36C24418Q0139-001.docx

B.2 NURSING HOME PERFORMANCE WORK STATEMENT

A. Overview

1. This Indefinite Delivery Contract (IDC) is a written instrument of understanding, negotiated between an agency or contracting activity and a contractor that (1) contains contract clauses applying to future contracts between the parties during its term created by orders placed by the Government and accepted either in writing or by performance by the contractor and (2) contemplates separate future contracts that will incorporate by reference or attachment the required and applicable clauses agreed upon in the IDC. This IDC itself is not a contract. Furthermore, this IDC itself does not, (1) Cite appropriations or obligate funds; (2) State or imply any agreement or guarantee by the Government to place future contracts or orders with the contractor.

2. Federal Acquisition Regulation (FAR) – Indefinite Delivery Contract. The IDC is for a time period of five (5) years from the “Award Date”. An order is formed, in accordance with the terms and conditions of this IDC, when the Department of Veterans Affairs (VA) agrees to place a patient in the Community Nursing Home (CNH) and the CNH agrees to accept the patient. Upon acceptance by the Contractor of beneficiaries of VA, all clauses and terms and conditions of this IDC shall apply and become a part of the resultant contract during such time as a VA patient remains in that CNH at the expense of VA.

3. Ordering (Authorization) Process. Location primarily will be selected based on the Veteran’s needs and proximity to the Veteran’s home if space is available. If the IDC holder has determined space is available and has accepted the Veteran, an authorization will be issued. VA acknowledges that, depending on the availability of resources at specific IDC holder facilities at specific times, acceptance of a referral may be commercially impracticable for the IDC holder. In that event, the IDC holder may decline to accept an authorization. The VA’s authorization for nursing home care shall be communicated verbally to the CNH prior to the Veteran’s placement in the CNH only by those VA personnel designated in writing to do so. No entity outside the Lebanon VA Medical Center has authority to admit. If the CNH accepts a Veteran without specific VA approval as previously indicated, neither the VA nor the Veteran will be responsible for payment. The VA’s verbal authorization shall be followed by the corresponding VA Form 10-7078, Authorization and Invoice for Medical and Hospital Services. The VA form 10-7078 will explicitly state the Veteran’s level of care, as well as the beginning and ending dates for which care is authorized to be provided. Any subsequent change to a Veteran’s original authorization shall be immediately communicated via a new authorization to the CNH.

4. Modifications. A IDC shall be changed only by modifying the IDC itself and not by individual orders issued under it. Modifying a IDC shall not retroactively affect orders previously issued under it. See FAR 16.703(c)(2).

5. Services Rendered at VA Per Diem Rates. Upon acceptance of a VA patient by the CNH, if and when requested by the VA Contracting Officer or authorized representative, the Contractor shall furnish all supplies and services herein described, at the per diem rates for the services specified on the MEDICARE PRICING Table in the Schedule of Items of this IDC. VA rates are generally based on CMS RUGs rates. See Section D.1 (Contract Documents, Exhibits or Attachments) for RUGs Descriptions. VA is only obligated to pay for patients that are placed in accordance with this IDC.

B. Introduction.

The Community Nursing Home (CNH) program is a key component of the Veterans Health Administration (VHA) continuum of care. The Contractor agrees to provide in accordance with the terms and conditions stated herein to the Lebanon VA Medical Center at the prices specified in the section titled Schedule of Items of this IDC. Nursing home facilities in the CNH program shall cooperate with VA staff in referral of appropriate veterans for care and accept veterans of which they have the capability/capacity to care. The term, “facilities,” shall include but not be limited to rooms, wards, sections, eating areas, drinking fountains, entrances, and other like areas. VA shall have the right to inspect the CNH and all appurtenances by authorized VA representative(s) to ensure that acceptable standards are maintained and that the necessary care to maintain the well-being of the patient is rendered.

C. Requirements

1. General. Nursing home facilities in the CNH program shall ensure that care meets the health needs and promotes the maximum well-being of VA patients. Nursing home care will be furnished to ensure the total medical, nursing, and psychosocial needs of VA beneficiaries. All nursing home facilities in VA’s CNH program must have current Center for Medicare and Medicaid Services (CMS) certification (Medicare and/or Medicaid) and a State nursing home license. VA developed quality of care standards utilizing CMS inspection criteria that are followed by VA in its selection of nursing homes. See VHA Handbook 1143.2, “VHA Community Nursing Home Oversight Procedures (June 4, 2004) a copy of which is available at: http://www.va.gov/vhapublications/publications.cfm?pub=2.

