Medical Foster Homes, 28917-28925 [2011-12253]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 76, Number 97 (Thursday, May 19, 2011)]
[Proposed Rules]
[Pages 28917-28925]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-12253]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AN80


Medical Foster Homes

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: This document proposes to amend the Department of Veterans 
Affairs (VA) ``Medical'' regulations to add rules relating to medical 
foster homes. Currently, VA's medical foster home program, whenever 
possible and appropriate, relies upon existing regulations that govern 
community residential care facilities; however, these existing 
regulations do not adequately or appropriately cover all aspects of 
medical foster homes, which provide community based care in a smaller, 
residential facility and to a more medically complex and disabled 
population. The proposed rules reflect current VA policy and practice, 
and generally conform to industry standards and expectations.

DATES: Comments on the proposed rule must be received by VA on or 
before July 18, 2011.

ADDRESSES: Written comments may be submitted through https://www.Regulations.gov; by mail or hand-delivery to the Director, 
Regulations 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-AN80, Medical Foster Homes.'' 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 
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 
at https://www.Regulations.gov through the Federal Docket Management 
System (FDMS).

FOR FURTHER INFORMATION CONTACT: Rick Greene, Office of Patient Care 
Services (114), Veterans Health Administration, Department of Veterans 
Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461-6786. 
(This is not a toll free number.)

SUPPLEMENTARY INFORMATION: 

General Background

    Many veterans who are disabled due to complex chronic disease or 
traumatic injury may be unable to live safely and independently, or may 
have health care needs that exceed the capabilities of their families. 
Many of these veterans are placed in nursing homes. However, with the 
proper support, many veterans who previously would have been placed in 
nursing homes can continue to live in a home and delay, or totally 
avoid, the need for nursing home care. VA's community residential care 
program, specifically authorized by 38 U.S.C. 1730 and implemented at 
38 CFR 17.61 through 17.72, has provided health care supervision to 
eligible veterans who are not able to live independently and have no 
suitable family or significant others to provide needed supervision and 
supportive care.
    A medical foster home is a specific type of community residential 
care facility that provides home-based care to a small number of 
residents with serious chronic disease and disability. Under 38 U.S.C. 
1730 as implemented by 38 CFR 17.61(b), community residential care is 
not a substitute for nursing home care. A medical foster home provides 
a greater level of care than a community residential care facility (and 
in this respect a medical foster home is more analogous to nursing home 
care), while allowing veterans to live in a home-like setting and 
maintain a greater degree of independence. VA interprets 38 U.S.C. 1730 
as authorizing a medical foster home program, as a subset of the 
community residential care program. In particular, we believe medical 
foster homes fit within the type of facility authorized by section 
1730(f), since they provide ``room and board and * * * limited personal 
care.'' The medical foster home program is targeted to the needs of 
veterans who meet the eligibility criteria, which we would establish in 
proposed 38 CFR 17.73(c).
    Through the medical foster home program, VA recognizes and approves 
certain medical foster homes for the placement of veterans. When a 
veteran is placed in an approved medical foster home, VA will provide 
inspections of the home, oversight, and medical foster home caregiver 
training. If a medical foster home does not meet our criteria for 
approval, VA will not provide these benefits and services, which, in 
turn, may discourage veterans from seeking to be placed in that home. 
Thus, the process of obtaining and maintaining VA approval has a 
substantial and vital impact on the lives of veterans, and is useful to 
medical foster homes.
    Currently, VA does not have regulations specifically targeted at 
governing medical foster homes, and, when necessary and appropriate, we 
have relied upon the regulations that govern all community residential 
care facilities, industry standards, and VA policy and practice to 
ensure the safety and quality of approved VA medical foster homes. 
However, many of our current regulations governing community 
residential care cannot or should not apply to medical foster homes. 
For example, the life safety provisions in 38 CFR 17.63 refer to 
industry standards that specifically govern facilities with four or 
more residents, while medical foster homes, by definition, provide care 
to three or fewer residents. By establishing these regulations, we 
intend to make clear to the public the criteria which VA will use when 
deciding whether to approve a medical foster home. Moreover, our 
current regulations applicable to community residential care facilities 
do not adequately protect bedridden patients. The current regulations 
are only intended to address homes where personal care services are 
provided to veterans and are not intended to address bedridden 
patients.
    This proposed rule would reflect current practice and policy and 
would require approved facilities to conform with applicable state and 
local regulations. The proposed rule is also based, as much as 
possible, on our current regulations governing community residential 
care. Because the proposed rule would reflect industry standards and 
current VA policy and procedures, we do not expect that it would have a 
significant or adverse impact on medical foster homes that are 
currently approved by VA, or on those that are not approved but who 
would seek approval under the proposed rule.

Section 17.73 Medical Foster Homes--General

    Proposed Sec.  17.73(a) would briefly describe the purpose of the 
medical foster home program, and clarify that a choice to become a 
resident in a medical foster home is a voluntary decision on

[[Page 28918]]

