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

VA Form 10-5588 or the "State Home Report And Statement Of Federal Aid Claimed" is a form issued by the United States Department of Veterans Affairs.

The latest fillable PDF version of the VA 10-5588 was issued on November 1, 2016 and can be downloaded down below or found on the Veterans Affairs Forms website.

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OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
EXP: 02/28/2019
VA FORM 10-5588
STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
1. GENERAL INFORMATION
1. STATION
2. VISN
3. MONTH/
4. REPORT
NUMBER
YEAR
QUARTER
Enter VA Facility
Enter Name & Address of State Home
5. TO:
6. FROM:
7. PAY TO:
2. CHANGE IN RESIDENCY FOR THE MONTH
ADULT DAY
LINE
ITEM
DOMICILIARY
NURSING HOME CARE
HEALTH CARE
NO
(A)
(B)
(C)
TOTAL VETERAN RESIDENTS PRESENT IN
8.
FACILITY AT END OF PRIOR MONTH
9.
ADMISSIONS (Change of Status)
10.
ADMISSIONS (Other)
11.
RETURN FROM LEAVE OF ABSENCE
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12.
DISCHARGES (Change of Status)
13.
DISCHARGES (Other)
14.
DEATH
15.
LEAVE OF ABSENCE
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16. TOTAL VETERAN RESIDENTS PRESENT AT END OF THE MONTH
3. STATUS AT THE END OF THE MONTH
ADULT DAY
LINE
ITEM
DOMICILIARY
NURSING HOME CARE
HEALTH CARE
NO
(A)
(B)
(C)
TOTAL NON-ELIGIBLE VETERAN AND CIVILIAN RESIDENTS
17.
REMAINING AT THE END OF THE MONTH
TOTAL NURSING HOME CARE VETS THAT ARE 70%-100% SC OR
18.
IN NEED OF NURSING HOME CARE FOR SC CONDITION
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FEMALE VETERAN RESIDENTS REMAINING AT THE END OF THE
19.
MONTH
4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
ADULT DAY
LINE
ITEM
DOMICILIARY
NURSING HOME CARE
HEALTH CARE
NO
(A)
(B)
(C)
TOTAL DAYS OF CARE FURNISHED TO NON ELIGIBLE VETERANS
20.
AND CIVILIANS
5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
DIRECT AND
DAILY COST OF
TOTAL
FEDERAL AID CLAIMED UNDER
LINE
AVERAGE DAILY
INDIRECT
CARE FOR THE
PER DIEM
AMOUNT
SEC 1741, TITLE 38, U.S.C.,
NO
DAYS OF CARE
CENSUS
COST
MONTH
CLAIMED
CLAIMED
AS AMMENDED
(A)
(B)
(C)
(D)
(E)
(F)
21. DOMICILIARY CARE
22. NURSING HOME CARE
23. ADULT DAY HEALTH CARE
24. TOTAL AMOUNT CLAIMED
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6. CLAIM FOR SC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
TOTAL
LINE
AVERAGE DAILY
PREVAILING
AMOUNT
VETERAN CATEGORY
NO
DAYS OF CARE
CENSUS
RATE
CLAIMED
(A)
(B)
(C)
(D)
25. HAS A SINGULAR OR COMBINED RATING OR 70% OR MORE BASED
ON 1 OR MORE SC DISABILITIES OR A RATING OR TOTAL
DISABILITY BASED ON INDIVIDUAL UNEMPLOYABILITY
26
IS IN NEED OF NH CARE FOR A VA ADJUDICATED SC DISABILITY
27. TOTAL AMOUNT CLAIMED
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VA FORM
SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.
