Free VA Form 10-5588 - State Home Report and Statement of Federal Aid Claimed - fillable - Federal

OMB Approval No. 2900-0160 Estimated Burden: Avg. 30 min.

INSTRUCTIONS FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED

1. USE OF VA FORM 10-5588, STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
The VA Form 10-5588 consists of several parts. This report is a monthly statement of gains and losses, days of care, average daily census, total per diem cost, per diem claimed and total amount claimed for hospital, nursing home, domiciliary, and adult day health care. The State home will be paid monthly. Payments will be made only after the State submits a completed VA Form 10-5588. a. One copy of the monthly statement of account will be submitted by each State home to VA medical center of jurisdiction by the end of the 5th workday after the close of each monthly report period. b. VA medical center of jurisdiction staff will review each monthly report for accuracy, resolve any discrepancies with the State home, make payment by electronic fund transfer and file the report. A report should not be accepted by a VA medical center staff if the report is incomplete (i.e., all appropriate blanks are complete and report is signed by the State home administrator and State employee when under management contract arrangement). c. The original monthly statement will be verified and signed by the VA medical center staff person assigned as the point of contact for oversight of the State Home Program and forwarded in duplicate to the Business Office for audit and payment. On completion of VA accounting certification, one copy of each report will be sent to VA Central Office, not later than the 15th workday after the month ends. This information is used to prepare the quarterly program reports of expenditures that are the basis or long range budget projections. The VA Central Office copy will be addressed to: Chief Consultant/Chief State Home Per Diem Program, Office of Geriatrics and Extended Care (114), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420.

2. GENERAL INSTRUCTIONS
a. Enter the last day of the calendar month covered by the report in the box labeled "For Month Ending." b. Enter line entries for domiciliary, column A; nursing home, column B; hospital, column C; or adult day health care, column D in appropriate columns. c. Lines 1 through 13 are to be completed for each level of care. Lines 1-9 will be completed as a monthly veteran residents accountability. Lines 10- 13 will be completed as the end of month resident accountability. (1) Line 1, Total Veteran Residents Remaining End of Prior Month. Enter the number of veteran eligible residents present and remaining on the rolls of the State home as of midnight on the last day of the prior month. Entries on this line will be the same as those shown on line 9 for the prior month. (2) Line 2, Admissions (Change of Status). Enter the number of eligible veterans whose status was changed by transfer from one level of care to another. (3) Line 3, Admissions (Other). Enter the number of eligible veterans admitted to the State home during the report month. (4) Line 4, Return From Leave of Absence of 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnight absences in a calendar year. (5) Line 5, Discharges (Change of Status). Enter the number of eligible veterans whose status was changed by transfer to another level of care in the State home. The total entries on line 2 and 5 for the month will be the same. (6) Line 6, Discharges (Others). Enter the number of eligible veterans who were discharged from the State home or dropped from the rolls, except for deaths. (7) Line 7, Deaths. Enter the number of eligible veterans who died during the report month. Attach a separate sheet to identify deaths by name. (8) Line 8, Leave of Absence of 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnight absences in a calendar year (9) Line 9, Total Veteran Residents Remaining End of Month. Enter the number of eligible male and female veterans present and remaining as of midnight on the last day of the report month. This entry will be equal to the sum of lines 1, 2, 3 and 4 minus lines 5, 6, 7 and 8. (10) Line 10, Non-Veteran Residents Remaining End of Month. Enter number of residents not eligible for reimbursement by VA that are present on the last day of the report month. DO NOT REPORT eligible veteran residents in this cell. (11) Line 11, Total Nursing Home Care Veterans that are 70% Disabled or Admitted for a Service Connected Condition. Enter number of residents included on line 9, that are over 70% service connected disabled or admitted for a service connected condition. (12) Line 12, Female Veteran Residents Remaining at the end of the month.
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CONTINUED INSTRUCTIONS FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID
(13) Line 13, Total Veteran Days of Care Provided. Enter total number of days of care provided, including days of care for eligible veterans with 10 consecutive overnight absences and for the first 12 other types of overnight absences in a calendar year. One day of care may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day of discharge. A gain and a loss on the same day will be reported as one day of care. When accounting for Nursing Home Care use lines 13a and 13b. (13a) Line 13a, Total Veteran Days of Care Provided for Nursing Home Care. Enter total number of days of care provided to veterans 70% or more disabled or admitted for a service connected disability, including days of care for eligible veterans with leave of absence of 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnight absences in a calendar year. One day of care may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day of discharge. A gain and a loss on the same day will be reported as one day of care.