the part of the veteran. The proposed regulation would note that VA's 
role is limited to referring veterans to approved medical foster homes, 
and that only veteran residents placed in approved homes can depend on 
VA to provide ongoing oversight and inspections of the home.
    Proposed Sec.  17.73(b) would contain definitions applicable to the 
medical foster homes program. These proposed definitions are consistent 
with current practice and policy.
    ``Labeled'' would have a definition consistent with the definition 
established in the 2009 edition of the National Fire Protection 
Association (NFPA) 101, Life Safety Code, Chapter 3, 3.2.4. Although 
proposed Sec.  17.74(a)(3) would make chapter 3 of the NFPA 101 
applicable to medical foster homes, we believe it would be useful to 
include a definition of this term in our regulations. Defining 
``labeled'' this way would ensure that medical foster homes adhere to 
certain standards when utilizing equipment.
    We would define ``medical foster home'' as ``a private home in 
which a medical foster home caregiver provides care to a veteran 
resident and: (1) The medical foster home caregiver lives in the 
medical foster home; (2) the medical foster home caregiver owns or 
rents the medical foster home; and (3) there are not more than three 
residents receiving care (including veteran and non-veteran 
residents).'' This definition would adequately identify and distinguish 
medical foster homes from other types of community residential care 
facilities that are governed by current Sec. Sec.  17.61 through 17.72. 
In addition, this definition reflects the intended purpose of a medical 
foster home, which is to provide care in a small, privately owned, 
residential-type facility.
    The proposed definition of ``medical foster home caregiver'' would 
be ``the primary person who provides care to a veteran resident.'' This 
would typically entail providing a safe environment, room and board, 
supervision, and personal assistance, as appropriate for each veteran. 
We would use the phrase ``primary person'' because relief caregivers 
may assist the medical foster home caregiver, as noted in the proposed 
definition.
    We would include a definition of ``placement'' that clarifies that 
VA does not ``place'' veterans in medical foster homes; rather, 
placement ``refers to the voluntary decision by a veteran to become a 
resident in an approved medical foster home.''
    We would define a ``veteran resident'' to be an eligible veteran 
residing in an approved medical foster home. This definition is 
necessary to clarify that only veterans placed in approved homes can 
depend on VA to provide ongoing oversight and inspections of the home.
    Proposed Sec.  17.73(c) would outline eligibility criteria that 
must be met before VA will refer a veteran to a medical foster home. We 
propose to condition eligibility on three criteria.
    In proposed Sec.  17.73(c)(1), we would condition eligibility on 
the veteran being unable to live independently safely, or being in need 
of nursing home level care. These alternate criteria are necessary 
because medical foster homes are intended to provide a higher level of 
care than most community residential care facilities. Medical foster 
homes are designed to be alternatives to nursing home care, or to 
provide support for veterans who do not live with a family member who 
is able to provide needed care and assistance. These alternate criteria 
will ensure that the medical foster home program reaches these types of 
veterans.
    In proposed Sec.  17.73(c)(2), we would condition eligibility on 
enrollment in either a VA Home Based Primary Care or VA Spinal Cord 
Injury Homecare program. VA Home Based Primary Care (HBPC) is a home 
care program designed to meet the longitudinal, primary care needs of 
an aging veteran population with complex, chronic, disabling disease. 
In contrast to the episodic, time-limited and focused skilled-care 
services reimbursed by other funding mechanisms such as Medicare, HBPC 
provides comprehensive longitudinal care of patients often for the 
remainder of their lives. HBPC provides cost effective primary care 
services in the home and includes palliative care, rehabilitation, 
disease management, and coordination of care. One of the principle 
requirements of VA HBPC program is an interdisciplinary team that 
includes a physician medical director, a program director, and staff 
from nursing, social work, rehabilitation, dietetics, and pharmacy. 
Other services frequently needed include pastoral care and mental 
health.
    Similar to the HBPC, the Spinal Cord Injury (SCI) Homecare program 
consists of interdisciplinary services as an integral part of SCI 
outpatient services. The SCI Homecare program supports the transition 
and medical needs of patients in the home setting, decreasing the need 
for hospitalization when possible. The program provides a full range of 
care for all enrolled veterans who have sustained a spinal cord injury 
or have a stable neurologic impairment of the spinal cord.
    Requiring participation in either HBPC or SCI Homecare Program is 
necessary because these are currently the only two VA programs through 
which we can use an interdisciplinary medical team to treat, or 
supervise the treatment of, medically complex veterans placed in the 
community. The criterion is consistent with current practice; 
currently, any veteran who wishes to be placed in a medical foster home 
must enroll in either a VA Home Based Primary Care or VA Spinal Cord 
Injury Homecare program. Similarly, when VA identifies veterans who 
might benefit from placement in a medical foster home, we require them 
first to enroll in one of these care programs, and then refer them to 
an approved medical foster home for placement. Again, as of the 
publication of this proposed rule, all veterans placed in medical 
foster homes are enrolled in one of the two programs identified in 
proposed paragraph (c)(2), and these are currently the only two VA 
programs that service the population of veterans who could benefit from 
medical foster home placement. Because VA may establish programs 
similar to the HBPC or SCI Homecare program in the future, we would 
also include as part of the eligibility criteria ``similar VA 
interdisciplinary program designed to assist medically complex veterans 
living in the home.'' Such programs would have similar missions (i.e., 
offering clinically sufficient care in a secure home environment) to 
HBPC and SCI Homecare program, and similar clinical staff dedicated to 
fulfill that mission.
    In proposed Sec.  17.73(c)(3) we would require VA approval of the 
medical foster home in accordance with proposed Sec.  17.73(d). This 
would premise eligibility on the medical foster home having met the 
standards in proposed Sec.  17.74.
    Proposed Sec.  17.73(d) would make the procedures for approving 
medical foster homes identical to the procedures for approving 
community residential care facilities. We have determined that current 
approval procedures for community residential care facilities would be 
adequate, irrespective of the smaller, less institutionalized nature of 
medical foster homes and the differing criteria for approval. This is 
because the salient concerns in the approval of medical foster homes 
are very similar to the factors to be considered in the approval of 
community residential care facilities, namely, the fitness of the 
facility for providing a safe and comfortable environment for veteran 
residents. Accordingly, proposed paragraph (d) is substantively 
identical to the first (undesignated) paragraph of

[[Page 28919]]

current Sec.  17.63. Additionally, proposed Sec.  17.73(d) would 
prescribe that the approval process is governed by the approval process 
for community residential care facilities in current Sec. Sec.  17.65 
through 17.72.
    Proposed Sec.  17.73(e) would establish the duties of medical 
foster home caregivers. We propose to require that the medical foster 
home caregiver, with assistance from relief caregivers, provide a safe 
environment, room and board, supervision, and personal assistance, as 
appropriate for each veteran.