10-5588
NOV 2016
Page of
OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
EXP: 02/28/2019
VA FORM 10-5588
STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
1. GENERAL INFORMATION
1. STATION
2. VISN
3. MONTH/
4. REPORT
NUMBER
YEAR
QUARTER
Enter VA Facility
Enter Name & Address of State Home
5. TO:
6. FROM:
7. PAY TO:
2. CHANGE IN RESIDENCY FOR THE MONTH
ADULT DAY
LINE
ITEM
DOMICILIARY
NURSING HOME CARE
HEALTH CARE
NO
(A)
(B)
(C)
TOTAL VETERAN RESIDENTS PRESENT IN
8.
FACILITY AT END OF PRIOR MONTH
9.
ADMISSIONS (Change of Status)
10.
ADMISSIONS (Other)
11.
RETURN FROM LEAVE OF ABSENCE
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12.
DISCHARGES (Change of Status)
13.
DISCHARGES (Other)
14.
DEATH
15.
LEAVE OF ABSENCE
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16. TOTAL VETERAN RESIDENTS PRESENT AT END OF THE MONTH
3. STATUS AT THE END OF THE MONTH
ADULT DAY
LINE
ITEM
DOMICILIARY
NURSING HOME CARE
HEALTH CARE
NO
(A)
(B)
(C)
TOTAL NON-ELIGIBLE VETERAN AND CIVILIAN RESIDENTS
17.
REMAINING AT THE END OF THE MONTH
TOTAL NURSING HOME CARE VETS THAT ARE 70%-100% SC OR
18.
IN NEED OF NURSING HOME CARE FOR SC CONDITION
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FEMALE VETERAN RESIDENTS REMAINING AT THE END OF THE
19.
MONTH
4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
ADULT DAY
LINE
ITEM
DOMICILIARY
NURSING HOME CARE
HEALTH CARE
NO
(A)
(B)
(C)
TOTAL DAYS OF CARE FURNISHED TO NON ELIGIBLE VETERANS
20.
AND CIVILIANS
5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
DIRECT AND
DAILY COST OF
TOTAL
FEDERAL AID CLAIMED UNDER
LINE
AVERAGE DAILY
INDIRECT
CARE FOR THE
PER DIEM
AMOUNT
SEC 1741, TITLE 38, U.S.C.,
NO
DAYS OF CARE
CENSUS
COST
MONTH
CLAIMED
CLAIMED
AS AMMENDED
(A)
(B)
(C)
(D)
(E)
(F)
21. DOMICILIARY CARE
22. NURSING HOME CARE
23. ADULT DAY HEALTH CARE
24. TOTAL AMOUNT CLAIMED
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6. CLAIM FOR SC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
TOTAL
LINE
AVERAGE DAILY
PREVAILING
AMOUNT
VETERAN CATEGORY
NO
DAYS OF CARE
CENSUS
RATE
CLAIMED
(A)
(B)
(C)
(D)
25. HAS A SINGULAR OR COMBINED RATING OR 70% OR MORE BASED
ON 1 OR MORE SC DISABILITIES OR A RATING OR TOTAL
DISABILITY BASED ON INDIVIDUAL UNEMPLOYABILITY
26
IS IN NEED OF NH CARE FOR A VA ADJUDICATED SC DISABILITY
27. TOTAL AMOUNT CLAIMED
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VA FORM
SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.
10-5588
NOV 2016
Page of
OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
I certify that this report is correct based on the documentation provided to the VA and that the bed capacity approved by the VA is correct.
7. BED CAPACITY APPROVED BY THE VA
28.
DOMICILIARY
29.
NURSING HOME CARE
30.
ADULT DAY HEALTH CARE
(A)
(B)
(C)
8. TOTAL STATE OPERATING BEDS AT THE END OF THE MONTH
31.
DOMICILIARY
32.
NURSING HOME CARE
33.
ADULT DAY HEALTH CARE
(A)
(B)
(C)
The daily cost of care is the direct cost plus the indirect cost for the month, divided by the total days of care of all enrollees or residents present in the
facility during the month regardless of the payer source. Compute the cost in accordance with Office of Management and Budget (OMB) cost principles
set forth in 2 CFR 225 (A-87) Cost Principles for State, Local, and Indian Tribal Governments (dated - August 2005).
9. STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CONTINUED
I certify that this report is correct, that all residents included in the report were physically present during the period for which Federal aid is claimed,
except for authorized absences for which the VA paid per diem, and the facility management has complied with all provisions of Title VI, Public Law
88-352, entitled Civil Rights Act of 1964.
Printed Name & Title:
34.
Signature of
SVH Administrator
Signature:
Date:
Printed Name & Title:
35.
Signature of State
Employee when Applicable
Signature:
Date:
36. Remarks:
Note: If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility
on a full-time, on site basis. This State employee must also certify that the information in the report is correct by signing and dating the report.
10. RECEIVING REPORT
37. TOTAL AMOUNT APPROVED BY VA FOR PAYMENT
(add blocks 24(F) and 27(D)
Services authorized under
38. SIGNATURE AND TITLE OF THE VA STATE HOME APPROVING OFFICIAL
provisions of section 1741,
1742, 1743, and 1745, Title
38, U.S.C., have been
Printed Name & Title:
rendered in the quantity
claimed and payment is
Signature:
Date:
recommended except as
follows.
39. ACCOUNTING CERTIFICATION - AUDIT BLOCK
Obligation Number
* Amount Due
(A)
(B)
40. Auditor signature and
ADHC
date
DOM
Date:
NHC BASIC
NHC P1/PREVAILING RATE
Signature of Auditor
Total Amount Due
PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995.
We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who
must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA
will be unable to provide reimbursement for services rendered without a completed form. Failure to complete the form will have no effect on any other benefits to which you maybe entitled. This
information is collected under the authority Of Title 38 CFR Parts 51 and 52. The information requested on this form is solicited under the authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is
being collected to enable us to determine your eligibility for medical benefits in the State Home Program and will be used for that purpose. The income and eligibility you supply may be verified through a
computer matching program at any time and information may be disclosed outside the VA as permitted by law; possible disclosures include those described in the "routine uses" identified in the VA
system of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary; however, the information is required in
order for us to determine your eligibility for the medical benefit for which you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be entitled.
Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the
administration of veterans benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title 38,
U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
VA FORM
SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.
10-5588
NOV 2016
Page of
OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
VA FORM 10-5588
INSTRUCTIONS FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID
CLAIMED
The VA Form 10-5588 consists of several parts. This report is a monthly statement of gains and losses, days of care, average daily census, allowable
cost, total per diem cost, per diem claimed and total amount claimed for nursing home, domiciliary, and adult day health care. Monthly payments will
be made to the State Home only after the State submits a completed VA Form 10-5588 and required supporting documentation.
1. GENERAL INSTRUCTIONS
VA Employees:
1. Station Number: Enter the station number where the VA Medical Center of jurisdiction is located.
2. VISN: Enter the Veteran Integrated Service Network (VISN) number where the VA Medical Center of jurisdiction is located.
State Home Employees:
3. Month/Year: Enter the calendar month and year covered by the report. (example: 05/2015).
4. Report Quarter: Enter the Report Quarter (Quarter 1: Oct to Dec, Quarter 2: Jan to Mar; Quarter 3: Apr to Jun; Quarter 4: Jul to Sep)
5. TO: Enter the Veteran Affairs Facility this report is submitted to.
6. From: Enter the State Veterans Home this Reports is submitted from.
7. Pay To: Enter to who the payment is to be made.
2. CHANGE IN RESIDENCY FOR THE MONTH
8. Enter the Total Veteran Residents Present in the Facility at the end of the prior month.
Column a. Domiciliary: Enter the number of eligible domiciliary Veteran residents present and remaining on the rolls as of midnight on the last day
of the prior month. When a Veteran overstays an approved absence of 96 hours, no portion of the leave may be claimed for VA payment. Note:
Present means any eligible Veteran that is physically in the SVH facility at midnight or on an approved paid VA leave of absence.
