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VA Prosthetics

VA Prosthetics Handbooks provide local VA staff with guidance on how to run the prosthetics program. Within these handbooks, veterans and advocates can find useful information to understand local policies and procedures, as well as to challenge adverse decisions.

This series deals specifically with the provision of various prosthetics, orthotics and durable medical equipment through the Veteran Health Administration's Prosthetics and Sensory Aids Service ("Prosthetics") or PSAS.

Prosthetics provides devices to eligible veterans for use outside of VA medical centers or facilities.

Additional information can be found at the VA Prosthetics Website.

1. VA Handbook 1173.1 - Prosthetics Eligibility

1.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent national policy and procedures for determination of eligibility of veteran beneficiaries for prosthetic services.

1.2. Eligibility

a. General. The Veterans' Health Care Eligibility Reform Act of 1996, Public Law 104- 262, significantly changed the eligibility of veterans to receive hospital care and outpatient medical services, including prosthetics, medical equipment, and supplies. For complete details on eligibility rules and the Department of Veterans Affairs (VA) enrollment system, reference should be made to the regulations governing VA's enrollment system and medical benefits package. They are published in Title 38 Code of Federal Regulations (CFR) Sections 17.36 ‘«Ű 17.38. Generally all veterans enrolled in the VA health care system are eligible for all needed prosthetics, medical equipment, and supplies. Certain veterans are eligible for needed prosthetics, medical equipment, and supplies even though not enrolled. The two most significant groups of veterans who do not need to be enrolled are:

(1) Veterans needing prosthetics, medical equipment, and supplies for a service connected disability, and

(2) veterans with a service connected disability rated at least 50 percent.

b. Special Eligibility for Children with Spina Bifida. VA provides needed health care benefits, including prosthetics, medical equipment, and supplies to certain children of Vietnam veteran, i.e., children who are suffering from spina bifida or a disability associated with such condition. For complete details on eligibility rules for such benefits, reference should be made to 38 CFR Sections 17.900 ‘«Ű 17.905.

c. Special Eligibility for Veterans Participating in Vocational Rehabilitation. Veterans participating in VA's vocational rehabilitation program may receive VA health care benefits including prosthetics, medical equipment, and supplies. For complete details on eligibility rules for such benefits, reference should be made to 38 CFR Section 17.47(j).

d. Limitations on Benefits Available to Veterans Outside the United States (U.S.). Veterans outside the U.S. are eligible for prosthetics, medical equipment, and supplies only for a service connected disability, except as otherwise provided in Title 38 United States Code (U.S.C.) Section 1724.

1.3. Definitions

a. Access Points (Outpatient Clinic). Medical facilities authorized in treating eligible beneficiaries outside of regular VA medical center settings. Includes the outpatient clinic of a regional office; independent VA outpatient clinic; and an outpatient clinic of a VA medical center.

b. Advisory Committee on Prosthetics and Special-Disabilities Programs. An advisory committee to the Secretary of Veterans Affairs established by Pub. L. 102-405 to provide advice concerning prosthetics for spinal cord injured veterans, blind veterans, veterans who have loss or loss of use of extremities, hearing impaired veterans and other veterans with serious incapacities in terms of daily life functions.

c. Aids For the Blind. Any device, equipment, or animal used in assisting a legally blind beneficiary in overcoming the handicap of blindness, to include guide dog, low vision aids, tools, utensils, mechanical or electronic items designed especially to overcome the handicap of blindness.

d. Amputee Clinic Team. A team of professionals responsible for the overall rehabilitation of amputee patients, e.g., pre- and post-operative counseling of the amputee, training in, preparation for, and use of artificial limbs, prescription and inspection of artificial limbs, followup activities, etc.

e. Appliance (device, item, etc.). Generic term used in referring to all prosthetic appliances, aids for the blind, and medical equipment.

f. Automobile Adaptive Equipment (AAE). Items and/or devices necessary to permit safe operation of, or permit access to and egress from an automobile or other conveyance.

g. Commission on Accreditation of Rehabilitation Facilities (CARF). Independent survey entity which accredits rehabilitation health care facilities.

h. Chief Medical Officer. The physician in charge of treatment at an outpatient clinic or outpatient care services at a VA medical center.

i. Clothing Allowance. An annual sum of money, specified by Congress, to be paid to each veteran who because of a service-connected disability wears or uses a prosthetic or orthotic appliance (including a wheelchair) which tends to wear out or tear the outer garments of clothing of said veteran; or uses medication which a physician has prescribed for a skin condition which is due to a service-connected disability determined by the Secretary to cause irreparable staining damage, or destruction from the necessity of frequent laundering to the veteran's outer garments. These provisions are applicable to 38 U.S.C. 1151 veterans.

j. Code of Federal Regulations (CFR). The CFR is the annual cumulation of executive agency regulations published in the Daily Register, combined with regulations issued previously that are still in effect. It contains the general body of regulatory laws governing practice and procedure before Federal administrative agencies. These regulations are cited using the title, part and section number, e.g., Title 38 CFR 17.115.

k. Contracting Officer's Technical Representative (COTR). A technical employee of a contracting activity designated by a contracting officer and responsible for monitoring the contractor's performance to ensure compliance with technical requirements.

l. Contracting Officers Certification Program (COCP). A formal program for the selection, appointment, and termination of appointment of contracting officers. Training, experience, education, performance, and conduct are the objective criteria reviewed prior to appointment as contracting officers. The head of the contracting activity manages the COCP program at the medical facility and can appoint contracting officers with authority to award contracts up to $100,000 or to place delivery orders under existing contracts.

m. Control Point. The division of monies from an appropriation to a specified service, activity or purpose.

n. Cost Center. A series of specific numerical digits assigned to a functional or?Šorganizational level for the purpose of classifying and accumulating costs applicable to that particular functional or organizational level, e.g., Prosthetics, Fiscal, Pharmacy.

o. Delayed Order. A prescription or prosthetic request that the local Prosthetic Service is unable to administratively process or take action on within 5 workdays.

p. Denver Distribution Center (DDC). A centralized provider of devices, accessories and repair services to eligible veterans when requested by the health care facility with Primary Service Area (PSA) responsibility wherever the beneficiary may reside or sojourn; this includes certain replacement items at the veteran's request, and distribution of selected devices, accessories or services to other VA programs or activities as designated. Such devices, accessories or services include: selected electronic, mechanical or other aids for the blind, hearing aids, batteries for hearing aids, provision of hearing aid repairs through internal or contract sources, orthopedic software, and such other items or services which may be designated by appropriate VHA Headquarters Program Officials.

q. Disability Codes. Decision Support System (DSS) identifiers assigned to a patient for specific disabilities.

r. Durable Medical Equipment (DME). Items determined to be medically necessary for home treatment including invalid lifts, hospital beds, commodes, etc.

s. Driver Rehabilitation Centers. Facilities specifically funded and equipped to train appropriate veteran beneficiaries to drive a motor vehicle independently and in accordance with State Department of Motor Vehicle regulations.

t. Enrollment. Effective October 1, 1998, VA is required to enroll patients annually and to ensure that enrollees receive health care. Veterans seeking care for service connected disabilities, and veterans with service connected disabilities rated at least 50 percent are exempt.

u. Federal Acquisition Regulation (FAR). The primary document in FAR system contains policies and procedures contained in regulations which govern all purchasing activities for Federal agencies.

v. Federal Procurement Data System (FPDS). A mechanism of collecting, developing, and disseminating procurement data to Congress, the Executive Branch, and the private sector, as directed by Pub. L. 93-400.

w. Health Care Procedural Code (HCPC). Medicare created HCPCS, the Health Care Financing Administration's Common Procedure Coding System, for the purpose of universal cost coding. This system has been adopted by VHA as a national mechanism of common identification. The codes are assigned to appliances, devices, medical equipment and supplies provided to patients. Each code corresponds to the Health Care Financing Administration (HCFA) designated 5-digit identifier or VA-unique 5-digit identifier.

x. Home Improvement and Structural Alterations (HISA) Committee. A committee composed of professional and ancillary service personnel responsible for determining whether requested benefits are necessary and appropriate for the effective and economical home health treatment of a veteran's disability. Requests may include, but are not limited to: construction of wheelchair ramps (permanent only), widening doorways for wheelchair access, lowering kitchen cabinets or counters for use by a wheelchair patient, improve otherwise inaccessible entrance paths and driveways, etc.

y. Integrated Funds Distribution, Control Point Activity, Accounting And Procurement (IFCAP). A fiscal accounting software package that automates fiscal, budgetary, inventory, billing and payment activities.

z. Item Master File. A listing which provides a full description of the item, related stock numbers, vendors, contract numbers and a procurement history.

aa. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A national independent accreditation organization which certifies health care organizations such as hospitals as compliant with its promulgated standards.

bb. Last Clinic. Facilities established at select VA medical centers which are staffed, funded, and equipped to develop lasts, perform measurements, cast patterns, and make modifications to/for custom-made orthopedic shoes.

cc. Major Appliances. Includes all custom-made prosthetic appliances, items of medical equipment which cost more than $6,000, artificial limbs and specialty equipment, e.g., Clinitron beds, communication devices, environmental control units.

dd. Major Medical & Special Equipment Committee (MMSEC). A committee composed of medical, therapy, engineering and allied health personnel who are knowledgeable about prosthetic equipment and rehabilitation responsible for reviewing requests and determining medical need for major items of prosthetic equipment.

ee. Major Medical Special and/or Experimental Appliances. Any newly developed or unusual non-contract orthopedic appliance, therapeutic or rehabilitative device, regardless of cost, which has not been previously issued by the health care facility.

ff. Medical Supplies. Expendable items generally required on a recurring basis for home treatment of specific disabilities, including supplies required for home hemodialysis.

gg. National Prosthetics Patient Database (NPPD). A compilation of statistical data extracted from each VA medical center's entries to the prosthetics package, reflecting both fiscal obligations and completed patient transactions.

hh. Patient Satisfaction Program. A survey and analysis of patient evaluation of prosthetic services provided by the VA.

ii. Preservation Amputation Care and Treatment (PACT). Model of care developed to prevent or delay amputation through early identification of patients who are at risk for limb loss.

jj. Primary Service Area (PSA) for Prosthetic Services. A defined geographical area responsible for providing complete prosthetic services, including the administration of HISA,?ŠHome Oxygen Therapy, Automobile Adaptive Equipment and Clothing Allowance Programs.

kk. Prosthetic Appliances. All aids, devices, parts or accessories which patients require to replace, support, or substitute for impaired or missing anatomical parts of the body. The items include artificial limbs, terminal devices, stump socks, braces, hearing aids and batteries, cosmetic facial or body restorations, optical devices, manual or motorized wheelchairs, orthopedic shoes, and similar items.

ll. Prosthetics. A broad term used to identify the total concept associated with replacing, supporting and/or complementing human anatomy impaired or destroyed as a result of trauma or disease. This term may be used to refer to orthotics, sensory aids, medical equipment, medical supplies, components, research, education and training, appliances, services, repairs, and any other related aspects of administering the total program.

mm. Prosthetic-Orthotic Laboratories. Facilities established at select VA medical centers to design, fabricate, repair and fit custom-made prosthetic appliances.

nn. Prosthetics Program. Includes any Prosthetic Treatment Center, Prosthetic and Sensory Aids Service, or section established in a VA field facility charged with the responsibility for the provision of prosthetics at that facility.

oo. Prosthetics Purchasing Agent. An employee in a VA medical center who is certified under COCP and specifically designated and trained to procure prosthetic appliances and repairs, thereof, usually at the simplified acquisition level.

pp. Prosthetics Treatment Center (PTC). A VA facility with an established Amputee Clinic Team, experienced prosthetic staff and Physical Medicine and Rehabilitation personnel capable of providing assistance necessary to resolve difficult prosthetic problems. These centers normally have a substantial number of special medical programs, i.e., Spinal Cord Injury Service (SCIS), Spinal Cord Injury Outpatient Support Clinic (SCI/OSC), Visual Impairment Services Team (VIST), Hospital Based Primary Care (HBPC), Prosthetic-Orthotic Laboratory (POL), Restoration Clinic (RC), Blind Rehabilitation Center or Clinic (BRC), Driver Rehabilitation (DR), Geriatric Research, Education and Clinical Center (GRECC), etc.

qq. Prosthetics Representative. A VA employee who is a patient advocate, manages the prosthetic program, and ensures that adequate resources are available to meet the medical needs of veterans requiring prosthetic services.

rr. Prosthetics Representative Management Trainee (PRMT) Program. An established educational experience designed to develop professionally competent personnel to conduct and manage the Prosthetic Program at a VA medical center.

ss. Prosthetic Request. An appropriately written medical prescription or electronic request by an authorized clinician, or patient's request for replacement of an issued item/service requiring action by the Prosthetic Service.

tt. VA Form 10-2501, Prosthetic Service Card (PSC). A debit-card issued to eligible beneficiaries authorizing repairs for artificial limbs, wheelchairs, braces, and aids for the blind. This card usage is limited to repairs.

uu. Prosthetic Stock Items. Any item of medical equipment, or prefabricated prosthetic appliances, or parts or components thereof, which has been procured with allocated medical funds, and which is currently stocked by a Prosthetic program for direct issue to eligible beneficiaries. This includes donated and/or reclaimed items of equipment.

vv. Prosthetic Surgical Implants. Artificial devices implanted in the patient to replace, support or substitute for deformed or weakened anatomical parts of the body, e.g., artificial hips, knees or other joints; cardiac pacemakers, heart valves, or implantable cardiac defibrillators; intraocular lenses, prosthetic arteries, penile implants, implantable nerve stimulators, etc.

ww. Purchase Card. A card similar to a credit card, with a pre-set monetary limit, used to pay for goods or services acquired by authorized and designated employees for the official VA use.

xx. Reconciliation. The process by which Integrated Funds Distribution, Control Point Authority, Accounting and Procurement (IFCAP) obligations are made compatible with invoices received for purchases initiated by a Purchase Card through the Veterans Health Information systems and Technology Architecture (VISTA) software package.

yy. Required Sources of Supplies and Services. Sources identified in Federal Acquisition Regulation (FAR) Part 8 that have priority as sources from which to acquire goods and services.

zz. Restoration Laboratory. Facilities established at select VA medical centers which custom-make artificial eyes, facial and body restorations, and similar appliances.

aaa. Sensory Aids. Items and/or devices designed to compensate for deficiencies in sense organs, e.g., hearing aids, optical prescriptions, low vision and mobility aids, speech and communication aids, etc.

bbb. Spina Bifida. A developmental anomaly characterized by defective closure of the bony encasement of the spinal cord, through which the cord and meninges may protrude.

ccc. Strategic Healthcare Group (SHG). A multidisciplinary group of personnel and programs organized generally to support the provision of a continuum of care to a specified population of patients or care in a particular setting. The SHG functions by integrating data, skills and best practices into system-wide policy, planning and service delivery through the development of clinical care strategies and decision support mechanisms.

ddd. Transaction. Any action with permanent numbering that affects a bill or an account that identifies a request; consisting of the Station Number - Fiscal Year - Quarter - Control Point Sequence Number.

eee. Vendor Master File. A listing which contains ordering and billing addresses, contract information, FPDS information and telephone numbers of businesses.

fff. Department of Veterans Affairs Acquisition Regulations (VAAR). Policies and procedures which pertain directly to procurement performed by the VA. These policies supplement FAR and will not duplicate it.

ggg. Veterans Integrated Service Network (VISN). A geographical area designated by the Department of Veterans Affairs Headquarters for the purpose of basic budgetary and planning of the veterans healthcare system. Each VISN will be led by a Director who will report to the VHA Chief Network Officer.

hhh. Visual Impairment Services Team (VIST). Health care and allied health care professionals charged with the responsibility for determining the comprehensive services required by a visually impaired veteran.

iii. Wheelchair Committee Clinic. A locally established team composed of a physician, rehabilitation therapist, and prosthetic representative charged with evaluating, refining,?Š and developing prescriptions for wheelchairs.

1.4. Prosthetics Services Authorized

a. Provision of Appliances and Repairs. VA will provide prosthetic appliances, aids for veterans who are blind, medical equipment, including repairs when required for the medical treatment of any veteran eligible for such services.

b. Acquisition of Prescribed Appliances and Repairs. After required approval, prescribed appliances and/or repairs will be furnished in accordance with the policies and procedures outlined in this manual and other pertinent directives. Purchase of appliances will be made in accordance with FAR and VAAR.

c. Inspection of Appliances or Equipment. Custom fit appliances will be inspected to insure that they have been fabricated according to prescription and that they function/fit properly.

1.5. Responsibility for Rendering Services

a. Prosthetic and Sensory Aids Services (PSAS) Programmatic Responsibilities. PSAS programmatic responsibilities will include, but are not limited to the following:

(1) Inspecting and evaluating artificial limbs and other custom-fitted devices for which replacements have been requested, and authorizing replacement of identical appliances when no medical problem is evident.

(2) Evaluating custom-fitted appliances prior to delivery to patients, and recommending acceptance or rejection of such items to prescribing physicians, clinic teams, or special committees.

(3) Authorizing the issuance of a second appliance when indicated.

(4) Coordinating with the facility AMMS Service, or other office responsible for the acquisition program at the facility, the establishment of local contracts that will expedite delivery of prosthetic appliances and/or services.

(5) Taking action to effect a beneficiary service contract for the purchase, delivery, set-up, instructional use and recovery of medical equipment. Items of equipment and supplies may include, but are not limited to the following items: hospital beds, trapeze assemblies,?Š attresses, over-the-bed tables, bedside commodes, patient lifts, oxygen equipment and respirators. Provisions for repair and storage may be included in these contracts. NOTE: Compliance with JCAHO and CARF Home Standards is required.

(6) Establishing formal systematic follow-up procedures to review all pending orders.

(7) Counseling beneficiaries concerning their eligibility to receive prosthetic appliances, devices, accessories, repairs, replacements, spares, and related training. NOTE: Notations of counseling are documented in appropriate medical records of beneficiaries.

(8) Providing liaison support and assistance to other facilities regarding the procurement?Š and delivery of prosthetic items and services.

(9) Implementing, maintaining, and monitoring a VA equipment accountability program in accordance with this manual.

b. Procurement Actions. All procurement actions for prosthetic items and/or services for Prosthetic Representatives, who are legally eligible for such treatment, will be approved by their immediate supervisor. The exception to this policy concerns requests for automobile adaptive equipment, which require the approval of the VISN Prosthetic Representative, and the Chief Consultant, Prosthetic and Sensory Aids Service (PSAS) SHG, VA Central Office.

c. Facilities without a Chief, PSAS

(1) The Chief of Staff will designate a staff physician to be responsible for the clinical aspects of the Prosthetic Program. This physician will be professionally responsible for the supervision of the development of prescriptions for appliances, evaluation of appliances prior to delivery to the veteran, condemnation of existing devices, and determination of the need for repairs. The administrative aspects of the program include, the determination of eligibility and/or entitlement; procurement; repairs, etc., will be supervised by the VISN Prosthetic Representative designated by VISN Director.

(2) An employee designated as prosthetic purchasing agent is responsible to the VISN Prosthetic Representative for all processing, clerical, accounting, and reporting duties?Š inherent in the administration of a limited Prosthetics Program.

d. Prosthetic Service Area?Š(PSA)

(1) The Directors of each of the VA medical centers will identify the geographical area to be served by each health care facility.

(2) Each medical center with a prosthetics program will provide all prosthetic services, consistent with its primary service area, including the administration of the Automobile Adaptive Equipment, HISA, Home Oxygen Therapy, and Clothing Allowance Programs, etc.

e. Furnishing of Special and/or Experimental Appliances. Replacement of an experimental appliance still considered in the experimental phase will not be authorized without specific VHA Headquarters approval in each case.

f. Furnishing of Appliances to Beneficiaries in other Federal Facilities, Non-VA Nursing Homes or other Institutions, State Veterans Homes, and Penal Institutions

(1) Other Federal Facilities. Appliances required for treatment in another Federal facility will normally be furnished under the Federal reciprocal per diem rate. When the other Federal facility is unable to furnish the appliances, or the item is not within the purview of the reciprocal per diem rate and is necessary for completion of hospital treatment or to affect discharge, the device will be provided by the Prosthetic Service with PSA responsibility authorizing the hospitalization.

(2) Non-VA Nursing Homes or Other Private Institutions

(a) Prosthetic appliances, medical equipment, and supplies will not be furnished to a veteran receiving community nursing home care at VA expense if the community nursing home is required by contract to provide that appliance, equipment, or supply item. Items normally required by contract are those which are for general use, e.g., hospital beds, mattresses, trapeze assemblies, side rails, over-bed tables, bedside tables, etc. Items which are not required to be furnished by a community nursing home by contract are those which are intended for the personal use of the veteran, e.g., artificial limbs, braces,?Š hearing aids, eyeglasses, walkers, canes, crutches, wheelchairs, cushions, etc.

(b) Prosthetic appliances, medical equipment, and supplies will not be furnished to a resident of a State veterans home on whose behalf VA aid payments are being made if the home is required to provide the appliance, equipment, or supply item by regulation. Items normally required by regulation are those which are for general use, e.g., hospital beds, mattresses, trapeze assemblies, side rails, over-bed tables, bedside tables, etc. Items which are not required to be furnished by a State home regulation are those which are intended for the personal use of the veteran, e.g., artificial limbs, braces, hearing aids, eyeglasses, walkers, canes, crutches, wheelchairs, cushions, etc.

(3) Penal Institutions. Appliances and/or repairs will be furnished to eligible veterans serving sentences in penal institutions who can present themselves for the required medical treatment. Before processing the application, prison officials must be advised and there must be an understanding that the veteran be able to report to the field facility, or to such other place as the field facility may direct, for any necessary measurements, fittings, or follow-up examinations. VA accepts no responsibility for the veteran's custody or actions during absence from the penal institution; written acknowledgment of same should be obtained prior to scheduling treatment. VA facility police will be notified whenever an incarcerated veteran is being treated.

g. Furnishing Appliances to Beneficiaries Residing or Sojourning in Foreign Countries or in Territories or Possessions of the United States

(1) Prosthetic appliances, sensory aids, aids for the blind, medical equipment, medical supplies, and/or repairs thereto will be furnished to eligible service-connected veterans sojourning or living in foreign countries or in U.S. Territories or possessions by referring the requests to the VA Health Administration Center, Denver, CO. Veterans residing in Canada will contact the VA Medical Center, White River Junction, VT. Stump socks and hearing aid batteries will be issued by the DDC, Denver, CO.

(2) Eligible beneficiaries who reside in a foreign country are entitled to prosthetic services at any VA facility with PSA responsibility when visiting the United States.

h. Furnishing of Appliances to Allied Beneficiaries Residing in the United States.

Appliances will be furnished to allied beneficiaries residing in the United States by the Prosthetic Service with PSA responsibility in accordance with M-1, Part I, Chapter 24.

i. Furnishing of Appliances as Loaned Items

(1) Any items or DME valued at $6,000 or more furnished to eligible beneficiaries may be loaned. Such loaned items will be prorated at 20 percent per year, and dropped as a loaned item upon being de-valued to zero dollar amount. Items and or DME may be loaned as "short-term" to beneficiaries with temporary disabling conditions or with poor prognoses, irrespective of cost.

Items previously loaned, but returned to VA and subsequently issued as a "VA stock" item will not be routinely loaned again. Examples include, but are not limited to hospital beds, wheelchairs, invalid lifts, etc.

(2) Form Letter (FL) 10-219, Notice to Veteran of Loan of Medical Accessories and Receipt Therefore, as provided through the correspondence option of the prosthetic software will be used to notify the veteran of the terms and conditions of the loan.

(3) Veterans with items and/or DME on loan will be permitted to take the items and/or DME to a new residence within another field facility's PSA. Records will be transferred to the responsible field facility to permit the necessary follow-up. Reclamation will be managed by the Prosthetic Service with PSA responsibility where the beneficiary resides.

(4) Loan items and/or DME provided to beneficiaries for which VA receives payment from a private insurance company under the Medical Care Cost Recovery (MCCR) Program will be permanently issued and dropped from all loan records.

(5) Whenever a veteran is initially furnished items and/or DME on a loan basis, FL 10-426a, Information Letter-Major Medical Equipment, will be provided advising the veteran of VA's policy concerning repairs, maintenance, recovery, etc. This form should be utilized via the correspondence option of the prosthetic software for recording to VA Form 10-2319 (ADP), Record of Prosthetic Service.

(6) Prior to initiating recovery action on any items and/or DME, the Prosthetic Service will make a comparison of the cost of recovery and the residual value of an item to determine the economic feasibility of recovery.

j. Replacement and Second Appliances

(1) Appliances will not be replaced until a feasibility determination is made by an?Šauthorized VA official that the current appliance is unsatisfactory for further use by the beneficiary.

(2) Second appliances may be furnished to eligible beneficiaries only after determination of need in each specific case. Such determination will be based on the seriousness of the disability, availability of adequate local facilities for prompt repair of the particular appliance and individual need of the beneficiary concerned.

(3) Replacement and second appliances that are serviceable and still meet the veteran's overall need, as determined by the Prosthetics Activity in consultation with the contractor and inhouse VA medical center committees, will not be replaced for the sole purpose of obtaining a newer model of the same or similar equipment. When substantiated abuse of the equipment can be documented as the basis to expedite replacement, the average useful life of the appliance will be established from the date of issue and applied in determining if replacement will be made.

k. Prosthetic Stock Items.

(1) A supply of prosthetic stock items is authorized for any VA facility to meet the immediate needs of the veteran population. This may include a variety of items of medical equipment, non custom-fitted appliances and select medical supplies. These items will be maintained and accounted for by Prosthetic Program Officials, or a designated official, in a VA field facility not having an established Prosthetic program.

(2) Program officials will compare issue and stock control record balances with the actual shelf inventory not less than on a quarterly basis. Stock record adjustments will be made for normal differences and an investigation will be made if abnormal and frequent discrepancies are discovered. Item usage will be reviewed to adjust stock and re-order levels on a locally established basis and should not exceed a 30-day supply.

(3) When equipment is stored by a contractor under the provisions of a local beneficiary delivery and/or service contract, program officials will review inventory levels on a monthly basis and compared to the stock control record affecting the delivery and/or service contract.

(4) Program officials will routinely inspect stock items during inventory reconciliation with special consideration given to appliances that deteriorate because of age or climatic conditions, that require special storage facilities such as refrigeration, darkness, security provisions, require repair or modification, or are surplus because of age, condition, or obsolescence, etc. Items which are identified as being excess to needs should be turned-in to Acquisition and Materiel Management Service, or the facility Accountable Officer, via VA Form 2237, Request, Turn-in, and Receipt for Property or Services.

1.6. VHA Headquarters Organziation and Responsibility

The Chief Consultant, Prosthetic and Sensory Aids Service (PSAS) Strategic Healthcare Group (SHG), recommends policies, plans, operational directives and professional standards pertaining to a unified and comprehensive VA prosthetic program, and coordinates activities with the other VHA Headquarters elements. In that connection, the Chief Consultant is responsible for:

a. Overall field consistency of the program; this includes field facility Prosthetic Programs, Prosthetic Treatment Centers, Prosthetic-Orthotic Laboratories, Orthopedic Shoe Last Clinics, Restoration Clinics, and Amputee Clinic Teams.

b. Analyzing, evaluating and responding to reports of audit, survey, and review teams, including recommendations made by the veteran service organizations.

c. Recommending standards, technical specifications and proposals for artificial limbs, wheelchairs and other contracts.

d. Rendering opinions on prosthetic matters to the Board of Veterans Appeals and Veterans Benefits Administration staff as requested.

e. Answering professional inquiries and controlled correspondence pertaining to the prosthetic program, as requested.

f. Preparing and maintaining a system of handbooks, directives, information letters, bulletins, and program guides covering pertinent aspects of the prosthetic program.

g. Maintaining a system of prosthetic program review and evaluation for purposes of management effectiveness by conducting planned and recurring visits to field facilities.

h. Conducting studies of program operations, preparing analyses of results, and implementing policy, standards or indicated procedural changes.

(1) Analyzes data related to workload, staffing, and special programs of field facilities.

(2) Reviews, evaluates, and/or coordinates with pertinent Clinical Program staff, requests for unusual or experimental prosthetic devices submitted by VA field facilities.

i. Analyzing and submiting data related to prosthetic program workloads, space allocations and staffing at VA field facilities to appropriate VHA Headquarters activities.

j. Assisting field facilities in recruiting, selection, and evaluation of various categories of prosthetics personnel.

k. Collaborating with the Employee Education Service in formulating and developing educational programs spanning the field of prosthetics, for professional, technical, and administrative staffs.

(1) Coordinates and supervises a centrally directed and funded training program for prosthetic representatives, orthotists, prosthetists, and restoration technicians.

(2) Authorizes VHA Headquarters' representatives or qualified field facility prosthetic representatives to conduct on-site evaluations of field facility prosthetic operations (in coordination with medical center staff), and provides the facility staffs with technical and operational training as indicated.

l. Planing and preparing prosthetic workshops, conferences, ad hoc committee meetings for VHA Headquarters, VISN, and field facility staff involvement in the broad areas of prosthetics.

m. Collaborating with responsible Program Officials, Rehabilitation Research and Development, Blind Rehabilitation, Physical Medicine and Rehabilitation, Spinal Cord Injury, Audiology and Speech Pathology, etc., relative to formulating and developing programs and projects that will benefit patients receiving prosthetic services.

n. Recommending short- and long-range plans pertaining to the prosthetic programs.

o. Preparing and submitting requests for General Counsel opinions on legal issues that arise in the administration of the program; such as, the scope of authority to furnish unusual appliances or services recommended for veteran patients.

p. Coordinating and administering the automobile adaptive equipment benefit program within VHA.

q. Coordinating and administering the clothing allowance benefit program within VHA.

r. Coordinating and administering the HISA Program benefit program within VHA.

s. Participating in professional meetings, conferences, national assemblies and Network meetings of the American Orthotic and Prosthetic Association, national service organizations, other Government agencies, educational and scientific institutions and private groups where necessary to represent the department and/or program in the broad field of prosthetics. This includes activities associated with the development, implementation and improvement of recognized national voluntary standards for prosthetic and sensory aids.

t. Maintaining current and historical records of activities of the prosthetic and sensory aids program.

1.7. Prosthetic Funding Management

In order to monitor, maintain and continually improve the fiscal accountability of prosthetics funding, all VA facilities will submit a budget plan by quarter each fiscal year to local designated management official for approval. This plan will be reviewed by the financial staff of the VISNs and PSAS Program officials to develop and implement a quarterly funding and workload analysis to monitor all prosthetic cost centers. The budget plan should be based on historical expenditures and projected need.

a. General Costing Instructions by Cost Center

(1) 8272 - Prosthetic Program. Includes cost for new and repair prosthetic equipment, appliances, devices, etc., for patients.

(2) 8201 - Medical. The cost of surgical implants (for the device only) when performed by Medical Service personnel, e.g., cardiac pacemakers, defibrillators, etc. NOTE: Do not include the cost of related items or equipment, e.g., sutures, staples, clips, pliers, etc.

(3) 8202 - Surgical. The cost of surgical implants (for the device only) when performed by Surgical Service personnel, e.g., artificial hips, knees and other joints, heart valves, galvanic nerve stimulators, dorsal column stimulators, intra-ocular lenses, vascular prostheses, bladder neck prostheses, etc.

(4) 8265 - Denver Distribution Center. Includes the cost incurred for hearing aids; hearing aid batteries, parts and accessories; prosthetic stump socks; prosthetic feet; flexible orthoses, etc.

(5) 8266 - Orthopedic Shoe Service. Includes the cost of centralized orthopedic shoe program (VA Medical Center, New York, NY, National Footwear Center only).

(6) 8273 - Orthotic Laboratories. Includes the cost of materials and components used in the fabrication of orthotic and/or prosthetic devices and prefabricated devices custom fitted to the patient (limited to VHA Headquarters-approved Prosthetic-Orthotic Laboratories).

(7) 8274 - Restoration Clinic. Includes the cost of materials used in the fabrication of cosmetic restorations, e.g., artificial eyes, ears, noses, etc., and supplies (limited to VA Central Office approved Restoration Clinics). November 2, 2000 VHA HANDBOOK 1173.1 15

(8) 8211 ‘«Ű Dialysis. Include the charges for home dialysis activities only when provided by services other than Prosthetics.

(9) 8364 - Contract Dialysis. Include the costs for supplies and equipment when provided under contract through Medical, Surgical, or Prosthetic Services. NOTE: Do not duplicate costs charged under Cost Center 211 and 272.

b. General Costing Instructions by BOC

(1) 2551 - Prosthetic Contractual Services. Includes repair and all contractual agreements and services required to provide prosthetic appliances, sensory aids, cosmetic restorations and sickroom accessories and equipment; veterinary treatment for guide dogs; repairing and reweaving of clothing damaged by wearing of prosthetic appliances, and is restricted to services furnished beneficiaries.

(2) 2574 ‘«Ű Home Oxygen Program. Includes the cost of home oxygen contractual agreements, rental fees for concentrators, portable systems, and cylinder contents or liquid contents.

(3) 2674 ‘«Ű Oxygen Supplies. Includes the purchase cost of oxygen equipment and supplies for home oxygen use.

(4) 2692 - Prosthetic Supplies. Includes the cost of all aids, appliances, parts or accessories which are required to replace, support, or substitute for a deformed, weakened, or missing anatomical parts of the human body. This includes complete prosthetic appliances, sensory aids, stump socks, hearing aid batteries, cosmetic restorations, medical accessories, dental maxillofacial prostheses and related implants and raw materials used in the fabrication or repair of such items. All prosthetic devices implanted in the patient; includes cardiac pacemakers, heart valves, artificial joints, intra-ocular lenses, prosthetic arteries, penile implants, medication pumps, neurostimulators, etc., are to be costed to Cost Center 8201 or 8202 under this sub-account.

(5) 2693 - Home Dialysis Equipment and Supplies. Includes the cost of dialysis equipment and recurring prosthetic supplies provided to veterans under the Home Dialysis Program.

1.8. Prosthetic Reports

a. Delayed Prosthetic Orders

(1) A delayed prosthetic order is an appropriate prosthetic request that affects the care and treatment of the beneficiary that has not been acted upon within 5 workdays. Requests for payment of PSC repairs, home oxygen invoices, invoices for services rendered, and disputed payment claims are not counted as delayed orders. Different items on the same request, will be counted in direct relationship to the number of individual sources required to fill the request.

(2) The number of orders will normally approximate the number of requests received and may be less than the number of items issued. All VA medical centers will submit a monthly report to the appropriate Network Director on delayed prosthetic orders.

b. National Prosthetic Patient Data (NPPD). A compilation of statistical data extracted from each VA medical center entries to the Prosthetic Package reflecting both fiscal obligations and completed patient transactions. This quarterly report, divided into new and repair sections, is designated by categories of items and services. Each category is sub-divided by unique numerical identifier, which is mapped by Health Care Procedural Codes (HCPC). This report replaces the Automated Information Management System (AMIS) as the primary collection method for this information.

c. Special Reports. Specified data requested to inform the Secretary, Under Secretary of Health, Congressional Committee inquiry, etc. about program performance, expenditures and related issues. Instructions for such reports will be disseminated to the field facilities.

d. Quality Improvement Reports (QIR). Documented evidence of substandard quality or performance of contracted equipment. Upon discovery, the Standard Form (SF) 380, Reporting and Processing Medical Material Complaints/Quality Improvement Reports, will be annotated and forwarded to the VHA Chief Financial Officer (176) through PSAS VHA Headquarters. Concurrent notification electronically will be accomplished concerning each QIR filed.

1.9. Basic Records and Forms

a. VA Form 10-1394 , Application for Adaptive Equipment-Motor Vehicle. A standardized document that authorizes the necessary equipment or adaptations for ingress, egress, and safe operation of an automobile or other conveyance.

b. VA Form 10-2319 (ADP), Record of Prosthetic Service. A form that will be created as a consolidated record of prosthetic services furnished to all beneficiaries. This form serves as the basic document of reference, and features screens of information. It will be initially prepared by the Prosthetic Program with PSA responsibility for wherever the veteran resides. The screens are:

(1) Screen 1 - Patient Demographics. Screen 1 contains the veteran's name, address, patient identification number (SSN), next of kin, prosthetic disability code(s), and veteran's eligibility (rating).

(2) Screen 2 - Clinic Enrollments/Correspondence. Screen 2 contains information about the veteran's hospital admissions and discharges, clinic enrollments, pending appointments, and correspondence. NOTE: One may create or view a letter to the veteran through this screen.

(3) Screen 3 - Entitlement Information. Screen 3 contains PSC information, Clothing Allowance, Automobile Adaptive Equipment, and Loaned Equipment data.

(4) Screen 4 - Appliance Transactions. Screen 4 contains all information regarding new appliances and repairs. Inquiries to individual transactions may be found on the sub-screen for each item.

(5) Screen 5 - Automobile Adaptive Equipment. Screen 5 contains all information concerning each vehicle and modifications under the adaptive equipment program. This screen should only be used for beneficiaries who are eligible under Pub. L. 91-666, Pub. L. 96-466, or Pub. L. 97-66.

(6) Screen 6 - Critical Comment. Screen 6 allows for entry of information that may be important to providing service to the beneficiary.

(7) Screen 7 - Add/Edit Disability Code. Screen 7enables the user to record a disability code to the record of prosthetic services.

(8) Screen 8 - Home Oxygen Program. Screen 8 contains all information concerning prescribed delivery systems, supplies, and associated costs.

c. VA Form 10-2341, Stump Sock Record. A document used to establish entitlement to receive stump sock from DDC at the beneficiary's request.

d. VA Form 2345, Veteran's Request For Stump Socks. A document used by the beneficiary to request replacement stump socks from DDC, when VA Form 10-2341 has been established.

e. VA Form 2346, Veteran's Request For Hearing Aid Batteries. A document used by the beneficiary to request batteries from the DDC.

f. VA Form 10-2421, ADP Prosthetic Authorization for Items or Services. A procurement document used to purchase new items and services for individual beneficiaries, to include the repair of same.

g. VA Form 10-2431, Request for Prosthetic Services. This is a physician's authorization, either manual or electronic, to provide a prosthetic item and service.

h. VA Form 10-2501, Prosthetic Service Card (PSC). This is a debit-card issued to eligible beneficiaries authorizing repairs for artificial limbs, wheelchairs, braces, and aids for the blind. This card is limited to repairs.

i. VA Form 10-2520, Prosthetic Service Card Invoice. This form is generated by a vendor for those PSC repairs which do not exceed the monetary limit.

j. VA Form 10-2529-3, Request and Receipt for Prosthetic Appliances or Services. A document used to obtain orthotics, prosthetics, restorations, and footwear from other VA facilities.

k. VA Form 10-2641, Authority for Issuance of Special and/or Experimental Appliances. A document requesting written authority to provide items designated for mandatory approval, high cost items, non-contract items, and for the purpose of advising VHA Headquarters, PSAS SHG of unusual field facility requests.

l. VA Form 10-2914, Prescription and Authorization for Eyeglasses. A procurement document for the purpose of prescribing and purchasing corrective lenses and frames.

m. VA Form Letter 10-55, Authority to Exceed Repair Costs of Prosthetic Appliances. A letter of authorization forwarded to a provider of PSC repairs, when the cost of that repair exceeds the limit authorized by the PSC. The letter should accompany the associated invoice.

n. VA Form 21-8678, Application for Annual Clothing Allowance. A form completed by the veteran or health care professional in which veteran's disability and prosthetic appliance is described and justification provided to request an annual clothing allowance.

o. VA Form 21-8679, Eligibility Determination for Clothing Allowance. A form used to enter appropriate eligibility information and document clothing allowance decisions made by the appropriate VA official.

2. VA Handbook 1173.2 - Furnishing Prosthetic Appliances and Services

2.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent national policy and procedures in furnishing prosthetic appliances to all eligible beneficiaries based upon the medical recommendations of Prosthetic Clinic Teams, staff physicians, or authorized fee-basis physicians. NOTE: Prosthetic staff will consider the recommendations of any private physician requesting a prosthetic appliance to treat a service connected condition, or any condition of a veteran 50 percent or more service connected.

2.2. Furnishing Appliances

a. In Department of Veterans Affairs (VA) facilities and VA nursing home care units, all prescriptions for appliances, repairs, or modifications requested for inpatients will be initiated sufficiently in advance of the patient's anticipated release date to permit procurement and delivery prior to discharge.

b. Special and non-routine prosthetic appliances will require approval of an appropriate committee, e.g., Major Medical and Special Equipment Committee (MMSEC), Home Improvement and Structural Alterations (HISA), VHA Headquarters, etc.

c. The Prosthetic representative will ensure compliance with the legal authority to provide services as outlined in Title 38, and ensure that the resources necessary to sustain a viable program are identified to appropriate top management officials.

d. The Prosthetic representative will review all requests from beneficiaries or their authorized representatives for determination of whether a previously provided appliance may be replaced or if circumstances indicate referral to the appropriate clinician for a new prescription.

e. In the absence of a Prosthetic representative, all requests from patients or their authorized representatives will be referred to a designated physician or the Prosthetic Team.

f. Personal equipment or appliances owned by a veteran, which have not been furnished by VA, may be added to the veteran's VA Form 10-2319 (ADP), Record of Prosthetic Service, at the veteran's request.

2.3. Stock Procurement

a. If the appliance is to be procured commercially, VA Form 2237, Request, Turn-in and Receipt for Property or Services, will be electronically prepared through the Veterans Health Information Systems and Technology Architecture (VISTA) software. The printed copy of the form will be retained as a delivery copy to compare with the item(s) received. Stock items may also be procured through use of the purchase card.

b. On receipt of the appliances at the facility warehouse, delivery will be made to the Prosthetics Service. If the received appliance meets the specification of the order, as verified by the suspense copy, VA Form 90-2138-7 (ADP), Order for Supplies or Service, will be signed and dated by an authorized receiving official.

c. Purchase Order Number. The purchase order number is assigned sequentially by the Integrated Funds Distribution, Control Point Activity, Accounting and Procurement (IFCAP) process at the time the order is obligated. The purchase order number from VA Form 90-2138-7 (ADP) will be used to exercise the option 'Record 2237 Purchase to 2319' after receipt. In recording the transaction to the VA Form 10-2319 (ADP), simultaneous posting to the National Prosthetic Patient Database (NPPD) occurs. The provision of items from stock is exercised through the Prosthetics software. Items and/or services are posted to the VA Form 10-2319 (ADP) and deleted from the quantity of existing stock.

d. Blanket Purchase Agreements (BPA). BPAs are designed to reduce the number of daily purchases and may be established for the purpose of obtaining large quantities of similar items and to benefit from quantity discounts. Under no circumstances should the existence of BPA for a particular product be used as a vehicle for denying issuance of a similar, non-BPA item that would be more appropriate for meeting a beneficiary's medical needs. These arrangements may be used jointly by several facilities. Items, equipment, and services obtained through BPAs are processed as described above using VA Form 2237.

e. Recommended Special and/or Experimental Appliance. If a special and/or experimental appliance is recommended for issuance to a beneficiary, VA Form 10-2641, Authorization for Issuance of Special and/or Experimental Appliances, will be prepared. Completion of this form is self-explanatory; however, a thorough and comprehensive justification for issuance of the requested item must be presented so that a proper decision can be made by VHA Headquarters personnel. In addition to the diagnosis, the following information will be required:

(1) A statement regarding the physical condition of the patient including an assessment of functional limitations and the reason why the particular device is needed.

(2) Reports of home visits (if applicable) including information on accessible space, floor plan layouts, available electrical power, or other factors effecting the use or installation of the requested equipment.

(3) Alternatives considered using more conventional devices or methods.

(4) The ability of the patient to use and operate the device and/or the availability of family members of family members or attendants to assist the veteran.

(5) Training provided to the veteran and/or family members.

(6) Illustrative literature or scientific articles (if pertinent) should be included particularly if the item is new to the market. VA Form 10-2641 will be signed by the appropriate physician, the Prosthetics representative, and will be forwarded to VHA Headquarters. A copy of the document will be held in suspense until a decision has been rendered. It is recommended that the "critical comment" on VA Form 10-2319 (ADP) be annotated to reflect the status of VA Form 10-2641. If the request is denied, the veteran will be notified of his appeal rights.

f. Approval for Issuance of the Special and/or Experimental Appliance. If approval for issuance of the special and/or experimental appliance is granted, the original VA Form 10-2641 will be returned to the field facility. On receipt of such approval, VA Form 10-2421 (ADP), Prosthetic Authorization for items or Services, or VA Form 2237 will be prepared in the usual manner, and a copy of the approval VA Form 10-2641 will be retained with the suspense copy of the procurement document as authority for procurement. It will be placed in the veteran's Consolidated Health Record upon receipt of the item and/or service.

g. Follow-up Procedures on All Pending Orders. All pending orders will be reviewed on a regular basis to determine that they are being processed in a timely fashion. Use of the IFCAP option List Purchase Card Transactions by Initiator ("LPCI") will identify obligated pending orders. Annotations to this list may include, but are not limited to: date of follow-up, person(s) contacted, general discussion, and changes in estimated delivery times.

2.4. Repairs to Appliances

a. Scope

(1) All parts procured or fabricated to replace existing parts or to modify a previously issued appliance will be considered as "repairs," regardless of whether installation is performed by a commercial source, a VA facility, or the beneficiary.

(2) Repairs will be obtained by use of either VA Form 10-2501, Prosthetic Service Card (PSC) or VA Form 10-2421, Prosthetic Authorization for Items or Services, or Purchase cards, whichever is most appropriate under the circumstances.

(3) PSCs shall be provided by all prosthetic programs at field facilities.

(4) Equipment repairs and services which may be authorized under the authority of PSCs include artificial limbs, aids for the blind and veterinary services for guide dogs, orthopedic braces, and wheelchairs.

(5) PSCs are limited to the following amounts:

(a) Blind aids and/or braces $100

(b) Wheelchairs $200

(c) Artificial limbs $300

(6) Invoices for repairs or veterinary treatment obtained under the authority of a PSC will be submitted to and paid for by the Prosthetic Service with Primary Service Area (PSA) responsibility where the veteran resides.

(7) When eligible beneficiaries requiring repairs to authorized appliances do not possess a PSC, prior approval for repairs must be given by the Prosthetic Representative, or designee, before payment of repairs can be made. NOTE: Exceptions to this policy are found in "Procedures for usage of PSC."

b. Responsibility

(1) Prosthetic representatives, or designated officials, are responsible for the overall administration of the PSCs, to include receiving and processing all PSC invoices submitted by vendors for repairs to appliances. Training will be provided to all subordinate staff with reference to what types of repairs are appropriate or acceptable cost limits that may be authorized on beneficiary appliances.

(2) Vendors are responsible for ensuring that the appliance being repaired is described on the PSC and for obtaining a Form Letter (FL) 10-55, Authority to Exceed Repair Costs of Prosthetic Appliance, when repairs exceed the authorized limitations of the card.

(3) Veterans are responsible for safeguarding their PSC, using it only for the identified appliance(s) and for updating as required. Veterans should take care to ensure that they do not sign a "blank" invoice, and to verify that the charges on the invoice are for services received.

c. Procedure

a. After determination of eligibility and review to assure that the beneficiary has no previously issued card, VA Form 10-2501 will be prepared.

(1) When an initial PSC is prepared, the date of preparation will be entered in the box "Date Card Issued"; subsequent cards will reflect this same initial date. "PSC/Entitlement Records" option in the VISTA Prosthetic software will be exercised to collect the data necessary for paying invoices.

(2) Beneficiaries with more than one type appliance for which a PSC is authorized will be furnished a separate PSC for each appliance.

(2) Limits for PSC Benefits

(a) Artificial Limbs. The price limitation of $300 will be entered in the appropriate space. The level of amputation, specification of left or right, of serviceable artificial limbs in the patient's possession, with the year of issue, will be entered in the description area for each amputation.

(b) Aids for the Blind. The price limitation of $100 will be entered in the appropriate space. The make, model, and serial number of each of the major aids in the patient's possession will be listed. When a dog guide is used, the breed and dog's name; e.g., "German Shepherd," "Fido," will be entered as one item and the harness as another.

(c) Orthopedic Braces. The price limitation of $100.00 will be entered in the appropriate space. The type of brace, specification of left, right, cervical spine, torso, etc., of serviceable orthopedic braces in the patient's possession, with the year of issue, will be entered in the description area.

(d) Wheelchairs. The price limitation of $200.00 will be entered. The make, model, and serial number of the authorized wheelchair(s) in the patient's possession, with the year of issue will be entered in the description area.

(3) Preparation and Issuance by Mail

(a) When a new or replacement PSC is requested by mail, and the personal information is not available, FL 10-216, Instructions for Issuance of New Prosthetic Service Card, will be developed through the VISTA Prosthetic software and mailed to the patient with a blank PSC and a return envelope.

(b) On return of FL 10-216, the signed PSC and the old card or statement confirming loss or destruction, the revised PSC will be processed and sent to the patient with FL 10-215, Prosthetic Service card instructions (Selected). The veteran's VA Form 10-2319 (ADP) will be annotated to reflect the issuance of the PSC.

(c) When preparing FL 10-215, the appropriate box explaining the reason for furnishing the PSC will be checked. If the PSC is replaced because of the issuance of a different appliance, the box requesting the destruction of the existing card will also be checked.

(d) When the personal information is available, the PSC will be processed and sent to the patient with a return receipt. Screen 6 of the VA Form 10-2319 (ADP) will be annotated to reflect the name of the signatory on the returned receipt.

(e) The patient will verify the information and sign the PSC in ink in the appropriate box. The PSC with FL 10-216 will be given to the veteran.

(4) PSC Invoices

(a) Upon the receipt of VA Form 10-2520, PSC Invoice, a purchase card obligation will be processed for the amount of the invoice using the control point assigned to repairs. In the event that it exceeds the PSC limitations, FL 10-55 will be employed.

(b) Every effort should be made to ensure that repairs that exceed the limitations of the appropriate PSC are authorized before the card limit is exceeded. There will be cases where the limit is inadvertently exceeded before proper authorization is given; however, this is unacceptable after more than one occurrence following documented notification from the repair source of the proper process. In such subsequent cases, only the card limit for the repairs will be paid, and a copy of the invoice will be returned with the balance marked as "unauthorized repair."

(c) The preparation of two separate invoices to cover a repair exceeding established PSC limits will not be approved for payment; invoices will be prepared only for each incident of repair to appliances.