Section 17.74 Standards Applicable to Medical Foster Homes

    Due to the fact that the Medical Foster Home program pre-dates this 
proposed rule, and that proposed Sec. Sec.  17.73 and 17.74 conform to 
current practice and enforcement policy, VA does not believe there are 
any approved medical foster homes that are not presently in compliance 
with the requirements of this proposed rule.
    Proposed Sec.  17.74(a) is based on current Sec.  17.63(a). 
Proposed Sec.  17.74(a)(1) and (2) are substantively identical to Sec.  
17.63(a)(1) and (3), except that we would add in proposed paragraph 
(a)(2) that ``[v]entilation for cook stoves is not required.'' We have 
determined that it is not necessary to impose this requirement on these 
smaller, home-based facilities that provide food for a small number of 
residents. Proposed Sec.  17.74(a)(3) is similar to current Sec.  
17.63(a)(2), except that it would make chapters 1 through 11, 24, and 
section 33.7 of the NFPA 101 applicable to medical foster homes.
    Proposed Sec.  17.74(b) would prescribe the community residential 
care facility standards that also would be applicable to medical foster 
homes. We note that we would make current Sec.  17.63(k), regarding the 
cost of community residential care, applicable to medical foster homes, 
but the reference would be to Sec.  17.63(k) as it is proposed to be 
amended.
    Beginning with proposed Sec.  17.74(c), we would set forth unique 
standards applicable to medical foster homes. Proposed paragraph (c), 
and most of the paragraphs that follow, would adopt and/or modify 
existing regulatory or NFPA standards to make them appropriate for 
medical foster homes, or would address safety standards imposed by VA 
because we believe that they are appropriate for such homes. We believe 
that the standards set forth in the proposed rule are clear and 
straightforward, and plainly necessary for the safety and comfort of 
medical foster home residents, but a few of these paragraphs warrant 
specific discussion. Moreover, all medical foster homes currently 
recognized by VA conform to these NFPA standards.
    Proposed paragraph (c) would require the medical foster home to 
plan and facilitate appropriate recreational and leisure activities 
because this requirement will help ensure the quality of life of the 
veteran resident(s). It is consistent with the current practice of all 
medical foster homes currently recognized by VA.
    Proposed Sec.  17.74(d) would contain standards for bedrooms in 
medical foster homes, just as current Sec.  17.63(e) establishes such 
standards for other community residential care facilities. We propose 
to require each veteran resident to have a bedroom (1) with a door that 
closes and latches; (2) that contains a suitable bed and appropriate 
furniture; and (3) that is single occupancy, unless the veteran agrees 
to a multi-occupant bedroom. We have determined that these requirements 
are necessary for the comfort of those who reside in medical foster 
homes, but due to the size of most medical foster homes, ordinarily a 
single family dwelling, we decline to set a minimum bedroom size as in 
Sec.  17.63(e).
    Proposed Sec.  17.74(e) would establish a temporary exception to 
chapter 24 of the NFPA 101, which is made applicable by paragraph 
(a)(3), concerning windows used as a secondary means of escape. Due to 
their small size and residential character, we expect some medical 
foster homes may not initially have windows that are in compliance with 
the requirements of chapter 24. Rather than failing to approve an 
otherwise acceptable medical foster home on this basis, we propose to 
provisionally approve a medical foster home, provided that the 
secondary means of escape is brought into compliance no later than 60 
days after a veteran resident is placed in the home. While current 
Sec.  17.65 provides for a 12-month provisional approval period, or 
such time as the parties determine is reasonably necessary for 
correcting deficiencies in community residential care facilities, that 
section provides a maximum length of time for all potential 
deficiencies, including deficiencies more problematic than issues with 
windows. We have determined that 60 days is a reasonable period of time 
to achieve compliance with this important, but relatively 
straightforward, requirement.
    Proposed Sec.  17.74(f) would permit special locking devices that 
do not conform to section 7.2.1.5 of NFPA 101 where the clinical needs 
of the veteran require specialized security measures, so long as there 
is written approval for the alternate device from both the VA 
clinician, as well as the VA fire/safety specialist or the Director of 
the VA Medical Center of jurisdiction. Nonstandard locking devices 
might be used for patient safety--particularly, to address concerns 
caused by ``wandering'' patients. The Life Safety Code does not allow 
such locking devices, which is why we need to establish this exception.
    Proposed Sec.  17.74(g) would concern smoke and carbon monoxide 
(CO) detectors. Due to their small size and residential character, some 
medical foster homes may not have detection systems that specifically 
meet the requirements of the proposed paragraph. We therefore propose 
to allow a 60-day provisional approval period for a medical foster home 
that mitigates risk through the use of battery-operated single station 
alarms for smoke and CO detection. In proposed paragraph (g)(1), we 
would require that homes install smoke detectors or smoke alarms in 
accordance with sections 24.3.4.1 or 24.3.4.2 of NFPA 101. We recognize 
that a UL985-listed household fire warning system or a UL864-listed 
fire alarm system would be permissible in these facilities, and note 
that the cited NFPA 101 sections are consistent with this recognition.
    Proposed Sec.  17.74(h) concerns sprinkler systems. Sprinkler 
systems would not be required in all medical foster homes. Rather, we 
would require sprinkler systems only when they are required by the 
NFPA, which only requires sprinkler systems for new construction 
pursuant to NFPA 13. However, when a medical foster home contains a 
sprinkler system, whether it was installed to comply with NFPA 13 or 
simply due to the wishes of the medical foster home caregiver, we would 
require it to be inspected, tested, and maintained in accordance with 
NFPA 25. This is to ensure that sprinkler systems in medical foster 
homes are in good working order and can safely be relied upon.
    In Sec.  17.74(o)(1), we would prescribe that ``[u]se of extension 
cords must be limited'' without prescribing any specific standard. It 
is not possible to prescribe a specific requirement, such as limiting 
the use to four or less extension cords, because different facilities 
will have different needs. By stating that the use must be limited, we 
intend to discourage the use of extension cords and to allow our field 
inspectors to use their expertise to determine whether a particular 
medical foster home is relying inappropriately on the use of extension 
cords. Extension cords could become