VA often has a particular need for specialty care services in the CNH program. The CNH also must be able to accept VA referrals in a timely fashion (ideally within 24 hours of request). The care provided will include room, meals, nursing care, and other services or supplies commensurate with the VA-authorized level of care, without extra charge. Duly authorized representatives of VA will provide quality oversight visits to veterans placed to assure continuity of care and to assist in the veterans’ transition back into the community when appropriate. These visits do not substitute nor relieve the CNH in any way of the responsibility for the daily care and medical treatment of the veteran. The per diem rate(s) established in this IDC will include the cost of nursing care, room and IDCrd, meals, primary medical care, one (1) face to face provider visit per month, to include a yearly physical and, as needed, to evaluate any change in Veteran’s condition, drugs and routine supplies, laboratory, x-ray, and other special services pre-authorized by VA, unless otherwise specifically excepted. (See Schedule of Items in this IDC for details regarding per diem rates and coverage).

2. Primary Medical Coverage. The assigned CNH duly licensed physician is the primary medical provider during the nursing home stay and is responsible for writing or approving admission and all other orders as soon as the veteran arrives at the CNH. The CNH provider is responsible for general medical care, urgent evaluation and intervention. Provider visits will be according to the Center for Medicare and Medicaid Services (CMS) guidelines. The assigned nursing home provider will provide timely care following the most current CMS guidelines; arranging 24/7 access for patient care; arranging easy access to staff for consultation; providing timely response to calls and arranging for timely provider back-up according to OBRA guidelines (42 CFR 483.40, OBRA Guidelines). The nursing service shall be under the direct supervision of a full-time, registered professional nurse. Full attention shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care. The Veteran’s dietary needs shall be met by menus planned to meet his/her nutritional needs and to follow the physician’s diet orders.

3. Specialty Services. The CNH will assume responsibility for arranging specialty care for veterans (e.g., dental care, podiatry and ophthalmology) that are not case managed or arranged through the VA.

4. Outpatient Visits to VA. The CNH is responsible for complying with all rules, policies and regulations expressed by the state in which they operate, as they relate to nursing facilities providing 24 hours per day protective oversight to their residents. Therefore, if a Veteran is sent to an outpatient clinic appointment at the VA, (or admission exam in the VA Emergency Department), the CNH must assure that adequate oversight is provided during the trip to the VA and while the Veteran remains on the VA campus as an outpatient. This oversight may be provided by a staff member, family member, or any other person who, in the judgment of the CNH, can responsibly and capably provide the Veteran with the necessary oversight and assistance with personal care needs. When the Veteran is an outpatient on the VA campus, he is still considered a resident of the nursing facility and the nursing facility is thereby responsible to provide physical assistance and protective oversight. VA reserves the right to send the Veteran back to the CNH without being seen if an escort is not provided, or a signed consent for treatment is needed and is not provided.

5. Transportation. Routine transportation for Veterans under contract is provided by VA only if arranged through the VA, and only if the Veteran has special transportation needs documented, such as being non-ambulatory and requiring a wheelchair or litter for safe transportation. Emergency transportation may be authorized provided VA’s authorization is obtained as soon as possible and not to exceed 72 hours of admission to a VA Medical Center or a non-Federal facility.

6. Termination of Services. VA reserves the right to remove any or all VA patients from the CNH at any time when it is determined to be in the best interest of VA or the patients without additional costs to the Government.

7. Medicare-Based Rates. The Resource Utilization Grouping (RUG) rate(s) will include the cost of medical care, medications, laboratory, x-ray, therapy (ies), and other special services pre-authorized by VA, unless otherwise specifically exempted. VA will contract for appropriate Medicare categories of care using Resource Utilization Groups (RUGs-IV) as a reference. A description of the RUGs-IV systems can be found in 42 CFR Parts 409, et al.