3. INSTRUCTIONS FOR MONTHLY SUMMARY STATEMENT ACCOUNT.
a. Column E, Days of Care, Lines 14, 15, 16, and 17. Enter from line 13 the data in columns A for domiciliary, C for hospital care and D for adult day health care to show the total number of days for each level of care for the month. Enter from line 13b for B for nursing home care to show the total number of day for Nursing home Care for patients less than 70% service disabled or not admitted for a service connected condition. One day of care may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day of discharge. A gain and a loss on the same day will be reported as one day of care. b. Column F, Average Daily Census, Lines 14, 15, 16, and 17. Enter the average daily census computed by dividing the appropriate entry in column J by the number of calendar days in the month, carried to one decimal place. c. Column G, Total Per Diem Cost, Lines 14, 15, 16, and 17. Enter on the appropriate line the total per diem costs for the month computed in accordance with relevant cost principles set forth in the Office of Management and Budget(OMB) Circular number A-87, dated May 4, 1995, "Cost Principles for State, Local, and Indian Tribal Governments." The total per diem cost will include the direct and indirect costs appropriate for each level of care. d. Column H, Per Diem Claimed, 14, 15, 16, and 17. Enter the authorized (VA approved per diem rate for the Fiscal Year) per diem rate or one-half the amount shown in column L carried to two decimal places whichever is the lesser, for the appropriate level of care. VA will pay monthly one-half of the cost of each eligible veteran's care (domiciliary, nursing home, hospital or adult day health care) for each day the veteran is in a facility recognized as a State home, not to exceed the approved per diem rate for that level of care. e. Column I, Total Amount Claimed. (1) Line 18. Verify that the total amount claimed in line 17 does not exceed one-half the sum of products of entries in columns E and I, lines 14, 15, 16 and 17.

4. INSTRUCTIONS FOR CLAIM PER DIEM PAYMENTS OF 70% SC VETERANS IN STATE NURSING HOMES.
a. Column J, Days of Care, Lines 19 and 20 total number of days for each level of care for the month. Including days of care for eligible veterans absent 10 consecutive overnight absences at a VA or other hospital and for the first 12 other types of overnight absences in a calendar year. One day of care may be counted for a veteran on the day the veteran is admitted. A day of care is not counted on the day of discharge. A gain and a loss on the same day will be reported as one day of care. Total on line 21. b. Column K, Total Veterans, Lines 19 and 20. Enter the total number of eligible veterans present on the last day of the report month on line 21. c. Column L, Rate Per Day of SC Vet, 19 and 20. Use prevailing rate chart or (G) 15, whichever is less. d. Column M, Amount Claimed, Lines 19 and 20. Enter the total amount by adding line 19 to line 20.

5. OPERATING BEDS
a. At the end of each month, State home management will enter the current operating bed capacities for domiciliary, nursing home, hospital or adult day health care in the appropriate spaces on Page 2 of the report form.b. Also on Page 2, facility management will enter bed capacities approved by VA. The approved bed capacity and the operating beds should be the same number of beds. If operating beds are closed for any reason, facility management is required to provide the date of closure, expected date the beds will be operational, type of bed (domiciliary, nursing home, hospital, or adult day health care), and the reason for the closure. Please specify if these beds were constructed with federal funds. Information related to closed beds may be entered under "Remarks".

6. CERTIFICATION
a. The facility management must certify that the information in the report is correct by signing and dating the report. b. If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility on a full-time, on site basis. This State employee must also certify that the information in the report is correct by signing and dating the report.
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STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
VA FACILITY NAME AND ADDRESS OF STATE HOME

TO PAY TO

FROM FOR MONTH ENDING CHANGES IN RESIDENCY FOR THE MONTH

LINE NO.

ITEM

DOMICILIARY (A)

NURSING HOME CARE (B)

HOSPITAL (C)

ADULT DAY HEALTH CARE (D)

1 2 3 4 5 6

TOTAL VETERAN RESIDENTS REMAINING AT END OF PRIOR MONTH ADMISSIONS (Change of status)
GAINS

ADMISSIONS (Other)
RETURNS FROM LEAVE OF ABSENCE

DISCHARGES (Change of status) DISCHARGES (Other)
LOSSES DEATHS LEAVES OF ABSENCE

7 8 9

TOTAL VETERAN RESIDENTS AT END OF THE MONTH STATUS AS OF THE END OF THE MONTH

LINE NO.