(5) Preparation and Processing of Invoices

(a) After repairs have been accomplished, the vendor will prepare invoices as illustrated on the reverse side of the PSC. VA Form 10-2520 may be used and will be furnished to vendors by the authorizing VA field facility on request. Verification will be required, to the best of the patient's ability, of the repair information and charges listed on the invoice to ascertain that the total charges have been typed or entered in ink or indelible pencil in the appropriate space on the invoice, and to sign the original only of the invoice, using the same signature as that on the PSC. Under no circumstances should the patient ever sign a blank PSC invoice. Verifiable indications of such occurrence may result in cancellation of the abusing beneficiary's PSC.

(b) The vendor will forward the original invoice and one copy, and the original FL 10-55, if applicable, to the VA field facility indicated on the PSC.

(c) On receipt of such invoices, the following actions will be taken:

1. The invoice will be entered into the Prosthetic VISTA software "suspense" option identifying the invoice amount and vendor.

2. The description of the appliance repaired and the issuance of a PSC will be checked against the information posted on the VA Form 10-2319 (ADP). Repair invoices for artificial limbs, aids for the blind, and braces should be compared to delivery dates; wheelchairs should be compared by serial numbers.

(6) Other Authorized PSC Repairs

(a) Price Limitations. Price limitations have been established for each appliance for which PSC repairs have been authorized. These are clearly defined on each PSC and may not be exceeded except in the following circumstances:

1. If a PSC is presented to a VA Orthotic Laboratory, any necessary repairs will be made without further authority, provided facilities and necessary parts or supplies are available, and the cost of the repairs do not exceed 50 percent of the cost of a replacement item. If the cost exceeds 50 percent, the Prosthetic representative with PSA responsibility over the veteran's treatment will be contacted for authorization to repair or replace the device.

2. On presentation of a PSC at any VA field facility with medical activities, the patient will be entitled to all required prosthetic services in connection with the appliances listed on the card, as well as to other appliances or accessories obviously required because of the condition for which the card was issued.

3. Major repairs to appliances in excess of the limitation listed on the PSC, or emergency replacement of such an item if medically indicated, will be provided without the necessity for prior eligibility certification from the field facility exercising jurisdiction over the veteran's case. Requests for prosthetic services under such circumstances will be processed as follows:

a. The patient will be immediately referred to an appropriate physician (if necessary) for examination and medical determination of need for the requested major repair or replacement.

b. If authorized, the Prosthetic representative, or designee, will make all necessary arrangements, in accordance with existing policies and procedures, to obtain immediate repairs or replacement. NOTE: Such cases will be processed as emergencies and every effort will be made to expedite service to the patient.

c. The field facility authorizing and procuring repairs or replacement appliances will be obligated for payment of all costs incurred, except for costs of any repairs obtained under direct authority of the PSC.

d. When any device is in the process of being repaired by a commercial vendor under the authority of a PSC, and it is found that more extensive repairs are absolutely essential to restore the device to serviceable condition, the vendor should immediately contact the Prosthetic representative of the field facility listed on the card. A full explanation of the situation and the total estimated cost for the repairs will be obtained from the vendor. A determination will then be made as to what action is to be taken in the case. If it is agreed that the repairs are necessary and economically feasible, FL 10-55 will be prepared by the Prosthetic activity.

e. If the quoted cost appears to be excessive for any reason and no emergency exists, the device (preferably with the patient) will be referred to the Prosthetic Service for clinical evaluation and possible replacement. If the need is emergent, minimal repairs will be authorized and the patient will be scheduled for examination.

f. If all of the conditions of preceding subparagraph 4c(6)(d)c. are met, but the Prosthetics representative cannot be contacted during non-office hours and prosthetic repairs must be accomplished in order to ambulate the patient, the minimum, absolutely essential repairs may be performed on the prerogative of both the patient and the vendor. However, the Prosthetic representative will be contacted by the vendor at the earliest opportunity and a complete explanation submitted. The invoices will then be processed on receipt.

(b) In using VA Form 10-2501, a terminal device may be repaired as part of an artificial arm.

(7) Revoked or Cancelled PSC. A beneficiary's PSC will be cancelled or revoked if:

(a) There is an adjudication rating action resulting in lack of eligibility for a beneficiary for the appliance or repairs thereto.

(b) There is a medical determination that there is no further need for the appliance.

(c) There is flagrant abuse of the benefits of the PSC, e.g., signing blank invoices, using the card for unauthorized purchases more than twice, etc.

1. When a determination to cancel has been made, immediate steps will be taken by the Prosthetic representative to re-possess the PSC. Such action will include informing the patient, in writing, of the reasons for the action, including the statement that continued use of the card to obtain repairs will be considered as a fraudulent act. Revocation letters forwarded for abuse or lack of cooperation will be sent via registered mail and contain a statement that the patient will obtain prior authority from the local facility of jurisdiction for all future repair services. This letter will be developed through the Prosthetic VISTA software "correspondence menu" to ensure inclusion and ready review on VA Form 10-2319 (ADP).

2. If the patient does not surrender the card, and does not submit a letter explaining the circumstances within 45 days of receipt of certified correspondence, VA Form 10-2319 (ADP) will be prominently annotated through the "critical comment" screen #6 to suspend payment of all subsequent invoices charged to the card. An investigation under the auspices of the District Counsel may be required when there is a dispute between the Prosthetic representative and the billing vendor over legitimate billing.

(8) Repairs VA Form 10-2421, Prosthetic Authorization for Items or Services. In the absence of a PSC or use of PSC, VA Form 10-2421 will be used to obtain repair or replacement parts for any appliances for eligible beneficiaries [qualifying under Pub. L. 104-262]. Service may be authorized up to one-half the replacement value of the item. These forms will be processed in the usual manner.

(9) Centralized Hearing Aids Repair Program

(a) A national centralized program for processing hearing aids for repair is established at the Denver Distribution Center (DDC), Denver, CO. Except for local emergency repairs, all hearing aids in possession of veterans will be processed for repair through this centralized system.

(b) Personally purchased hearing aids may be included in the centralized program upon approval of the Audiology and Speech Pathology Service (ASPS) with PSA responsibility where the veteran resides and detailed notification to the DDC. ASPS will input data through the Remote Order Entry System.

(c) On receipt of notification indicating the issuance of a hearing aid to a veteran not already participating in the program, the DDC will forward a mailing carton and instructions to facilitate repairs of the aid.

(d) The Prosthetic Service with PSA responsibility where the veteran resides will authorize and pay for appropriate local emergency repairs to hearing aids when repair by DDC is not feasible.

(e) VA facilities requiring repairs to hearing aids for long-term non service-connected patients may forward such aids to the DDC. VA Form 10-2529-3, Request and Receipt for Prosthetic Appliances or Services, should be prepared by the Prosthetic Service with PSA responsibility in the usual manner and clearly annotated to identify the hearing aid by manufacturer, model number and serial number.

(f) All costs for repairs of hearing aids by the DDC will be charged to the Prosthetic Service with PSA responsibility where veteran resides. Procedures for processing emergent repairs by VA field facilities will be established at the local level.

2.5. Loan of Appliances

a. Scope

(1) The procedures for furnishing appliances as outlined are generally applicable to major items of medical equipment which are loaned or furnished to eligible veterans.

(2) Necessary forms for managing the issuance of major items of medical equipment and the procedures, i.e., FL 10-219, Notice to Veteran of Loan of Medical Accessories and Receipt; FL 10-219a, Release from Responsibility for Government Property; and FL 10-426a, Information Letter ‘«Ű Major Medical Equipment, should be created in the local "correspondence menu" of the prosthetics VISTA software. This ensures that a copy is reserved in VA Form 10-2319 (ADP) when the original is sent to a beneficiary. It is not necessary that a separate letter be sent whenever multiple or subsequent issues of the major medical equipment are involved. One letter sent upon the issuance of the first item is sufficient to inform the veteran of the existing policy.

(a) Reusable medical equipment will be recovered, if offered, refurbished if necessary, and reissued whenever such actions are cost-effective. For the purposes of recovery, loan items will be depreciated at the rate of 20 percent per year from the date purchased. If it is not costeffective to recover a particular item, the offer will be politely declined and the veteran or family member will be advised to donate it to some nonprofit organization; e.g., a veterans service organization, the Red Cross, or the American Cancer Society.

(b) Appliances and/or items will be furnished on loan when the purchase cost of the item exceeds $6,000 or the Durable Medical Equipment (DME) item with a life-span of 1 to 5 years is only required for a short period of time, generally 1 to 3 months, or less.

(c) Appliances and/or items whose loan periods have expired will be deleted from the loan program and permanently issued to the veteran.

b. Responsibility

(1) The Prosthetic representative is responsible for the overall administration of the loan program. This includes identifying those items that are to be loaned, the duration of the loan period, establishing loan records, maintaining an inventory of returned loaned items, and documenting the records of veterans in receipt of loaned items.

(2) The Prosthetic representative with PSA responsibility will repair and/or replace any loaned equipment in the possession of a veteran residing within that PSA.

c. Procedure

(1) The VISTA "Loan Program" menu will be selected. The equipment may be placed on loan by responding to prompts for the usual information. No item may be placed on loan that is not entered on the veteran's VA Form 10-2319 (ADP) prior to initiating the loan process.

(2) VA Form 10-1439, Prosthetic Inventory Card Prosthetic - Loaner Item, an automated loan card, will be maintained to document actions during the serviceable life of an appliance, which will be 5 years from the initial purchase and/or delivery date. Particular care should be taken to ensure that the item's description, value, and purchase date is accurately recorded, as this information is critical in the follow-up activity.

(3) The VISTA software will establish the dates of follow-up. With the exception of 'shortterm" loans (1 to 12 months), the first date will be 6 months from the date of loan. Routine follow-up dates are 6 months, 12 months, and annually thereafter. When electronically transferred and downloaded to another facility, these dates remain unchanged to accommodate subsequent follow-up including the loan expiration date originally established.

(4) Items over 5 years old will not normally be loaned, nor will items which have been recovered after being loaned two times.

(5) Loaned items that are returned to inventory that have a residual value greater than $6,000 will be loaned, if provided to another veteran within 5 years from the date of purchase.

(6) FL 10-219, incorporated in the local VISTA correspondence menu, will be printed in duplicate and the original and one copy will be forwarded to the patient at the time the loaned appliance is shipped or delivered. An entry will be made in the electronic loan correspondence suspense file pending return of the signed original from the patient. On receipt of the signed copy of the FL 10-219, it will be filed in the veteran's Consolidated Health Record. The electronic loan correspondence suspense file entry will be closed.

(7) When alerted by the prosthetic software that a loan follow-up is required, it will be accomplished by one of the following:

(a) Personal Contact. If the Prosthetic representative has personal knowledge that the veteran is using the device, the appropriate option of the loan program will be exercised, and "personal" will be selected as the type of contact.

(b) Record Review. If the Prosthetic representative does not have personal knowledge of the veteran's continued need for the item, a review of the veteran's VA Form 10-2319 (ADP) or Consolidated Health Record will be made to determine if the veteran has requested service to the item, was recently issued items of a similar nature, or if the veteran's medical condition is such that continued need for the item can be established. If it can be reasonably assumed that the veteran still requires the item, the appropriate option of the loan program will be exercised, and "Record Review" will be selected as the type of contact.

(c) Telephone or Letter. If continued need cannot be established by the preceding methods, contact will be made by telephone or FL 10-426, Temporary Loan Follow-up Letter. If a letter is the method of follow-up, an entry will be made in the electronic loan correspondence suspense file. This file may be dated for automatic 'alert' or 'print' by the imputing user. The incomplete follow-up will appear each time the "Follow-up Loan Report" is viewed and remains open, pending receipt of a response. If it can be reasonably assumed that the veteran still requires the item, the appropriate option of the loan program will be exercised, and "Telephone or Letter" will be selected as the type of contact.

(8) If any methods of follow-up indicate that a veteran no longer needs the item, appropriate arrangements for the return of the loaned property will be made, if economically feasible. The recovery of equipment for which recovery costs exceed the residual value of an item will not normally be authorized, unless it is known that the item is in very good condition and the item is suitable for reissue.

(9) If a follow-up letter is returned as undeliverable or no response is received, a second attempt will be made to contact the veteran during the next review period. If unsuccessful, the "Comments" section of the inventory card will be documented with the phrase "unable to contact," the card will be printed for filing in the veteran's Consolidated Health Record, and deleted from the loan program (in that order).

(10) When loaned items are recovered or permanently issued, a "loan release form" will be generated from the prosthetics software correspondence option, and forwarded to the veteran and automatically documented on the veteran's VA Form 10-2319 (ADP).

2.6. VA Prosthetics and Orthotic Laboratories

a. Scope

(1) The size of a VA Prosthetic and Orthotics Laboratory will vary depending on the needs of the VA medical center. Laboratories may be established as a necessary part of patient treatment services in any VA medical center when analyzed as cost-effective.

(2) The Prosthetic and Orthotic Laboratory will be assigned organizationally to the Prosthetic Service.

(3) Prosthetic and orthopedic appliances, when required to be custom-fabricated for specific veterans, may be procured from commercial vendors where adequate facilities are conveniently available. However, existing VA Prosthetic and Orthotic Laboratories will be used as a primary source and will be utilized to the fullest extent possible.

(4) Laboratories employing two or more technicians will serve as a referral source for the fabrication of orthotic and/or prosthetic devices for other VA facilities without a Prosthetic and Orthotic Laboratory or for those facilities with smaller laboratories.

(5) In field facilities having established VA Prosthetic and Orthotic Laboratories, the Chief Consultant, Prosthetic and Sensory Aids Service Strategic Healthcare Group (SHG), will periodically conduct an evaluation to ensure that the:

(a) Laboratory is being properly utilized to its full capacity; that the quality of appliances fabricated is completely satisfactory to prescribing physicians and is at least equal to the best available from local commercial vendors.

(b) Needs of the patients are being fully met through a combination of internal fabrication and commercial procurement.

(c) Laboratory is operating as efficiently and economically as possible.

(d) Current staffing is proper for the amount of work being done.

(6) In field facilities not having a VA Prosthetic and Orthotic Laboratory, but desiring to establish one, a request for authority, with full justification, will be submitted to the Chief Consultant, Prosthetic and Sensory Aids Service SHG, through the appropriate Network Director.

(7) VA Prosthetic and Orthotic Laboratories have been established at selected VA facilities (see App. C).

b. Responsibility

(1) The Chief Consultant, Prosthetic and Sensory Aids Service SHG, is responsible for the formulation of policies, standards, and scope of VA Prosthetic and Orthotic Laboratory activities, including, but not limited to, providing training and technical assistance to the laboratories, participating in the development and recommendation of space, equipment, and funds to be provided, and recommending proper staffing levels.

(2) The Director of a facility in which a VA Prosthetic and Orthotic Laboratory is located will be responsible for assuring that other VA facilities requesting services from the laboratory are afforded fair and equitable priorities, and the requirements of any one facility (including the Director's own) do not take precedence over any other. The Director will be responsible to the same degree for successful operation of this activity as for the conduct of other activities that solely benefit the Director's own facility.

(3) The Prosthetic representative will ensure that the quality of the appliances fabricated is satisfactory to patients and prescribing physicians, the time required for delivery is not excessive or will not result in prolonged hospital stays for patients, and the prices charged for such appliances are reasonable.

d. The Prosthetic and Orthotic Laboratory Supervisor is responsible to the Prosthetic Program Manager, for the efficient and economical administration and operation of the laboratory in accordance with established policies, standards and procedures.

c. Procedure

(1) VA Prosthetic and Orthotic Laboratories design, fabricate, repair, and fit custom-made artificial limbs, braces, corsets, surgical belts, arch supports, and similar appliances for VA beneficiaries on receipt of a properly prepared VA Form 10-2529-3, from any facility. The fabrication of permanent type artificial limbs may be authorized in accordance with the following policy:

(a) Non-service connected veterans who are new amputees will be provided a preparatory limb using conventional endoskeletal componentry. Once the veteran has achieved appropriate shrinkage and is ready for a permanent prosthesis, the socket may be replaced and the limb cosmetically finished. These veterans will not be referred to a commercial contractor unless such action is necessary to expedite the treatment process.

(b) Eligible veterans will select their provider for artificial limbs from the listing of contract vendors, including capable VA Prosthetic and Orthotic Laboratories. Service connected veterans who have obtained their most recent limb from a non-contract provider will be allowed to have their subsequent limb manufactured by the VA non-contract provider as long as the prosthetist is willing to accept the geographic VA preferred provider payment rate for the State in which the prosthetist performs this service. The VA Prosthetic and Orthotic Laboratory will be on the same listing, and may be selected to fabricate definitive limbs.

(2) Prosthetic and Orthotic Laboratories designated as Orthopedic Shoe Last clinics may fabricate or modify custom-made orthopedic shoes.

(3) Prosthetic and Orthotic Laboratories will store, modify as necessary, fit, and issue prefabricated orthotic devices, i.e., corsets, belts, elastic hosiery, and other appliances provided under centralized distribution programs or purchased from commercial sources.

(4) Prosthetic and Orthotic Laboratories must repair artificial limbs, braces, wheelchairs, and other appliances in possession of eligible veterans on receipt of VA Form 10-2529-3 or on presentation by the veteran of a valid PSC.

(5) Prosthetic and Orthotic Laboratories may participate in clinical evaluation studies of newly developed prosthetic and orthotic devices initiated by the Chief Consultant, Prosthetic and Sensory Aids Service SHG.

2.7. VA Restoration Clinics

a. Scope

(1) Restoration Clinics will be used as a primary fabrication source for VA beneficiaries and will be utilized to the fullest extent possible.

(2) Restoration Clinics will be assigned organizationally to the Chief, Prosthetic Service.

(3) In field facilities having established VA Restoration Clinics, the facility Director will conduct an annual evaluation to ensure that the clinic is being properly utilized to its full capacity; that the quality of appliances fabricated is completely satisfactory and is at least equal to the best available from local commercial facilities; that the needs of patients are being fully met; that the clinic is operating as efficiently and economically as possible; and that current staffing is proper for the amount of work being done. The Chief Consultant, Prosthetic and Sensory Aids Service SHG, will assist in such evaluation by providing comparative statistical analyses of all VA Restoration Clinics in operation with specific recommendations when requested.

(4) Custom made artificial eyes, facial and body restorations, cosmetic partial hands and similar appliances may be procured from commercial sources if the quality of the appliance is satisfactory, the time required for delivery is not excessive, and prices charged for such appliances are reasonable.

(5) Cosmetic gloves for partial hand amputees may be fabricated by the Restoration Clinic located in New York if commercially available sources are not adequate. Such appliances will be made available to any VA facility upon receipt of a properly prepared VA Form 10-2529-3.

(6) VA Restoration Clinics have been established at selected VA facilities (see App. D).

b. Responsibility

(1) The Chief Consultant, Prosthetic and Sensory Aids Service SHG, is responsible for:

(a) The formulation of policies, standards, and scope of VA Restoration Clinic activities, including, but not limited to, providing training and technical assistance to the clinics, participating in the development and recommendation of space, equipment, and funds to be provided, and recommending proper staffing levels.

(b) Directing the use of standardized materials and techniques if required for efficient operation and/or uniformity of services to patients.

(2) The facility Director in which a VA Restoration Clinic is located is responsible for ensuring that other VA facilities requesting services from the clinic are accorded fair and equitable priorities and that the requirements of any one facility (including the Director's own) do not take precedence over any other. NOTE: The Director is responsible to the same degree for successful operation of this activity as for the conduct of other activities that solely benefit the Director's own facility.

(3) The Chief, Prosthetic Service, must ensure that the quality of the appliances fabricated is satisfactory to patients and prescribing physicians, the time required for delivery is not excessive or will not result in prolonged hospital stay for patients, and the prices charged for such appliances are reasonable.

(4) The Supervisor of the Restoration Clinic is responsible to the Prosthetic representative for the efficient and economical administration and operation of the clinic in accordance with established policies, standards, and procedures.

c. Procedure

(1) Restoration Clinics custom make artificial eyes, facial and body restorations, cosmetic partial hands, ear inserts and similar appliances for eligible VA beneficiaries on receipt of clinical notes and VA Form 10-2529-3, from all VA facilities. For referrals, VA Form 10-10EZ, Application for Medical Benefits, is also required.

(2) Restoration Clinics may participate in clinical evaluation studies of new materials and techniques initiated by the Chief Consultant, Prosthetic and Sensory Aids Service SHG.

(3) Restoration Clinics will fabricate or repair special appliances in possession of their own eligible VA beneficiaries, and for beneficiaries of other field facilities, provided such work can be done with existing staff and without detriment to direct patient services.

2.8. VA Denver Distribution Center (DDC)

The DDC provides for the warehousing, procurement, and distribution of hearing aids, hearing accessories, hearing aid batteries, artificial larnyxes, prosthetic stump socks, select aids for the blind and flexible orthoses, and repairs hearing aids.

NOTE: Any changes in policy and/or procedures concerning the centralized distribution of prosthetic items will be coordinated among the Prosthetic and Sensory Aids Service Strategic Healthcare Group, DDC, and the involved VHA Clinical Program.

a. Responsibility

(1) The Office of Acquisition and Materiel Management (OA&MM) provides internal management including:

(a) Supervision of the personnel involved in the centralized distribution of prosthetic items,

(b) The review and development of the policies and procedures needed to operate the centralized distribution functions,

(c) Preparation of annual budget estimates to support resource requirements, and

(d) Initial funding from the Supply Fund (escrow account).

(2) VHA Headquarters Program Officials provide:

(a) Review of the resources requirements, and

(b) Oversight of the distribution functions in terms of the various VHA programs involved, i.e., Prosthetic and Sensory Aids, Audiology and Speech Pathology, and Blind Rehabilitation.

b. Procedures

(1) Initial items will be obtained from DDC by utilizing the Remote Order Entry System (ROES), an automated process that orders, certifies, issues and invoices local facilities for services rendered to beneficiaries residing within their PSA. Similar or other select items will be furnished to beneficiaries through VA health care facilities, Blind Rehabilitation Centers and VA or contract Audiology Clinics.

(2) Replacement items may be obtained by the following processes:

(a) Local facility ordering for individual beneficiary through the ROES process.

(b) Individual beneficiary requests by use of written correspondence or established VA Form 2346, Veterans Request for Hearing Aid Batteries, and VA Form 2345, Veterans Request for Stump Socks.

(c) Items may be furnished by direct issue to VA beneficiaries whenever they reside or sojourn in foreign countries, provided that written correspondence or VA Form 2345 and VA Form 2346 are mailed in an envelope with postage of the foreign country affixed.

(3) Payments for the items acquired from DDC are accomplished via an established 1358 account. Billing reports (Order Detail by Commodity/Facility) are received from DDC at the end of each month for payment certification.

2.9. Direct Purchasing by Prosthetic Activities Under COCP

a. Scope

(1) The Contracting Officers Certification Program (COCP) is a formal process for the delegation of procurement authority to contracting officers. This program establishes a chain of contracting authority within the Department as required by law, regulations, and Executive Order 12931, and ensures a trained, experienced and regulated workforce.

(2) Warrants to Prosthetic and Sensory Aids Service (PSAS) are authorized up to $100,000 for open market purchases and "the maximum order limitation of the contract," which means the money limit is determined by the specific established Federal Supply Schedules, decentralized and local beneficiary service contracts. The purchasing authority encompasses procurement of all items required for the medical treatment and rehabilitation of beneficiaries. Appropriate delegations of authority are required for Prosthetic staff in addition to their warrants to ensure compliance with MP-2, 108-25.5002.

b. Responsibility

(1) Managers of Fiscal Service and Acquisition and Materiel Management Service will conduct periodic reviews, to ensure that Prosthetic purchasing activities are in compliance with applicable acquisition and accounting regulations. Monthly reports are required to provide information for the Federal Procurement Data System (FPDS).

(2) OA&MM is responsible for providing required training to the appropriate prosthetic staff. This training should consist of "VA Small Purchase Procurement Procedures: Level A, Module I & II."

(3) All PSAS personnel involved in purchasing must complete the required training, pass the written exam, and obtain a warrant. A pre-test will be administered by the responsible training official to determine the level of familiarity or training required. A post-test will be administered to ensure successful completion of the training and to issue a warrant. Any PSAS employee requiring a warrant, who has not been provided the requisite training for reasons beyond the employee's control, may be issued an interim warrant for a period of 90 days from the date of issuance.

c. Procedures

(1) VA Form 1358, Estimated Miscellaneous Obligation or Change in Obligation, may be established on a monthly basis for utilizing known sources of procurement not capable of processing orders through the Purchase Card system. VA Form 1358 will be closed on a monthly basis in compliance with established fiscal regulations.

(a) A review of the past 12 months of activity with the source(s) requiring VA Form 1358 use, will be conducted to determine the average monthly allocation.

(b) Funds used in establishing VA Form 1358s are deducted from assigned control points on the basis of appropriate BOC designation. The authorization number, for example C80423, provided by Fiscal Service delineates the year (C8), month (04), and expenditure purpose (23) in an alphanumeric format.

(c) When control point balances are not sufficient to support the VA Form 1358 requirement, a written request to Fiscal Service justifying the need for additional funds will be made.

(d) The IFCAP option of VISTA will be used to create and record sequential transactions against the balance of the existing VA Form 1358. These transactions are identified as purchase order numbers, i.e., #POC40823-0002, when using documents other than those in the Purchase Card system.

(2) Purchase Card Procurement. The Purchase Card, a procurement card with a pre-set monetary limit, will be the primary method of authorizing purchases by designated employees. The use of this card results in obligations against a specific fund control point in a sequential manner. Available fund control balances will not reflect purchase charges until reconciliation of applicable invoices.

(a) PC 2421 is the software option for generating an Purchase Card document containing the necessary information to procure the items and/or services requested.

(b) Whenever feasible, deliveries of Purchase Card items should be made directly to the cardholder. However delivery of equipment and/or supplies may be to the veteran, the Prosthetic Department, or to the facility's receiving warehouse.

(c) A Dispute Officer or Purchase Card Auditor is responsible for coordinating and monitoring billing errors, disputed procurements, and credits which can not be resolved within 30 days. Activity of this type is identified as a Statement of Questioned Item (SQI).

(3) VA Form 10-2421. VA Form 10-2421 will be used when the Purchase Card is not accepted by the procurement source. It must be obligated against an established VA Form 1358. Use of this form will require that the vendor submit an invoice which must be certified for payment purposes.

(4) Rescinding of Procurement Authority by PSAS Under COCP

(a) Authority to procure under COCP may be rescinded when supplies and services are not consistent with organizational responsibilities and are outside the applicable VA Acquisition Regulations (VAAR) and Federal Acquisition Regulations (FAR).

(b) Any decision by the local contracting officer to rescind a warrant for other than normal reasons, i.e., change of duty station, retirement, etc., will be reported to the Deputy Assistant Secretary for Acquisition and Materiel Management and the Chief Consultant, Prosthetic and Sensory Aids Service SHG through the Veterans Integrated Services Network (VISN) Director, along with a complete explanation of the circumstances leading to the rescission action. The decision shall be reviewed by both OA&MM and VHA Program staff. The local contracting officer will be notified in writing as to the concurrence or non-concurrence in the warrant rescission.

2.10. Prothetic Treatment Centers

a. Scope

The facilities designated as Prosthetic Treatment Centers (PTCs) in Appendix B have established amputee clinic teams, experienced Prosthetic Staff and Physical Medicine and Rehabilitation Service personnel capable of providing assistance necessary to resolve difficult prosthetic problems. They may also have a substantial number of special medical programs, e.g., Spinal Cord Injury Service (SCIS), Spinal Cord Injury Outpatient Support Clinic (SCI/OSC), Visual Impairment Services Team (VIST), Hospital-based Primary Care (HBPC), Prosthetic- Orthotic Laboratory (POL), Restoration Clinic (RC), Blind Rehabilitation Clinic (BRC), Driver rehabilitation (DR), Geriatric Research, Education, and Clinical Care (GRECC), etc., and the personnel experienced in treating specific disabilities which require prosthetic appliances and/or equipment.

b. Responsibility

(1) The PTC will ensure that appropriate prescriptions are developed and that protocol checkout procedures are followed on all appliances required for all authorized patients referred by other VA field facilities.

(2) The PTC provides or arranges for adequate pre-prosthetic therapy and post-prosthetic training in the use of prosthetic devices.

(3) A paramount responsibility is to fabricate artificial limbs, braces, orthopedic shoes, artificial eyes, cosmetic restorations, and similar devices. When required devices are commercially procured, the PTC will monitor the adherence to prescription on the same basis as in-house fabrication.

(4) The PTC initiates and, after approval by VHA Headquarters, conducts limited research studies in the field of prosthetics or orthotics dealing with the development of new materials, devices, or fabrication techniques for applicants or with the problems and reactions of patients wearing or using devices.

(5) The PTC provides the professional and technical guidance in the training of all employees who have an interest in prosthetics.

(6) The Prosthetic representative will be responsible for coordinating all aspects of required care, and arranging for necessary patient travel.

(7) The clinical staff normally involved in the treatment of the patient's disability, e.g., spinal cord injury, blindness, amputation, etc., will be responsible for the care of the patients referred to a facility designated as a PTC.

c. Procedures

(1) Patients to be considered for referral to a facility designated as a PTC include those with conditions deemed to be complicated or unusual enough to require specialized evaluations, prescription, fabrication and training to resolve the patient's problem.

(2) Referrals will be arranged by the following process:

(a) Communication between the referral and receiving facility regarding the need for clinical records, pertinent findings with regard to other known medical conditions is a prerequisite.

(b) The appropriate administrative records such as VA Form 10-10EZ, VA Form 10-2529-3, and supportive medical documentation will be provided to the PTC when a patient referral is accepted.

(c) If a referral results in a prescription for a custom appliance, the PTC will provide the required equipment and/or appliance. If the referral results in a standardized prosthetic appliance, the equipment and/or appliance will be provided by the facility which initiated the referral.

(d) The PTC must provide copies of documented treatment to the referring Prosthetic representative within 15 working days of any episode of care.

2.11. Major Medical and Special Equipment Committee (MMSEC)

a. Scope

(1) All facilities providing prosthetic equipment and/or appliances should establish a MMSEC. The MMSEC should be comprised of knowledgeable medical, therapy, engineering, and administrative specialists with PSA responsibility for prosthetic services; referrals will be made when the expertise does not exist at the local VA medical center.

(2) The MMSEC may review requests for major items; e.g., environmental control systems, motorized wheelchairs, hospital beds, patient lifts, respiratory equipment, etc., as well as special items of automobile adaptive equipment; i.e., van modifications, sensitized brakes and steering systems. Special equipment may also include experimental appliances and/or devices as well as unusual requests for modalities of care.

(3) The MMSEC will be outlined in a medical center Policy Memorandum, meet on a regularly scheduled basis, and maintain minutes.

b. Responsibility

(1) The MMSEC Chairperson, a physician who is knowledgeable about prosthetic equipment and rehabilitation, will be charged with the direct professional responsibility for all patients referred to the Committee.

(2) The Prosthetic representative will serve as the coordinator and be responsible for the overall administrative management of the Committee. The remaining composition of the MMSEC will be flexible and should include a specialty physician involved in the patient's treatment, a rehabilitation medicine therapist, a nurse, a driver rehabilitation specialist, a social worker, and a biomedical engineer (when indicated).

(3) The MMSEC will review prescriptions written by fee-basis or private physicians to ensure that the requested items are necessary for the treatment or rehabilitation of the veteran.

(4) The MMSEC will arrange for home visits necessary to assess the available space in the veteran's home, power capability, ingress or egress to the home and/or bathroom facilities, and the need for the requested equipment.

(5) The MMSEC will finalize prescriptions for the needed equipment and arrange for training of the veteran and/or care provider in the use and operation of the equipment.

c. Procedure

(1) Upon receipt of a request that requires MMSEC consideration, the beneficiary will be afforded ample opportunity to attend the meeting for presenting information that may not be a part of the medical record. The veteran's personal comments and desires will be solicited before a final decision is made; this participation will be encouraged.

(2) Scheduling of veterans to the Committee will be accomplished through the VISTA appointment menu. Relevant medical records will be obtained for the meeting.

(3) The Committee coordinator will briefly outline the cases to be considered prior to seeing the veteran; the driver training specialist and/or therapist (as applicable) will give a brief verbal summary of each case.

(4) The medical findings and recommendations will be included in the veteran's medical records. Appropriate prescriptions will be written to cover all approved items. The MMSEC chairperson will arrange for:

(a) Any medical consultation, if indicated.

(b) Professional training, if indicated.

(5) The MMSEC Committee coordinator will prepare correspondence to the beneficiary and/or representatives on its decisions; decisions will be communicated to the veteran including the reasons for denial and the veteran will be advised in writing regarding appellate and reconsideration rights.

(6) The MMSEC Committee coordinator will arrange for the provision of the approved items and/or services, and prepare a VA Form 10-2641, for submission to the VISN and VHA Headquarters, if required.

2.12. Visual Impairment Services Team (VIST)

a. Scope

(1) This team will serve as the primary source for determining the specialized and/or custom equipment needs of all visually impaired and blind veterans eligible for VA health care, and will make necessary referrals to BRCs.

(2) The team will be comprised of health care and allied health care professionals charged with the responsibility for determining the comprehensive services required by a visually impaired veteran. Representatives may include, but are not limited to, the following Services: Ophthalmology, Optometry, Medicine, Audiology and Speech Pathology, Prosthetics, Social Work, Nursing, Administration, Vocational Rehabilitation, Adjudication and Veterans Benefits Administration. The VIST may also include a representative from the local Blinded Veterans Association as well as a representative from a local agency for the blind.

(3) The VIST chairperson will be elected by the team members and will serve a 1-year term.

(4) Veterans enrolled in the VIST Program will be offered an annual evaluation for continued appropriateness of equipment, medical and social needs.

b. Responsibility

(1) The Prosthetic representative will provide prescribed equipment and repairs for all eligible blind and visually impaired veterans.

(a) The Prosthetic representative at a field facility with a BRC will provide the initial lowvision aid or blind equipment recommended for all veterans who successfully complete training at that facility.

(b) The Prosthetic representative at the facility with PSA responsibility for the veteran will provide replacement and repairs to low vision aids or blind equipment provided by the BRC.

(2) The VIST Coordinator will carry overall responsibility to coordinate, act as consultant and as resource person, blindness services for blinded veterans. NOTE: Recommendations for blind aids from other disciplines, not developed through the VIST, will be referred to the VIST Coordinator. The VIST Coordinator will work with Prosthetics to obtain the appropriate blind aids.

c. Procedure

(1) All team members will determine and ensure that legally blind veterans with whom they have contact are enrolled in the VIST Program.

(2) The treatment records of all VIST enrollees will be reviewed to ensure that they are evaluated at least annually by designated disciplines of the team.

(3) The Blind Rehabilitation Outpatient Specialist (BROS) is responsible for recommending prosthetic equipment for veterans participating in the BROS Program.

(4) The VIST Coordinator is responsible for assisting eligible veterans in applying for blind rehabilitation training.

(5) Prosthetic requests will be developed by VIST for all items and/or services deemed necessary for any treatment of VIST enrollees. VA Form 10-2641 will be required when requests are for special mechanical or electronic devices, i.e., speech recognition systems, computers, and software.

2.13. Appendix A - Amputee Clinic Teams

VISN I

Boston Health Care System

Manchester, NH

Providence, RI

Togus, ME

Connecticut Health Care System

White River Junction, VT

VISN II

Albany, NY

Syracuse, NY

Western New York Health Care System

VISN III

Bronx, NY

New Jersey Health Care System

Lyons, NJ

New York, NY

Northport, NY

Hudson Valley Health Care System

VISN IV

Clarksburg, WV

Lebanon, PA

Philadelphia, PA

Pittsburgh (University Drive), PA

Wilkes-Barre, PA

Wilmington, DE

VISN V

Maryland Health Care System

Martinsburg, WV

Washington, DC

VISN VI

Asheville, NC

Hampton, VA

Durham, NC

Richmond, VA

Salem, VA

Salisbury, NC

Beckley, WV

VISN VII

Atlanta, GA

Augusta, GA

Birmingham, AL

Charleston, SC

Columbia, SC

Dublin, GA

Montgomery, AL

VISN VIII

Ft. Myers, FL (Outpatient Clinic (OPC))

Bay Pines, FL

Miami, FL

North Florida and South Georgia Health Care System

San Juan, PR

Tampa, FL

VISN IX

Lexington, KY

Memphis, TN

Mountain Home, TN

Nashville, TN

Murfreesboro, TN

Louisville,KY

Huntington, WV

VISN X

Chillicothe, OH

Cincinnati, OH

Cleveland, OH

Columbus, OH

Dayton, OH

VISN XI

Ann Arbor, MI

Detroit, MI

Indianapolis, IN

Battle Creek, MI

Danville, IL

Marion, IL

Ft. Wayne, IN

VISN XII

Chicago (Lakeside), IL

Chicago (Westside), IL

Hines, IL

Milwaukee, WI

North Chicago, IL

Madison, WI

VISN XIII

Fargo, ND

Minneapolis, MN

Sioux Falls, SD

VISN XIV

Des Moines, IA

Iowa City, IA

Knoxville, IA

Lincoln, NE

Omaha, NE

VISN XV

Columbia, MO

Kansas City, MO

Leavenworth, KS

St. Louis, MO

Topeka, KS

Wichita, KS

VISN XVI

Alexandria, LA

Biloxi, MS

Houston, TX

Jackson, MS

Little Rock, AR

Muskogee, OK

New Orleans, LA

Oklahoma City, OK

Shreveport, LA

Tulsa, OK (OPC)

VISN XVII

Dallas, TX

San Antonio, TX

Temple, TX

VISN XVIII

Albuquerque, NM

Amarillo, TX

El Paso, TX (OPC)

Phoenix, AZ

Tucson, AR

VISN XIX

Denver, CO

Ft. Harrison, MT

Salt Lake City, UT

Cheyenne, WY

VISN XX

Boise, ID

Portland, OR

Roseburg, OR

Puget Sound Health Care System

Spokane, WA

Walla Walla, WA

White City, OR

Anchorage, AK

VISN XXI

Fresno, CA

Honolulu, HI

Manila, PI

Palo Alto, CA

Reno, NV

San Francisco, CA

Northern California System of Clinics

VISN XXII

Las Vegas, NV

Loma Linda, CA

Long Beach, CA

Los Angeles, CA (OPC)

San Diego, CA

Sepulveda, CA

West Los Angeles, CA

2.14. Appendix B - Designated Prosthetic Treatment Centers

VISN I

Boston Health Care System

West Haven, CT

VISN II

Albany, NY

Buffalo, NY

Syracuse, NY

VISN III

Bronx, NY

Brooklyn, NY

East Orange, NJ

New York, NY

VISN IV

Pittsburgh (University Drive), PA

Wilkes-Barre, PA

VISN V

Washington, DC

Maryland Health Care System

VISN VI

Richmond, VA

Hampton, VA

Durham, NC

VISN VII

Augusta, GA

Birmingham, AL

Columbia, SC

Decatur (Atlanta), GA

VISN VIII

Bay Pines, FL

Miami, FL

San Juan, PR

Tampa, FL

West Palm Beach, FL

North Florida and South Georgia (Gainesville)

VISN IX

Memphis, TN

Nashville, TN

Louisville, KY

VISN X

Cleveland, OH

Cincinnati, OH

VISN XI

Detroit, MI

Indianapolis, IN

VISN XII

Hines, IL

Chicago (WS), IL

Milwaukee, WI

VISN XIII

Minneapolis, MN

VISN XV

Kansas City, MO

St. Louis, MO

VISN XVI

Houston, TX

Central Arkansas Veterans Health Care System

New Orleans, LA

Oklahoma City, OK

VISN XVII

Dallas, TX

San Antonio, TX

VA Central Texas Health Care System (Temple)

VISN XVIII

New Mexico Health Care System

Phoenix, AZ

Southern Arizona Health Care System

VISN XIX

Denver, CO

Salt Lake City, UT

VISN XX

Portland, OR

Puget Sound Health Care System

VISN XXI

Palo Alto, CA

San Francisco, CA

VISN XXII

Sepulveda, CA

Long Beach, CA

San Diego, CA

West Los Angeles, CA

2.15. Appendix C - Prosthetic - Orthotic Laboratories Authorized in VA Field Facilities

VISN Facility Station Number
VISN I

Boston Healthcare System

Togus, ME

523

525

VISN II Buffalo, NY 528

VISN III

Bronx, NY

Brooklyn, NY (St. Albans)

East Orange, NJ

Northport, NY

Castle Point, NY

New York, NY

526

527

561

632

533

630

VISN IV

Pittsburgh, PA

Wilkes-Barre, PA

646

691

VISN V

Ft. Howard, MD

Martinsburg, WV

566

613

VISN VI

Hampton, VA

Richmond, VA

590

652

VISN VII

Columbia, SC

Decatur, GA (Atlanta)

Montgomery, AL

544

508

619

VISN VIII

West Palm Beach, FL

North Florida and South Georgia Health Care System (Gainesville)

Bay Pines, FL

Miami, FL

San Juan, PR

Tampa, FL

598

573

516

546

455

673

VISN IX

Louisville, KY

Nashville, TN

Memphis, TN

603

626

624

VISN X

Cincinnati, OH

Cleveland, OH

Dayton, OH

539

541

552

VISN XI

Detroit, MI

Indianapolis, IN

553

583

VISN XII

Chicago (Westside), IL

Hines, IL

Milwaukee, WI

537

578

695

VISN XIII Minneapolis, MN 618
VISN XV

Kansas City, MO

St. Louis, MO

Wichita, KS (ROC)

589

657

452

VISN XVI

New Orleans, LA

Oklahoma City, OK

Little Rock, AR

Houston, TX

629

635

598

580

VISN XVII

Dallas, TX

San Antonio, TX

Temple, TX

549

671

674

VISN XVIII

Albuquerque, NM

Tucson, AZ

501

678

VISN XIX Denver, CO 554
VISN XX

Portland, OR

Seattle, WA

648

663

VISN XXI

Manila, PI (RO)

Palo Alto, CA

San Francisco, CA

358

640

662

VISN XXII

Long Beach, CA

San Diego, CA

Sepulveda, CA

West Los Angeles, CA

600

664

665

691

2.16. Appendix D - Restoration Clinics Authorized in VA Field Facilities

VISN FACILITY STATION NUMBER
VISN III VA Medical Center, New York, NY 630
VISN VII VA Medical Center, Decatur, GA (Atlanta) 508
VISN X VA Medical Center, Cleveland, OH 541
VISN XV VA Medical Center, St. Louis, MO 657
VISN XX VA Medical Center, Portland, OR 648
VISN XXII VA Medical Center, West Los Angeles, CA 691

3. VA Handbook 1173.3 - Amputee Clinic Teams

3.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent system-wide procedures for conducting amputee clinics and providing artificial limbs to amputee veterans.

3.2. Amputee Clinic Teams

a. Purpose

(1) Amputee Clinic Teams provide treatment to amputee veterans by:

(a) Examining VA beneficiaries requesting or requiring major prosthetic appliances.

(b) Determining that an appliance is no longer serviceable and needs to be replaced.

(c) Conducting closely-controlled clinical evaluations on new techniques and componentry under policies and procedures announced by the Chief Consultant, Prosthetic and Sensory Aids Service (P&SAS) Strategic Healthcare Group (SHG).

(d) Inspecting and evaluating new prostheses.

(e) Conducting follow-up examinations and treatments of beneficiaries who have received prescriptions through the clinic team.

(2) Amputee Clinic Teams are established in selected field facilities under the supervision of a physician who is knowledgeable about prosthetics and physical disabilities.

b. Responsibility

(1) The Chairperson, Amputee Clinic Team, must be a physician with a specialty in Physical Medicine and Rehabilitation, Orthopedic Surgery, or Vascular Surgery. The Chairperson, charged with the responsibility for the clinical treatment of all patients referred to the team, normally serves on an attending basis and is appointed by the Chief of Staff. NOTE: Exceptions to the appointment of a physician chairman requires the approval of the Chief Consultant, Rehabilitation Strategic Healthcare Group.

(2) The Chief, P&SAS, at a facility in which an Amputee Clinic Team is located, is responsible for the overall administrative management of the team. The prosthetic manager serves as coordinator, technical advisor, and the Chief, P&SAS's designee in inspecting and evaluating all appliances prescribed by the Clinic.

(3) The Amputee Clinic Team is responsible for orienting and training physicians, medical residents, and other clinical specialists who have an interest in prosthetics and/or will be working with amputee patients.

c. Composition

(1) The Amputee Clinic Team is comprised of an interdisciplinary group of professional providers with combined expertise to carry out all necessary and appropriate functions of the team as specified in subparagraph 2f. The team may remain flexible and be adjusted to meet local needs. In addition to the physician Chair and the Chief, P&SAS, members may include a podiatrist, physical therapist, occupational therapist, kinesiotherapist, the Preservation Amputation Care and Treatment (PACT) coordinator, a prosthetist (either VA or commercial), and other medical specialists as required. The physician directing the clinic must have appropriate medical training and a minimum of 2-years experience as a collaborative team member providing amputee services in a comprehensive amputee program. In lieu of 2-years experience, continuing education and mentorship may be used to gain this experience. Local prosthetic VA contract providers may be invited to attend the clinic. It is recommended that three to five providers be awarded contracts depending on the geographic area of coverage and volume of workload. If a commercial provider has fabricated a limb, the commercial provider may be invited to present the patient with the new prosthesis for evaluation and delivery to the clinic. NOTE: Every effort will be made to limit the size of the clinic team to a maximum of eight people.

(2) All assignments of VA personnel to Amputee Clinic Teams must be based on professional expertise, and are considered to be part of the regular assignment of clinical duties.

d. Procedures

(1) Beneficiaries requiring artificial limbs are to be referred to the nearest Amputee Clinic Team when they are:

(a) Residing within the Prosthetic Primary Service Area (PSA) of the facility in which the clinic team is located.

(b) Residing within the PSA of another VA facility, which does not have an Amputee Clinic Team, or has been unable to resolve the patient's prosthetic problem.

(c) Determined to be a good candidate for a special (microprocessor knee units or other state of the art designs) or experimental type appliance which may only be prescribed by the team.

(2) Hospitalized or domiciled beneficiaries may be referred to Amputee Clinic Teams at other facilities, after appropriate arrangements have been made with the prosthetic representative of the facility in which the team is located. In such cases, a brief review of the beneficiary's problem, the local medical recommendation, and the objective expected to be accomplished must be provided to the amputee clinic where the beneficiary is to receive care and treatment.

e. Scheduling of Appointments and Preparation of Records

(1) The Prosthetic Representative of each Amputee Clinic Team arranges appointments for veterans to appear before the Clinic team. An appointment management entry must be established for each patient scheduled with the Amputee Clinic.

(2) Field facilities referring patients to the Clinic team must request appointments by use of electronic consults, or VA Form 10-2529-3, Request and/or Receipt for Prosthetic Appliances or Services (which can be found at: http://vaww.va.gov/vaforms/Search_action.asp).

f. Conduct of Amputee Clinic Team Meetings

(1) The patient must be treated with courtesy, respect, and empathy. The patient's personal preferences are to be solicited and considered before a final decision is made.

(2) Evaluation. Evaluations must be performed by professionals with the clinical expertise appropriate to the examination performed. The evaluation of each amputee patient needs to include, but not be limited to:

(a) Patient's current medical status;

(b) Medications;

(c) Date of amputation;

(d) Reason for amputation;

(e) Current weight;

(f) Current functional status and level of activity;

(g) Problems with the current prosthesis;

(h) History of prosthetic use;

(i) Reason for attending amputee clinic;

(j) Pertinent medical findings;

(k) Full physical examination of patient's residual and contralateral limb for strength, ROM, and sensation; and

(l) Gait with the current prosthesis.

(3) Each beneficiary must be carefully examined in a private room by the entire clinic team in order to assess the patient's needs. If a new or replacement prosthesis is indicated, the advantages of new technology are to be fully explained to the patient. However, if a patient has worn or used a particular type of appliance for several years without difficulty, and wishes to have an identical replacement, the patient's wishes are to be honored, unless there are definite medical contraindications.

(a) A new prosthetic prescription for the lower extremity prosthesis includes: type and shape of socket, type of suspension, knee component (TFA), foot and/or ankle components, endoskeletal versus exoskeletal.

(b) The new prosthetic prescription for an upper extremity prosthesis includes: type and shape of socket, body powered and/or myoelectric, suspension system, elbow component (THA), terminal device.

(4) In amputee evaluations, the medical findings and recommendations of the clinic team, with the specific component prescription for an artificial limb or major repair, must be included in the patient's Consolidated Health Record (CHR).

(5) If, prior to prescription of the prosthesis, additional treatment is indicated, the provision of the prosthetic limb will be deferred pending treatment outcome. If this is a first prosthesis, gait deviations or deviations in functional ADL's are significant. If significant changes are being made to the limb prescription, then prosthetic training by physical therapy, occupational therapy, and/or kinesiotherapy must be offered to the patient.

(6) Follow-up examinations must be scheduled, as needed, during the initial prosthetic fitting.

NOTE: It is recommended that after the definitive fitting, evaluations be scheduled annually, or more frequently if clinically indicated.

g. Action Following a Meeting of Amputee Clinic Team.

When the meeting of the Amputee Clinic Team is adjourned, the prosthetic representative is responsible for the following actions:

(1) Upon receipt of the prescription and contractor selection, the veteran must be provided specific instructions regarding travel, delivery, training, and follow-up. When pricing for the prescribed limb is not determined in the clinic, VA Form Letter (FL) 10-90 (ADP), Request for Firm to Submit Estimated Cost of Prosthetic Appliance, or a contractor's letterhead quote is necessary before procurement can be completed.

(2) In the event that a beneficiary fails to appear for a scheduled appointment without contacting the clinic coordinator, the referring facility must be advised that the appointment was not kept and that a future appointment must be scheduled as though it were an original request.

(3) In the case of beneficiaries referred from other field facilities and examined by the clinic team, a Standard Form (SF) 509, Medical Record ‘«Ű Progress Note, must be prepared, in duplicate, and the original immediately forwarded to the facility from which the beneficiary was referred. The remaining copy must be retained for the clinic team file.

NOTE: Appliances or repairs prescribed by the clinic team must be obtained, inspected, evaluated and delivered in accordance with procedures outlined in this manual.