8. Medicare Rate Determination. The per diem rate is established by the current Medicare rate for Medicare- approved nursing homes including the cost of supplies, services, and equipment above that is provided under Medicare. Rates established after the Effective Date of this IDC will require a modification to the IDC. The RUGS IV rates include room, IDCrd, and routine nursing care, rehabilitation therapy (including physical, speech and occupational therapy), respiratory therapy, oxygen therapy, medical and nursing supplies (including items such as urological and colostomy supplies), most oral medications, most items of durable medical equipment (excluding ventilators), x-rays, and routine laboratory tests (see Schedule of Items in this IDC for details on rates). Any additional requests for payment to the all-inclusive per diem rates must be pre-approved.

9. The CNH’s Minimum Data Set (MDS) Assessment for Medicare: The CNH’s Minimum Data Set (MDS) assessment will be completed on the same schedule as the current Medicare MDS-Scheduled assessments, including close of therapy (COT) assessments. Classification changes will be approved by VA, dependent on projection for short-term or long-term residence, and adhering to the most current MDS frequency guidelines from Medicare. The applicable per diem rate will continue until the next assessment. Classification changes may also occur based on a determination by VA.

10. HIPAA Compliance. HIPAA compliance is required. The Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the National Standards to Protect the Privacy and Security of Protected Health Information (PHI). As required by HIPAA, the Department of Health and Human Services (HHS) has promulgated rules governing the security and use and disclosure of protected health information by covered entities, including the Department of Veterans Affairs (VA). In accordance with HIPAA, the Contractor may be required to enter into a Business Associate Agreement (BAA) with VA, but VACO has recognized CNH Facilities as an entity that does not require a BAA as long as they are conducting health care on VA’s behalf. The CNH care program qualifies as a medical service, so no BAA is required.

11. State Licensure; Access to CNH Quality of Care Reports (QASP Indicator #1). The CNH must maintain a current and unrestricted state license to operate as a skilled nursing facility. Changes in the status of the licensure will be immediately reported to the Lebanon VA Medical Center, Home and Community Care Department at 717/272-6621 extension 4365. VA will monitor the professional care and administrative management of services provided to VA beneficiaries, through one or any combination of the following methods: reviews of State agencies reports; on-site inspection of the CNH by VA staff; and/or on-site monitoring of VA patients. The CNH shall provide VA with copies of all State agency reports when requested, and cooperate fully with VA’s quality improvement or quality assurance program functions, including VA’s on-site inspection and monitoring. The VA Contracting Officer shall make all final determinations as to the Contractor’s reasonable cooperation with VA and compliance with these requirements.

12. Corrective Action Plan (QASP Indicator #2): The CNH will cooperate with timely development of Corrective Action Plans (CAPs) related to identified deficiencies from the State, Federal or VA surveys. The CNH will develop, in the time period specified by VA, timely and appropriate CAPs for VA surveys or investigation of complaints related to quality of care or sentinel events. The CNH will also supply related documents or data as specified by VA. The CAPs will include but are not limited to the following criteria and shall:

a. contain elements detailing how the CNH will correct the deficiency as it relates to the individual;

b. indicate how the CNH will act to protect residents in similar situations;

c. include the measures the CNH will take or systems that will be altered to ensure that the problem will not recur. The CNH must look at the system and determine if a change to the existing system will work, if a new system is necessary, or if a system does not exist and must be developed;

d. indicate how the CNH plans to monitor performance to make sure that solutions are permanent. The CNH must develop a quality assurance tool for ensuring that correction is achieved and sustained. This tool must be implemented. Failure to implement a quality assurance tool to sustain compliance will reflect that the CNH has an ineffective quality assurance system; and

e. provide dates when corrective action will be completed.

