[Federal Register Volume 80, Number 116 (Wednesday, June 17, 2015)]
[Proposed Rules]
[Pages 34794-34820]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-13838]



[[Page 34793]]

Vol. 80

Wednesday,

No. 116

June 17, 2015

Part II





Department of Veterans Affairs





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38 CFR Parts 17, 51, and 52





Per Diem Paid to States for Care of Eligible Veterans in State Homes; 
Proposed Rules

  Federal Register / Vol. 80 , No. 116 / Wednesday, June 17, 2015 / 
Proposed Rules  

[[Page 34794]]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Parts 17, 51 and 52

RIN 2900-AO88


Per Diem Paid to States for Care of Eligible Veterans in State 
Homes

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to 
reorganize, update (based on revisions to statutory authority), and 
clarify its regulations that govern paying per diem to State homes 
providing nursing home and adult day health care to eligible veterans. 
The reorganization will improve consistency and clarity throughout 
these State home programs. We propose to revise the regulations 
applicable to adult day health care programs of care so that States may 
establish diverse programs that better meet participants' needs for 
socialization and maximize their independence. Currently, we require 
States to operate these programs exclusively using a medical 
supervision model. We expect that these liberalizing changes would 
result in an increase in the number of States that have adult day 
health care programs. We also propose to establish new regulations 
governing the payment of per diem to State homes providing domiciliary 
care to eligible veterans, because the current regulations are 
inadequate. Moreover, we propose to eliminate the regulations governing 
per diem for State home hospitals because there are no longer any State 
home hospitals. In general, this rulemaking is consistent with current 
regulations and policies, and we do not expect that these proposed 
rules would have a negative impact on State homes; rather, we believe 
that these proposed regulations would clarify current law and policy, 
which should improve and simplify the payment of per diem to State 
homes, and encourage participation in these programs.

DATES: Comments must be received on or before August 17, 2015.

ADDRESSES: Written comments may be submitted through 
www.Regulations.gov; by mail or hand-delivery to the Director, 
Regulation Policy and Management (02REG), Department of Veterans 
Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; or by 
fax to (202) 273-9026. Comments should indicate that they are submitted 
in response to ``RIN 2900-AO88-Per Diem Paid to States for Care of 
Eligible Veterans in State Homes.'' Copies of comments received will be 
available for public inspection in the Office of Regulation Policy and 
Management, Room 1068, Department of Veterans Affairs, 810 Vermont 
Avenue NW., Washington, DC 20420, between the hours of 8:00 a.m. and 
4:30 p.m. Monday through Friday (except holidays). Please call (202) 
461-4902 for an appointment. (This is not a toll-free number.) In 
addition, during the comment period, comments may be viewed online 
through the Federal Docket Management System (FDMS) at 
www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Dr. Richard Allman, Chief Consultant, 
Geriatrics and Extended Care Services (10P4G), Veterans Health 
Administration, 810 Vermont Avenue NW., Washington, DC 20420, (202) 
461-6750. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: Currently, VA pays per diem to State homes 
for three types of care provided to eligible veterans: nursing home 
care, domiciliary care, and adult day health care. The statutory 
authority for these payment programs is set forth at 38 U.S.C. 1741-43 
and 1745. Currently, VA has regulations at 38 CFR part 51 that apply to 
the payment of per diem for nursing home care and 38 CFR part 52 that 
apply to the payment of per diem for adult day health care. Many of the 
sections in parts 51 and 52 are similar or identical. In particular, 
subparts A, B and C of both parts (which collectively concern 
procedural rules, recognition, and certification requirements for the 
payment of per diem) contain a great deal of redundancy. In some cases, 
we have regulations in parts 51 and 52 that have identical substantive 
effect, but we have unintentionally worded them differently. Subparts D 
of parts 51 and 52 set forth unique standards applicable to the 
recognition and certification of nursing homes or adult day health care 
programs (although both subparts D do contain some overlap).
    In order to eliminate redundancy and clarify the procedures for 
recognition and certification of State homes, we propose this extensive 
rewrite and reorganization of parts 51 and 52. This rulemaking would 
remove part 52. Part 51 would be re-titled ``Per Diem for Nursing Home, 
Domiciliary, or Adult Day Health Care of Veterans in State Homes,'' 
adding domiciliary and adult day health care to the title of part 51, 
which had formerly applied only to nursing home care. The regulations 
in subparts A and B of part 52 would be consolidated with similar 
regulations in part 51, and would be organized in subparts A and B of 
part 51. Proposed part 51, subpart C, would include regulations 
governing payments and eligibility for all three types of care. These 
proposed regulations would supersede the regulations currently 
contained in 38 CFR 17.190 through 17.200, which pertain to the payment 
of per diem for hospital and domiciliary care in State homes. 
Therefore, we propose to remove Sec. Sec.  17.190 through 17.200.
    Subpart D of part 51 would continue to set forth the standards 
applicable to the payment of per diem for nursing home care.
    The regulations in subpart D of part 52, concerning adult day 
health care programs, would be moved to a new subpart F of part 51, and 
would be revised to broaden the ability of State home adult day health 
care programs to operate in a manner that emphasizes participant 
independence over a strict medical model of care. There are currently 
only two State homes receiving per diem from VA for adult day health 
care, and we wish to increase the number of such homes throughout the 
country because we believe that such care is a viable and healthier 
alternative for veterans who otherwise would require nursing home care.
    This rulemaking would also establish new regulations that set forth 
standards that State homes must meet to receive per diem for 
domiciliary care. The proposed standards would supersede all non-CFR 
policies that contain standards for VA payment of per diem for 
domiciliary care in State homes.
    Moreover, the proposed rule is generally consistent with the 
current regulations on the payment of per diem for domiciliary care 
except as discussed below. In fact, much of the current guidance for 
domiciliary per diem is substantively similar to the rules already 
established for nursing home care and adult day health care in current 
parts 51 and 52, and therefore the general rules in proposed subparts A 
and B would apply equally to domiciliary care. The standards applicable 
to domiciliary care are proposed at subpart E. In other words, for 
purposes of regulatory organization, we propose to treat domiciliary 
care in the same manner that we would treat our other two State home 
programs.
    We would also update the authority citation for part 51 to include 
38 U.S.C. 1745, which pertains to State home nursing home care for 
certain veterans with service-connected disabilities and was enacted 
after we published part 51. We have not yet updated the authority 
citation for all of part 51 to include 38 U.S.C. 1745, though certain 
sections

[[Page 34795]]

were updated to include a citation to it. This amendment would have no 
substantive effect but would clarify that it is one of VA's authorities 
for all of part 51.
    A detailed discussion of the proposed revised part 51 follows, 
organized by subpart and section.

Subpart A--General

51.1 Purpose and Scope of Part 51

    Section 51.1would describe the purpose, scope, and organization of 
part 51.

51.2 Definitions

    Section 51.2 would set forth definitions applicable to terms used 
throughout part 51. Definitions of terms that are currently defined in 
Sec.  51.2 are unchanged, except where the same term was technically 
(but not substantively) defined differently in current Sec.  52.2 such 
that minor technical revision was required. Definitions in current 
Sec.  52.2 would be added to Sec.  51.2 without substantive change, 
except as noted below. Also, we would adopt the regulatory definition 
of domiciliary care in 38 CFR 17.30(b) that currently applies to State 
homes in proposed Sec.  51.2 except that the proposed definition would 
not include ``travel and incidental expenses pursuant to Sec.  17.143'' 
because State homes are not required to pay these expenses pursuant to 
Sec.  17.143. Finally, a few new definitions would be added, as 
explained below.
    Current Sec.  52.2 does not define ``adult day health care;'' 
however, part 52 does establish standards applicable to State home 
adult day health care. Many States would like to use a model of adult 
day health care that emphasizes socialization and maximizes participant 
independence, but does not provide as much medical supervision or 
involvement as is generally required by current part 52. Therefore, we 
propose to amend the regulations governing State home adult day health 
care to allow for flexibility and to establish standards of medical 
care only when the State home provides such care. These revisions are 
discussed in greater detail in the portion of this notice describing 
proposed subpart F of part 51. In Sec.  51.2, we would set forth a 
definition of adult day health care that will allow for flexibility in 
terms of the services provided. As revised, this type of adult day 
health care program would serve as an alternative to full-time nursing 
home care; it emphasizes group activities and is designed to reduce or 
postpone the need for institutional placement (such as placement in a 
nursing home), rather than emphasizing medical treatment. We believe 
that these proposed revisions will expand the availability of adult day 
health care within State homes and for veterans who wish to live at 
home but who require daily care, and may lead to decreased demand for 
costly nursing home care. As such, we believe that this would produce a 
positive result for veterans.
    We note that current 38 CFR 17.111(c)(1) defines ``adult day health 
care'' for the purposes of a copayment determination for adult day 
health care provided by VA. This regulation does not apply to the State 
home program. However, VA is currently considering whether the expanded 
definition of adult day health care that would apply to State homes 
under this rulemaking should also apply to VA adult day health care. 
Any revisions to part 17 would appear in a separate rulemaking.
    We will not provide different rates of payment to State home adult 
day health care programs that provide intensive medical supervision and 
those that do not. Adult day health care provided under the current 
definition is typically more expensive than what States could offer 
using the broader definition of adult day health care programs proposed 
in this rulemaking; however, current State participation in adult day 
health care for veterans is virtually nonexistent due to this higher 
cost. In part because current VA requirements are too expensive to 
implement, we are proposing these revisions in an effort to expand 
State home adult day health care as an option for our veterans.
    We propose a definition of clinical nurse specialist that accords 
with the intended meaning of the term for all these State home 
programs. Currently, both parts 51 and 52 require that a clinical nurse 
specialist be ``a licensed professional nurse with a master's degree in 
nursing and a major in a clinical nursing specialty from an academic 
program accredited by the National League for Nursing.'' However, 
current Sec.  51.2 also requires that the nurse be ``certified by a 
nationally recognized credentialing body (such as the National League 
for Nursing, the American Nurses Credentialing Center, or the 
Commission on Collegiate Nursing Education).'' We no longer believe 
that such certification is necessary in order for a nurse to be 
qualified, which is why we had dropped that additional language when we 
promulgated part 52. Therefore, in these new regulations, we would also 
drop the additional language from the rules that apply to nursing home 
care.
    We would establish that references to ``Director'' in this part 
would be to the Director of the VA medical center of jurisdiction, 
unless the section specifically refers to another type of director. 
This is a nonsubstantive change that is intended to clarify references 
in the regulations.
    Current Sec.  17.30(b) defines ``domiciliary care'' for the 
purposes of VA's ``medical regulations,'' i.e., current part 17. VA's 
current regulations for payment of per diem to state homes for 
domiciliary care are part of those regulations. Therefore, this 
definition applies to the State home program. We propose adopting a 
similar definition of domiciliary care in Sec.  51.2, except that we 
would update the language and delete the requirement that State home 
domiciliaries provide ``travel and incidental expenses pursuant to 
Sec.  17.143,'' which previously was the regulation implementing VA's 
authority to pay beneficiary travel of certain veterans. VA's current 
beneficiary travel regulations are set forth in 38 CFR part 70, and 
they generally require VA to pay for eligible Veterans' travel to and 
from VA facilities. In any case, those regulations only require VA to 
pay for travel; they do not apply to State homes. We thus propose to 
not require State homes to pay for travel in the same manner as VA does 
under VA's beneficiary travel program. We also propose to remove the 
requirement that State home domiciliaries provide residents with 
clothing. Although VA is required by 38 U.S.C. 1723 to provide clothing 
under certain circumstances in its own facilities, this statute does 
not apply to State homes. VA erroneously included provision of clothing 
in the current regulation.
    We would add a definition of ``[e]ligible veteran.'' The term would 
refer to a veteran whose care may serve as a basis for per diem 
payments. The definition would reference the substantive sections under 
which such eligibility would be established for each of the three per 
diem programs.
    We would eliminate the current definition of ``facility'' in 
Sec. Sec.  51.2 and 52.2 because it is not necessary. We would add a 
definition of ``licensed medical practitioner.'' The term would 
encompass and would refer to the following terms we further define in 
this section: Nurse practitioner; physician; physician assistant; and 
primary physician or primary care physician.
    We would revise the definition of ``nursing home care'' to be 
consistent with the statutory definition of that term in 38 U.S.C. 
101(28).
    We would define ``participant'' as an individual receiving adult 
day health care and ``resident'' as an individual receiving nursing 
home or domiciliary

[[Page 34796]]

care. The proposed definitions would be consistent with the uses of 
those terms in both the current regulations and the proposed 
regulations.
    The last sentence of the definition of ``physician assistant'' in 
current Sec.  51.2 states that a physician assistant must be able to 
perform certain tasks ``under appropriate physician supervision which 
is approved by the primary care physician.'' The last sentence of the 
same definition in Sec.  52.2 states that a physician assistant must be 
able to perform the same tasks ``under the appropriate supervision by 
the primary care physician.'' Thus, part 52 requires actual supervision 
by the primary care physician, but part 51 does not. We did not intend 
these provisions to be different, and would require in revised Sec.  
51.1 that the physician assistant be able to perform such tasks ``under 
appropriate physician supervision.'' This would allow clinicians to 
determine on a case-by-case basis what level of supervision is 
required.
    We would define a ``program of care'' as any of the three levels of 
care for which VA may pay per diem under part 51. Current regulations 
use this term, and it is convenient to retain it.
    We would revise the definition of ``State,'' which currently 
includes ``possessions of the United States.'' Although this definition 
is consistent with the definition in 38 U.S.C. 101(20), the definition 
of State home, in 38 U.S.C. 101(19), does not include a home 
established in a possession of the United States. Because the 
definition of State in part 51 applies only to part 51, and we are not 
authorized to provide per diem to State homes in possessions of the 
United States, we would delete the reference to possessions in the 
definition of ``State.'' This is a substantive change; however, it has 
no actual impact because there are not any State homes established in a 
possession. Also, we are not aware that any possessions have permanent 
populations that would justify the establishment of a State home.
    The statutory definition of ``State'' includes ``Territories'' of 
the United States. 38 U.S.C. 101(20). The Department of the Interior, 
which has administrative responsibility for coordinating federal policy 
in Island groups in the Insular Area, has identified the United States 
Virgin Islands, Guam and American Samoa as territories of the United 
States, and the Northern Mariana Islands as a Commonwealth in Political 
Union with the United States, which is treated as a U.S. territory for 
purposes of the State home per diem payment program. See VAOPGCCONCL 
10-98 and VAOPGCPREC 55-91. We thus propose to amend the definition of 
``State'' to include the Virgin Islands, Guam, the Commonwealth of the 
Northern Mariana Islands, and American Samoa. The Commonwealth of 
Puerto Rico would remain part of the definition. The proposed revisions 
would make this definition of ``State'' consistent with the definition 
of ``State'' for purposes of the program that provides grants to States 
for construction and acquisition of State homes. See 38 CFR 59.2. 
Because this proposed definition of ``State'' would name each of the 
included territories of the United States, we propose to delete the 
reference to ``territories'' in the definition.
    We would revise the current regulatory definition of ``State home'' 
to eliminate the reference to hospital care because we no longer pay 
per diem for hospital care through the State home per diem program. 
This is also an important reason to eliminate current 38 CFR 17.190-
17.200 which concern in part payment of per diem for hospital care in 
State homes.
    We would define a ``veteran'' as a veteran under 38 U.S.C. 101.
    We would not include from current Sec.  52.2 the definition of 
``instrumental activities of daily living'' because the term would not 
appear in part 51. It is no longer necessary to the adult day health 
care program, and is not used in the administration of nursing home 
care or domiciliary care. Changes to the adult day health care program 
are further explained below.

Subpart B--Obtaining Recognition and Certification for Per Diem 
Payments

    Subpart B would establish the procedures for obtaining State home 
recognition and certification, in order to receive per diem payments. 
These procedures would be common to all three programs, except as 
specifically noted in the proposed regulations. We propose to remove 
current Sec.  51.10, because it is unnecessary and merely restates 
information that is set forth in more detail in other sections of 
subpart B. Despite the removal of Sec.  51.10, we would keep the 
section numbering in subpart B the same, or reasonably similar, to the 
current numbering.

51.20 Recognition of a State Home

    Section 51.20 is based on current regulations governing the 
recognition and certification process, but the proposed rule would 
establish clearer and simpler procedures, without making significant 
substantive changes to the current process. We discuss the proposed 
process in detail below.
    A key difference in the new process is that the current process 
requires both recognition and ``initial certification'' by the Under 
Secretary for Health for State home nursing homes and adult day health 
care programs, but does not clearly distinguish between the 
requirements for recognition versus the requirements for initial 
certification. Moreover, ``initial certification'' is no different from 
the ongoing annual certification, except that ``initial certification'' 
is provided by the Under Secretary for Health while annual 
certifications are authorized by the Director of the VA medical center 
of jurisdiction. It is confusing to have the same decision, 
certification, be authorized by two different individuals, particularly 
because the annual certification is then appealable to the Under 
Secretary for Health. Therefore, the proposed process would refer to 
the initial determination by the Under Secretary solely as a 
``recognition'' determination, and all subsequent determinations (other 
than those following revocation) as ``certifications.'' We emphasize 
that this change would not affect the State homes themselves, because 
current regulations require State homes to follow all applicable 
regulations in order to obtain recognition and initial certification as 
well as annual certification. We believe that it is clearer to 
distinguish recognition, which requires the Under Secretary for 
Health's approval, from certification, which requires only approval at 
the level of the Director of the VA medical center of jurisdiction. 
Another significant change is the delegation to the Under Secretary for 
Health for all recognition and appeal decisions related to 
domiciliaries. We believe it is more appropriate for the Under 
Secretary, who has direct responsibility for the provision of health 
care by VA, to make such decisions. This difference, and any other 
differences between the current regulations in part 17 regarding State 
homes and proposed part 51, would be resolved by this rulemaking for 
the policy reasons set forth in this rulemaking.
    In current Sec.  51.20(a), we require that requests for recognition 
be sent to the Chief Consultant, Office of Geriatrics and Extended Care 
(114). The Veterans Health Administration (VHA) recently changed its 
management structure, so that the Director of the Office of Geriatrics 
and Extended Care Operations now performs the management and operations 
duties for State homes that were formerly performed by the Chief 
Consultant of