3.3. Definitions

a. Computer Assisted Design or Computer Assisted Manufacture (CAD/CAM). CAD/CAM is a process of fabricating and fitting artificial limbs using computer aided design and manufacturing techniques.

b. CAD/CAM Host Facility. A CAD/CAM Host Facility is a Prosthetic Referral Center equipped with CAD/CAM technology and designated as a central fabrication center to fabricate sockets for other VA Orthotic Labs.

c. CAD/CAM Remote Facility. A CAD/CAM Remote Facility is a VA Orthotic Laboratory that has CAD/CAM technology and equipment to scan patients and send modem- modified images to a Host Facility for fabrication of socket.

d. VA Orthotic Laboratory. A VA Orthotic Laboratory is a VA facility employing at least one orthotist and/or is prosthetist-equipped to provide custom mobility aids, such as: artificial limbs, orthotic devices, power or manual wheelchairs, and non-custom items like cervical collars, elastic hose, and crutches.

e. Prosthetist or Orthotist. A Prosthetist or Orthotist is an individual trained in mechanics and biomechanics to manufacture and fit custom or non-custom devices, and to assist physicians in prescribing these devices.

f. Preparatory Prosthesis. A preparatory prosthesis is the first limb a new amputee wears. It consists of a plaster or fiberglass cast (applied during or shortly after surgery) and basic components, which are easily removed. It controls swelling and protects the residual limb while allowing minimal (standing, touchdown, weight bearing) ambulation.

g. Temporary Prosthesis. A temporary Prosthesis is an artificial limb designed for the evaluation and training of a new amputee. It consists of a plastic socket attached to modular (alignable) components. Temporary limbs are worn the first few months following amputation until the residual limb has matured. Components are adjusted or changed until optimal function is achieved.

h. Permanent Prosthesis. A permanent prosthesis is an artificial limb used by amputees whose residual limb has matured and the amputee has satisfactorily completed the temporary limb phase. The socket and components are manufactured to provide lasting durability and a proper cosmetic appearance.

i. Exoskeletal Prosthesis. An exoskeletal prosthesis is an artificial limb whose cosmetic and structural components are combined. Wood or plastic is used to provide structural support and is then shaped to resemble the uninvolved side. A laminate is applied to the exterior of the shaped part to provide color and additional strength.

j. Endoskeletal Prosthesis. An endoskeletal prosthesis is an artificial limb whose cosmetic and structural components are separate. Internal components are used to provide structural support and then foam is shaped to resemble the uninvolved side. Cosmetic hose or a "skin" is applied to provide color.

k. Recreational Prosthesis. A recreational prosthesis is an artificial limb that is specifically designed to permit the amputee to participate in a particular activity, e.g., swimming, skiing, running, etc., when a conventional prosthesis is not suitable. These prostheses are constructed in such a manner as to resist environmental conditions and/or external forces which would adversely affect conventional prosthetic designs.

l. Prosthetic Sheath. A prosthetic sheath is a sock-like item made of synthetic materials manufactured in one thickness, which is worn over the residual limb to reduce abrasion.

m. Prosthetic Sock. A prosthetic sock is made of a soft fabric that is applied directly to the residual limb; it acts as an interface between the residual limb and the prosthetic socket. Prosthetic socks are used to provide comfort, absorb perspiration, reduce irritation and re- establish proper fit of the socket. They come in varying thicknesses called ply (usually from one to eight ply) and in varying materials (usually wool, cotton, nylon, or a blend of man-made materials). In addition, prosthetic socks are available with varying thickness of silicone gel impregnated into the fabric.

n. Artificial Limb Contract. An Artificial Limb Contract is a competitively-bid contract locally awarded to preferred providers and used by VA personnel for the purchase of artificial limbs.

o. Non-contract Artificial Limb. A non-contract artificial limb is a commercially available artificial limb, which is not on the current Artificial Limb Contract.

p. Terminal Devices. Terminal devices are artificial hands or hooks designed for use with upper-extremity prostheses.

q. Myoelectric or External-powered Devices. Myoelectric or external-powered devices are upper-limb prostheses that can be operated through use of electrodes contacting the skin or by switches attached to the harness or prosthesis.

r. Microprocessor Knee Units. Microprocessor knee units are on-board microprocessors which control hydraulic fluid flow in the knee joint allowing optimum swing control and, in some prostheses, stance control.

s. Standard Upper-Limb Prosthesis. Standard upper-limb prosthesis is an artificial limb used in partial or complete arm amputation. Components can be endoskeletal or exoskeletal. The prosthesis provides cosmesis, prehension, movement, and function by body movement, usually through a harness and cable system.

t. Centers for Medicare and Medicaid Services (CMS) Lower Extremity Functional Levels. CMS has used a rating scale (K0 to K4) to determine the level of daily activity and ambulation that a patient may achieve on a daily basis. This functionality rating enables the selection of the appropriate componentry for the potential level of the patient. June 4,

(1) K0 ‘«Ű Lower-extremity prosthesis functional level 0. The patient does not have the ability or potential ability to ambulate or transfer safely with or without assistance and a prosthesis does not enhance the patient's quality of life or mobility.

(2) K1 ‘«Ű Lower-extremity prosthesis functional level 1. The patient has the ability or potential ability to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence. Typical of the limited and unlimited household ambulator.

(3) K2 ‘«Ű Lower-extremity prosthesis functional level 2. The patient has the ability or potential ability for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.

(4) K3 ‘«Ű Lower-extremity prosthesis functional level 3. The patient has the ability or potential ability for ambulation with a variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and who may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

(5) K4 ‘«Ű Lower-extremity prosthesis functional level 4. The patient has the ability or potential ability for prosthetic ambulation that exceeds the basic ambulation skills, and exhibits high-impact, stress, or energy levels, typical of the prosthetic demands of a child, active adult, or athlete.

3.4. Provision of Artificial Limbs

a. Artificial limbs, parts and repairs must be procured, fabricated and issued to eligible beneficiaries by prescription from a designated physician assigned to the Amputee Clinic Team or from the Prosthetic Representative in accordance with the policies and procedures outlined in VHA Handbook 1173.1, VHA Handbook 1173.2, and VHA Handbook 1173.3. Prescription for the initial prosthesis, and any change in the prescription, requires the involvement of the Amputee Clinic team physician, or in the case of a partial foot amputation, the podiatrist assigned to the Amputee Clinic Team. A prescription for a new prosthesis, or a change in the current prosthetic prescription, occurs in conjunction with an appointment in an Amputee Clinic.

b. These artificial limbs (appliances) can be procured from contract vendors where adequate appliance facilities are available, the time required to receive delivery of the appliance is not excessive for patients, and the prices charged for such appliances are reasonable. NOTE: VA Orthotic Laboratories with a certified prosthetist may also be used as a source in the fabrication of preparatory, temporary, and permanent artificial limbs.

c. Eligible veterans, as identified in VHA Handbook 1173.1, who have previously received artificial limbs from commercial sources, will continue to have their choice of vendors on contract with VA or their non-contract prosthetist, providing the prosthetist accepts the VA preferred provider rate for the geographic area. VA facilities with Orthotic Laboratories that have certified prosthetists, or facilities with access to a VA Laboratory, will provide eligible veteran amputees with the preparatory or temporary prosthesis and permanent limbs. NOTE: When the patient has achieved appropriate shrinkage and is ready for a permanent prosthesis, the preparatory or temporary prosthesis is replaced.

d. Terminal devices, i.e., hooks, hands, must be provided with replacement artificial arms. When a terminal device is prescribed, the selection of a particular type of hook and/or hand must be based upon a patient's lifestyle or vocational needs.

e. Recreational artificial limbs, which allow an amputee to participate in a specific recreational or athletic activity, may be provided. The following guidelines need to be followed whenever the issue of a recreational prosthetic appliance is contemplated:

(1) The physician assigned to the VA Amputee Clinic Team must prescribe the prosthesis.

(2) The prescription must indicate the therapeutic, rehabilitative or psychological benefit to be expected or achieved through participation in this specialized activity.

(3) The prescription must indicate that a conventional prosthesis, which is worn daily, is unsuitable for use in the recreational activity either because of environmental factors which would affect the prosthesis, or because a specialized function not available in the conventional limb is required in the activity.

(4) Frequently required prosthetic components (within the limitation of the storage area provided to P&SAS and the Orthotic Laboratories) are to be stocked to expedite patient care.

3.5. VA Source for Artificial Limbs Purchased for VA Beneficiaries

a. The VA Artificial Limb Contract must be used as a primary source in custom fabrication for artificial limbs purchased for VA beneficiaries. However, fabrication may be from VA Orthotic Laboratories where adequate facilities are conveniently available, certified staff is available to patients and prescribing physicians, the time required for delivery is not excessive or will not result in prolonged hospital stay for patients, and the prices charged for such appliances are reasonable.

b. Work for Other Stations

(1) Facilities with a CAD/CAM remote system requiring the services of a VA Orthotic Laboratory with CAD/CAM host system must determine whether the desired appliance can be fabricated utilizing the CAD/CAM system, or if the beneficiary will be required to travel to the receiving station. In order to avoid delays and backlogs in the laboratory's production schedule, the referring facility must confirm an appointment prior to sending a beneficiary to the laboratory. NOTE: Orders are be processed on a first in-first out basis, regardless of origin.

(2) CAD/CAM host facilities which fabricate sockets for distant facilities, where the patient will not be seen and is not in the Veterans Health Information System and Technology Architecture (VistA), must receive a VA Form 10-2529-3, from the referring station utilizing the remote order section of the electronic - 3 package. For stations that do not use the VA Form 10- 2529-3, a CPRS Prosthetic Consult can be generated and faxed to the receiving station along with a completed VA Form 10-2421. Reimbursement costs for the fabrication of sockets must be negotiated between the facilities and/or VISNs involved.

3.6. Stump Socks

a. Stump socks, sheaths, and other socket interface products are to be furnished to eligible mputees, VA Orthotic Laboratories, and VA medical centers by the Denver Distribution Center (DDC), Denver, CO.

b. Veterans residing in the United States (U.S.), U.S. possessions, or Puerto Rico are furnished stump socks directly by initiating a request into the Remote Order Entry System (ROES) to the DDC, Denver, CO.

c. Veterans whose eligibility is based upon enrollment are monitored bi-annually, and the DDC informed of any change. The ROES electronic order must be generated by the facility, which has the responsibility of maintaining the veteran's VA Form 10-2319, Record of Prosthetic Service. The ROES order must be transmitted to the DDC on all initial cases and VA Form 10-2319, annotated appropriately.

d. Veterans residing in a foreign country receive direct mail orders through the local consular office of the U.S. State Department. VA Form 10-2345, Veterans Request for Stump Socks, will be provided with all issues for the purpose of ordering future supplies. Veterans need to be advised that the VA Form 10-2345 must be mailed in an envelope with the necessary foreign postage when mailed through their foreign postal service. Repairs to artificial limbs need to be directed to the Health Administration Center, Denver, CO.

(1) For Allied veterans residing in the U.S. or Puerto Rico, issues are made as indicated in preceding subparagraph 6a. The original or certified copy of the letter of authorization from the allied government must be on file at the DDC to indicate eligibility for continuing services.

(2) Stump socks may be stocked at VA facilities for issuance to eligible beneficiaries where there is an active amputee rehabilitation program and temporary limb fitting.

3.7. Commercial Sources

The local Artificial Limb Contract must be used as the primary source for commercial procurement of limbs purchased for VA beneficiaries. Prosthetics Representatives are responsible for compliance with the terms and conditions of this contract, and they must perform inspections of contractor facilities. Any changes in qualified personnel, i.e., regarding certified prosthetists or VA qualified prosthetists, which occur during the contract year, must be reported to the contracting officer at the local facility.

a. Eligible veterans will be permitted to obtain authorized artificial limbs and/or terminal devices from any commercial artificial limb dealer who is under a current local contract to the VA or the veteran's preferred prosthetist who agrees to accept the preferred provider rate. Such procurements are subject to the following restrictions and limitations:

(1) The physician's prescription must be specific as to the type of limb recommended and must include specific instructions as to the components to be used; e.g., type of knee joints, type of foot, etc. Any changes to the prescription deemed necessary by the prosthetist, must be presented to Prosthetics and the prescribing physician for approval.

(2) If an outpatient, the veteran's choice of an approved contractor is normally limited to those in the veteran's residential geographical area.

(a) If the prescribed limb is not available from any of the local contractors, the Chief, P&SAS, must seek another Prosthetic and/or Orthotic Laboratory that can provide the veteran with the appropriate prosthesis.

(b) If a veteran selects an approved contractor, other than a contractor in the local geographical area, any travel costs incurred must be at the veteran's own expense. NOTE: Exceptions are only made in those instances when it is clearly indicated that it is in the best interest of both the veteran and VA.

b. To assist all eligible veterans authorized permanent artificial limbs using a commercial contractor, a current list of approved contractors in the immediate geographical area must be provided to each. Included in this list will be the VA Prosthetic-Orthotic Laboratories, when applicable. Except in those rare instances where a physician determines it to be necessary for the proper medical treatment of the veteran, VA personnel are not allowed to direct, guide, or prompt a veteran to go to a specific contractor. NOTE: A rotating contractor schedule will not be used as a method of selecting a contractor for the fabrication of a limb.

(1) A list of VA contractors (in alphabetical order) must be developed locally and must include all contractors who are located in the facility's area of prosthetic jurisdiction and have a current VA contract.

(2) Each list must contain the following statement in bold face type:

YOU HAVE THE RIGHT TO SELECT THE ARTIFICIAL LIMB CONTRACTOR OF YOUR CHOICE FROM ANY OF THE FOLLOWING LISTED VA-APPROVED CONTRACTORS. ANY ATTEMPT TO INFLUENCE YOUR DECISION, OR TO DIRECT YOU TO ANY PARTICULAR CONTRACTOR, SHOULD BE REPORTED TO THE DIRECTOR OF THIS FACILITY.

c. When the designated physician of the Amputee Clinic Team prescribes a limb or componetry that cannot be provided by a VA prosthetist or contract vender:

(1) A qualified non-contract vender may be offered the fabrication of the limb, or

(2) A veteran who has a long standing relation with a qualified vendor not currently under contract, may request that vender to fabricate the limb, provided charges do not exceed the average discount price of preferred vendors.

NOTE: Appropriate non-contract components (which are commercially available) may be added to a contract limb and approved locally by the Prosthetic representative, provided the cost of the component does not exceed the dollar limitation stated in the current Centers for Medicare and Medicaid Services (CMS) L-Code schedule plus the discount.

3.8. Replacements

a. An artificial limb or prosthetic component (issued to an eligible VA beneficiary) must be replaced after it is determined that the limb or component is no longer serviceable, or that physical changes of the beneficiary's residual limb renders the appliance unsuitable for further use. NOTE: Appliances in serviceable condition will be used for as long as it is feasibly possible. Useful life through repair will always be investigated before a new appliance is authorized.

b. The determination of need for the replacement of a prosthetic appliance is made and documented in the veteran's CHR by the Chief, P&SAS, based upon physical examination of the appliance for which a replacement is requested. The progress note must document that the appliance has been examined and that it is unsatisfactory for future use or that a replacement is necessary due to physical changes in the beneficiary's condition. NOTE: Replacement required due to physical change in the beneficiary's condition necessitates reevaluation by the Amputee Clinic Team.

c. If a beneficiary claims that a prosthesis is lost or destroyed, or if it is determined by examination that the appliance has been damaged through other than normal use, the Chief, P&SAS, may initiate an inquiry into the facts of the case. If the findings indicate the appliance has been willfully lost, damaged, or destroyebeneficiary receives adequate counseling.

3.9. Spare Artificial Limbs

Spare artificial limbs and terminal devices may be furnished to eligible veterans after clinical determination of need in each case. Such determination is based on environmental factors, such as: where the veteran lives or works, the availability of repair facilities, and the particular needs of the beneficiary concerned. The spare prosthesis needs to be suitable for constant use over long periods of problematic repairs where specialized componentry has to be ordered for the primary prosthesis.

3.10. Commercial Repairs

The procedures outlined in Handbook 1173.2 are applicable to the furnishing repairs to artificial limbs and limb components.

a. Repairs may be obtained through commercial sources with the authority of:

(1) VA Form 10-2501, the Prosthetic Service Card, (PSC), not to exceed $500, or

(2) A prosthetic card when authorized by the Chief, P&SAS, or designee.

b. Prosthetic and/or orthotic appliances may be repaired if the cost of the repair is less than one-half the cost of a comparable replacement. The Chief, Prosthetic and Sensory Aids Service, or designee, will determine whether it is more practical, from an economic point of view, to repair or replace the appliance.

c. A veteran who owns a VA issued artificial limb is to be encouraged to have repairs and/or adjustments made to the appliance by the contractor or vendor who fabricated the item. If eligible for a PSC, the veteran is to be encouraged to use the card whenever possible and practical.

d. Whenever repairs or adjustments to an artificial limb or terminal device are required within 1 year of delivery, care needs to be exercised to determine whether the repairs or adjustments are necessitated because of defective materials and/or workmanship. If so, the guarantee provisions of the contract or warranty period under which the item was procured must be enforced.

NOTE: VA Orthotic Laboratories may furnish repairs to artificial limbs if adequate parts and qualified manpower are available. Follow the procedures outlined in VHA Handbook 1173.2 and VHA Handbook 1173.6.

e. When replacement of a component still under manufacturer's warranty is necessary, the commercial vendor can not charge for cost of replacement components. Reasonable labor hours (usually in units of 15 minutes each) may be paid. Some examples of warranty items include: microprocessor knee joints, hydraulic knee joints, and energy storing prosthetic feet.

4. VA Handbook 1173.4 - Automotive Adaptive Equipment

4.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent system-wide and procedures for all field stations when furnishing automobile adaptive equipment. The VHA automobile adaptive equipment program provides the necessary equipment and training to enable a disabled veteran to operate a motor vehicle safely and permit access to and from the vehicle in a safe manner. The primary concerns are the safety of the veteran and other people on our nation's highways. To do this requires cooperation of physicians, driver rehabilitation specialists, and prosthetic representatives.

4.2. Background

Driving an automobile can be a complex undertaking for most people. Consequently, persons with disabilities find this process even more complex and challenging. Mastering the tasks involved in driving may be quite difficult, in as such that the vehicle may require adaptive equipment to meet the needs of a disabled driver.

4.3. Definitions

a. Automobile Adaptive Equipment. Automobile adaptive equipment is used to permit physically challenged persons to enter, exit, and or operate a motor vehicle or other conveyance. It includes, but is not limited to, power steering, power brakes, power windows, power seats, and other special equipment necessary to assist the eligible person. The term also includes airconditioning when necessary for the health and safety of the person, and any modification of the size of the interior space of the automobile or other conveyance if needed because of the physical condition of such persons when deemed essential.

b. Ankylosis. Ankylosis is the immobility and fusion of a joint, due to disease, injury, or surgical procedure. For the purpose of this handbook, this term is applicable to knee(s) and hip(s).

c. Conveyance. A conveyance is a means of transportation that includes but is not limited to conventional vehicles such as a car, truck or van.

d. Acuity. Acuity refers to detectable, recognizable or being able to resolve or localize.

e. Reimbursement. Repayment for money spent for adaptive equipment, whether new or repaired.

f. Repairs. Repair means to restore to sound working condition; to renew, e.g., to rebuild an automatic transmission.

g. Vehicle Modification. Vehicle modification generally means alterations that permit eligible veterans to enter, exit, and safely operate the vehicle.

h. Medical Equipment. Medical equipment is non-operational automobile adaptive equipment such as equipment necessary for entering or leaving the vehicle, air conditioning, etc.

i. Operational Equipment. Operational equipment is equipment medically necessary for the safe operation of the vehicle. Examples include hand controls, low-effort steering, automatic transmission, power brakes, power transfer seat, etc.

4.4. Scope

a. VA policy requires that certain items of automotive adaptive equipment be issued on the prescription of a physician. Such prescriptions must be based upon a knowledge of the skills and abilities required for safe and effective driving, the limitations imposed by disease and disability, and how these limitations can be compensated for by adaptive equipment and driver rehabilitation. Current adaptive equipment allows many disabled individuals to drive who could not do so a few years ago, and advances in adaptive equipment technology are appearing at an accelerated pace. As adaptive equipment becomes more sophisticated, it becomes mandatory that the prescription be individualized. In addition, more sophisticated driver rehabilitation becomes necessary. Thus, although the prescription must be issued by a physician, it will most likely be developed as a team effort involving the physician, the driver rehabilitation specialist and the prosthetic representative.

b. In many cases, the problem is simple. For example, in the case of the loss of or loss of use of an extremity, the adaptive equipment needed is standardized (see par. 19.). In other cases, particularly those with multiple handicaps, an individualized prescription is needed. Unless the physician has had the opportunity to keep abreast of the current state-of-the-art in adaptive equipment, it is best to have applicants evaluated by a driver rehabilitation specialist. The physician should report any defects or limitations identified that might affect driving to the driver training instructor as part of the referral. The driver rehabilitation specialist can make an evaluation of the applicant under simulated driving conditions and in actual adapted vehicles. The final prescription for adaptive equipment will then reflect the applicant's needs and demonstrated abilities, and is more likely to assure safe and effective driving.

4.5. Authority

a. The basic authority to provide automobile adaptive equipment is Title 38 United States Code (U.S.C.) Chapter 39 and implementing regulations in Title 38 Code of Federal regulations (CFR) 17.155 ‘«Ű 17.159. This authority is extended to the following:

(1) Veterans who are service connected for the loss or loss of use of one or both feet or hands, or who have a service connected ankylosis of one or both knees or one or both hips.

(2) Veterans with service connection for permanent impairment of vision of both eyes who have a central visual acuity of 20/200 or less in the better eye with corrective eyewear, or greater than 20/200 where the visual field of the better eye is 20 degrees or less, and who are licensed and capable of operating a motor vehicle.

b. Veterans must be in receipt of an approved VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment, or their rating sheet. The VA Regional Office Adjudication Officer approves applications for automobile adaptive equipment by certifying Section II of this form (ref. Public Law (Pub. L.) 91-666 (1-11-71)).

c. Veterans rated service connected for ankylosis of one or both knees or of one or both hips must be in receipt of a letter from the Adjudication Officer from the Regional Office verifying service connection for the disability (ref. Pub. L .97-66 (10-1-81)).

d. Veterans undergoing vocational rehabilitation under 38 U.S.C. Chapter 31, in order to achieve their goals of the rehabilitation program, and whose Vocational Rehabilitation and Counseling (VR&C) Division case manager, has determined that the veteran is eligible due to service connected disabilities, but not under 38 U.S.C. Chapter 39, and the veteran has been evaluated and deemed unable to achieve rehabilitation by alternate means, such as: training in home or by an individualized instructor when alternative means are less expensive and equally suitable (ref. Pub. L. 96-466 (10-17-80)). NOTE: Automobile adaptive equipment provided under this authority may be provided for one vehicle and will not exceed the benefit for veterans under 38 U.S.C. Chapter 39.

e. Certain items, i.e., van lifts, raised doors, raised roofs, air-conditioning and wheelchair tiedowns for passenger use, may be furnished as part of medical services VA is providing under 38 U.S.C. 1701, as a follow-up to VA hospitalization, provided the equipment is medically necessary for the care and treatment of the veteran. Vehicle modifications, such as raised doors or van lifts, may be furnished to eligible veterans, who are wheelchair-bound, when necessary to allow such person to enter and exit. NOTE: Automobile adaptive equipment provided under this authority may be provided for one vehicle and will not exceed the benefit for veterans under 38 U.S.C. Chapter 39. Operational equipment, hand controls, power brakes, power steering, automatic transmission, etc., will not be authorized. NOTE: All enrolled veterans who are prescribed medical equipment described in this paragraph are eligible for such equipment. Enrolled veterans do not need additional documentation to establish eligibility for non-operational adaptive equipment. [Emphasis added.]

4.6. Reimbursement

a. VA may not reimburse a veteran for automobile adaptive equipment more than two times within a 4-year period. The establishment of the 4-year period begins on the date the adaptive equipment is authorized. VA may not reimburse a veteran for adaptive equipment for more than two vehicles at any one time. An exception may be made to the limitation of two reimbursements in the 4-year period in cases where one of the two authorized adapted vehicles is not available for the veteran's use due to uncontrollable circumstances, e.g., theft, fire, accident, court or legal action, repairs so costly as to be prohibitive or changes in a veteran's physical condition necessitating a different type of vehicle.

b. If the veteran already has two vehicles of record, the veteran must show proof of disposition for at least one vehicle to be eligible for reimbursement for another adapted vehicle to be within the two vehicle limitation. These vehicles may not be sold or given to a spouse, family member or other party residing in the same household as the veteran, or transferred to a business owned by the veteran.

c. Cost limitations are not to exceed the allowable reimbursable amounts for certain items of automobile adaptive equipment, e.g., automatic transmissions, power brakes, power steering, etc. NOTE: The allowances for this equipment shall be updated annually in a VHA directive to reflect increases or decreases in retail prices.

4.7. Adaptive Equipment

a. Requests for automobile adaptive equipment for eligible Chiefs, Prosthetics Services, require the approval of the Chief Consultant, Prosthetic and Sensory Aids Service (PSAS) Strategic Health Group (SHG), VHA Headquarters, prior to being submitted to the regional office. NOTE: VA Form 10-1394, Application for Adaptive Equipment ‘«Ű Motor Vehicle, for these veterans is to be referred to VHA Headquarters with all supporting documentation through the appropriate Network Director (10N_/113).

b. Automobile adaptive equipment, available to the general public, which is manufactured under standards of safety imposed by a Federal agency, shall be deemed to meet the required standards for use as adaptive equipment. Only approved equipment listed in current VHA directives pertaining to these types of items may be furnished to eligible persons. These items include automatic transmissions, power brakes, power steering, etc. This equipment list will be updated frequently as the results of testing become available.

(1) Certain items of adaptive equipment for which standards have not been developed may be furnished under the authority of Title 38 Code of Federal Regulations (CFR) 17. 155(c), provided the equipment meets industry standards and authorizing officials are assured of its safety and quality.

(2) Special equipment to assist a veteran who is eligible for automobile adaptive equipment in getting into and out of an automobile or other conveyance, or interior space modifications necessary because of the size or physical condition of an eligible veteran, may be approved locally subject to the special conditions set forth in this Handbook. This applies regardless of whether the vehicle is to be operated by the eligible veteran or if it is to be operated by another person for the veteran.

c. No operational equipment, e.g., automatic transmission, power brakes, power steering, hand controls, modifications of the driver's area, etc., may be furnished to a veteran who is eligible for adaptive equipment if the veteran does not desire to drive, or if the veteran cannot drive because of the severity of the disability, e.g., total blindness, advanced multiple sclerosis, high level quadriplegic, etc. Furthermore, no operational equipment may be furnished as part of medical services to veterans who are not eligible for automobile adaptive equipment but who otherwise are eligible for prosthetic services.

d. Vehicle modifications and modifications to motor homes require prior authorization.

e. Repairs to automobile adaptive equipment on leased vehicles will not be authorized unless the lease clearly states that the repairs are the responsibility of the person who has leased the vehicle, in this case, the eligible veteran.

f. The following items will not be authorized as automobile adaptive equipment: refrigerators, intermittent windshield wipers, power trunk locks, tires, remote controlled starting devices, garage door openers, or any item which may be construed as being furnished for comfort or convenience purposes.

4.8. Prosthetic Representative

a. Role. The Prosthetic representative will ensure that:

(1) A copy of a certified VA Form 21-4502, is on file in the veteran's outpatient treatment file to support eligibility determinations; or if the veteran's eligibility for adaptive equipment is based on a service connected ankylosis, a copy of the veteran's VA Form 21-6796, Rating Decision, will be filed. If the veteran is seeking only medical equipment, the Prosthetic representative will ensure that the veteran is enrolled in VA's health care system. NOTE: A VA Form 21-4502 will not exist for these veterans since they have no eligibility for the automobile grant.

(2) The veteran has a valid driver's license and is capable of operating a motor vehicle, if operational equipment is authorized.

(3) Reimbursement for a replacement vehicle does not exceed two vehicles in any 4-year period.

(4) All adaptive equipment authorized is consistent with VA policy, e.g., cost limitations have not been exceeded, the equipment has been approved for issue to VA beneficiaries, etc.

(5) Prescriptions have been written and are supported by medical findings for all items where a prescription is required.

(6) The supplier has certified that the amounts billed do not exceed the usual and customary cost for the items or services furnished.

(7) The equipment furnished has been inspected (if required).

(8) The veteran's request for adaptive equipment is processed within 5 days after all information, invoices, prescriptions, reviews, inspections, etc., have been completed. After posting to the veteran's VA Form 10-2319, Record of Prosthetic Services, the original VA Form 10-1394, Application for Adaptive Equipment ‘«Ű Motor Vehicle, the window sticker and supporting invoices will be forwarded to the Finance activity of the regional office having jurisdiction over the veteran's case. Copies of the VA Form 10-1394 and all supporting documentation concerning the processing of the claim are to be filed in the veteran's Consolidated Health Record.

(9) Requests for automobile adaptive equipment for veterans undergoing a course of vocational rehabilitation will be processed in the same manner as those veterans eligible for adaptive equipment under 38 U.S.C. Chapter 39 with the following exceptions:

(a) VA Form 28-8861, Request for Medical Services - Chapter 31, is required from the Vocational Rehabilitation and Education (VR&E) case manager before any action is taken to furnish, repair or replace automobile adaptive equipment.

(b) Replacement equipment is subject to the limitations or authorization of supplies issued under the regulations, policy and procedures for implementing the provisions of 38 U.S.C. Chapter 31.

NOTE: It should be noted that these procedures are considerably more stringent in relation to the replacement of equipment than those for replacement under the authority of 38 U.S.C. Chapter 39. In general, adaptive equipment will only be authorized for one vehicle during the veteran's training program unless a replacement vehicle is required because of loss of the modified vehicle due to circumstances beyond the veteran's control, e.g., fire, theft, court action, etc. Title 38 U.S.C. Chapter 15 veterans are not eligible for automobile adaptive equipment.

b. Responsibilities. The Prosthetics Representative is responsible for the administration of the automobile adaptive equipment program at each medical center which has jurisdiction over a given geographical area. All Prosthetics Representatives will ensure that the following conditions are met:

(1) All approved vehicle modification vendors are informed that pre-authorization is required before any work is initiated.

(2) Information is provided to the medical staff, veterans or their representatives on the adaptive equipment which has been tested and found to meet the VA standards of safety and quality.

(3) Local procedures are developed in accordance with the policies stated in this chapter to ensure effective, economical and uniform administration of the adaptive equipment program at their facility. Written guidelines concerning automobile adaptive equipment will be published in a separate facility memorandum or included in the facility memorandum on Prosthetic Services. These guidelines will contain specific instructions regarding the evaluation, prescription, patient referral for, and authorization of, automobile adaptive equipment.

(4) All applications for adaptive equipment submitted by beneficiaries are reviewed to determine that the applicant is eligible, licensed, and that the provision of the requested adaptive equipment to the veteran is within the limitations stated in this Handbook.

(5) Direct contact is maintained with local distributors, installers, service and repair facilities, state licensing authorities, etc., in connection with providing adaptive equipment for specific beneficiaries.

(6) Reimbursements to applicant, a company, or other third parties that furnished adaptive equipment, repairs, or services to the veteran are approved.

(7) The beneficiary is assisted in arranging for special driver training, when requested or when it is apparent that an applicant requires training.

(8) Workmanship is inspected for all vehicle modifications and low-effort steering systems purchased. The inspection will include, at a minimum, functional testing and observation of the structural integrity of the installation. It will also include verification and documentation of serial numbers, the type of equipment and identification of the vehicle in which they are installed. Copies of inspection reports and all documentation supporting an adaptive equipment claim will be filed in the veteran's Consolidated Health Record and Adaptive Equipment file maintained in Prosthetic Service.

(9) Eligible veterans will not be required to obtain bid quotes.

4.9. Guidelines for Physicians

The following guidelines have been developed to assist the physician in evaluating applicants in certain specific situations:

a. Veterans requesting driver training, sensitized steering systems, or who are in need of driver training will be referred to the nearest VA Driver Rehabilitation Center listed in paragraph 20 of this Handbook. Referrals for driver rehabilitation at those facilities with approved centers are processed as any referral to a PM&RS for treatment. Particular attention should be given to the following:

(1) Determine if the veteran has, or has had, any medical conditions which would make driving unsafe because of the possibility of interruption of vehicle control due to sudden or unexpected loss of physical ability arising from weakness, impairment of perception or consciousness, or occurrence of distracting pain or sensation.

(2) Identify all medical conditions and physical deficits, which could affect driving ability so as to ensure that the person providing the driver training and evaluation for adaptive equipment has sufficient information about the veteran.

(3) Provide current PM&RS examination including an updated VA Form 10-2617, Self-Care Activities-Functional Evaluation.

b. Veterans who are requesting vehicle modifications, or questionable items of adaptive equipment, should, whenever practical, be evaluated by a VA driver rehabilitation specialist. If this is not possible, the case should be reviewed by the physician, physical medicine and rehabilitation therapist, and prosthetic representative to ensure every consideration when developing an appropriate prescription.

c. Physicians will make every effort to ensure that prescriptions are consistent with the veteran's disability and that they are in compliance with the specific policies stated in this Handbook.

4.10. Driver Rehabilitation Specialist

a. The VA driver rehabilitation specialist will assist the veteran in the selection of the appropriate vehicle and add-on adaptive equipment necessary to enable the veteran to operate a motor vehicle in a safe manner, or that equipment which is necessary for the transportation of a veteran who is incapable of driving. All veterans will be advised of the dangers of driving from a wheelchair and will be encouraged to transfer to more appropriate automotive type seats whenever possible.

b. All recommendations for adaptive equipment will be in accordance with the guidelines and policy set forth in this Handbook. Driver Rehabilitation Specialists should make no commitments to the veteran regarding what VA will, or will not, provide.

4.11. The Prescribing Physician

The physician's major responsibilities are to determine the overall ability of the applicant to drive safely and effectively, including entering and exiting the vehicle, and to identify any defects or limitations the applicant may have in the needed skills and abilities. The National Highway Traffic Safety Administration of the United States (U.S.) Department of Transportation has developed a set of guidelines, "Functional Aspects of Driver Impairment, a Guide for State Medical Advisory Boards," that can assist the physician in making decisions. Copies have been distributed to all Chiefs, Prosthetic Services, and driver rehabilitation specialists.

4.12. Veterans Benefits Administration (VBA)

a. Upon payment of the automobile allowance, the VBA Finance Activity will reproduce a copy of the completed VA Form 21-4502, and/or the covering invoice(s) and forward them to the VA outpatient clinic having jurisdiction over the area in which the veteran resides. NOTE: This information is used by the Prosthetic Service to establish eligibility for future actions.

b. VBA regional offices will continue to authorize basic operational adaptive equipment specific for disabilities, listed as part of VA Form 21-4502, with the payment of the automobile allowance without referral to VHA.

c. Vocational Rehabilitation and Education (VR&E) case managers, who identify veterans who may require automobile equipment to enable them to achieve their program goals of rehabilitation services, will complete VA Form 28-8861. This form will be forwarded to the Prosthetic Representative at the nearest VA medical center. VBA program officials should make no commitments to the veteran regarding what VA will, or will not provide.

4.13. Purchase of a Vehicle

a. Prorate the reimbursable amounts authorized for adaptive equipment when used vehicles are purchased. Used vehicles will be prorated by reducing the standard equipment reimbursable amount for like items by 10 percent per year with a residual value of 10 percent for vehicles 10 years old or older. Invoices or bills of sale used to substantiate vehicle purchases must list the items of adaptive equipment on the vehicle.

b. If for some reason the window sticker is not available, an itemized invoice may be used to substantiate the purchase of the vehicle and the items of automobile adaptive equipment purchased. Subject to the following limitations, reimbursement should not be made in amounts exceeding the "sticker price" levels:

(1) If the equipment is listed as standard on the window sticker and no price is given, the amount payable will be the "Standard Equipment Reimbursable Amount" listed in the current VHA Directive. Rebates, discounts, etc., will not affect the reimbursable amounts for eligible veterans.

(2) If the window sticker price is available, the amount payable will not exceed the "Maximum Sticker Reimbursable Amount" listed in the current VHA directive on this subject.

(3) If no window sticker is available and an itemized invoice is used, and the item is indicated in Edmund's New Car Prices or other similar established reference guides as standard equipment, the reimbursable amounts will be the "Standard Equipment Reimbursable Amount" listed in the current copy of the VHA Directive.

(4) If the item is not standard, the invoice amount may be paid, but will not exceed the "Maximum Sticker Reimbursable Amount" listed in the current VHA directive on this subject.

(5) If the item is not standard and the item is not on the VHA directive, such as a raised roof, air conditioning (after market installation), then an invoice needs to be obtained from the dealer or vehicle conversion company substantiating the cost to be reimbursed.

c. Eligible veterans may be provided automobile adaptive equipment for any non-service connected disability of a veteran who is already eligible for adaptive equipment because of service connected disabilities or eligible through 38 U.S.C Chapter 31, Vocational Rehabilitation.

4.14. Guidelines that Apply When Furnishing Automotive Adaptive Equipment for Purchased or Leased Vehicles

The following are the guidelines that apply when furnishing automobile adaptive equipment for purchased or leased vehicles:

a. An automatic transmission may be furnished to eligible licensed veterans who have a loss, or loss of use of, one or both hands or feet, or who have ankylosis of one or both knees or one or both hips.

b. Power steering may be furnished to eligible licensed veterans who have loss, or loss of use of, one or both hands or both feet.

c. Power brakes may be furnished to eligible licensed veterans who have a loss, or loss of use of one or both feet, or who have ankylosis of one or both knees or one or both hips.

d. Additional equipment or modification of dimmer switches, parking brakes, gas or brake pedals, steering wheel knob or ring, etc., may be furnished for single or multiple disabilities listed in paragraph 19.

e. Power windows may be furnished to eligible licensed veterans who require the use of hand controls; for veterans who have the loss or loss of use of an arm; or severe impairment of one upper extremity rated at 30 percent service connected.

f. A CB radio or a car phone may be furnished when prescribed by a physician knowledgeable in the area of Physical Rehabilitation or when recommended by a state licensing authority with the concurrence of the Chief, PM&RS, Chief, Spinal Cord Injury Service, or other designated physicians.

g. CB radios and/or car phones will normally be provided to veterans who have a loss or loss of use of both lower or upper extremities, or a loss or loss of use of one upper and one lower extremity. CB radios and/or car phones may also be considered for veterans who have a loss or loss of use of one lower extremity if the prescribing physician believes that abandoning the vehicle would be impossible, especially during adverse weather conditions. Other medical conditions that should be considered as possibly creating a special need associated with safe vehicular operation would include, but not be limited to, cardiovascular, neurological or pulmonary diseases.

h. CB radios and/or car phones will be furnished with antenna and permanent installation in accordance with existing purchase reimbursement procedures for automobile adaptive equipment. The amount payable will be the invoice amount for the CB radio and/or car phone antenna and installation, but will not exceed the maximum reimbursable amount listed in the current copy of the VHA Directive.

i. Cruise control may be furnished to eligible licensed veterans who have a loss, or loss of use of, one or both feet; or who have ankylosis of one or both knees or one or both hips. j. Rear window defrosters may be furnished to eligible licensed veterans who, because of physical limitations, would be unable to remove ice or fog from the rear window. This would include veterans who have a loss, or loss of use of, at least one lower extremity or both upper extremities, e.g., quadriplegia, amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), etc.

k. Power door locks may be furnished to eligible licensed veterans who have such severe impairment that they are prohibited from using conventional door locks, e.g., quadriplegia, paraplegia, ALS, MS, etc.

l. Power seats may be furnished to an eligible licensed veteran who has the loss of, or loss of use of, both lower extremities, or ankylosis of both knees or both hips, to assist the veteran in entry into or out of the vehicle, or in the case of wheelchair use, to permit storage behind the driver's seat. Power seats may also be furnished in the absence of the above conditions when recommended by a driver trainer for safe operation of the vehicle.

m. A tilt steering wheel may be furnished to permit access to a vehicle or when it is necessary to achieve an optimal steering wheel position for veterans who have loss of use of one or both lower extremities.

n. Air conditioning may be furnished to eligible beneficiaries, whether or not they are capable of operating the vehicle, when prescribed by a physician. Air conditioning may be considered for veterans, when prescribed by a physician, who suffer from the following conditions:

(1) Spinal cord injuries.

(2) Neurological diseases when the condition of the individual is substantially worsened by exposure to heat and humidity.

(3) Amputees who suffer from thermal regulatory dysfunction secondary to a loss of body surface area when this equipment is necessary to maintain the body core temperature within the normal range. It may also be provided to permit the effective use of artificial limbs; e.g., to maintain suction in above knee limbs or to amputees who suffer a skin breakdown secondary to increased sweating and irritation brought about by repeated contact with the socket wall or suspension components.

(o) Low-effort or sensitized steering and braking systems, such as Digi-Drive, Drive Master, and Touch Pad System, may be furnished to veterans whose upper extremities are involved to such a degree that they cannot operate conventional steering, braking systems, and secondary controls.

4.15. Modifications

a. In the case when a used vehicle is purchased that already has a van lift installed or other modifications that would normally be approved for a new vehicle being purchased, the veteran may be reimbursed for those modifications but they will be prorated at 10 percent per year. In determining the cost of the modifications, if the original invoice is not available, then the average and customary costs of that geographic location will be used for prorating.

b. All modifications to vehicles and other conveyances must be pre-authorized. The following procedures apply:

(1) Van lifts, which have been tested and found to meet VA standards of safety, and quality may be furnished when prescribed to permit the wheelchair-bound eligible veteran to enter and exit the van.

(2) Electric door openers may be furnished to eligible wheelchair-bound veterans who require van modifications provided they are licensed to drive independently. Veterans who are transported as passengers do not require this modification because an able-bodied driver accompanies them at all times.

(3) A raised roof may be furnished to eligible veterans who use wheelchairs to prevent the danger of head bumping while the vehicle is in motion. In general, veterans who have a seating height of 52 inches or more will require this modification. Roll bars or other structural supports will be provided whenever a raised roof is furnished.

(4) Raised doors may be furnished to eligible wheelchair-bound veterans who do not have sufficient head clearance to avoid bumping the bottom of the upper door jam. In general, this would include wheelchair-bound veterans who sit higher than 49 inches and who are unable to lean forward to clear the door jam and resume the normal sitting position. Veterans, who because of a disability require special high-backed wheelchairs, may also require raised doors.

(5) Lowered floors may be furnished to eligible wheelchair-bound veterans as an alternative to provide more headroom. In general, floor conversions offer the most advantages to the veteran who must drive from a wheelchair. It allows the wheelchair to be placed in the same position as the original driver's seat and, therefore, provides the best visibility. The criteria for furnishing this modification are generally the same as for raised roofs and raised doors.

(6) Powered floor pans may be furnished to eligible veterans who are required to drive from a wheelchair when it is necessary to provide adequate visibility. Normally, if a raised roof or a lowered floor is provided, this item is not required. However, in rare instances, it may be provided in addition to a raised roof if the veteran's vision of the road is distorted.

(7) Driver's swivel transfer seats may be furnished to eligible veterans to permit the veteran to transfer from a wheelchair to the swivel seat located in place of the regular driver's seat.

(8) Powered transfer seats may be furnished to eligible veterans who are capable of wheelchair transfer but for whom the swivel seat does not allow sufficient room for a safe transfer. The powered transfer seat travels backward from the driver's area providing sufficient distance to allow an optimum position for wheelchair transfers.

(9) Wheelchair tie-downs will be furnished to all veterans who are authorized van modifications and who ride or drive in a wheelchair. Veterans who drive from a wheelchair will be furnished a tiedown, which they are capable of operating independently. These tie-downs will either be electrical, semiautomatic or manual, as indicated by the physical abilities of the veteran. However, electrical or semiautomatic tie-downs can be provided when prescribed by a qualified driver rehabilitation specialist, Manager, PM&RS, or Manager, Spinal Cord Injury Center. The veteran may be furnished either a driver's tie-down or a passenger's tie-down, but not both.

(10) Chest and shoulder harnesses will be provided to all eligible veterans with poor trunk stability.

(11) Dual battery systems will be furnished to all veterans authorized van modifications to avoid the possibility of the veteran being temporarily trapped or stranded in a hazardous environment due to a low or discharged battery. These systems not only allow for the operation of the adaptive equipment, but also allows for the starting of the vehicle.

(12) The Prosthetic representative will review the claim for automobile adaptive equipment mini-van conversion, conduct an analysis of the existing conversion, and conduct an analysis of the existing conversion costs associated with conventional van conversions.

(a) The Prosthetic representative will include the following items (note the addition of the gas tank) in making the appropriate amount calculation: 1. Van lift, 2. Electric door openers, 3. Raised roof with roll bar or structural support, 4. Extended doors, 5. Back-up battery system, and 6. Remove and relocate gas tank.

(b) VA will reimburse the service connected veteran for the mini-van conversion claim in an amount equal to or less than the average cost of the conventional van modification plus 25 percent. The use of an Under Vehicle Lift (UVL) in the calculations is not permitted. Requests for the provision of UVLs must be sent to VHA Headquarters for review and approval by the Chief Consultant for PSAS and the National Program Director for PM&RS.

[c. Omitted from original text.]

d. The following specific limitations apply when providing automobile adaptive equipment for motor homes:

(1) All modifications must be pre-authorized.

(2) Only VA approved add-on equipment may be authorized.

(3) The maximum reimbursable amounts established for automobile adaptive equipment will not be exceeded for similar items authorized as adaptive equipment in a motor home.

(4) The amount authorized for the purchase and installation of an approved lift in a motor home will not exceed the average amount authorized for purchase and installation of similar lifts installed in vans by the authorizing VA facility.

(5) VA will not pay for the removal, modification or reinstallation of any convenience items contained in a motor home, e.g., cabinets, stoves, showers, refrigerators, etc.

4.16. Repairs

Prosthetics representatives will carefully review the veteran's repair history prior to authorizing any repairs. Particular attention will be given to the frequency and cost of repairs. If necessary, any case of abuse may be referred to VHA Headquarters using VA Form 10-2641, Authority for Issuance of Special and/or Experimental Appliances, prior to authorizing any additional repairs.

a. Authorization for, or reimbursement of, repairs is limited to the vehicle(s) of record, and includes only those basic components authorized as adaptive equipment. For example, when power brakes are authorized, only repairs to the power boost option may be approved. All repairs to conventional components of the brake system, e.g., brake shoes or pads, turning of brake drums, etc., are the responsibility of the veteran. The same principle applies to automatic transmissions, and power steering. Routine service such as brake linings, front-end alignment, lubrication, etc., will not be considered as repairs to adaptive equipment.

b. The maximum amount authorized an eligible veteran for repairs will be the amount of the invoice but reimbursement will not exceed the cost of the parts and labor for similar repairs as listed in the current Mechanical Parts and Labor Estimating Guide for Domestic Cars, available from Mitchell Manuals Incorporated, 9889 Willow Creek Road, P.O. Box 26260, San Diego, CA 92126.

c. VA Form 10-1394, may be used to authorize and/or reimburse veterans for repair services.

d. Repairs are limited to the current vehicles of record and only those basic components authorized as automobile adaptive equipment. Reimbursement is limited to the cost of the part(s) and labor based on descriptions published in Mitchell, Mechanical Parts and Labor Estimating Guide Domestic Cars, which may be procured through the local VA medical center library or by purchasing direct from Mitchell International, 9889 Willow Creek Road, P.O. Box 26260, San Diego, CA 92196-0260.

4.17. Disposition of Replaced Adaptive Equipment

Every effort will be made to transfer add-on adaptive equipment from one vehicle to another as long as the equipment is adequate for the veteran's disability and in serviceable condition. Serviceable adaptive equipment, which cannot be reinstalled in a vehicle subsequently purchased by a beneficiary, will be recovered if on loan, or accepted if offered, for possible use by other beneficiaries. When it becomes apparent that a facility cannot use the recovered equipment, it will be surveyed through the Manager, Supply Service, in the normal manner. Unusable or unserviceable equipment will be disposed of in accordance with existing regulations.

4.18. Unusual Requests

Unusual requests or inquiries relating to the automobile adaptive equipment program should be referred to the VHA Headquarters Automobile Adaptive Equipment Committee by submitting a VA Form 10-2641 in the routine manner. The committee will act as a review board to resolve any questionable claims for automobile adaptive equipment denied at the local level. This review procedure is intended to expedite the resolution of disputed claims and should not be considered as a substitute for the formal appeal process.

4.19. Additional Automobile Adaptive Equipment

a. Single Disabilities

(1) Foot

(a) Loss of Left Foot (Including Loss of Use), Ankylosis of Left Knee or Hip

1. Hand-operated dimmer switch (nonstandard).

2. Hand-operated parking brake (nonstandard).

3. If standard transmission is selected, bar welded to clutch pedal to prevent foot slipping down or off to side.

(b) Loss of Right Foot (Including Loss of Use), Ankylosis of Right Knee or Hip

1. Left foot operated gas pedal.

2. Hand-operated dimmer switch (nonstandard).

3. Hand-operated parking brake (nonstandard).

4. Extension on brake pedal for left foot operation if not part of car.

5. If standard transmission selected, bar welded to clutch pedal so both clutch and brake pedals may be operated with the left foot.

b. Hand

(1) Loss of Left Hand (Including Loss of Use)

(a) Steering wheel knob or ring.

(b) Right hand operated direction signals.

(c) Right hand or foot operated parking brake (nonstandard).

(d) Relocation of control switches, as needed.

(2) Loss of Right Hand (Including Loss of Use)

(a) Steering wheel knob or ring.

(b) Left hand or foot operated parking brake (non-standard).

(c) Relocation of control switches, as needed.

(d) Left hand gearshift lever.

b. Multiple Disabilities

(1) Feet. The loss of both feet (including loss of use) ankylosis of both knees or both hips.

(a) Hand-operated brake and gas pedal in combination.

(b) Hand-operated parking brake (nonstandard).

(c) Hand-operated dimmer switch (nonstandard).

(d) Steering wheel knob or ring.