13. Life Safety Code. The CNH’s building shall conform to the most recent standards of the Life Safety Code (National Fire Protection Association Standard #101) in effect on the date of the IDC award and compliance with all applicable Federal, State and local regulations. The administrator of the CNH is required to notify the VA Contracting Officer in writing at least thirty (30) calendar days prior to any planned facility changes that could impact the Life Safety Code and other safety features of the facility which were in existence at the time this IDC became effective. The VA Contracting Officer will notify the VA Safety Manager responsible for the Life Safety Code inspection of the CNH and he/she will review (inspect the facility if required) the proposed changes and provide necessary approval or disapproval of the CNH to house veterans during and/or after the proposed changes. These changes may include but are not limited to:

a. Interior changes requiring VA approval. Some examples of facility changes that require the VA Contracting Officer notification are as follows: corridor partitions/walls, patient room doors, linen or trash chutes, exits, emergency lighting, fire alarm systems, automatic sprinklers, smoke barrier walls or doors, oxygen systems, compressed gas storage, HVAC, electrical and fuel gas systems;

b. Automatic sprinkler system. All VA contracted CNH facilities are to be fully-equipped with a fully- automatic sprinkler system installed in accordance with the National Fire Protection Association’s (NFPA) standards and be 100% sprinkled;

c. Natural disasters. In the event of a natural disaster (flood, tornado, etc.), the CNH shall communicate all action plans to VA as soon as practicable. The action plans will at a minimum identify temporary transfers of location, dates, and names of veterans transferred; and

d. Major construction; additions; and renovations. Major construction including building additions or other renovations which may affect physical plant integrity; SHALL MEET latest NFPA 101 Life/Safety Code requirements as well as any additional VA CNH construction standards in place at time of renovation or alteration.

14. Acceptable Safety and Sanitation Practices. Acceptable safety and sanitation practices shall be observed throughout the facility. The CNH will address employee and patient safety practices through staff orientation, training and adherence to related policy or procedures to provide a safe and clean environment.

15. Emergency/Hospital Care (QASP Indicator #3). In emergencies, nursing home staff will utilize the 911 local emergency systems as for any resident. A Veteran who begins to require acute hospital care (or more than the level of care authorized by the VA) may be readmitted to the appropriate VA facility, as determined and authorized by the VA. When such admission is not feasible because of the nature of the emergency, it is agreed that hospitalization in a non-Federal facility may be accomplished provided the VA’s authorization is obtained as soon as possible and not to exceed 72 hours of admission to the non-Federal facility. If hospitalization of a non-emergency nature is required, it is agreed that readmission to a VA facility will be accomplished as soon as the Veteran’s condition is sufficiently stabilized to permit admission. The veteran’s authorization agreement (VA Form 10-7078) will terminate whenever the Veteran is re-hospitalized for 15 calendar days or more in a Federal or non-Federal facility. If, after hospitalization, the Veteran requires nursing home care, a new VA Form 10-7078 shall be communicated to the CNH facility.

16. Bed Holds –If a Veteran receiving care under this agreement is hospitalized from the nursing home, the nursing home and VA facility will arrange to hold a bed in reserve, when such a decision is in the best interest of the Veteran and the VA. The number of covered bed hold days shall be determined by VA on a case-by-case basis, but shall not exceed the number of bed hold days allowed by state regulations, which is 15 days. Bed Hold rate is 1/3 the basic per diem rate. The nursing home is responsible to notify the family if a bed hold is required for a period longer than 15 days. The family would then make arrangements with the home to hold the bed at private pay, if desired.

17. Leave days – The VA may approve leave days (days away from the nursing home) for long-term Veteran placements. The leave must be part of a written therapeutic plan of care, and must be approved in advance by the VA and the CNH physician. Leave days at the VA’s expense are limited to 30 days per Veteran per calendar year, and will be paid at 1/3 the Basic per diem rate. Exceptions may be approved by the VA Community Specialty Services Program Manager or designee.

18. Death of a Veteran- In the event of a Veteran’s death, the CNH will promptly notify the VA within 24 hours or immediately the first business day after a weekend or holiday. The facility will assemble, inventory and safeguard the Veteran’s personal effects pending further guidance by the VA, the Veteran’s family or Power of Attorney.

19. Reportable Events (QASP Indicator #4). VA requires CNHs to report to the CNH Coordinator at VA any of the following events within 24 hours or immediately the first business day after a weekend or holiday: 1) sentinel events; 2) when there is a pending change of ownership of the CNH; 3) when there is a change of nursing home administrator or Director of Nursing/Director of Nursing Service; 4) substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH veteran’s property; 5) elopements of CNH veterans pursuant to state regulations; 6) infectious outbreaks; 7) resident to resident or resident to staff altercations involving a CNH veteran resulting in any injury that is other than minor; 8) copies of annual surveys or substantiated complaint investigations conducted by a State oversight agency; and 9) adverse events. Reporting shall include date of occurrence and patient disposition and outcome.