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the Office of Geriatrics and Extended Care. The proposed rule would 
change references to the ``Chief Consultant'' to the ``Office of 
Geriatrics and Extended Care'' in Sec.  51.20(a). We make the same 
change in proposed Sec. Sec.  51.120(a)(3) and 51.210(b). VHA will 
publish policy documents to inform State homes of the addresses to 
which any documents must be mailed.
    Current Sec. Sec.  51.20 and 52.20 require that the request for 
recognition be signed by ``the State official authorized to establish 
the State home.'' State homes are often established through acts of the 
State legislature. Therefore, we would revise the language to require 
signature by ``the State official authorized to make the request.'' 
This is in fact how the current process works, so this revision would 
merely be a clarification. Current Sec.  17.191 requires that 
applications for recognition of State home domiciliaries be filed with 
the Under Secretary for Health and provides that the Secretary of VA 
will make the final decision after considering a recommendation from 
the Under Secretary for Health. As noted above, the proposed rules 
would delegate recognition authority to the Under Secretary for Health. 
In addition, proposed Sec.  51.20 would make the process of requesting 
and obtaining recognition of a State home domiciliary otherwise 
consistent with the process applicable to State nursing homes and adult 
day health care programs. There is simply no longer any reason to 
support using different procedures.
    Proposed Sec.  51.20(b)(1) would state that after receiving a 
request for recognition under Sec.  51.20(a), VA will survey the home 
in accordance with Sec.  51.31. This is consistent with current 
practice governing domiciliaries and with current Sec. Sec.  51.30 and 
52.30. Paragraph (b)(1) would also provide that in surveying the home 
VA must determine if the home meets the standards set forth in this 
Part and that those standards which impose requirements on State homes 
would apply to homes that are being considered for recognition. This is 
necessary because proposed Sec.  51.2 defines ``State home'' as a home 
that has already been recognized by VA.
    Paragraphs (b)(2) and (3) would require the Director to submit to 
the Under Secretary for Health a written recommendation for or against 
recognition. Proposed paragraph (b)(3), concerning recommendations 
against recognition, is based on parallel provisions in the current 
regulations; however, we would revise the description, currently in 
Sec. Sec.  51.30(a)(2) and 52.30(a)(2), of the State's rights in a case 
where the Director does not recommend recognition. The current 
regulations provide that the State may appeal such recommendation to 
the Under Secretary for Health; however, the Director is not authorized 
to award recognition and therefore the Director's recommendation has no 
direct adverse effect on the State. The Director's recommendation 
carries no legal effect, and merely serves as evidence considered by 
the Under Secretary for Health. Therefore, it would be incorrect to 
characterize the State's response to this recommendation as an appeal. 
At the same time, the Director's recommendation may influence the Under 
Secretary for Health's determination on the recognition request, and 
therefore the State should have an opportunity to present evidence to 
the Under Secretary for Health to support a decision that is contrary 
to the Director's recommendation. Thus, we would explain that the State 
must be afforded 30 days to submit a response and any additional 
evidence to the Under Secretary for Health.
    In proposed paragraph (c), we would clearly state that the Under 
Secretary for Health's decision may be appealed to the Board of 
Veterans' Appeals. This is consistent with current law and practice and 
current Sec.  51.30(f), but is not clearly stated in our regulations 
governing per diem for State home domiciliaries and adult day health 
care programs.
    In addition, current Sec.  52.30(a)(1) requires the Director to 
make a ``tentative determination'' regarding recognition and 
certification, while current Sec.  51.30(a)(2) requires the director to 
make a ``recommendation.'' The latter is more accurate, and Sec.  51.30 
would accordingly refer throughout to a ``recommendation.''
    Proposed Sec.  51.20(d) is based on the last sentences of current 
Sec. Sec.  51.30(b) and 52.30(b). Paragraph (d)(1) would clarify that 
recognition of a home means that the State home met all applicable 
requirements of part 51 at the time of recognition. Paragraph (d)(1) 
would also indicate, for purposes of clarity, that certification must 
thereafter be obtained no later than 450 days after the home is 
recognized and every 450 days thereafter, in accordance with Sec.  
51.30(b).
    Proposed paragraph (d)(2) would state that ``any new annex, new 
branch, or other expansion in the size of a home or any relocation of 
the home to a new facility must be separately recognized.'' This is 
consistent with current practice and Sec. Sec.  51.30(b) and 52.30(b). 
We also propose in paragraph (d)(2) a substantive change to the current 
requirements, which would be that ``changes in the use of particular 
beds between recognized programs of care and increases in the number of 
beds that are not described in the previous sentence require 
certification of the beds, but not recognition.'' This means that a 
State with a recognized domiciliary and nursing home may change the use 
of one or more beds in the domiciliary to nursing home care without 
requesting recognition from the Under Secretary for Health. A survey 
would still be required, but only certification by the Director would 
be needed. This would allow State homes to change the uses of beds 
without going through the cumbersome recognition process and at the 
same time would enable VA to ensure that the State home meets the 
applicable standards of care and can adequately meet the needs of the 
new residents assigned to those beds.
    We note that current Sec. Sec.  17.190 through 17.193 impose 
several requirements regarding recognition and certification of State 
home domiciliaries. Some of these requirements are similar to the 
requirements in this Notice of Proposed Rulemaking, but others 
conflict. For example, current Sec.  17.192 provides that separate 
applications for domiciliary recognition must be filed for any annex, 
branch, enlargement, expansion, or relocation of a recognized home that 
is not on the same or contiguous grounds on which the parent facility 
is located. But proposed Sec.  51.20(d) would require a separate 
application for recognition of any such change, regardless of whether 
the change would be made on the same or contiguous grounds. This is 
necessary to ensure that the facility continues to meet the standards 
applicable to domiciliaries. It is also consistent with the manner in 
which VA handles similar applications in the nursing home or adult day 
health care contexts.

51.30 Certification

    Proposed Sec.  51.30 is based on the annual and provisional 
certification requirements in current Sec. Sec.  51.30 and 52.30. 
Although the recognition process proposed in Sec.  51.20 is similar to 
the current process, we propose significant simplifications and changes 
to the certification process that will improve VA's ability to 
authorize programmatic changes and allow State homes greater 
flexibility in meeting the needs of their resident populations.
    Proposed paragraph (a) would state that State homes must allow a VA 
survey of the home in order to be certified by VA. It would also state 
that a State home must be certified within 450 days after the State 
home is

[[Page 34798]]

recognized and that certifications expire 600 days after they are 
issued. This would ensure that VA has sufficient time to survey and 
recertify State homes if certification is warranted. This provision is 
based on current Sec. Sec.  51.30(c) and 52.30(c), with clarifications 
due to the proposed simplified certification procedures.
    Proposed Sec.  51.30(b)(1) would state that the Director of the VA 
medical center of jurisdiction would certify a State home based on a 
survey conducted at least once every 270-450 days, at VA's discretion, 
and would require the Director to notify the State home of a 
certification decision within 20 days of the decision. Twenty days is 
sufficient time for VA to ensure notification, and is comparable to the 
time periods required for other actions under this rulemaking. See 
proposed Sec.  51.30(c)(1)(iii). Requiring a periodic survey is 
entirely consistent with current regulations and practice as to all 
three programs of care.
    Proposed paragraph (c) would revise VA's current certification 
procedures to make it easier for a State to change the size of a 
recognized program of care. Under current regulations, changes to the 
size of a program of care require a new recognition decision.
    In proposed paragraph (c)(1), we would require only a new survey 
and certification decision when an existing State home increases the 
number of available nursing home or domiciliary beds in a recognized 
program of care, except increases described in the first sentence of 
Sec.  51.20(d)(2), or when a State home recognized to provide both 
domiciliary and nursing home care switches beds between recognized 
programs of care. The proposed regulations would allow the Director to 
precertify, at the request of a State home, the increased number of 
beds or beds switched between recognized programs of care in an 
existing State home so that payments can be made for care of eligible 
veterans in these beds during the certification survey process for up 
to 360 days or until VA issues a certification decision, whichever 
occurs first. We would provide that precertification would be 
authorized if the Director reasonably expects, based on prior surveys 
and any other relevant information, that the State home would continue 
to comply with part 51 until the State home is surveyed and certified. 
We would also provide that VA would pay per diem for the care of 
eligible veterans in the beds provided on and after the date the 
Director precertifies the beds. Permitting precertification would allow 
VA to provide guidance to the State home in advance of VA's 
certification survey.
    In proposed paragraph (c)(2), we would require the State to report 
to the Director any decreases in the number of beds available and an 
explanation of such decrease within 30 days. Currently, 38 CFR 51.30(b) 
requires certification when a State home reduces the number of beds, 
and we do not believe that it is a good use of resources to require VA, 
or the State home, to go through the certification process in such 
cases. Thus, under paragraph (c)(2), decreases in size would be 
explicitly exempted from requiring certification.
    Proposed paragraph (d) would govern the provisional certification 
process. Paragraph (d)(1) would require the Director to issue a 
provisional certification under specified circumstances. This is mostly 
consistent with current practice. We would require that the State's 
corrective action plan be submitted to the Director no later than 20 
days after receipt by the State home of the survey report. If the State 
does not submit a corrective action plan within 20 days, the Director 
would not issue a provisional certification. Twenty days is a 
reasonable amount of time, particularly because proposed Sec.  51.30(b) 
would require VA to provide a copy of the survey report within 20 days 
after the survey is completed. We would provide that the Director must 
determine that the corrective action plan is reasonable. We would also 
require the Director to send written notice to the appropriate 
person(s) at the State home informing them that the Director agrees 
with the plan.
    The current regulations recommend that certifications, including 
provisional certifications, should be made every 12 months. But they do 
not address how a provisional certification of more than 12 months 
would affect the annual certification requirement. This can be 
confusing. Therefore, proposed paragraph (d)(2) would clarify that VA 
will continue to survey the State home while it is under a provisional 
certification in accordance with proposed Sec. Sec.  51.30 and 51.31, 
and will continue the provisional certification so long as the criteria 
for issuing the initial provisional certification, listed in proposed 
paragraph 51.30(d)(1), remain true. This means that if new deficiencies 
are identified during an annual survey, then a new provisional 
certification (or denial of certification) would be required as to 
those new deficiencies.
    Proposed paragraph (d)(3) would clarify what happens if a State 
home fails to adhere to the corrective action plan. In such instances, 
we would no longer make issuance of a provisional certification 
mandatory, but would allow the Director the discretion to issue another 
one if the State submits a new written plan to remedy each remaining 
deficiency within a reasonable time. The new written plan must be 
submitted no later than 20 days after the expiration of the time 
specified to remedy all deficiencies in the original plan, which VA has 
determined is a reasonable time to develop a plan to remedy any 
remaining deficiencies. This would enable a case-specific approach, so 
that State homes that have made efforts to correct problems and that 
otherwise provide important services to veterans can continue to 
receive per diem, but VA would not be required to fund State homes 
that, in the Director's view, have not shown either the ability or 
willingness to correct problems. Under paragraph (e), the State home 
would have the right to appeal the Director's decision not to issue an 
additional provisional certification, which is described in more detail 
in the discussion of proposed Sec.  51.30(e) that follows.
    Proposed Sec.  51.30(e) is based on current Sec.  51.30(a)(2), (d), 
(e), and (f), and parallel provisions in current Sec.  52.30. Although 
the information on notice and the right to appeal is reorganized, it is 
not substantively different, except as noted below.
    First, in Sec.  51.30(e), we would eliminate any implied right to 
appeal provisional certifications. These certifications have no adverse 
effect on the State, and, indeed, the State must agree to correct any 
deficiency before VA would issue a provisional certification. 
Therefore, there is no need to appeal provisional certifications.
    In proposed Sec.  51.30(e)(1) through (3), we would clearly set 
forth the review and appeal procedures for a decision by VA not to 
issue a certification of a State home. Currently, VA delegates the 
annual certification process to its local VA medical center Directors--
unlike the recognition decision, which is made by the Under Secretary 
for Health. Therefore, an appeal from the Director's decision includes 
review by the Under Secretary for Health. The proposed rule is 
consistent with current practice. Also consistent with current 
practice, we would explain in paragraphs (e)(1) and (e)(2) that per 
diem payments will continue during the appeals process. Finally, we 
would state in Sec.  51.30(e)(3) that a denial of certification may be 
appealed to the Board of Veterans' Appeals only if it results in a loss 
of payments to the State, and that VA would discontinue payment of per 
diem if the Under Secretary for Health affirms the Director's decision. 
The current

[[Page 34799]]

regulation at Sec.  51.30(f) allows States to appeal any denial of 
certification to the Board of Veterans' Appeals. VA proposes this 
change because deficiencies at a State home that do not result in a 
loss of per diem payments are best remedied through a written plan and 
corrective actions, as required by proposed paragraph (d). Under the 
proposed rule, VA would terminate payments on the date of a decision 
affirming the denial of certification, or on a later date specified in 
the decision by the Under Secretary for Health, which allows the Under 
Secretary to accommodate State homes that lose certification while 
providing care to veterans.
    Proposed Sec.  51.30(f) would state that appeals of all other 
matters will be governed by VHA's appeals regulations in 38 CFR part 
20.
    Current Sec.  51.31, ``Automatic recognition,'' was essentially a 
grandfather clause allowing those State homes recognized by VA at the 
time that part 51 was promulgated in 2000 to maintain their 
recognition, but requiring them to be certified annually. There is no 
need to maintain this provision because all such State homes have been 
``grandfathered in.'' We therefore propose to remove this section.

51.31 Surveys for Recognition and/or Certification

    Proposed Sec.  51.31 concerns surveys, and applies to both the 
first VA survey for recognition and surveys for certification. 
Paragraph (a) is based on current Sec. Sec.  51.30(c) and 52.30(c), 
except as noted below.
    VA routinely conducts annual surveys without advance notice, but VA 
always provides advance notice before the recognition survey is 
conducted. In fact, for recognition surveys VA wants the home to be 
fully prepared so that VA can determine whether it has the capability 
to meet the applicable requirements. Accordingly, proposed Sec.  
51.31(a) would indicate that VA will provide advance notice before a 
recognition survey, and may notify the State before other surveys. This 
is a substantive change to both parts 51 and 52 that should improve the 
ability of State homes to prepare for VA recognition surveys.
    Current VA regulations (Sec. Sec.  51.30(c) and 52.30(c)) provide 
that a survey will cover all parts of a nursing home or adult day 
health care facility. There are times, however, when VA needs to survey 
only part of a home. For example, if a recognition survey finds that a 
home does not meet several standards, the State may request another VA 
survey after fixing those deficiencies. VA believes that only a survey 
of that part of the home that would permit a determination as to 
whether the standards have been met would be necessary. Accordingly, 
Sec.  51.31(a) would permit surveys to cover all parts of a home or 
only certain parts.
    In the last sentence of proposed paragraph (a), we would permit the 
Director to designate VA officials and/or contractors to survey a home. 
The designation of contractors is not specifically authorized by the 
current regulations, but it reflects the modern way in which VA 
conducts these surveys. The use of contractors, rather than local VA 
employees, is one way in which VA attempts to ensure that surveys 
across the country are conducted in a timely and similar manner. 
Moreover, we would eliminate the current language stating that the 
surveying team ``may include'' certain listed professionals (i.e., 
physicians, nurses, fiscal officers, etc.), because the language is 
hortatory and because we have found that the use of specifically 
trained contractors has, in most cases, eliminated the need to include 
some of these professionals.
    Proposed Sec.  51.31(b)(1) would establish the minimum occupancy 
threshold required before VA will conduct a recognition survey of a 
domiciliary. We would require that a domiciliary have at least 21 
residents or a number of residents consisting of at least 50 percent of 
the resident capacity of the domiciliary before VA will undertake a 
survey. This is the same requirement for nursing homes which is in 
current Sec.  51.30(a)(1) and which we propose including in this 
paragraph. Proposed Sec.  51.31(b)(2) would establish the minimum 
participation threshold required before VA will conduct a recognition 
survey of an adult day health care program. For an adult day health 
care program of care, we would require that it have at least 10 
participants or a number of participants consisting of at least 50 
percent of participant capacity. We believe that this is the minimum 
participant capacity necessary for VA to determine whether the program 
is able to meet the applicable standards. We also note that the current 
rule applies the occupancy requirement to ``new'' nursing homes. By 
``new,'' we intended to refer to homes that have not previously been 
recognized, but did not intend the requirement to apply only to new 
construction. We would remove the word ``new'' because it is 
unnecessary and potentially ambiguous. No substantive change is 
intended.
    Proposed Sec.  51.31(c) is based on current Sec. Sec.  51.30(g) and 
52.30(g), without substantive change.

51.32 Terminating Recognition

    As noted above, proposed Sec.  51.32 is based on the first sentence 
of current Sec. Sec.  51.30(b) and 52.30(b). VA would terminate 
recognition of a State home if the State requests that VA terminate it 
or if VA makes a final decision not to certify the State home.

Subpart C--Eligibility, Rates, and Payments

51.40 Basic Per Diem Rates

    Proposed Sec.  51.40 would set forth the basic method for 
calculating the basic per diem payment rate, and establish that this 
method is the same for all three programs. The per diem rates would be 
calculated in the same manner as they are in the current regulations, 
but technical aspects of the rules on per diem rates are outdated or in 
need of revision and would be updated.
    First, current Sec.  17.197, applicable to domiciliary care, 
indicates that VA will publish the actual per diem rates, whenever they 
change, in a Federal Register Notice. Proposed Sec.  51.40 does not 
include this requirement because any State home providing domiciliary 
care would be given actual and timely notice of any changes in the per 
diem rates. Second, current Sec.  52.40(a)(1), which applies to adult 
day health care, includes an outdated reference to the rate for fiscal 
year 2002. The current rule on basic per diem rates for nursing home 
care, at Sec.  51.40(a)(2), is also outdated because it refers to the 
rate for fiscal year 2008. The rates are currently, and would continue 
to be, established in accordance with 38 U.S.C. 1741(a) and (c). We 
propose to make a more general statement, without reference to any 
particular fiscal year, describing how the basic per diem rate is 
calculated. This would ensure that our regulations do not become 
outdated within a year of publication.
    Proposed Sec.  51.40(b) would set forth VA's formula for 
calculating the daily cost of care of a veteran, which is consistent 
with current practice and regulation at Sec.  51.43(e). We do not 
propose any substantive revisions to this formula for calculating basic 
per diem rates.
    Paragraph (c) of proposed Sec.  51.40 would incorporate current 
Sec.  51.43(c), with minor clarifying changes to the paragraph, which 
was amended by the direct final rule published on September 27, 2012. 
77 FR 59318, 59320, Sept. 27, 2012.
    Proposed paragraph (d) would describe how to determine whether a

[[Page 34800]]

veteran has spent a day in an adult day health care program. Current 
Sec.  52.40(a)(2) defines ``a day'' as ``[s]ix hours or more in one 
calendar day; or . . . [a]ny two periods of at least 3 hours each (but 
each less than six hours) in any two calendar days in a calendar 
month.'' A question has arisen regarding whether time spent in State-
provided transportation between the veteran's home and the State home, 
in transportation to a health care visit, or accompanied by State home 
staff during a health care visit, should be included as time a veteran 
received adult day health care. If adult day health care were not 
available to these veterans, they would need to leave their own 
residences for nursing home care, and therefore special State-provided 
transportation is an important part of their care. State homes offer 
most adult day health care program participants transportation to and 
from health care visits with drivers who are certified in basic life 
safety and can provide basic assessments, ambulation escorts, 
wheelchair lift services, and proper handoffs at the site of the health 
care visit. Transportation between the veteran's residence and the 
State home includes door-to-door care. Therefore, to ensure continuity 
of care, we believe that time spent in transportation and accompanied 
by State home staff should be included as times that veterans receive 
adult day health care, and we propose to clarify paragraph (d)(3) 
accordingly.