(2) Hands. The loss of both hands, triple extremity loss or quadruple extremity loss (including loss of use). Any combination of hand and/or foot control which does not involve steering, and relocation of control switches or levers as required. NOTE: A distinction must be made between those items which are optional and those items referred by the manufacturer to be "standard" or "included."

4.20. Driver Rehabilitation Centers

Driver Rehabilitation Centers are located at the following VA medical centers:

a. Boston Health Care System, West Roxbury Campus, MA

b. VA Medical Center, Indianapolis, IN

c. VA Medical Center, Albuquerque, NM

d. Central Iowa Health Care System, Knoxville, IA

e. VA Medical Center, Detroit, MI

f. VA Medical Center, Long Beach, CA

g. VA Medical Center, Augusta, GA

h. VA Medical Center, Memphis, TN

i. VA Medical Center, Biloxi, MS

j. VA Medical Center, Miami, FL

k. VA Medical Center, Milwaukee, WI

l. VA Medical Center, Minneapolis, MN

m. VA Medical Center, Bronx, NY

n. VA Medical Center, Palo Alto, CA

o. VA Hudson Valley Health Care System, Castle Point, NY

p. VA Pittsburgh Health Care System, Pittsburgh, PA

q. VA Medical Center, Cleveland, OH

r. VA Medical Center, Portland, OR

s. VA Medical Center, Columbia, SC

t. VA Medical Center, Richmond, VA

u. VA North Texas Health Care System, Dallas, TX

v. VA Medical Center, Salisbury, NC

w. Atlanta VA Medical Center, Decatur, GA

x. VA Medical Center, San Juan, PR

y. VA Medical Center, Denver, CO

z. VA New Jersey Health Care System, East Orange, NJ

aa. VA Southern California System of Clinics, Sepulveda, CA

bb. VA Maryland Health Care System, Fort Howard, MD

cc. VA Medical Center, Jefferson Barracks, St. Louis, MO

dd. VA Medical Center, Hampton, VA

ee. VA Medical Center Tampa, FL

ff. VA Medical Center, Hines IL

gg. VA Eastern Kansas Health Care System, Topeka, KS

hh. VA Medical Center, Houston, TX

ii. VA Pugent Sound Health Care System, Seattle, WA

jj. VA South Texas Health Care System, San Antonio, TX

kk. VA Medical Center, Albany, NY

ll. VA Medical Center, Phoenix, AZ

mm. VA Medical Center, Salt Lake City, UT

nn. VA Medical Center, West Palm Beach, FL

5. VA Handbook 1173.5 - Aids for the Blind and Visually Impaired

5.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent system-wide policy and procedures for furnishing aids to blind and severely visually impaired veteran beneficiaries through the Prosthetic and Sensory Aids Service (PSAS).

5.2. Eligibility

a. Mechanical aids for the blind, and repairs to these aids, must be furnished to eligible veterans to overcome the physical and economic impairments associated with blindness when the veteran is enrolled under Title 38 Code of Federal Regulations (CFR) Part 17, Section 17.36 and the Department of Veterans Affairs (VA) Medical Benefits Package set forth in CFR 17.38.

b. Aids for the blind and repairs may be furnished to any veteran eligible for medical and or prosthetic services provided the equipment is medically and rehabilitatively indicated, as defined in Handbook 1173.1.

5.3. Definitions

a. An Aid for the Blind. An aid for the blind is any prosthetic device, item of equipment, or animal used in assisting a beneficiary in overcoming the impairments associated with blindness and vision loss, including, but not limited to:

(1) Devices or items specially designed for use by persons who are blind or visually impaired, such as long canes, writing guides, Braille writers, Braille or low-vision talking watches, signature guides, talking calculators, and optical character readers.

(2) Devices usually used by sighted persons, but which have been approved for use by blind or visually impaired beneficiaries for the specific purpose of assisting them in overcoming functional deficits related to vision loss, in addition to ensuring safety, e.g., electric razors, voice- activated organizers, typewriters, recording devices, computers, Brett guards (plastic corner cover for saws), and large-print playing cards.

(3) Guide dogs specially trained to assist blind persons.

(4) Any device or item requiring evaluation and/or training by a low-vision specialist or blind rehabilitation professional with the exception of optical low-vision devices.

(5) Specially-adapted medical devices such as glucometers, blood pressure monitors, thermometers, and audible prescription reading devices.

b. Basic Low-Vision Services. Basic low-vision services are provided at all VA eye clinics. These services include, but are not limited to, clinical low-vision examinations and changes to spectacle prescriptions that may include separate reading spectacles or increased bifocal aids, simple magnifiers or telescopes, absorptive lenses, lamps, reading stands and other optical and non-optical devices that meet the needs of patients that are transitioning to visual impairment but do not require extensive specialized training.

c. Competencies. VA staff with a degree in blind rehabilitation or certification in an area of expertise (i.e., low vision) will be deemed competent to evaluate and train on various devices for which they have demonstrated educational or on-the-job experience. NOTE: Blind Rehabilitation Service (BRS), VA Central Office, encourages competency training on specific equipment for interested staff that otherwise do not have a professional background in blind rehabilitation.

d. Continuum of Care Program. The Continuum of Care Program is a comprehensive nationwide system for visually impaired veterans which integrate rehabilitation services for those patients with visual impairments into VA health care services.

(1) This program encompasses the full range of vision rehabilitation services from basic low-vision care to inpatient blind rehabilitation. Basic low-vision services are provided at all VA eye clinics. Intermediate low-vision clinics deal with more advanced devices and training for performance of everyday tasks such as reading, writing, and meal preparation. Advanced low-vision clinics provide a full range of devices where treatment extends beyond vision rehabilitation to address other functional deficits such as hearing loss and mobility problems. Advanced blind rehabilitation clinics offer short term comprehensive rehabilitation programs for veterans who do not require intensive inpatient programs. Blind Rehabilitation Centers (BRC) provide intensive and comprehensive inpatient blind rehabilitation.

(2) Continuum of Care programs that are monitored by the Blind Rehabilitation Service include:

(a) Visual Impairment Services Team (VIST). VIST is a team comprised of health care and allied health care professionals charged with the responsibility of ensuring that blind veterans are identified, evaluated, and provided health and rehabilitation services to maximize their adjustment to sight loss. A designated VIST coordinator provides case management, prosthetic devices, counseling, referrals, and benefits for veterans who are legally blind or who have excess visual disability. VIST team representatives may include, but are not limited to the following specialties: social work, ophthalmology, optometry, prosthetics, primary care, vocational rehabilitation, nursing, audiology, podiatry, nutrition, psychology, Veterans Benefits Administration (VBA), blind veterans' consumer organizations, blind consumers, and state or community agencies for persons who are blind.

(b) Blind Rehabilitation Outpatient Specialist (BROS). A BROS is a multi-skilled college or university trained (bachelor or masters degree in blind rehabilitation) and experienced blind rehabilitation specialist who has advanced technical knowledge and competencies in at the journeyman level in at least two of the following disciplines: orientation and mobility; living skills (vision-rehabilitation therapy) and visual skills (low-vision therapy). BROS have been cross-trained to acquire broad-based knowledge in each of the BRC disciplines. BROS provide assessment and training on-site in patients' homes, communities, and job sites.

(c) Intermediate Low-vision Clinic. Intermediate low-vision clinics are staffed by an eye care professional and a low-vision therapist. In this clinic, a moderate breadth and level of complexity of low-vision services are provided. Services include a thorough low-vision functional assessment of daily tasks along with training on the use of devices and limited to Activities of Daily Living (ADL) training.

(d) Advanced Low-Vision Clinic. Advanced Low-vision Clinics include a licensed eye care practitioner or provider trained in low-vision rehabilitation as well as low-vision therapists, orientation and mobility (O&M) specialists and others working as an interdisciplinary team to provide low-vision care. Visual skills assessment and training is more extensive than that provided in the intermediate low-vision care program. Limited O&M training and ADL skills are also taught. Psychosocial counseling for adjustment to blindness is available on a limited basis and audiology services are available to eligible veterans.

(e) Advanced Outpatient Blind Rehabilitation Clinic. Advanced Outpatient Blind Rehabilitation Clinics are staffed with a small team of blind rehabilitation and low-vision professionals along with an optometrist or ophthalmologist trained in low-vision rehabilitation. They offer short term comprehensive rehabilitation programs similar to BRC programs but are designed for veterans who do not require intensive inpatient programs. Advanced low-vision services are provided. Training to enhance independent function is more intense than those provided in the advanced low-vision clinics. Additional adjustment counseling and audiology services are available. Training for computer access for e-mail, Internet, and word processing is provided.

(f) Visual Impairment Services Outpatient Rehabilitation Program (VISOR). An outpatient intermediate rehabilitation program that provides comfortable, safe, overnight accommodations (hospital hotel setting) for beneficiaries who are visually impaired and requiring temporary lodging in order to access services provided through the program. The program offers skills training, orientation and mobility, and low-vision therapy. VISOR programs are currently located at the VA Medical Center in Lebanon, PA, and the VA Medical Center in West Haven, CT.

(g) Blind Rehabilitation Centers (BRC). A BRC is a special organizational unit established at select VA medical centers to provide comprehensive rehabilitation of veterans who have functional deficits related to vision loss. BRAC services include, but are not limited to: training in orientation and mobility, communication skills, activities of daily living, manual skills, low- vision and computer access training. This comprehensive training is provided through a residential or inpatient program model, generally lasting several weeks for each admission.

e. Legal Blindness. Legal blindness exists when a person's best corrected central visual acuity in the better eye is less than or equal to 20/200, or if the central visual acuity in that eye is better than 20/200, but the visual field dimension is less than or equal to 20 degrees at the widest diameter.

f. National Program Consultant. Professional field representatives of the Director of Blind Rehabilitation Service who provide ongoing support and consultative services to the BRC, BROS, and VIST.

g. National Standards for Issuance. PSAS, in collaboration with BRS, Optometry, Ophthalmology, VA Central Office, and other stake holders, develops and publishes VHA Prosthetic Clinical Management Program (PCMP) Clinical Practice Recommendations for prescription and issuance of various types of prosthetic equipment.

h. Optical Low-Vision Devices. Optical low-vision devices alter the image focus, size (magnification or minification), contrast, brightness, color, or directionality of an object through the use of lenses or other technology. Such devices include, but are not limited to: prescription eyeglasses or spectacles (with or without tint), specialty contact lenses, microscopic spectacles, hand-held magnifiers, stand magnifiers, telescopes (monocular or binocular), head-borne lenses, magnifiers, minifiers, prisms, and closed-circuit televisions (CCTVs) and electronic optical enhancements devices (EOEDs). These optical low-vision devices must be prescribed by an appropriately credentialed and privileged optometrist or ophthalmologist.

i. Non-Optical Low-Vision Devices. Non-optical low-vision devices are those that use senses other than vision to enlarge. Examples include, but are not limited to large phone dials, touch watches, larger print books, audible clocks, and alarms. These devices do not require a prescription by an eye care provider

j. Visual Impairment Center to Optimize Remaining Sight (VICTORS). VICTORS is a comprehensive low-vision program developed by VHA Directors of Optometry, Blind Rehabilitation and Social Work Services to complement existing inpatient Blind Rehabilitation Centers (BRCs) to care for veterans with significant visual impairment. The interdisciplinary VICTORS outpatient program represents a unique team approach to vision rehabilitation using the disciplines of optometry, ophthalmology, social work, psychology, and low-vision therapists. VICTORS provides rehabilitation through definitive medical diagnosis, functional vision evaluation, prescribing, and training in use of low-vision aids, counseling and follow-up. Frequently, other necessary patient care services (e.g., social work, psychology, audiology and ophthalmology) are provided at the local station. There are currently four VICTORS programs located in Kansas City, MO; Chicago, IL; Northport, NY; and Lake City, FL.

5.4. Responsibilities of the Facility Director

The Facility Director is responsible for ensuring that the processes defined in this Handbook are implemented as appropriate and necessary.

5.5. Issuing Aids for the Blind

NOTE: The procedures outlined in Handbook 1173.1, Eligibility, and Handbook 1173.2, Furnishing Prosthetic Appliances and Services, are generally applicable to furnishing aids to veterans who are blind.

a. Aids and devices for the blind may be issued by the local VIST Coordinator, BROS, BRC, VICTORS, VISOR, or Continuum of Care Program Staff provided the following conditions are met:

(1) Optical low-vision devices must be prescribed by an appropriately credentialed and privileged licensed eye care practitioner or provider (ophthalmologist or optometrist).

(2) The veteran has a stated need for each device issued.

(3) The veteran demonstrates the ability to use the device correctly.

(4) When training is required, it must be provided in accordance with the national standards for issuance of a particular device. If a standard for issuance has not been developed for a particular device, then the program (BRC, VIST, BROS, VICTORS, VISOR, or Continuum of Care Program) may develop local standards until such time that a national standard is published. The training must be provided by an individual with appropriate competencies to teach the particular device.

b. Veterans requesting issuance of a device through the VA will be provided evaluation, training (if necessary), and issuance if the preceding conditions are met in a timely manner. When local issuance is being considered, every effort needs to be made to begin evaluation and training within 30 days of request from the veteran. If all criteria are met for issuance of the device, the device is to be issued within 72 hours of completion of training. Devices that are related to patient safety need to be evaluated and issued immediately, or within a 24-hour period from the time of request.

c. Evaluation and training on equipment for the blind needs to be provided by specialists with appropriate competencies, in the least restrictive environment available and in accordance with the accepted issuance criteria established for each device. The evaluation and training can be provided by any qualified low-vision professional (optometrist, ophthalmologist, low-vision therapist, VICTORS, or blind rehabilitation professional (BRC, BROS, VIST, VICTORS, VISOR)) or Continuum of Care Program or non-VA (state or private) program.

d. Issuance of a device must be based on demonstrated proficiency and ability to safely and independently use the device. The issuance of a device must follow nationally established guidelines for issuance and must include written justification of need, training provided, and the capability of the veteran to utilize the equipment.

(1) Whenever eligible beneficiaries are referred to a regional BRC, BROS, VICTORS, VISOR, or Continuum of Care Program, all aids for the blind and special equipment recommended by that center for issuance to the veteran upon completion of training will be furnished by the prosthetic activity at the VA institution where the training was provided. At a BRC, the Chief of the program is the approving official. Copies of all procurement documents and records of issuance must be sent to the veteran's primary service facility.

(2) In most cases, veterans are to be encouraged to attend the appropriate VA program to address their needs (BRC, BROS, VICTORS, VISOR, or Continuum of Care Program). However, alternative non-VA (state or private) programs may be used as a resource for the evaluation and training of a veteran when appropriate for the needs of the veteran. The results and recommendations made following the referral to a non-VA agency must be reviewed by the local VIST for appropriate action.

e. Personal computers and certain add-on(s) electronic sensory equipment such as synthesizers, speech recognition systems, software, optical character recognition systems, etc., must be issued when medical and/or rehabilitative need is determined and the ability to appropriately use the device is demonstrated.

(1) The law permits the issuance of a wide variety of equipment to eligible veterans to overcome the handicap of blindness under Title 38 United States Code (U.S.C.) Chapter 17, Section 1714(b).

(2) Initial requests and/or prescriptions for computer-based electronic sensory equipment for veterans who are blind are to be reviewed by the field facility's VIST.

(3) Computer equipment issued to the veteran becomes the property of the veteran. Due to the possibility of private and personal information being stored on this equipment, VA does not recover this equipment for re-issuance or disposal.

5.6. Request Procedure

a. Veterans must submit their requests for aids for the blind through their VIST Coordinator. The prosthetic activity is responsible for eligibility determinations. If the veteran is eligible, the VIST reviews the request and conducts an assessment regarding the veteran's diagnosis, prognosis, need for equipment, etc., to determine the veteran's potential to successfully learn to use the equipment.

b. VIST, in consultation with a National Program Consultant, will determine the most appropriate place for further evaluation, and/or training and issuance. The request may be handled locally, if the issuance can be effectively completed either directly through VIST, BROS, or with assistance from a qualified community resource. If the request cannot be completed locally (i.e., requires evaluation and/or training not available at the local level), the request is to be forwarded to the appropriate program capable of providing the service. A veteran requesting focused training at a BRC program (i.e., one device only) may be considered for admission to a BRC if training is not an option at the local level or through the appropriate Continuum of Care Program, VICTORS, or VISOR.

c. Oversight is provided by BRS to ensure that appropriate assessment and training competencies are maintained.

5.7. Criteria for Issuance

The veteran must demonstrate proficiency to use the requested equipment to perform the tasks for which the equipment is being requested. NOTE: Issuance of applicable software is limited to that which was utilized as part of the veteran's training at a VA BRC, VISOR, VICTORS, Continuum of Care Program and/or local training facility. Application software associated with the veteran's operational environment is limited to that required to overcome the handicap of blindness.

5.8. Training

Upon completion of the initial evaluation, a determination is made as to whether training should be initiated. Training needs to be conducted in the least restrictive environment available to the veteran based upon the availability of appropriate, quality local resources for the blind (i.e., BROS or community agencies). If the training cannot be provided locally or the veteran requests training at a specific program (VICTOR, VISOR, Continuum of Care or BRC), VIST is to refer the veteran to the program of jurisdiction for further evaluation and training. Training materials developed by the manufacturer are utilized by the training centers with appropriate additions, deletions, and/or modifications of training to meet the special needs of the veteran.

5.9. Replacement Appliances

a. Aids for the blind may be replaced after it is determined that it is no longer serviceable due to fair wear and tear, no longer meets the veteran's stated needs, or has been replaced with a new device with superior technological capabilities. In consultation with the low-vision specialists responsible for the veteran's care and treatment, such determination is made by the Chief of the prosthetic activity at the facility with outpatient clinic of jurisdiction responsibility (see VHA Handbook 1173.2).

b. For optical low-vision devices, the prescribing licensed credentialed and privileged eye care practitioner or provider (ophthalmologist or optometrist) must be consulted and replacement eyeglasses or optical low-vision devices provided in compliance with current VHA policy on Prescribing Hearing Aids and Eyeglasses, VHA Handbook 1173.12, Prescription Optics and Low-Vision Devices, and VHA Clinical Management Program (PCMP) Clinical Practice Recommendations for Prescription and Provision of Optical Low-vision Devices to Aid in Overcoming Visual Impairment.

c. Veterans having in their possession items of equipment, with the exception of computers, which are surplus to their needs, may return such equipment to their local PSAS at any time without forfeiting their eligibility to such equipment at some future time. At no time, however, will such action be permitted for the sole purpose of obtaining a newer model of similar type equipment.

5.10. Duplicate issuance of Appliances

a. Veterans who are furnished aids for the blind may be authorized duplicate aids when the following conditions are met:

(1) The veteran is eligible for such aids under the authority of 38 U.S.C. Chapter 17, Section 1714(b) (see par. 2).

(2) The item significantly contributes to the veteran overcoming the physical or economic handicap of blindness, i.e., it is required for vocational or avocational activities.

b. Spare devices will not normally be authorized to veterans who have been furnished aids for the blind as part of their care and treatment. Unusual cases will be referred to the Veterans Integrated Service Network (VISN) for consideration by submitting VA Form 10-2641, Authority for Issuance of Special and/or Experimental Appliance, in the normal manner.

5.11. Repairs

a. Repairs for aids for the blind are obtained by use of VA Form 10-2501, Prosthetic Service Card (PSC), or VA Form 10-2421, whichever is most appropriate. PSCs have a price limitation. PSCs are only to be issued by the outpatient clinic with jurisdiction for providing the veteran's prosthetic service. NOTE: The policy for issuance of PSCs is contained in VHA Handbooks 1173.1 and 1173.2.

b. Maintenance contracts may be considered for veterans with continuing eligibility who have been issued extremely costly electronic items, when it is cost-effective and when it is in the best interest of the veteran and the Government. Maintenance contracts are not issued for items with relatively low or moderate cost, e.g., CCTVs, laser canes, optacon, etc.

5.12. Guide Dogs

a. Guide dogs may be authorized for issuance to eligible veterans who are enrolled under 38 U.S.C. Chapter 17, Section 1705. Guide dogs must be obtained through private agencies as the VA does not pay for the animal itself.

b. Each request from an eligible veteran for a guide dog must be subject to the requirements of that guide dog agency.

c. If the veteran appears to be a good candidate for the use of a guide dog, the request, with all pertinent information needs to be forwarded to the guide dog agency concerned. Forms may be obtained from the guide dog agency or local VA medical center. Travel arrangements will be made through the Chief Business Office or equivalent office at the local VA medical center.

d. If the veteran becomes adjusted to a guide dog, it will be explained to the veteran that the dog is the veteran's property and that the veteran is responsible for procuring and paying for license tags (if required), food, and for liability of any damages inflicted by the dog on others. Veterinary treatment and harness repairs may be authorized as repair services under the authority of a PSC or VA Form 10-2421.

5.13. Stock Items

a. A supply of aids for the blind used in the activities of daily living needs to be maintained at VA field facilities for immediate issuance to eligible beneficiaries; these include, but are not limited to: signature guides, electric razors, watches, clocks, tape recorders, etc.

b. A supply of aids for the blind that are designed to ensure patient safety may be maintained at all VA field facilities for immediate issuance to eligible beneficiaries, provided appropriate training is available; these include, but are not limited to: long or folding canes, magnifiers, talking glucometers, talking blood pressure monitors, talking thermometers, e.

c. Prosthetic activities located at facilities having a BRC, VISOR, or Advanced Outpatient Blind Rehabilitation Clinic must maintain a comprehensive stock of aids for the blind for the immediate issuance to veterans trained at those programs.

5.14. Home Set-Up of Equipment

Some types of electronic equipment may require assistance for set-up in the veteran's home. VIST and BRCs are encouraged to work with the prosthetic activity and all available resources to ensure that equipment is properly issued, set-up, and maintained in the veteran's home environment. This may be accomplished through BROS or a home visit by a BRC instructor if the veteran lives in close proximity to a BRC. In other cases, the VIST or BRC needs to identify a vendor or third-party assistance with home set-up of special electronic equipment and convey this information to the prosthetic activity. The cost of set-up and delivery can be arranged and funded by the prosthetics activity.

6. VA Handbook 1173.6 - Wheelchairs and Special Mobility Aids

6.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent Department of Veterans Affairs (VA) procedures for providing wheelchairs and special mobility aids to VA beneficiaries.

6.2. Scope

NOTE: The initial determination of eligibility for the provision of wheelchairs is defined in Handbook 1173.01, Eligibility, Title 38 United States Code (U.S.C.) 1710, and Title 38 Code of Federal Regulations (CFR) 17.150 and is subject to the provisions of this Handbook.

a. Wheelchairs may be permanently issued or loaned at the discretion of the prescribing physician or Prosthetic Representative. This decision is based on the nature of the veteran's disability, the cost of the wheelchair, and the length of time the wheelchair will be required. Facility property wheelchairs, when available, are generally loaned by other than prosthetic personnel for leave periods or weekend passes. However, the Prosthetics Service may loan reclaimed wheelchairs for this purpose when necessary.

b. All wheelchairs are to be prescribed as far in advance of discharge as possible. Local medical center policies need to stress the importance of early prescription to ensure adequate time for delivery and patient education in its use and maintenance. If the prescribing physician is unfamiliar with the wheelchair requirements of the patient, the request needs to be referred to Physical Medicine and Rehabilitation Service (PM&RS), Spinal Cord Injury (SCI) Service or the Prosthetics Representative to ensure that all possible modifications are considered in developing an appropriate prescription to meet the medical and physical requirements of the patient. Unless it is contraindicated by the veteran's size, physical condition, or medical condition, beneficiaries who are permanently confined to a wheelchair are to be given a choice of style and colors of wheelchairs available, including the choice of manufacturer, under existing VA contracts.

NOTE: The existence or non-existence of a Blanket Purchase Agreement in a particular Veterans Integrated Service Network (VISN), or other cost-saving incentives, does not affect the beneficiary's freedom of choice. This provision applies to all wheelchairs furnished to a beneficiary (primary, spare, sports-model, hand cycle, replacements, etc.)

c. All wheelchairs for use by eligible beneficiaries must be purchased from current VA contracts using established procedures unless customized wheelchairs are needed to meet unique patient needs as with SCI.

d. Unusual requests or experimental-type wheelchairs must be referred to Prosthetic Program officials in VHA Central Office in accordance with existing policy and procedures.

e. All Prosthetic activities need to maintain a stock of basic wheelchairs and the more frequently prescribed custom wheelchairs with the most common modifications for immediate issue. The number and type of wheelchairs to be stocked is to be based on the needs of the facility, as determined by an internal review and analysis of previous issues.

f. Whenever possible, reclaimed wheelchairs that have been restored are to be reissued and/or provided as a ward chair. Wheelchairs that cannot be economically repaired and reissued must be turned in to the Acquisition and Materiel Management Service, or other appropriate service for disposition.

6.3. Classification of Commercial Source Wheelchairs

Commercial source wheelchairs are classified as follows:

a. Amputee Wheelchair. An Amputee Wheelchair is a commercially-manufactured wheelchair in which the rear axles are offset further to the rear to shift the center of gravity for greater weight balance or stability, thereby compensating for the loss of the lower extremities.

b. Basic Wheelchair. A basic wheelchair is a manual wheelchair with 8 inch front wheels and usually 24 inch hard rubber rear wheels but with minimal modification possibilities. It is a basic, inexpensive wheelchair that needs to be stocked at each medical center and outpatient clinic in suitable quantities to satisfy immediate needs.

c. Custom Wheelchair. A custom wheelchair is a wheelchair produced on the assembly line in accordance with a prescription, which requires structural changes and specialized seating requirements, e.g., increased height.

d. Lightweight or Ultralite Wheelchair. A lightweight or ultralite wheelchair is any wheelchair constructed of aluminum, titanium, plastic, or other light weight material, etc. These wheelchairs may fold or have rigid frames. NOTE: Numerous colors are available, as well as optional choices in front rigging and front and rear wheels.

e. Manual Wheelchair. A manual wheelchair is a generic term for wheelchairs that are propelled by hand.

f. Pushrim-Activated Power-Assist Wheelchairs (PAPAW). PAPAWs require users to stroke the hand rims to activate small, lightweight motors, which then drive the wheels for a brief period of time (seconds). To keep a PAPAW moving, users must continue to stroke the hand rims as they would if they were propelling standard manual wheelchairs.

g. Motorized Wheelchair. A motorized wheelchair is any wheelchair modified to be self- propelled by the use of an electric motor. It is designed to compensate for a patient's inability to use a manual wheelchair. NOTE: Batteries and a battery charger are necessary components.

h. Enhanced Function Power Wheelchairs. The term "enhanced function power wheelchair" refers to power wheelchairs with augmented capacities such as the ability to change the user's vertical position in space (elevate, go low to ground), stand, access multiple inhospitable terrains, and/or climb stairs.

i. Scooters (3 or 4 wheel). Three or four wheel scooters are any electrically-motorized mobility device guided by a tiller with limited seat modification capabilities for use by persons who are unable to propel a manual wheelchair, but who retain the ability to independently transfer onto and off of the device. Scooters are for patients who are able to negotiate their home environment without powered mobility, but who require powered mobility outside the home.

j. Sports Model Wheelchair. A sports model wheelchair is any wheelchair which is specifically built for sports activities, e.g., basketball, track, tennis, etc. Handcycles or handbikes fall into this category.

k. Stock Wheelchair. A stock wheelchair is a wheelchair available from a manufacturer not requiring modification, but includes special features, e.g., removable arms, elevating leg rests, adjustable height and back, one-arm drive, etc. It may vary in size and weight.

6.4. Guidelines for Issuing Wheelchairs

a. Basic or Stock Wheelchair. A basic or stock wheelchair may be considered for VA beneficiaries when the disability requires a wheelchair, but the veteran has retained the ability to stand and transfer, or has a disability of a temporary nature. No special features or modifications are required for this wheelchair to accommodate physical condition or size.

b. Lightweight or Ultralite Wheelchairs. Lightweight or ultralite wheelchairs may be considered for eligible veterans meeting the criteria for normal wheelchairs; however, special attention is required when prescribing an ultralite wheelchair. Unique modifications in height of seat and back, angle of seat, back, and footrests and in the wheel chamber are essential elements for users of ultralite wheelchairs. Care needs to be exercised to ensure that the veteran's physical condition does not contraindicate the use of this type of wheelchair on a daily basis.

c. Sport Model Wheelchairs. A sport model wheelchair may be considered for eligible VA beneficiaries who have a disability resulting in the anatomical loss, or loss of use, of at least one lower extremity which prohibits their participation in normal sports activities. It must be determined that the VA beneficiary is actively engaged in a sports activity which requires a specially-designed sports wheelchair for attainment of maximum rehabilitation. One sport model wheelchair may be furnished in addition to the regular allotment for a VA beneficiary who requires the continued use of a wheelchair for mobility. The request needs to be approved by the Major Medical Equipment Committee, local Wheelchair Committee, or by a physician who specializes in rehabilitation medicine.

(1) Sport model wheelchairs may be furnished to eligible veterans in lieu of a conventional- type chair, even if the veteran is not actively engaged in a sports activity, provided the unique modifications in height, depth, and width contained in the sport chair are appropriate for the veteran's physical condition and there are no contraindications for daily use.

(2) Replacement of sports model wheelchairs may not be authorized merely because a veteran desires a new model or type, or solely because a chair has been used for a particular length of time.

d. Hand Cycles. Hand cycles may be furnished under the same provisions as for sport model wheelchairs.

e. Motorized Wheeled Mobility Devices. Clinical practice recommendations for scooters, PAPAWs, power wheelchairs, power wheelchairs with enhanced function, and iBOT?ę motorized devices can be found under the Prosthetic Clinical Management Program (PCMP) link at: http://vaww.pclo.med.va.gov

NOTE: As new and emerging wheelchair technology becomes available, which requires patient referrals to specialized evaluation sites, the referral sites are responsible for the cost of the device once it has been recommended by the evaluation team and authorized by VHA Central Office through the submission of VA Form 10-2641, Authority for Issuance of Special and/or Experimental Appliances. The VA Form 10-2641 is to be prepared by the referral site with all applicable supportive documentation and evaluation results prepared by the evaluation site (e.g, iBOT?ę).

6.5. Spare Wheelchairs

a. Veterans who are eligible for outpatient services and require the constant and continued use of a wheelchair are to be furnished a second manual wheelchair of equal quality when the prescribing physician and/or Prosthetic Representative have established that the absence of a manual wheelchair during repair periods would create a severe hardship. If a spare wheelchair is considered appropriate, responsibility for procurement is with the prescribing facility.

b. Spare motorized wheelchairs may be furnished when an unusual circumstance occurs. In such cases, all pertinent facts and complete medical justification must be forwarded to the local Wheelchair Clinic or Major Medical Equipment Committee for determination.

c. The issuance of a manually-propelled wheelchair needs to be considered for all outpatients who have been furnished a motorized wheelchair where the limitations of use, time required for repairs, and other circumstances create a severe hardship for the veteran.

6.6. Wheelchair Replacement

NOTE: Replacement wheelchairs may not be authorized merely because a new model is manufactured or solely because a wheelchair has been in use for a particular length of time.

a. Replacement wheelchairs may be authorized without personal examination of the patient and/or the wheelchair if the Prosthetic representative has sufficient knowledge of the case to determine that there are no new medical problems and one of the following conditions exists:

(1) The repair costs exceed one-half of the replacement costs.

(2) Loss or destruction was due to circumstances beyond the control of the veteran. If negligence or willful action is established, the local Prosthetic Representative determines whether a replacement may be issued, dependent upon the circumstances. NOTE: Prosthetic Program officials in VHA Central Office may be consulted for an opinion.

b. When a wheelchair no longer meets the patients needs due to change in medical condition, the patient is required to obtain a new prescription through PM&RS or SCI.

c. In those instances where the wheelchair prescription has changed and the wheelchair in the patient's possession is still serviceable and not intended to be used as a spare, the Prosthetic Service must recover the chair for reissue.

6.7. Repairs

a. Repairs may be obtained through local sources on the authority provided by VA Form 10-2501, Prosthetic Service Card (PSC), and VA Form 10-2421 (ADP), Prosthetic Authorization for Items or Services, a Purchase Card, or through local VA repair facilities.

b. Wheelchairs need to be repaired if the cost of the repair is less than one-half the cost of replacement. The Prosthetic Representative, or designee, determines whether it is more practical, from an economical standpoint, to repair or to replace the wheelchair. In cases of substantial repairs, the wheelchair needs to be shipped or delivered to the respective health care facility for inspection; or arrangements must be made for a repair shop to furnish a complete assessment or repair estimate before the approval of repair is granted.

c. The expense of a wheelchair repair incurred without prior authorization for a veteran with a service-connected disability or a veteran with other continuing eligibility, may be paid or furnished on the basis of a timely-filed claim if:

(1) Obtaining the repairs locally was necessary, expedient, and not a matter of preference over using authorized sources; and

(2) It is determined that the costs were not excessive or unreasonable. NOTE: If it is determined that the costs were excessive or unreasonable, the claim may be allowed to the extent the costs were deemed reasonable, and the remainder disallowed.

d. Expense for damages to wheelchairs that were intentional or caused by negligence are the responsibility of the VA beneficiary.

e. Eligible beneficiaries are issued a PSC upon initial issue of the wheelchair. The PSC pre- authorizes repairs to the specific wheelchairs listed on it, not to exceed the current dollar limitation. Repairs exceeding this limitation may be approved by telephone with a follow-up repair authorization by the VA beneficiary 's Prosthetics Representative. NOTE: Form Letter (FL) 10-55, Authorization to Repair Prosthetic Appliance, may be used for this purpose.

NOTE: Repairs and/or replacements for wheelchairs not furnished by a facility will be provided once a patient is enrolled at the new referral facility. Prosthetic staff is required to input the item(s) to be repaired into the patient's VA Form 10-2319, Record of Prosthetic Services, as historical data for tracking purposes. If a replacement is deemed necessary, follow procedures outlined in paragraph 6.

7. VA Handbook 1173.7 - Audiology and Speech Devices

7.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent Department policy and procedures for providing audiology and speech devices to veteran beneficiaries.

7.2. Scope

a. Hearing Aids can only be issued to eligible patients in accordance with existing Department of Veterans Affairs (VA) regulations, 38 C.F.R., 17.149. Eligibility for a hearing aid will be verified through Remote Order Entry System (ROES) by the Audiology and Speech Pathology Clinic before the veteran is scheduled for a hearing aid evaluation (HAE) exam. The Audiology Clinic will prepare the ROES automated form, VA Form 10-2477a, Hearing Aid Order and Issuance Form, and schedule the veteran for an exam.

b. All requests for hearing aids will be referred directly to a VA medical center's Audiology and Speech Pathology Clinic or to the nearest Independent Hearing Aid Dispensing Program.

c. If the Audiology and Speech Pathology Clinic is unable to verify the veteran's eligibility in ROES, the veteran will be referred to Health Administration Service (HAS) to update the patient's file. If the veteran's file is current and the veteran does not have continuing eligibility, Audiology and Speech Pathology will request, through ROES, an eligibility determination by the Prosthetic and Sensory Aids Service (PSAS).

7.3. Definitions

a. Audiology and Speech Pathology Clinic. An Audiology and Speech Pathology Clinic is a VA or contract facility that is specially staffed and equipped to provide audiological and speech services.

(1) Independent Hearing Aid Dispensing Programs. Independent Hearing Aid Dispensing Programs are designated by the Director, Audiology and Speech Pathology Service, and provide services in a defined geographical area (generally the primary service area of the medical center). These services include examinations for compensation and pension claims, assessment of social efficiency, audiological and hearing aid evaluations, the provision of hearing aids and other supplementary devices associated with hearing health care, special medical-diagnostic evaluations, and aural rehabilitation. These clinics maintain a stock of hearing aids and accessories which are furnished and replenished through a centralized distribution program by the Denver Distributing Center (DDC), Denver, CO.

(2) Basic Audiology and Speech Pathology Clinics (satellite clinics). Basic Audiology and Speech Pathology Clinics (satellite clinics) provide services for patients from a more restricted geographical area. These have a smaller audiology and/or speech pathology staff and usually serve only inpatients and other veterans for whom travel might be a hardship. Veterans who require special procedures, which cannot be provided at these clinics, are referred to Independent Hearing Aid Dispensing Programs.

b. Hearing Aid Evaluation (HAE). A HAE is a procedure used by an audiologist to determine the extent of hearing impairment and the selection of an appropriate corrective instrument.

c. Cochlear Implant. A Cochlear implant is a surgically implanted device which stimulates the auditory cochlea directly. The unit consists of a speech processor which stimulates the electrodes which have been implanted into the cochlea. NOTE: This item is only implanted at authorized medical centers.

d. Assistive Listening Devices. Assistive listening devices are items used to assist a person to hear or amplify sound. Telephone amplifiers, personal amplifiers, infrared television amplifiers are examples of these devices.

e. Assistive Device. Examples of assistive devices used in daily living activities are: telephone or door bell signaling devices, telecaption television decoders, bed vibrators, strobe lights.

f. Artificial Larynx. An artificial larynx is an electronic device which provides external vibration for phonation.

7.4. Referrals

The professional management of each patient will be determined by the Chief, Audiology and Speech Pathology at the VA medical center that provides the patient care. The Chief of the Audiology and Speech Pathology Service determines whether the veteran should be referred to an Independent Hearing Aid Dispensing Program, referred to another Audiology Clinic, receive an itinerant visit by a VA audiologist, or referred to a private audiologist.

a. When a veteran is referred to another VA medical center, the referring station will send the veteran's audiological file, a VA Form 10-10EZ, Application for Medical Benefits, and any other pertinent data necessary to evaluate the veteran. The medical center that will be examining the veteran schedules the veteran's appointments and issues the appropriate hearing aid.

b. Referrals to a private audiologist will be coordinated through HAS and by the Chief, Audiology and Speech Service. After the private audiologist examines the veteran, the private audiologist sends the ear impression, the results of the hearing aid evaluation, and a recommendation as to the make and model of the hearing aid the veteran requires, to the referring VA Audiology and Speech Pathology Service. The VA Audiology and Speech Pathology Clinic will have the ear mold made, or order the custom hearing aid from the DDC, and return the hearing aid (and ear mold if it is an over-the-ear hearing aid) to the private hearing aid center for fitting.

c. Non-Contract Hearing Aids. All orders for non-contract hearing aids will be ordered by the PSAS when it is determined by the VA audiologist that a contract aid is not appropriate for the veteran's medical needs.

d. Foreign Countries. When an eligible veteran resides outside of the continental limits of the United States (U.S.), current model hearing aids may be furnished in accordance with the provision of Handbook 1173.2.

7.5. Ear Molds (Acoustic Couplers)

The type and style of ear mold will be determined by the Audiology Clinic issuing the hearing aid.

a. Ear impressions must be taken in order to make a custom ear mold. The impressions will be taken by an audiologist. When non-VA facilities are being used, the audiologist will take the ear impression and return it to the VA Audiology and Speech Pathology Service for fabrication.

b. Custom ear molds are fabricated from the impressions by a commercial source.

c. In emergency situations, temporary ear inserts may be fabricated or stock ear inserts may be used by the Audiology Clinic in the evaluation but must be replaced with a permanent custom ear mold at a later date.

d. In cases where the veteran is not seen in a VA Audiology Clinic, the type and style of ear mold will be left to the discretion of the service provider.

7.6. Procedures for Issuance of Batteries

a. Authorized Devices. Batteries may only be provided for use in authorized hearing aids or electronic devices.

(1) Hearing aids or electronic devices that were not provided by VA may be authorized for batteries if VA determines that the item is medically necessary and appropriate for the eligible veteran's disability. Hearing aids will be authorized by Audiology and Speech Pathology Service using the ROES Hearing Aid Registration option. Prosthetic and Sensory Aids Service will authorize electronic devices using the ROES Assistive Device Registration option.

(2) The Chief, Audiology and Speech Pathology Service will authorize hearing aids using ROES automated form, VA Form 10-2477a and electronically transmit them to the DDC. PSAS will authorize other electronic devices using the ROES Assistive Device Registration option.

b. Batteries for Veterans. Batteries will normally be furnished upon request to eligible veterans using hearing aids or other medically prescribed electronic devices.

(1) Beneficiaries who are Enrolled

(a) Veterans Residing in the U.S., U.S. Territorial Possessions, or Puerto Rico. These veterans will order replacement batteries using VA Form 2346, Veterans Request for Hearing Aid Batteries, which is enclosed with each issue of batteries shipped from DDC. If a veteran loses the form, ordering of batteries may be made by an electronic mail message, postcard, letter, or by contacting the Audiology and Speech Pathology Service.

(b) Veterans Residing or Traveling in Foreign Countries. Direct mail order issues will be made through the local Consular Office of the U.S. State Department to these veterans. VA Form 2346 will be provided with each issue and the veteran will use this form to request additional batteries. The veteran must mail the form in an envelope with the postage of the foreign country affixed when mailed through their postal service to the DDC.

(c) Allied Veterans Residing in the U.S. or Puerto Rico. Batteries will be provided as in subparagraph 6a(1)(a). A copy of the letter of authorization from the allied government concerned will be on file at the DDC to indicate eligibility for continuing service. If the allied veteran moves from outside the U.S., U.S. territorial possessions, or Puerto Rico, service will be terminated by the DDC.

(d) Veterans in Receipt of Aid and Attendance or Housebound Benefits. Batteries will be provided as in subparagraph 6a(1)(a). However, as veterans' eligibility status is subject to change due to income limitations, annual checks should be made to verify current eligibility. Termination of aid and attendance or housebound status will be reported to the DDC by the Audiology and Speech Pathology Service.

(e) Inpatients and Outpatients will be furnished batteries by the Audiology and Speech Pathology Service or the Prosthetic and Sensory Aids Service which will order the batteries using the ROES Battery Order option.

(2) Batteries for Clinics. Stocks of batteries will not normally be carried by field facilities for issuance to beneficiaries except in Audiology Clinics where a 90-day stock of batteries is authorized for hearing aid and artificial larynx fittings and for initial issuance of new instruments. Upon issuance of the device, the veteran will be provided a 4-week supply of batteries. Bulk replenishment for the Audiology and Speech Pathology Clinic will be made by using Battery Stock Order Option in ROES.

(3) Battery Issuance and Usage. Quantities of batteries furnished to all eligible beneficiaries will normally be based upon an adequate supply and the following criteria:

(a) Monaural Usage. The maximum number of batteries determined necessary for the operation of one, or the alternate operation of the two authorized hearing aids, for the hours per day and days per week that the beneficiary states the aid(s) are used.

(b) Binaural Usage. Battery issues will be adjusted as required to operate both instruments simultaneously.

(c) Artificial Larynx Usage. The number of batteries provided will be based upon the manufacturer's recommendations and history of beneficiary usage pending the completion of studies relative to power requirements.

(d) Other Electronic Devices. Supplies will be based on battery drain information and history of beneficiary usage.

(e) Excessive Battery Usage. Where there are indications of unusual battery requirement, or a beneficiary indicates that the number of batteries is inadequate, the local Audiology Clinic will be contacted and asked to review the matter with the veteran.

7.7. Speech and Communication Aids

a. Artificial Larynxes. Artificial larynxes, regardless of type, will not be issued to an eligible veteran until it has been certified by a speech pathologist that speech without the use of a mechanical device is not feasible. NOTE: A limited stock of artificial larynxes for issuance may be kept on hand in the Prosthetic and Sensory Aids Service or the Audiology and Speech Pathology Service.

b. Communication and Assistive Listening Devices and Assistive Devices

(1) Prescriptions and requests for special function and/or communication electronic devices will be developed by the audiologist or speech pathologist. The special needs of each patient will be documented to clearly establish that the special function device provides superior performance over any of the more common and conventional appliances.

(2) Telecaption television decoders and other assistive listening devices to overcome the handicap of deafness may be provided to veterans who are profoundly deaf and entitled to compensation on account of a hearing impairment. Veterans who are rated 80 percent or more service connected for a hearing impairment are generally considered profoundly deaf. NOTE: This should not be confused with all assistive devices which are commonly used in auditory rehabilitation which take the place of, or are used in conjunction with, a hearing aid, e.g., telephone amplifiers, amplified headsets, etc., which may be provided to eligible veterans.

7.8. Replacement

a. Hearing aids, assistive listening devices, and artificial larynxes will be replaced when the instrument proves to be ineffective, irreparable, or the veteran's medical condition has changed and a different device is needed. Devices will not be replaced because of age or a new make or model is available.

b. Devices may be replaced if the item was destroyed or lost due to circumstances beyond the control of the veteran. If negligence or willful action is suspected, the Chief, Audiology and Speech Pathology Service will determine whether a replacement may be issued, and depending upon the circumstances, VHA Headquarters may be consulted for an opinion.

7.9. Spares

a. Hearing Aids. Upon request, veterans who have continuing eligibility may be issued a spare hearing aid if the initial hearing aid has been used successfully on a continuing basis. Binaural hearing aids are to be considered as a single unit. A veteran who has a binaural aid may be issued a second binaural unit as a spare.

b. Other Devices. Spare assistive listening devices, assistive devices, or artificial larynxes will not normally be provided.

8. VA Handbook 1173.8 - Medical Equipment and Supplies

8.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent national procedures for providing medical equipment and supplies to veteran beneficiaries.

8.2. Definitions

a. Beneficiary Service Contract. A beneficiary service contract is a competitively bid, locally-awarded contract for the purchase, delivery, set-up, recovery, and storage of major items of medical equipment used by veteran beneficiaries for the treatment of their specific disabilities.

b. Medical Equipment. Medical equipment includes all items of a therapeutic or rehabilitative nature, which are determined as medically necessary for home treatment of eligible veterans, e.g., hospital beds, over-bed tables, bathroom equipment, invalid lifts, hand cycles, stair glides, room air conditioners, standing tables, portable ramps, mobility (walking) aids, environmental control units (ECUs), etc.

c. Medical Supplies. Medical supplies are expendable items required on a recurring basis for the home treatment of specific disabilities, e.g., incontinence supplies, sheepskins, catheters, etc.

d. Respiratory Equipment. Respiratory equipment includes mechanical devices to support or aid patients in normal respiration, e.g., concentrators, ventilators, Continuous Positive Air Pressure (C-PAP), Bi-level Positive Airway Pressure (Bi-PAP), nebulizers, humidifiers, masks, cannulas, etc. NOTE: For further information regarding home respiratory equipment, refer to VHA Handbook 1173.13.

8.3. Scope

a. Medical equipment, supplies and accessories are procured for, and issued or loaned to, eligible veterans upon receipt of a medical prescription in accordance with the procedures for providing treatment contained in VHA Handbook 1173.01, VHA Handbook 1173.02, and the special instructions contained in this Handbook. Strict adherence to the procedures concerning loaned equipment is required.

b. Medical supplies are normally provided by the Pharmacy Service; however, local circumstances may necessitate the involvement of the Prosthetic Service in the purchase of some items. Prosthetics Representatives must remain flexible and provide those items necessary in the interest of patient care. When circumstances require Prosthetic Service to be the primary provider of the medical supplies, documentation must be present for multi-level review.

c. Prosthetic Services are responsible for providing home oxygen equipment, accessories, and contract management. NOTE: For further information regarding home oxygen, see VHA Handbook 1173.13 and the Clinical Practice Recommendation (CPR) dated June 10, 2005, found at: http://vaww1.va.gov/prosthetics/

d. The use of a competitively bid, locally-awarded beneficiary service contract may be considered for the delivery, set up, recovery, reissue, maintenance, and storage of medical equipment. This type contract needs to be considered if it will improve service and if the Department of Veterans Affairs (VA) facility does not have the available internal resources to provide timely delivery and set-up in a veteran's home. The use of this type of contract is optional and supplemental methods may be indicated depending on local conditions. Purchase of devices through locally-awarded beneficiary service contracts may also be considered for devices not available for procurement from Prosthetic Clinical Management (PCM) mandatory contracts.

8.4. Issuing Medical Equipment for Home Use

a. Beds.?ŠDesignated standard electric hospital beds are to facilitate the care of the patient by a caregiver and/or functional independence, as described in following subparagraphs 4a(1), 4a(2), and 4a(3) and per PCM Clinical Practice Recommendations (CPR) for Prescription of Electric Hospital Beds for Home Setting:

(1) Electric hospital beds, when not designated as standard issue, may be considered whenever they offer specific functions that would be advantageous to the patient's medical condition, or if the attendant is unable to operate a manual bed. For example, patients with spinal cord injuries may gain a height advantage which facilitates transfers through the use of the high and low feature of an electric bed. Other bed-ridden patients may use an electric bed to change positions and thus provide better weight distribution.

(2) Any request for other than a standard issue hospital bed must be prescribed and justification provided to support the need.

(3) Accessories used with a hospital bed, e.g., trapezes, over-bed tables, half-side rails, foot boards, etc., must be furnished as prescribed.

b. Invalid Lifts. These lifts are electrically or manually operated and are designed to lift a patient from bed to wheelchair or wheelchair to bed. Invalid lifts may be considered when prescribed for those patients who cannot transfer independently as described in following subparagraphs 4b(1), 4b(2), and 4b(3) and per CPR for Prescription of Patient Lifts at: http://vaww1.va.gov/prosthetics/ . NOTE: Training of the person who is to operate the lift is essential prior to issuance of the lift.

(1) Accessories, e.g., special purpose slings, may be furnished when prescribed.

(2) Specialized lifts with an extended mast and smaller casters may be necessary for specialty beds.

(3) A back-up lift may be issued when prescribed.

c. Stair Glides

(1) Electrically operated stair glides are designed to carry a patient from one level of the home to another to access essential lavatory and/or living facilities (i.e., bedroom, bathroom, and kitchen). In general, there are two types:

(a) The platform type, which is designed to carry the patient while seated in a wheelchair.

(b) The chair type, which requires a patient to transfer into a specially designed chair which travels up and down the staircase.

(2) Stair glides may be furnished as part of medical and/or prosthetic services to eligible veterans provided that they are medically necessary for the veteran's care and treatment. In many cases the need is apparent; e.g., access to dialysis equipment located in the basement of the home. In other cases the need is not as clear; e.g., prescribed, rehabilitative exercise equipment located on another level, leather crafts or some other vocational pursuit prescribed for rehabilitation, etc.

(3) The following action must be taken whenever a request for a stair glide is received:

(a) A home visit by an evaluation team consisting of the Prosthetic Representative and/or a Physical Medicine and Rehabilitation Service (PM&RS) therapist, or engineering personnel or other appropriately-trained individual to determine that alternative facilities or rooms suitable for the prescribed activity are not available on the accessible level of the home.