Column b. Nursing Home: Enter the number of eligible nursing home Veteran residents present and remaining on the rolls as of midnight on the
last day of the prior month, as well as, the number of Veterans who were on a VA approved bed hold for overnight hospital stays or non-hospital leave
and eligible for VA nursing home payments on the last day of the prior month.
Column c. Adult Day Health Care: Enter the number of eligible adult day health care occupants on the rolls for receiving adult day health care
services as of midnight the last day of the prior month. Per diem will be paid only for a day that the Veteran is under the care of the facility at least six
hours. For purposes of this paragraph a day means six hours or more in one calendar day or any two periods of at least 3 hours each (but each less
than six hours) in any two calendar days in a calendar month.
Entries on this line will be the same as those shown on line 16 for the prior month.
9. Admissions (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer from one level of care to another
within the State Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health care. The entries on
lines 9 and 12 for the month will be the same.
10. Admission (Other). Enter the number of eligible Veterans admitted to the State Home nursing home, domiciliary during the report month and/or
enrolled in the adult day health care.
11. Return From Leave of Absence. Enter eligible Veterans returning from a non-VA paid overnight absence in a VA hospital or other hospital and for
Veterans returning from an overnight absence for non-hospital leave and for domiciliary residents returning from absences of greater than 96 hours.
Applicable when a Veteran is absent from the home on a non-VA paid absence and/or does not return to the home. DO NOT report leave of absence
for which the VA paid per diem.
12. Discharges (Change of Status). Enter the number of eligible Veterans whose status was changed by transfer to another level of care within the
State Home. Change in level of care is referring to transfers between domiciliary, nursing home, and adult day health care. The entries on lines 9 and
12 for the month will be the same.
13. Discharges (Other). Enter the number of eligible Veterans who were discharged from the State Home or dropped from the rolls, except for deaths.
Do not count discharges for hospitalizations. Applicable when a Veteran on a VA-paid bed hold for overnight hospital stays or non-hospital leave,
does not return to the nursing home.
The effective date of discharge will be the date the home is notified the Veteran will not return.
14. Deaths. Enter the number of eligible Veterans who died while enrolled in the State Home Per Diem program during the report month.
15. Leave Of Absence. For Nursing Home Care beds, enter the number of eligible Veterans who have a non-VA paid overnight stay in a VA hospital
or other hospital or who are absent for reasons other than hospital care. DO NOT report leave of absence for which the VA paid per diem i.e. bed
holds, 10 consecutive days of leave for hospitalization or 12 days for non-hospital leave granted to nursing home residents in a calendar year.
For Domiciliary Care beds, enter the number of eligible Veterans who have an overnight stay in a VA hospital or other hospital at VA expense and
when a domiciliary residents is absent more than 96 hours.
VA FORM
SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.
10-5588
NOV 2016
Page of
OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
VA FORM 10-5588
INSTRUCTIONS-CONTINUED
FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
Note: Per diem payments for bed holds are authorized when the nursing home occupancy rate is 90% or above: In those instances where the nursing
home daily occupancy rate falls below 90%, the State Home is not eligible for bed hold per diem. The Veteran should be listed as on leave of absence
from the State Home facility and recorded on line 15. If the facility occupancy rate returns to 90% or greater and the Veteran is still absent, this
constitutes a return from leave of absence and should be noted on line 11 for VA to resume VA per diem payments. If a Veteran has not returned to
the home after 10 consecutive days for hospital leave or 12 days for non hospital leave, count the Veteran on line 8 as being absent from the facility.
A Veteran may have more than one 10 consecutive day episode of hospital leave in a calendar year, provided the Veteran has an overnight stay in the
SVH between each period of hospitalization; but no more than 12 days of non-hospital leave within a calendar year. (Not applicable to domiciliary or
adult health care program).
16. Total Veteran Residents Present at End of Month. Enter the number of eligible Veteran residents present as of midnight on the last day of the
report month. Additionally, count eligible nursing home care Veterans who are on VA paid leave of absence for hospitalization and for non-hospital
absences and count domiciliary Veterans who are absent from the facility on a VA paid pass of 96 hours or less. This entry will be equal to the sum of
lines 8, 9, 10 and 11 minus lines 12, 13, 14 and 15.