51.42 Payment Procedures

    Proposed Sec.  51.42(a)(1) is based on current Sec. Sec.  51.43(a) 
and 52.40(a)(5); proposed Sec.  51.42(a)(2) is based on current 
Sec. Sec.  51.43(b) and 52.40(a)(3); proposed Sec.  51.42(b)(1) is 
based on current Sec. Sec.  51.43(d) and 52.40(a)(4); proposed Sec.  
51.42(b)(2) is based on current Sec. Sec.  51.43(d) and 52.40(a)(4). 
Proposed 51.42(b)(3) is based on current Sec. Sec.  51.43(a) and 
52.40(a)(5). Slight differences between regulations in parts 51 and 52 
have been corrected to accurately reflect the forms required under this 
section.
    In proposed paragraph (a)(1), we would clarify that the forms 
required under the regulation must be submitted when a veteran is 
admitted to a State home (for State homes that have already been 
recognized and certified), or at the time of the recognition survey 
(for a home that a State has submitted an application for recognition 
as a State home).
    In addition, we would clarify in paragraph (a)(2) that the VA Form 
10-5588 must be submitted every month in order for VA to pay per diem 
for the prior month. The proposed rule is also consistent with payment 
rules related to domiciliaries, at Sec.  17.198, but provides greater 
clarity. Finally, we would add a statement to Sec.  51.42(a)(1)(i) to 
clarify that nursing home applicants and residents and enrolled adult 
day health care participants do not need to complete the financial 
disclosure section of VA Forms 10-10EZ and 10-10EZR under certain 
specified circumstances, but domiciliary applicants and residents must 
do so, and adult day health care applicants may be required to provide 
financial information to enroll with VA.
    In paragraph (b)(1), we would state that payments will not be made 
until the home is recognized, which is consistent with the current 
regulations, and that each veteran resident is verified as eligible for 
the program, which is not stated in the current regulations, but has 
been VA's consistent practice, as VA may only pay for care provided to 
veterans who are eligible for the program.
    In paragraph (b)(2), we would clarify that VA will make payments 
for care in beds certified or precertified under Sec.  51.30(c) 
retroactive to the date of precertification of the beds and to the date 
of the completion of the survey if the Director certifies the beds as a 
result of that survey. The current regulations in Sec. Sec.  51.43(d) 
and 52.40(a)(4) specify that VA will pay retroactive to the date of the 
completion of the recognition survey, but do not address 
precertification and certification of State home beds provided for in 
proposed Sec.  51.30(c).
    Proposed paragraph (b)(3) explains when VA would begin making 
payments or make retroactive payments based on the State home's 
submissions of forms in accordance with the proposed rule. VA proposes 
to expand the current deadline to receive paperwork and begin per diem 
payments from 10 days to 12 days.

51.43 Drugs and Medicines for Certain Veterans

    Proposed Sec.  51.43(a) is substantively identical to current Sec.  
51.42(a); the only changes made were technical changes to conform to 
the proposed reorganization.
    Proposed Sec.  51.43(b) would reference the other authority for VA 
to provide drugs and medicines to veterans in a State home: 38 U.S.C. 
1712(d), as implemented by Sec.  17.96. Consistent with current Sec.  
51.41(c), this authority would be subject to the limitation in proposed 
Sec.  51.41.
    Proposed Sec.  51.43(c) is based on current Sec.  51.42(b). We 
propose to extend its application, however, to drugs and medicines 
furnished under 38 U.S.C. 1712(d), as implemented by Sec.  17.96. 
Requiring that VA furnish a drug or medicine only if the drug or 
medicine is included on VA's National Formulary unless VA determines a 
non-Formulary drug or medicine is medically necessary should result in 
significant savings because, insofar as possible, the VA National 
Formulary consists of generic medications that often cost much less 
than brand medications. These are the same medications used for VA 
nursing home residents.
    Proposed Sec.  51.43(d) is substantively identical to current Sec.  
51.43(f). Most of current Sec.  51.43 would be deleted and 
reincorporated into proposed Sec.  51.40, but paragraph (f) deals 
specifically with payments for drugs and medicines, and therefore would 
be moved to proposed Sec.  51.43. For consistency and to avoid 
confusion, we propose to require that States also submit a completed VA 
Form 10-0460 when requesting drugs for veterans eligible under Sec.  
17.96.

51.50-51.52 Eligibility

    Proposed Sec. Sec.  51.50, 51.51, and 51.52 would set forth the 
eligibility criteria that a veteran must meet in order for that 
veteran's care to serve as a basis for a per diem payment under each of 
the three programs. The minimum periods of active duty service required 
in 38 U.S.C. 5303 and 5303A apply to all three programs of care; 
therefore proposed Sec. Sec.  51.50, 51.51, and 51.52 would each state 
the requirement. The minimum service requirement is in the current 
adult day health care regulations at Sec.  51.52, but was inadvertently 
omitted from the nursing home eligibility regulations in current Sec.  
51.50. Nevertheless, VA has enforced this provision, as required by 
law, and therefore this proposed rule does not impose a new limitation 
on eligibility. In addition, in these sections we adopt the 
interpretation of 38 U.S.C. 101(2) regarding the character of discharge 
required for the provision of VA benefits to veterans that is set forth 
in 38 CFR 3.12. The interpretation of 38 U.S.C. 101(2) regarding the 
character of discharge is adopted in order to be consistent with the 
interpretation adopted for purposes of other VA benefit programs.
    Section 51.50 (nursing home care) is virtually identical to current 
Sec.  51.50, except for the addition of the requirement regarding the 
character of the veteran's discharge and certain other minor technical 
changes. We propose to add veterans who were awarded the Purple Heart 
or the medal of honor to the eligibility category in Sec.  51.50(b) 
because these veterans are now eligible

[[Page 34801]]

by statute. See 38 U.S.C. 1705(a)(3), 1710(a)(2)(D). We propose to 
remove the provision regarding eligibility for veterans of the Mexican 
border period and World War I, because there are no living veterans of 
these eras. We also propose to add a note to Sec.  51.50 to clarify 
that enrollment and eligibility to enroll in the VA health care system 
are not required for a veteran to be an ``eligible veteran'' for 
purposes of per diem payments. Finally, we propose to add veterans 
seeking care ``for any illness associated with service in combat in a 
war after the Gulf War or during a period of hostility after November 
11, 1998, as provided and limited in 38 U.S.C. 1710(e)'' because these 
veterans are now eligible by statute. See 38 U.S.C. 1710(e)(1)(D), 
(e)(2)-(3).
    Current Sec.  17.194 provides that VA pays per diem for domiciliary 
care for veterans who are eligible for domiciliary care in a VA 
domiciliary. This is consistent with the statutory requirement in 38 
U.S.C. 1741(a). However, we believe that it would be useful to the 
States and VA personnel for the regulation to set forth which veterans 
are eligible for domiciliary care in VA facilities. Eligibility for VA 
domiciliary care is set forth in Sec. Sec.  17.46(b) and 17.47(b)(2). 
Proposed Sec.  51.51 would thus describe the veterans who meet the 
requirements set forth in Sec. Sec.  17.46(b) and 17.47(b)(2) and state 
that they are ``eligible veterans'' for the purpose of payment of per 
diem for domiciliary care in a State home.
    Section 51.52 would set forth the criteria for determining whether 
a veteran's care is eligible for per diem for adult day health care. 
Based on a statutory change to 38 U.S.C. 1720(f)(1)(A), a veteran is 
now eligible for adult day health care if the veteran is enrolled in 
the VA health care system and otherwise would require nursing home 
care. Accordingly, Sec.  51.52 would reflect the new requirement.
    In addition, we propose to include in paragraph (d) criteria that 
reflect the level of care required by a veteran who would benefit from 
adult day health care. These criteria are derived from current Sec.  
52.80, but have been modified (made less stringent) to encompass an 
alternative model in addition to the medical model required by current 
Sec.  52.80. For example, the requirements in proposed paragraph (c) 
are identical to the requirements in current Sec.  52.80, except that 
we would add criteria to address individuals who live alone in the 
community or who are determined by a VA licensed medical practitioner 
to need adult day health care services. These additional criteria 
should broaden the potential adult day health care population to 
include others who could benefit from such care. In the regulation 
text, the medical model would be referred to as an adult day health 
care program that offers medical supervision. We are attempting to 
encourage States to provide adult day health care for our Nation's 
veterans. For example, we would eliminate the requirement that the 
veteran be dependent in three or more instrumental activities of daily 
living (such as using a telephone, cooking, shopping, etc.), and 
instead require that the veteran be dependent in three activities of 
daily living (such as ambulation, eating, bathing etc.). This decreased 
dependency requirement reflects our desire to permit State homes to 
provide an alternative to the medical model of adult day health care 
and to increase the number of veterans who could qualify for this less-
institutionalized form of care. This rationale explains the other 
changes from the current requirements, such as the elimination of the 
requirements of recent discharge from a nursing home or hospital and of 
significant cognitive impairment characterized by multiple behavior 
problems.
    Proposed Sec.  51.52(d) would allow VA to pay for adult day health 
care based on less severe disabilities than those for which veterans 
currently may be eligible. This change would expand the cohort of 
eligible veterans and assist in cultivating a broader spectrum of adult 
day health care programs, which would be consistent with the rest of 
this rulemaking.

51.58 Standards Applicable for Payment of Per Diem

    Proposed Sec.  51.58 is based on current Sec. Sec.  51.60 and 
52.60, without substantive change.

51.59 Authority To Continue Payment of Per Diem When Veterans Are 
Relocated Due to Emergency

    Proposed Sec.  51.59 is substantively identical to current Sec.  
51.59, which was promulgated on September 8, 2011, after having been 
published for public comment. See 76 FR 55570. A few minor, technical 
changes are included that would conform to this rewritten regulatory 
framework.

Subpart D--Standards Applicable to the Payment of Per Diem for Nursing 
Home Care

    Subpart D would set forth the standards applicable to the payment 
of per diem for nursing home care. VA proposes to change the title of 
this subpart from the current title of ``Standards'' to ensure clarity 
and aid readers in distinguishing between the new standards being set 
forth for domiciliary and adult day health care. These standards are 
currently set forth at Sec. Sec.  51.70-51.210, and would not be 
changed by this notice of proposed rulemaking, except as noted below.

51.140 Dietary Services

    Current Sec.  51.140(d)(4) requires a State home to offer 
substitutes of similar nutritive value to residents ``who refuse food 
served.'' We propose to delete ``who refuse food served.'' We do not 
believe that residents should have to refuse food in order to be 
offered alternative choices. Residents should always have more than one 
option at meal time.

51.210 Administration

    We would amend the current rule concerning administration of 
nursing homes, which we also propose to make applicable in whole to 
domiciliaries and in part to adult day health care programs. The 
amendment would require a State home to disclose to VA whenever there 
is a change in the State home's director of nursing services, or any 
other individual who is in charge of nursing services. Such changes may 
have significant ramifications for a State home, and may also affect 
VA's coordination of VA care with the care provided by the State home. 
Therefore, VA needs to be aware of the change. We note that most adult 
day health care programs do not offer nursing services; however, this 
paragraph would apply to those that do. Thus, the proposed change would 
require those adult day health care programs that have a person in 
charge of nursing services to notify VA when such person changes.
    VA proposes to add a new paragraph (h)(3) to clarify procedures for 
State homes to assist veterans who need health care that State homes 
are not required to provide under part 51. This provision would state 
that State homes may assist the veteran with seeking care from other 
sources, including VA. It would also state that if VA is contacted, VA 
would make a determination about the best way to provide the needed 
services and would notify the Veteran, or the authorized 
representative, of that decision. This is consistent with the manner in 
which VA currently handles these situations, and ensures that veterans 
receive all needed health care.

[[Page 34802]]

Subpart E--Standards Applicable to the Payment of Per Diem for 
Domiciliary Care and Subpart F--Standards Applicable to Adult Day 
Health Care Programs of Care

    Subpart E would provide the standards for domiciliary care. As we 
have noted throughout this notice, these standards would supersede all 
existing regulations, directives, handbooks, or other statements of 
policy to the extent that some might be read to conflict with these 
proposed regulations. Subpart F would be based on current part 52, 
subpart D (current Sec. Sec.  52.60 et seq.). Several sections in 
current part 52, subpart D, were intended to be (or are) identical to 
sections in current part 51, subpart D. Rather than restate identical 
requirements, we would simply refer the reader to the current part 51 
section. We believe that this would simplify the process and help all 
parties concerned--residents, their families, State staff, and VA 
surveyors--understand where identical requirements are intended. 
However, there may be a few examples where we have restated the 
requirements rather than cross-reference them--this was done for ease 
of use.
    We would do the same when identical standards apply to domiciliary 
care in subpart E, for which we do not currently have detailed 
regulatory standards.
    Finally, we would remove several sections from subpart D of part 
52, without proposing parallel sections in part 51. First, we propose 
to remove Sec.  52.61without establishing a similar provision in 
subpart F. Current Sec.  52.61, ``General requirements for adult day 
health care program,'' describes a program requiring medical 
supervision, which is cost prohibitive for many States. Thus, there are 
currently only two adult day health care programs in the nation. We are 
restructuring program guidelines to provide States an opportunity to 
establish a range of adult day health care programs that reflect the 
needs of the local veteran population. Many States have expressed an 
interest in establishing adult day health care programs under these 
proposed new guidelines. More adult day health care programs would help 
VA support the provision of non-institutional care to veterans who 
might otherwise be forced into a nursing home in order to receive 
adequate care. Our goal is to increase participation in these non-
institutional programs.

51.300 Resident Rights and Behavior; State Home Practices; Quality of 
Life

    Proposed Sec.  51.300 would state that States must protect and 
promote the rights and quality of life of participants in domiciliary 
programs of care, as they do for residents in State nursing homes. We 
would thus require domiciliary programs of care to comply with Sec.  
51.70, 51.80, 51.90, and 51.100.

51.310 Resident Assessment

    The proposed rule is based on current Sec.  51.110. However, 
different specific requirements would apply in paragraphs (b) through 
(d) because under Sec.  51.110(b)(1)(i), which would not be revised by 
this rulemaking, the assessment tool for nursing homes is a nationally 
published tool, the Resident Assessment Instrument/Minimum Data Set. No 
such tool exists for domiciliaries or adult day health care programs. 
The requirements that would apply under the proposed rule are currently 
used by VA in assessments of State home domiciliary and adult day 
health care programs of care. We welcome comments on these provisions, 
but expect that they will be familiar to the affected State homes.

51.320 Quality of Care

    Proposed Sec.  51.320 is based on current Sec.  51.120, which 
describes quality of care standards for State home nursing home 
residents; however, we would tailor the proposed regulation to the 
needs of the domiciliary care population, which is generally capable of 
a greater level of self-care than those in nursing homes. For this 
reason, the examples of ``sentinel events'' in paragraph (a)(2) are 
slightly different; however, the term is intended, and defined, to have 
the same meaning throughout part 51.
    Paragraphs (d) through (f), (h) and (k) of current Sec.  51.120 
would not be included in the proposed rule because they pertain to 
medical issues that would not be presented by domiciliary residents. In 
proposed Sec.  51.320(f), we would not include the references to 
``[p]arenteral and enteral fluids,'' which is contained in current 
Sec.  51.120(l)(2), ``[t]racheostomy care,'' which is contained in 
current Sec.  51.120(l)(4), or ``[t]racheal suctioning,'' which is 
contained in 51.120(l)(5), because these services are not provided by 
domiciliaries.

51.330 Nursing Care

    Proposed Sec.  51.330 would describe the nursing care required in 
domiciliaries. What would be required would be similar to what is 
required in nursing homes, except that we would not require the same 
level of skilled nursing supervision, based on the lower level of care 
required by residents of domiciliaries. To be admitted, domiciliary 
residents must retain higher functional capabilities than a nursing 
home resident, and therefore domiciliary residents require less skilled 
nursing care. Due to these key differences, we cannot simply adopt the 
standards applicable to nursing homes; therefore, we would modify them 
to meet the generally accepted needs of domiciliary residents. These 
standards are similar to the expectations currently placed on State 
home domiciliaries. We welcome comments on these provisions, but expect 
that they will not present a new burden to the affected State homes.

51.340 Physician and Other Licensed Medical Practitioner Services

    We propose to establish that State homes must provide the necessary 
primary care for their residents. This is consistent with VA General 
Counsel Precedent opinion 1-2014 which is on the web at: http://www.va.gov/OGC/docs/2014/VAOPGCPREC1-2014.pdf. We also propose that 
when a resident needs care that is other than what the State home is 
required to provide under this subpart, the State home is responsible 
for assisting the resident in obtaining that care. This would allow 
State homes to refer veterans to VA and other outside providers for 
care that the State home is not required to provide. Under the proposed 
rule, we would require that a physician must ``personally approve[ ] in 
writing a recommendation that an individual be admitted to a 
domiciliary.'' We would also require that each resident ``must remain 
at all times under the care of a licensed medical practitioner assigned 
by the State home.'' This accommodates those homes that may utilize, in 
addition to primary care physicians, other practitioners who are 
licensed to practice medicine. We clearly define by title those 
professions to be considered licensed medical practitioners in proposed 
Sec.  51.2. By requiring State homes to provide physician services as 
set forth in the proposed regulation, it would continue VA policy of 
not providing physician services for Veterans in State home 
domiciliaries because the State home has a duty to provide these 
services. See 38 CFR 17.30(b), 17.38(c)(5).
    Proposed paragraphs (a) and (b) address the appropriate use and 
supervision of non-physician licensed medical practitioners. Under 
paragraph (a), we would require that ``[a]ny licensed medical 
practitioner who is not a physician may provide medical care to a 
resident within the practitioner's scope of practice without physician 
supervision when permitted by state law.'' This would clarify that 
homes must ensure that residents receive appropriate medical 
supervision at all

[[Page 34803]]

times. Under proposed paragraph (b), when the licensed medical 
practitioner assigned to a particular resident is unavailable, we would 
require that the home ensure that another licensed medical practitioner 
be available to provide care to that resident. This would assist VA in 
providing a resident-centered approach to domiciliary care. It would 
also provide consistency between the level of care provided to veterans 
in State homes and in VA settings, in which we utilize supervised 
licensed medical practitioners.
    Proposed paragraph (c) would define the scope of care expected to 
be provided by primary care physicians or other licensed medical 
practitioners to residents during visits. We would specify that the 
resident's total program of care be reviewed, to include medications 
and treatment, and that progress notes documenting each visit must be 
in writing, signed, and dated. We would also require that all orders be 
signed and dated.
    Proposed paragraph (d) would mandate the frequency of primary care 
physician or other licensed medical practitioner visits. We would 
specify that the resident must be seen by the primary care physician or 
other licensed medical practitioner at least once every 30 days for the 
first 90 days after admission, and at least once a calendar year 
thereafter, or more frequently based on the condition of the resident. 
We believe this requirement would be sufficient to meet the needs of 
the resident population in these homes. It strikes an appropriate 
balance between providing needed medical care and the lower need for 
ongoing medical supervision of residents in domiciliaries.
    Proposed paragraph (e) would mandate that the domiciliary provide 
or arrange for the provision of physician or other licensed medical 
practitioner services 24 hours a day, 7 days a week, in case of an 
emergency.

51.350, 51.390 Incorporation of Standards to State Home Domiciliaries

    Proposed Sec.  51.350 would apply VA's State nursing home standards 
for dietary, dental, pharmacy services, infection control, and the 
physical environment to State home domiciliaries. Proposed Sec.  51.390 
would apply VA's State nursing home standards for administration to 
State home domiciliaries.

51.400 Participant Rights

    Proposed Sec.  51.400 would state that States must protect and 
promote the rights of participants in adult day health care programs of 
care, as they do for residents in State nursing homes. We would thus 
require adult day health care programs of care to comply with Sec.  
51.70 except for Sec.  51.70(m) regarding the right of married 
residents to share a room when both live in the State home.

51.405 Participant and Family Caregiver Responsibilities

    Section 51.405 would be based on current Sec.  52.71, with minor 
technical and stylistic revision. Additionally, we would revise the 
introductory paragraph to permit the adult day health care program to 
provide a copy of the statement of participant and family caregiver 
responsibilities ``at or before the time of the intake screening.'' The 
current regulation requires that the copy be provided at the intake 
screening, which is too restrictive.