A sentinel event may include, but is not limited to the following: 1) a fall resulting in death or injury; 2) elopement resulting in a missing patient; 3) patient abuse confirmed or under suspicion; 4) a medication error resulting in patient illness or injury; 5) death or patient injury related to restraint (including side rails) use; or 6) death related to an unconfirmed or suspicious cause. When an adverse event occurs involving a CNH Veteran which is not determined to be a Sentinel Event( but that the State requires that the occurrence be reported to the State), such event is also to be reported to VA’s CNH program office. Some adverse events, such as minor medication errors without catastrophic outcomes, are managed by the CNH in the context of their quality improvement programs. It is not necessary for nursing homes to report such incidents to the CNH program office.

20. Exclusion Criteria- A CNH may be excluded from the VA’s CNH Program participation when any four of these seven factors are present in the current Office of Health Facility Licensure and Certification (OHFLAC) or CMS database:

21. VA Actions Regarding Serious Quality of Care Deficiencies. In cases of serious deficiencies affecting the health or safety of veterans or in cases of continued uncorrected deficiencies, VA will take one or more of the following actions:

22. VA Staff Access to CNH Records (QASP Indicator #5). All medical records concerning the veteran’s care in the CNH will be readily accessible to VA. Upon discharge or the death of a patient, medical records will be retained by the CNH for a period of at least five (5) years following termination of care. Patient records will be maintained in conformance with the Privacy Act of 1974 (5 U.S.C. § 552a). A medical record shall be maintained for each patient, which includes at least the following:

a. Admission Identification record

b. Admitting evaluation (Including diagnosis) by the CNH physician

c. Physician orders

d. Progress notes (the physician orders/notes shall be charted immediately after patient is seen)

e. Special reports (laboratory tests, X-rays, activity, etc.)

f. Minimum Data Set (MDS) information

g. Advance Directive and/or appropriate documentation

h. Person to contact in an emergency situation;

i. Name of attending medical practitioner;

Clinical Record Safeguards: The CNH must safeguard clinical record information against loss, destruction, or unauthorized use. If the CNH maintains a veteran’s record by computer, electronic signatures are acceptable. If attestation is done on computer records, safeguards to prevent unauthorized access and to provide for reconstruction of information must be in place.

23. Charitable Contributions. The CNH will not solicit contributions, donations, or gifts from patients or family members. Note: Established charitable fundraising activities of a CNH fall outside the scope of this language.

24. CNH Billing (QASP Indicator #6). Invoices for IDCrd, care and ancillary services shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered. The CNH will promptly notify the VA CNH Coordinator regarding any change in Veteran status: discharge, transfer, against medical advice (AMA), hospitalization, death and/or any changes in payer source and any ability to complete timely billing. All invoices must include the full name and address of the CNH and shall reflect the patient’s name, social security number, number of days billed, and agreed upon RUG rate (s). Failure to include this information may result in delayed payment.

25. VA Authorizations. It is impossible to determine the exact or estimated amount, which will be expended under this IDC. No obligation will be incurred by VA under this IDC, until authorizations are issued for nursing home care of specific beneficiaries. VA agrees to make payment on a timely basis for services rendered in accordance with such authorizations upon receipt of proper invoices submitted by the CNH as outlined in this IDC. VA will make payment for the day a recipient enters the CNH but not the day the recipient leaves a CNH unless entrance and departure are on the same day, then payment will be made for one (1) day.

26. VA Payments. Payments made by VA under any contract pursuant to this IDC, constitute the total cost of nursing home care. No additional charges will be billed to Medicare (with the exception of hospice), Medicaid, or private insurance, the beneficiary or his/her family, either by the CNH or any third party furnishing services or supplies required for such care, unless and until specific prior authorization in writing is obtained from the VA facility authorizing placement. The patient, family and any other entitlement programs (e.g., Medicare, Medicaid, etc.) will not be billed for uncovered services or costs during the VA contract period. This constitutes double-billing and Federal fraud.

END PERFORMANCE WORK STATEMENT

Performance Work Statement B. 2 – Page 1