[[Page 28920]]

overloaded if users attach equipment that draws more amperage (current) 
than the amperage for which the cord is rated. Drawing more current 
than the cord is rated for could result in overheating of the cord and 
presents a fire hazard. Extension cords should not be used as a branch 
circuit of the home electrical system. Rather, fixed circuits should be 
installed. If the extension cords are run through doorways, the action 
of the door over time could wear off the outer insulation of the cord, 
resulting in a shock hazard. The insulation could also become worn off 
if the extension cord is run under the carpeting. Extension cords could 
also create a tripping hazard.
    In proposed Sec.  17.74(o)(2), we would require that flammable or 
combustible liquids and other hazardous material be safely and properly 
stored in either the original, labeled container, or in a safety can as 
defined by NPFA 30 (2008 edition). This is to ensure that dangerous 
materials are only kept in containers that are specifically designed to 
store them as safely as possible, rather than in ordinary household 
containers which might increase fire risk associated with those 
materials.
    In proposed Sec.  17.74(p), we would prescribe special requirements 
for emergency egress and relocation drills in order to ensure that 
medical foster homes have a workable plan to be able to evacuate all 
residents in case of an emergency. In particular, in paragraph (p)(2), 
we would require that the medical foster home caregiver ``demonstrate 
the ability to evacuate all occupants within three minutes to a point 
of safety outside of the medical foster home that has access to a 
public way.'' The term ``all occupants'' means every person in the home 
at the time of the emergency egress and relocation drill, including 
non-residents. Although the purpose of the proposed rule is to 
establish requirements for the approval of medical foster homes for use 
by veteran residents, we do not believe that it is realistic merely to 
demonstrate the ability to evacuate all veteran-residents. In a real 
emergency, the medical foster home caregiver will need to ensure the 
timely evacuation of up to three residents and any other persons inside 
the home. As such, we would require a demonstration of such ability. 
For any home that fails to meet the evacuation requirements of proposed 
paragraph (p)(2), we would in paragraph (p)(3) allow a 60-day 
provisional approval during which time the medical foster home must 
establish an alternative to such evacuation. During that provisional 
approval period, VA inspectors would be authorized to require the home 
to increase its fire protection measures. Facilities that are unable to 
comply with paragraph (p)(2) would be required to implement one of the 
remedial options outlined in paragraph (p)(3), both of which are 
reasonable ways to ensure the safety of veteran residents in the event 
of a fire at the home.
    In proposed Sec.  17.74(q), we would incorporate all records 
requirements contained in current Sec.  17.63(i), except for the 
``statement of needed care'' requirement, because no such statement is 
required for medical foster homes. The statement is not needed because 
interdisciplinary VA clinical teams provide direct assistance to the 
veteran and medical foster home caregiver pursuant to the requirement 
that the veteran be enrolled in one of the programs identified in the 
proposed definition of veteran resident in Sec.  17.73.
    In proposed Sec.  17.74(s), we would authorize approval of 
equivalencies in extremely rare circumstances, and only when the 
equivalencies are in accordance with NFPA 101, section 1.4.3, and with 
the approval of the appropriate Veterans Health Administration, 
Veterans Integrated Service Network (VISN) Director. These criteria are 
designed to ensure that equivalencies are only granted when the 
equivalency will not endanger resident safety, the medical foster home 
cannot comply with all requirements of this part without prohibitive 
expense, and when VA's decision not to approve the medical foster home 
in question would lead to a shortage of approved medical foster homes 
in a given area. Further, we would require that a veteran placed in the 
home be given notice of the equivalencies and the reasons for them. 
This notice would describe the equivalency with particularity, 
including identifying the exempted requirement and explaining why the 
exemption is necessary. We intend that veterans would make informed 
choices when they decide to live in a medical foster home that has been 
granted an equivalency. We would limit the authority to grant an 
equivalency to circumstances where the technical requirements of the 
proposed rule would cause an undue expense, there is no other nearby 
home to provide an adequate alternative, and the equivalency is in the 
best interest of the veteran. This might occur, e.g., when a veteran 
wishes to be placed in a home located near his or her family's 
residence, but that home fails to meet a requirement such as that the 
windows are a quarter of an inch too small to meet the proposed Sec.  
17.74(e) standard. If such a defect can be remedied without imposing a 
cost on the medical foster home that the VISN Director considers undue 
expense, an equivalency would not be authorized. If there is no 
adequate alternative to the equivalency and the VISN Director 
determines the equivalency is in the best interest of the veteran, it 
would be authorized.
    Proposed Sec.  17.74(u)(1) would clarify that payment for the 
charges to veterans for the cost of medical foster home care is not the 
responsibility of the U.S. Government. However, paragraphs (u)(2) and 
(3) would prescribe requirements designed to ensure that medical foster 
homes approved by VA do not charge usurious rates or rates that are not 
comparable to the rates charged to non-veterans in the same or 
comparable medical foster homes. We also want to ensure that we do not 
approve a home that dramatically increases the rates charged to a 
veteran resident after the veteran has moved into the home, without a 
reasonable basis for such increase (such as a worsening of the 
veteran's condition requiring an increased level of care). These 
provisions are designed to allow the medical foster home to charge an 
appropriate rate based on the level of care and supervision required by 
the particular veteran, but are also designed to ensure that VA does 
not approve a home that charges unfair rates. They are also designed to 
be flexible, based on the resources of the particular medical foster 
home. We note that it is only in very rare cases that VA would use 
costs as a reason to not approve a medical foster home. We also note 
that this ``costs'' paragraph is significantly different from the one 
applicable to other community residential care facilities, i.e., 
current Sec.  17.63(k), because of the higher degree of medical 
complexity and care required by medical foster home residents. It is 
not feasible to apply an across-the-board base rate for each facility 
as we did with Community Residential Care facilities in Sec.  17.63(k) 
because the higher degree of medical complexity associated with each 
veteran means that appropriate levels of care and therefore costs will 
vary widely between medical foster home patients.

Incorporations by Reference

    Proposed Sec.  17.74(t) would incorporate by reference the NFPA 
standards identified in proposed Sec. Sec.  17.73 and 17.74. Because of 
the unique nature of medical foster homes, we cannot rely solely on 
particular, existing NFPA publications, as we do with other community 
residential care and housing regulations. On February 24, 2011, VA 
published in the Federal Register, at 76

[[Page 28921]]

FR 10246, a final rule to establish a centralized regulation (38 CFR 
17.1) for incorporations by reference in part 17 of title 38 CFR. This 
proposed rule would incorporate by reference the versions of the NFPA 
standards that are current as of the date of publication of the 
proposed rule. In the future, we will amend this regulation if and when 
the incorporated NFPA standards are changed in a way that we believe is 
relevant to medical foster homes. We believe that this will assist 
medical foster homes in clearly identifying whether any changes are 
required based on changes to the NFPA codes cited herein.