51.410 Transfer and Discharge

    Section 51.410 is based on current Sec. Sec.  52.80(b) and 
52.210(p), with the substantive changes noted below.
    We would not include the requirement in current Sec.  52.80(b)(2) 
that ``[a]ll participants' preparedness for discharge from adult day 
health care must be a part of a comprehensive care plan.'' We do not 
maintain comprehensive care plans for VA-operated adult day health care 
programs. The State home must record information about a participants' 
discharge from an adult day health care program in the clinical record 
as described in Sec.  51.410(c) and the participant must receive 
information about the discharge as described in proposed Sec.  
51.410(e).
    Proposed Sec.  51.410(a) also would not include a provision 
parallel to current Sec.  52.80(b)(3), concerning the documentation by 
a primary physician that is required for a transfer and discharge. We 
would not include this requirement because the veteran's primary 
physician would generally not be on staff with the adult day health 
care program, and therefore would generally not have privileges to 
document notes in the program's clinical records.
    Finally, we would incorporate current Sec.  52.210(p) into this 
rule at proposed Sec.  51.410(g) because it also concerns transfers.

51.411 Program Practices

    Proposed Sec.  51.411 would include those parts of current Sec.  
52.80 that are not included elsewhere. We would not include a provision 
parallel to current Sec.  52.80(f) because we do not require VA-
operated adult day health care programs to have caregiver support 
programs. The purpose of adult day health care is to provide most or 
all of the services generally performed by caregivers.

51.415 Restraints, Abuse, and Staff Treatment of Participants

    Proposed Sec.  51.415 would apply to State home adult day health 
care programs the same requirements regarding the use of restraints and 
staff treatment of participants as apply to State home nursing homes.

51.420 Quality of Life

    Section 51.420 would be based on current Sec.  52.100, with minor 
revisions in paragraph (g). Current Sec.  52.100(g)(3) states that the 
State home must provide private storage space for each participant 
sufficient for a change of clothes. We propose to require that each 
private storage space be capable of being secured with a lock for 
protection of the contents. Requiring a lock would ensure that whatever 
the participant stores in their private space (such as clothes, a 
wallet, or a purse) can be safely stored. Current Sec.  52.100(g)(5) 
requires State homes to provide a clean bed for acute illness. We 
propose in Sec.  52.420(g)(5) to require that the State home provide 
either a clean bed or a reclining chair.

51.425 Physician Orders and Participant Medical Assessment

    Section 51.425 would restate current Sec.  52.110, with a number of 
changes concerning physician orders and participant assessments. This 
section, among other things, is designed to ensure that appropriate 
plans of care are prepared and updated based on assessments.
    Proposed paragraph (a) would restate the admission requirements in 
current Sec.  52.110(b), with some changes. We would continue to 
require a medical history and physical examination of the participant, 
but would additionally require documentation of tuberculosis (TB) 
screening. Presently, VA requires the examination within a reasonable 
time of the resident's admission, not to exceed 72 hours following 
admission. We propose to require that the examination occur no earlier 
than 30 days before admission. The proposed changes to this section 
would ensure that State homes receive current information about 
veterans' conditions for the purposes of making determinations 
regarding admission, and would ensure that participants will not 
endanger themselves or others because of TB, which could easily spread 
in an adult day health care setting.
    Proposed paragraph (b) would revise current Sec.  52.110(c), with a 
proposed change to the method for conducting

[[Page 34804]]

assessments of participants. The current regulation requires that a 
comprehensive plan of care be developed from comprehensive assessments 
based on the Minimum Data Set for Home Care (MDS-HC) Instrument Version 
2.0, August 2, 2000. The MDS-HC is not used in adult day health care 
programs because it requires more of an assessment than is necessary 
for participants in such programs. We propose to base assessments 
conducted under proposed paragraph (b) on the criteria stated in 
proposed paragraph (d), described below.
    In proposed paragraph (c)(2), we would continue to require that 
each person who completes a portion of the assessment sign and certify 
the accuracy of that portion of the assessment in order to ensure 
accuracy and accountability for the assessment.
    In proposed paragraph (d), we would require the State home to 
ensure that each participant has a care plan based on criteria VA 
developed to describe the issues that need to be addressed for 
participation in an adult day health care program. The criteria would 
be set forth under paragraph (d), and would ensure that participants 
receive appropriate care. Current Sec.  52.110(e)(1) requires the State 
home to ``develop'' such a plan. We are changing the language to 
require that the participant have a plan rather than that the State 
home develop the plan because, in some cases, the plan may have been 
created before the participant entered into the State home's program of 
adult day health care. The word ``develop'' in the current rule can be 
misread to require the State home to create a new plan, even when VA 
has already created one. Under the proposed paragraph (d)(1), the plan 
of care must include measurable objectives and timetables for meeting 
the needs identified in the assessment. With the simplified assessments 
this can and should be readily accomplished without the need for 
interdisciplinary teams that are required by the current regulations.
    Proposed paragraph (e) is based on current 52.110(f), with no 
substantial changes.

51.430 Quality of Care

    Section 51.430 would restate current Sec.  52.120, with some 
significant changes. First, we would clarify in proposed Sec.  
51.430(a)(2) that a home must report only sentinel events that happen 
``while the participant is under the care of the State home, including 
while in State home-provided transportation.'' It is not necessary for 
a program to report a sentinel event that did not occur while the 
veteran was under the care of the State home. Thus, to the extent that 
a sentinel event--such as an attempted suicide or misuse of prescribed 
medication--may occur in the evening, the adult day health care program 
would not be required to report that event to VA. In proposed Sec.  
51.430(c), State homes would continue to be required to make counseling 
and related psychosocial services available to improve the mental and 
psychological functioning of adult day health care participants with 
psychosocial needs, as individuals in such programs often have, or are 
at risk for developing, psychosocial problems. We would update the 
phrasing of this requirement to make clear the types of services that 
State homes must provide. Other paragraphs in Sec.  51.430 of the 
proposed rule are identical to current Sec.  51.210, and would 
reference that section.
    Current Sec.  52.120(c) through (f) and Sec.  52.120(k) set forth 
requirements concerning vision and hearing, pressure ulcers, urinary 
and fecal incontinence, range of motion, accidents, nutrition, 
hydration, unnecessary drugs, and antipsychotic drugs in adult day 
health care programs of care. We propose to remove these provisions 
because they are not pertinent to care at a State home providing adult 
day health care.

51.435 Nursing Services

    Current Sec.  52.130 would become Sec.  51.435, and the last 
sentence of paragraph (a) of the current rule would be removed. That 
sentence recommends that duty nurses be geriatric nurse practitioners 
or clinical nurse specialists. We propose to remove this recommendation 
because this level of specialty is not necessary for an adult day 
health care program. Because there is no collection of information 
associated with this regulation, we propose to remove the OMB control 
number that appears in current Sec.  52.130 from proposed Sec.  51.435.

51.440 Dietary Services

    Proposed Sec.  51.440 would apply to State home adult day health 
care programs the State nursing home standards for dietary services.

51.445 Physician Services

    Proposed Sec.  51.445 would be based on current Sec.  52.150, which 
sets standards for physician services in adult day health care. The 
first two sentences of the current rule require that adult day health 
care participants ``obtain a written physician order for enrollment'' 
and ``remain under the care of a physician.'' This would be required in 
the proposed rule, irrespective of the level of medical supervision 
provided in the State home adult day health care program. The 
requirement that participants remain under the care of a physician 
would not impose a staffing burden on State homes because the veterans 
would be enrolled in the VA health care system, and therefore many 
would be under the care of a VA physician. A physician must approve a 
veteran's participation in an adult day health care program in the 
written order for enrollment and, moreover, must indicate whether there 
are medical needs that would require placement in an adult day health 
care program that offers medical supervision.
    However, the level of involvement of the State home adult day 
health care program in the participant's medical care depends on 
whether the program of care offers medical supervision. Therefore, we 
propose changes to paragraphs (a), (b) and (c) of the current rule text 
to indicate that they only apply if the program of care offers 
``medical supervision.'' If medical supervision is offered, physician 
supervision and review must be appropriate to the level of care 
required by the participant.
    We propose to revise the language of current Sec.  52.150(d) to 
clarify that the program management need only ensure that participants 
are able to obtain emergency care when necessary. This requirement 
could be met if the program management called 911 on behalf of the 
participant. States may provide emergency care if they desire, but they 
would not be required to do so.

51.450 Specialized Rehabilitative Services

    Current Sec.  52.160, which sets standards for specialized 
rehabilitative services in adult day health care, would become proposed 
Sec.  51.450. We note that unlike current Sec.  52.150 and proposed 
Sec.  51.445, no adjustments to the current language are required. This 
rule would apply only where the participant's individualized care plan 
requires the provision of specialized rehabilitative services. If a 
State home does not have the capability to provide specialized 
rehabilitative services, it would not accept a veteran with such needs 
for placement in its adult day health care program. Because there is no 
collection of information associated with this regulation, we propose 
to remove the OMB control number that appears in current Sec.  52.160 
from proposed Sec.  51.450.

51.455 Dental Services

    Current Sec.  52.170, which sets standards for dental services in 
adult day health care, would become proposed Sec.  51.455. We propose 
minor changes to the current language so that

[[Page 34805]]

this regulation would apply only to State homes that offer an adult day 
health care program with medical supervision.

51.460 Administration of Drugs

    Current Sec.  52.180, which sets standards for administration of 
drugs in adult day health care, would become proposed Sec.  51.460. We 
propose minor changes to the current language so that this regulation 
would apply only to State homes that offer medical supervision in their 
adult day health care programs.

51.465 Infection Control

    Proposed Sec.  51.465 would apply the State nursing home standards 
for infection control to State home adult day health care programs.

51.470 Physical Environment

    Proposed Sec.  51.470 is based on current Sec.  52.200, with the 
following revisions.
    First, current Sec.  52.200 requires State homes to meet certain 
standards established in outdated editions of the National Fire 
Protection Association (NFPA) code. However, current Sec.  51.200 cites 
more recent editions of the standards. We propose to merely cross-
reference the Sec.  51.200(a) requirement in Sec.  51.470, to clarify 
that the same fire-safety standards apply to adult day health care 
programs, except that those provisions that only apply to nursing homes 
would not apply. In this manner, we would ensure that adult day health 
care programs and nursing homes are required to comply with the same 
edition of the appropriate NFPA publication. We note that most State 
homes must abide by the current versions of these standards in order to 
obtain appropriate permits and licenses from authorities other than VA.
    In addition, current 38 CFR 52.200(b)(4)(v) requires a State home 
to have a quiet room with at least one bed, which functions to isolate 
participants who become ill or disruptive, or who require rest, 
privacy, or observation. We propose to change this requirement to 
permit the home to have either a bed or a reclining chair. We believe 
that this would satisfy the specified needs. Also, we would indicate 
that the purpose of the quiet room is for separation from other 
participants rather than isolation from other participants. This 
accomplishes the intended purpose without the connotation of restraint 
which often would not apply.

51.475 Administration

    We would adopt all of the requirements of current Sec.  51.210 
except for those that do not apply to adult day health care programs 
that do not provide medical supervision. We would update the authority 
citation to reflect VA's current adult day health care authorities.

51.480 Transportation

    Current 38 CFR Sec.  52.220 concerns the transportation of 
participants. Paragraph (b) specifies that the program management must 
have a transportation policy that includes routine and emergency 
procedures. The current regulation further states that a copy of the 
procedures must be located in all program vehicles. We propose to 
delete the provisions regarding the placement of the procedures in 
program vehicles. Instead, we propose to add language requiring that 
all such transportation (including that provided under contract) must 
be in compliance with the procedures. The goal is to achieve 
compliance, and we do not believe that it is necessary to impose 
requirements regarding the methods of obtaining compliance.
    Current 38 CFR 52.220(c) requires that all vehicles transporting 
participants be equipped with a device for two-way communication. We 
propose revising this to clarify that the vehicle itself does not need 
to be equipped with the device. However, we propose to require that the 
driver have access to such a device. We also propose to revise this 
requirement to clarify that it only applies to State home-provided 
transportation, not transportation arranged by the veteran.
    Current Sec.  52.220(e) specifies that the time to transport a 
participant to or from the home must not be more than 60 minutes except 
under unusual conditions, e.g., bad weather. We propose to delete this 
provision. Instead, we propose to require that State homes ensure that 
the care needs of each participant are addressed during travel. This 
requirement more directly addresses the particular needs of each 
participant.

Other Technical Changes

    We would make other technical, non-substantive changes to 
provisions amended by or established by this rulemaking. Notably, we 
describe veterans as being ``admitted'' (or a derivative) when 
discussing the adult day health care program, where the current part 52 
often uses the term ``enrolled'' (or a derivative). This is intended to 
make sure that a reader does not mistake the use of the term 
``enrolled'' to mean enrollment in the VA health care system when it is 
intended to refer to participation in a State home program of care.

Effect of Rulemaking

    The Code of Federal Regulations, as proposed to be revised by this 
proposed rulemaking, would represent the exclusive legal authority on 
this subject. No contrary rules or procedures would be authorized. All 
VA guidance would be read to conform with this proposed rulemaking if 
possible or, if not possible, such guidance would be superseded by this 
rulemaking.

Paperwork Reduction Act

    This proposed rule includes provisions constituting collections of 
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521) that require approval by the Office of Management and Budget 
(OMB). Accordingly, under 44 U.S.C. 3507(d), VA has submitted a copy of 
this rulemaking to OMB for review.
    OMB assigns control numbers to collections of information it 
approves. VA may not conduct or sponsor, and a person is not required 
to respond to, a collection of information unless it displays a 
currently valid OMB control number. Proposed Sec.  17.74(q) contains a 
collection of information under the Paperwork Reduction Act (44 U.S.C. 
3501-3521). Proposed Sec. Sec.  51.20, 51.30, 51.31, 51.42, 51.210, 
51.300, 51.310, 51.320, 51.350, and 51.390 contain new collections of 
information under the Paperwork Reduction Act of 1995. State home 
domiciliaries are already submitting this information voluntarily as 
part of their participation in VA's State home program, because this is 
necessary in order for VA to provide payment to them for the care that 
they provide. There is, therefore, little or no additional burden to 
State home domiciliary programs due to this rulemaking. Because these 
requirements are virtually identical to those imposed upon the other 
two programs of care and approved under control number 2900-0160, VA 
seeks to amend that approved collection of information to include State 
home domiciliaries, as described in further detail below. Additionally, 
VA proposes minor modifications to collections of information from 
State home nursing homes and adult day health care programs that are 
already approved under control number 2900-0160 and set forth at 
Sec. Sec.  51.210, 51.415, 51.425, 51.430, and 51.460 of the proposed 
regulations.
    If OMB does not approve the collections of information as 
requested, VA will immediately remove the provisions containing a 
collection of information or take such other action as is directed by 
OMB.

[[Page 34806]]

    Comments on the collections of information contained in this 
proposed rule should be submitted to the Office of Management and 
Budget, Attention: Desk Officer for the Department of Veterans Affairs, 
Office of Information and Regulatory Affairs, Washington, DC 20503, 
with copies sent by mail or hand delivery to the Director, Regulation 
Policy and Management (02REG), Department of Veterans Affairs, 810 
Vermont Avenue NW., Room 1068, Washington, DC 20420; fax to (202) 273-
9026; or through www.Regulations.gov. Comments should indicate that 
they are submitted in response to ``RIN 2900-AO88 Per Diem Paid to 
States for Care of Eligible Veterans in State Homes.''
    OMB is required to make a decision concerning the collections of 
information contained in this proposed rule between 30 and 60 days 
after publication of this document in the Federal Register. Therefore, 
a comment to OMB is best assured of having its full effect if OMB 
receives it within 30 days of publication. This does not affect the 
deadline for the public to comment on the proposed rule.
    VA considers comments by the public on proposed collections of 
information in--
     Evaluating whether the proposed collections of information 
are necessary for the proper performance of the functions of VA, 
including whether the information will have practical utility;
     Evaluating the accuracy of VA's estimate of the burden of 
the proposed collections of information, including the validity of the 
methodology and assumptions used;
     Enhancing the quality, usefulness, and clarity of the 
information to be collected; and
     Minimizing the burden of the collections of information on 
those who are to respond, including through the use of appropriate 
automated, electronic, mechanical, or other technological collection 
techniques or other forms of information technology, e.g., permitting 
electronic submission of responses.
    The proposed amendments to title 38 CFR part 51 contain collections 
of information under the Paperwork Reduction Act of 1995 for which we 
are requesting approval by OMB. These collections of information are 
described immediately following this paragraph, under their respective 
titles.
    Title: Per Diem Paid to States for Care of Eligible Veterans in 
State Homes.
     Summary of collection of information: Section 51.210 would 
require State homes to submit information about the individuals 
responsible for administration of the homes. Most of the collections in 
Sec.  51.210 are currently approved for State home nursing homes and 
adult day health care programs of care, with the exception of a new 
collection in proposed Sec.  51.210(b)(3), which would require State 
homes to submit the name of the director of nursing services. All of 
the collections in proposed Sec.  51.210 would constitute new 
collections for State home domiciliaries.
    Sections 51.20, 51.30, 51.31, 51.42, 51.300, 51.310, 51.320, 
51.350, and 51.390 would require State homes domiciliary programs to 
submit information about veterans receiving domiciliary care. State 
home domiciliaries would be required to furnish an application for 
recognition based on certification; appeal information, application and 
justification for payment; records and reports which program management 
must maintain regarding activities of residents or participants; 
information relating to whether the domiciliary meets standards 
concerning residents' rights and responsibilities prior to admission or 
enrollment, during admission or enrollment, and upon discharge; the 
records and reports which management and health care professionals must 
maintain regarding residents or participants and employees; documents 
pertain to the management of the home; food menu planning; 
pharmaceutical records; and life safety documentation. Without access 
to such information, VA would not be able to determine whether high 
quality care is being provided to veterans.
    The information that VA would collect from State home domiciliaries 
under this proposed rulemaking is already collected from State home 
nursing homes and adult day health care programs under OMB control 
number 2900-0160, pursuant to 38 CFR parts 51 and 52, State Home 
Programs, and on VA forms as follows: State Home Inspection--Staffing 
Profile, VA Form 10-3567, Instructions for State Home Report and 
Statement of Federal Aid Claimed, VA Form 10-5588, State Home Program 
Application for Veteran Care--Medical Certification, VA Form 10-10SH, 
Department of Veterans Affairs Certification Regarding Drug-Free 
Workplace Requirements for Grantees Other Than Individuals, VA Form 10-
0143, Statement of Assurance of Compliance with Section 504 of the 
Rehabilitation Act of 1973, VA Form 10-0143a, Certification Regarding 
Lobbying, VA Form 10-0144; Statement of Assurance of Compliance with 
Equal Opportunity Laws, VA Form 10-0144a, and Request for Prescription 
Drugs from an Eligible Veteran in a State Home, VA Form 10-0460. VA is 
amending these forms in a separate request; that request includes a 
request to include State home domiciliaries as respondents to the 
forms, in addition to other amendments that would apply as to all State 
Home programs of care. VA therefore seeks approval in this proposed 
rule only for the information that would be required of State home 
domiciliaries by proposed part 51 that would not be included on the 
forms listed above.
    VA proposes to modify the collections of information from State 
home adult day health care programs of care as set forth at proposed 
Sec. Sec.  51.415, 51.425, and 51.430. OMB has approved most of the 
collections in these sections under OMB control number 2900-0160. VA 
proposes to modify these collections as follows. In proposed Sec.  
51.425(a), VA would require programs to collect documentation of 
participants' tuberculosis screening, in addition to the current 
requirement that State homes record the participant's medical history 
and document a physical examination. In proposed Sec.  51.425(b), VA 
would change the criteria that programs would use to record each 
participants' assessment from the Minimum Data Set for Home Care to new 
criteria developed by VA. In proposed Sec.  51.430(a), VA would clarify 
that State homes must report sentinel events only when they occur while 
the veteran is under the care of the home; the current regulations 
indicate such reports are necessary regardless of when or where a 
sentinel event occurs.
     Description of the need for information and proposed use 
of information: VA uses this information in order to effectively manage 
the operations and payment of per diem through the State home 
domiciliary program of care. Specifically, the information collected is 
used to determine eligibility of veterans for participation in the 
program; whether State home domiciliary programs meet appropriate 
clinical, safety, and quality standards; and to calculate the amount of 
payments that are due for care provided to veterans on a monthly basis.
     Description of likely respondents: State home domiciliary 
programs that seek payment from VA.
     Estimated number of respondents: 53 per year.
     Estimated frequency of responses: Once per year.
     Estimated average burden per response: 7 minutes.
     Estimated total annual reporting and recordkeeping burden: 
6.2 hours.