(b) An evaluation by PM&RS to assess the veteran's ability to safely transfer, if a chair type of stair glide is being requested.

d. Porch Lifts. Porch lifts which are electronically operated and designed to lift a wheelchair-bound patient from the ground level to the entrance level of the patient's home may be furnished when prescribed, provided they are the most effective and economical means of providing access to the home. NOTE: Using portable and/or modular ramps or permanent ramps furnished under the Home Improvement and Structural Alterations (HISA) Program needs to be considered prior to providing a porch lift.

e. Ramps

(1) Portable ramps are prefabricated ramps that are compact, lightweight, transportable, and constructed in various lengths that are used for temporary needs of short height elevations. They can be made of metal, fiberglass, etc., and are designed to allow access to a home. They may be prescribed for a wheelchair-bound veteran and must be installed in compliance with the American Disabilities Act Accessibility Guidelines. Portable ramps are to be a first consideration prior to the request of a permanent ramp under HISA benefits.

(2) Modular ramps are prefabricated ramp sections in various lengths, landings, fully- adjustable support legs and handrails that are installed semi-permanently and can be disassembled (by trained personnel) for relocation to a new site, if required.

(3) Permanent ramps constructed of wood, concrete, or a combination thereof, are in the nature of a home improvement and may be furnished only as a HISA benefit, subject to the applicable HISA benefit dollar limits. There is no other basis under Title 38 United States Code (U.S.C.) Chapter 17 for VA to provide permanent or custom-made ramps. NOTE: For guidelines relating to the HISA Grant program, refer to VHA Handbook 1173.14.

f. Air Conditioner. Room air conditioners, when prescribed, may be provided to an eligible veteran suffering from a spinal cord injury, neurological condition(s), and/or severe respiratory or coronary disease, which is substantially worsened by exposure to heat and humidity, and where the absence of a controlled environment subjects the veteran to health-threatening circumstances. NOTE: Prosthetic and Sensory Aids Service (PSAS) can provide a room air conditioner only for the primary living quarters. If central air conditioning is required, it can only be considered under the HISA benefit.

g. Environmental Control Unit (ECU)

(1) The ECU consists of an array of components designed to provide a severely-disabled patient the opportunity for independent action in some of the activities of daily living. The unit may be furnished when prescribed for high-level spinal cord injury patients, patients suffering from advanced neurological diseases, or any other condition resulting in severe impairment of motor control.

(2) ECUs are normally voice-activated, switch-activated, or a combination of voice and switch activations. Voice-activated units are operated through verbal commands into a microphone. Switch-activated units are operated through a control panel, e.g., sip and puff device.

(3) The selection of the appropriate activation tool for the veteran is critical to its successful implementation. The veteran needs to have at a minimum, the following skills in order for the ECU to be used effectively:

(a) Ability to read, comprehend, and speak the appropriate language required to operate the ECU;

(b) An understanding of cause and effect;

(c) An understanding of timing issues involved with scanning (if used);

(d) Perceptual acuity;

(e) Controllable actions;

(f) Repeatable actions;

(g) Positional reliability;

(h) Endurance;

(i) Accuracy; and

(j) An acceptance of assistive technology as a component of life.

(3) As the goals are being determined by the PM&RS team and the veteran, the following critical areas are to be considered:

(a) Is the system going to be used in a single room or in several different environments?

(b) Can the veteran use the switch for more than one task?

(c) What intervention is necessary for the veteran to use the device?

(d) With what level of complexity will the veteran feel comfortable?

(4) Before the team designs the unit to be used, the medical issues related to the veteran's needs must be explored. The range of medical issues addressed by an ECU can vary from a reduction of attendant care during the day, or telephone access for emergency assistance, to the security of monitoring the home, and controlling the entrance and lighting of the house. Several of these factors are generally present and when properly addressed, the solution contributes to an improvement in the veteran's quality of life.

(5) When the goals of the veteran have been determined and the most effective tool has been identified, the process of selecting a device to achieve these goals can begin. Understanding how the device influences the environment is important to creating a successful solution. Some of the common effectors used with ECUs are infra-red (a non-visible beam of light that requires an unobscured path for transmission), radio frequency transmission (which can penetrate some obstacles), power line transmission (X-10) or ultra-sonic (not as common as it once was). These transmission signals are used to cause an action in the object that is under control. The action from the ECU should not interfere with the normal operation of the device in question.

(6) Items within the home that can be controlled by an ECU are: lights (on and off, brighten, dim), appliances (on and off, brighten, dim), phone (answer, random dial, speed dial, hang-up, call waiting, etc.), infra-red remote control devices (TV, VCR, cable, stereo, DVD, CD player, satellite, etc.), bed control (foot, head, up and down mattress), accessories (door openers, page turners, nurse calls), etc., and possibly medical equipment.

(7) Prescriptions for environmental control units for home use must be developed well in advance of the patient's discharge. A home visit by a person knowledgeable about the equipment; e.g., Prosthetic Representative, Biomedical Engineer, PM&RS Therapist, etc., must?Šbe made to ensure that conditions and attendants are compatible with the patient's needs and that the equipment can be accommodated.

(8) ECUs for use by long-term, severely-disabled inpatients must be provided as with any other hospital equipment. PSAS are not normally involved with furnishing these units unless discharge is planned for the near future and an ECU is necessary to train the patient. In these instances, the ECU provided would be the unit installed in the patient's home. h. Care Coordination and Telehealth Devices. Care coordination technologies are home telehealth technologies that are suitable to use in managing the care of veterans in the home setting (refer to PCMP Clinical Practice Recommendations for the Ordering of Care Coordination and Telehealth Devices for Veteran Patients found at: http://vaww1.va.gov/prosthetics/.

i. Seat Lift Mechanisms. Seat lift mechanisms need to be considered for patients who are unable to achieve the standing position when seated in a conventional height seat, when the patients have the ability to ambulate independently in a safe manner once in the standing position (refer to PCM Clinical Practice Recommendations for Prescription of Seat Lift Mechanisms found at: http://vaww1.va.gov/prosthetics/. NOTE: Lift chairs may not be provided.

j. Mobility and/or Walking Aids. Mobility and/or walking aids are devices used to support the body while walking: e.g., canes, crutches, walkers, etc.

(1) Standard canes, crutches, and standard aluminum walkers (folding or non-folding) must be furnished to eligible veterans based upon the determination of medical need (refer to PCM Clinical Practice Recommendations on the Issuance of Walkers found at: http://vaww1.va.gov/prosthetics/ . PM&RS may maintain the stock of these devices in coordination with PSAS inventory control mechanisms and protocols if PM&RS provides training in accordance with the established facility policy and guidelines.

(2) Metal forearm crutches, or other specialized types of crutches, canes, and/or walkers must be furnished to eligible veterans when specific determination of need is made by the prescribing physician (refer to PCM Clinical Practice Recommendations on the Issuance of Walkers found at: http://vaww1.va.gov/prosthetics/ . Specialty types of crutches, canes, and/or walkers are not normally furnished for temporary disabilities, such as fractures, and are limited to those cases when there is a continued need over an extended period of time.

(3) Accessories for crutches, canes, and/or walkers; i.e., handgrips, pads, tips, walker wheels, and brakes must be stocked and may be maintained by PM&RS in coordination with PSAS inventory control mechanisms and protocols to facilitate patient care. Issuance must be in accordance with policy and procedures concerning eligibility and VA issue. A mechanism must be established between the PM&RS and the PSAS to maintain accurate records, once a prosthetic appliance has been issued to a patient by PM&RS. These issuances must be recorded and PSAS inventory updated in order to be accounted for in the National Prosthetics Patient Database. PM&RS staff must submit a completed Computerized Patient Record System (CPRS) consult, listing the item issued (including any pertinent serial numbers, etc.) and including a statement that the patient has already received the requested equipment.

k. Rehabilitative and/or Recreational Equipment. VA may provide recreational equipment, which falls under the broad definition of a prosthetic appliance (all aids, appliances, parts, and accessories which are required to replace, support, or substitute for a deformed, weakened, or missing part of the body). NOTE: For guidance on recreational prostheses refer to VHA Handbook 1173.03.

(1) Rehabilitative sporting equipment that facilitates access for therapeutic and rehabilitative reasons may be provided to eligible veterans, when prescribed with a valid medical justification. Prescription(s) must include:

(a) Description of the veteran's sports activity which requires specially designed sports equipment for attainment of maximum rehabilitation; or

(b) Proof of proper training on the prescribed equipment; and

(c) Approval by the Major Medical Equipment Committee, local Wheelchair Committee, or by a physician who specializes in rehabilitation medicine. NOTE: All requests for equipment of this nature must be submitted to VHA Central Office on VA Form 10-2641, Authorization for Issuance of Special and/or Experimental Appliances, to include medical justification.

(2) Exercise equipment may be issued if it is medically indicated for home use, for example, a prescribed cardiac rehabilitation program, whereby the desired results cannot be achieved from walking, jogging, or any other type of recommended home exercise program.

l. Other Items of Medical Equipment. Other items of medical equipment, e.g., commodes, shower chairs, alternating pressure pads, wheelchair cushions, flotation cushions, standing tables, grab-bars, raised toilet seats, etc., may be furnished to a veteran eligible under VA regulations, when prescribed as being a necessary aspect of the veteran's VA care and treatment.

8.5. Beneficiary Services Contract

a. A local beneficiary services contract is indicated when:

(1) Delivery and pick-up services are not available within the facility resources.

(2) The hospital discharge may be delayed and/or the care and treatment of outpatients may be compromised because of the time incurred by normal procurement procedures.

b. Contract provisions may authorize the return of Government property in the possession of the contractor. The contractor must provide a monthly inventory of VA-owned property. Prosthetic Representatives must reconcile the inventory in the same manner as other prosthetic stock items. Unannounced periodic inspections must be conducted, as indicated, to resolve any differences.

c. A single contract may be established for services to a single medical center or to several medical centers within the Veterans Integrated Service Network (VISN).

d. Local contracts are negotiated by the Contracting Section of Acquisition and Materiel Management Service or VISN-established acquisition centers based on the needs, specifications, and work statements identified by PSAS.

e. The inclusion of Prosthetic Service responsibilities in Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards (e.g., Equipment Management) has made the use of a local contractor more important and more widely utilized for (at a minimum) delivery, equipment set-up, patient education and proper pick-up, cleaning, and storage of recovered equipment.

f. Prosthetic activities pay for the initial delivery, set-up, and installation of medical equipment (e.g., hospital beds, lifts, etc.) in the veteran's home. If the veteran relocates, the cost of the transfer of the equipment from one residence to another must be borne by the veteran.

8.6. Patient Education and JCAHO Standards

Whenever an eligible veteran is issued medical equipment, patient education must be provided and documented. JCAHO standards provide guidance for this documentation, which can be found at: www.jointcommision.org.

8.7. Medical Supplies

Pharmacy Service normally provides expendable medical supplies generally required on a recurring basis for home treatment of specific disabilities including, but not limited to: incontinence supplies; colostomy, ileostomy, and urostomy supplies; urinals; catheters; etc.

a. PSAS may furnish certain items, which are not provided by the Pharmacy Service; e.g., specific brands, odd sized items, etc., when prescribed.

b. PSAS does not stock or furnish items normally provided by the Pharmacy Service.

c. A limited stock of those medical supplies unavailable through the Pharmacy Service may be maintained by the Prosthetic Service for immediate issue to eligible veterans. The quantities and the amounts to be stocked depend on local circumstances.

8.8. Replacement and Spare Equpment

a. Medical equipment is not to be replaced until a determination is made, through a Prosthetic Service evaluation, that the current equipment is unsatisfactory for further use. Evaluation criteria to consider include fair wear and tear and the repair cost involved.

b. Generally, spare medical equipment, with the exception of respiratory equipment, is not provided, unless there are unusual circumstances which would adversely affect the veteran's medical condition.

8.9. Repairs

a. The procedures for repairs contained in VHA Handbook 1173.01 and VHA Handbook 1173.02 apply to required repairs for medical equipment.

b. Repairs to medical equipment may be obtained through internal VA facility resources provided they are the most cost-effective, timely, or convenient service for the veteran.

8.10. Installations and Removals

a. Installation of Durable Medical Equipment (DME) (e.g., grab bars, porch lifts, stair glides, etc.) is paid through centralized funds and should not exceed the usual and customary local costs. Installation costs need to be notated as "not exceeding usual and customary costs" on the final invoice.

b. If a situation should arise where a patient moves to a new home location, VA is not responsible for moving any issued equipment to the new location. The equipment is considered part of the veteran's household goods and is to be moved accordingly.

c. If DME-installed equipment, which involves alteration of the house or its physical appearance, is removed from the veteran's residence, VA assumes no responsibility for returning the affected area to its original condition; this includes cosmetic adjustments.

8.11. Issuance of Medical Equipment

a. Prosthetic Service coordinates the issuance of medical equipment with the locally established Major Medical Equipment Committee, HISA Committee, Home-based Primary Care Program, or other applicable committee or team, and the professional service providing the care and treatment to the veteran.

b. The guidelines for the issuance of those specific items of medical equipment identified in this Handbook have been based upon the medical requirements of the eligible veteran. Although every attempt has been made to develop realistic criteria, it is impossible to cover all items of medical equipment or all disabilities that require equipment. Physicians and Prosthetic personnel must carefully evaluate each case based on the needs of the veteran, especially in cases of severe disability.

c. Unusual requests or inquiries relating to the issuance of medical equipment may be referred to Prosthetic Program officials in VHA Central Office by submitting a VA Form 10-2641, in the normal manner.

9. VA Handbook 1173.9 - Footwear and Foot Orthoses

9.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent national policy and procedures in providing footwear and shoe modifications to veteran beneficiaries.

9.2. Scope

a. Arch supports, shoe modifications, functional foot orthotics, all inlay shoes, healing shoes, custom-made orthopedic shoes and alternative footwear must be provided to beneficiaries who are eligible for prosthetic services in accordance with the policies and procedures contained in VHA Handbook 1173.1, VHA Handbook 1173.2, and this Handbook.

NOTE: The footwear prescription criteria contained in Appendix A are the basis from which determinations are generally made to provide orthopedic footwear, shoe modifications, or orthotics.

b. All prescriptions for orthopedic footwear, modifications or functional foot orthotics must be reviewed by the Prosthetic Representative, Chief of the Prosthetic Clinic Team, or designee, for program compliance. The authorization of appliances for conditions other than those stated in the prescription criteria contained in Appendix A will only be granted when the foot disorder cannot be accommodated or treated with the appliance listed. The most medically and cost- effective method for treatment of the disability is to be used. Custom-made orthopedic shoes need to be authorized only when all other footwear options have been considered.

9.3. Definitions

a. Accommodative Foot Orthoses. Accommodative Foot Orthoses are custom or non- custom inlays fabricated for the purpose of providing relief from callosities and pressure points, and maintaining the integrity of the longitudinal arch and/or the metatarsal heads.

b. Functional Foot Orthoses. Functional Foot Orthoses Are foot plates fabricated from plaster molds of the feet or electronic (computer) imaging in a semi-weight bearing or non- weight bearing, neutral position, with corrections built in to prevent abnormal compensation during the gait cycle.

c. Custom-Made Orthopedic Shoes. Custom-made Orthopedic Shoes are shoes fabricated over special modified lasts (see subpar. 3g) in accordance with prescriptions and specifications to accommodate gross or greater foot deformities or shortening of a leg at least 1 and 1/2 inches or greater.

d. Depth Inlay Shoes. Depth Inlay Shoes are prefabricated shoes with a higher toe box to accommodate for hammer toes and other deformities. This shoe may also accommodate the insertion of special inserts. These shoes are traditionally made of plastizote or other pressure absorbent material.

e. Healing Shoes. Healing Shoes are prefabricated shoes with a higher toe box to accommodate for hammer toes and other deformities. This shoe may also accommodate the insertion of special inserts.

f. Patterns. Patterns are cardboard tracing (templates) comprising the shoe's upper and innersole components.

g. Last. A Last is a form which is shaped like the human foot over which a shoe is manufactured or repaired.

h. Shoe Modification. A shoe modification is a medically prescribed alteration(s) to a shoe(s) to accommodate minor foot deformities, disabilities, or leg shortening of less than 1 and ?Ę inches.

i. Standard Orthopedic Oxford. A Standard Orthopedic Oxford is a prefabricated shoes that can accommodate an inlay, e.g., dress, casual, and athletic shoes.

9.4. Beneficiaries

Beneficiaries issued orthopedic footwear are authorized to have two serviceable pairs at all times. However, one additional pair of either dress or work shoes may be authorized if required by the beneficiary's occupation due to the climate, the environment of the work place, or as other circumstances warrant.

9.5. Shoe Modifications

Shoe modifications, e.g., rocker soles, shoe buildups, metatarsal bars, shoe stretching, Thomas heels, tongue pads, velcro closures, modified lacers, etc., may be applied to personally purchased shoes of an eligible beneficiary, upon medical determination of need, to compensate for minor foot deformities.

9.6. Orthopedic Footwear

NOTE: Over the Counter (OTC) Standard Orthopedic Oxford (dress, casual, athletic) need to be used when a foot can be reasonably accommodated in this type of shoe.

a. Inlay shoes may be furnished to eligible beneficiaries after it has been determined that shoe modifications will not accommodate the foot deformity and that an insole or additional space is necessary.

(1) Inlay shoes may be ordered from commercial sources when cost-effective to prevent a hardship to the beneficiary.

(2) Modifications or repairs of the insole and/or inlay shoes need to be done by the local VA Orthotic Laboratory. Facilities not having Orthotic Laboratories may request modifications from their nearest Shoe Last clinic. All requests for modifications must be initiated by a VA Form 10- 2529-3 (ADP), Request and Receipt for Prosthetic Appliances or Services, clearly identifying the modification desired. The same ordering procedures may be applied electronically (Prosthetic Veterans Health Information Systems and Technology Architecture (VISTA) Program).

(3) Replacements of all shoes must be authorized when repairs are no longer practical. Eligibility must be confirmed prior to initiating any replacement order by the referring station.

(4) The issuance of spare shoes must be in accordance with the general policy for spare custom-made orthopedic footwear contained in subparagraph 6i(2).

(5) VA facilities may be authorized to maintain a limited supply of the most common sizes of shoes to facilitate immediate patient care.

NOTE: Inventory control must be in accordance with VA policy and procedures contained in subparagraph 6d(3) of this Handbook.

b. Healing and/or cast shoes may be authorized when medical determination has been made that the foot cannot be slipped into a standard shoe.

(1) Healing and/or cast shoes must be obtained from local commercial sources.

(2) Modifications to healing and/or cast shoes must be done by VA Orthotic Laboratory or qualified commercial sources.

(3) The issuance of replacement, authorization of spares, or repair of healing and/or cast shoes is not usually required since this type of shoe is normally needed for a short period of time.

c. Alternative footwear may be authorized when a medical determination is made that no other type of shoe or modification adequately accommodates the foot deformity or condition.

(1) Molded shoes may be purchased from established VA contracts.

(2) Molded shoes must be replaced sufficiently in advance so as not to interrupt their use; the amount of repair that can be done to this type of shoe is minimal.

(3) Spare molded shoes must be furnished in accordance with the general policy for spare orthotic footwear.

d. Plastizote healing shoes may be furnished to eligible beneficiaries when medically indicated.

(1) Plastizote healing shoes may be obtained from commercial sources.

(2) Modifications to plastizote healing shoes need to be done by VA Orthotic Laboratories or qualified commercial sources.

(3) VA facilities may be authorized to maintain a limited stock of the most common sizes of plastizote shoes to facilitate patient care. All requests for inventory must be initiated by memorandum from the Prosthetic Representative. Inventory control must be in accordance with VA policies and procedures.

(4) Replacement plastizote shoes may be authorized when necessary for the treatment of eligible beneficiaries. Spares will not normally be provided since these shoes are used for a short duration.

e. Custom-made orthopedic shoes may be initially furnished to eligible beneficiaries upon receipt of a properly executed prescription. The orthopedic shoes must be custom fabricated at the VA Shoe Last Clinic or by a local contractor. Reasonable doubt regarding the patient's need for orthopedic shoes normally is resolved in favor of the beneficiary. In conflicting situations, the facts will be referred to the Prosthetic Clinic Team of the field facility for resolution.

(1) Initial issues of custom-made orthopedic shoes are authorized when a physician or podiatrist determines that the severity of the foot condition is such that a lesser means, for example, inlay shoes, shoe modifications, etc., cannot adequately compensate for the deformity or there is a leg discrepancy length at least of 1 and 1/2 inches in length or greater.

(2) Initial custom-made orthopedic shoes, lasts, and patterns normally are obtained when the severity of the foot disability requires the physical presence of the beneficiary for casts, measurements, and possible trial fittings.

NOTE: There is not to be a foot examination at a VA Shoe Last Clinic when the measurements and prescribed corrections can be transmitted by mail.

f. VA Form 10-2908, Measurement for Orthopedic Shoes, must be used in conjunction with VA Form 10-2529-3 (ADP) to order initial orthopedic shoes. The same ordering procedures may be applied electronically (Prosthetic VISTA Program).

NOTE: See clinical evaluation notes section in Footwear Program Guide for checkout procedure for custom orthopedic shoes.

g. All orthopedic shoes are to be appropriately coded indicating the: month, year of fabrication, and the source, which is obtained from a block of numbers in numerical sequence assigned to each VA Shoe Last Clinic or local contractor. h. Initial custom-made orthopedic shoes, lasts, and patterns must be obtained from the nearest VA Shoe Last Clinic when:

(1) The severity of the foot disability requires the physical presence of the beneficiary for casts, measurements, and trial fittings.

(2) The measurement and desired corrections cannot be transmitted by mail and there are no qualified local contractors.

NOTE: VA Form 10-2529-3 (ADP) must be used to order custom-made orthopedic shoes from the nearest VA Shoe Last Clinic. The same ordering procedures may be applied electronically through the Prosthetic VistA Program.

i. Initial custom-made orthopedic shoes, lasts, and patterns must be obtained from the local contractor.

(1) Initial custom-made orthopedic shoes, lasts, and patterns must be obtained from local contractors when mail transmittal of measurements and corrections is not feasible and the veteran cannot be transported to the nearest VA Shoe Last Clinic or, it is economically in the best interest of VA. NOTE: VA Form 10-2421 (ADP), Prosthetic Authorization for Items or Services, is to be used as the normal procurement document.

(2) The facility must provide spare or repeat orders of custom-made orthopedic shoes when a VA Shoe Last Clinic has delivered a second pair of custom-made orthopedic shoes which are medically acceptable.

(a) VA Shoe Last Clinics, or local commercial contractors, normally provide replacement custom-made orthopedic shoes.

(b) VA Shoe Last Clinics, or local commercial contractors, need to retain the lasts and patterns after the second successful fitting of a patient.

j. Continued service may be furnished by a VA Shoe Last Clinic when it has been medically determined that the severity of the foot condition requires personal fitting and an examination prior to the fabrication of each additional pair of shoes.

k. Local contractors may be used for the procurement of additional pairs of custom-made orthopedic shoes whenever replacements are warranted and the veteran has previously been furnished shoes through that source.

l. Repairs to custom-made orthopedic shoes must be provided when required.

m. Repairs for beneficiaries must be submitted by the medical center responsible for the beneficiary's treatment. VA Form 10-2529-3 (ADP) must be prepared. The same ordering procedures may be applied electronically by using the Prosthetic VistA Program.

n. VA Shoe Last Clinics routinely provide repairs for permanent Shoe Last Clinic cases. Pre- addressed labels and mailing containers may be furnished to eligible beneficiaries to facilitate repair services. When shoes are referred from a field facility, VA Form 10-2529-3 (ADP) must be used to request repairs. VA Shoe Last Clinics may provide minor repairs to custom orthopedic shoes.

o. Local sources need to repair custom orthopedic shoes purchased from that source. Repairs to shoes provided by VA Shoe Last Clinics may be provided by local sources if mail transmittal is not feasible and the veteran cannot be transported to the nearest VA Shoe Last Clinic or it is economically in the best interest of VA.

9.7. Appendix A - Footwear Prescription Guidelines

Pathology Shoe Type Insert Modification (as needed) Comments

1. Foot Deformities

Hallux abducto valgus,hallux varus, hallux rigidus

1. Standard Therapeutic Oxford: dress and/or casual shoe.*

2. Standard Therapeutic Oxford walking shoe.**

3. Oxford style boot.**

4. Depth shoe.

5. Custom molded.

1. Semi-rigid or rigid functional orthosis.

2. Additional accommodative padding as needed.

The type of shoe must be determined based on the severity of the pathology. ?ŠThe prescribing physician should work with the Prosthetics Service to ensure the most basic equipment to manage the condition is used.

2. Midfoot Deformities

Charcot Foot

1. Depth shoe.

2. Custom molded.

3. Oxford style boot.

1. Semi-rigid or rigid functional orthosis.

2. Additional accommodative padding as needed.

3. Ankle-foot orthosis or other stabilization and/or immobilization brace.

The type of shoe and orthotic must be determined based on the severity of the pathology. ?ŠThe prescribing physician should work with the Prosthetics Service to ensure the most basic equipment to manage the condition is used.

3. Rearfoot Deformities

a. Symptomatic pronation

b. Symptomatic supination

c. Symptomatic Pes Cavus

d. Symptomatic Pes Planus

e. Heel Pain

e1. Retrocalcaneal

e2. Inferior calcaneal

f. Symptomatic equines

g. Tarsel coalition

h. Ankle instability

i. Charcot foot

1. Standard Therapeutic Oxford: dress and/or casual shoe.*

2. Standard Therapeutic Oxford walking shoe.**

3. Oxford style boot.**

4. Depth shoe.

5. Custom molded.

1. Semi-rigid or rigid functional orthosis.

2. Additional accommodative padding as needed.

3. Ankle-foot orthosis or other stabilization and/or immobilization brace.

4. Heel cup.

The type of shoe and orthotic must be determined based on the severity of the pathology. ?ŠThe prescribing physician should work with the Prosthetics Service to ensure the most basic equipment to manage the condition is used.
4. Diabetic Neuropathology with no concominant deformities. Depth shoe.

1. Over-the-Counter (OTC).

2. OTC Accommodation Orthoses.

3. Semi-rigid or rigid functional orthosis.

4. Additional accommodative padding as needed.

As a preventative measure, this group of patients should be followed on a regular basis for the development of pathology to ensure quick intervention as needed.
5. Peripheral Vascular Disease with non concominant deformities (arterial or venous). Depth shoe.

1. Over-the-Counter (OTC).

2. OTC Accommodation Orthoses.

3. Semi-rigid or rigid functional orthosis.

4. Additional accommodative padding as needed.

As a preventative measure, this group of patients should be followed on a regular basis for the development of pathology to ensure quick intervention as needed.
6. Digital and Midtarsal amputations.

1. Depth shoe.

2. Custom molded.

1. Semi-rigid or rigid functional orthosis.

2. Appropriate filler.

3. Additional accommodative padding as needed.

As a preventative measure, this group of patients should be followed on a regular basis for the development of pathology to ensure quick intervention as needed.

* - In order to accommodate the need to address both dress and exercise requirements, two categories of oxford style shoes are listed.?Š The exercise?Šshoe must be accompanied by an indication that it is a requirement as part of a therapeutic plan listed in the progress note and consultation form.

** - Certain conditions and circumstances may require the use of boots that add ankle support.?Š The boot must be accompanied by an indication that it?Šis a requirement as part of a therapeutic plan listed in the progress note and consultation form.

10. VA Handbook 1173.10 - Orthotic Devices and Repairs

10.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent Department of Veterans Affairs (VA) procedures for providing orthotic devices and repairs to veteran beneficiaries.

10.2. Definitions

a. Orthosis. An orthosis is a device fitted externally to an anatomical portion of the body to influence motion by assisting, resisting, blocking, or unloading part of the body weight. An orthosis may be used to correct deformity, compensate for weakness, or protect a body segment. It includes, but is not limited to custom and non-custom devices, corsets, trusses, and belts.

b. Custom Orthosis. A custom orthosis is made from measurements, tracings, a digitized body segment from a negative impression (cast), or may incorporate a unique design based on specific patient measurements.

c. Prefabricated Orthosis. A prefabricated orthosis (also referred to as an off-the-shelf orthoses) is an orthotic device that is commercially manufactured in quantities for public issue in a limited number of sizes.

d. VA Orthotic and Prosthetic Laboratory. The VA Orthotic and Prosthetic Laboratory is a section within the Prosthetic Service staffed with a Certified Orthotist or non-certified staff under the supervision of a certified practitioner, equipped to provide a range of custom orthotic or custom fitted orthotic devices.

e. Contract Provider. A contract provider refers to an independent business that fabricates and/or fits custom-made orthotic devices, or custom fits prefabricated orthotic devices.

f. Certified Orthotist. A Certified Orthotist is a trained professional that designs, fabricates, and fits custom and non-custom orthoses.

g. Orthotic Fitter. An orthotic fitter is an individual trained to fit non-custom orthotic devices and/or soft goods (i.e., lumbosacral corsets, elastic knee orthoses, ankle and elbow supports).

h. Orthotic Technician. An orthotic technician is an individual trained to fabricate custom orthoses under the supervision of a Certified Orthotist.

i. Orthotic Laboratory Workorder (OWL). An OWL is a work order for custom fabrication and/or repairs made to orthotic devices by an in-house VA Orthotic and Prosthetic Laboratory.

10.3. Procedures

a. Medically prescribed orthotic devices and repairs must be provided in a timely and efficient manner to beneficiaries who are eligible for prosthetic services.

b. Upon receipt of a prescription, an evaluation of the patient by the Orthotist determines the appropriate orthotic device and/or service.

c. The VA Orthotic and Prosthetic Laboratory must provide orthotic devices and repairs to beneficiaries to the fullest extent possible. At facilities not having access to the VA Orthotic and Prosthetic Laboratory or where the laboratory's workload is such that the Orthotic and Prosthetic Laboratory cannot provide prompt service, local contracts are to be awarded to private contractors for procurement. Contract devices must be of high quality and are to be inspected by the Chief, Orthotic and Prosthetic Laboratory, Orthotist designee, or Orthotic Clinic within 30 days of delivery.

d. The Prosthetic and Sensory Aids Service (PSAS) and the Orthotic and Prosthetic Laboratory need to maintain an inventory of the more frequently requested prefabricated orthotic appliances and soft goods that are stocked for immediate issue to eligible beneficiaries. The local medical staff prescribing these items is to be kept informed of their immediate availability.

NOTE: In accordance with a memorandum from the Chief Prosthetics and Clinical Logistics Officer, the maximum level of inventory on hand is not to exceed 30 days or 1 percent of the allotted yearly budget.

e. Facilities requiring the services of a VA located at another facility, must schedule and obtain confirmation of an appointment prior to referring beneficiaries to the laboratory in order to avoid delays and backlogs in the Orthotic and Prosthetic Laboratory's treatment schedule.

f. When a custom device or repair is authorized by a Prosthetic Request (using the Computerized Patient Record System (CPRS)), and is to be done at the VA Orthotic and Prosthetic Laboratory, an OWL is created to document all components, materials, and labor used. Upon completion of the job and delivery of the device, the OWL is completed and a CPRS progress note is entered in the patient's record.

g. Within the OWL Business Practice Guidelines, when a prefabricated orthosis is fitted by the VA Orthotic and Prosthetic Laboratory, the item fitted is to come from "stock issue," and there is no need to create an OWL. The Orthotist must document in a CPRS progress note, all work done and the instructions given to the patient for care and maintenance of the fitted device. Additionally, the electronic consult and/or suspense note are to be closed upon issuance of the device to the patient.

h. Within the OWL Business Practice Guidelines, when a custom appliance or repair is authorized, an OWL must be prepared and the original and a copy forwarded, by the most expeditious means, to the VA Orthotic and Prosthetic Laboratory selected. An OWL must be prepared for each beneficiary for whom an appliance is to be custom fabricated or repaired. If the patient is to receive more than one custom appliance, an OWL needs to be created for each custom item or repair. Once the OWL is closed, this must be posted to the patient's record.

i. Upon receipt of an OWL for a custom appliance or repair, the Orthotic and Prosthetic Laboratory must take the following action:

(1) A "Work Order Number" is automatically assigned during the creation of the OWL work order and can be used to track the progress of the job.

(2) All information on the OWL must be checked for accuracy and the item or services to be furnished, based on the CPRS Consult.

(3) All working time spent on the specific job by one or more practitioners or technicians and all materials used must be entered in the appropriate sections of the OWL (Materials and Labor Sections) record section as the work progresses or upon completion.

(4) Upon completion of the job, the appliance must be reviewed and inspected by the Chief, Orthotic and Prosthetic Laboratory, or Lead Prosthetist or Orthotist, to ensure the accuracy, fit and function of the device. The OWL is then completed and a CPRS progress note is posted to the patient's record.

(5) The Chief, Orthotic and Prosthetic Laboratory, Lead Prosthetist, Orthotist, or designated practitioner, is responsible for computing, as accurately as possible, the actual cost of materials and labor.

(6) If the completed device or repair is to be returned to the requesting VA facility (another station), a copy of the OWL is sent to that station indicating all work done and associated costs for materials and labor. The requesting facility has the responsibility for follow-up.

(7) If the completed appliance or repair is delivered directly to the beneficiary by the VA Orthotic and Prosthetic Laboratory, the following procedures apply:

(a) The date delivered must be completed on the OWL.

(b) The OWL automatically totals material and labor costs as this information is posted to the OWL.

(8) When a VA Orthotic and Prosthetic Laboratory request that work be done by another VA Orthotic or Prosthetic Laboratory involving custom fabrication, the requesting laboratory must prepare the OWL and forward it to the laboratory where the work is to be done. The procedure for processing such requests in the receiving laboratory is essentially the same as that outlined in subparagraph 3i.

(9) When a veteran presents a VA Form 10-2501, Prosthetic Service Card (PSC), to an authorized contract provider (commercial orthotic facility) of their choice, to have repairs made to their appliance, the commercial Orthotic facility submits the invoice for payment to PSAS, who then makes payment using a credit card. NOTE: VA Form 10-2501 authorizes a specific amount for repairs, and to exceed this amount, requires the prior authorization by VA Prosthetic Representative, or designee.

(10) The Orthotist must enter a progress note into the CPRS, which documents all work that was done during a specific appointment for a patient (i.e., casting, fitting, repair, instructions, etc.).

10.4. Repairs to Orthotic Devices

a. Repairs to orthoses may be obtained through local sources on the authority of VA Form 10-2501, (see subpar. 3i(9)).

b. Orthotic devices may be repaired if the cost of the repair is less than one-half the cost of replacement. The Prosthetics Representative, or designee, determines whether it is more practical, from an economic point of view, to repair or replace the appliance.

c. Eligibility Considerations. Eligible beneficiaries must be issued a PSC upon initial issue of an orthosis. The PSC pre-authorizes commercial repairs to the orthosis listed thereon not to exceed the dollar limitation, as previously described in subparagraph 3i(9). Repairs exceeding the cost limitation may be approved by telephone with a follow-up for repair authorization to the Chief, or designee.

10.5. Replacement to Orthotic Devices

a. Orthotic devices issued to eligible beneficiaries are replaced only after the Prosthetics Representative determines that the appliance is no longer suitable, or that it is unserviceable for continued use due to fair wear and tear, or there are changes in the veteran's medical condition. Appliances in serviceable condition continue to be in use, regardless of age, if suitable for the beneficiary's medical care. The possibility of further useful life through repair must always be determined before a new appliance is authorized.

b. If a beneficiary claims that an orthotic appliance is lost or destroyed, or it is determined by examination that the appliance has been damaged through other than fair wear and tear, the Prosthetics Representative, or designee, may make a full inquiry into the facts of the case, and make a decision to replace the device based on the facts of the inquiry.

10.6. Issuance of Duplicate Orthosis or Soft Goods

If the beneficiary's medical condition, environmental conditions, or work-related needs warrant the issuance of a duplicate device, the Prosthetic Representative or designee, is authorized to do so at the Prosthetic Representative's discretion.

11. VA Handbook 1173.11 - Ocular Prostheses and Facial Restorations

11.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent system-wide procedures in providing ocular prostheses, facial restorations, craniofacial implants, and somato prostheses to veteran beneficiaries.

11.2. Scope

a. Loss of an eye, ear, nose, cheek, hand, foot, are examples of items replaced with removable custom-fabricated prostheses at Restoration Clinics. Facial and somato restorations are custom-fabricated, are usually composed of plastic and/or silicone, and are maintained by the beneficiary or guardian. The life span of the prosthesis is from 1 to 2 years, excluding anatomical changes. The life span of the plastic eye prostheses is 2 to 5 years; however, some individuals are able to wear them for a longer period of time without anatomical changes. As a general rule, patients need to have their ocular prosthesis replaced at least every 5 years. At least once a year, prosthetic eye polishing is required to reduce the risk of papillary conjunctivitis, which is very difficult to treat.

b. In cases where an item is unsatisfactory due to wear, the individual beneficiary's prosthesis needs to be examined, by appropriate Prosthetic staff or another medical professional designated as the examining expert, to determine if a replacement is required.

c. Ocular prostheses, facial restorations, craniofacial implants, and somato prostheses (to include all repairs) must be custom-fabricated for eligible beneficiaries, when prescribed by a Department of Veterans Affairs (VA) physician, and obtained using an Orthotic Laboratory Work Order (OWL) for the Restorations Laboratory. NOTE: Repairs may be initiated when determined necessary by a qualified anaplastologis or VA physician.

d. All restoration prostheses are custom-fabricated and must be delivered in person to the beneficiary after a final fitting by a qualified practitioner. The mailing of items is to be limited to prosthetic eyes that have been polished for persons who are unable to travel because of medical reasons, provided there is little chance of any complications.

e. When a VA Restorations Clinic is not available, all restoration services that are contracted out to a local vendor must be evaluated for compliance to VA standards of patient care and VHA Handbook 1173.11, Ocular Prostheses and Facial Restorations. NOTE: It is desirable for both VA Restoration clinicians and private contractors to have a professional certification.

11.3. Definitions

a. Anaplastologist. An anaplastologist is one who restores injured, deformed, or missing anatomical human parts.

b. Anophthalmic. Anophthalmic is the absence of the eyeball.

c. Auricular Prosthesis. Auricular prosthesis relates to the artificial replacement of the hearing organs.

d. Bulbar. Refers to or related to the eyeball.

e. Ocular Conformer. An ocular conformer is an intricate and complex, acrylic thin prosthesis designed to fit over a physical eye, evisceration or enunciation with or without a cornea to facilitate post operative healing of the eye socket to the specific shape of the conformer.

f. Cosmetic Scleral Shell. A cosmetic scleral shell is the intricate and complex acrylic thin eye prosthesis designed to fit over a physical eye or evisceration with or without a cornea. It replaces volume and reduces possible infections of the eye socket.

g. Enucleation. Enucleation is the complete surgical removal of the eyeball.

h. Evisceration. Evisceration is the surgical removal of the contents of the eyeball with retention of the sclera or cornea and sclera.

i. Exenteration. Exenteration is the surgical removal of all the orbital contents which may include the removal of the eyelids.

j. Eye (orbital) Implant. An eye implant is a device used as volume replacement of the eye.

k. Facial Prosthesis. A facial prosthesis is a custom-fabricated and fitted prosthesis made of medical grade silicone or acrylic that replaces the anatomical structures of the face and which integrates function and replaces the patient's natural appearance.

l. Implant. An implant is a custom fitted prosthesis made of medical grade silicone, acrylic, or metal used as volume replacement and insert for areas of the body.

m. Impressions. An impression is the duplication of a defected area of the body by use of alginate (seaweed) or silicone base materials. It gives the provider a negative mold, which is used to create a positive cast. The positive cast is modified to form the final prosthesis.

n. Maxillofacial Prosthesis. A maxilloficial prosthesis is the replacement of anatomical structures of the face and oral cavity, which integrates function and replaces the natural appearance. It is custom-fitted and normally fabricated with silicone.

o. Ocularist. An ocularist is one who fits and fabricates custom ocular prostheses.

p. Ocular Prosthesis. An ocular prosthesis is a plastic or glass fabricated eye that replaces the volume of the enucleated eye socket and gives the appearance of the natural eye.

(1) Left Eye Prosthesis. Ocular Sinister (left eye).

(2) Right Prosthesis. Ocular Dexter (right eye).

q. Orbital Prosthesis. An orbital prosthesis is an artificial silicone replacement of the facial bony cavity that contains the eye and its associated parts, e.g., eyelid, eyebrow, etc.

r. Orthotic Laboratory Work Order (OWL). OWL is a document to be created to obtain the fabrication or repair of facial, ophthalmic or other restoration clinic prosthesis when the labor time is greater than eight minutes.

s. Phthisical. Phthisical means wasted away, as a shrunken eyeball.

t. Polymethylmethacrylate (PMMA). PMMA is the plastic used in the manufacture of artificial eyes, contact lenses, implants, inserts, etc.

u. Silicone. Silicone or Polydimethylsiloxane is a rubber material used for the fabrication of facial prostheses, hands, and feet.

v. Somato Prosthesis. Somato prosthesis is a body restoration, as a breast, cosmetic gloves for partial hand, finger or foot amputations, prostheses, etc,

11.4. Procedures for Furnishing Appliances

a. VA Restoration Clinics

(1) VA Restoration Clinics must be used as the primary source for restorative items whenever the patient is able to travel and the distance to be traveled is not excessive. The referring physician must make these determinations after communicating with the patient, and the patient family members for input. Travel exceptions need to be based on medical and/or clinical limitations, supported by the referring physician, and documented in the patient treatment file and/or electronic consult.

(2) Patients requiring ocular prostheses, orbital prosthesis, implants, facial and body restorations, cosmetic gloves for partial hand amputations, prostheses, etc., may be referred by any VA facility to the nearest VA Restoration Clinic.

(a) Cosmetic gloves for partial or complete hand amputees may be fabricated by a Restoration Clinic if commercially available sources are not adequate. Such prostheses are made available to any veteran upon receipt of an OWL.

(b) Functional prosthetic devices, for use by partial or complete hand amputees requiring an opposition post or other modification, must be fabricated by an Orthotic Laboratory prior to requesting a cosmetic glove. The cast of the patient's hand and the device fabricated are to be forwarded to the selected procurement source for the glove whenever an initial cosmetic glove is requested.

(3) When a custom prosthesis or repair is authorized, use the following instructions:

(a) An OWL must be prepared electronically and forwarded, by the most expeditious means, to the clinic selected with documentation of eligibility for VA medical care and a Health Information Network Query (Eligibility Verification Form).

(b) A separate OWL must be prepared for each beneficiary for whom the prosthesis is to be fabricated or repaired. NOTE: Two or more items for a beneficiary may be included on a single request form.

(c) The referring facility must retain an OWL in suspense, identifying the preparing office pending delivery of the prosthesis, and notification that the patient is satisfied with the completed product or repair.

(d) Field facilities requiring the services of a Restoration Clinic located at another facility need to coordinate the scheduling and obtain confirmation of an appointment prior to referring beneficiaries or sending an OWL to the clinic.

(e) The Restoration Clinic must document the patient's record by creating a progress note into the Computerized Patient Record System (CPRS) describing each visit and what was done during the visit. All electronic consults and suspense items must be completed and closed upon issuance of the cosmetic device or repair.

(f) All patient appointments for services provided by the Restoration Clinic must be scheduled through the Appointment Management menu in the Veterans Health Information System and Technology Architecture (VistA).

(4) The receiving facility initiates an OWL, identifying the referring facility in the appropriate section of the OWL; then the completed OWL is transmitted to the referring site.

11.5. Appendix A - Restoration Clinics Authorized in VA Field Facilities

1. Veterans Integrated Service Network (VISN)7

Atlanta, GA

2. VISN 15

St. Louis, MO

3. VISN 20

Portland, OR

4. VISN 21

San Francisco, CA

5. VISN 22

Los Angeles, CA

12. VA Handbook 1173.12 - Prescription Optics and Low-Vision Devices

12.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent procedures for providing prescription optics and low-vision devices to veteran beneficiaries.

12.2. Scope

a. Prescriptions for eyeglasses must be filled in accordance with Title 38 Code of Federal Regulations (CFR) 17.149, and with policies and guidelines established by the Department of Veterans Affairs (VA) and the local facility.

b. Eligible beneficiaries may be furnished an initial pair of corrective eyeglasses when prescribed by a VA or fee-basis ophthalmologist or optometrist. Two pairs of single-vision eyeglasses, one for reading and one for distance vision, will be provided if prescribed by the ophthalmologist or optometrist in cases where bifocal lenses are contraindicated. Post-surgical aphakic cataract patients may also be provided two pair of eyeglasses (in addition to contact lenses): a pair of cataract eyeglasses (aspheric lenticular) and a pair of single-vision eyeglasses (for use over contact lenses) when prescribed by a VA or VA fee-basis ophthalmologist or optometrist.

c. When a beneficiary is found to need an ophthalmic prescription, but is not eligible to receive prescription optics at VA expense, the beneficiary may request and obtain a copy of the prescription from the examining ophthalmologist or optometrist. These prescriptions must be issued and stamped with a disclaimer reading, "Not to be filled at VA expense," to indicate that the beneficiary must spend personal funds to obtain the prescribed item(s).

d. Ophthalmic prescriptions are filled for beneficiaries receiving medical care when determined medically necessary for the beneficiary's care by an ophthalmologist or optometrist.

e. Beneficiaries with a service-connected disability for the loss of vision in an eye (or the enucleation or evisceration of one eye) are eligible for eyeglasses for defective vision in the remaining eye and/or to protect the vision in the remaining eye (safety eyeglasses or polycarbonate lenses, as appropriate).

12.3. Definitions

a. Single Vision Lens. A single vision lens is a spectacle lens having the same focal power throughout its useful area, for reading, intermediate or distant vision.

b. Bifocal Lens. A bifocal lens is a spectacle lens of two portions whose focal powers differ from each other. Usually the upper portion is larger and is for distant vision, and the lower portion is smaller and is for near vision.

c. Trifocal Lens. A trifocal lens is a multifocal lens of three portions whose focal powers differ from each other. Usually the top portion is the largest and is for distant vision, the middle for intermediate distances, and the bottom for near vision.

d. Progressive Addition Lens. A progressive addition lens is a multifocal lens having a progressive increase in positive power from the distance-seeing portion to the near-seeing portion.

e. Tinted Lens. A tinted lens is a lens with color absorption properties designed to reduce light transmission and/or selectively absorb undesirable incident radiations, such as ultraviolet (UV) radiation, etc. In contact lenses, the color may be also for facilitating location.

f. Photochromic Lens. A photochromic lens is a lens with substances which change in color and in light transmission properties upon exposure to a change in light intensity or to UV radiation. The change may, or may not, be reversible.

g. Coating, Lens. A lens coating is a thin deposit of a metallic salt, such as magnesium fluoride, about one-fourth as thick as a wavelength of light, applied to a surface of a lens to reduce, by interference, the amount of light reflected, and, if combined with a coloring ingredient, to reduce light transmission, and, to impart scratch resistance.

h. Prismatic Lens. A prismatic lens is a lens with prism power that deviates the path of light.

i. Lenticular Lens. A lenticular lens is an ophthalmic or spectacle lens of high dioptric power with the prescription ground only in the central portion, the peripheral (usually a focal) portion of the lens serving only to give dimensions suitable for mounting in a spectacle, permitting a reduced center thickness in the case of convex lenses and a reduced edge thickness in the case of concave lenses.

j. Aspherical Lens. An aspherical lens is a lens in which one or both surfaces in the central sagittal section do not describe a circle, usually conforming instead to a parabola or some similar curve systematically deviant from a circle from the center to the periphery of the lens, so designed to correct for or reduce certain types of aberrations.

k. Balance Lens. A balance lens is a spectacle lens of undesignated power serving only to balance the weight and the appearance of its mate in front of the other eye.

l. Bridge. The bridge is that part of a spectacle front which connects the two eye wires, the lens arms, or the nasal straps. Its name stems from the early type of saddle bridge which rested on the bridge of the nose.

m. Temple. A temple is one of a pair of shafts extending backward from the end pieces of a spectacle frame or mounting to rest against the head or the ears for the purpose of holding the frame or mounting in position.

n. Low-vision Device. A low-vision device is a special aid, appliance, or technique used to improve the vision or functional rehabilitation ability of a beneficiary with subnormal vision.

o. Subnormal Vision. Subnormal vision is vision considered being inferior to normal vision, as represented by accepted standards of visual acuity, field of vision, or motility, and uncorrectable by conventional lenses, or the branch of visual care identified with its correction or rehabilitation or special aids or techniques.

p. Safety Spectacles. Safety spectacles are the result of the combination of frames and lenses that meet American National Standards Institute Z80 safety standards to provide protection to the eyes, especially from injury due to impact.

q. Polycarbonate. Polycarbonate is a transparent material consisting of thermoplastic linear polyesters of carbonic acid, made by the polymeric condensation of bisphenols with a phosgene or its derivatives and used for injection molding of certain ophthalmic lenses.

r. Photophobia. Photophobia is an abnormal intolerance or fear of light.

s. Photosensitivity. Photosensitivity is the capacity of the cells of an organ or an organism to be stimulated to activity by light; it is also the property of certain chemicals to react to light.

t. Enucleation. Enucleation is the removal of a whole tumor or an entire organ, as in the removal of the eye from its socket.

u. Evisceration of the Eye. Evisceration of the eye is the surgical removal of the inner contents of the eye, the sclera being left intact.

v. American National Standards Institute (ANSI) Accredited Committee Z80 for Ophthalmic Standards. The ANSI Accredited Committee Z80 for Ophthalmic Standards is the nationally-recognized organization that establishes standards that apply to:

(1) Ophthalmic lenses, equipment, instruments, and processes used in the final fabrication level which affects the relationship to ophthalmic frames, sunglasses, and fashion eyewear;

(2) Contact lenses and accessories for their use;

(3) Intraocular implant lenses, low-vision devices, and ophthalmic contact devices; and

(4) Optical instrumentation used in ophthalmic procedures and vision evaluation.

NOTE: Standards established by the ANSI Z80 Committee do not apply to industrial safety devices, or to procedures used in clinical ophthalmic examinations.