Approval of Incorporations by Reference

    We propose to amend our regulations to require medical foster homes 
seeking VA approval to meet the requirements of the following NFPA 
codes and standards: NFPA 10, Standard for Portable Fire Extinguishers 
(2010 edition); NFPA 13, Standard for the Installation of Sprinkler 
Systems (2010 edition); NFPA 13D, Standard for the Installation of 
Sprinkler Systems in One- and Two-Family Dwellings and Manufactured 
Homes (2010 edition); NFPA 13R, Standard for the Installation of 
Sprinkler Systems in Residential Occupancies Up To and Including Four 
Stories in Height (2010 edition); NFPA 25, Standard for the Inspection, 
Testing, and Maintenance of Water-Based Fire Protection Systems (2008 
edition); NFPA 30, Flammable and Combustible Liquids Code (2008 
edition); NFPA 72, National Fire Alarm and Signaling Code (2010 
edition); and NFPA 720, Standard for the Installation of Carbon 
Monoxide (CO) Detection and Warning Equipment (2009 edition). We also 
propose to amend our regulations to require medical foster homes 
seeking VA approval to meet the requirements of the following chapters 
and/or sections of NFPA 101, National Fire Protection Association's 
Life Safety Code (NFPA 101) (2009 edition): Chapters 1 through 11, 24, 
and section 33.7.
    This action is necessary to ensure that medical foster homes meet 
current industry-wide safety standards. We will request that the Office 
of the Federal Register approve our incorporation by references.
    These materials for which we are seeking incorporation by reference 
are available for inspection at the Department of Veterans Affairs, 
Office of Regulations Management (02REG), 810 Vermont Avenue, NW., Room 
1068, Washington, DC 20420, or at the National Archives and Records 
Administration (NARA). For information on the availability of this 
material at NARA, call (202) 741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. Copies may be obtained from the National Fire 
Protection Association, Battery March Park, Quincy, MA 02269. (For 
ordering information, call toll-free 1-800-344-3555.)
    Currently Sec.  17.1 contains the materials that are incorporated 
by reference (IBR) for part 17. The Office of the Federal Register 
requires that if an agency has established an IBR section, then all 
approvals must be listed in that part. We, therefore, propose to amend 
Sec.  17.1(b) to add the new IBR approvals contained in this proposed 
rulemaking.

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 given year. The proposed rule would have no such 
effect on state, local, and Tribal governments, or on the private 
sector.

Paperwork Reduction Act

    This proposed rule includes a collection of information under the 
Paperwork Reduction Act (44 U.S.C. 3501-3521) that requires approval by 
the Office of Management and Budget (OMB). Accordingly, under section 
3507(d) of the Act, VA has submitted a copy of this rulemaking to OMB 
for review. OMB assigns a control number for each collection of 
information it approves. Except for emergency approvals under 44 U.S.C. 
3507(j), 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). 
If OMB does not approve the collection 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.
    Comments on the collection 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: Director, Office of 
Regulation Policy and Management (02REG), Department of Veterans 
Affairs, 810 Vermont Ave., NW., Room 1068, Washington, DC 20420; fax to 
(202) 273-9026; or through https://www.Regulations.gov. Comments should 
indicate that they are submitted in response to ``RIN 2900-AN80-Medical 
Foster 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 chapter 17 contain 
collections of information under the Paperwork Reduction Act for which 
we are requesting approval by OMB.
    Title: Medical Foster Homes.
    Summary of collection of information: Paragraph (q) would require 
medical foster homes to comply with the recordkeeping requirements of 
38 CFR 17.63(i) regarding facility records, and must document all 
inspection, testing, drills and maintenance activities required by this 
section. Such documentation must be maintained for 3 years or for the 
period specified by the applicable NFPA standard, whichever is longer. 
Documentation of emergency egress and relocation drills must include 
the date, time of day, length of time to evacuate the home, the name of 
each medical foster home caregiver who participated, the name of each 
resident,

[[Page 28922]]

whether the resident participated, and whether the resident required 
assistance.
    Description of the need for information and proposed use of 
information: The information is needed to ensure the safety of veteran 
residents because medical foster homes operate in a residential setting 
in the community.
    Description of likely respondents: Medical foster homes who seek to 
be approved by VA.
    Estimated number of respondents per year: 300 medical foster homes.
    Estimated frequency of responses per year: 6 times per year.
    Estimated total annual reporting and recordkeeping burden: 600 
hours.

Executive Order 12866

    Executive Order 12866 directs agencies to assess all 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, 
and other advantages; distributive impacts; and equity). The Executive 
Order classifies a ``significant regulatory action,'' requiring review 
by 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 planned or taken 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 
the Executive Order.
    The economic, interagency, legal, and policy implications of this 
proposed rule have been examined, and it has been determined not to be 
a significant regulatory action under Executive Order 12866.

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. In addition to having an effect on individuals 
(veterans), the proposed rule would have an insignificant economic 
impact on a few small entities. Most of the minimum standards that 
would be established by this rulemaking are already required by state 
and local regulations, and medical foster homes should already be in 
compliance with those regulations or with the current NFPA codes. Any 
additional costs for compliance with the proposed rule would constitute 
an inconsequential amount of the operational costs of such facilities. 
Accordingly, pursuant to 5 U.S.C. 605(b), this rule is exempt from the 
initial and final regulatory flexibility analysis requirements of 
sections 603 and 604.

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.

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. John R. 
Gingrich, Chief of Staff, Department of Veterans Affairs, approved this 
document on May 11, 2011, for publication.

List of Subjects in 38 CFR Part 17

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

    Dated: May 13, 2011.
Robert C. McFetridge,
Director, Regulations Policy and Management, Department of Veterans 
Affairs.

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

PART 17--MEDICAL

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

    Authority: 38 U.S.C. 501, 1721, and as noted in specific 
sections.

    2. Revise Sec.  17.1(b) to read as follows:


Sec.  17.1  Incorporation by reference.

