VA Form 10-3567: State Home Staffing Profile Guide

VA Form 10-3567: State Home Staffing Profile Guide – State Veterans Homes (SVHs) provide essential nursing home, domiciliary, and adult day health care services to eligible veterans across the United States. The U.S. Department of Veterans Affairs (VA) ensures quality care through annual inspections and per diem payments. A critical document in this process is VA Form 10-3567, officially titled State Home Inspection—Staffing Profile.

This comprehensive guide explains the form’s purpose, how to complete it, its role in VA certification, and why accurate staffing documentation matters for facilities serving veterans.

What Is VA Form 10-3567?

VA Form 10-3567 is a standardized staffing profile used during VA inspections of State Veterans Homes. It documents the facility’s operating beds, patient census, authorized staffing levels (FTEE), and detailed nursing care hours per patient per day across different levels of care: Adult Day Health Care (ADHC), Nursing Home Care (NHC), and Domiciliary (DOM).

The current version (December 2023) has an OMB Control Number 2900-0883 and an estimated completion time of 30 minutes. It expires on December 31, 2026.

Facilities use this form to demonstrate compliance with VA regulations under Title 38 CFR Parts 51.30 and 52.30, which govern staffing and care standards in state homes.

Purpose of the State Home Inspection Staffing Profile

The primary purpose of VA Form 10-3567 is to provide VA surveyors with a clear snapshot of a State Veterans Home’s staffing resources and patterns at the time of inspection. This helps verify that the facility maintains adequate staffing to deliver safe, high-quality care to veterans and non-veterans.

Key objectives include:

  • Calculating direct nursing care hours per patient per day.
  • Ensuring alignment between authorized beds, actual census, and available Full-Time Employee Equivalents (FTEE).
  • Supporting VA’s per diem payment decisions and facility certification.
  • Identifying potential staffing gaps that could affect resident care quality.

Accurate completion is mandatory for certification. Without it, VA cannot fully certify the home for per diem payments.

Who Must Complete VA Form 10-3567?

Administrators and staff at State Veterans Homes (SVHs) complete this form during annual VA inspections. As of June 2026, there are approximately 177 State Veterans Homes nationwide, including 171 nursing homes, 47 domiciliaries, and 3 adult day health care programs.

These facilities are state-owned and operated but must meet VA standards to receive federal per diem support for eligible veteran residents. The form applies to all levels of care provided.

How to Fill Out VA Form 10-3567: Step-by-Step Instructions?

The form consists of five parts. Follow the official instructions carefully to avoid errors during inspection.

Part I: Facility Overview

Record totals and breakdowns for:

  • Operating Beds / Participant Slots
  • Authorized Approvals (VA-recognized for per diem)
  • Patient Census (veterans + non-veterans)
  • FTEE Authorized
  • FTEE Available

Break down by ADHC, NHC, and DOM. Use precise definitions provided in the form instructions.

Part II: Staff Positions

List FTEE for various roles across the total facility and each level of care, including:

  • Physicians, PAs, Dentists
  • Social Workers (MSW/BSW)
  • Registered Nurses, LPNs/LVNs, CNAs
  • Therapists (PT, OT, Speech), Dietitians, Pharmacists, and others

Include contract and agency staff.

Parts III–V: Nursing Staffing Patterns (Four-Week Average)

For each level of care (ADHC, Nursing Home, Domiciliary):

  • Select 4 random one-week schedules from the previous 12 months (one must include a holiday).
  • Calculate average hours for RN, LPN, and CNA by shift and day.
  • Compute total direct care nursing hours and the hours per patient per day using the provided formula.

Note: The form uses 8-hour shift equivalents. Adjust longer shifts accordingly. If multiple buildings exist, average data or use separate pre-work forms.

Download VA Form 10-3567 PDF

You can download the latest fillable version directly from the official VA website:

Download VA Form 10-3567 (PDF)

Always use the most current form from va.gov for inspections.

Importance of Staffing Compliance in State Veterans Homes

Proper staffing documentation via VA Form 10-3567 supports:

  • Resident Safety and Quality of Care — Adequate RN, LPN, and CNA hours directly impact clinical outcomes.
  • VA Certification and Funding — Non-compliance can delay or jeopardize per diem payments.
  • Regulatory Alignment — Meets standards under 38 CFR Parts 51 and 52.
  • Overall Program Oversight — Helps VA monitor the network of State Veterans Homes serving thousands of veterans.

VA conducts comprehensive annual surveys covering clinical care, life safety, and financial operations. Staffing data is a key component.

Tips for Successful Completion and Inspection Preparation

  • Gather payroll and schedule data in advance.
  • Ensure averages accurately reflect real staffing patterns.
  • Double-check calculations for nursing hours per patient per day.
  • Maintain supporting documentation for all entries.
  • Coordinate with your facility’s VA survey team for any questions.

State homes often achieve strong CMS star ratings, reflecting effective staffing practices.

Conclusion

VA Form 10-3567 is more than paperwork—it’s a vital tool ensuring State Veterans Homes maintain the staffing levels needed to honor and care for America’s veterans. Accurate completion demonstrates commitment to quality and compliance with VA standards.

Facility administrators should treat this form as a priority during inspection preparation. For the latest guidance, always refer to official VA sources.

This article is for informational purposes only and is not a substitute for official VA instructions or legal advice. Consult the VA or your state veterans home administration for specific requirements.