12.4. Eligibility

NOTE: Beneficiaries' eligibility for prescription optics is determined using criteria and guidelines set forth in 38 CFR 17.149 and present VHA policy.

a. Facility Director. The facility Director is responsible for

(1) Furnishing needed eyeglasses to the following veterans:

(a) Those with any compensable service connected disability.

(b) Those who are former prisoners-of-war (POWs) or recipients of Purple Heart.

(c) Those in receipt of benefits under Title 38 United States Code (U.S.C.) 1151.

(d) Those in receipt of an increased pension based on being permanently housebound or in need of regular aid and attendance (Priority 4); and

(e) Those other veterans with non-service connected or non-compensable service connectedisabilit5ies with one of the following conditions:

1. Those who have visual impairment resulting from the existence of another medical condition for which the veteran is receiving VA care, or which resulted from treatment of that medical condition, e.g., stroke, diabetes, multiple sclerosis, vascular disease, geriatric chronic illnesses, ocular toxicity from drugs, ocular photosensitivity from drugs, cataract surgery, and/or other surgeries performed on the eye resulting in visual impairment.

2. Those with significant functional or cognitive impairment evidenced by deficiencies in the ability to perform activities of daily living, but not including routinely occurring visual impairments correctable by conventional lenses.

3. Beneficiaries who are visually impaired with subnormal vision to the degree that the provision of corrective optics or other similar devices is necessary to permit active participation in their own medical treatment and/or care may be provided prescription optics and low-vision devices.

4. Those who are so severely hearing-impaired that the provision of sensori-neural aids is necessary to permit active participation in their own medical treatment and to reduce the impact of dual sensory impairment.

b. Eye Care Practitioner (optometrist or ophthalmologist). Since visual disorders requiring eyeglasses are so varied and complex that in some cases, a combination of visual acuity level and clinical guidelines does not address all possible prescribing indications, the eye care practitioner is responsible for using all the following in prescribing eyeglasses:

(1) Visual acuity;

(2) Literature-based clinical guidelines (see subpars. 15c, 15d, and 15l); and

(3) Guidelines for Furnishing Sensori-neural Aids (see subpar. 15a);

(4) Prescription optics will not be provided to otherwise ineligible beneficiaries with normally occurring correctable visual impairments, such as near-sightedness, far-sightedness, or presbyopia (see subpars. 15h, 15i, 15j, and 15k).

12.5. Special Eyeglasses, Lenses, Tints, or Frames

a. Lenses, tinted lenses, prismatic lenses, and other ophthalmic aids and low-vision devices may be procured upon approval of the Chief of Optometry or Chief of Ophthalmology, as appropriate, on a per-beneficiary basis provided a medical need exists and justification is given for the prescription.

b. Special frames, prescribed for medical reasons and not for cosmetic purposes, are procured upon prescription by a VA staff ophthalmologist or optometrist.

c. Special eyeglasses or frames required for cosmetic facial restorations may be procured upon the recommendation of the Chief, Plastic Eye and Restoration Clinic, and the approval of a VA staff ophthalmologist or optometrist. In such cases, corrective lenses are authorized for any refractive error present.

d. Prescriptions of safety spectacles and/or for eyeglasses with tinted lenses are filled for beneficiaries who are monocular, and those with post-cataract surgery, chronic uveitis, severe corneal disease, clinically significant macular degeneration, clinically significant cataract, ocular photosensitivity from drugs, significant visual field loss, significant amblyopia in the fellow eye (worse than 20/40 correctable visual acuity by conventional lenses), photophobia and/or retinal or other medical eye conditions, as appropriate. Tinted lenses will not be provided solely for comfort; medical need must be documented by a VA staff or VA contract ophthalmologist or optometrist; this need may include the need for ocular protection from undesirable incident radiations, such as UV radiation, etc.

e. Special upgrade requests for eyeglasses, lenses and frames between the veteran and the vendor are not encouraged by VA. While private transactions are not prohibited, direct solicitation by the vendor is not allowed and as such are the sole responsibility of the veteran beneficiary.

12.6. Replacement Eyeglasses

a. Replacement of corrective eyeglasses necessitated by fair wear and tear, loss or breakage due to circumstances beyond the control of the beneficiary, or due to required change of prescription, may be made at any time for VA beneficiaries who are enrolled.

(1) When replacement eyeglasses are prescribed because of a change in refractive error, the change must require at least an increase in sphere, cylinder and/or power as follows:

Sphere Power of + or - .25 diopter

Cylinder Power of + or - .50 diopter

Axis change of:

+ or - .25 to .75 diopters 5 degrees

+ or - 1.00 to 2.00 diopters 3 degrees

+ or - 2.25 or more 2 degrees

(2) Replacement eyeglasses can be prescribed at any time due to required refractive change of prescription to improve one line of visual acuity.

NOTE: Appropriate prescriptions and resultant sphere, cylinder and/or axis changes must be determined by the examining ophthalmologist or optometrist. Replacement eyeglasses are procured and issued in the same manner as the initial prescription when the criteria are met.

b. Eyeglasses will not be replaced because of availability of newer technology, unless there is evidence that it will significantly benefit the veteran. NOTE: Eyeglasses are not to be replaced solely for cosmetic purposes.

c. Multiple replacement eyeglasses within a relatively short period of time due to excessive wear, tear, or loss may be addressed on an individual basis by the local VA facility.

12.7. Second Pair and Spare Eyeglasses

a. A second pair of corrective eyeglasses will not be issued to any beneficiary unless there are compelling medical circumstances requiring a second pair. NOTE: Two pairs of single vision eyeglasses, one for reading and one for distance, will be provided in cases where bifocal lenses are contraindicated.

b. Spare glasses may be issued, if necessary, but only as determined by the eye care practitioner (optometrist or ophthalmologist); they will not be routinely issued.

c. When providing spare eyeglasses from any existing prescription, the prescription must be current and appropriate for the visual needs of the beneficiary.

12.8. Contact Lenses

Contact lenses may be provided to eligible beneficiaries with monocular aphakia, binocular aphakia, severe astigmatism, pathologic myopia, keratoconus, aniseikonia, or other ocular and vision conditions, when prescribed by a VA or fee-basis ophthalmologist or optometrist and only when contact lenses are superior to eyeglasses in improving or protecting the beneficiary's visual or medical function.

12.9. Replacement Contact Lenses

a. Replacement contact lenses are provided to eligible beneficiaries upon approval of a staff ophthalmologist or optometrist.

b. Replacement contact lenses are not normally provided to beneficiaries unless medically necessary for the continuation of post-hospital care treatment for a condition which requires contact lenses.

12.10. Second Pair of Contact Lenses

Beneficiaries who are enrolled and who have an eye or vision condition requiring contact lenses may be provided a second lens or pair of lenses when loss or destruction of the beneficiary's contact lens(es) creates a severe hardship or a compelling medical need.

12.11. Procedures for Furnishing Prescription Optics

a. Local procedures must be developed at each medical facility to ensure that a beneficiary's eligibility for ophthalmic prescriptions (eyeglasses and contact lenses) is established prior to issuance of prescription optics.

b. When beneficiaries undergo an eye examination in conjunction with an examination for medical reasons other than the sole purpose of obtaining prescription optics, and are not eligible for VA-furnished optics, the beneficiary may, upon request, secure a copy of the prescription from the examiner. When providing this prescription, copy four of VA Form 10-2914, Prescription and Authorization for Eyeglasses, VA Form 10-2577f, Security Prescription Form, or any other form developed for this purpose, will be used and annotated "not to be filled at VA expense." An appropriate disclaimer needs to be stamped on the VA Form 10-2914 to avoid difficulties should the beneficiary find the prescription inadequate after spending personal funds to purchase optics based on a refraction provided by VA.

12.12. Procuring Eyeglasses Using VA Forms 10-2914 and 10-2421

a. A written policy must be developed at each medical facility outlining procedures for procurement of prescription optics from a local licensed optometrist, ophthalmologist, or optician vendor for those beneficiaries authorized to use fee-basis optometrists or ophthalmologists (see the Eyeglasses Solicitation Template Guidelines on the Prosthetics Intranet Website: http://vaww.va.gov/prosthetics for guidance.

(1) Eyeglasses may be delivered to the optometry clinic, ophthalmology clinic, optical dispensary, Prosthetics and Sensory Aids Service, or beneficiary's home address when direct delivery is in the best interest of the beneficiary. Patient education materials on Care of Your Eyeglasses (App. A), and Bifocal Adaptation (App. B) need to accompany the delivery of eyeglasses, as appropriate to the recommended prescription optics.

(2) Verification that the spectacles match the appropriate prescription within applicable ANSI Z80 standards and tolerances must be conducted by the vendor prior to delivery of each pair of eyeglasses.

(3) The prosthetic activity or VA-owned optical laboratory must sample at least five pairs of prescription optics per month of the home delivery patients, and five pairs of prescription optics per month of those patients receiving prescription optics at the VA facility in order to ensure prescriptions were filled correctly within applicable ANSI Z80 standards and tolerances.

(a) Adherence to ANSI Z80 Standards will be determined by local community eyeglass providers (optician, optometrist, or ophthalmologist) through the "Voucher for Eyeglasses Adjustment and Analysis" template for home delivery patients (see par. 16).

(b) For prescription optics dispensed at the local VA facility, the optometry clinic and/or ophthalmology clinic, as appropriate, is responsible for an ongoing quality assurance verification program in concert with the local VA prosthetic activity.

(4) The facility needs to maintain one copy of either VA Form 10-2421 (ADP) or VA Form 10- 2914 in a pending order file until delivery is completed.

(5) After completion, one copy of the VA Form 10-2421, or the VA Form 10-2914 and the shipping document must be filed in the beneficiary's Consolidated Health Record (CHR) i.e., the patient's medical paper file at the local facility.. NOTE: Attach the invoice to the copy of the 10- 2421 or the 10-2914.

b. Local policy must be developed to verify receipt of eyeglasses and payment procedures using the appropriate ADP or VA forms.

c. In the event eyeglasses are not within tolerance, the local prosthetic activity returns them to the vendor for correction. While this may result in eventual receipt of two pairs of eyeglasses, this is acceptable under the circumstances.

d. Upon receipt of a bill or invoice, the local prosthetic activity must verify that amounts are correct and certify appropriate documents for payme

12.13. Repairs to Eyeglasses

Whenever practical, repairs to eyeglasses are to be procured from the optical company that furnished the glasses. In the event this is not possible or is not feasible, the glasses are to be forwarded to the nearest local optical dispenser or ophthalmic laboratory for repair.

12.14. Procedures for Furnished Repairs

a. When repairs to eyeglasses are to be obtained from the optical vendor who provided them initially, the following procedures apply:

(1) If one or both lenses are broken and there is any indication that the beneficiary's vision has changed, or if it has been more than 1 year since the beneficiary's eyes were last examined, the beneficiary is to be referred to an ophthalmologist or optometrist before new lenses are ordered.

(2) If one or both lenses are broken, the prescription is less than a year old, and there is no indication of a change in the beneficiary's vision, the local prosthetic activity prepares the appropriate procurement documentation, copies the lens instructions from the previous prescription in the beneficiary's CHR, and gives a description of the necessary repairs.

(3) If no lens is broken, but repair of the frame or a new frame is required, appropriate procurement documentation is to be prepared in the usual manner.

b. To ensure the appropriate level of care for beneficiaries, local procurement is preferred to contracts.

12.15. References

a. Title 38 CFR Section 17.149. Sensori-neural Aids.

b. Title 38 U.S.C.1701 (6)(A)(i). Definitions: Sensori-neural Aids.

c. Preferred Practice Patterns, Vision Rehabilitation for Adults, American Academy of Ophthalmology. http://www.aao.org/aao/education/library/ppp

d. VHA Handbook 1173.5.

e. Griffin JR, Cline D, Hofstetter, HW. Dictionary of Visual Science, Fourth Edition, Chilton Trade Book Publishing, Radnor, Pennsylvania.

f. Optometric Clinical Practice Guideline, Care of the Patient with Presbyopia, American Optometric Association. http://www.aoanet.org/documents/CPG-17.pdf

g. Optometric Clinical Practice Guideline, Care of the Patient with Myopia, American Optometric Association. http://www.aoanet.org/documents/CPG-15.pdf

h. Optometric Clinical Practice Guideline, Care of the Patient with Hyperopia, American Optometric Association. http://www.aoanet.org/documents/CPG-16.pdf

i. Optometric Clinical Practice Guideline, Care of the Patient with Amblyopia, American Optometric Association. http://www.aoanet.org/documents/CPG-4.pdf

j. VHA Prosthetic Clinical Management Program (PCMP) Clinical Practice Recommendations: Prescription and Provision of Optical Low-vision Devices to Aid in Overcoming Visual Impairment, September 2004.

k. VHA PCMP Clinical Practice Recommendations for Prescription of Closed Circuit Televisions (CCTVs) and other Electronic Optical Enhancement Devices (EOEDs), August 2002.

l. American National Standards Institute (ANSI) Accredited Committee Z80 for Ophthalmic Standards. Optical Laboratories Association, Merrifield, Virginia. http://www.ola-labs.org

12.16. Prescription Optics Mailed Directly to Veterans

a. An increasing number of veterans provided prescription optics by VA and other Federal agencies do not return to the prescribing facility to receive those eyeglasses for various reasons. Some of these reasons include: increasing age, living alone, lack of readily available transportation, distance from the prescribing facility, and a preference to avoid highly-congested metropolitan areas. As a consequence, without great assistance, many of these veterans may not have the eyeglasses properly fitted and/or adjusted on their face, or may not be informed on the proper use and care of eyeglasses.

b. Prosthetic and Sensory Aids Service (PSAS) is responsible for ensuring that all known veterans, or those who have later elected to receive their eyeglasses through the mail and indicated they will not return to the facility for fitting, be given useful information on the eyeglasses and authorization to have adjustment and/or fitting of eyeglasses at VA expense. Veterans need to be encouraged to return to the dispensing facility for adjustment and fitting whenever possible. Whether initial, previous, or on-going users, single copies of Appendix A and Appendix B are to be mailed with the letter of notification that eyeglasses are on order; this letter is mailed at the time the eyeglasses are ordered and is generally received 4 to 5 days before the eyeglasses arrive.

c. At least five pairs of prescription optics per month of patients receiving eyeglasses by mail must be sampled by PSAS or a VA optical laboratory to monitor the quality of fabrication, patient satisfaction, and timeliness of delivery.

d. When veterans eligible and entitled for eyeglasses indicate that they will not return to the facility to pick-up the eyeglasses, their prescription will be flagged to ensure that appropriate information is mailed to them. A letter notifying the veteran of when the eyeglasses may be expected to arrive is to be developed through the prosthetic software at the time the purchasing document to the contractor is being prepared. A copy of Appendix A must be included with every letter. If the prescription includes 'bifocal lens,' a copy of Appendix B must be included with the notification letter. All veterans who are mailed eyeglasses are to be encouraged to have them adjusted and/or fitted..

e. When the adjusting and/or fitting optician, optometrist, or ophthalmologist indicates that the eyeglasses are not made within the American National Standards Institute (ANSI) Z80 standards of manufacturing tolerances, local facility prosthetics activity contacts the eyeglasses fabricator for a remake and notifies the Contracting Officer. When the adjusting and/or fitting optician, optometrist, or ophthalmologist indicates that the eyeglasses comply with the written prescription, but that the prescription does not meet the veteran's visual needs, the local prosthetic activity must arrange for another eye examination at the prescribing facility or in the veteran's local area, as appropriate. Annually, a report of the events is to be provided to the Chief of Optometry, Chief of Ophthalmology, or Chief of Eye Clinic.

12.17. Appendix A - Care of Your Eyeglasses

1. Cleaning Your Lenses

a. Never wipe your plastic lenses when they are dry.

b. Never wipe your polycarbonate lenses when they are dry.

c. Rinse your lenses off under running water.

d. Use liquid dish soap or glass cleaner (with ammonia).

e. Wash the lenses to clean off dirt and grease.

f. When they are clean, wipe them with tissue or a lint-free cloth.

2. Screws. Keep the screws on your glasses' frame tight.

a. If the screws become loose, you could lose a lens from your glasses.

b. Have someone where you had your eyeglasses adjusted tighten the screws or purchase an eyeglass screwdriver set and tighten the screws regularly yourself.

3. Removing Glasses. Always use two hands to take your glasses off your face. Using one hand twists the frame and the lenses could pop out. Keep your glasses in your case when you are not using them.

4. "Photogray" Lenses. If you received "Photogray" lenses, they need to be primed before use.

a. Priming the lenses helps them to darken as fast as possible.

b. Put the glasses in their case. Then put the glasses and case in the freezer of your refrigerator for 30 minutes.

c. To prime lenses:

(1) Use extreme cold temperature;

(2) Set the glasses with front side facing up in bright sunlight; or

(3) Leave them in the sun for about 1 hour. The bright sun light can also prime the lenses.

5. If your lenses become chipped, they should be replaced.

12.18. Appendix B - Bifocal Adaptation

1. Bifocals are a handy way to have clear vision for both distance and reading in a single pair of eyeglasses.

2. There are a few hints that are helpful in getting used to these new glasses:

a. When you pick up your new glasses, make sure they are adjusted on your face.

b. Do not drive while wearing your new eyeglasses until you have become familiar with wearing them.

c. Wear your new glasses at home and in familiar areas for about 1 week.

d. After 1 week (or more), then you can wear them elsewhere.

3. The line will be the hardest to adapt to. a. Look above or below the line, never through it. b. Move your eyes up and down to look around the line. c. Move your head and bend your neck as little as possible.

4. When stepping off curbs and walking on stairs, you must bend your head down and look over the line. If you don't, your feet will be blurred and you may trip.

5. Practice with your new glasses.

a. Sit and watch a TV program while looking over the line.

b. Switch to a book in your lap and look under the line to read.

6. Bifocals are like new shoes.

a. Just as you break in shoes over days and weeks, you may need to so with new glasses.

b. Give yourself time to adapt to them.

c. Make it easy for yourself while you get familiar with your new glasses.

d. Wear them at home and in non-stressful situations.

13. VA Handbook 1173.13 - Home Respiratory Care Program

13.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent national procedures in administering the Home Respiratory Care Program to veteran beneficiaries.

13.2. Scope

a. The term "home respiratory care" pertains to the provision of home oxygen/respiratory care services necessary to assist the eligible person with home respiratory care. The program uses an interdisciplinary approach, involving members of Medical Service, Pharmacy Service, Prosthetic and Sensory Aids Service (PSAS), Acquisition and Materiel Management Service (A&MMS), Nursing Service, Health Administration Service, and contractors who comply with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.

b. There are three primary methods for providing oxygen therapy in the home:

(1) Compressed gas,

(2) Oxygen concentrators, and

(3) Liquid oxygen.

c. The most efficient and medically appropriate system for providing oxygen will be determined by the prescribing physician based upon the flow rate (per minute) desired, the daily period of usage, the patient's physical condition and daily activities. For instance, an ambulatory patient may need a more portable oxygen system than a bed-confined or homebound patient.

13.3. Definitions

a. Concentrator. A concentrator is an electrical device used to deliver oxygen therapy in the home.

b. Liquid Stationary System. A liquid stationary system is a device used to store and dispense liquid oxygen therapy.

c. Liquid Oxygen. Liquid oxygen is medical oxygen dispensed by the pound.

d. Oxygen Tanks. An oxygen tank is where medical oxygen is stored; it is dispensed in a gaseous state in cylinders made of steel, light steel, and aluminum; it is known as compressed gas.

e. Intermediate Positive Pressure Breathing (IPPB) Machine. An IPPB machine is a device used to deliver air under pressure into a patient's lungs.

f. Ventilators or Bi-Pap. A ventilator or Bi-pap is a device used for the continuous mechanical ventilation of a patient.

g. Continuous Positive Air Pressure (C-PAP). C-PAP is a device used to provide continuous positive air pressure for breathing.

h. Suction machine. A suction machine is a device used to evacuate a patient's lungs.

i. Nebulizers. A nebulizer is a device used to dispense medication with the use of an electrically operated compressor.

13.4. Guidelines for Issuing Respiratory Equipment

a. Home oxygen services will be provided as medically needed to all eligible beneficiaries accepted for care within the Department of Veterans Affairs (VA).

(1) Oxygen is provided in a large cylinder under a compressed gas system. For those who require portability, a small tank with a cart is provided. This particular system requires a regulator to adjust the flow rate, a stand to secure the large cylinder, and in some cases, a humidifier to moisten the air. This oxygen system is normally furnished to patients who do not need continuous oxygen or were prescribed a low flow rate. When this particular system is provided, preset oxygen flow regulators should be provided unless the physician indicates otherwise.

(2) The oxygen concentrator delivery system provides an economical method of therapy when patients need continuous oxygen, and are relatively housebound or have minimal portability needs. The furnishing of a separate "E" cylinder or other appropriate size of compressed gas cylinder is necessary for emergency needs or to meet temporary portability needs as they may occur.

(3) The liquid oxygen system includes a reservoir canister and a portable device which can be filled from the reservoir. This method is prescribed for ambulatory patients who can use an extensive amount of oxygen from portable sources.

(4) Home oxygen should be provided by the most cost-effective means. The cost- effectiveness of using a concentrator versus compressed gas depends on local vendor charges. Local contracts for both delivery systems should be analyzed. The contract prices together with the patient's prognosis and projected liter flow rate will be the determining factors in choosing the most economical delivery system in each case. The Chief, A&MMS, in coordination with the Chief, PSAS; Chief, Health Administration Service; and Respiratory Therapy should periodically complete a market analysis in their geographical area to determine the availability of the different types of home oxygen systems, and the contractors capable of providing the required services prior to issuing formal solicitations. The solicitations should be written in such a manner as to foster competition. In some areas it may be necessary to issue separate solicitations for each system. This is dependent upon the level of competition. The quoted prices, together with the patient's prognosis and projected usage, will be used to determine the most cost-effective method in the local area for the delivery of home oxygen systems. Contract price quotations should be documented and considered in the cost analysis of the various systems. The most economical method will be used in determining purchase versus rental of equipment.

(5) All patients placed on a home oxygen therapy program should be reevaluated and the need for oxygen therapy documented every 6 months for the first year. Thereafter, the need for continuing oxygen must be documented at least annually.

13.5. Procedures for Veterans on Ventilators

a. Ventilators which are required for the continuous mechanical ventilation of a patient will be furnished when prescribed only after the patient has been evaluated by the VA Respiratory Therapy Service.

b. Whenever a patient is totally dependent on a ventilator for continuous mechanical ventilation, a spare ventilator with accessories will always be furnished.

c. The veteran and family care takers will be thoroughly trained in the function and use of the ventilator and its accessories prior to discharging the patient.

d. All ventilators will be furnished in accordance with VA policies and procedures.

NOTE: A backup ventilator will be provided when the patient is discharged to the patient's home.

e. IPPB machines

(1) IPPB machines, which are used to deliver air under pressure into the patients lungs for periods of time, will be furnished when prescribed by a physician specializing in pulmonary disease.

(2) This equipment is used to treat patients with acute pulmonary edema and chronic obstructive pulmonary disease.

(3) Physicians should only consider an IPPB machine for medication administration after patients have had a trial with one or more of the types of devices with unsatisfactory results as determined by the physician and respiratory therapy personnel.

f. Rocking Beds

(1) Rocking beds which are specially designed to control respiration of a patient will be furnished when prescribed by a physician specializing in pulmonary medicine.

(2) Rocking beds may be rented if duration of use is expected to be short or, as an interim measure to permit discharge from an inpatient facility pending receipt of a rocking bed ordered for a patient.

(3) Rocking beds will only be installed by personnel familiar with their function, i.e., biomedical engineer, engineering staff accompanied by a respiratory therapist or the JCAHO accredited personnel of a commercial contractor who specializes in respiratory equipment. This is essential as the rate of respiration is controlled by the frequency of the rock and inspiration and expiration is controlled by the angle of the rock.

g. Phrenic nerve stimulators which are designed to initiate breathing through stimulation of the diaphragm via the phrenic nerve will be furnished, including batteries, when prescribed by the appropriate medical personnel. NOTE: Batteries to power phrenic nerve stimulators will be provided by Prosthetic Service.

h. Other less expensive, less complicated, and usually effective types of equipment are available for routine aerosolization of medications. These include cartridge inhalers, handheld nebulizers, and portable compressor nebulizers.

i. Other items of respiratory equipment may be purchased, when prescribed, in accordance with VA policy and procedures.

13.6. Responsibilities

a. The Chief of Staff at the local VA Medical Center. The Chief of Staff at the local VA medical center is responsible for:

(1) Coordinating the efforts of all medical disciplines required for treatment of patients who require home respiratory care.

(2) Selecting a home respiratory care team (HRCT) comprised of the involved medical disciplines and designating the chairman of the team. The team will normally consist of a physician responsible for respiratory care as the Chairman, a prosthetic representative as the coordinator and a VHA Respiratory Care Practitioner. The team may also include representatives of Pharmacy Service, Nursing Service, Health Administration Service, Quality Management, and the contractor's respiratory care practitioner as dictated by local needs.

(3) Reviewing the program on a quarterly basis and advising the HRCT as to any necessary adjustment of team composition or quality assurance initiative changes that may be necessary from time to time.

b. Prescribing Clinician. The Prescribing Clinician will be responsible for:

(1) Determining the need for home respiratory care based on the patient's prognosis, medical history, results of 1) arterial blood gases (ABG's) or pulse oximetry, according to the Guidelines for home oxygen in the Department of Defense/VHA Clinical Practice Guidelines for Asthma/COPD,** 2) sleep study, 3) effective ventilator settings, or 4) effectiveness of other interventions.

(2) Assure the prescription/consult includes the following general information: a) home oxygen: method of delivery, liter flow FiO2 (continuously, on exertion, at night), method of delivery, and duration. b) Airway pressure: mask type, settings, spacers, other associated devices.?Šc) Ventilator: settings, FiO2, mode. **While the guidelines only address the use of oxygen for COPD, exceptions to the criteria may be clinical conditions where it has become practice to try oxygen therapy, i.e., cluster headaches, end stage CHF or other terminal illness. In general, if the patient does not desaturate to the level of 55 PaO2, even in light dyspnea, supplemental oxygen is not indicated. Physician discretion should be employed.

(3) Re-evaluating the patient to ensure the continued need for intervention. The initial re- evaluation may be accomplished from 4 weeks to 3 months, depending upon the reason for the intervention. A re-evaluation for veterans requiring long-term oxygen and mechanical ventilation will occur at least annually. The clinician.will notify Prosthetics of the continued need or the need to discontinue intervention.

(4) Authorizing fee-basis evaluations, if so indicated in accordance with VA Acquisition Regulation 801.670-3, Medical, Dental, and ancillary services, for eligible patients who are unable to report to the VA medical center for evaluation of continued need or initial determination of need for home respiratory care.

c. Prosthetic Service. The Prosthetic Service, or other responsible entity, is responsible for administering the program. This includes the following functions:

(1) Determining the eligibility of the veteran for home respiratory care.

(2) Working with the responsible home oxygen therapy physician to identify contracted home oxygen therapy requirements for equipment management such as concentrators, tanks, regulators, canulas, masks, tubing, Continuous Positive Air Pressure (CPAP) devices, ventilators, and other respiratory care equipment. This responsibility also includes submission of the home respiratory care requirements to A&MMS for development of a solicitation for bids or offers and inspection of bidders' or offerors' facilities prior to award of the contract to provide home oxygen therapy to eligible VA beneficiaries or identifying vendors already under contract.

(3) When designated by the contracting officer, appropriate personnel will serve as the Contracting Officer's Technical Representative (COTR) for the home respiratory care contract. The designee will ensure the contractor's compliance with technical requirements of the contract, including all JCAHO requirements as specified in the contract.

(4) Monitoring contractual compliance and JCAHO standards on a quarterly basis. For example, this will be accomplished through site visits, receipt and review of all required documentation and performance improvement activities, customer satisfaction surveys and patient interactions. The results will be documented and maintained according to established local policy.

(5) Scheduling home visits at a minimum of 10 percent (10%) of the patients on home respiratory care on a yearly basis. These random home visits are necessary to provide quality assurance of this treatment modality. Individual home visits may be conducted by multi- disciplinary teams consisting of clinicians and prosthetic representatives.

(6) In concert with clinical respiratory representative, formulation and distribution of the medical center's policy relating to the home respiratory care program including eligibility criteria and clinical and administrative responsibilities.

(7) Recording all transactions/expenditures for this program by utilizing the appropriate prosthetic software module, i.e., Home Oxygen Program. Recording home oxygen use as follows: Budget Object Code (BOC) 2574, Cost Center 8272, for rental item, repair, preventative maintenance, cylinder contents or liquid oxygen contents or other service contract cost; and BOC 2674, Cost Center 8272, for purchasing new equipment and/or supplies for home oxygen use

(8) Budget management and control of all Fund Control Points relating to home respiratory care.

(9) Purchase of equipment such as Continuous Positive Airway Pressure (CPAP devices), Bi- level Positive Airway Pressure (BiPAP devices), concentrators, ventilators, nebulizers, etc.

(10) Rental of equipment as concentrators, cylinder tanks, liquid reservoirs, ventilators, etc.

(11) Payment for liquid oxygen and cylinder tank fills and refills, and all invoices reflecting charges associated with the home respiratory care program.

(12) Purchase of consumable supplies such as masks, tubing, disposable nebulizer kits, nasal cannulars, humidification bottles, nasal pillows, etc.

(13) Performance Maintenance Inspections (PMIs) on VA owned equipment.

d. Home Respiratory Care Team. The Home Respiratory Care Team is responsible for:

(1) Reviewing all aspects of the home oxygen program in relation to local needs and resources to ensure that patients receive appropriate care, home oxygen equipment, and other aspects of the program are available.

(2) Recommending changes in the medical center policy on home respiratory care.

14. VA Handbook 1173.14 - Home Improvements and Structural Alterations (HISA) Program

14.1. Purpose

This Veterans Health Administration (VHA) Handbook establishes uniform and consistent Department of Veterans Affairs (VA)-wide procedures governing the Home Improvement and Structural Alterations (HISA) program for veteran beneficiaries. NOTE: Each individual case must be reviewed and evaluated based on the specific needs of the veteran involved; this is especially true where the patient presents multiple disabilities.

14.2. Scope

The Home Improvements and Structural Alterations, (HISA) Program†benefit is limited to the improvement and structural alterations necessary only to ensure the continuation of treatment and/or to provide access to the home or to essential lavatory and sanitary facilities. NOTE: It does not include those improvements which would serve only to lend comfort to the individual, or to make life outside the health care facility more acceptable.

Home Improvements and Structural Alterations, (HISA) Program, provides†Grant Amounts Lifetime HISA benefit up to $6,800 that may be provided for:

  • Veterans and Servicemembers who have a service connected condition
  • Veterans who have a non-service connected condition rated 50% or more service connected

Lifetime benefit up to $2,000 may be provided for Veterans who have a non-service connected condition

14.3. HISA Grants

a. HISA grants provide for medically necessary improvements and/or structural changes to the veteran's residence for the following purposes:

(1) Allowing entrance to, or exit from, the veteran's residence.

(2) Use of essential lavatory and sanitary facilities.

(3) Allowing accessibility to kitchen or bathroom sinks or counters.

(4) Improving entrance paths or driveways in immediate area of the home to facilitate access to the home by the veteran.

(5) Improving plumbing or electrical systems made necessary due to installation of dialysis equipment in the home.

b. All improvements must adhere to the Minimum Property Requirements (MPRs) as outlined in Department of Veterans Affairs (VA) Pamphlet 26-13, Handbook for Design, and VA Manual M26-12, Chapter 7, Section B. All improvements must meet, or exceed, local building authority requirements.

c. Improvements can include, but are not limited to:

(1) Door Latches. Door latch handles must be easy to operate and grasp.

(2) Entrances. The minimum width of all doors needs to be 3 feet (36 inches). In renovation work where 3 foot openings are impossible, an opening of 2 feet 8 inches (32 inches) is acceptable; however, ingress and egress doorways, h must always be a minimum of 36 inches. A maneuvering area with a minimum length of 4 feet 6 inches (54 inches) must be provided on each side of all doors.

(3) Electrical Outlets and Wall Switches. Wall mounted outlets must be located at a maximum height of 4 feet (48 inches) and a minimum height of 1 foot, 6 inches (18 inches).

(4) Handrails. The primary functions of hand rails are to act as a safety barrier to protect the user from a fall, to aid with balance, or to allow a wheelchair user a means for propulsion. The railing can be of wood or metal that is a minimum 1.5 inches in diameter with a 1.5 - 2 inch clearance from the wall. The railing needs to be smooth, continuous, and uninterrupted in the vertical or horizontal plane. If used with a ramp, handrails must be provided on both sides.

(5) Ramps. Permanent ramping constructed of wood or concrete must be built according to VA Minimum Property Requirements (see subpar. 3b).

(6) Windows. Windows must have a maximum sill height of 2 feet, 9 inches (33 inches). Window controls must be accessible and easy to operate. Controls for windows are to be located at a maximum height of 3 feet, 6 inches (42 inches). Controls for curtains and blinds need to be similarly accessible. NOTE: Window tint or shades can be provided if prescribed and sufficient medical justification substantiates the need to block harmful sunrays from entering the primary living quarters.

(7) Central Air. Central air systems may be provided, when prescribed to an eligible veteran suffering from a spinal cord injury, neurological conditions, and severe respiratory or coronary disease, which are substantially worsened by exposure to heat and humidity, and where the absence of a controlled environment subjects the veteran to health-threatening circumstances. NOTE: Room air conditioners are provided, if necessary, and are charged as a prosthetic item. If the need for a central air conditioning system exists, the medical justification must be sufficient to substantiate cooling an area beyond the primary living quarters (see VHA Handbook 1173.08).

(8) Flooring. New or improved flooring can be provided for veterans when it is necessary for the veteran to navigate the interior of the home in order to access essential sanitary and lavatory facilities, e.g., if a veteran has a manual wheelchair and his home has carpeting that doesn't allow for optimum operation of the wheelchair, the HISA Grant may be used to remove the carpeting and replace it with vinyl or wood flooring or thinner carpet.

14.4. Eligibility

Veterans receiving medical services furnished under title 38 U.S.C., Section 1710(a)(1) or or a disability described in section 1710(a)(2)(C) are eligible for:

a. A $6,800.00 lifetime HISA benefit when it is necessary for:

(1) A service-connected condition.

(2) A non-service-connected condition of a veteran rated 50 percent or more service connected.

(3) A non-service-connected condition of a veteran in receipt of benefits under 38 U.S.C., Section 1151 for the condition requiring such benefit.

b. A $2,000 lifetime HISA benefit all other veterans receiving medical services furnished under title 38 U.S.C. 1710(a)(2) and (3).

NOTE: If the veteran has a balance remaining when, or if, Congress passes an increase in the lifetime limit, the veteran will be eligible for the difference between what remains from the original balance and the new limitation, subject to reapplication. However, if the benefit has been exhausted, no new benefit is allowed regardless of the increase in limitation. If a veteran receives a change in their rating decision from "non-service connected" to "service connected" after the veteran has used the non-service-connected grant, the veteran is entitled to the difference in amounts. In total, the veteran may not receive more than the current service connected amount.

14.5. Chargeable Improvement and Structural Alterations

Improvement and structural alterations chargeable against the veteran's cost limitation include, but are not limited to:

a. Roll-in showers or walk-in bathtubs.

b. Construction of wooden or concrete permanent ramping to provide access to the home.

c. Widening doorways to bedroom, bathroom, etc., to achieve wheelchair access.

d. Lowering of kitchen or bathroom counters and sinks.

e. Improving entrance paths and driveways in the immediate area of the home to facilitate access to the home, to include concrete pads for wheelchair lifts utilized for ingress and egress from vehicle.

f. Interior and exterior railing or lighting deemed necessary for patients with ambulatory capability or for veterans rated legally blind.

g. Improvements to plumbing or electrical systems made necessary due to the installation of dialysis or other sanitary equipment in the home.

h. Any cost associated with permits, inspection fees, etc., that are required by local ordinances.

14.6. Non-chargeable Improvement and Structural Alterations

Improvements and structural alterations, which are not chargeable against the veteran's HISA limitation include:

a. Exterior decking (in excess of 8 foot by 8 foot or the area necessary to accommodate wheelchair access).

b. Construction of pathways to exterior buildings such as barns or workshops.

c. Widening driveways (in excess of 8 foot by 8 foot, or an area necessary to accommodate wheelchair and van lifts).

d. Purchase or installation of spa, hot tub, or jacuzzi-type tubs.

e. Purchase of removable equipment or appliances such as portable ramps, porch lifts, and stair glides. NOTE: These removable items are chargeable as a prosthetic item and not HISA.

f. Projects which would duplicate services previously or currently being provided by the Veterans Benefits Administration (VBA) Specially Adapted Housing (SAH) grant, such as: ramping, central air conditioning, and roll-in showers. HISA and SAH are mutually exclusive of each other; however, they may be used concurrently.

(1) Prosthetic Service needs to work closely with the SAH agent to ensure the veteran's grants are used in the most efficient way possible. Prosthetic Service is only to give the HISA grant for a specific project within the SAH construction or renovation. All the rules and requirements for obtaining HISA still apply, except for acquiring three bids and plans, as that has already been performed by the SAH agent and veteran for the larger SAH project.

(2) The SAH agent is responsible for providing Prosthetic Service all pertinent information under subparagraphs 12b(3) and 12c of this Handbook.

(3) The SAH agent must notify Prosthetics when improvements have been inspected and approved by the VA compliance inspector.

g. Purchase or installation of home security systems.

h. Routine repairs done as part of regular home maintenance, e.g., replacing roofs, furnaces, air conditioner, etc. NOTE: Repairs or improvements to previous HISA projects can be authorized within the benefit limit; however, the veteran must reapply to use remaining grant allotment.

14.7. HISA Program Responsibilities of Chief Prosthetics and Clinical Logistics Officer

The Chief Prosthetics and Clinical Logistics Officer (10FP), is responsible for monitoring the HISA Program to ensure appropriate funding and consistency in the administration of the HISA benefits.

14.8. HISA Program Responsibilities of Facility Director (or VISN Prosthetic Representative)

The facility Director, (or the VPR, when applicable) has responsibility for:

a. Publishing local facility policy memoranda to inform staff, Veterans Service Organizations (VSOs), and veterans of the procedures to follow to obtain HISA benefits.

b. Establishing a facility HISA Committee that must consist of such staff physicians, therapists, nurses, social workers, patient representatives, the SAH agent from VBA, and representatives of the VSOs as are deemed necessary.

c. Appointing the Chief, Prosthetic and Sensory Aids Service (P&SAS), as the committee coordinator and to serve as the veterans' point of contact.

14.9. Responsibilities of the Facility HISA Committee

The facility HISA Committee is responsible for:

a. Determining if the veteran has received the SAH grant for the item(s) requested by contacting the SAH agent at VBA.

b. Evaluating, and approving or disapproving the request and bid.

c. Referring the request to the appropriate VA facility, iIn the event the veteran resides outside the local Prosthetic Primary Service Area (PSA).

14.10. Responsibilities of the Chief, PSAS

The Chief, P&SAS, or designee, is to:

a. Actively publicize the HISA Programs in order to identify eligible veterans and inform them of their benefits.

b. Assist designated Committee members in becoming familiar with the applicable guidelines for administering the HISA Program.

c. Screen applications to ensure that:

(1) There is no duplication of benefits,

(2) The benefit is used appropriately, and

(3) The application is complete prior to presentation to the HISA Committee.

d. Present the complete application to the Committee members for approval or disapproval.

e. Communicate the Committee's decision to the applicant.

f. Authorize the licensed or bonded contractor to proceed with the project, if approved.

g. Review the SAH benefits as administered by VBA to avoid any duplication of benefits, e.g., SAH provision of accessible bathroom would eliminate future need for bathroom modifications, central air conditioning provided under SAH cannot be repaired or replaced under HISA, etc.

h. Administer the appropriate obligations to the contractor to facilitate the completion of the approved project. If a licensed or bonded contractor is not utilized, the Chief, P&SAS, is responsible for notifying the facility Engineering Service at the local facility to inspect the property to ensure compliance with established guidelines.

i. Authorize claims for prompt payment, or reimbursement, of costs or services performed (without prior authorization), when:

(1) The veteran meets both the legal eligibility and medical criteria for the modifications for which reimbursement is sought, and

(2) The claim is submitted within 30 days of the date that the improvement or alteration was performed, or

(3) Documented evidence indicates that an application was made for the actual home modification, or a VA physician recommended furnishing the improvement or alteration before the work was performed. NOTE: Follow-up on approved projects as to the status is the responsibility of the Chief, P&SAS.

j. Ensure, that if the work on a project has begun and is cancelled for any reason (i.e., veteran death or relocation, etc.), the vendor is paid for the portion of the work completed.

k. Perform random inspections of fifteen projects per year where the VA provided modifications. Any deficiencies noted during the inspections must be addressed accordingly by the Chief of Prosthetics. (12) Ensure all projects are completed in compliance with Minimum Property Requirements (see subpar. 3c).

14.11. Responsibilities of the Purchasing Agent

The Purchasing Agent is responsible for:

a. Initiating the purchase order utilizing the correct costing center, budget object code (BOC), and posting to Prosthetic Veterans Health Information System and Technology Architecture (VistA) on each veteran's VA Form 10-2319 (ADP), Records of Prosthetic Service, utilizing the appropriate Health Care Financing Administration Common Procedure Coding System (HCPCS) code.

b. Reconciling all charges for payment and posting any HISA benefit balance in the remarks section of VA Form 10-2319.

14.12. Application for HISA Benefits

Application For HISA Benefits -†Download HISA Application PDF

a. A prescription from a VA, or fee-basis physician for HISA modifications is required and must include the following:

(1) The specific item(s) needed, such as: wheelchair ramp, widening of doorways, bathroom modifications. NOTE: If the physician needs assistance in determining what modifications are needed, the patient is to be referred to Physical Medicine and Rehabilitation Service for consultation.

(2) Diagnosis and medical justification for the item or modification(s) requested.

(3) Veteran's name, address, last four digits of Social Security Number (SSN), and phone number.

b. The veteran must provide the following:

(1) A completed and signed VA Form 10-0103, Veterans Application for Assistance in Acquiring HISA.

(2) If the veteran leases or rents a home, a written statement from the owner of the property authorizing the project to be done. NOTE: The veteran is responsible for all costs above the limit to which the veteran is entitled.

(3) Three competitive bids from licensed or bonded contractors, if required by state law. However, if the veteran is unable to obtain three bids, one bid may be sufficient as long as it is documented as a sole source. NOTE: The local Prosthetic Service staff, taking steps to avoid specific recommendations, may supply a list of contractors who have provided prior services to assist veterans in finding available contractors. Each bid must include the following:

(a) The contractor's name, address, telephone number, and last four digits of SSN or Federal tax identification (ID) number along with the contractor's applicable license and bonding information.

(b) The veteran's name, address, and telephone number.

(c) A written statement and the plans for the project that is to be performed to include a detailed drawing or sketch of the work to be completed.

(d) An itemized list of materials, material costs, and labor costs for each part of the project.

(e) The total cost for labor and materials for the entire project.

(f) Permits, if required by local government agency. Obtaining permits is the licensed or bonded contractor's responsibility.

(4) A signed acknowledgement that VA:

(a) Assumes no responsibility for maintenance, item repair or replacement;

(b) Assumes no liability for the product;

(c) Extends no warranties, either expressed or implied;

(d) Assumes no liability for damage caused by such equipment or devices, or for their removal, when the equipment or device(s) is no longer needed or wanted.

c. The following is required from the contractor.

(1) The contractor must:

(a) Be willing to accept a government purchase order.

(b) Understand that the payment will not be made until completion of the authorized work.

(c) Understand that the receipt of a signed letter of satisfaction from the veteran and a photo of the completed work must be submitted with final invoice.

(d) Obtain all required permits.

(e) Comply with all state and local building codes.

(f) Certify, upon completion, that the work meets, or exceeds VA Minimum Property Requirements and VA specifications as contained in the scope of work.

(g) Warrant the work against defects or poor workmanship for at least 1 year.

(h) Include a statement that certifies the charges contained in the invoice do not exceed the usual and customary charges for that type of work.

(2) Contractor bids must provide a complete description of the proposed project to include:

(a) A detailed and dimensioned set of construction plans of the area to be altered, or improved, as it currently appears. It must show the location of permanent fixtures such as walls, doors, windows, shower stalls, driveways, or walks, if appropriate. The plans must include measurements and specifications of these items.

(b) A detailed and dimensioned set of construction plans showing the area as it will appear after the proposed project including a photo of the proposed work site prior to the approval of the bid. NOTE: The items mentioned in preceding subparagraph 7c(2)(a), need to be shown with the new specifications and measurements.

(c) If a ramp is to be constructed, an individual detailed and dimensioned set of construction plans of the ramp indicating type of construction materials, slope width, and slope height.

1. The slope of a ramp cannot be approved if it exceeds 1 inch increase in height per running foot of ramp. In general, a ramp cannot be approved if it has more than 5 percent grade, or has a maximum slope of 1:12 or less.

2. A new ramp or walkway must have a minimum width of 48 inches, and must be constructed to be non-slip, or be treated to prevent slipping when wet.

a. Any ramp must include railings and low curb or guard rails on both sides to prevent a wheelchair or scooter from running off the edges.

b. A 5'x 5' rest platform must be provided every 30 feet or less depending on the design, or the veteran's ability. NOTE: VA Minimum Property Requirements are the standard for VHA (see subpar. 3c).

(d) If a driveway or walkway is to be improved, information about the material composing the existing area, such as: gravel, concrete, asphalt, etc. NOTE: Requirements for slope are the same as ramp requirements.

14.13. Costing

HISA program costs are posted to the appropriate Cost Center on each veteran's VA Form 10-2319, utilizing the appropriate HCPCS code.

14.14. Inquiries

Unusual requests, waivers from the VA Minimum Property Requirements, or inquiries relating to the HISA Program that cannot be resolved by the local HISA Committee are to be referred to the Chief Prosthetics and Clinical Logistics Officer (10FP), VA Central Office, Washington, DC, by submitting a VA Form 10-2641, Authority for Issuance of Special or Experimental Appliances. NOTE: This review is intended to expedite a resolution of unusual requests or inquiries; it is not to be considered as a substitute for the normal process.

15. VA Handbook 1173.15 - Clothing Allowance Benefit

15.1. Veterans Health Administration Clothing Allowance Handbook

VHA CLOTHING ALLOWANCE HANDBOOK

1. PURPOSE: This Veterans Health Administration (VHA) Handbook defines and describes the procedures to administer the annual clothing allowance benefit to Veterans. Veterans with service-connected disabilities and disabilities compensable under Title 38 United States Code (U.S.C.) section 1151 who are prescribed a prosthetic or orthopedic appliance that tends to wear out or tear the clothing of a Veteran and/or a skin medication that causes irreparable damage to the Veteran's outergarments are entitled to receive a clothing allowance to replace or repair their clothing. AUTHORITY: 38 CFR 3.810.

2. DEFINITIONS: For purposes of this Handbook, the following definitions apply (see paragraph 8):

a. Prosthetic/Orthopedic Appliance. Prosthetic/orthopedic appliances are aids, parts or accessories required to replace, support, or substitute for impaired or missing anatomical parts of the body.

b. Outergarment. An outergarment is a type of garment worn over other garment (e.g., shirt, blouse, pants, skirt, coat, jacket, blazer).

c. Skin Medication. Skin medication is a cream, salve, ointment, lotion, or semisolid medicine that is used to treat, prevent, heal, protect and alleviate symptoms from a skin condition.

d. Undergarment. An undergarment is a garment worn under outergarments next to the skin (e.g., stockings, panties, boxers, briefs, trunks, bra, bathing suit).

3. SCOPE: The clothing allowance program is jointly administered with the Veterans Benefits Administration (VBA) for Veterans who have qualifying service-connected disabilities and Veterans with disabilities compensable under section 1151. Under this collaborative effort, entitled Veterans are paid one or more clothing allowance benefit each year. Evidence in support of a Veteran's claim is to be obtained from VHA clinicians or records, e.g., VHA prescriptions, health care consultations, medical evaluations, rehabilitation assessments, or prosthetic and sensory aids services (see paragraph 6).

4. ELIGIBILITY TO APPLY FOR THE CLOTHING ALLOWANCE:

a. AratingspecialistfromVBA'sVeteransServiceCenterisresponsiblefor confirming whether a Veterans disability is service-connected or is compensable under 38 U.S.C. 1151 as if it were service-connected. In positive cases, the specialist is responsible for notifying the Veteran in writing that he or she may be entitled to an annual clothing allowance if: (1) the Veteran applies for the benefit and (2) the claim is ultimately determined by VHA to meet the criteria of Title 38 Code of Federal Regulations (CFR) 3.810(a). An application (VA Form 10-8678, Application for Annual Clothing Allowance located at: http://www.va.gov/vaforms) by the Veteran is required before these benefits may be paid. Veterans determined to be entitled to the allowance

1

VHA HANDBOOK 1173.15 May 14, 2015

will receive an annual lump sum payment. See paragraphs 9 and 10.a. for a full description of the application and renewal procedures.

b. IncaseswhereaVeteranappliesfortheclothingallowanceandisdeterminedto be entitled to the benefit but dies before receiving it, the Veteran's estate may apply for accrued benefits using form VA Form 21-601, Application for Accrued Amounts Due A Deceased Beneficiary, or VA Form 21-534EZ, Application for Dependency Indemnity Compensation, Death Pension, and/or Accrued Benefits, on behalf of the Veteran. All accrued benefit applications are forwarded by the receiving parties to the nearest VBA Regional Office for processing. A list of VBA Regional Offices can be found at: http://vbaw.vba.va.gov/ro/index.htm, or by calling 1-800-827-1000. NOTE: This is an internal VBA Web site that is not available to the public.

