN

LPN

NA

RN

LPN

NA

RN LPN

NA

RN

LPN

NA

RN

LPN NA

RN

LPN

NA

RN

LPN

NA

DAY

EVENING

NIGHT

PART IV
SUNDAY SHIFT

NURSING HOME (Average hours NHC
MONDAY TUESDAY WEDNESDAY THURSDAY

)
FRIDAY SATURDAY

RN

LPN

NA

RN

LPN

NA

RN LPN

NA

RN

LPN

NA

RN

LPN

NA

RN LPN

NA

RN

LPN

NA

DAY

EVENING

NIGHT

PART V
SUNDAY SHIFT MONDAY

DOMICILIARY (Average hours Dom.
TUESDAY WEDNESDAY THURSDAY

)
FRIDAY SATURDAY

RN

LPN

NA

RN

LPN

NA

RN LPN

NA

RN

LPN

NA

RN

LPN NA

RN

LPN

NA

RN

LPN

NA

DAY

EVENING

NIGHT VA FORM JUL 2006

10-3567

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