* * * * *
    (b) The following materials are incorporated by reference into this 
part.
    (1) NFPA 10, Standard for Portable Fire Extinguishers (2010 
edition), Incorporation by Reference (IBR) approved for Sec. Sec.  
17.63, 17.74, and 17.81.
    (2) NFPA 101, Life Safety Code (2009 edition), IBR approved for 
Sec. Sec.  17.63, 17.74 (chapters 1 through 11, 24, and section 33.7), 
17.81, and 17.82.
    (3) NFPA 101A, Guide on Alternative Approaches to Life Safety (2010 
edition), IBR approved for Sec.  17.63.
    (4) NFPA 13, Standard for the Installation of Sprinkler Systems 
(2010 edition), IBR approved for Sec.  17.74.
    (5) NFPA 13D, Standard for the Installation of Sprinkler Systems in 
One- and Two-Family Dwellings and Manufactured Homes (2010 edition), 
IBR approved for Sec.  17.74.
    (6) NFPA 13R, Standard for the Installation of Sprinkler Systems in 
Residential Occupancies Up To and Including Four Stories in Height 
(2010 edition), IBR approved for Sec.  17.74.
    (7) NFPA 25, Standard for the Inspection, Testing, and Maintenance 
of Water-Based Fire Protection Systems (2008 edition), IBR approved for 
Sec.  17.74.
    (8) NFPA 30, Flammable and Combustible Liquids Code (2008 edition), 
IBR approved for Sec.  17.74.
    (9) NFPA 72, National Fire Alarm and Signaling Code (2010 edition), 
IBR approved for Sec.  17.74.
    (10) NFPA 720, Standard for the Installation of Carbon Monoxide 
(CO) Detection and Warning Equipment (2009 edition), IBR approved for 
Sec.  17.74.

(Authority: 5 U.S.C. 552(a), 38 U.S.C. 501, 1721)


    3. Sections 17.73 and 17.74 are added to read as follows:


Sec.  17.73  Medical foster homes--general.

    (a) Purpose. Through the medical foster home program, VA recognizes 
and approves certain medical foster homes

[[Page 28923]]

for the placement of veterans. The choice to become a resident of a 
medical foster home is a voluntary one on the part of each veteran. 
VA's role is limited to referring veterans to approved medical foster 
homes. When a veteran is placed in an approved home, VA will provide 
inspections to ensure that the home continues to meet the requirements 
of this part, as well as oversight and medical foster home caregiver 
training. If a medical foster home does not meet VA's criteria for 
approval, VA will not refer any veteran to the home or provide any of 
these services. VA may also provide certain medical benefits to 
veterans placed in medical foster homes, consistent with the VA program 
in which the veteran is enrolled.
    (b) Definitions. For the purposes of this section and Sec.  17.74:
    Labeled means that the equipment or materials have attached to them 
a label, symbol, or other identifying mark of an organization 
recognized as having jurisdiction over the evaluation and periodic 
inspection of such equipment or materials, and by whose labeling the 
manufacturer indicates compliance with appropriate standards or 
performance.
    Medical foster home means a private home in which a medical foster 
home caregiver provides care to a veteran resident and:
    (1) The medical foster home caregiver lives in the medical foster 
home;
    (2) The medical foster home caregiver owns or rents the medical 
foster home; and
    (3) There are not more than three residents receiving care 
(including veteran and non-veteran residents).
    Medical foster home caregiver means the primary person who provides 
care to a veteran resident in a medical foster home.
    Placement refers to the voluntary decision by a veteran to become a 
resident in an approved medical foster home.
    Veteran resident means a veteran residing in an approved medical 
foster home who meets the eligibility criteria in paragraph (c) of this 
section.
    (c) Eligibility. VA health care personnel may assist a veteran by 
referring such veteran for placement in a medical foster home if:
    (1) The veteran is unable to live independently safely or is in 
need of nursing home level care;
    (2) The veteran must be enrolled in, or agree to be enrolled in, 
either a VA Home Based Primary Care or VA Spinal Cord Injury Homecare 
program, or a similar VA interdisciplinary program designed to assist 
medically complex veterans living in the home; and
    (3) The medical foster home has been approved in accordance with 
paragraph (d) of this section.
    (d) Approval of medical foster homes. Medical foster homes will be 
approved by a VA Medical Foster Homes Coordinator based on the report 
of a VA inspection and on any findings of necessary interim monitoring 
of the medical foster home, if that home meets the standards 
established in Sec.  17.74. The approval process is governed by the 
process for approving community residential care facilities under 
Sec. Sec.  17.65 through 17.72 except as follows:
    (1) Where Sec. Sec.  17.65 through 17.72 reference Sec.  17.63.
    (2) Because VA does not physically place veterans in medical foster 
homes, VA also does not assist veterans in moving out of medical foster 
homes as we do for veterans in other community residential care 
facilities under Sec.  17.72(d)(2); however, VA will assist such 
veterans in locating an approved medical foster home when relocation is 
necessary.
    (e) Duties of Medical foster home caregivers. The medical foster 
home caregiver, with assistance from relief caregivers, provides a safe 
environment, room and board, supervision, and personal assistance, as 
appropriate for each veteran.

(Authority: 38 U.S.C. 501, 1730)

Sec.  17.74  Standards applicable to medical foster homes.

