83 FR 14804 - Definition of Domiciliary Care

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 83, Issue 67 (April 6, 2018)

The Department of Veterans Affairs (VA) proposes to amend its rule defining domiciliary care, to accurately reflect the scope of services currently provided under the Domiciliary Care Program. VA's Domiciliary Care Program provides a temporary home to certain veterans, which includes the furnishing of shelter, goods, clothing and other comforts of home, as well as medical services. In 2005 VA designated its Mental Health Residential Rehabilitation Treatment Program (MH RRTP) as a type of domiciliary care. MH RRTP provides clinically intensive residential rehabilitative services to certain mental health patient populations. We propose to amend the definition of domiciliary care to reflect that domiciliary care includes MH RRTP. In addition, VA domiciliary care, as a matter of long-standing practice, includes non-permanent housing, but this is not clear in the regulation. The proposed rule would clarify that domiciliary care provides temporary, not permanent, residence to affected veterans.

[Federal Register Volume 83, Number 67 (Friday, April 6, 2018)]
[Proposed Rules]
[Pages 14804-14807]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2018-07082]


-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AP00


Definition of Domiciliary Care

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

-----------------------------------------------------------------------

SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its 
rule defining domiciliary care, to accurately reflect the scope of 
services currently provided under the Domiciliary Care Program. VA's 
Domiciliary Care Program provides a temporary home to certain veterans, 
which includes the furnishing of shelter, goods, clothing and other 
comforts of home, as well as

[[Page 14805]]

medical services. In 2005 VA designated its Mental Health Residential 
Rehabilitation Treatment Program (MH RRTP) as a type of domiciliary 
care. MH RRTP provides clinically intensive residential rehabilitative 
services to certain mental health patient populations. We propose to 
amend the definition of domiciliary care to reflect that domiciliary 
care includes MH RRTP. In addition, VA domiciliary care, as a matter of 
long-standing practice, includes non-permanent housing, but this is not 
clear in the regulation. The proposed rule would clarify that 
domiciliary care provides temporary, not permanent, residence to 
affected veterans.

DATES: Comment Date: Comments on the proposed rule must be received by 
VA on or before June 5, 2018.

ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand delivery to the Director, 
Regulation Policy and Management (00REG), Department of Veterans 
Affairs, 810 Vermont Avenue NW, Room 1063B, Washington, DC 20420; or by 
fax to (202) 273-9026. Comments should indicate that they are submitted 
in response to ``RIN 2900-AP00--Definition of Domiciliary Care.'' 
Copies of comments received will be available for public inspection in 
the Office of Regulation Policy and Management, Room 1063B 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 at 
www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Jamie R. Ploppert, National Director, 
Mental Health Residential Treatment Programs (10P4M), Veterans Health 
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, 
Washington, DC 20420 or (757) 722-9991 extension 1123. (This is not a 
toll-free number.)