5. ENTITLEMENT CRITERIA: VA will pay one or more annual clothing allowance payment(s) to a Veteran: (1) Who has a service-connected disability or a disability compensable under 38 U.S.C. 1151 as if it were service-connected and (2) who meets the clinical eligibility requirements of 38 CFR 3.810. Section 3.810 provides in substance as follows:

a. One Clothing Allowance. A Veteran is entitled to one annual clothing allowance if:

(1) A VA examination or a hospital or examination report from a facility specified in section 3.326(b) establishes that the Veteran, because of a service-connected disability or disabilities due to loss or loss of use of a hand or foot compensable at a rate specified in section 3.350(a), (b), (c), (d), or (f), wears or uses one qualifying prosthetic or orthopedic appliance (including, but not limited to, a wheelchair) which tends to wear or tear clothing; or

(2) The Under Secretary for Health, or a designee, certifies that

(a) A Veteran, because of a service-connected disability or disabilities, wears or uses one qualifying prosthetic or orthopedic appliance (including, but not limited to, a wheelchair) which tends to wear or tear clothing; or

(b) A Veteran uses a skin medication prescribed by a physician for one skin condition, which is due to a service-connected disability that causes irreparable damage to the Veterans outergarments.

b. More than One Clothing Allowance. A Veteran is entitled to more than one annual clothing allowance if:

(1) Multiple types of garments are affected. A Veteran is entitled to an annual clothing allowance for each prosthetic or orthopedic appliance (including, but not limited to, a wheelchair) or skin medication used by the Veteran if each prostheses, appliance or skin medication:

(a) Satisfies the requirement of paragraph (a)(1) of section 3.810; and

(b) Affects a distinct type of article of clothing or outergarment.

(2) Single type of garment is affected. A Veteran is entitled to two annual clothing allowances if a Veteran uses more than one prosthetic or orthopedic appliance (including, but not limited to, a wheelchair), skin medication for more than one skin condition, or an prosthetic, orthopedic appliance and a skin medication, and the prostheses, orthopedic appliance(s) or skin medication(s):

(a) Each satisfies the requirements of paragraph (a)(1) of section 3.810; and

(b) Together tend to wear or tear a single type of article of clothing or irreparably damage a type of outergarment at an increased rate of damage to the clothing or outergarment due to a second orthopedic appliance or skin medication.

c. The Under Secretary for Health designee is the Prosthetic Representative. If a clinical determination is required under paragraph 6 of this Handbook, then the Under Secretary for Health designee will be the appropriate clinician (e.g., VHA clinician, Prosthetist, Orthotist, or Pharmacist). To determine that a Veteran is entitled to the allowance, the Under Secretary for Health designee must find and document that:

(1) The use of the prosthetic, orthopedic appliance, or skin medication is medically necessitated for a service-connected disability or disabilities;

(2) The prosthetic, orthopedic appliance, or skin medication meets the definition in this Handbook; and

(3) The prosthetic or orthopedic appliance tends to wear out or tear the clothing of the Veteran and/or the skin medication causes irreparable damage (e.g., permanent irreversible staining, bleeding or damage not removable with laundering or dry cleaning) to the Veteran's outergarments.

d. SeeAppendixAandexamplesofprosthetics,appliances,andskinmediations that are generally covered in paragraph 8 below.

6. CLINICAL EVALUATIONS/RE-EVALUATIONS:

a. Ifinsufficientmedicalevidenceofrecordexiststoawardtheclaim,then,aclinical review and/or physical evaluation of the prosthetic, orthopedic appliance, and/or skin medication is warranted. As part of the clinical review, the Under Secretary for Health designee will require the Veteran to provide the prosthetic, orthopedic appliance, or skin medication to assist with making an entitlement decision.

b. Thetreatingphysicianwillre-evaluatetheVeterantodeterminewhetherthe prosthetic, orthopedic appliance or skin medication is still medically necessary for their service-connected disability or disabilities. An annual re-evaluation of the Veterans prosthetic, orthopedic appliance or skin medication is recommended. NOTE: In no circumstances will the Veteran be instructed to provide any articles of clothing for clinical evaluations/reevaluations (e.g., requiring Veterans to bring in clothing to VA†medical facility). For unusual circumstances Veterans can submit pictures to certify their prescribed prosthetic or orthopedic appliance, or skin medication causes wear, tear or irreparable staining. Submission of pictures by the Veteran is considered sufficient evidence.

7. SCHEDULE OF PAYMENT:

a. PaymentoftheclothingallowanceismadeinalumpsumannuallytoVeterans when entitlement is established prior to August 1st, otherwise known as the anniversary date (anniversary dates are only August 1st). If entitlement and processing is completed before August 1st of the benefit year, VBA will release the annual clothing allowance payment(s) September 1st - October 31st of the same benefit year. Current clothing allowance rates can be found at: http://www.benefits.va.gov/COMPENSATION/special_Benefit_Allowances_2013.asp.

b. Veteranswhoareincarceratedduringtheclothingallowanceyearwillhavetheir payment prorated for each day in which the Veteran is incarcerated. NOTE: The VETSNET system prorates automatically using VBA information (CFR 3.810(d)).

c. In order to establish an anniversary date, the Veteran will have a service- connected disability prior to August 1st, prescribed and utilizing the qualifying prosthetic, orthopedic appliance, and/or skin medication. The Veteran can apply using VA Form 10-8678, Application for Annual Clothing Allowance, for that given year's benefit up to 1 year from the established anniversary date. The clothing allowance benefit year spans from August 1st to July 31st of each calendar year.

Example: A Veteran receives a service-connected rating for arthritis, for which the Veteran is prescribed a rigid knee brace that causes irreparable damage to his or her pants on May 10, 2012. Since the anniversary date is August 1, 2012, the Veteran will have until July 31, 2013 to apply for a clothing allowance for benefit year 2012.

d. If a Veteran establishes eligibility for the clothing allowance as of August 1st or later of any year, the Veteran is not entitled to any payment for that year. No amount is payable until the annual payment becomes due on the following August 1st. Likewise, a partial refund is not required if the Veterans entitlement is terminated during a period after the annual clothing allowance is furnished.

Example: A Veteran is service-connected for an ankle condition and is prescribed an orthosis on September 10, 2012. The anniversary date is August 1, 2013. The Veteran has until July 31, 2014 to apply for the 2013 annual clothing allowance, but is not eligible to receive a clothing allowance for benefit year 2012 since the anniversary date falls after the August 1st deadline.

8. PROSTHETICS, ORTHOPEDIC APPLIANCES AND SKIN MEDICATIONS: While the ultimate determination is left to the individual treating provider, the following guidance is provided:

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May 14, 2015 VHA HANDBOOK 1173.15

a. Examples of items that tend to tear and wear clothing include: Prostheses, rigid braces, ankle/foot orthosis (AFO) with hooks, rigid AFO, manual wheelchairs without clothing guards, specialized wheelchairs with sliding board/sliding transfer functionalities, and wheelchairs with positioning and posturing adaptations, crutches, wrist braces, prosthesis, rigid orthotics, service dogs, colostomy or ileostomy, cervical braces. A guide and updated listing created by the Orthotic and Prosthetic (O&P) Field Advisory Committee identifies prostheses and orthotics that may cause wear and tear to outergarments. It is available under the Clothing Allowance folder on the Prosthetic and Sensory Aids SharePoint at: http://vaww.infoshare.va.gov/sites/prosthetics/default.aspx. NOTE: This is an internal VA Web site and is not available to the public. Prostheses and orthotics not included in the guide should be reported to VHA's Rehabilitation and Prosthetics Services (10P4R). The O&P Field Advisory Committee will review the prostheses and orthotics to determine its impact on clothing. Consultation with local VHA Orthotists and Prosthetists can substitute when a prompt decision is needed. This list is updated by the O&P Field Advisory Committee on a semi-annual basis, provided new prostheses and orthotics may qualify for the clothing allowance benefit.

b. Examples of items that do not tend to tear and wear clothing include: Soft orthotics, transcutaneous electrical nerve stimulation (TENS) units, shoes, shoe inserts, non-specialized wheelchairs (sedentary/sitting purposes), scooters, canes, rollador, walkers, elastic/flexible braces, items with Velcro stays, hinged braces covered in fabric (metal stays covered), braces with plastic stays covered in fabric.

c. A guide and updated listing created by the Prosthetic and Pharmacy workgroup identifies skin medications, ointments, or lotions that may cause irreparable staining, discoloration, bleeding, and damage not removable by laundering or dry cleaning. It is available under the Clothing Allowance folder on the Prosthetic and Sensory Aids SharePoint at: http://vaww.infoshare.va.gov/sites/prosthetics/default.aspx. NOTE:
This is an internal VA Web site and is not available to the public. Skin medications not included in the guide should be reported to VHA's Rehabilitation and Prosthetics Services (10P4R). The Prosthetic and Pharmacy workgroup will review the skin medication to determine its impact on clothing. Consultation with a local VHA Pharmacist can substitute when a prompt decision is needed. This list is updated by the Prosthetic and Pharmacy workgroup on a semi-annual basis, provided any new skin medication, ointment, or lotion may qualify for the clothing allowance. Over-the-counter skin medications, ointments and lotions that are prescribed by a VHA physician are to meet the same criteria in paragraph 5 of this Handbook.

9. SYSTEM PROCEDURES:

a. WhenaVeteranratingdecisionisprocessedthatinitiallyestablishesservice- connection or entitlement to 38 U.S.C. 1151 benefits, the Veteran is informed by VBA's Veterans Service Center of potential entitlement to the clothing allowance benefit. The Veteran is instructed accordingly by the notification letter released by VBA's Veterans Service Center to apply for the clothing allowance benefit utilizing VA Form 10-8678, Application for Annual Clothing Allowance, located at: http://www.va.gov/vaforms/and submitting it to the nearest Prosthetic and Sensory Aids Service. All foreign clothing

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VHA HANDBOOK 1173.15 May 14, 2015

allowance claims are submitted by the claimant to the nearest VBA Regional Office for processing. NOTE: Multiple clothing allowances are not authorized prior to the 2012 clothing allowance cycle. The Veteran is allowed from the date of eligibility until July 31st of the following year to apply.

Example: A Veteran's service-connected disability is established on March 2, 2011. If entitled, the Veteran's clothing allowance benefit or anniversary date is August 1, 2011. The Veteran can apply any time between March 2, 2011, and July 31, 2012, for the clothing allowance benefit.

b. WhenVeteranServiceOrganizationsorpersonnelattheVAmedicalfacilityor VBA Regional Office identifies a Veteran with potential eligibility, assistance to complete the form is provided to the Veteran by completing VA Form 10-8678, Application for Annual Clothing Allowance. Once the completed application is received via mail or in person, the nearest VHA Prosthetic and Sensory Aids Service (PSAS) will process within 5 business days. *All foreign clothing allowance claims are accepted and processed at the designated VA medical facility. Documentation of all actions, favorable or unfavorable, is recorded in the Veterans electronic prosthetic record.

*South America, Central America and Mexico territories (Houston PSAS); European countries and territories (Pittsburg PSAS); and Canada and surrounding foreign territories (Denver PSAS).

c. When the Veteran applies for a clothing allowance and there is no record of a prescription for the prosthetic, orthopedic appliance and/or skin medication, an administrative review and/or physical evaluation is scheduled by the Under Secretary for Health designee prior to making a determination. The Under Secretary for Health designee, usually the Prosthetic Representative, will follow guidance in paragraph 6 on "Evaluations/Re-evaluations" of this Handbook. NOTE: Reasonable doubt is resolved in favor of the Veteran.

d. Whentheentitlementdeterminationisfavorable,theProstheticRepresentative will annotate VA Form 10-2319, Automated Date Processing (ADP), Record of Prosthetic Service, on page 6; to reflect receipt of VA Form 10-8678, as follows:

(1) Access the Add/Edit Clothing Allowance option under the PSC/Entitlement Records section of the Prosthetic and Sensory Aids Service (PSAS) official's menu. Enter the Veterans name at the prompt, and then complete the remainder of the fields beginning with the date the claim is processed by the PSAS activity.

(2) Enter the name of the Prosthetic Representative determining the clothing allowance entitlement decision. Enter appropriate identifying information at the "Clothing Allowance Description" prompt, including the appliance for which the claim is approved per the following format:

Desc: FY12 Wyatt Ointment-approved; Rt Knee Brace-approved

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May 14, 2015 VHA HANDBOOK 1173.15

e. Whenentitlementisunfavorable,annotateVAForm10-2319(ADP),Recordof Prosthetic Service, on page 6 to reflect receipt of VA Form 10-8678, as follows:

(1) Access the Add/Edit Clothing Allowance option under the PSC/Entitlement Records section of the PSAS official's menu. Enter the Veterans name at the prompt, and then complete the remainder of the fields beginning with the date the claim is processed by the PSAS activity.

(2) Enter the name of the Prosthetic Representative determining the clothing allowance entitlement decision. Enter appropriate identifying information at the "Clothing Allowance Description" prompt to include the appliance for which the claim is disapproved per the following format:

Desc: FY12 Wyatt Ointment-denial 1173.15 Sec D,e3; Rt Knee BraceĖDenial 1173.15 Sec D,e1.

(a) Appliance causing wear or tear is not worn, or skin medication causing damage is not used;

(b) Appliance not worn for service-connected condition, or skin medication not used for service-connected condition; and/or

(c) Appliance worn not medically prescribed, or skin medication used not medically prescribed; and

f. Notification letters for all determinations, favorable or unfavorable, are sent to each Veteran and, if applicable, their designated Power of Attorney. In the case of denials, a VA Form 4107, Your Rights to Appeal our Decision, will accompany all favorable and unfavorable entitlement decisions.

g. Appealsarehandledaccordingtothelocalofficialappealsprocessadministered by the Chief Business Officer and VBA's Regional Office. Boards of Veterans Appeals Handbooks/Directives are located at: http://vaww.bva.va.gov/BVA_Materials.asp. NOTE: This is an internal VA Web site and is not available to the public.

(1) No clothing allowance award is terminated, reduced or otherwise adversely affected unless the Veteran is notified of such adverse action, and is provided a period of 60 days in which to submit evidence for the purpose of showing that the adverse action is not warranted (38 CFR 3.103(b)(2)).

(2) If the Veteran does not submit any evidence to support such adverse action, then the Prosthetic Representative will terminate or reduce the clothing allowance benefit.

h. PSASisresponsiblefortheawardactionontheannualre-certificationportionof the clothing allowance benefit. However, the funding for the clothing allowance remains in the VBA benefit appropriation. The Veterans Integrated Service Network (VISN) Prosthetic Representative (VPR) coordinates the award action at the VA medical facility level and ensures all appropriate staff are trained in the procedures of processing

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VHA HANDBOOK 1173.15 May 14, 2015

payment for clothing allowance benefits in VETSNET as applicable. All training and user guides are accessible under the clothing allowance folder located on the Prosthetic and Sensory Aids Web site at: http://vaww.infoshare.va.gov/sites/prosthetics/default.aspx. NOTE: This is an internal VA Web site and is not available to the public.

10. RESPONSIBILITIES:

a. Prosthetic Representative. The Prosthetic Representative will:

(1) Review VA Form 10-8678, Application for Annual Clothing Allowance; VA Form 21-6796, Rating Decision; VA Form 10-2319, Record of Prosthetic Services, SHARE, VETSNET and other medical documentation to determine entitlement for the clothing allowance benefit;

(2) Determine entitlement, consult and notify the Veteran in writing of entitlement status whether the decision is favorable or unfavorable;

(3) Consult appropriate clinician (e.g., VHA clinician, Orthotist, Prosthetist, or Pharmacist) on clinical determinations. See paragraph 6 of this Handbook to determine when clinical evaluations/re-evaluations are warranted.

(4) Generate and/or authorize award actions using VETSNET;

(5) Record decisions in the Veterans Prosthetic Record using procedures in paragraph 9 of this Handbook; and

(6) Complete and file Statement of Case, when necessary.

b. Clothing Allowance Super Users. The Clothing Allowance Super Users (e.g., Chief of Prosthetics, Supervisory Prosthetic Representatives, Subject Matter Experts, etc.) will:

(1) Assist with identifying technical and system issues by reporting them to the PSAS and VBA's Central Offices;

(2) Assist with completing necessary paperwork for access to VETSNET;

(3) Provide refresher training at the VA medical facility and VISN levels;

(4) Partner and collaborate with VBA's Clothing Allowance Coordinators, other Clothing Allowance Super Users, and Prosthetic Representatives to streamline processes and procedures;

(5) Verify and authorize award action, if the Veteran is eligible for more than three clothing allowances; and

(6) Coordinate and collaborate with VBA's Clothing Allowance Coordinators.

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May 14, 2015 VHA HANDBOOK 1173.15 c. Veterans Benefit Administration. VBA will:

(1) Notify eligible Veterans on an annual basis on how to apply for the annual clothing allowance benefit;

(a) The anniversary date will depend on when the Veteran is notified of his or her rating decision.

(b) Each annual clothing allowance application requires eligibility on or before August 1 of the year for which payment is requested (e.g., A Veteran eligible as of July 1, 2013, is entitled to receive the 2013 clothing allowance benefit) (see Appendix B).

NOTE: (If a Veterans status is static/recurring and receives an annual clothing allowance he or she will continue to receive a recurring automatic payment without having to reapply each year. However, as of August 1, 2012, if the Veterans status is static/recurring and applies or receives more than one clothing allowance, he or she MUST RE-APPLY each year. A Veteran who applies for the first time after August 1, 2012 must APPLY on an annual basis).

(2) Designate and provide VHA's Prosthetic Representatives with updated information for all Clothing Allowance Coordinators on a semi-annual basis; and

(3) Provide resources to VHA upon request on data management, Information Technology support, and appropriation management, training, and updated User Guides.

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VHA HANDBOOK 1173.15 APPENDIX A

DETERMINING ENTITLEMENT

a. One Clothing Allowance. A clothing allowance is approved for certain Veterans who wear or use a prescribed prosthetic, orthopedic appliance, and/or skin medication and who otherwise meet the criteria in paragraph 6 of this Handbook. For example: A Veteran is prescribed and uses a right knee brace for his or her service-connected condition. The right knee brace has rigid hinges which tears the Veterans pants. This Veteran qualifies for one clothing allowance payment.

b. More Than One Clothing Allowance. Multiple clothing allowances are approved if:

(1) A Veteran uses multiple qualifying prostheses, orthopedic appliances, and skin medications each satisfy the requirements in paragraph 6 of this Handbook; each approved prostheses, orthopedic appliance and skin medication impacts a distinct outergarment, i.e., upper outergarment (shirt/blouse) and lower outergarment (pants/skirt).

Example: Veteran is a service-connected paraplegic who uses a specialized wheelchair with adaptations for posturing and positioning. The Veteran also applies a prescribed skin cream known to stain clothing. Because the wheelchair wears and frequently tears the shirt, and the skin medication stains the shirt, the Veteran qualifies for two clothing allowance payments.

(2) The qualifying prostheses, orthopedic appliances and skin medications each satisfy the requirements in paragraph 6 of this Handbook, and together tend to tear or wear or irreparably damage an outergarment, requiring replacement at a faster rate than if the outergarment is affected by a single qualifying prosthetic, orthopedic appliance or skin medication.

Example: Veteran wears a prescribed rigid elbow brace for his or her service- connected condition, which satisfies requirements in paragraph 6 of this Handbook.
The Veteran also uses a prescribed skin cream on the same arm that causes the shirt to fade at an increased rate. The Veteran qualifies for two clothing allowances payments, as both the rigid elbow brace and cream meet the requirements of paragraph 6 of this Handbook and together cause an increased rate of damage to a distinct outergarment (shirt/blouse).

Example: Veteran with paralysis due to a service-connected condition uses a specialized wheelchair adapted for sliding transfers that tears his or her upper and lower outergarments (shirts and pants). The Veteran also uses a prescribed skin cream and rigid AFO impacting his or her lower outergarments (pants) to wear out at a faster rate. The Veteran qualifies for three clothing allowance payments.

Example: Veteran is prescribed upper and lower prostheses for upper and lower amputations. A knee brace for the opposite leg of the lower prostheses is prescribed for another service-connected condition. The Veteran also is prescribed skin cream for

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VHA HANDBOOK 1173.15 May 14, 2015

irritation on the opposite arm of the upper prostheses that causes the Veterans article of clothing (shirt/blouse) to fade. The Veteran qualifies for four clothing allowance payments.

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May 14, 2015

VHA HANDBOOK 1173.15 APPENDIX B

ELIGIBILITY NOTIFICATIONS

Example: If a Veteran is notified in March 2013 that a qualifying service-connected disability rating is awarded and effective September 2011. The Veteran is allowed one year from the date of notification to apply for retroactive clothing allowance payments. If the Veteran applies for clothing allowance benefit within one year from the date of notification, then the Prosthetic Representative can go back to August 1, 2012 and pay the clothing allowance for the years 2012 and 2013.

Example: A Veteran is notified in March 2012 that he or she is awarded a qualifying service-connected disability rating effective November 2008. The Veteran is allowed one year from the date of notification to apply for retroactive clothing allowance benefit. *If the Veteran applies for the clothing allowance benefit on June 27, 2013 (not within 1 year of being notified) the clothing allowance is paid for the years 2012 and 2013.

*This is possible because the Veterans anniversary date is August 2012. The Veteran is allowed a year to file for a 2012 payment (from August 2012 to July 31, 2013). Since the Veteran filed in June 2013, this makes the Veteran eligible for 2012. The Veteran is also eligible for the 2013 payment since the Veteran applied during the allowance timeframe for 2013 (see Title 38 Code of Federal Regulations (CFR) 3.810(c).

Example: If a Veteran is notified in March 2010 that a qualifying service-connected disability rating is awarded, but the Veteran received an approved prostheses, orthopedic appliance and/or skin medication in January 2013, then the clothing allowance is paid for 2013 (August 2012 to July 2013). However, no retroactive payment from 2010-2012 is allowed as the Veteran did not receive his or her approved prosthetic, orthopedic appliance and/or skin medication until the anniversary date (August 2013).

B-1†

15.2. Authority

a. Under Title 38 United States Code (U.S.C.) 1162, the Department of Veterans Affairs (VA) must pay an annual clothing allowance to veterans if the veteran has a service-connected disability or condition, or a disability compensable under 38 U.S.C. 1151 that requires the veteran to wear or use a prosthetic or orthopedic device that wears out or tears clothing, e.g., pants, shirts, etc. (see Title 38 Code of Federal Regulations (CFR) 3.810).

b. The clothing allowance may also be paid if the veteran uses, for a service-connected skin condition, medication prescribed by a physician, which causes irreparable damage to the veteran's outer garments. NOTE: Irreparable damage does not include stains that are removable through regular laundering or dry cleaning. Approval of a claim based on use of medication requires a medical determination. A skin condition requiring use of a medication is not considered static, and a re-determination is required each year.

15.3. Scope

a. Veterans Service Center officials in the Veterans Benefits Administration (VBA) refer applications for the clothing allowance benefit to VHA in all cases, with the exception of a clothing allowance benefit as an accrued benefit after the veteran's death.

b. Certain clothing allowance claims require a determination by a Prosthetic Representative, or designated physician, when the veteran's disability appears temporary in nature or when, for other reasons, a review of the record and/or physical examination of the veteran is necessary.

c. In all cases where a review is determined to be necessary, the Prosthetic Representative, and/or designated physician, must determine that:

(1) Use of the device or skin medication is medically prescribed; and

(2) In the case of a device, such device qualifies as a prosthetic or orthopedic appliance;

(3) The device or skin medication tends to wear out, tear, or cause irreparable damage to the veteran's clothing; and

(4) The veteran actually uses the device or skin medication with sufficient consistency to wear out, tear, or cause irreparable damage to clothing. If it cannot be determined from the veteran's records that all preceding conditions have been met, an examination and/or evaluation is required.

d. The clothing allowance may be authorized for veterans who wear braces, rigid spinal braces, rigid cervical braces, or who use wheelchairs, crutches, rigid orthotics and/or ankle and/or foot orthosis (AFOs), ileostomy and colostomy appliances or similar devices, or who use certain skin medications and/or ointments.

e. Payment of the clothing allowance is made in a lump sum annually to those for whom entitlement is established as of August 1. Future annual payments are made to those who are on the rolls with established permanent or temporary entitlement on August 1 of subsequent years. These annual payments are not related to specific periods and prorated payments are not made. For example, if a veteran establishes eligibility for the clothing allowance as of any date after August 1 of any year, the claimant is not entitled to any payment for that year. No amount is payable until the annual payment becomes due on the following August 1. Likewise, a partial refund is not required should the veteran's entitlement be terminated during a period after the annual clothing allowance has been furnished, which is prior to the succeeding August 1.

15.4. Eligibility For Clothing Allowance

Eligibility for Clothing Allowance

You may receive a clothing allowance as a Veteran who uses either of the following:

  • -Prosthetic or orthopedic appliance, such as a wheelchair or crutches, because of a service-connected disability (Note: soft and flexible devices, such as an elastic stocking, are not included)
  • -Medication prescribed by a physician for a service-connected skin condition that causes permanent stains or otherwise damages outer garments

Additional clothing allowances may be provided if more than one prosthetic or orthopedic appliance, or medication described above, is used and/or affects more than one type of clothing garment.

15.5. Procedures

a. When a rating decision is processed which initially establishes service connection, and the patient, because of a service-connected disability, wears or uses a prosthetic or orthotic appliance, the veteran must be informed of potential eligibility for the clothing allowance by the Veterans Service Center. The veteran is instructed to apply for the clothing allowance benefit at a VHA health care facility utilizing VA Form 10-8678, Application for Annual Clothing Allowance, and submitting it to the nearest VHA health care facility.

b. When other veterans with potential eligibility are identified by Prosthetic Representatives at VHA health care facilities, assistance must be provided to the claimant after VA Form 10- 8678 is completed. The completed application will be processed at the health care facility. Documentation of all actions, favorable or unfavorable, will be recorded in the patient's Computerized Patient Record System (CPRS) record.

c. Annotate VA Form 10-2319 (ADP), Record of Prosthetic Service, on page 3 to reflect receipt of VA Form 10-8678, as follows:

(1) Access the Add/Edit Clothing Allowance option under the PSC/Entitlement Records section of the Prosthetic official's menu.

(2) Enter the patient's name at the prompt, and then complete the remainder of the fields beginning with the date the claim was processed by the Prosthetic activity.

(3) Enter the name of the person performing the clothing allowance examination.

(4) Enter appropriate identifying information at the "Clothing Allowance Description" prompt, including the appliance for which the claim was made.

(5) When entitlement is not recommended, indicate one or more of the following at the "Clothing Allowance Description" prompt:

(a) Appliance causing wear or tear is not worn, or medication causing damage is not used;

(b) Appliance not worn for service connected condition, or medication not used for service connected condition;

(c) Appliance worn, not medically prescribed, or medication used not medically prescribed.

d. Notification letters for all determinations made must be sent to each veteran and their designated power of attorney. This includes denials.

e. When the veteran certifies use of an appliance and/or medication which damages clothing and there is no record of VA issue, a physical examination needs to be scheduled prior to a recommendation for denial of entitlement. In determining whether these devices and/or medications tend to damage clothing, each individual application is to be considered on the objective findings of the case; this may include a medical examination and an inspection and evaluation of the device(s) claimed to cause damage to the clothing. Staff must ensure that they do not routinely require the production of worn or torn clothing. NOTE: Reasonable doubt should be resolved in favor of the veteran.

f. Appeals must be handled according to the official appeals process administered by the facility Chief Business Officer.

g. VHA Prosthetic and Sensory Aids Service is responsible for the award action on the annual re-certification portion of the Clothing Allowance benefit. However, the funding for the Clothing Allowance remains in the VBA benefit appropriation. The Veterans Integrated Service Network (VISN) Prosthetic Representative (VPR) coordinates the award action at the facility level and ensures all appropriate staffs have been trained in the procedures of processing payment for clothing allowance benefits in VBA's Benefits Delivery Network (BDN). NOTE: All training and user manuals can be located on the prosthetic website at: http://vaww.va.gov/prosthetics .

h. Authorization of a clothing allowance to a veteran, who is in receipt of military retired pay and for whom an active master record does not exist, must be made each year for the current annual payment. If continuing eligibility has been established, payment of the next and succeeding annual clothing allowance payment may be made without re-determination of eligibility. For non-static disabilities, reapplication, using VA Form 10-8678, is required for each subsequent annual payment. NOTE: Veterans Service Center officials have been instructed to verify addresses in cases involving continuing eligibility on, or about, August 1 of each year through individual communication.

i. Veterans rated as service connected and determined to be eligible on a continuing basis (per 38 CFR 3.810(a)(1)) for loss of use (at a rate specified in 38 CFR 3.350(a),(b),(c),(d), or (f)(1)), are not required to reapply. Their clothing allowance is included in the automated payment process; this, however, does not preclude the possibility of future recertification as to the wear or use of the appliance.

j. Veterans whose determination, completed at a VHA facility, states "the condition requiring use of such device is not static," are required to reapply at the local VHA facility on an annual basis prior to August 1 of each year.

16. VA Handbook 1173.16 - Driver Rehabilitation for Veterans with Disabilities Program

16.1. Purpose

Veterans and members of the Armed Forces with disabilities are entitled to have the opportunity to learn to drive a motorized vehicle on the Nation's public highways. Depending upon the severity of the disability and the available adaptive equipment designed for utilization in today's motor vehicles, the disabled individual should enjoy the independence and freedom of mobility offered all citizens. This Veterans Health Administration (VHA) Handbook provides procedures for all matters regarding the Driver Rehabilitation Program for Veterans with disabilities and establishes guidelines for these procedures.

16.2. Authority

a. Public Law (P.L.) 93-538, signed December 1974, mandated VA to provide opportunities for driver education and training for all eligible Veterans with disabilities and certain military personnel.

b. Title 38 United States Code (U.S.C.) Section 3903(e) authorizes driver training activity in VA. It directs that:

(1) The Secretary shall provide, directly or by contract, for the conduct of special driver training courses at every hospital and, where appropriate, at regional offices and other medical facilities, of the Department to instruct such eligible person to operate the type of automobile or other conveyance such person wishes to obtain with assistance under this chapter, and may make such courses available to any Veteran, eligible for care under chapter 17 of this title or member of the Armed Forces, who is determined by the Secretary to need the special training provided in such courses even though such Veteran or member is not eligible for the assistance provided under this chapter. (38 U.S.C. 3903(e)(1)).

(2) The Secretary is authorized to obtain insurance on automobiles and other conveyances used in conducting the special driver training courses provided under this subsection and to obtain, at Government expense, personal liability and property damage insurance for all persons taking such courses without regard to whether such persons are taking the course on an in-patient or out-patient basis. (38 U.S.C. 3903(e)(2)).

(3) Notwithstanding any other provision of law, the Secretary may obtain, by purchase, lease, gift, or otherwise, any automobile, motor vehicle, or other conveyance deemed necessary to carry out the purposes of this subsection, and may sell, assign, transfer, or convey any such automobile, vehicle, or conveyance to which the Department obtains title for such price and upon such terms as the Secretary deems appropriate; and any proceeds received from any such disposition shall be credited to the applicable Department appropriation. (38 U.S.C. 3903 (e)(3)).

16.3. Definition

Driver rehabilitation for the disabled, within the Department of Veterans Affairs (VA), is defined as: a Professional Services Medical Training Program designed to provide professional evaluation and instruction for eligible Veterans in the safe, competent utilization of special add- on equipment, and mastery of specific skills and techniques to effectively drive a motor vehicle, independently, and in accordance with State Department of Motor Vehicles (DMV) regulations.

16.4. Scope

a. Driver rehabilitation provides Veterans with disabilities (inpatients or outpatients in accordance with P. L. 93-538) appropriate assistance in acquiring skills that make it possible for them to qualify to drive their own vehicles.

(1) Evaluation and assessment are provided to eligible patients having a variety of limiting physical and mental disabilities, whether chronic or progressive-degenerative.

(2) Patients referred to the VA's Driver Rehabilitation Program suffer from a wide range of physical and mental disabilities. Basic instructional techniques in driver education and training are common in many disabilities. Specific and isolated disabilities could require special evaluation and adaptations; i.e., C4 or C5 tetraplegia or triplegia. The multi-modal evaluation and training program is necessitated by those disabilities which are not common to the conventional norm of the disabled population; i.e., Veterans with disabilities using very sophisticated vehicles or training equipment.

b. The program provides assistance in the selection of an appropriate vehicle and equipment for the Veteran with disabilities;thereby increasing mobility and allowing the individual the opportunity to independently enter the mainstream of society.

c. Evaluation and consultative services are provided to Veterans with severe disabilities and family/caregivers who require special considerations to safely ride as a passenger, including ingress and egress of the individual's private vehicle.

16.5. Objectives

a. The objectives of this Handbook are to:

(1) Acquaint VA medical facilities with basic information on the operation, application, and procedures involved in the VA Driver Rehabilitation Program.

(2) Provide general and specific guidance to designated driver rehabilitation specialists and to members of the medical facility's administrative and supporting staff regarding the purpose, scope, procedures, and technicalities of VA's comprehensive Driver Rehabilitation Program for Veterans with disabilities.

b. To further the full implementation of this program, VA has:

(1) Established approximately 45 driver training facilities for Veterans with disabilities throughout the United States;

(2) Purchased specially equipped vehicles;

(3) Designated, funded, and trained driver rehabilitation specialists;

(4) Authorized, purchased, and installed add-on adaptive equipment; and

(5) Purchased sophisticated training equipment (e.g., simulators, high-tech driving systems, etc.)

16.6. Responsibilities of the PM&R National Program Director

The PM&RS National Program Director is responsible for:

a. Developing national policy and procedures for Drivers Rehabilitation programs based on relevant laws, regulations and VA's mission, goals and objectives.

b. Providing consultation and guidance to Veterans Integrated Service Networks (VISNs) and VA medical facilities that have Driver Rehabilitation programs.

c. Reviewing and submitting Driver Rehabilitation National program reports.

d. Ensuring liability insurance contract is in place for the Driver Rehabilitation program.

e. Appointing a VA Field Advisor who is responsible for advising VHA Central Office on new techniques and equipment relating to driver rehabilitation; educational needs of the driving rehabilitation specialists; problem areas involved in teaching the disabled individual; and all pertinent information which will assist VHA Central Office's administrative officials in maintaining adequate background knowledge of this specialty area and when directed, act for or represent VHA Central Office program officials at meetings, conferences, and/or work groups.

16.7. Responsibilities of the VISN Director

Each VISN Director is responsible for ensuring Driver Rehabilitation programs are conducted in compliance with relevant Public Laws, regulations, and VHA policy and procedures.

16.8. Responsibilities of the Facility Director

Each Facility Director, or designee, that has a Driver Rehabilitation program is responsible for:

a. Providing and maintaining program oversight to ensure quality services and compliance with VHA policy and procedures.

b. Ensuring adequate resources are devoted to the program including, Full Time Equivalent (FTE), space, equipment, repairs, education needs, travel needs and other recourses necessary to maintain the program.

c. Ensuring accurate and reliable program data is captured and forwarded to appropriate authority.

16.9. Responsibilities of the Chief, PM&R or Appropriate care Line Manager

The Driver Rehabilitation Program is under the professional direction of the Chief, Physical Medicine and Rehabilitation Service (PM&RS), or appropriate care line manager. Technical direction and supervision are the responsibility of the Chief, PM&RS, or designee, the appropriate section supervisor under which the Driver Rehabilitation Program is assigned, and/or the qualified rehabilitation specialist. The Chief PM&R or Designee is responsible for:

a. Promoting, advocating and supporting the Drivers training program to top management in the areas of FTE, space, equipment, repairs, education needs, travel needs and other resources necessary to maintain the program.

b. Designating a qualified individual as the primary driver rehabilitation specialist (instructor).

c. Designating a qualified individual as the alternate driver rehabilitation specialist. The alternate specialist may be responsible for assuming driver rehabilitation responsibilities in the absence of the primary specialist, or may provide only part-time duty to this program. Alternate driver rehabilitation specialists must have completed the VA Driver Rehabilitation Instructor's Training Course prior to assuming the driver rehabilitation specialist duties and responsibilities.

NOTE: It is important that this program be active on a continuing basis so that patients are treated without interruption.

16.10. Responsibilities of the Driver Rehabilitation Specialist(s)

The primary and/or alternate driver rehabilitation specialist is responsible for:

a. Initiating driver rehabilitation program tasks;

b. Assigning the workloads;

c. Assisting in the evaluation and selection of additional driver rehabilitation specialist(s);

d. Recommending appropriate equipment and supplies;

e. Supervising maintenance of the equipment;

f. Taking precautions to ensure that the vehicle is secure; and

g. Submitting any necessary reports requested by medical facility management and/or VHA Central Office. NOTE: Performance requirements must be developed and published as part of each instructor's annual performance appraisal.

16.11. Other Guidance

a. Rotation of Instructors. Rotation (planned, periodic type) of instructors is believed to be highly detrimental to the success and quality of VA's Driver Rehabilitation Program. A considerable amount of money and training time is invested in preparing the designated instructors for this role within PM&RS. The product of this training (as the qualified driver rehabilitation specialist) must demonstrate unique abilities, attitudes, and capabilities in order to provide the highest quality of service in driver rehabilitation to the Veteran. The skills, psychological adjustment, teaching expertise, and tools utilized by the therapist in driver rehabilitation are different from those attributes needed in other treatment areas, and cannot be readily acquired.

b. Education. In addition to the basic qualifications required for the driver rehabilitation specialist, the following educational experiences are offered:

(1) Instructor Training Facility. The VA Medical Facility Long Beach, CA, has been designated as the primary training facility for newly appointed driver rehabilitation instructors. The National Director, PM&R Program Office, may designate an additional training site, as necessary to meet VA's need for training new instructors. A minimum of one 2-week training program must be provided each year in collaboration with the assigned VA Employee Education Resource Facility (see Appendix. C).

(2) Mandatory. All primary and alternate instructors must receive a minimum of 2 weeks of instruction in a VA Central Office approved Driver Rehabilitation Specialists Trainee (DRST) (one time only) course, provided in collaboration with the assigned VA Employee Education Resource Facility prior to assuming responsibilities for the Driver Rehabilitation Program.

(3) Continuing Education. PM&RS VHA Central Office promotes the provision of workshops, seminars, and/or educational conferences for all active specialists; this includes training in special skill areas as simulation and vehicle modification. NOTE: If VHA Central Office support is not available, or specifically appropriate for continuing education needs, contact the facility ACOS for Education.

(4) Procedures. Primary and alternate instructors, or their supervisors, must be contacted prior to scheduling for VHA Central Office sponsored training. Travel, per diem, and tuition costs are the responsibility of the local facility or VISN.

c. Business Office

(1) Initial staffing, annual operational fund, and equipment were centrally funded in 1976 and became part of each designated driver rehabilitation center's recurring budget base in 1979. Since that time centers have been expected to cover all future medical care requirements of this program.

(2) Local medical care and equipment funds may be used for:

(a) Purchase and/or replacement of driver rehabilitation vehicles (automobiles, vans, etc.) which are approved by the Under Secretary for Health and which meet the current standards (see Para. 13).

(b) Purchase of add-on adaptive equipment for installation in, or on, the vehicles.

(c) Purchase of simulators for training purposes.

(d) Costs of repair and maintenance of vehicles and other driving rehabilitation equipment used in conducting the program.

(e) Purchase of special equipment to be used for demonstrations at VHA Central Office, or medical facilities.

(f) Per diem and travel for new driver rehabilitation instructor candidates to attend a required 2-week VA Instructor's Training Course prior to assuming program responsibilities.

(g) Cost of transporting vehicles from one site to another when it involves contracting with a transport company. NOTE: Facility travel funds must be used if a VA employee is required to drive the vehicle.

(h) Coverage of non-VA consultants for program review, attendance at conferences, etc., must be covered by contract.

d. Supporting Services

(1) Clinical support of the Driver Rehabilitation Program needs to be available from various services in the host Medical Facility. Educational efforts need to be coordinated though the Associate Chief of Staff for Education. Likewise, additional clinical support needs to be solicited from Audiology and Speech Pathology Service, Neurology Service, Nursing Service, Ophthalmology/Optometry Service, Pharmacy Service, Prosthetic and Sensory Aids Service, Psychiatry and Psychology Services, and Spinal Cord Injury Service. Any or all these services can provide valuable input to assist the Driver Training Instructor in obtaining more detailed assessment, and in planning an individualized plan of care for a Veteran enrolled in the program.

(2) Administrative services also play a key role in the success of the program. Services such as Engineering/Facilities Management, Fiscal/Business Office, and Office of Acquisition and Logistics (OAL) are integral in ensuring that the resources are available for the program, and that the equipment is maintained and available for the program. Additional support may be needed in eligibility determination and in transferring of patients from one facility to another if Driver Training Services are not available. (See VHA Handbook 1601B.05.)

e. Professional Organizations. Certain professional and service organizations can provide support, guidance, and assistance in the administration of local Driver Rehabilitation Programs. Identification of these groups is appropriate and each driver rehabilitation specialist needs to make an effort to utilize such resources. These organizations include, but are not limited to:

(1) American Driver and Traffic Safety Education Association (ADTSEA) and the State affiliates.

(2) The Association of Driver Rehabilitation Specialists (ADED), formerly known as the Association of Driver Educators for the Disabled.

(3) American Automobile Association (AAA).

(4) American Congress of Rehabilitation Medicine (ACRM).

(5) American Kinesiotherapy Association (AKTA).

(6) American Occupational Therapy Association (AOTA).

(7) American Optometric Association (AOA).

(8) American Physical Therapy Association (APTA).

(9) Society of Automotive Engineers.

f. Other Federal and Local Organizations. Some Federal agencies and local rehabilitation centers, etc., involved in activities relating to driver rehabilitation of the disabled include the:

(1) National Highway Traffic Safety Administration of the Department of Transportation (NHTSA).

(2) Rehabilitation Services Administration of the Department of Education Resources.

(3) Transportation Research Board, a division of the National Research Council.

(4) National Mobility Equipment Dealers Association.

g. Safety Performance Standards. Safety Performance Standards for the conduct of VA's Driver Rehabilitation Program must be developed and published as part of each driver rehabilitation specialist's annual performance appraisal.

h. Public Information. The Drivers Rehabilitation Specialist and other key leadership staff need to ensure that eligible Veterans are aware of the existence of the program and the referral mechanisms needed for enrollment.

i. Study and Research. Research activities in Driver Rehabilitation Programs for the disabled are encouraged. Driver Rehabilitation Programs are dynamic and are constantly evolving, thus requiring constant updating, evaluation, and supportive data. NOTE: Competent proposals for study and/or research must be reviewed for approval and possible funding by the Coordinator, VA Driver Rehabilitation Program, VHA Central Office and by Rehabilitation Research and Development (122). Research and other forms of independent study are important avenues of improving local programs and providing additional visibility to driver rehabilitation activities, and they need to be supported at all VA driver rehabilitation centers. NOTE: These studies are to be conducted with the approval of the local Research and Development (R&D) Committee and coordinated through the local ACOS for R&D.

j. Statistical Reports

(1) The gathering and accumulation of data in the Driver Rehabilitation Program are important and must be stressed in the program's overall operation.

(a) This information permits local administrators and VHA Central Office to justify staffing, equipment, and other program needs to higher authority.

(b) These statistics help in the development of standards-productivity, staffing, operations, and program utilization.

(2) VA Form 10-4790 the Annual Report on Driver Training (RCS 10-0099), available at http://vaww.va.gov/vaforms, (This is an internal web site not available to the public) must be completed and forwarded electronically to PM&RS VHA Central Office (117), no later than October 31. NOTE: Further clarification and information may be received by contacting the Coordinator of Driver Rehabilitation in VHA Central Office (117).

16.12. Staffing Qualifications

Designated primary and alternate driver rehabilitation specialists must be Kinesiotherapists, Occupational Therapists or Physical Therapists, who are licensed, registered, or certified by their respective professional organizations. Candidates must have a minimum of a Baccalaureate Degree in kinesiotherapy, physical therapy, occupational therapy, or a specifically related rehabilitation therapy area. Appropriate referrals need to be initiated by the driver rehabilitation specialist to other services for more detailed evaluations, as indicated (i.e., cognitive assessment, neuro-sensory evaluation, visual examination, etc.). All therapists designated as instructors must receive the special 2-week course, "Driver Rehabilitation Instructor Training Course," sponsored by VHA Central Office and the Employee Education Service. NOTE: Additional university credentials, State certification and/or successful completion of the National Driver Rehabilitation Specialist Examination sponsored by Association for Driver Rehabilitation Specialists (ADED), formerly known as the Association for Driver Educators for the Disabled, is encouraged.

(1) The individual driver rehabilitation specialist must possess:

(a) Special abilities and technical skills, related to the provision of driver rehabilitation services;

(b) A medical rehabilitation background;

(c) Knowledge of residuals of traumatic and non-traumatic disabilities; and

(d) Special experience in order to evaluate and determine physical limitations of the Veteran with disabilities and the following modalities; i.e., hand controls, lifts, specialty adaptive driving systems, etc.

(2) The individual driver rehabilitation specialist must maintain a current knowledge of:

(a) Technological advances in adaptive equipment and high-tech driving systems;

(b) Changes in automotive design; and

(c) Other factors which may influence an individual's capacity to safely operate a motor vehicle.

16.13. Equipment

New or replacement vehicles must be processed through the facility equipment replacement program. These replacement vehicles can be either medium-sized or full-sized automobiles, or mini or full-size vans to accommodate the veteran trainee with more severe disabilities. Selection of the type and size of vehicle is determined locally, based on need and previous history of training and disability types. Each medical facility Director has the discretion to replace the current automobile or van. Reusable portions of add-on adaptive equipment may be retained for installation in, or on, the new vehicle. If funding is available and justification of the need to replace the present vehicle(s) can be provided, documentation must be submitted to the local OAL Officer utilizing the appropriate Integrated Funds Distribution, Control Point Activity, Accounting and Procurement Package (IFCAP) equipment replacement procedures, or as prescribed by existing VA policy.

a. Vehicles

NOTE: The following specifications, current at the time of issuance of this Handbook, are subject to change due to changes in vehicle design and technological advances. Specific needs will, for the most part, be left to the discretion of the local driver rehabilitation center programs officials.

(1) Automobiles. The basic automobile utilized in driver rehabilitation may be a mid-size or full-size two-door or four-door sedan. The following specifications are suggested:

(a) Color-keyed carpeting, windshield washer and wipers, heater, courtesy lights, lamps and switches, clock, and all other equipment customarily furnished.

(b) Automatic transmission.

(c) Power-locked doors.

(d) Power windows, power steering, and power brakes.

(e) Electric outside mirrors.

(f) Air-conditioning.

(g) Tilt-adjustable steering wheel.

(h) Split-bench front seat with individual controls for six-way power movement.

(i) Deicer and defogger on the rear window.

(j) Belts; i.e., for shoulder, chest, and lap.

(k) AM-FM radio.

(l) State of California emission controls on all vehicles issued in that State.

(m) Suggested optional equipment includes: rear window wiper, vinyl or leather upholstery, remote keyless entry, remote starting, heavy duty battery and alternator to accommodate large lift systems and a special electronic package, and free delivery (free on board (FOB)) to destination, i.e., to the nearest dealer who prepares the automobile for driveway delivery.

(2) Full-size Vans. Full-size vans require:

(a) Full-size windows;

(b) A V-8 engine with handling and towing package, which meet National Highway Traffic Safety Administration (NHTSA) specification for gross motor vehicle weight capacity;

(c) Automatic transmission;

(d) A sliding side or side cargo door;

(e) Cruise control;

(f) High-capacity air conditioning;

(g) Tilt-steering wheel;

(h) Power steering;

(i) Power windows;

(j) Power brakes;

(k) Power-door locks;

(l) Power-outside mirrors;

(m) AM and FM stereo; and

(n) A conversion package.

(3) Mini-vans. Mini-vans require:

(a) Full-size windows;

(b) A V-6 engine;

(c) Automatic transmission;

(d) A Sliding-side door;

(e) Cruise control;

(f) Three-zone climate-control air conditioning;

(g) Tilt-steering wheel;

(h) Power windows;

(i) Power brakes;

(j) Power-door locks;

(k) Power-outside mirrors;

(l). AM and FM stereo; and

(m) Accommodations for a drop-floor, ramp-kneeling system which meet NHTSA gross motor vehicle weight capacity.

(4) Maintenance and Repair. Routine vehicle servicing is mandatory. All maintenance and repair work on the driver rehabilitation automobile is the responsibility of the VA medical facility. Arrangements may be made with the medical facility's Engineering Service to maintain the vehicle at its peak performance. If Engineering Service does not keep current maintenance records on the vehicle, it is the responsibility of the driver rehabilitation specialist to maintain an up-to-date, legible, and complete service maintenance record on each vehicle assigned to the program. NOTE: As result of recent surveys for accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Joint Commission (TJC), the PM&RS Program Office recommends a weekly maintenance schedule be maintained with the vehicle.

(5) Government Services Administration (GSA) Credit Card. It is suggested that a GSA credit card be issued and utilized to expedite vehicle servicing. Major repairs or maintenance costs may be requested and approved under local VA policy.

(6) Selection of Vehicles for Client. The driver rehabilitation specialist is responsible for advising the patient about the types of vehicles appropriate for the Veteran's accessibility and equipment needs.

(7) Parking Space. Parking sites for the driver rehabilitation vehicles must receive priority rating at all facilities having Driving Rehabilitation Programs. Parking sites must be immediately accessible to the classroom or clinical area in which the patient receives appropriate pre-driving instruction. Efforts need to be made to have adequate room for egress and ingress for the disabled trainee on both sides of the vehicle, and in case of a van, adequate room must be maintained at the sides and rear for wheelchair lift systems.

(8) Security

(a) When not in use, the Driver Training Vehicle must be kept in a secure location and adequate precautionary measures need to be in place such as security checks provided by Medical Facility Security.

(b) Any damage or loss must be reported to OAL Service (90), in accordance with VA Handbook 7002.

(9) Insurance. To ensure that adequate liability coverage is provided enrolled driver trainees, an annual commercial automotive liability insurance contract has been established to automatically cover all designated driver rehabilitation vehicles, including leased vehicles at any VA medical facility in which an approved Driver Rehabilitation Program is functioning. Coverage under the contract is for personal liability and property damage. All changes in driver rehabilitation vehicle inventory must be immediately reported to the PM&R Program Office to ensure the applicable vehicles are added, or removed, from the national insurance contract. When the enrolled driver trainee is personally injured during the course of VA-sponsored training, a claim for medical care may be filed with VA. NOTE: Information on specific insurance claims may be received by contacting PM&RS VHA Central Office staff (117), or VHA Fleet Management Office.

(10) Safety. All rules for the safe operation and maintenance of the driver rehabilitation vehicle are to be based on Federal and State laws and regulations governing the area in which the vehicle is operating. Local policies regarding emergency procedures and protocols must be available in the driver rehabilitation vehicle at all times.