    (a) General. A medical foster home must:
    (1) Meet all applicable state and local regulations, including 
construction, maintenance, and sanitation regulations.
    (2) Have safe and functioning systems for heating, hot and cold 
water, electricity, plumbing, sewage, cooking, laundry, artificial and 
natural light, and ventilation. Ventilation for cook stoves is not 
required.
    (3) Except as otherwise provided in this section, meet the 
applicable provisions of chapters 1 through 11 and 24, and section 33.7 
of NFPA 101, National Fire Protection Association's Life Safety Code 
(NFPA 101) (2009 edition) (incorporated by reference, see Sec.  17.1), 
and the other codes and chapters identified in this section, as 
applicable.
    (b) Community residential care facility standards applicable to 
medical foster homes. Medical foster homes must comply with Sec.  
17.63(c), (d), (f), (h), (j) and (k).
    (c) Activities. The facility must plan and facilitate appropriate 
recreational and leisure activities.
    (d) Residents' bedrooms. Each veteran resident must have a bedroom:
    (1) With a door that closes and latches;
    (2) That contains a suitable bed and appropriate furniture; and
    (3) That is single occupancy, unless the veteran agrees to a multi-
occupant bedroom.
    (e) Windows. VA may grant provisional approval for windows used as 
a secondary means of escape that do not meet the minimum size and 
dimensions required by chapter 24 of NFPA 101 (incorporated by 
reference, see Sec.  17.1) if the windows are a minimum of 5.0 square 
feet (and at least 20 inches wide and at least 22 inches high). The 
secondary means of escape must be brought into compliance with chapter 
24 no later than 60 days after a veteran resident is placed in the 
home.
    (f) Special locking devices. Special locking devices that do not 
comply with section 7.2.1.5 of NFPA 101 (incorporated by reference, see 
Sec.  17.1) are permitted where the clinical needs of the veteran 
resident require specialized security measures and with the written 
approval of:
    (1) The responsible VA clinician; and
    (2) The VA fire/safety specialist or the Director of the VA Medical 
Center of jurisdiction.
    (g) Smoke and carbon monoxide (CO) detectors and smoke and CO 
alarms. Medical foster homes must comply with this paragraph (g) no 
later than 60 days after the first veteran is placed in the home. Prior 
to compliance, VA inspectors will provisionally approve a medical 
foster home for the duration of this 60-day period if the medical 
foster home mitigates risk through the use of battery-operated single 
station alarms, provided that the alarms are installed before any 
veteran is placed in the home.
    (1) Smoke detectors or smoke alarms must be provided in accordance 
with sections 24.3.4.1 or 24.3.4.2 of NFPA 101 (incorporated by 
reference, see Sec.  17.1); section 24.3.4.3 of NFPA 101 will not be 
used. In addition, smoke alarms must be interconnected so that the 
operation of any smoke alarm causes an alarm in all smoke alarms within 
the medical foster home. Smoke detectors or smoke alarms must not be 
installed in the kitchen or any other location subject to causing false 
alarms.
    (2) CO detectors or CO alarms must be installed in any medical 
foster home with a fuel-burning appliance, fireplace, or an attached 
garage, in accordance with NFPA 720, Standard for the Installation of 
Carbon Monoxide (CO) Detection and Warning Equipment (2009 Edition) 
(NFPA 720) (incorporated by reference, see Sec.  17.1).

[[Page 28924]]

    (3) Combination CO/smoke detectors and combination CO/smoke alarms 
are permitted.
    (4) Smoke detectors and smoke alarms must initiate a signal to a 
remote supervising station to notify emergency forces in the event of 
an alarm.
    (5) Smoke and/or CO alarms and smoke and/or CO detectors, and all 
other elements of a fire alarm system, must be inspected, tested, and 
maintained in accordance with NFPA 72, National Fire Alarm and 
Signaling Code (2010 edition) (incorporated by reference, see Sec.  
17.1) and NFPA 720 (incorporated by reference, see Sec.  17.1).
    (h) Sprinkler systems. (1) If a sprinkler system is installed, it 
must be inspected, tested, and maintained in accordance with NFPA 25, 
Standard for the Inspection, Testing, and Maintenance of Water-Based 
Fire Protection Systems (2008 edition) (incorporated by reference, see 
Sec.  17.1), unless the sprinkler system is installed in accordance 
with NFPA 13D, Standard for the Installation of Sprinkler Systems in 
One- and Two-Family Dwellings and Manufactured Homes (2010 Edition) 
(NFPA 13D) (incorporated by reference, see Sec.  17.1). If a sprinkler 
system is installed in accordance with NFPA 13D (incorporated by 
reference, see Sec.  17.1), it must be inspected annually by a 
competent person.
    (2) If sprinkler flow or pressure switches are installed, they must 
activate notification appliances in the medical foster home, and must 
initiate a signal to the remote supervising station.
    (i) Fire extinguishers. At least one 2-A:10-B:C rated fire 
extinguisher must be visible and readily accessible on each floor, 
including basements, and must be maintained in accordance with the 
manufacturer's instructions. Portable fire extinguishers must be 
inspected, tested, and maintained in accordance with NFPA 10, Standard 
for Portable Fire Extinguishers (2010 edition) (incorporated by 
reference, see Sec.  17.1).
    (j) Emergency lighting. Each occupied floor must have at least one 
plug-in rechargeable flashlight, operable and readily accessible, or 
other approved emergency lighting. Such emergency lighting must be 
tested monthly and replaced if not functioning.
    (k) Fireplaces. A non-combustible hearth, in addition to protective 
glass doors or metal mesh screens, is required for fireplaces. Hearths 
and protective devices must meet all applicable state and local fire 
codes.
    (l) Portable heaters. Portable heaters may be used if they are 
maintained in good working condition and:
    (1) The heating elements of such heaters do not exceed 212 degrees 
Fahrenheit (100 degrees Celsius);
    (2) The heaters are labeled; and
    (3) The heaters have tip-over protection.
    (m) Oxygen safety. Any area where oxygen is used or stored must not 
be near an open flame and must have a posted ``No Smoking'' sign. 
Oxygen cylinders must be adequately secured or protected to prevent 
damage to cylinders. Whenever possible, trans-filling of liquid oxygen 
must take place outside of the living areas of the home.
    (n) Smoking. Smoking must be prohibited in all sleeping rooms, 
including sleeping rooms of non-veteran residents. Ashtrays must be 
made of noncombustible materials.
    (o) Special/other hazards. (1) Extension cords must be three-
pronged, grounded, sized properly, and not present a hazard due to 
inappropriate routing, pinching, damage to the cord, or risk of 
overloading an electrical panel circuit.
    (2) Flammable or combustible liquids and other hazardous material 
must be safely and properly stored in either the original, labeled 
container or a safety can as defined by section 3.3.44 of NFPA 30, 
Flammable and Combustible Liquids Code (2008 edition) (incorporated by 
reference, see Sec.  17.1).
    (p) Emergency egress and relocation drills. Operating features of 
the medical foster home must comply with section 33.7 of NFPA 101 
(incorporated by reference, see Sec.  17.1), except that section 
33.7.3.6 of NFPA 101 does not apply. Instead, VA will enforce the 
following requirements:
    (1) Before placement in a medical foster home, the veteran will be 
clinically evaluated by VA to determine whether the veteran is able to 
participate in emergency egress and relocation drills. Within 24 hours 
after arrival, each veteran resident must be shown how to respond to a 
fire alarm and evacuate the medical foster home, unless the veteran 
resident is unable to participate.
    (2) The medical foster home caregiver must demonstrate the ability 
to evacuate all occupants within three minutes to a point of safety 
outside of the medical foster home that has access to a public way, as 
defined in NFPA 101 (incorporated by reference, see Sec.  17.1).
    (3) If all occupants are not evacuated within three minutes or if a 
veteran resident is either permanently or temporarily unable to 
participate in drills, then the medical foster home will be given a 60-
day provisional approval, after which time the home must have 
established one of the following remedial options or VA will terminate 
the approval in accordance with Sec.  17.65.
    (i) The home is protected throughout with an automatic sprinkler 
system in accordance with section 9.7 of NFPA 101 (incorporated by 
reference, see Sec.  17.1) and whichever of the following apply: NFPA 
13, Standard for the Installation of Sprinkler Systems (2010 edition) 
(incorporated by reference, see Sec.  17.1); NFPA 13R, Standard for the 
Installation of Sprinkler Systems in Residential Occupancies Up To and 
Including Four Stories in Height (2010 edition) (incorporated by 
reference, see Sec.  17.1); or NFPA 13D, Standard for the Installation 
of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured 
Homes (2010 edition) (incorporated by reference, see Sec.  17.1).
    (ii) Each veteran resident who is permanently or temporarily unable 
to participate in a drill or who fails to evacuate within three minutes 
must have a bedroom located at the ground level with direct access to 
the exterior of the home that does not require travel through any other 
portion of the residence, and access to the ground level must meet the 
requirements of the Americans with Disabilities Act. The medical foster 
home caregiver's bedroom must also be on ground level.
    (4) The 60-day provisional approval under paragraph (p)(3) of this 
section may be contingent upon increased fire prevention measures, 
including but not limited to prohibiting smoking or use of a fireplace. 
However, each veteran resident who is temporarily unable to participate 
in a drill will be permitted to be excused from up to two drills within 
one 12-month period, provided that the two excused drills are not 
consecutive, and this will not be a cause for VA to not approve the 
home.
    (5) For purposes of paragraph (p), the term all occupants means 
every person in the home at the time of the emergency egress and 
relocation drill, including non-residents.
    (q) Records of compliance with this section. The medical foster 
home must comply with Sec.  17.63(i) regarding facility records, and 
must document all inspection, testing, drills and maintenance 
activities required by this section. Such documentation must be 
maintained for 3 years or for the period specified by the applicable 
NFPA standard, whichever is longer. Documentation of emergency egress 
and relocation drills must include the date, time of day, length of 
time to evacuate the home, the name of each medical foster home 
caregiver who participated, the name of each resident, whether the 
resident participated, and whether the resident required assistance.