SUPPLEMENTARY INFORMATION: Title 38, United States Code (U.S.C.), 
section 1710(b)(2) authorizes VA to provide needed domiciliary care to 
veterans whose annual income does not exceed the applicable maximum 
annual rate of VA pension and to veterans who have no adequate means of 
support. The term ``domiciliary care'' is currently defined at 38 Code 
of Federal Regulations (CFR) 17.30(b) as the furnishing of a home to a 
veteran, embracing the furnishing of shelter, food, clothing and other 
comforts of home, including necessary medical services, as well as 
travel and incidental expenses pursuant to 38 CFR 70.10. Veterans must 
meet eligibility criteria found in Sec.  17.46(b) as well as Sec.  
17.47(b)(2) and (c) to receive domiciliary care.
    The domiciliary program was authorized to provide eligible veterans 
with a home and coordinated ambulatory medical care as needed. 
Typically, domiciliaries are co-located with VA medical centers or 
exist as designated bed-settings within the centers. By law, eligible 
veterans include only: Those 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) those who have no adequate means of support, 
as this phrase is defined in 38 CFR 17.47(b)(2), who can perform the 
activities specified in 38 CFR 17.46(b) but who suffer from a chronic 
disability, disease, or defect that results in the veteran being unable 
to earn a living for a prospective period. See 38 CFR 17.47 (b)(2) and 
(c).
    VA domiciliaries served initially as ``Soldiers' Homes'' for 
economically-disadvantaged Veterans with chronic medical needs that can 
be addressed on an outpatient basis. Domiciliary care provides services 
to economically-disadvantaged veterans, and VA remains committed to 
serving that group. Historically, domiciliary care in VA has primarily 
been focused on delivering care to older residents who cannot live 
independently but who do not require admission to a nursing home. 
However, ``domiciliary care'' has expanded to also provide services to 
veterans who require residential rehabilitation treatment for mental 
health or substance use issues. While the above-referenced statutory 
definitions and eligibility criteria still apply as do the regulatory 
criteria of Sec. Sec.  17.46(b) and 17.47(b)(2), the scope of services 
furnished under the program has evolved significantly, requiring 
revision of Sec.  17.30(b) and Sec.  17.47(c). We propose to amend the 
definition of domiciliary care to reflect that change.
    The scope of clinical services available to VA domiciliary 
residents has necessarily become specialized over time due to the 
characteristics of the patient populations served by the residential 
rehabilitation treatment model. In 2005, VA administratively designated 
all MH RRTP facilities as domiciliary care facilities to fully 
integrate mental health; residential rehabilitation; and treatment and 
domiciliary care. VA established the first MH RRTP in 1995. MH RRTPs 
provide comprehensive supervised treatment and rehabilitative services 
to veterans with mental health or substance use disorders, and 
coexisting medical or psychosocial needs such as homelessness and 
unemployment. MH RRTPs identify and address goals of rehabilitation, 
recovery, health maintenance, improved quality of life, and community 
integration in addition to specific treatment of medical conditions, 
mental illnesses, addictive disorders, and homelessness. The 
residential component emphasizes incorporation of clinical treatment 
gains into a lifestyle of self-care and personal responsibility. MH 
RRTPs provide a 24 hours-per-day, 7 days-per-week structured and 
supportive residential environment similar to that in traditional 
domiciliary care. However, there are differences in the type of care 
delivered. The goals of care for residential rehabilitation treatment 
reflect a stronger emphasis on rehabilitative services, including 
professional, counseling, and guidance services as well as treatment 
programs. Rehabilitative services are designed to facilitate the 
process of recovery from injury, illness, or disease. These services 
are intended to restore, to the maximum extent possible, the physical, 
mental, and psychological functioning of veterans receiving residential 
rehabilitation treatment.
    Since 2010, domiciliary care has been included as part of VA's MH 
RRTP, which began in 1995. VA domiciliaries are used currently for VA's 
Domiciliary Residential Rehabilitation Treatment Programs; Domiciliary 
Care for Homeless Veterans Program; Health Maintenance Domiciliary Beds 
Program; General Domiciliary or Psychosocial Residential Rehabilitation 
Treatment Program; Domiciliary Substance Abuse Programs; and 
Domiciliary Post-Traumatic Stress Disorder Programs. These are the 
patient populations currently residing in our domiciliaries. VA 
therefore proposes to update the definition of domiciliary care in 
Sec.  17.30(b) to reflect the scope of clinically intensive 
rehabilitation services included in the program.
    Current Sec.  17.30(b) defines domiciliary care as the furnishing 
of a home to a veteran, embracing the furnishing of shelter, food, 
clothing and other comforts of home, including necessary medical 
services. We would amend this definition by stating that domiciliary 
care means a ``temporary home'' rather than ``home.'' This is 
consistent with VA's long-standing practice of providing domiciliary 
care as a non-permanent living arrangement for eligible veterans. This 
proposed change would not alter VA's commitment to ensure extended or 
geriatric care is available to older

[[Page 14806]]

veterans eligible for VA domiciliary care, that is, those who cannot 
live independently but who do not require admission to a nursing home. 
These veterans receive their domiciliary care through State Veterans 
Homes Domiciliary Programs and VA pays half of the cost of that care 
through per diem payments. We would define domiciliary care to also 
mean a day hospital program consisting of intensive supervised 
rehabilitation and treatment provided in a therapeutic residential 
setting for residents with mental health or substance use disorders, 
and co-occurring medical or psychosocial needs such as homelessness and 
unemployment.
    Current Sec.  17.47 addresses considerations applicable in 
determining eligibility for hospital care, medical services, nursing 
home care, or domiciliary care. Current paragraph (c) clarifies that 
``domiciliary care, as the term implies, is the provision of a home, 
with such ambulant medical care as is needed.'' For the reasons stated 
above, we would amend this paragraph to reflect that domiciliary care 
provides a temporary home.