[[Page 34807]]

State Home Nursing Homes and Adult Day Health Care Programs

    Although this action contains provisions constituting collections 
of information at 38 CFR 51.20, 51.30, 51.31, 51.42, 51.210, 51.300, 
51.310, 51.320, 51.350, 51.390, 51.400, 51.405, 51.410, 51.415, 51.420, 
51.425, 51.430, 51.445, 51.460, and 51.475, under the provisions of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521), no new or 
proposed revised collections of information are associated with these 
sections. The proposed regulations impose certain paperwork 
requirements on States with State homes receiving per diem for nursing 
home care (at Sec. Sec.  51.20, 51.30, 51.31, 51.42, and 51.210) and 
impose similar paperwork requirements on State homes receiving per diem 
for adult day health care (at Sec. Sec.  51.20, 51.30, 51.31, 51.210, 
51.400, 51.405, 51.410, 51.415, 51.420, 51.425, 51.430, 51.460, and 
51.475). The information collection requirements for Sec. Sec.  51.20, 
51.30, 51.31, 51.42, 51.210, 51.400, 51.405, 51.410, 51.415, 51.420, 
51.425, 51.430, 51.460, and 51.475 are currently approved by OMB 
(except for the proposed minor modifications to Sec. Sec.  51.415, 
51.425, and 51.430 described above) and have been assigned OMB control 
number 2900-0160. This rulemaking simply reorganizes the material to 
which this control number has already been applied in the current U.S. 
Code of Federal Regulations. As stated above, VA is revising the forms 
used for these approved collections from State Home nursing home and 
adult day health care programs under OMB control number 2900-0160, and 
will seek approval for the proposed revisions in a separate request for 
OMB review. Additionally, Sec.  51.42 in effect imposes paperwork 
requirements on certain Veterans seeking admission to a State home 
program of care. The information collection requirement pertaining to 
Veterans under these sections is currently approved by OMB and has been 
assigned OMB control number 2900-0091.

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule would not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This proposed rule would affect veterans, State homes, 
and pharmacies. The State homes that are subject to this rulemaking are 
State government entities under the control of State governments. All 
State homes are owned, operated and managed by State governments except 
for a small number that are operated by entities under contract with 
State governments. These contractors are not small entities. Also, this 
rulemaking would not have a consequential effect on any pharmacies that 
could be considered small entities. Therefore, pursuant to 5 U.S.C. 
605(b), this rulemaking is exempt from the initial and final regulatory 
flexibility analysis requirements of sections 603 and 604.

Executive Orders 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines a 
``significant regulatory action'' requiring review by the Office of 
Management and Budget (OMB), unless OMB waives such review, as ``any 
regulatory action that is likely to result in a rule that may: (1) Have 
an annual effect on the economy of $100 million or more or adversely 
affect in a material way the economy, a sector of the economy, 
productivity, competition, jobs, the environment, public health or 
safety, or State, local, or tribal governments or communities; (2) 
Create a serious inconsistency or otherwise interfere with an action 
taken or planned by another agency; (3) Materially alter the budgetary 
impact of entitlements, grants, user fees, or loan programs or the 
rights and obligations of recipients thereof; or (4) Raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in this Executive Order.''
    The economic, interagency, budgetary, legal, and policy 
implications of this regulatory action have been examined, and it has 
been determined to be a significant regulatory action under Executive 
Order 12866. VA's impact analysis can be found as a supporting document 
at http://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of the 
rulemaking and its impact analysis are available on VA's Web site at 
http://www.va.gov/orpm/, by following the link for ``VA Regulations 
Published From FY 2004 Through Fiscal Year to Date.''

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in an expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any one year. This proposed rule would have no such 
effect on State, local, and tribal governments, or on the private 
sector.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.005, Grants to States for 
Construction of State Home Facilities; 64.007, Blind Rehabilitation 
Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical 
Care Benefits; 64.010, Veterans Nursing Home Care; 64.011, Veterans 
Dental Care; 64.012, Veterans Prescription Service; 64.013, Veterans 
Prosthetic Appliances; 64.014, Veterans State Domiciliary Care; 64.015, 
Veterans State Nursing Home Care; 64.016, Veterans State Hospital Care; 
64.018, Sharing Specialized Medical Resources; 64.019, Veterans 
Rehabilitation Alcohol and Drug Dependence; 64.022, Veterans Home Based 
Primary Care; and 64.026, Veterans State Adult Day Health Care.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Jose D. 
Riojas, Chief of Staff, approved this document on January 15, 2015, for 
publication.

List of Subjects in 38 CFR Parts 17, 51 and 52

    Administrative practice and procedure, Claims, Day care, Dental 
health, Government contracts, Grant programs--health, Grant programs--
veterans, Health care, Health facilities, Health professions, Health 
records, Mental health programs, Nursing homes, Reporting and 
recordkeeping requirements, Travel and transportation expenses, 
Veterans.


[[Page 34808]]


    Approved: June 2, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management.

    For the reasons stated in the preamble and under the authority of 
of 38 U.S.C. 1741-1743 and 38 U.S.C. 1745, the Department of Veterans 
Affairs proposes to amend 38 CFR parts 17, 51, and 52 as set forth 
below:

PART 17--MEDICAL

0
1. The authority citation for part 17 continues to read as follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections.


Sec. Sec.  17.190-17.200  [Removed].

0
2. Amend part 17 by removing Sec. Sec.  17.190-17.200.

PART 51--PER DIEM FOR NURSING HOME, DOMICILIARY, OR ADULT DAY 
HEALTH CARE OF VETERANS IN STATE HOMES

0
3. The authority citation for part 51 is amended to read as follows:

    Authority: 38 U.S.C. 101, 501, 1710, 1720, 1741-1743, 1745, and 
as stated in specific sections.

0
4. Subparts A, B, and C of part 51 are revised to read as follows:
Subpart A--General
Sec.
51.1 Purpose and Scope of part 51
51.2 Definitions
Subpart B--Obtaining Recognition and Certification for Per Diem 
Payments
51.20 Recognition of a State home
51.30 Certification
51.31 Surveys for recognition and/or certification
51.32 Terminating recognition
Subpart C--Eligibility, Rates, and Payments
51.40 Basic per diem rates
51.42 Payment procedures
51.43 Drugs and medicines for certain veterans
51.50 Eligible veterans-nursing home care
51.51 Eligible veterans-domiciliary care
51.58 Standards applicable for payment of per diem
51.59 Authority to continue payment of per diem when veterans are 
relocated due to emergency

Subpart A--General


Sec.  51.1  Purpose and scope of part 51.

    The purpose of this part is to establish VA's policies, procedures, 
and standards applicable to the payment of per diem to State homes that 
provide nursing home care, domiciliary care, or adult day health care 
to eligible veterans. Subpart B of this part sets forth the procedures 
for recognition and certification of a State home. Subpart C sets forth 
rules governing the rates of, and procedures applicable to, the payment 
of per diem; the provision of drugs and medicines; and which veterans 
on whose behalf VA will pay per diem. Subparts D, E, and F set forth 
standards that must be met by any State home seeking per diem payments 
for nursing home care (subpart D), domiciliary care (subpart E), or 
adult day health care (subpart F).

(Authority: 38 U.S.C. 501)

Sec.  51.2  Definitions.

    For the purposes of this part:
    Activities of daily living (ADLs) means the functions or tasks for 
self-care usually performed in the normal course of a day, i.e., 
mobility, bathing, dressing, grooming, toileting, transferring, and 
eating.
    Adult day health care means a therapeutic outpatient care program 
that includes one or more of the following services, based on patient 
care needs: medical services, rehabilitation, therapeutic activities, 
socialization, and nutrition. Services are provided in a congregate 
setting.
    Clinical nurse specialist means a licensed professional nurse with 
a master's degree in nursing and a major in a clinical nursing 
specialty from an academic program accredited by the National League 
for Nursing.
    Director means the Director of the VA medical center of 
jurisdiction, unless the reference is specifically to another type of 
director.
    Domiciliary care means the furnishing of a home to a veteran, 
including the furnishing of shelter, food, and other comforts of home, 
and necessary medical services as defined in this regulation.
    Eligible veteran means a veteran whose care in a State home may 
serve as a basis for per diem payments to the State. The requirements 
that an eligible veteran must meet are set forth in Sec. Sec.  51.50 
(nursing home care), 51.51 (domiciliary care), and 51.52 (adult day 
health care).
    Licensed medical practitioner means a nurse practitioner, 
physician, physician assistant, and primary physician or primary care 
physician.
    Nurse practitioner means a licensed professional nurse who is 
currently licensed to practice in a State; who meets that State's 
requirements governing the qualifications of nurse practitioners; and 
who is currently certified as an adult, family, or gerontological nurse 
practitioner by a nationally recognized body that provides such 
certification for nurse practitioners, such as the American Nurses 
Credentialing Center or the American Academy of Nurse Practitioners.
    Nursing home care means the accommodation of convalescents or other 
persons who are not acutely ill and not in need of hospital care, but 
who require nursing care and related medical services, if such nursing 
care and medical services are prescribed by, or are performed under the 
general direction of, persons duly licensed to provide such care. Such 
term includes services furnished in skilled nursing care facilities, in 
intermediate care facilities, and in combined facilities. It does not 
include domiciliary care.
    Participant means an individual receiving adult day health care.
    Physician means a doctor of medicine or osteopathy legally 
authorized to practice medicine or surgery in the State.
    Physician assistant means a person who meets the applicable State 
requirements for physician assistant, is currently certified by the 
National Commission on Certification of Physician Assistants as a 
physician assistant, and has an individualized written scope of 
practice that determines the authorization to write medical orders, 
prescribe medications and to accomplish other clinical tasks under 
appropriate physician supervision.
    Primary physician or Primary care physician means a designated 
generalist physician responsible for providing, directing and 
coordinating health care that is indicated for the residents or 
participants.
    Program of care means any or all of the three levels of care for 
which VA may pay per diem under this part.
    Resident means an individual receiving nursing home or domiciliary 
care.
    State means each of the several states, the District of Columbia, 
the Virgin Islands, the Commonwealth of Puerto Rico, Guam, the 
Commonwealth of the Northern Mariana Islands, and American Samoa.
    State home means a home recognized and, to the extent required by 
this part, certified pursuant to this part that a State established 
primarily for veterans disabled by age, disease, or otherwise, who by 
reason of such disability are incapable of earning a living. A State 
home must provide at least one program of care (i.e., domiciliary care, 
nursing home care, or adult day health care).
    VA means the U.S. Department of Veterans Affairs.
    Veteran means a veteran under 38 U.S.C. 101.

(Authority: 38 U.S.C. 101, 501, 1741-1743)


[[Page 34809]]



Subpart B--Obtaining Recognition and Certification for Per Diem 
Payments


Sec.  51.20  Recognition of a State home.

    (a) How to apply for recognition. To apply for initial recognition 
of a home for purposes of receiving per diem from VA, a State must 
submit a letter requesting recognition to the Office of Geriatrics and 
Extended Care in VA Central Office, 810 Vermont Avenue NW., Washington, 
DC 20420. The letter must be signed by the State official authorized to 
make the request. The letter will be reviewed by VA, in accordance with 
this section.
    (b) Survey and recommendation by Director. (1) After receipt of a 
letter requesting recognition, VA will survey the home in accordance 
with Sec.  51.31 to determine whether the facility and program of care 
meet the standards in subpart D, E, or F, as applicable. For purposes 
of the recognition process including the survey, references to State 
homes in the standards apply to homes that are being considered by VA 
for recognition as State homes.
    (2) If the Director of the VA Medical Center of jurisdiction 
determines that the applicable standards are met, the Director will 
submit a written recommendation for recognition to the Under Secretary 
for Health.
    (3) If the Director does not recommend recognition, the Director 
will submit a written recommendation against recognition to the Under 
Secretary for Health and will notify in writing the State official who 
signed the letter submitted under paragraph (a) of this section and the 
State official authorized to oversee operations of the home. The 
notification will state the following:
    (i) The specific standard(s) not met; and
    (ii) The State's right to submit a response, including any 
additional evidence, within 30 days after the date of the notification 
to the State.
    (c) Decision by the Under Secretary for Health. After receipt of a 
recommendation from the Director, the Under Secretary for Health will 
award or deny recognition based on all available evidence. The 
applicant will be notified of the decision. Adverse decisions may be 
appealed to the Board of Veterans' Appeals (see 38 CFR part 20).
    (d) Effect of recognition.
    (1) Recognition of a State home means that, at the time of 
recognition, the facility and its program of care meet the applicable 
requirements of this part. The State home must obtain certification 
after recognition in accordance with Sec.  51.30.
    (2) After a State home is recognized, any new annex, new branch, or 
other expansion in the size of a home or any relocation of the home to 
a new facility must be separately recognized. However, changes in the 
use of particular beds between recognized programs of care and 
increases in the number of beds that are not described in the previous 
sentence require certification of the beds, but not recognition, in 
accordance with paragraph (c)(1) of this section.

(Authority: 38 U.S.C. 501, 511, 1742, 1743, 7104, 7105)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.30  Certification.

    (a) General certification requirement. In order to be certified, 
the State home must allow VA to survey the home in accordance with 
Sec.  51.31. A State home must be certified within 450 days after the 
State home is recognized. Certifications expire 600 days after the date 
of their issuance.
    (b) Periodic certifications required. The Director of the VA 
medical center of jurisdiction will certify a State home based on a 
survey conducted at least once every 270-450 days, at VA's discretion, 
and will notify the State official authorized to oversee operations of 
the State home of the decision regarding certification within 20 days 
after the Director's decision.
    (c) Certification of beds based on changes in the program of care--
(1) Switching beds between programs of care or increasing beds in a 
program of care. When a State home that is recognized to provide both 
domiciliary and nursing home care changes the care provided in one or 
more beds, or when a State home increases the number of nursing home or 
domiciliary beds (except increases described in the first sentence of 
Sec.  51.20(d)(2) of this part), VA must survey the home taking the 
proposed changes into account and the Director must certify the beds 
before VA may pay per diem under this part for care provided in those 
beds. However, the Director may precertify, at the request of a State 
home, the increased number of beds or beds that are switched between 
programs of care. Precertification is authorized if the Director 
reasonably expects, based on prior surveys and any other relevant 
information, that the State home will continue to comply with this part 
until such time as the State home is surveyed and certified. 
Precertifications will continue for 360 days or until the Director next 
issues a certification of the State home under Sec.  51.30(b), 
whichever occurs first. VA will pay per diem for the care of eligible 
veterans in the beds provided on and after the date the Director 
precertifies the beds.
    (2) Decreasing beds for a program of care. The State must report 
any decreases in the number of beds that may be used for a particular 
program of care to the Director within 30 days after such decrease, and 
must provide an explanation for the decrease.
    (d) Provisional certification--(1) When issuance is required. After 
a VA survey, the Director must issue a provisional certification for 
the surveyed State home if the Director determines that all of the 
following are true:
    (i) The State home does not meet one or more of the applicable 
standards in this part;
    (ii) None of these deficiencies jeopardize the health or safety of 
any resident or participant;
    (iii) No later than 20 days after receipt by the State home of the 
survey report, the State submitted to the Director a written plan to 
remedy each deficiency in a specified amount of time; and
    (iv) The plan is reasonable and the Director has sent a written 
notice to the appropriate person(s) at the State home informing them 
that the Director agrees to the plan.
    (2) Surveys to continue while under provisional certification. VA 
will continue to survey the State home while it is under a provisional 
certification in accordance with this section and Sec.  51.31. After 
such a survey, the Director will continue the provisional certification 
if the Director determines that the four criteria listed in paragraphs 
(c)(1)(i)-(iv) of this section are true.
    (3) Issuance of additional provisional certification. If the State 
fails to remedy the identified deficiencies within the amount of time 
specified in the written plan described in paragraph (d)(1)(iii) of 
this section, the State must submit, no later than 20 days after the 
expiration of the time specified in the written plan, a new written 
plan to remedy each remaining deficiency in a reasonable time. Upon 
receiving the plan within the 20 day period, the Director may issue 
another provisional certification if all the criteria listed in 
paragraphs (c)(1)(i)-(iv) of this section are true. If not, the 
Director will deny certification.
    (e) Notice and the right to appeal a denial of certification. A 
State home has the right to appeal when the Director determines that a 
State home does not meet the requirements of this part (i.e., denies 
certification). An appeal is not provided to a State for a State home 
that

[[Page 34810]]

receives a provisional certification because, by providing the 
corrective action plan necessary to receive a provisional 
certification, a State demonstrates its acceptance of VA's 
determination that it does not meet the VA standards for which the 
corrective action plan was submitted.
    (1) Notice of decision denying certification. The Director will 
issue in writing a decision denying certification that sets forth the 
specific standard(s) not met. The Director will send a copy of this 
decision to the State official authorized to oversee operations of the 
State home, and notify that official of the State's right to submit a 
written appeal to the Under Secretary for Health as stated in paragraph 
(d)(2). If the State home does not submit a timely written appeal, the 
Director's decision becomes final and VA will not pay per diem for any 
care provided on or after the 31st day after the State's receipt of the 
Director's decision.
    (2) Appeal of denial of certification. The State must submit a 
written appeal no later than 30 days after the date of the notice of 
the denial of certification. The appeal must explain why the denial of 
certification is inaccurate or incomplete and provide any relevant 
information not considered by the Director. Any appeal that does not 
identify a reason for disagreement will be returned to the sender 
without further consideration. If the State home submits a timely 
written appeal, the Director's decision will not take effect and VA 
will continue to pay per diem to the State home pending a decision by 
the Under Secretary for Health.
    (3) Decision on appeal of a denial of certification. The Under 
Secretary for Health will review the matter, including any relevant 
supporting documentation, and issue a written decision that affirms or 
reverses the Director's decision. The State will be notified of the 
decision, which may be appealed to the Board of Veterans' Appeals (see 
38 CFR part 20) if it results in a loss of per diem payments to the 
State. VA will terminate recognition and certification and discontinue 
per diem payments for care provided on and after the date of the Under 
Secretary for Health's decision affirming a denial of certification or 
on a later date that must be specified by the Under Secretary for 
Health.
    (f) Other appeals. Appeals of matters not addressed in this section 
will be governed by 38 CFR part 20.