3. STATUS AS OF THE END OF THE MONTH
17. Non-Eligible Veterans And Civilians Remaining End Of Month. Enter the number of nursing home, domiciliary residents, and adult day health
care enrollees not eligible for payment from VA who was present on the last day of the report month. DO NOT REPORT eligible Veteran residents in
this cell.
18. Total Nursing Home Care Veterans who Are 70% to 100% service connected or in need of nursing home care for a service connected condition.
Enter the total number of eligible nursing home Veterans who are 70% to 100% service connected or in need of nursing home care for a service-
connected condition and also include Veterans who have a VA rating of Total Disability based on Individual Unemployability.
19. Eligible Female Veteran Residents Remaining At The End Of The month. Enter the number of eligible female Veteran residents present and
remaining in the facility at the end the month.
4. TOTAL DAYS FURNISHED TO NON ELIGIBLE VETERANS AND CIVILIANS FOR THE MONTH
20. Total Days of Care Furnished to Non Eligible Veterans and Civilians. Enter all days of care provided to non-eligible Veterans and civilians for
domiciliary care, nursing home care and adult day health care in blocks 20A, 20B, and 20C respectively. Do not count any overnight absence from the
facility such as private paid bed holds as a day of care.
5. CLAIM FOR BASIC PER DIEM PAYMENTS FOR ELIGIBLE VETERANS
Lines 21, 22, 23 and 24:
Column a. Days of Care: A day of care is counted when an eligible Veteran has an overnight stay in the facility. Enter total domiciliary days of care
on line 21, nursing home care on line 22 and adult day health care on line 23. For nursing home beds: A day of care is also counted when the VA is
paying per diem for an eligible Veteran resident on bed hold for 10 consecutive overnight hospital stays or 12 non-hospital leave.
For domiciliary beds: A day of care is counted when an eligible Veteran is present in the facility for any portion of the day or absent from the facility
up to 96 hours. If a Veteran is absent more than 96 hours, no portion of the absence is counted as a day of care.
For adult day health care, a day of
care is credited when the Veteran is under the care of the facility at least six hours in one calendar day or any two periods of at least 3 hours each (but
each less than six hours) in any two calendar days in a calendar month. The day of admission is counted as a day of care. An admission and loss on
the same day is counted as a day of care. Day of discharge (removed from the rolls) is not counted as a day of care.
Column b. Average Daily Census: Enter the average daily census computed by dividing the days of care in column A by the number of calendar
days in the month, carried to one decimal place for each level of care.
Column c. Direct and Indirect Cost (Allowable Cost): Enter the total of direct and indirect cost (allowable cost) for providing care to all residents in
the home for the month regardless of the payer source.
Column d. Daily Cost of Care for the Month: The daily cost of care for the month is the direct cost plus the indirect (allowable) cost, divided by ALL
residents' days of care. Compute cost in accordance with cost principles set forth in the Office of Management and Budget (OMB) Circular number 2
CFR 200 (formerly A- 87), (dated 12/26/2013), "Uniform Administrative Requirements, Cost Principles, and Audit Requirement in Federal Awards" (2
CFR Part 200.400 to 475 for cost principles). Divide the direct and indirect cost for the month in column C by the sum of days of care on lines 20 and
21 for each level of care provided.
Column e. Per Diem Claimed: Enter the current fiscal year per diem rate or one-half the daily cost of care shown in column D carried to two decimal
places, whichever is the lesser, for each level of care. VA will pay monthly one-half of the cost of each eligible Veteran's care (domiciliary, nursing
home, or adult day health care) for each day the Veteran is in a facility recognized as a State home, not to exceed the approved per diem rate for that
level of care.