Effect of Rulemaking

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

Paperwork Reduction Act

    This proposed rule contains no provisions constituting a collection 
of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 
3501-3521).

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 directly affect only 
individuals treated within VA and would not affect any 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, 13563 and 13771

    Executive Orders (E.O.) 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). E.O. 13563 (Improving Regulation and Regulatory Review) 
emphasizes the importance of quantifying both costs and benefits, 
reducing costs, harmonizing rules, and promoting flexibility. E.O. 
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 not to be a significant regulatory action under E.O. 
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 website at 
http://www.va.gov/orpm/, by following the link for ``VA Regulations 
Published From FY 2004 Through Fiscal Year to Date.''
    This proposed rule is not expected to be an E.O. 13771 regulatory 
action because this proposed rule is not significant under E.O. 12866.

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 the 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 64.007, 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; 64.018, Sharing Specialized Medical 
Resources; 64.019, Veterans Rehabilitation Alcohol and Drug Dependence; 
64.022, Veterans Home Based Primary Care; and 64.024, VA Homeless 
Providers Grant and Per Diem Program.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Government contracts, 
Grant programs--health, Grant programs--veterans, Health care, Health 
facilities, Health professions, Health records, Homeless, Medical and 
dental schools, Medical devices, Medical research, Mental health 
programs, Nursing homes, Reporting and recordkeeping requirements, 
Travel and transportation expenses, Veterans.

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. Gina S. 
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on February 27, 2018, for publication.

    Dated: April 3, 2018.
Consuela Benjamin,
Regulations Development Coordinator, Office of Regulation Policy & 
Management, Office of the Secretary, Department of Veterans Affairs.

    For the reasons stated in the preamble, Department of Veterans 
Affairs proposes to amend 38 CFR part 17 as follows:

PART 17--MEDICAL

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


[[Page 14807]]


    Authority:  38 U.S.C. 501, and as noted in specific sections.
    Section 17.38 also issued under 38 U.S.C. 101, 501, 1701, 1705, 
1710, 1710A, 1721, 1722, 1782, and 1786.
    Section 17.63 also issued under 38 U.S.C. 1730.
    Section 17.169 also issued under 38 U.S.C. 1712C.
    Sections 17.380 and 17.412 are also issued under sec. 260, 
Public Law 114-223, 130 Stat. 857.
    Section 17.410 is also issued under 38 U.S.C. 1787.
    Section 17.415 is also issued under 38 U.S.C. 7301, 7304, 7402, 
and 7403.
    Sections 17.640 and 17.647 are also issued under sec. 4, Public 
Law 114-2, 129 Stat. 30.
    Sections 17.641 through 17.646 are also issued under 38 U.S.C. 
501(a) and sec. 4, Public Law 114-2, 129 Stat. 30.

0
2. Amend Sec.  17.30 by revising paragraph (b) to read as follows:


Sec.  17.30  Definitions.

* * * * *
    (b) Domiciliary care. The term domiciliary care--
    (1) Means the furnishing of:
    (i) A temporary home to a veteran, embracing the furnishing of 
shelter, food, clothing and other comforts of home, including necessary 
medical services; or
    (ii) A day hospital program consisting of intensive supervised 
rehabilitation and treatment provided in a therapeutic residential 
setting for residents with mental health or substance use disorders, 
and co-occurring medical or psychosocial needs such as homelessness and 
unemployment.
    (2) Includes travel and incidental expenses pursuant to Sec.  70.10 
of this chapter.
* * * * *
0
3. Amend Sec.  17.47 by removing the word ``home'' in the second 
sentence of paragraph (c) and adding, in its place, ``temporary home''.

[FR Doc. 2018-07082 Filed 4-5-18; 8:45 am]
 BILLING CODE 8320-01-P