(Authority: 38 U.S.C. 501, 511, 1741-1743, 7104, 7105).



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-XXXX)


Sec.  51.31  Surveys for recognition and/or certification.

    (a) General. Both before and after a home is recognized and 
certified, VA may survey the home as necessary to determine whether it 
complies with applicable regulations. VA will provide advance notice 
before a recognition survey, but advance notice is not required before 
other surveys. A survey, as necessary, may cover all parts of the home 
or only certain parts, and may include review, audit, and production of 
any records that have a bearing on compliance with the requirements of 
this part (including any reports from state or local entities), as well 
as the completion and submission to VA of all required forms. The 
Director will designate the VA officials and/or contractors to survey 
the home.
    (b) Recognition surveys. VA will not conduct a recognition survey 
unless the following minimum requirements are met:
    (1) For nursing homes and domiciliaries, the home has at least 21 
residents or has a number of residents consisting of at least 50 
percent of the resident capacity of the home;
    (2) For adult day health care programs of care, the program has at 
least 10 participants or has a number of participants consisting of at 
least 50 percent of participant capacity of the program.
    (c) Threats to public, resident, or participant safety. If VA 
identifies a condition at the home that poses an immediate threat to 
public, resident or participant safety, or other information indicating 
the existence of such a threat, the Director of the VA medical center 
of jurisdiction will immediately report this to the VA Network Director 
(10N1-22); the Assistant Deputy Under Secretary for Health (10N); the 
Office of Geriatrics and Extended Care in VA Central Office; and the 
State official authorized to oversee operations of the home.

(Authority: 38 U.S.C. 501, 1741, 1742)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-XXXX)


Sec.  51.32  Terminating recognition.

    Once a home has achieved recognition, the recognition will be 
terminated only if the State requests that the recognition be 
terminated or VA makes a final decision that affirms the Director's 
decision not to certify the State home.

(Authority: 38 U.S.C. 501, 1742)

Subpart C--Eligibility, Rates, and Payments


Sec.  51.40  Basic per diem rates.

    (a) Basic rate. Except as provided in Sec.  51.41, VA will pay per 
diem for care provided to an eligible veteran at a State home at the 
lesser of the following rates:
    (1) One-half of the daily cost of the care for each day the veteran 
is in the State home, as calculated under paragraph (b) of this 
section.
    (2) The basic per diem rate for each day the veteran is in the 
State home. The basic per diem rate is established by VA for each 
fiscal year in accordance with 38 U.S.C. 1741(a) and (c).

    Note: To determine the number of days that a veteran was in a 
State home, see paragraph (c) of this section.

    (b) How to calculate the daily cost of a veteran's care. The daily 
cost of care consists of those direct and indirect costs attributable 
to care at the State home, divided by the total number of residents 
serviced by the program of care. Relevant cost principles are set forth 
in the Office of Management and Budget (OMB) Circular number A-87, 
dated May 10, 2004, ``Cost Principles for State, Local, and Indian 
Tribal Governments.'' (OMB Circulars are available at the addresses in 
5 CFR 1310.3.)
    (c) Determining whether a veteran spent a day receiving nursing 
home and domiciliary care. Per diem will be paid for each day that the 
veteran is receiving nursing home or domiciliary care and has an 
overnight stay. Per diem also will be paid for a day when there is no 
overnight stay if the State home has an occupancy rate of 90 percent or 
greater on that day. However, these payments will be made only for the 
first 10 consecutive days during which the veteran is admitted as a 
patient for any stay in a VA or other hospital (a hospital stay could 
occur more than once in a calendar year) and only for the first 12 days 
in a calendar year during which the veteran is absent for purposes 
other than receiving hospital care. Occupancy rate is calculated by 
dividing the total number of residents (including nonveterans) in the 
nursing home or domiciliary on that day by the total recognized nursing 
home or domiciliary beds in that State home.
    (d) Determining whether a Veteran spent a day receiving adult day 
health care. Per diem will be paid only for a day of adult day health 
care. For purposes of this section a day of adult day health care 
means:
    (1) Six hours or more in one calendar day in which a veteran 
receives adult day health care; or

[[Page 34811]]

    (2) Any two periods of at least 3 hours each but less than 6 hours 
each in any 2 calendar days in the same calendar month in which the 
veteran receives adult day health care.
    (3) Time during which the State home provides transportation 
between the veteran's residence and the State home or to a health care 
visit, or provides staff to accompany a veteran during transportation 
or a health care visit, will be included as time the veteran receives 
adult day health care.

(Authority: 38 U.S.C. 501, 1710, 1741-1744)

Sec.  51.42  Payment procedures.

    (a) Forms required--(1) Forms required at time of admission or 
enrollment. As a condition for receiving payment of per diem under this 
part, the State home must submit the forms identified in paragraphs (i) 
through (ii) of this paragraph to the VA medical center of jurisdiction 
for each veteran at the time of the veteran's admission or enrollment 
(or, if the home is not a recognized State home, the home must, after 
recognition, submit forms for Veterans who received care on and after 
the date of the completion of the VA survey that provided the basis for 
determining that the home met the standards of this part), and with any 
request for a change in the type of per diem paid on behalf of a 
veteran as a result of a change in the veteran's program of care or a 
change in the veteran's service-connected disability rating that makes 
the veteran's care eligible for payment under Sec.  51.41. Copies of VA 
Forms can be obtained from any VA Medical Center and are available on 
our Web site at www.va.gov/vaforms. The required forms are:
    (i) A completed VA Form 10-10EZ, Application for Medical Benefits 
(or VA Form 10-10EZR, Health Benefits Renewal Form, if a completed Form 
10-10EZ is already on file at VA). Note: Domiciliary applicants and 
residents must complete the financial disclosure sections of VA Forms 
1010-EZ and 10-10EZR, and adult day health care applicants may be 
required to complete the financial disclosure sections of these forms 
in order to enroll with VA; however, State homes should not require 
nursing home applicants or residents or adult day health care 
participants to complete the financial disclosure sections of VA Forms 
10-10EZ and 10-10EZR as long as these veterans sign the form, thereby 
indicating knowledge of, and willingness to pay, any applicable co-pays 
for the treatment of nonservice-connected conditions by VA.
    (ii) A completed VA Form 10-10SH, State Home Program Application 
for Care--Medical Certification.
    (2) Form required for monthly payments. Except as provided in 
(b)(1) and (b)(2), VA pays per diem on a monthly basis for care 
provided during the prior month. To receive payment, the State must 
submit each month to the VA a completed, VA Form 10-5588, State Home 
Report and Statement of Federal Aid Claimed.
    (b) Commencement of payments--(1) Per diem payments for a newly-
recognized State home. No per diem payments will be made until VA 
recognizes the home and each veteran resident for whom VA pays per diem 
is verified as being eligible; however, per diem payments will be made 
retroactively for care that was provided on and after the date of the 
completion of the VA survey that provided the basis for determining 
that the home met the standards of this part.
    (2) Per diem payments for beds certified or precertified under 
Sec.  51.30(c). Per diem will be paid for the care of veterans in beds 
precertified in accordance with Sec.  51.30(c) retroactive to the date 
of precertification. Per diem will be paid for the care of veterans in 
beds certified in accordance with Sec.  51.30(c) retroactive to the 
date of the completion of the survey if the Director certifies the beds 
as a result of that survey.
    (3) Payments for eligible veterans. When a State home admits or 
enrolls an eligible veteran, VA will pay per diem under this part from 
the date of receipt of the completed forms required by this section, 
except that VA will pay per diem from the day on which the veteran was 
admitted or enrolled if the Director receives the completed forms 
within 12 days of the date of admission or enrollment. VA will make 
retroactive payments of per diem under paragraphs (b)(1) and (b)(2) 
only if the Director receives the completed forms that must be 
submitted under this section.

(Authority: 38 U.S.C. 510, 1741, 1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.43  Drugs and medicines for certain veterans.

    (a) In addition to the per diem payments under Sec.  51.40 of this 
part, the Secretary will furnish drugs and medicines to a State home as 
may be ordered by prescription of a duly licensed physician as specific 
therapy in the treatment of illness or injury for a veteran receiving 
nursing home care in a State home, if:
    (1) The veteran:
    (i) Has a singular or combined rating of less than 50 percent based 
on one or more service-connected disabilities and is in need of such 
drugs and medicines for a service-connected disability; and
    (ii) Is in need of nursing home care for reasons that do not 
include care for a VA adjudicated service-connected disability, or
    (2) The veteran:
    (i) Has a singular or combined rating of 50 or 60 percent based on 
one or more service-connected disabilities and is in need of such drugs 
and medicines; and
    (ii) Is in need of nursing home care for reasons that do not 
include care for a VA adjudicated service-connected disability.
    (b) VA will also furnish drugs and medicines to a State home for a 
veteran receiving nursing home, domiciliary and adult day health care 
in a State home pursuant to 38 U.S.C. 1712(d), as implemented by Sec.  
17.96 of this chapter, subject to the limitation in Sec.  51.41(c)(2).
    (c) VA may furnish a drug or medicine under paragraph (a) of this 
section and under Sec.  17.96 of this chapter only if the drug or 
medicine is included on VA's National Formulary, unless VA determines a 
non-Formulary drug or medicine is medically necessary.
    (d) VA may furnish a drug or medicine under this section and Sec.  
17.96 of this chapter by having the drug or medicine delivered to the 
State home in which the veteran resides by mail or other means and 
packaged in a form that is mutually acceptable to the State home and VA 
set forth in a written agreement.
    (e) As a condition for receiving drugs or medicine under this 
section or under Sec.  17.96 of this chapter, the State must submit to 
the VA medical center of jurisdiction a completed VA Form 10-0460 for 
each eligible veteran. The corresponding prescriptions also should be 
submitted to the VA medical center of jurisdiction.

(Authority: 38 U.S.C. 501, 1712, 1745)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.50  Eligible veterans-nursing home care.

    A veteran is an eligible veteran for the purposes of payment of per 
diem for nursing home care under this part if VA determines that the 
veteran needs nursing home care; is not barred from receiving care 
based on his or her service (see 38 U.S.C. 5303-5303A), is

[[Page 34812]]

not barred from receiving VA pension, compensation or dependency and 
indemnity compensation based on the character of a discharge from 
military service (see 38 CFR 3.12) and is within one of the following 
categories:
    (a) Veterans with service-connected disabilities;
    (b) Veterans who are former prisoners of war, who were awarded the 
Purple Heart, or who were awarded the medal of honor under 10 U.S.C. 
3741, 6241, or 8741 or 14 U.S.C. 491;
    (c) Veterans who were discharged or released from active military 
service for a disability incurred or aggravated in the line of duty;
    (d) Veterans who receive disability compensation under 38 U.S.C. 
1151;
    (e) Veterans whose entitlement to disability compensation is 
suspended because of the receipt of retired pay;
    (f) Veterans whose entitlement to disability compensation is 
suspended pursuant to 38 U.S.C. 1151, but only to the extent that such 
veterans' continuing eligibility for nursing home care is provided for 
in the judgment or settlement described in 38 U.S.C. 1151;
    (g) Veterans who VA determines are unable to defray the expenses of 
necessary care as specified under 38 U.S.C. 1722(a);
    (h) Veterans solely seeking care for a disorder associated with 
exposure to a toxic substance or radiation, for a disorder associated 
with service in the Southwest Asia theater of operations during the 
Persian Gulf War, as provided in 38 U.S.C. 1710(e), or for any illness 
associated with service in combat in a war after the Gulf War or during 
a period of hostility after November 11, 1998, as provided and limited 
in 38 U.S.C. 1710(e);
    (i) Veterans who agree to pay to the United States the applicable 
co-payment determined under 38 U.S.C. 1710(f) and 1710(g).

    Note: Neither enrollment in the VA healthcare system nor 
eligibility to enroll is required to be an eligible veteran for the 
purposes of payment of per diem for nursing home care.


(Authority: 38 U.S.C. 501, 1710, 1741-1743)

Sec.  51.51  Eligible veterans-domiciliary care.

    (a) A veteran is an eligible veteran for the purposes of payment of 
per diem for domiciliary care in a State home under this part if VA 
determines that the veteran is not barred from receiving care based on 
his or her service (see 38 U.S.C. 5303-5303A), is not barred from 
receiving VA pension, compensation or dependency and indemnity 
compensation based on the character of a discharge from military 
service (see 38 CFR 3.12), and the veteran is:
    (1) A veteran whose annual income does not exceed the maximum 
annual rate of pension payable to a veteran in need of regular aid and 
attendance; or
    (2) A veteran who VA determines has no adequate means of support. 
The phrase no adequate means of support refers to an applicant for 
domiciliary care whose annual income exceeds the rate of pension 
described in paragraph (1), but who is able to demonstrate to competent 
VA medical authority, on the basis of objective evidence, that deficits 
in health and/or functional status render the applicant incapable of 
pursuing substantially gainful employment, as determined by the Chief 
of Staff of the VA medical center of jurisdiction, and who is otherwise 
without the means to provide adequately for self, or be provided for in 
the community.
    (b) For purposes of this section, the eligible veteran must be able 
to perform the following:
    (1) Daily ablutions, such as brushing teeth; bathing; combing hair; 
body eliminations, without assistance.
    (2) Dress self, with a minimum of assistance.
    (3) Proceed to and return from the dining hall without aid.
    (4) Feed self.
    (5) Secure medical attention on an ambulatory basis or by use of 
personally propelled wheelchair.
    (6) Have voluntary control over body eliminations or control by use 
of an appropriate prosthesis.
    (7) Share in some measure, however slight, in the maintenance and 
operation of the State home.
    (8) Make rational and competent decisions as to his or her desire 
to remain or leave the State home.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)

Sec.  51.52  Eligible veterans-adult day health care.

    A veteran is an eligible veteran for payment of per diem to a State 
for adult day health care if VA determines that the veteran
    (a) Is not barred from receiving VA pension, compensation or 
dependency and indemnity compensation based on the character of a 
discharge from military service (see 38 CFR 3.12)
    (b) Is enrolled in the VA health care system,
    (c) Would otherwise require nursing home care;
    and
    (d) Needs adult day health care because the veteran meets any one 
of the following conditions:
    (1) The veteran has three or more Activities of Daily Living (ADL) 
dependencies.
    (2) The veteran has significant cognitive impairment.
    (3) The veteran has two ADL dependencies and two or more of the 
following conditions:
    (i) Seventy-five years old or older;
    (ii) High use of medical services, i.e., three or more 
hospitalizations per calendar year, or twelve or more visits to 
outpatient clinics and emergency evaluation units per calendar year;
    (iii) Diagnosis of clinical depression; or
    (iv) Living alone in the community.
    (4) The veteran does not meet the criteria in paragraphs (d)(1), 
(d)(2), or (d)(3) of this section, but nevertheless is determined by a 
VA licensed medical practitioner to need adult day health care 
services.

(Authority: 38 U.S.C. 501, 1720(f), 1741-1743)

Sec.  51.58  Standards applicable for payment of per diem.

    A State home must meet the standards in the applicable subpart to 
be recognized, certified, and receive per diem for that program of 
care:
    (a) For nursing home care, subpart D.
    (b) For domiciliary care, subpart E.
    (c) For adult day health care, subpart F.

(Authority: 38 U.S.C. 501)

Sec.  51.59  Authority to continue payment of per diem when veterans 
are relocated due to emergency.

    (a) Definition of emergency. For the purposes of this section, 
emergency means an occasion or instance where all of the following are 
true:
    (1) It would be unsafe for veterans receiving care at a State home 
to remain in that home.
    (2) The State is not, or believes that it will not be, able to 
provide care in the State home on a temporary or long-term basis for 
any or all of its veteran residents due to a situation involving the 
State home, and not due to a situation where a particular veteran's 
medical condition requires that the veteran be transferred to another 
facility, such as for a period of hospitalization.
    (3) The State determines that the veterans must be evacuated to 
another facility or facilities.
    (b) General authority to pay per diem during relocation period. 
Notwithstanding any other provision of this part, VA will continue to 
pay per diem for a period not to exceed 30 days for any eligible 
veteran who resided in a State home, and for whom VA was paying per 
diem, if such veteran is evacuated during an emergency into a facility 
other than a VA nursing home,

[[Page 34813]]

hospital, domiciliary, or other VA site of care if the State is 
responsible for providing or paying for the care. VA will not pay per 
diem payments under this section for more than 30 days of care provided 
in the evacuation facility, unless the official who approved the 
emergency response under paragraph (e) of this section determines that 
it is not reasonably possible to return the veteran to a State home 
within the 30-day period, in which case such official will approve 
additional period(s) of no more than 30 days in accordance with this 
section. VA will not provide per diem if VA determines that a veteran 
is or has been placed in a facility that does not meet the standards 
set forth in paragraph (c)(1) of this section, and VA may recover all 
per diem payments made for the care of the veteran in that facility.
    (c) Selection of evacuation facilities. The following standards and 
procedures apply to the selection of an evacuation facility in order 
for VA to continue to pay per diem during an emergency; these standards 
and procedures also apply to evacuation facilities when veterans are 
evacuated from a nursing home in which care is being provided pursuant 
to a contract under 38 U.S.C. 1720.
    (1) Each veteran who is evacuated must be placed in a facility 
that, at a minimum, will meet the needs for food, shelter, toileting, 
and essential medical care of that veteran.
    (2) For veterans evacuated from nursing homes, the following types 
of facilities may meet the standards under paragraph (c)(1) of this 
section:
    (i) VA Community Living Centers;
    (ii) VA contract nursing homes;
    (iii) Centers for Medicare and Medicaid Services certified 
facilities; and
    (iv) Licensed nursing homes.

    Note to paragraph (c)(2): If none of the above options are 
available, veterans may be evacuated temporarily to other facilities 
that meet the standards under paragraph (c)(1) of this section.

    (3) For veterans evacuated from domiciliaries, the following types 
of facilities may meet the standards in paragraph (c)(1) of this 
section:
    (i) Emergency evacuation facilities identified by the city or 
State;
    (ii) Assisted living facilities; and
    (iii) Hotels.
    (d) Applicability to adult day health care programs of care. 
Notwithstanding any other provision of this part, VA will continue to 
pay per diem for a period not to exceed 30 days for any eligible 
veteran who was receiving adult day health care, and for whom VA was 
paying per diem, if the adult day health care facility becomes 
temporarily unavailable due to an emergency. Approval of a temporary 
program of care for such veteran is subject to paragraph (e) of this 
section. If after 30 days the veteran cannot return to the adult day 
health care program in the State home, VA will discontinue per diem 
payments unless the official who approved the emergency response under 
paragraph (e) of this section determines that it is not reasonably 
possible to provide care in the State home or to relocate an eligible 
veteran to a different recognized or certified facility, in which case 
such official will approve additional period(s) of no more than 30 days 
at the temporary program of care in accordance with this section. VA 
will not provide per diem if VA determines that a veteran was provided 
adult day health care in a facility that does not meet the standards 
set forth in paragraph (c)(1) of this section, and VA may recover all 
per diem payments made for the care of the veteran in that facility.
    (e) Approval of response. Per diem payments will not be made under 
this section unless and until the Director of the VA medical center of 
jurisdiction determines, or the director of the VISN in which the State 
home is located (if the VAMC Director is not capable of doing so) 
determines, that an emergency exists and that the evacuation facility 
meets VA standards set forth in paragraph (c)(1) of this section.