Column f. Total Amount Claimed: Enter the product of columns A and E for each level of care on lines 21, 22, and 23. On line 24, sum the totals
for each level of care.
VA FORM
SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.
10-5588
NOV 2016
Page of
OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
VA FORM 10-5588
INSTRUCTIONS-CONTINUED
FOR STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED
6. CLAIM FOR PAYMENTS FOR SERVICE CONNECTED VETERANS IN STATE NURSING HOME SECTION UNDER A PROVIDER
AGREEMENT or CONTRACT
Lines 25, 26 and 27:
Column a. Days of Care: A day of care is counted when an eligible Veteran has an overnight stay in the facility. For nursing home beds: A day of
care is also counted when the VA is paying per diem for an eligible Veteran resident on bed hold for 10 consecutive overnight hospital stays or 12 days
for non-hospital leave. Line 25 represents eligible nursing home Veteran residents who have a singular or combined service connection rating of 70%
or greater or has a VA rating of total disability based on Individual Unemployability. Line 26 represents eligible Veteran residents who require nursing
home care due to a service-connected disability. A day of care is counted for a Veteran on the day the Veteran is admitted to the SVH. An
admission (gain) and loss on the same day is counted as a day of care. Day of discharge is not counted as a day of care. Sum lines 25 and 26 on line
27.
Column b. Average Daily Census: Enter the average daily census computed by dividing the days of care in column A for each level of care by the
number of calendar days in the month, carried to one decimal place.
Column c. Prevailing Rate: Enter the VA prevailing rate for your geographical area from the chart for the current Fiscal Year.
Column d. Total Amount Claimed: Using the VA prevailing rate methodology, multiply the days of care from line 25 and 26 in column A by the
prevailing rate in column C.
7. BED CAPACITY APPROVED BY THE VA: At the end of each month, State home management will enter the bed capacity approved during the
latest recognition survey for domiciliary, nursing home and adult day health care in blocks 28, 29 and 30 respectively.
8. TOTAL STATE OPERATING BEDS AT THE END OF THE MONTH: At the end of each month, State Home management will enter the total
operating beds at the end of the month for domiciliary, nursing home, and adult day health care in blocks 31, 32 and 33 respectively. The VA approved
bed capacity and the operating beds should be the same number of beds. If operating beds are closed for any reason, facility management must
notify the VA Geriatrics and Extended Care Operations Office (GEC) that indicates the date of closure, expected date the beds will be operational, type
of bed (domiciliary, nursing home), or slot-adult day health care, and the reason for the closure. Please specify if these beds were constructed with
federal funds. Information related to closed beds may be entered under "Remarks".
9. STATE HOME REPORT AND STATEMENT OF FEDERAL AID CLAIMED CERTIFICATION
34. Signature of SVH Administrator: Print name and title of SVH Home Administrator, sign and date.
35. Signature of State Employee When Applicable: If the facility is managed by a contractor, a State Employee must print name and title, sign and
date. If the facility is under contract, the signature of the SVH Administrator is not required.
Note: If the facility is operated by an entity contracting with the State, the State must assign a State employee to monitor the operations of the facility
on a full-time, on site basis. This State employee must also certify that the information in the report is correct by signing and dating the report.
36.
Remarks:
10. RECEIVING REPORT
37. Total Amount Approved by VA for Payment: Sum the totals of blocks 24 and 27.
38. Signature of the VA State Home Approving Official: Print name and title of approving official, sign and date.
39. Accounting Certification-Audit Block: In column A enter obligation numbers for each level of payment claimed and in column B enter amount due
for each level of payment claimed.
Total Amount Due: Sum the amount due in column B and enter in the Total Amount Due. This sum should be equal to the amount entered on line 34
of the receiving report.
Auditor Signature and Date: Auditor sign and date report
Note: If the receiving report is not completed in its entirety, it could result in an improper payment.
VA FORM
SUPERSEDES VA FORM 10-5588, JUN 2009, WHICH WILL NOT BE USED.
10-5588
NOV 2016
Page of

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