[[Page 28925]]

    (r) Local permits and emergency response. Where applicable, a 
permit or license must be obtained for occupancy or business by the 
medical foster home caregiver from the local building or business 
authority. When there is a home occupant who is incapable of self-
preservation, the local fire department or response agency must be 
notified by the medical foster home within 7 days of the beginning of 
the occupant's residency.
    (s) Equivalencies. Any equivalencies to VA requirements must be in 
accordance with section 1.4.3 of NFPA 101 (incorporated by reference, 
see Sec.  17.1), and must be approved in writing by the appropriate 
Veterans Health Administration, Veterans Integrated Service Network 
(VISN) Director. A veteran living in a medical foster home when the 
equivalency is granted or who is placed there after it is granted must 
be notified in writing of the equivalencies and that he or she must be 
willing to accept such equivalencies. The notice must describe the 
exact nature of the equivalency, the requirements of this section with 
which the medical foster home is unable to comply, and explain why the 
VISN Director deemed the equivalency necessary. Only equivalencies that 
the VISN Director determines do not pose a risk to the health or safety 
of the veteran may be granted. Also, equivalencies may only be granted 
when technical requirements of this section cannot be complied with 
absent undue expense, there is no other nearby home which can serve as 
an adequate alternative, and the equivalency is in the best interest of 
the veteran.
    (t) Incorporation by reference. The standards required in this 
section are incorporated by reference into this section with the 
approval of the Director of the Federal Register under 5 U.S.C. 552(a) 
and 1 CFR part 51. To enforce any edition other than that specified in 
this section, VA will publish a notice of proposed rulemaking regarding 
the change in the Federal Register and the material will be made 
available to the public. All approved material is available for 
inspection at the Department of Veterans Affairs, Office of Regulation 
Policy and Management (02REG), Room 1068, 810 Vermont Avenue, NW., 
Washington, DC 20420, or at the National Archives and Records 
Administration (NARA). For information on the availability of this 
material at NARA, call (202) 741-6030, or go to: https://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. Copies may be obtained from the National Fire 
Protection Association, Battery March Park, Quincy, MA 02269. (For 
ordering information, call toll-free 1-800-344-3555). The NFPA home 
page is: https://www.nfpa.org/. For information on NFPA codes or 
standards see the NFPA Web site at: https://www.nfpa.org/aboutthecodes/list_of_codes_and_standards.asp. The VA-controlled Web site that 
provides access to all NFPA codes and standards is: https://vaww.ceosh.med.va.gov/01FS/pages/NFPAWarning.shtml.
    (u) Cost of medical foster homes. (1) Payment for the charges to 
veterans for the cost of medical foster home care is not the 
responsibility of the United States Government.
    (2) The resident or an authorized personal representative and a 
representative of the medical foster home facility must agree upon the 
charge and payment procedures for medical foster home care.
    (3) The charges for medical foster home care must be comparable to 
prices charged by other assisted living and nursing home facilities in 
the area based on the veteran's changing care needs and local 
availability of medical foster homes.

(Authority: 38 U.S.C. 501, 1730)


[FR Doc. 2011-12253 Filed 5-18-11; 8:45 am]
BILLING CODE 8320-01-P