(Authority 38 U.S.C. 501, 1720, 1742)


0
4. Amend the heading of Subpart D, part 51, to read as follows:

Subpart D--Standards applicable to the payment of per diem for 
nursing home care.


Sec.  51.120  [Amended]

0
5. Amend Sec.  51.120(a)(3) by replacing ``Chief Consultant, Office of 
Geriatrics and Extended Care (114)'' with ``Office of Geriatrics and 
Extended Care in VA Central Office.''


Sec.  51.140  [Amended]

0
6. Amend Sec.  51.140(d)(4) by removing ``who refuse food served''.
0
7. Amend Sec.  51.210 by:
0
a. In paragraph (b), replacing ``Chief Consultant, Office of Geriatrics 
and Extended Care (114)'' with ``Office of Geriatrics and Extended 
Care''.
0
b. Revising paragraph (b)(2), redesignating (b)(3) as (b)(4), and 
adding new paragraphs (b)(3) and (h)(3), to read as follows:


Sec.  51.210  Administration.

* * * * *
    (b) * * *
    (2) The State home administrator;
    (3) The director of nursing services (or other individual in charge 
of nursing services); and
    (4) The State employee responsible for oversight of the State home 
if a contractor operates the State home.
* * * * *
    (h)(3) If a veteran requires health care that the State home is not 
required to provide under this part, the State home may assist the 
veteran in obtaining that care from sources outside the State home, 
including the Veterans Health Administration. If VA is contacted about 
providing such care, VA will determine the best option for obtaining 
the needed services and will notify the veteran or the authorized 
representative of the veteran.
* * * * *
0
8. Amend part 51 by adding subparts E and F, to read as follows:
Subpart E--Standards Applicable to the Payment of Per Diem for 
Domiciliary Care
Sec
51.300 Resident rights and behavior; State home practices; quality 
of life
51.310 Resident assessment
51.320 Quality of care
51.330 Nursing care
51.340 Physician and other licensed medical practitioner services
51.350 Provision of certain specialized services and environmental 
requirements
51.390 Administration
Subpart F--Standards Applicable to Adult Day Health Care Programs of 
Care
51.400 Participant rights
51.405 Participant and family caregiver responsibilities
51.410 Transfer and discharge
51.411 Program practices
51.415 Restraints, abuse, and staff treatment of participants
51.420 Quality of life
51.425 Physician orders and participant medical assessment
51.430 Quality of care
51.435 Nursing services
51.440 Dietary services
51.445 Physician services
51.450 Specialized rehabilitative services
51.455 Dentist
51.460 Administration of drugs
51.465 Infection control
51.470 Physical environment
51.475 Administration
51.480 Transportation

Subpart E--Standards Applicable to the Payment of Per Diem for 
Domiciliary Care


Sec.  51.300  Resident rights and behavior; state home practices; 
quality of life.

    The State home must protect and promote the rights and quality of 
life of each resident receiving domiciliary care, and otherwise comply 
with the

[[Page 34814]]

requirements set forth in Sec. Sec.  51.70, 51.80, 51.90, and 51.100. 
For purposes of this section, the references in the cited sections to 
nursing home and nursing facility refer to a domiciliary.

(Authority: 38 U.S.C. 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.310  Resident assessment.

    The State home must conduct a comprehensive, accurate, and written 
assessment of each resident's medical and functional capacity upon 
admission, annually, and as required by a change in the resident's 
condition.
    (a) Admission orders. At the time each resident is admitted, the 
State home must have physician orders for the resident's immediate care 
and a medical assessment, including a medical history and physical 
examination, within a time frame appropriate to the resident's 
condition, not to exceed 72 hours after admission, except when the 
required physical examination was performed within five days before 
admission and the findings were recorded in the medical record on 
admission, in which case the physician orders may be submitted when 
available.
    (b) Use. The State home must use the results of the assessment to 
develop, review, and revise the resident's treatment plan.
    (c) Coordination of assessments. Each assessment must be conducted 
or coordinated by a registered nurse with the appropriate participation 
of health professionals, including at least one physician, the 
registered nurse, and one social worker. The registered nurse must sign 
and certify the assessment.
    (d) Treatment plans. (1) The State home must develop a treatment 
plan for each resident that includes measurable objectives and 
timetables to address a resident's physical, mental, and psychosocial 
needs that are identified in the written assessment. The treatment plan 
must describe the following:
    (i) The services that are to be furnished to support the resident's 
highest practicable physical, mental, and psychosocial well-being as 
required under Sec.  51.350; and
    (ii) Any services that would otherwise be required under Sec.  
51.350 but are not provided due to the resident's exercise of rights 
under Sec.  51.300, including the right to refuse treatment.
    (2) A treatment plan must be:
    (i) Developed within 7 calendar days after completion of the 
comprehensive assessment;
    (ii) Prepared by health professionals, that include the primary 
physician, a social worker, and a registered nurse who have 
responsibility for the resident, and other appropriate staff in 
disciplines as determined by the resident's needs, and, to the extent 
practicable, the participation of the resident and the resident's 
family (subject to the consent of the resident) or the resident's legal 
representative, if appropriate; and
    (iii) Periodically reviewed and revised by a team of qualified 
persons after each assessment.
    (3) The services provided by the facility must--
    (i) Meet professional standards of quality; and
    (ii) Be provided by qualified persons in accordance with each 
resident's written treatment plan.
    (e) Discharge summary. Prior to discharging a resident, the State 
home must prepare a discharge summary that includes--
    (1) A recapitulation of the resident's stay;
    (2) A summary of the resident's status at the time of the discharge 
to include a summary of the resident's progress on the treatment plan 
in paragraph (d)(2) of this section; and
    (3) A post-discharge plan of care that is developed with the 
participation of the resident and, to the extent practicable and 
appropriate, his or her family, (subject to the consent of the 
resident) and legal representative, which will assist the resident to 
adjust to his or her new living environment.

(Authority: 38 U.S.C. 501, 1720(f), 1741-1743)


(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.320  Quality of care.

    The State home must provide each resident with the care described 
in this subpart in accordance with the assessment and plan of care.
    (a) Reporting of sentinel events. (1) A sentinel event is an 
adverse event that results in the loss of life or limb or permanent 
loss of function.
    (2) Examples of sentinel events are as follows:
    (i) Any resident death, paralysis, coma or other major permanent 
loss of function associated with a medication error; or
    (ii) Any suicide of a resident; or
    (iii) Assault, homicide or other crime resulting in resident death 
or major permanent loss of function; or
    (iv) A resident fall that results in death or major permanent loss 
of function as a direct result of the injuries sustained in the fall.
    (3) The State home must report sentinel events to the Director 
within 24 hours of identification. The VA medical center of 
jurisdiction must report sentinel events by notifying the VA Network 
Director (10N1-10N22) and the Director, Office of Geriatrics and 
Extended Care--Operations (10NC4) within 24 hours of notification.
    (4) The State home must establish a mechanism to review and analyze 
a sentinel event resulting in a written report to be submitted to the 
VA Medical Center of jurisdiction no later than 10 working days 
following the event. The purpose of the review and analysis of a 
sentinel event is to prevent injuries to residents, visitors, and 
personnel, and to manage those injuries that do occur and to minimize 
the negative consequences to the injured individuals and the State 
home.
    (b) Activities of daily living. Based on the comprehensive 
assessment of a resident, the State home must ensure that a resident's 
abilities in activities of daily living do not diminish unless 
circumstances of the individual's clinical condition demonstrate that 
diminution was unavoidable, and the resident is given appropriate 
treatment and services to maintain or improve his activities of daily 
living. This includes the resident's ability to:
    (1) Bathe, dress, and groom;
    (2) Transfer and ambulate;
    (3) Toilet;
    (4) Eat; and
    (5) Talk or otherwise communicate.
    (c) Vision and hearing. To ensure that residents receive proper 
treatment and assistive devices to maintain vision and hearing 
abilities, the State home must, if necessary, assist the resident:
    (1) In making appointments, and
    (2) By arranging for transportation to and from the office of a 
practitioner specializing in the treatment of vision or hearing 
impairment or the office of a professional specializing in the 
provision of vision or hearing assistive devices.
    (d) Mental and Psychosocial functioning. Based on the comprehensive 
assessment of a resident, the State home must assist a resident who 
displays mental or psychosocial adjustment difficulty, obtain 
appropriate treatment and services to correct the assessed problem.
    (e) Accidents. The State home must ensure that:
    (1) The resident environment remains as free of accident hazards as 
possible; and

[[Page 34815]]

    (2) Each resident receives adequate supervision and assistance 
devices to prevent accidents.
    (f) Nutrition. The State home must follow Sec.  51.120(j) regarding 
nutrition in providing domiciliary care.
    (g) Special needs. The State home must provide residents with the 
following services, if needed:
    (1) Injections;
    (2) Colostomy, ureterostomy, or ileostomy care;
    (3) Respiratory care;
    (4) Foot care; and
    (5) Non-customized or non-individualized prosthetic devices.
    (h) Unnecessary drugs. The State home must ensure that the 
standards set forth in Sec.  51.120(m) regarding unnecessary drugs are 
followed in providing domiciliary care.
    (i) Medication Errors. The State home must ensure that the 
standards set forth in Sec.  51.120(n) regarding medication errors are 
followed in providing domiciliary care.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.330  Nursing care.

    The State home must provide an organized nursing service with a 
sufficient number of qualified nursing personnel to meet the total 
nursing care needs, as determined by the resident assessment and 
individualized treatment plans, of all residents within the facility, 
24 hours a day, 7 days a week.
    (a) The nursing service must be under the direction of a full-time 
registered nurse who is currently licensed by the State and has, in 
writing, administrative authority, responsibility, and accountability 
for the functions, activities, and training of the nursing service's 
staff.
    (b) The director of nursing service must designate a licensed nurse 
as the supervising nurse for each tour of duty.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)

Sec.  51.340  Physician and other licensed medical practitioner 
services.

    The State home must provide the necessary primary care for its 
residents to permit them to attain or maintain the highest practicable 
physical, mental, and psychosocial well-being. When a resident needs 
care other than what the State home is required to provide under this 
subpart, the State home is responsible for assisting the resident in 
obtaining that care. The State home must ensure that a physician 
personally approves in writing a recommendation that an individual be 
admitted to a domiciliary. Each resident must remain at all times under 
the care of a licensed medical practitioner assigned by the State home. 
The name of the practitioner will be listed in the resident's medical 
record. The State home must ensure that all of the following conditions 
are met:
    (a) Supervision of medical practitioners. Any licensed medical 
practitioner who is not a physician may provide medical care to a 
resident within the practitioner's scope of practice without physician 
supervision when permitted by state law.
    (b) Availability of medical practitioners. If the resident's 
assigned licensed medical practitioner is unavailable, another licensed 
medical practitioner must be available to provide care for that 
resident.
    (c) Visits. The primary care physician or other licensed medical 
practitioner, for each visit required by paragraph (d) of this section, 
must--
    (1) Review the resident's total program of care, including 
medications and treatments;
    (2) Write, sign, and date progress notes; and
    (3) Sign and date all orders.
    (d) Frequency of visits. The resident must be seen by the primary 
care physician or other licensed medical practitioner at least once 
every 30 days for the first 90 days after admission, and at least once 
a calendar year thereafter, or more frequently based on the condition 
of the resident.
    (e) Availability of emergency care. The State home must assist 
residents in obtaining emergency care.

 (Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)

Sec.  51.350  Provision of certain specialized services and 
environmental requirements.

    The State home must comply with the requirements, set forth in 
Sec. Sec.  51.140, 51.170, 51.180, 51.190, and 51.200 concerning 
dietary, dental, pharmacy services, infection control, and physical 
environment. For purposes of this section, the references in the cited 
sections to nursing home and nursing facility refer to a domiciliary.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.390  Administration.

    The State home must follow Sec.  51.210 regarding administration in 
providing domiciliary care. For purposes of this section, the 
references in the cited section to nursing home and nursing home care 
refer to a domiciliary and domiciliary care.

(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)

Subpart F--Standards Applicable to Adult Day Health Care Programs 
of Care


Sec.  51.400  Participant rights.

    The State home must protect and promote the rights of a participant 
in an adult day health care program, including the rights set forth in 
Sec.  51.70, except for the right set forth in Sec.  51.70(m). For 
purposes of this section, the references in the cited section to 
resident refer to a participant.

(Authority: 38 U.S.C. 501)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
0160.)


Sec.  51.405  Participant and family caregiver responsibilities.

    The State home must post in a place where participants in the adult 
day health care program and their families will see it a written 
statement of participant and family caregiver responsibilities and must 
provide a copy to the participant and caregiver at or before the time 
of the intake screening. The statement of responsibilities must include 
the following responsibilities:
    (a) Treat personnel with respect and courtesy;
    (b) Communicate with staff to develop a relationship of trust;
    (c) Make appropriate choices and seek appropriate care;
    (d) Ask questions and confirm your understanding of instructions;
    (e) Share opinions, concerns, and complaints with the program 
director;
    (f) Communicate any changes in the participant's condition;
    (g) Communicate to the program director about medications and 
remedies used by the participant;
    (h) Let the program director know if the participant decides not to 
follow any instructions or treatment; and
    (i) Communicate with the adult day health care staff if the 
participant is unable to attend adult day health care.

[[Page 34816]]


(Authority: 38 U.S.C. 501)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-0160)


Sec.  51.410  Transfer and discharge.

    (a) Definition. For purposes of this section, the term ``transfer 
and discharge'' includes movement of a participant to a program outside 
of the adult day health care program whether or not that program of 
care is in the same facility.
    (b) Transfer and discharge requirements. The possible reasons for 
transfer and discharge must be discussed with the participant and, to 
the extent practicable and appropriate, with family members (subject to 
the consent of the participant) and legal representatives at the time 
of intake screening. In the case of a transfer and discharge to a 
hospital, the transfer and discharge must be to the hospital closest to 
the adult day health care facility that is capable of providing the 
necessary care. The State home must permit each participant to remain 
in the program of care, and not transfer or discharge the participant 
from the program of care unless:
    (1) The transfer and discharge is necessary for the participant's 
welfare and the participant's needs cannot be met in the adult day 
health care setting;
    (2) The transfer and discharge is appropriate because the 
participant's health has improved sufficiently so the participant no 
longer needs the services provided in the adult day health care 
program;
    (3) The safety of individuals in the facility is endangered;
    (4) The health of individuals in the facility would otherwise be 
endangered;
    (5) The participant has failed, after reasonable and appropriate 
notice, to pay for participation in adult day health care; or
    (6) The adult day health care program of care ceases to operate.
    (c) Notice before transfer. Before an adult day health care program 
undertakes the transfer and discharge of a participant, the State home 
must:
    (1) Notify the participant or the legal representative of the 
participant and, if appropriate, a family member, of the transfer and 
discharge and the reasons for the move in writing and in a language and 
manner they can understand;
    (2) Record the reasons in the participant's clinical record; and
    (3) Include in the notice the items described in paragraph (e) of 
this section.
    (d) Timing of the notice. (1) The notice of transfer and discharge 
required under paragraph (c) of this section must be made by the State 
home at least 30 days before the participant is given a transfer and 
discharge, except when specified in paragraph (d)(2) of this section.
    (2) Notice may be made as soon as practicable before a transfer and 
discharge when--
    (i) The safety of individuals in the facility would be endangered;
    (ii) The health of individuals in the facility would be otherwise 
endangered;
    (iii) The participant's health improves sufficiently so the 
participant no longer needs the services provided by the adult day 
health care program of care; or
    (iv) The resident's needs cannot be met in the adult day health 
care program of care.
    (e) Contents of the notice. The written notice specified in 
paragraph (c) of this section must include the following:
    (1) The reason for the transfer and discharge;
    (2) The effective date of the transfer and discharge;
    (3) The location to which the participant is taken in accordance 
with the transfer and discharge, if any;
    (4) A statement that the participant has the right to appeal the 
action to the State official responsible for the oversight of State 
Veterans Home programs; and
    (5) The name, address and telephone number of the State long-term 
care ombudsman.
    (f) Orientation for transfer and discharge. The State home must 
provide sufficient preparation and orientation to participants to 
ensure safe and orderly transfer and discharge from the State home.
    (g) Written policy. The State home must have in effect a written 
transfer and discharge procedure that reasonably ensures that:
    (1) Participants will be given a transfer and discharge from the 
adult day health care program to the hospital, and ensured of timely 
admission to the hospital when transfer and discharge is medically 
appropriate as determined by a physician; and
    (2) Medical and other information needed for care and treatment of 
participants will be exchanged between the facility and the hospital.

(Authority: 38 U.S.C. 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-0160)


Sec.  51.411  Program practices.

    (a) Equal access to quality care. The State home must establish and 
maintain identical policies and practices regarding transfer and 
discharge under Sec.  51.410 and the provision of services for all 
participants regardless of the source of payment.
    (b) Admission policy. The State home must not require a third-party 
guarantee of payment as a condition of admission or expedited 
admission, or continued admission in the program of care. However, the 
State home may require a participant or an individual who has legal 
access to a participant's income or resources to pay for the care from 
the participant's income or resources, when available.
    (c) Hours of operation. Each adult day health care program of care 
must provide at least 8 hours of operation 5 days a week. The hours of 
operation must be flexible and responsive to caregiver needs.

(Authority: 38 U.S.C. 501, 1741-1743)

Sec.  51.415  Restraints, abuse, and staff treatment of participants.

    The State home must meet the requirements regarding the use of 
restraints, abuse, and other matters concerning staff treatment of 
participants set forth in Sec.  51.90. For purposes of this section, 
the references in the cited section to resident refer to a participant.

(Authority: 38 U.S.C. 501)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.420  Quality of life.

    The State home must provide an environment that supports the 
quality of life of each participant by maximizing the participant's 
potential strengths and skills.
    (a) Dignity. The State home must promote care for participants in a 
manner and in an environment that maintains or enhances each 
participant's dignity and respect in full recognition of his or her 
individuality.
    (b) Self-determination and participation. The State home must 
ensure that the participant has the right to--
    (1) Choose activities, schedules, and health care consistent with 
his or her interests, assessments, and plans of care;
    (2) Interact with members of the community both inside and outside 
the facility; and
    (3) Make choices about aspects of his or her life in the facility 
that are significant to the participant.