(11) Transfer of Vehicle. Transfers of driver rehabilitation vehicles from one driver rehabilitation center to another is authorized, initiated, and coordinated by the sending facility with notification to PM&RS VHA Central Office staff (117). Transfers of vehicles must be coordinated through the Chief, OAL, at both the losing and gaining facilities.

(12) Loaned Vehicle. Using driver rehabilitation vehicles on a loan basis from an automobile dealership is discouraged; however, such practice is permissible under certain conditions. Most importantly, the dealer needs to provide adequate and documented proof that the vehicle is insured by the dealer. VA cannot accept responsibility of providing comprehensive insurance on a loaned vehicle. If acceptable, the loaned vehicle needs to be used as a supplemental training vehicle for the VA-issued, or purchased vehicle, and not as a replacement. The loaned vehicle must meet the specifications and standards maintained by VA for use as a driver rehabilitation vehicle and needs to be used for driver rehabilitation purposes only. NOTE: Loaned vehicles and/or equipment must be reported to the Chief, OAL.

(13) Restriction in Use of Driver Rehabilitation Vehicle. Use of vehicles purchased and leased for the VA Driver Rehabilitation Program for purposes other than driver rehabilitation is strictly discouraged. VA Driver Rehabilitation Program vehicles shall be used only for official purposes and use of the vehicle for driver rehabilitation purposes must take precedence over any other need. Family members of persons being trained in the driver rehabilitation vehicle may not drive or ride in the training vehicle. It is permissible, for VA employees to ride in the vehicle for evaluation, orientation, or teaching purposes; clinical training students in the allied health disciplines who have VA appointments may ride in the vehicle, as long as such involvement is undertaken within a phase of their active clinical internship. For safety precautions, the adaptive equipment must not be utilized by unauthorized personnel or untrained VA employees; the inappropriate use of such equipment may pose a safety hazard to non-disabled operators and is strictly prohibited.

(14) First Aid Kits, Fracture Splints, and Road Emergency Kits. Automobiles used in driver rehabilitation must be equipped with first-aid kits, universal precaution packages, fracture splints, and road emergency kits (safety triangles, booster cable, etc.).

(15) Telephone. Cellular telephones are mandated. A global-positioning system (GPS) may also be purchased and is highly recommended. Specific approval and licensing must be processed through the local telecommunication office.

b. Adaptive Equipment for Driver Rehabilitation Vehicles

(1) Adaptive Equipment for Automobiles. Adaptive equipment, which is to be purchased by the medical facility for installation, must include the following:

(a) Hand control (reversible) with optional dimmer switch and horn button;

(b) Ignition key adapter;

(c) Dimmer switch on steering column;

(d) Transfer bar inside (portable);

(e) Steering devices (spinner knob, v-grip, tri-pin, and amputee ring);

(f) Assorted safety belts;

(g) Panavision rear view mirrors;

(h) Parking brake extension;

(i) Left-foot gas pedal;

(j) Right-turn signal adapter;

(k) Shift lever extension;

(l) Spinner mount receivers for various assistive devices;

(m) Driver training sign;

(n) Slide boards-varied designs;

(o) Instructor braking system;

(p) Instructor rear view mirror; and

(q) Instructor eye-check mirror.

(2) Van Modification and Adaptive Equipment. Van modification and adaptive equipment must include:

(a) Power doors and switches in the steering area and right rear fender;

(b) A side-mount lift and/or side-ramp system;

(c) A dropped-floor with leveling and appropriate wheelchair flooring;

(d) A raised roof with structural support and insulation (a full-size van must have, in addition, a headliner);

(e) A removable 6-way power transfer seat base;

(f) An occupant-restraint system with wheelchair tie-down system in the driver station;

(g) An occupant-restraint system with wheelchair tie-down in the passenger area;

(h) A variable steering and braking system with backup;

(i) An extended-steering column, as applicable;

(j) A key extension;

(k) An electric emergency brake;

(l) A dual back-up battery system;

(m) Hand control (reversible) with dimmer switch and horn button;

(n) Spinner mount receivers for various assistive devices;

(o) Steering devices such as: spinner knob, v-grip, tri-pin, and amputee ring;

(p) An instructor and/or dual steering system for high-tech driving systems;

(q) An instructor and/or dual braking system;

(r) A turn signal extension;

(s) A gear shift extension;

(t) A secondary control system for high-tech driving systems, e.g., touch-pad, voice- activated system, etc.;

(u) An instructor rear-view mirror; and

(v) An instructor eye-check mirror.

(3) Maintenance and Safety. Routine maintenance and weekly safety checks of all adaptive equipment must be scheduled and documented. Driver rehabilitation specialists need to be able to identify the operational defects of the adaptive equipment; other specialists such as medical facility engineers, vendors, and the manufacturing representatives of the equipment, may be consulted. A copy of the safety policies and procedures must be maintained in the vehicle at all times.

(4) Program Guide on Adaptive Equipment. VHA Handbook 1173.4, Automobile Adaptive Equipment Program, is available on-line at VHA Publications web site (http://www1.va.gov/vhapublications/) for the use of all VA medical facilities having an official designated Driver Rehabilitation Program.

c. Clinical Evaluation for Adaptive Equipment. The following areas of clinical evaluation are defined.

(1) Vision. Portable vision devices provide an evaluation of certain vision factors necessary to perform a safe driving task. Equipment must be available to measure the following: visual acuity, color perception, field of vision, depth perception, glare recovery, and night vision.

(2) Reaction Time. A device is used to measure reaction time from acceleration to braking.

(3) Cognitive and Perceptional Screening. In screening of basic cognitive and perceptional motor materials, identification and/or verification of a potential problem must be referred to the appropriate professional for a more in-depth evaluation.

(4) Neuromotor Assessment. This is a physical assessment of range of motion, strength, sensation, coordination, and endurance.

d. Simulation Equipment

(1) Utilization. Simulators create a classroom driving situation, which duplicates the visual, aural, and biomechanical environment of driving without motion. The simulator increases the number of patients who can be trained by providing driving experience in a classroom setting. It is an important tool in evaluating and determining the physical and mental capabilities of all types of disabled patients.

(2) Training. At the time of purchase of a simulator, a minimum of 1 full day of training must be incorporated into the purchase order. Driver rehabilitation specialists must be totally familiar with operation and maintenance of the simulator, as well as how the equipment can be incorporated into the training program for disabled drivers. NOTE: Before purchasing a simulator, the Office of the Director, PM&RS, VA Central Office, needs to be consulted.

(3) Space. It is recommended that a single room, measuring approximately 18' by 16,' needs to be provided for projection-type simulator training at a driver rehabilitation center.

16.14. Driver Rehabilitation Program Procedures

a. Procedures

(1) Referrals for driver evaluation must be received from the physician or service most knowledgeable of the patient's physical and mental problem(s).

(2) Veterans referred for driver rehabilitation, who are not involved with a rehabilitation treatment team, should be considered for a team-based comprehensive rehabilitation needs assessment due to the likelihood of having other physical, behavioral, or functional problems that may need to be addressed.

(3) Treatment may be terminated if the patient is using illegal substances, abusing prescription medication, or consuming alcohol at risky levels. If treatment is terminated because of alcohol or drug problems, the patient should be referred to the VHA Substance Use Disorder Program. The patient may be re-admitted to the Driver Rehabilitation Program only after written certification by the Substance Use Disorder Program manager that the patient no longer constitutes a likely safety risk due to use of drugs or alcohol.

(4) Termination from the Driver Rehabilitation Program, other than for medical reasons, before successful completion of the program will be based upon professional judgment of the driver rehabilitation specialist.

(5) Final determination of patient's capacity to drive and be licensed rests with the appropriate State licensing agency.

b. Determining Eligibility for Driver Rehabilitation

(1) "Eligible Person." For the purposes of this Handbook, the term "eligible person", according to 38 U.S.C. 3901, means:

(a) Any veteran entitled to compensation under chapter 11 of this title for any of the disabilities described in subparagraph 1., 2., or 3. below, if the disability is the result of an injury incurred or disease contracted in or aggravated by active military, naval, or air service:

1. The loss or permanent loss of use of one or both feet;

2. The loss or permanent loss of use of one or both hands;

3. The permanent impairment of vision of both eyes of the following status: central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than twenty degrees in the better eye; or NOTE: Permanent impairment of vision in both eyes, as described in this subparagraph, ordinarily will rule out special driver rehabilitation. It is necessary, that each visually-impaired applicant be separately evaluated since certain vision impairments, as field defects, may not bar participants. Some States will issue a drivers license to wearers of spectacle mounted telescopes that correct vision to 20/40 or better)

(b) Any member of the Armed Forces serving on active duty who is suffering from any disability described in subparagraph 1., 2., or 3. of subparagraph. (a) of this paragraph if such disability is the result of an injury incurred or disease contracted in or aggravated by active military, naval, or air service.

(2) Additional Persons Able to Receive Driver Rehabilitation Training

(a) Any veteran eligible for medical care under 38 U.S.C. Chapter 17, and any member of the Armed Forces who is determined by the VA to need this special driver rehabilitation, even though such Veteran and member are not eligible for financial assistance in the purchase of an automobile or other conveyance under 38 U.S.C. Chapter 39.

(b) Any non-veteran referred as part of an authorized sharing agreement under authority of VHA Directive 1660.1, as described in preceding subparagraph 14b.

(3) Other Participation Criteria

(a) The patient must be eligible for a valid State permit or license.

(b) The patient must be willing to release medical information to the State in accordance with individual Department of Motor Vehicles (DMV) policy.

(c) The patient must not have used illegal substances in the past 45 days and must be in compliance with local state law and vehicle codes regarding operation of a motor vehicle. NOTE: The ultimate goal of the Driver Rehabilitation Program is to return the Veteran back to full driving with appropriate modifications to the vehicle. The program cannot make a legal determination as to whether a Veteran with a progressive disorder can safely operate a motor vehicle. The determination of whether someone should maintain their driver's license is the responsibility of the state in which they reside. Appropriate mechanisms should be developed to refer patients with progressive disorders such as dementia directly to the state for assessment.

c. Referral

(1) The Electronic Consultation Form must be used. A request for "Evaluation for Driver Rehabilitation" from the primary care or attending physician must be sent through the PM&RS, or appropriate care line. Driver rehabilitation services may be provided to inpatients and outpatients, although it is anticipated that the majority will be on outpatient status during training. NOTE: PM&RS evaluates each applicant and accepts only those candidates for training who meet the various minimum requirements.

(2) The consultation must contain:

(a) The medical history of the driving candidate,

(b) A list of medications which may affect driving, and

(c) A list of the concurrent limitations which accompany the patient's primary disability (see App. D) NOTE: It is recommended that the Driver Rehabilitation Specialist work with local computer specialists to develop a consult referral template to ensure all needed information is present on the referral.

(3) Psychiatric Care Status. Referral by the Mental Health Team is required for patients currently under care for a psychiatric disorder. Those referred patients may receive driver rehabilitation if they meet all other eligibility requirements for PM&RS treatment, and they pass the evaluation procedures provided by the PM&RS physician and the Psychiatry and/or Psychology staff.

d. Admission Criteria

(1) The furnishing of driver rehabilitation for persons with disabilities is a medical therapy furnished in the same manner as other therapy.

(2) After determination of legal eligibility by the Business Office, the inpatient or outpatient applicant is referred to PM&RS for physical and/or psychological examinations for the decision as to the medical feasibility of undergoing the special training on an inpatient or outpatient basis. NOTE: Occupational Therapy, Speech Language Pathology and Psychology Service may be consulted to provide an evaluation in those patients with a history of or evidence of significant cognitive deficiencies.

(3) If a decision is reached to obtain training from a non-VA source and a satisfactory source is identified (see subpar. 14g), the medical facility initially receiving and processing the request must complete the required contract (Memorandum of Understanding (MOU)) and pay all charges. For example, if the request is initially processed at the Outpatient Clinic, Oakland Park, FL, and a decision made to obtain contract or MOU services, the necessary contract or MOU must be developed by the VA Medical Facility Miami, FL (the parent facility), and related charges are to be paid by that medical facility. NOTE: VA medical facilities not having special driver rehabilitation activities may obtain consultative services from medical facilities which do.

e. Training of Non-Veterans. According to law, only a "Veteran or member of the Armed Forces, eligible for care under 38 U.S.C. Chapter 17," is permitted to receive driver training. All other individuals have to be referred to non-VA resources for such training (see 38 U.S.C. Section 3903(e)(1)). However, some individual driver rehabilitation centers may qualify as "sharing of health care resources" under 38 U.S.C. Section 8153, and enter into a sharing agreement with other medical facilities. Public Law 104-262, Section 301, "Revision of Authority to Share Medical Facilities, Equipment, and Information," dated October 6, 1996, expanded VA's capacity to enter into sharing agreements with other health care providers.

(1) Agreements for driver rehabilitation services need to be between the local VA facility and appropriate health care facilities, or other governmental agencies, requiring such services. Such agreements must be established according to local and national policies.

(2) Training must only be provided by a Certified Driver Rehabilitation Specialist.

(3) Services must only be provided within excess capacity of the program and must not result in any delay of services to eligible Veterans or Armed Services personnel.

f. Transfers of Veterans to Driver Rehabilitation Centers. When the physician's findings indicate an applicant can be expected to satisfactorily complete a special driver rehabilitation course, and the applicant accepts the plan offered, arrangements must be made to move the person to the nearest VA Driver Rehabilitation Center having authorized accommodations for completing the special training. The use of hoptel beds is encouraged for those patients that do not require overnight nursing care. NOTE: Movement of patients between facilities is governed by VA Handbook 1601B.05 Beneficiary Travel. Direct commuting from a patient's home to the training facility may be utilized when so warranted. Following completion or termination of the training, the patient is to be provided whatever return transportation is needed and for which the patient is entitled to receive under applicable authorities. Funding for these transfers are provided by the "releasing facility" (see App. D).

g. Non-VA Training Programs

(1) Certain situations may demand that a veteran seek driver training at some rehabilitation center other than an approved VA Driver Rehabilitation Program. Such situations could include:

(a) Inability to leave area of residence for family reasons,

(b) Inability to travel long distances to reach the nearest driver rehabilitation center, or

(c) Unavailability of space.

(2) If any of these situations exist, it may be necessary to contract or provide this training through a MOU at the nearest non-VA Driver Rehabilitation Program offering appropriate services to meet the Veteran's needs. It is the responsibility of a knowledgeable PM&RS specialist to review the non-VA facilities to determine whether or not they meet VA standards for training of the disabled; e.g., adequate and safe adaptive equipment, a state-certified instructor, a respectable training record, etc., before the Veteran receives such training, or the contract or MOU is developed to authorize payment of such service.

h. Training in Veteran's Personal Vehicle or Vendor Equipped Vehicle. It is permissible to teach adaptive driving skills to a Veteran in the Veteran's own personal vehicle, or in a vendor-equipped vehicle, as long as the Veteran, or vendor, can show documented proof that the vehicle is covered by the minimum State requirements for insurance. This situation may occur when the Veteran has need for special adaptive equipment or structural modifications of the vehicle not ordinarily utilized or available in the VA driver rehabilitation vehicle(s). NOTE: It is recommended that in such training situations, an instructor's brake needs to be installed prior to beginning the training. Magnetic signs indicating student driver need to be affixed to the vehicle.

i. Certificate Of Training. In order to standardize the certification completion of the VA driver rehabilitation course, VHA Central Office has determined that VA Form 3904, Certificate of Training, is to be awarded to all patients who successfully complete the VA Driver Rehabilitation Program. State licensure is not a prerequisite for obtaining this certificate; in fact, the certificate needs to be given prior to taking the State DMV examination. NOTE: VA Form 3904 can be ordered through the local "forms officer" in Human Resources Management, or from A&MM. The stock number is F05525.

j. Medical Advisory Boards. It is strongly recommended that each VA Driver Rehabilitation Program establishes a local Medical Advisory Board and/or Major Medical Equipment Committee to oversee the operations of the program, and to assist in the medical evaluation procedures in difficult or questionable circumstances.

k. Licensing. The final responsibility for licensing the patient who completes the VA Driver Rehabilitation Program rests with the individual Veteran and the individual State DMV. The VA staff needs to be aware of the State eligibility requirements, and to cooperate with the State, as much as possible,?Šin accordance with the Hospital Insurance Portability and Accountability Act (HIPAA), on behalf of the patient.

l. Night Driving. The ability to drive at night or at dusk is quite different from daytime driving. The glare from lights of oncoming traffic, lower-visual acuity, inability to determine road width, or to see directional signs may be influenced when switching from daylight to nighttime driving. Medical facility authorities are encouraged to support all driver rehabilitation specialists in providing a portion of the teaching program to night instruction.

m. Release of Medical Information. With the patient's written consent, a page(s) of the patient's medical record, which shows the patient's status in the Driver Rehabilitation Program, may be duplicated (with appropriate clearance from the Business Office) and forwarded to the State DMV for determination as to whether or not the veteran can be examined for licensure.

n. Limitations. The goal of the Driver Rehabilitation program is to determine the Veteran's functional ability to drive safely; however, there is no guarantee that participation in the program will ensure safe driving 100 percent of the time.

16.15. Operational Guidelines

a. Instructor-Patient Relationship. The heart of the VA Driver Rehabilitation Program is the actual instructor-patient relationship during the period between the receipt of the physician's referral to the attainment of a Certificate of Training. The driver rehabilitation specialist is well- versed in treating disabilities and in identifying residuals and/or deficits that may affect a patient's driving capabilities. This guidance in this Handbook is critical to the driver rehabilitation specialist in eliciting a Driver Rehabilitation Program specific to the needs of each patient and within the patient's physical and emotional capabilities.

b. Types of Disabilities that are Treated in the VA Driver Rehabilitation Program

(1) Paraplegia;

(2) Tetraplegia;

(3) Traumatic Brain Injury (TBI);

(4) Hemiplegia;

(5) Neurological and brain disorders;

(6) Amputation, i.e., upper and lower extremities;

(7) Orthopedic problems;

(8) Mental health problems;

(9) Disabilities associated with aging.

c. General Behavioral Objectives Expected of Patients

(1) The patient must acquire knowledge of all areas of the Driver Rehabilitation Program specific to their individual needs. Both didactic theory and practical experience must be provided.

(2) Psychomotor improvements in handling the segments of the driver rehabilitation task (e.g., space-cushioned driving) may be noted by comparison of function before and after completion of the Driver Rehabilitation Program.

(3) The patient needs to develop a favorable psychological attitude toward the everyday driving responsibilities.

(4) The patient is to become as proficient a driver as possible through the use of the most modern education, teaching, and rehabilitation techniques (e.g., search, identify, predict, decide, execute (SIPDE)). NOTE: The use of adaptive equipment and vehicle modification enables as many disabled individuals as possible to become independent in their transportation needs.

d. Pre-driving Assessment and Evaluation. The Driver Rehabilitation Specialist must ensure the following areas are addressed as part of the initial assessment and evaluation:

(1) Initial Contact. Have the initial contact with patient (driver rehabilitation candidate) in an interview atmosphere.

(2) VA Form 10-9028, Driver Training Functional Evaluation Record. This form is available for use or may be used as a guide for the assessment process.

(3) History. Obtain from patient the history of the patient's driving record, including any citations, accidents, or suspensions, as well as military defensive driving strategies which may have been taught to the Veteran.

(4) Medical Clearance. Inform patient of steps to be taken to obtain medical clearance, if such is required from the State medical authority.

(5) Pre-driving Testing

(a) Performed by Driver Rehabilitation Specialist

1. Visual acuity, depth-perception, color-vision, peripheral-vision, night acuity, and glare recovery (tests may be administered by use of visual screening tools).

2. Functional muscle testing.

3. Basic perceptual test (e.g., dynamic figure-ground).

4. Range of motion of all extremities, plus neck, if feasible. If lower extremities are non- functional, emphasis on exactness of upper extremity range of motion becomes greater.

5. Coordination testing.

6. Hearing (subjective).

7. Balance (static and dynamic).

8. Activity tolerance and susceptibility to fatigue.

9. Spasticity.

10. Bowel or bladder control.

11. Reaction time, i.e., response time from accelerator to brake.

12. Sensation and proprioception.

13. Functional activities of daily living (ADL).

14. Educational training (classroom portion).

(b) To be Performed by other Service Staff Members, as appropriate, to the Patient's Medical and/or Mental Health Diagnosis

1. Standard psychological tests, if applicable, administered by a staff psychologist and/or neuropsychologist to determine candidate's emotional and mental capacities to operate a motor vehicle.

2. Extensive perceptual tests given by qualified allied health care professional.

3. Evaluation of patient's communication and hearing potential, to be administered by Audiology and Speech Pathology.

4. Advanced visual evaluation as indicated by an Optometrist or Ophthalmologist.

(6) Driving Simulator. The driver rehabilitation specialist needs to be aware of the many benefits and limitations of the driver simulator as an evaluation tool and instructional device. Included in this understanding of the simulator are its design, concepts, capabilities, limitations, and preventive maintenance.

(7) Valid Driver's License. The driver rehabilitation specialist must be sure the patient has a valid driver's license or valid learner's permit before beginning on-the-road driving. Coordination with the local DMV is essential. NOTE: Some patients may not be required to take written, vision, and/or driving examination at the DMV. If it is determined that the patient's license had been suspended or revoked, the patient must be discontinued from the program until such time as permission has been obtained from the DMV to resume the training.

(8) Counseling and Education. In counseling the patient, it is essential to:

(a) Remind patients of the patient's responsibilities.

(b) Discuss the perils of being under the influence of alcohol and illicit drugs, as well as prescribed and non-prescription medications, when driving.

(c) Review potential distractions during driving such as cell phone use, setting GPS systems, passenger behavior, etc.

(d) Educate the individual about strategies to eliminate potentially dangerous compensatory mechanisms learned while on active duty when driving in the civilian world.

(e) Elaborate on the statement, "Driving is a privilege, not a right."

e. Four Phases of In-Vehicle Instruction. During all four phases the instructor must continually emphasize the benefits of defensive driving.

(1) Phase One Instructions. Phase One instruction includes:

(a) Training in transferring to and from vehicle.

(b) Evaluating the need for assistive and prosthetic devices.

(c) Orienting the patient to vehicle controls and add-on adaptive equipment.

(d) Assisting the patient to assume proper body positioning and alignment (e.g., seat height, position of legs).

(e) Teaching mirror references, including "blind spot" checks and tests.

(f) Noting passenger responsibilities (e.g., seat belts, lock doors).

(g) Emphasizing pre-driving check which includes external (e.g., lights) and internal (e.g., gas supply) considerations.

(h) Practicing ingress and egress of mobility aids.

(i) Preparing lesson plans and course routes for all steps of vehicle in motion training, such as:

1. Starting and stopping;

2. Right and left turns;

3. Centrifugal forces;

4. Backing-up;

5. Parking with no obstacles;

6. Reaction time (gas to brake);

7. Smooth acceleration and braking; and

8. Visual tracking.

(2) Phase Two Instructions. NOTE: Enter this phase only after student has mastered all steps in Phase One. Phase Two is carried out in a quiet residential area with light traffic and no hills, and includes:

(a) Limit-line approaches to intersections.

(b) Intersections.

(c) SIPDE Drills. Search (visual scanning), Identify (possible hazards), Predict (possible consequences of hazards), Decide (what to do if potential hazard becomes a reality), Execute (carry out planned action).

(d) Two-second rule.

(e) Lane changes.

(f) U-turns and three-point turnabouts.

(g) Parallel parking.

(h) Emotional stability behind the wheel.

(i) Training in the Smith System by:

1. Aiming high in steering,

2. Getting the big picture,

3. Keeping your eyes moving,

4. Making sure on coming traffic can see you, and

5. Leaving yourself an "out."

(3) Phase Three Instructions. Complex driving includes taking the patient downtown, on hills, in traffic circles, and on congested roads:

(a) Hill driving; Uphill and downhill parking, speed control.

(b) Passing other vehicles.

(c) Hazardous driving situations (e.g., inclement weather, stuck accelerator, brake failure, flat tire).

(d) Changing traffic flows.

(e) Awareness of pedestrian hazards.

(4) Phase Four Instructions. Phase four includes:

(a) Freeway entry and exit.

(b) Car control.

(c) Emergency stops.

(d) Night driving, to include: glare avoidance, visibility reduction, and fatigue with extended trips. NOTE: In all lessons, goals and expectations must be discussed with the patient prior to in- vehicle training and a critique must follow road performance. Specifics of driving techniques not included in the preceding are to be covered as road conditions arise. No specific number of lessons is prescribed for a patient with a certain disability. It may take a spinal cord injured patient (X) lessons to adjust to using hand controls, or it may take a stroke victim (Y) lessons to learn to compensate for the patient's affected side.

f. Certificate of Training. Upon completion of the in-car training, the patient may be scheduled for a driving examination at the DMV. A Certificate of Training is given to the patient at this time, signifying successful completion of the course.

g. Selection of Vehicle. The driver rehabilitation specialist assists the patient in the selection of an appropriate vehicle, vehicle modification, and proper add-on adaptive equipment to meet the patient's needs according to current eligibility requirements, either as a driver, or as a passenger.

h. Documentation of Clinical Chart. The patient's progress must be documented in the medical record from time of initial evaluation and/or assessment until completion of the Driver Rehabilitation Program. Documentation must follow local medical facility policy and be in compliance with appropriate accreditation standards (i.e., the Joint Commission and the Commission on the Accreditation of Rehabilitation Facilities (CARF).

16.16. Standards

a. Productivity

(1) It is necessary in any medical program to have the capabilities of judging the effective utilization of such a program. There may be a need to determine upgrading, counseling, or possible termination efforts in the conduct of one or more of the designated facilities.

(2) Three categories of evaluation currently exist to provide the basis for productivity:

(a) Number of annual referrals to the program,

(b) Number of annual training hours provided in the program, and

(c) The amount of time each instructor gives to the program.

(3) New methods of measuring productivity including use of Event Capture, Current Procedural Terminology (CPT) Codes, and International Classification of Diagnoses, Clinical Modifications, 9th Edition (ICD-9-CM) Codes are being incorporated into the Decision Support System (DSS) as new means for effectively measuring productivity and costs. All driver rehabilitation clinics need to have stop code 230 in the primary credit position. The secondary credit stop code should be devoted to the discipline providing the training, such as 214 for Kinesiotherapy, 206 for Occupational Therapy, 205 for Physical Therapy, etc. NOTE: The Coordinator of the Driver Rehabilitation Program, VHA Central Office, reviews the Annual Reports to assess existing workload and productivity. Consideration is given to those medical facilities in isolated geographic areas where veteran activity is known to be low.

(4) Specific workload data must be maintained by the PM&RS Program Office (117).

b. Nonproductivity. Efforts must be made to review the annual report data from each facility; to determine those driver rehabilitation centers which do not meet these standards over an established period of time; and to recommend termination or intensive upgrading of delinquent centers. All such action is to be cleared through the appropriate VISN and the Office of PM&RS, VHA Central Office.

c. Accreditation. Driver Rehabilitation programs that are a part of a programming that is CARF accredited must adhere to the applicable CARF Standards.

16.17. Appendix A - References and Related Supportive Material

1. References

a. Public Law 93-538.

b. VHA Handbook 1660.01, Enhanced Health Care Resource Sharing Authority ‘«Ű Selling.

c. VHA Handbook 1173.4, Automobile Adaptive Equipment Program.

d. VHA Handbook 1173.08, Medical Equipment and Supplies.

e. VA Handbook 7002, Logistics Management Procedures

f. American Automobile Association Foundation for Traffic Safety. www.aaafoundation.org or www.seniordirvers.org

g. American Medical Association: Physician's Guide to Assessing and Counseling Older Drivers. http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.shtml

h. National Highway Traffic Safety Administration. www.nhtsa.gov i. AARP formally American Association of Retired Persons. www.aarp.org/driver

j. American Society on Aging. www.asaging.org/drivewell

k. ADED: Association for Driver Rehabilitation Specialists. www.aded.net

l. National Mobility Equipment Dealers Association: NMEDA. www.nmeda.org

m. American Occupational Therapy Association. www.aota.org/olderdriver

n. Commission on Accreditation of Rehabilitation Facilities (CARF). Accreditation manuals available through the VA Office of Quality and Performance. http://vaww.oqp.med.va.gov/default.htm

2. Supportive Material. Current information and technological advances in driver rehabilitation may be obtained through literature search. The following rehabilitation journals often contain interesting articles on driver rehabilitation:

a. Archives of Physical Medicine and Rehabilitation.

b. Clinics in Geriatric Medicine.

c. Rehab Management.

d. Journal of Rehabilitation Research and Development.

e. American Journal of Occupational Therapy.

f. Paraplegic News.

16.18. Appendix B - Sample of a Driver Rehabilitation Instructor Training Course

NOTE: This was prepared by the Department of Veterans Affairs (VA), Physical Medicine and Rehabilitation Service (PM&RS), in cooperation with the Employee Education Service (EES) and the Long Beach VA Medical Facility

1. Purpose. The 10-day course is to provide basic training for rehabilitation therapists to become driver rehabilitation specialist in the theory, skills, and techniques required to teach disabled persons to drive and to administer a Driver Rehabilitation Program.

2. Objective. At the completion of the course the prospective driver rehabilitation specialist is able to:

a. Evaluate disabled persons in terms of basic mental and physical capability to perform the driving task.

b. Analyze individual disabilities in terms of performance of the driving task and prescribe necessary adaptive devices.

c. Prepare and conduct specific driver rehabilitation lessons designed to enable individual disabled patients to become competent drivers.

d. Perform skills comprising the driving task in on-road traffic situations both with usual vehicle controls and with special modalities enabling the disabled to drive.

e. Evaluate patient performance in achieving competence in the driving tasks.

f. Determine individual need and manage ancillary learning enabling the patient to own, insure, maintain, and operate, a specially adapted vehicle.

g. Facilitate individual patient compliance with pre-and post-instruction licensing requirements of the Department of Motor Vehicles (DMV).

h. Perform proper administrative tasks in operation of a Driver Rehabilitation Program.

i. Perform follow-up evaluation of patients as needed to determine continued suitability of adaptive devices to patient's needs.

3. Accreditation. VA is an approved provider of training courses and workshops endorsed by the Association for Driver Rehabilitation Specialists (ADED (formerly known as the Association of Educators and Drivers for the Disabled)). All faculty members must hold current certification as a driver rehabilitation specialist.

4. Agenda

a. Session 1

(1) Welcome

(2) Course Registration

(3) Review of Pre-course Assignment

(4) Assignment of Reports on Disability

b. Session 2

(1) Individual Traffic

(2) Driving Exam

c. Session 3

(1) Introduction to the library and educational resource center

(2) Work-up of Reports on Disability

d. Session 4

(1) Vision and Driving

(2) Perception and the Driving Task

e. Session 5

(1) Basic Cognition and Visual

(2) Perceptual Motor Screening

(3) Driving with Perceptual Deficits

f. Session 6

(1) Shared-risk

(2) Identification of Visual and Neuro-muscular Deficiencies

(3) Assessment and Techniques

g. Session 7

(1) Traffic Safety and Driver Education

(2) Search, Identify, Predict, Decide, and Evaluate (SIPDE)

(3) Smith System

(4) Space Cushion

h. Session 8

(1) In-car Instruction

(2) Taking Control by Instructor

(3) Driving from Instructor Position

i. Session 9

(1) Preparing Lesson Plans

(2) Preparation and Practice for Road; Lesson #1, Driving Only on Medical facility Grounds

j. Session 10

(1) Initial Clinical Evaluation with Patient for Sensory Integration

(2) Neuro-muscular and Motor Skills

(3) Student Instruction with Patients

(4) Road Lesson #1 in Automobile

(5) Critique - Road Lesson #1

k. Session 11

(1) Reduced-risk Turns

(2) Turning Paths

l. Session 12.?ŠPreparation and Practice for Road; Lesson #2

m. Session 13

(1) Student Instruction with Patients

(2) Road Lesson #2 in Automobile

(3) Critique Road Lesson #2

n. Session 14. Wheelchair to Car and/or Van Transfers

o. Session 15

(1) Adaptive Driving Equipment

(2) Van Modifications

p. Session 16

(1) Wheelchair Lifts

(2) Specialized Driving Systems

q. Session 17. Vendor Tour for presentation of available vehicles, modifications and equipment

r. Session 18

(1) Van Operation

(2) Behind-the-Wheel

s. Session 19. Written Vehicle Modification Prescription

t. Session 20. Freeway and Expressway Driving

u. Session 21. Preparation and Practice for Road Lesson #3

v.?ŠSession 22

(1) Evaluation of Older Drivers

(2) Proper Vehicle Selection

w. Session 23

(1) Student Instruction with Patients

(2) Road Lesson #3 in Automobile

(3) Critique Road Lesson #3

x. Session 24. Roundtable Discussion: Problems in In-car Instruction with Patients

y. Session 25. Accident Reporting

z. Session 26. Program Administration

aa. Session 27. Role of Prosthetic Service

bb. Session 28

(1) Vehicle Selection for the Person with Disabilities

(2) Automotive and Van Adaptive Equipment Prescription

(3) Practical Exam

cc. Session 29. Introduction and Advantages to Simulation for Drivers with Disabilities #1

dd. Session 30. Student Reports

ee. Session?Š31. Introduction and Advantages to Simulation for Drivers with Disabilities #2

ff. Session 32. Familiarization with Audio-visual Equipment and Classroom Aids

gg. Session 33. Final Road Test Utilizing Vehicle Adaptive Equipment

hh. Session 34. Participant Competency Demonstration

ii. Session 35

(1) Course Evaluation

(2) Presentation of Certificates

16.19. Appendix C - Medical facility Procedures Regarding Referral and Request for Driver Rehabilitation

1. A Department of Veterans Affairs (VA) facility requesting the transfer of a patient for the purpose of providing driver rehabilitation needs to initiate the procedure through its Physical Medicine and Rehabilitation Service (PM&RS) or appropriate rehabilitation care line. The facility needs to make an application, at least 30 days in advance, to the Chief, PM&RS, through the Business Office at the receiving facility. The minimal requirements include:

a. A recent medical summary adequate to determine the feasibility for driver rehabilitation.

b. Four basic types of medical information, which may affect a veteran's ability to drive, need to be addressed:

(1) Conditions which affect one's ability to perceive the environment because of loss of consciousness (as in epilepsy) or the limitation of a single sense (such as vision).

(2) Conditions which alter one's judgmental processes; e.g., mental health problems, senile changes, or brain damage.

(3) Motor and/or sensory response conditions which limit the ability to respond rapidly to changes in traffic.

(4) Diseases such as alcoholism, which may impair all three types of functions.

c. If any of the preceding medical conditions impair driving ability, the medical examination must be sufficiently detailed to allow PM&RS physicians at the VA facility to make an informed decision regarding medical appropriateness.

d. Current PM&RS examination including the Functional Independence Measure (FIM), or other appropriate self-care assessment.

e. Auditory examination and visual examination.

2. The Chief, PM&RS, and staff, upon receipt of the application, determines acceptability of the applicant and sets a reporting date for admission to the program. Transfer is accomplished by Standard Business Office Procedures. Spinal cord patients (non-traumatic and traumatic) are to be admitted on the Spinal Cord Injury (SCI) Service. Other appropriate patients are to be admitted to the medical rehabilitation inpatient unit or other appropriate cost effective setting.

3. The Driver Rehabilitation Program covers a maximum period of 10 working days (intra- medical facility patients). Upon completion of the training, the patient is then transferred back to the patient's original facility, as mutually arranged.

4. The Driver Rehabilitation Program covers special reviews as requested by the Department of Motor Vehicles to discuss the patient's driving records and/or physical disability.

16.20. Appendix D - VA Driver Rehabilitation Centers

1. VA Upstate New York, Albany, NY

2. VA New Mexico HCS, Albuquerque, NM

3. VA Medical Facility, Ann Arbor, MI

4. VA Medical Facility, Atlanta, GA (Decatur)

5. VA Medical Facility, Augusta, GA

6. VA Baltimore HCS, MD

7. VA Gulf Coast HCS, Biloxi, MS

8. VA Boston HCS, Brockton, MA

9. VA Medical Facility, Bronx, NY

10. VA Medical Facility, Butler, PA

11. VA Hudson Valley, Castle Point, NY

12. VA Medical Facility, Cleveland, OH

13. VA Medical Facility, Columbia, SC

14. VA North Texas HCS, Dallas, TX

15. VA Medical Facility, Denver, CO

16. VA New Jersey HCS, East Orange, NJ

17. Eastern Kansas HCS, Leavenworth & Topeka, KS

18. VA Medical Facility, Hampton, VA

19. VA Medical Facility, Hines, IL

20. VA Medical Facility, Houston, TX

21. VA Medical Facility, Indianapolis, IN

22. VA Central Iowa HCS, Knoxville, IA

23. VA Medical Facility, Lexington, KY

24. VA Medical Facility, Little Rock, AR

25. VA Medical Facility, Long Beach, CA

26. VA Medical Facility, Memphis, TN

27. VA Medical Facility, Miami, FL

28. VA Medical Facility, Milwaukee, WI

29. VA Medical Facility, Minneapolis, MN

30. VA Medical Facility, Oklahoma City, OK

31. VA Medical Facility, Palo Alto, CA

32. VA Medical Facility, Philadelphia, PA

33. VA Medical Facility, Phoenix, AZ

34. VA Medical Facility, Portland, OR

35. VA Medical Facility, Richmond, VA

36. VA Medical Facility, Salisbury, NC

37. VA Medical Facility, Salt Lake City, UT

38. VA South Texas HCS, San Antonio, TX

39. VA Medical Facility, San Juan, PR

40. VA Puget Sound HCS, Seattle, WA

41. VA Greater Los Angeles HCS, Sepulveda, CA

42. VA Medical Facility, Sheridan, WY

43. VA Medical Facility, St. Louis, MO

44. VA Medical Facility, Tampa, FL

45. VA Medical Facility, Tucson, AZ

46. VA Medical Facility, Washington, DC

47. VA Medical Facility, West Palm Beach, FL

17. VA Handbook 1173.17 - Home Telehealth Equipment Management Procedures

17.1. Purpose

This Veterans Health Administration (VHA) Handbook standardizes various equipment management aspects of the Care Coordination Home Telehealth (CCHT) program relating to the patient, care coordinators, prosthetic representatives and other program leads.

17.2. Background

a. In Fiscal Year (FY) 2003, the newly created Office of Care Coordination Services (OCCS) was charged with implementing a CCHT program in each of the 21 Veterans Integrated Service Networks (VISNs). During the subsequent 2 years, each VISN was allocated $1 million to implement a CCHT program which has been accomplished.

b. The VHA Prosthetic Clinical Management Program (PCMP) created Clinical Practice Recommendations (CPRs) for ordering Care Coordination and Telehealth Devices for veteran patients that were approved by the Under Secretary for Health on March 9, 2004. The CPRs covered the clinical aspects of CCHT technology and prescribed criteria for eligible veteran patients; but it only covered home telehealth equipment procurement in a general way. As the CCHT program continues to expand, there is a need to standardize the way VISNs procure and utilize this equipment. Such uniformity allows both the Prosthetic and Sensory Aids Service (PSAS) and the OCCS to collaboratively obtain accurate data on the number and dollar value of the CCHT devices purchased and issued to veterans, and remaining balances at each VA facility.

17.3. Definition of the Care Coordinator

The Care Coordinator is a professional at the facility-level who coordinates care for a panel of patients throughout the continuum of care to ensure that care is timely, appropriate, of high quality and cost effective. The Care Coordinator works closely with primary care providers, other health care professionals and team members, clinics, internal or external services, and community agencies. The Care Coordinator provides professional assessment, coordination and planning of multiple health care services; acts on behalf of the veteran to ensure that necessary clinical services are provided and that progress is being made. In addition, the Care Coordinator provides ongoing evaluation of care management services. NOTE: Collaboration between PSAS and OCCS programs is essential for effective and efficient management of home telehealth equipment. The PSAS staff works in conjunction with the Care Coordinators to ensure proper procurement and inventory management of the home telehealth equipment.

17.4. Scope

It is VHA policy to standardize the issuance, installation, and the retrieval or refurbishment of home telehealth equipment.

17.5. Responsibility of the Office of Care Coordination Service (OCCS)

The OCCS has a VHA Internal Accreditation Program for CCHT at the VISN level called Conditions of Participation," established to ensure a consistent quality of clinical, technical and business processes for CCHT throughout VHA. A section of the VISN-level compliance review for CCHT's Conditions of Participation, undertaken by a designated OCCS Quality Manager, relates to Home Telehealth Equipment Management requirements and specifies that:

a. The CCHT program and PSAS implement a systematic telehealth technology and equipment tracking process;

b. The CCHT program and PSAS ensure that all CCHT equipment is consistently tracked through the Prosthetics Inventory Package (PIP); and

c. The CCHT program consistently track trends and report equipment and vendor problems through facility, VISN, and OCCS processes.

17.6. Responsibility of the VISN Prosthetic Manager

The VISN Prosthetic Manager, in conjunction with the VISN CCHT Lead, is responsible for establishing VISN policies and procedures for the procurement, inventory, assignment, distribution, retrieval, and disinfection of CCHT equipment within the VISN.

17.7. Responsibility of the VISN CCHT Lead

The VISN CCHT Lead is responsible for coordinating, organizing, integrating and evaluating home telehealth equipment processes at the VISN level, on a regular basis, to identify and respond to issues. The VISN CCHT Lead works with key staff at both the VISN and facility levels in the implementation of pertinent home telehealth equipment guidelines to ensure compliance with all regulations, policies, and procedures established both locally and by OCCS.

17.8. Responsibility of the Facility Director

The Facility Director, or designee, is responsible for:

a. Ensuring facility compliance with Home Telehealth Equipment policy and procedures.

b. Ensuring that prior to usage, all CCHT medical equipment is inspected and that the preventative maintenance requirements are performed for returned and refurbished devices in accordance with facility policy regarding the maintenance of medical equipment. Inspections must be conducted by a facility level designated person.

c. Designating a fund control point specifically for the purchase of CCHT equipment and supplies.

(1) Fund administrators are to use Accounting Classification Code (ACC) 0100A6000, Cost Center (CC) 8250, and Budget Object Code (BOC) 3131 for all CCHT equipment purchases.

(2) The Health Care Financing Administration's Common Procedures Coding System (HCPCS) codes must be entered on the electronic Prosthetics consult; they are:

(a) TH 100 Messaging and Measuring Devices.

(b) TH 102 Monitoring and Measuring Devices.

(c) TH 103 Telehealth Peripheral Devices.

(d) TH 104 Video Phones.

(e) TH 105 Telehealth Accessories, Cables, Surge Protectors, etc.

17.9. Responsibility of the Prosthetics Representative

The Prosthetics Representative is responsible for managing the purchase, inventory and storage of home telehealth equipment for patient use.

17.10. Responsibility of the Facility Care Coordinator

The facility Care Coordinator is responsible for:

a. Prescribing Authority

(1) The Prescribing Authority as outlined in this policy only applies to:

(a) CCHT programs that are designated by the OCCS. This designation is awarded to programs that have met the OCCS Conditions of Participation specified in paragraph 5.

(b) Equipment purchased to deliver routine medical care services to patients and thereby covered by VHA's medical care appropriation. If the home telehealth equipment is being provided to patients solely for research purposes and not for routine medical care, it cannot be prescribed in the manner outlined in this policy.

(2) The Clinical Practice Recommendations for the Care Coordination-Home Telehealth Program contains a memorandum which establishes the Medical Center staff authorized to prescribe home telehealth technologies. NOTE: The Prescribing Authority can be accessed at http://vaww.teamshare.va.gov/PCLO/ProstheticsPCMP/Home%20Telehealth%20Devices/CPR- TelehealthDevicesAppendixes.pdf . A copy of this memorandum is filed in the PSAS at each VA medical center.

b. Patient Needs Assessment. ?ŠThe Care Coordinator assesses the patient upon enrollment and assigns appropriate technology to be used in accordance with the Care Coordination Technology Assignment Algorithm established by OCCS. This algorithm is an update to the algorithm included in the Clinical Practice Recommendations for Care Coordination-Home Telehealth, Appendix F, dated March 9, 2004, and can be accessed at http://vaww.va.gov/occ/Docs/Technology_Assignment_Algorithm.pdf

c. Issuing Equipment to a Patient

(1) The patient must be provided a copy of the set up guide and installation instructions, and an informational pamphlet.

(2) The Care Coordinator enters a prosthetics consult using a locally-developed CCHT Equipment Request to include the serial number of the device issued to the patient and whether the equipment is new or refurbished. If the serial number of the device is not available, it should be annotated when the consult is closed.

(3) The item must be issued from the Prosthetic Inventory Package (PIP) to the appropriate patient, and include entering the serial number and HCPCS code of the device on the patient's VA Form 10-2319, Prosthetics Record of Patient Services.

(4) There are four options to provide the device to the patient:

(a) During the patient's visit to the clinic,

(b) During a home visit by the CCHT staff,

(c) Mailed to the patient's home, or

(d) Through contract with a durable medical equipment (DME) provider to deliver or mail.

d. Installation of Equipment. The Care Coordinator is responsible for the coordination of any device installation, until successfully completed.

(1) In-home messaging devices and stand-alone videophone devices are installed either by the Care Coordinator, or designee during a home visit or by the patient. Telemonitors must be installed by the Care Coordinator, or designee.

(2) Patients planning to install the device themselves must be trained by the Care Coordinator, or designee, (using scripted guidelines developed by the Care Coordinator) on how to install, connect, and operate the device. The Care Coordinator must educate the patient on how to use any peripheral device(s), and how to interact with the device(s), to include, as appropriate, the expectations for answering questions and completing and submitting vital sign measurements and other data. The patient must demonstrate competency in the installation and use of equipment, and any peripheral devices, which must be documented by the Care Coordinator in the patient's record.

(3) The Care Coordinator must routinely follow-up with patients who have installed the device themselves, or by a designee, either during a following home visit or by a telephone call.

(4) The Care Coordinator verifies the correct installation of in-home messaging devices or stand-alone videophones by receipt of patient data. If the device is not transmitting data within 2 workdays after the installation was completed, the Care Coordinator, or designee, must call or visit the patient's home to ensure appropriate installation.

e. Handling Equipment Failure

(1) Upon enrollment in the program, the patient is provided with a contact number for the Care Coordinator. The patient is instructed to notify the Care Coordinator, or designee, in the event of any equipment malfunction.

(2) Once notified of an equipment malfunction, the Care Coordinator, or designee, must troubleshoot the device remotely or by a telephone call to the patient. If this proves unsuccessful, the item may be replaced at the discretion of the Care Coordinator, or designee.

(3) If a replacement item is to be issued, the serial number of the non-functional unit must be replaced with the serial number of the new device in the patient record. In accordance with the Safe Medical Devices Act (SMDA), manufacturers and the FDA must be notified if the medical device:

(a) Caused or contributed to a death, serious illness or serious injury; or

(b) Malfunctioned, and there is a probability that if the malfunction were to recur, the device would cause or contribute to a death, serious injury or serious illness.

(4) The Care Coordinator, or designee, must report all unresolved equipment and/or vendor issues related to the National Contracts by using VA Form 0729, Quality Improvement Report (QIR) accessible at http://vaww.teamshare.va.gov/PCLO/ProstheticsContracts/Quality%20Improvement%20Report %20VA%20Form%200729/Forms/AllItems.aspx. This form must be forwarded through the VISN CCHT Lead to the Chief of Prosthetics for signature prior to submission to the National Acquisition Center (NAC).

f. Retrieval and Refurbishment of Equipment

(1) Patients discharged from the CCHT Program can return equipment to the issuing facility through one of the following mechanisms:

(a) Delivery to the Care Coordinator during a regular visit to the issuing VA facility, or

(b) A patient can package the equipment in the provided shipping box (NOTE: The shipping box must be disposed as part of the infection control process by the designated person.) and mail it to the Care Coordinator, or designee, or

(c) The Care Coordinator, or designated person, can pick up the equipment at the patient's home.

(2) The Care Coordinator must document the return of the device and its serial number in the patient's Computerized Patient Record System (CPRS) medical record, inform the Prosthetics office of the return, and ensure that pertinent local safety and maintenance procedures are followed for the device.

(3) The facility Prosthetics Manager, or designee, must ensure that the patient's CPRS record is updated to reflect the return of the device and that the National Prosthetic Patient Database (NPPD) is updated to reflect the return.

(4) The returned equipment must be disinfected and reprogrammed by the designated person(s) following the manufacturer's guidelines and in accordance with VISN policy. All patient data must be permanently deleted from the device.

(5) After disinfecting the equipment and verifying proper function, it is returned to inventory, where it can be re-issued to another patient.

17.11. Procurement of Equipment

a. Individual Users

(1) Each VISN needs to procure CCHT equipment for individual patients use following VHA Handbook 1730.1, and applicable VA Acquisition Regulations (VAAR) or Federal Acquisition Regulations (FAR). As appropriate, National PCMP Contracts and/or Blanket Purchase Agreements must be utilized. The VISN CCHT Lead collaborates with their counterparts in the VISN office, facility Care Coordinators, and PSAS to decide on the number and type of technology needed to be purchased for inventory.

(2) The CCHT items in the PIP are included in the 30-day inventory rule defined in VHA Handbook 1173.2 and in the monthly PIP reports. Placing equipment in the PIP allows VA Central Office to utilize a national nomenclature to track CCHT dollars expended on devices being held in inventory waiting to be prescribed and issued to patients.

(3) Procurement decisions regarding CCHT equipment are made by each VISN. Each facility Care Coordinator needs to work with the facility PSAS to place an order.

(4) Once the CCHT equipment is procured, the equipment must be entered into the PIP at the purchasing facility.

b. Multiple Users. No procurement of CCHT equipment for the Medical Center is to be procured from PSAS funding.

(1) Prosthetic funding is to be used strictly for individual patient orders. Procurement of equipment purchased for multiple users is at the discretion of the VISN; however, this procurement must be approved by the VISN CCHT Lead, or designee, and is considered Medical Center equipment.

(2) This equipment needs to be purchased and tracked following local purchasing procedures for non-expendable medical equipment.

(3) An example of a device with multiple users would be one being used in an assisted living facility by several patients. This type of device is considered medical center equipment and is not to be included in PIP because it is not assigned to one individual patient; it is not to be purchased with PSAS specific purpose funds.