ITEM

DOMICILIARY (A)

NURSING HOME CARE (B)

HOSPITAL (C)

ADULT DAY HEALTH CARE (D)

10 11

TOTAL NON-VETERAN RESIDENTS AT THE END OF THE MONTH TOTAL NURSING HOME CARE VETS THAT ARE 70% OR MORE SC OR IN NEED OF NH CARE FOR A SC CONDITION FEMALE VETERAN RESIDENTS REMAINING AT THE END OF THE MONTH TOTAL DAYS OF CARE FOR THE MONTH

12

LINE NO.

ITEM TOTAL DAYS OF CARE FURNISHED TO VETERANS WHO ARE ELIGIBLE FOR PER DIEM PAYMENTS (Excluding 13a) TOTAL DAYS OF CARE FURNISHED TO VETERANS 70% OR MORE SC OR IN NEED OF CARE FOR A SC CONDITION

DOMICILIARY (A)

NURSING HOME CARE (B)

HOSPITAL (C)

ADULT DAY HEALTH CARE (D)

13 13a
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STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CONTINUED
CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS LINE NO.
FEDERAL AID CLAIMED UNDER SEC.1741, TITLE 38, U.S.C., AS AMENDED DOMICILIARY CARE NURSING HOME HOSPITAL CARE ADULT DAY HEALTH CARE DAYS OF CARE (E) AVERAGE DAILY CENSUS (F) DAILY COST OF CARE FOR THE MONTH* (G) PER DIEM CLAIMED (H) TOTAL AMOUNT CLAIMED (I)

14 15 16 17 18

TOTAL AMOUNT CLAIMED CLAIM FOR PER DIEM PAYMENTS FOR CERTAIN SC VETERANS IN STATE NURSING HOMES

LINE NO.

VETERAN CATEGORY

DAYS OF CARE (J)

AVERAGE DAILY CENSUS (K)

PREVAILING RATE FROM CHART OR (G) 15 WHICHEVER IS LESS (L)

AMOUNT CLAIMED (M)

19

HAS A SINGULAR OR COMBINED RATING OF 70% OR MORE BASED ON 1 OR MORE SERVICE-CONNECTED DISABILITIES OR A RATING OF TOTAL DISABILITY BASED ON INDIVIDUAL UNEMPLOYABILITY

20 21

IS IN NEED OF NH CARE FOR A VA ADJUDICATED SC DISABILITY

TOTALS: FOR UNITED STATES DEPARTMENT OF VETERANS AFFAIRS USE ONLY

I certify that this report is correct based on documentation provided to VA and that the bed capacity approved by VA is correct. BED CAPACITY APPROVED BY VA
DOMICILIARY CARE NURSING HOME CARE HOSPITAL CARE ADULT DAY HEALTH CARE

RECEIVING REPORT

TOTAL AMOUNT APPROVED BY VA FOR PAYMENT (add block 18i and 21M)

DATE - Services authorized under provisions SIGNATURE AND TITLE OF VA STATE HOME COORDINATOR of Sec. 1741, 1742, 1743 and 1745, Title 38, U.S.C., have been rendered ACCOUNTING CERTIFICATION - AUDIT BLOCK in the quantity claimed and payment is recommended except as follows: DATE VOUCHER AUDITOR AMOUNT DUE SIGNATURE AND TITLE OF AUDITOR DATE

The daily cost of care per veteran is the direct cost plus the indirect cost for the month, divided by patients or residents days of care. Compute this cost in accordance with relevant cost principles set forth in the Office of Management and Budget (OMB) Circular number A-87, dated May 4, 1995, Cost Principles for State, Local, and Indian Tribal Governments.
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STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CONTINUED
TOTAL STATE OPERATING BEDS AT END OF THE MONTH
DOMICILIARY CARE NURSING HOME CARE HOSPITAL CARE ADULT DAY HEALTH CARE

I certify that this report is correct, that all residents included in the report were physically present during the period for which Federal aid is claimed, except for authorized absences, and that facility management has complied with all provisions of Title VI, Public Law 88-352, entitled Civil Rights Act of 1964.
SIGNATURE OF STATE HOME ADMINISTRATOR DATE

SIGNATURE OF STATE EMPLOYEE WHEN APPLICABLE

DATE

REMARKS

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 provide reimbursement for services rendered 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 MAY 2009

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in

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