[[Page 34817]]

    (c) Participant and family concerns. The State home must document 
any concerns submitted to the management of the program by participants 
or family members.
    (1) A participant's family has the right to meet with families of 
other participants in the program.
    (2) Staff or visitors may attend meetings of participant or family 
groups at the group's invitation.
    (3) The State home must respond to written requests that result 
from group meetings.
    (4) The State home must listen to the views of any participant or 
family group and act upon the concerns of participants and families 
regarding policy and operational decisions affecting participant care 
in the program.
    (d) Participation in other activities. The State home must ensure 
that a participant has the right to participate in social, religious, 
and community activities that do not interfere with the rights of other 
participants in the program.
    (e) Therapeutic participant activities. (1) The State home must 
provide for an ongoing program of activities designed to meet, in 
accordance with the comprehensive assessment, the interests and the 
physical, mental, and psychosocial well-being of each participant.
    (2) The activities program must be directed by a qualified 
professional who is a qualified therapeutic recreation specialist or an 
activities professional who:
    (i) Is licensed, if applicable, by the State in which practicing; 
and
    (ii) Is certified as a therapeutic recreation specialist or an 
activities professional by a recognized certifying body.
    (3) A critical role of adult day health care is to build 
relationships and create a culture that supports, involves, and 
validates the participant. Therapeutic activity refers to that 
supportive culture and is a significant aspect of the individualized 
plan of care. A participant's activity includes everything the 
individual experiences during the day, not just arranged events. As 
part of effective therapeutic activity, the adult day health care 
program of care must:
    (i) Provide direction and support for participants, including 
breaking down activities into small, discrete steps or behaviors, if 
needed by a participant;
    (ii) Have alternative programming available for any participant 
unable or unwilling to take part in group activity;
    (iii) Design activities that promote personal growth and enhance 
the self-image and/or improve or maintain the functioning level of 
participants to the extent possible;
    (iv) Provide opportunities for a variety of involvement (social, 
intellectual, cultural, economic, emotional, physical, and spiritual) 
at different levels, including community activities and events;
    (v) Emphasize participants' strengths and abilities rather than 
impairments and contribute to participants' feelings of competence and 
accomplishment; and
    (vi) Provide opportunities to voluntarily perform services for 
community groups and organizations.
    (f) Social services. (1) The State home must provide medically-
related social services to participants and their families.
    (2) An adult day health care program of care must provide a 
qualified social worker to furnish social services.
    (3) Qualifications of social worker. A qualified social worker is 
an individual with:
    (i) A bachelor's degree in social work from a school accredited by 
the Council of Social Work Education (Note: A master's degree social 
worker with experience in long-term care is preferred);
    (ii) A social work license from the State in which the State home 
is located, if that license is offered by the State; and
    (iii) A minimum of one year of supervised social work experience in 
a health care setting working directly with individuals.
    (4) The State home must have sufficient social workers and support 
staff to meet participant and family social services needs. The adult 
day health care program of care must:
    (i) Provide counseling to participants and families/caregivers;
    (ii) Facilitate the participant's adaptation to the adult day 
health care program of care and active involvement in the plan of care, 
if appropriate;
    (iii) Arrange for services not provided by adult day health care 
and work with these resources to coordinate services;
    (iv) Serve as an advocate for participants by asserting and 
safeguarding the human and civil rights of the participants;
    (v) Assess signs of mental illness and/or dementia and make 
appropriate referrals;
    (vi) Provide information and referral for persons not appropriate 
for adult day health care;
    (vii) Provide family conferences and serve as liaison between 
participant, family/caregiver and program staff;
    (viii) Provide individual or group counseling and support to 
caregivers and participants;
    (ix) Conduct support groups or facilitate participant or family/
caregiver participation in support groups;
    (x) Assist program staff in adapting to changes in participants' 
behavior; and
    (xi) Provide or arrange for individual, group, or family 
psychotherapy for participants with significant psychosocial needs.
    (5) Space for social services must be adequate to ensure privacy 
for interviews.
    (g) Environment. The State home must provide:
    (1) A safe, clean, comfortable, and homelike environment, and 
support the participants' ability to function as independently as 
possible and to engage in program activities;
    (2) Housekeeping and maintenance services necessary to maintain a 
sanitary, orderly, and comfortable interior;
    (3) Private storage space that can be secured with a lock for each 
participant sufficient for a change of clothes;
    (4) Interior signs to facilitate participants' ability to move 
about the facility independently and safely;
    (5) A clean bed or reclining chair available for acute illness;
    (6) A shower for residents;
    (7) Adequate and comfortable lighting levels in all areas;
    (8) Comfortable and safe temperature levels; and
    (9) Comfortable sound levels.

(Authority: 38 U.S.C. 101, 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
0160.)


Sec.  51.425  Physician orders and participant medical assessment.

    (a) Admission. At the time of admission, the State home must have 
physician orders for the participant's immediate care and a medical 
assessment including a medical history and physical examination (with 
documentation of TB screening) completed no earlier than 30 days before 
admission.
    (b) Assessments. On the participant's first visit, the State home 
must ensure that the participant has an individualized care plan that 
meets the requirements of paragraph (d) of this section. Additional 
assessments must be conducted annually, as well as promptly after every 
significant change in the participant's physical, mental, or social 
condition. The State home must immediately change the participant's

[[Page 34818]]

care plan when warranted by an assessment. Assessments must meet the 
other applicable criteria of this section, and the written assessment 
must address the following:
    (1) Ability to ambulate,
    (2) Ability to use bathroom facilities,
    (3) Ability to eat and swallow,
    (4) Ability to hear,
    (5) Ability to see,
    (6) Ability to experience feeling and movement,
    (7) Ability to communicate,
    (8) Risk of wandering,
    (9) Risk of elopement,
    (10) Risk of suicide,
    (11) Risk of deficiencies regarding social interactions, and
    (12) Special needs (such as regarding medication, diet, nutrition, 
hydration, prosthetics, etc.).
    (c) Coordination of assessment. (1) Each assessment must be 
conducted or coordinated with the appropriate participation of health 
professionals.
    (2) Each person who completes a portion of the assessment must sign 
and certify the accuracy of that portion of the assessment.
    (d) Care plans. (1) The State home must ensure that each 
participant has a care plan. A participant's care plan must be 
individualized and must include measurable objectives and timetables to 
meet all physical, mental, and psychosocial needs identified in the 
most recent assessment. The care plan must describe the following:
    (i) The services that are to be provided as part of the program of 
care and by other sources to attain or maintain the participant's 
highest physical, mental, and psychosocial well-being as required under 
Sec.  51.430;
    (ii) Any services that would otherwise be required under Sec.  
51.430 but are not provided due to the participant's exercise of rights 
under Sec.  51.70, including the right to refuse treatment under Sec.  
51.70(b)(4);
    (iii) Type and scope of interventions to be provided in order to 
reach desired, realistic outcomes;
    (iv) Roles of participant and family/caregiver; and
    (v) Discharge or transition plan, including specific criteria for 
discharge or transfer.
    (2) The services provided or arranged by the State home must:
    (i) Meet professional standards of quality; and
    (ii) Be provided by qualified persons in accordance with each 
participant's care plan.
    (e) Discharge summary. Prior to discharging a participant, the 
State home must prepare a discharge summary that includes:
    (1) A recapitulation of the participant's care;
    (2) A summary of the participant's status at the time of the 
discharge to include items in paragraph (b) of this section; and
    (3) A discharge/transition plan related to changes in service needs 
and changes in functional status that prompted another level of care.

(Authority: 38 U.S.C. 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.430  Quality of care.

    Each participant must receive, and the State home must provide, the 
necessary care and services to attain or maintain the highest 
practicable physical, mental, and psychosocial well-being, in 
accordance with the comprehensive assessment and plan of care.
    (a) Reporting of sentinel events.
    (1) Definition. A ``sentinel event'' is defined in Sec.  
51.120(a)(1).
    (2) Duty to report, review, and prevent sentinel events. The State 
home must comply with the duties to report, review, and prevent 
sentinel events as set forth in Sec.  51.120(a)(3) and (4) except that 
the duty to report applies only to a sentinel event that occurs while 
the participant is under the care of the State home, including while in 
State home-provided transportation.
    (3) Review and prevention of sentinel events. The State home must 
establish a mechanism to review and analyze a sentinel event resulting 
in a written report to be submitted to the VA Medical Center of 
jurisdiction no later than 10 working days after the event. The purpose 
of the review and analysis of a sentinel event is to prevent future 
injuries to participants, visitors, and personnel.
    (b) Activities of daily living. Based on the comprehensive 
assessment of a participant, the State home must ensure that:
    (1) No diminution in activities of daily living. A participant's 
abilities in activities of daily living do not diminish unless the 
circumstances of the individual's clinical condition demonstrate that 
diminution was unavoidable. This includes the participant's ability 
to--
    (i) Bathe, dress, and groom;
    (ii) Transfer and ambulate;
    (iii) Toilet; and
    (iv) Eat.
    (2) Appropriate treatment and services given. A participant is 
given the appropriate treatment and services to maintain or improve his 
or her abilities specified in paragraph (b)(1) of this section.
    (3) Necessary services provided to participant unable to carry out 
activities of daily living. A participant who is unable to carry out 
activities of daily living receives the necessary services to maintain 
good nutrition, hydration, grooming, personal and oral hygiene, 
mobility, and bladder and bowel elimination.
    (c) Mental and Psychosocial functioning. The State home must make 
counseling and related psychosocial services available for improving 
mental and psychosocial functioning of participants with mental or 
psychosocial needs. The services available must include counseling and 
psychosocial services provided by licensed independent mental health 
professionals.
    (d) Medication errors. The State home must comply with Sec.  
51.120(n) with respect to medication errors.

(Authority: 38 U.S.C. 101, 501, 1741-1743)


(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-
XXXX.)


Sec.  51.435  Nursing services.

    The State home must provide an organized nursing service with a 
sufficient number of qualified nursing personnel to meet the total 
nursing care needs, as determined by participant assessment and 
individualized comprehensive plans of care, of all participants in the 
program.
    (a) There must be at least one registered nurse on duty each day of 
operation of the adult day health care program of care. This nurse must 
be currently licensed by the State and must have, in writing, 
administrative authority, responsibility, and accountability for the 
functions, activities, and training of the nursing and program 
assistants.
    (b) The number and level of nursing staff is determined by the 
authorized capacity of participants and the nursing care needs of the 
participants.
    (c) Nurse staffing must be adequate for meeting the standards of 
this part.

(Authority: 38 U.S.C. 501, 1741-1743)

Sec.  51.440  Dietary services.

    The State home must comply with the requirements concerning the 
dietary services set forth in Sec.  51.140. For purposes of this 
section, the references in the cited section to resident refer to a 
participant.

(Authority: 38 U.S.C. 101, 501, 1741-1743)


[[Page 34819]]




Sec.  51.445  Physician services.

    As a condition of enrollment in adult day health care program, a 
participant must have a written physician order for enrollment. If a 
participant's medical needs require that the participant be placed in 
an adult day health care program that offers medical supervision, the 
order for enrollment from the physician must state that. Each 
participant must remain under the care of a physician.
    (a) Physician supervision. If the adult day health care program 
offers medical supervision, the program management must ensure that:
    (1) The medical care of each participant is supervised by a primary 
care physician;
    (2) Each participant's medical record must contain the name of the 
participant's primary physician; and
    (3) Another physician is available to supervise the medical care of 
participants when their primary physician is unavailable.
    (b) Frequency of physician reviews. If the adult day health care 
program offers medical supervision:
    (1) The participant must be seen by the primary physician at least 
annually and as indicated by a change of condition.
    (2) The program management must have a policy to help ensure that 
adequate medical services are provided to the participant.
    (3) At the option of the primary physician, required reviews in the 
program after the initial review may alternate between personal 
physician reviews and reviews by a physician assistant, nurse 
practitioner, or clinical nurse specialist in accordance with paragraph 
(e) of this section.
    (c) Availability of acute care. If the adult day health care 
program offers medical supervision, the program management must provide 
or arrange for the provision of acute care when it is indicated.
    (d) Availability of physicians for emergency care. In case of an 
emergency, the program management must ensure that participants are 
able to obtain emergency care when necessary.
    (e) Physician delegation of tasks. (1) A primary physician may 
delegate tasks to:
    (i) A certified physician assistant or a certified nurse 
practitioner, or
    (ii) A clinical nurse specialist who--
    (A) Is acting within the scope of practice as defined by State law; 
and
    (B) Is under the supervision of the physician.
    (2) The primary physician may not delegate a task when the 
provisions of this part specify that the primary physician must perform 
it personally, or when the delegation is prohibited under State law or 
by the State home's own policies.

(Authority: 38 U.S.C. 101, 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-0160)


Sec.  51.450  Specialized rehabilitative services.

    (a) Provision of services. If specialized rehabilitative services 
such as, but not limited to, physical therapy, speech therapy, 
occupational therapy, and mental health services for mental illness are 
required in the participant's comprehensive plan of care, program 
management must:
    (1) Provide the required services; or
    (2) Obtain the required services and equipment from an outside 
resource, in accordance with Sec.  52.210(h), from a provider of 
specialized rehabilitative services.
    (b) Written order. Specialized rehabilitative services must be 
provided under the written order of a physician by qualified personnel.

(Authority: 38 U.S.C. 101, 501, 1741-1743)

Sec.  51.455  Dental services.

    (a) If the adult day health care program offers medical 
supervision, program management must, if necessary, assist the 
participant and family/caregiver:
    (1) In making appointments; and
    (2) By arranging for transportation to and from the dental 
services.
    (b) If the adult day health care program offers medical 
supervision, program management must promptly assist and refer 
participants with lost or damaged dentures to a dentist.

(Authority: 38 U.S.C. 101, 501, 1741-1743)

Sec.  51.460  Administration of drugs.

    If the adult day health care program offers medical supervision, 
the program management must assist participants with the management of 
medication and have a system for disseminating drug information to 
participants and program staff in accordance with this section.
    (a) Procedures. The State home must:
    (1) Provide reminders or prompts to participants to initiate and 
follow through with self-administration of medications.
    (2) Establish a system of records to document the administration of 
drugs by participants and/or staff.
    (3) Ensure that drugs and biologicals used by participants are 
labeled in accordance with currently accepted professional principles, 
and include the appropriate accessory and cautionary instructions, and 
the expiration dates when applicable.
    (4) Store all drugs, biologicals, and controlled schedule II drugs 
listed in 21 CFR 1308.12 in locked compartments under proper 
temperature controls, permit only authorized personnel to have access, 
and otherwise comply with all applicable State and Federal laws.
    (b) Service consultation. The State home must provide the services 
of a pharmacist licensed in the State in which the program is located 
who provides consultation, as needed, on all the provision of drugs.

(Authority: 38 U.S.C. 101, 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-0160)


Sec.  51.465  Infection control.

    The State home must meet the requirements concerning infection 
control set forth in Sec.  51.190. For purposes of this section, the 
references in the cited section to resident refer to a participant.

(Authority: 38 U.S.C. 501)

Sec.  51.470  Physical environment.

    The State home must ensure that the physical environment is 
designed, constructed, equipped, and maintained to protect the health 
and safety of participants, personnel and the public.
    (a) Life safety from fire. The State home must meet the 
requirements of Sec.  51.200(a), except as to any standard in the 
National Fire Protection Association code that only applies to nursing 
homes.
    (b) Space and equipment. (1) The State home must--
    (i) Provide sufficient space and equipment in dining, health 
services, recreation, and program areas to enable staff to provide 
participants with needed services as required by these standards and as 
identified in each participant's plan of care; and
    (ii) Maintain all essential mechanical, electrical, and patient 
care equipment in safe operating condition.
    (2) Each adult day health care program of care, when it is co-
located in a nursing home, domiciliary, or other care facility, must 
have its own separate designated space during operational hours.
    (3) The indoor space for adult day health care must be at least 100 
square feet per participant including office space for staff and must 
be 60 square feet per participant excluding office space for staff.
    (4) Each program of care will need to design and partition its 
space to meet its

[[Page 34820]]

own needs, but the following functional areas must be available:
    (i) A dividable multipurpose room or area for group activities, 
including dining, with adequate table-setting space.
    (ii) Rehabilitation rooms or an area for individual and group 
treatments for occupational therapy, physical therapy, and other 
treatment modalities.
    (iii) A kitchen area for refrigerated food storage, the preparation 
of meals and/or training participants in activities of daily living.
    (iv) An examination and/or medication room.
    (v) A quiet room (with a bed or a reclining chair), which functions 
to separate participants who become ill or disruptive, or who require 
rest, privacy, or observation. It should be separate from activity 
areas, near a restroom, and supervised.
    (vi) Bathing facilities adequate to facilitate bathing of 
participants with functional impairments.
    (vii) Toilet facilities and bathrooms easily accessible to people 
with mobility problems, including participants in wheelchairs. There 
must be at least one toilet for every eight participants. The toilets 
must be equipped for use by persons with limited mobility, easily 
accessible from all programs areas, i.e., preferably within 40 feet 
from that area, designed to allow assistance from one or two staff, and 
barrier-free.
    (viii) Adequate storage space. There should be space to store arts 
and crafts materials, wheelchairs, chairs, individual handiwork, and 
general supplies. Locked cabinets must be provided for files, records, 
supplies, and medications.
    (ix) An individual room for counseling and interviewing 
participants and family members.
    (x) A reception area.
    (xi) An outside space that is used for outdoor activities that is 
safe, accessible to indoor areas, and accessible to those with a 
disability. This space may include recreational space and garden area. 
It should be easily supervised by staff.
    (c) Furnishings. Furnishings must be available for all 
participants. This must include functional furniture appropriate to the 
participants' needs. Furnishings must be attractive, comfortable, and 
homelike, while being sturdy and safe.
    (d) Participant call system. The coordinator's station must be 
equipped to receive participant calls through a communication system 
from:
    (1) Clinic rooms; and
    (2) Toilet and bathing facilities.
    (e) Other environmental conditions. The State home must provide a 
safe, functional, sanitary, and comfortable environment for the 
participants, staff and the public. The facility management must:
    (1) Establish procedures to ensure that water is available to 
essential areas if there is a loss of normal water supply;
    (2) Have adequate outside ventilation by means of windows, or 
mechanical ventilation, or a combination of the two;
    (3) Equip corridors, when available, with firmly-secured handrails 
on each side; and
    (4) Maintain an effective pest control program so that the facility 
is free of pests and rodents.

(Authority: 38 U.S.C. 101, 501, 1741-1743)

Sec.  51.475  Administration.

    For purposes of this section, the references in the cited section 
to nursing home and nursing home care refer to adult day health care 
programs and adult day health care. The State home must comply with all 
administration requirements set forth in Sec.  51.210 except for the 
following if the adult day health care program does not offer medical 
supervision:
    (a) Medical director. State home adult day health care programs are 
not required to designate a primary care physician to serve as a 
medical director, and therefore are not required to comply with Sec.  
51.210(i).
    (b) Laboratory services, radiology, and other diagnostic services. 
State home adult day health care programs are not required to provide 
the medical services identified in Sec.  51.210(m) and (n).
    (c) Quality assessment and assurance committee. State home adult 
day health care programs are not required to comply with Sec.  
51.210(p), regarding quality assessment and assurance committees 
consisting of specified medical providers and staff.

(Authority: 38 U.S.C. 501, 1741-1743)



(The Office of Management and Budget has approved the information 
collection requirements in this section under control number 2900-0160)


Sec.  51.480  Transportation.

    Transportation of participants to and from the adult day health 
care facility must be a component of the overall program of care.
    (a)(1) Except as provided in paragraph (a)(2) of this section, the 
State home must provide for transportation to enable participants, 
including persons with disabilities, to attend the program and to 
participate in State home-sponsored outings.
    (2) The veteran or the family of a veteran may decline 
transportation offered by the adult day health care program of care and 
make their own arrangements for the transportation.
    (b) The State home must have a transportation policy that includes 
procedures for routine and emergency transportation. All transportation 
(including that provided under contract) must be in compliance with 
such procedures.
    (c) The State home must ensure that the transportation it provides 
is done by drivers who have access to a device for two-way 
communication.
    (d) All systems and vehicles used by the State home to comply with 
this section must meet all applicable local, State and federal 
regulations.
    (e) The State home must ensure that the care needs of each 
participant are addressed during transportation furnished by the home.

(Authority: 38 U.S.C. 101, 501, 1741-1743)

PART 52--[REMOVED]

0
8. Remove part 52.

[FR Doc. 2015-13838 Filed 6-16-15; 8:45 am]
 BILLING CODE 8320-01-P