36C24520R0022-001.docx

36C24520R0022

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

DUNS:

DUNS+4:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

36C24520R0022 01-13-2020

JABBAR PRINGLE/CONTRACT OFFICER

(304)263-0811 x2031 09-01-2020 Department of Veterans Affairs VA Maryland Health Care System 510 Butler Ave Martinsburg

WV

25401 X 623110 N/A X Department of Veterans Affairs VA Maryland Health Care System Louis A. Johnson VAMC 1 Med Center Drive Clarksburg

WV

26301 Department of Veterans Affairs VA Maryland Health Care System 510 Butler Ave Martinsburg

WV

25401

PAYMENT WILL BE MADE USING VA FORM 1358.

THE VA USES VA FORM 1358 AS AN

OBLIGATION CONTROL DOCUMENT FOR

CONTRACTS THAT ARE AWARDED FOR

COMMUNITY NURSING HOME SERVICES.

See CONTINUATION Page

TO PROVIDE COMMUNITY NURSING HOME SERVICES FOR THE

LOUIS A. JOHNSON VETERANS AFFAIRS MEDICAL CENTER.

PLEASE SEE PAGE 21 FOR PERIOD OF PERFORMANCE AND PRICE

SCHEDULE.

CONTRACTOR IS RESPONSIBLE FOR CORRECT WAGE TITLES AND

COMPLIANCE WITH ALL APPLICABLE WAGE AND HOUR LAWS.

See CONTINUATION Page X X X Jabbar Pringle Table of Contents

Table of Contents

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.5 PERFORMANCE WORK STATEMENT

A. Overview

1. Federal Acquisition Regulation (FAR) – Indefinite Delivery Contract (IDC). In accordance with FAR 16.504, Indefinite-Quantity Contracts, this is a five (5) year IDC from time of award.

2. 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” Levels of Care” specified in the Schedule of Items of this IDC. The VA “Levels of Care” are defined in an attachment in Section D.1 of the solicitation and the IDC. VA is obligated only to the extent authorized placement of patients is made in accordance with this IDC.

3. Ordering. Orders will be issued by Ordering Officers to place Veterans in Nursing Homes, often on a sole source basis using an Exception to Fair Opportunity and utilizing the CPRS system at VA hospital sites (Reference FAR 16.505 (b)(2)(i)(B)). Ordering Officer Contact information is as follows:

Agency task and delivery order ombudsman (see 16.505(b)(8)) if multiple awards may be made.

B. Background/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 U.S. Department of Veterans Affairs Louis A. Johnson VA Medical Center in Clarksburg, West Virginia 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 which includes exclusionary criteria on which the CNH is evaluated. 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 VA requires CNHs to have bed capacity to ensure their ability to take referrals when requested. The CNH also must be able to accept VA referrals in a timely fashion (ideally within 24 hours of request). Provider visits will be available at the rate of one (1) visit per month. Laboratory, x-ray, and other special services will be available to VA patients as needed. In addition, 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. 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 primary medical care, one (1) provider visit per month and needed consultation, drugs and routine supplies, laboratory, x-ray, and other special services authorized by VA, unless otherwise specifically excepted (see Schedule of Items in this IDC for details regarding per diem rates and coverage). 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.

2. 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.

3. VA Authorizations. Authorization for nursing home care will be submitted on VA Form 10-7078, “Authorization and Invoice for Medical and Hospital Services.” Each authorization validity period will be noted on the VA Form 10-7078 with a beginning and end date. Any extension to the original authorization validity period, regardless of the number of days, requires a new VA Form 10-7078.

4. 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 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.

5. 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 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, board, 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.

6. 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. This request should be submitted on the Level of Care Authorization Form provided to the facility. VA will make the determination whether classification changes require readmission to VA. VA staff will audit approximately 20% of the MDS assessments.

The Level of Care classification and associated per diem rates will remain in effect for each placement until and unless one of the following events takes place:

a. Re-hospitalization that may be associated with a change in level of care;

b. Need for more intensive therapy;

c. Significant change in condition; or

d. Classification changes may also occur based on a determination by VA.

7. Primary Medical Coverage. The assigned CNH provider 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 VA 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).

8. Rehabilitation Criteria. All therapy provided under this IDC will be individual therapy, rather than group therapy, unless otherwise ordered by the authorizing VA facility. Therapy may require pre-approval by VA before services are provided. Medical Restorative criteria will be used for physical therapy, occupational therapy, and speech therapy. Therapy must be skilled, relate to safety and be restorative according to Medicare criteria.

a. Description of Rehabilitative Therapy. The concept of rehabilitative therapy includes recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, or decrease in severity, or justification for an optimistic outlook to justify continued treatment. Covered therapy services shall be rehabilitative therapy services unless they meet the criteria for maintenance therapy requiring the skills of a therapist.

b. Evaluations/re-evaluations should consider the following: Establishment of treatment goals specific to the patient’s disability or dysfunction and designed to specifically address each problem identified in the evaluation; design of a plan of care addressing the patient’s disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment; continued assessment and analysis during implementation of the services at regular intervals; instruction leading to establishment of compensatory skills; selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short-term training on use of the device or system); and patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family should be ongoing.

9. Emergency Care; Financial Responsibility; Advanced Directives. In emergencies, nursing home staff will utilize the 911 local emergency systems as for any resident. Advance directives or living wills shall be adhered to according to CNH physician’s orders. When private hospitalization or emergency services are required, the patient, spouse, financial guardian or insurer is financially responsible. Service-connected veterans may qualify for VA coverage of emergency care provided the VA Health Care System (VAHCS) is contacted by the private hospital provider within 72 hours of admission on the first business day following a weekend or holiday. This includes the cost of necessary transportation for such care.

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 Louis A. Johnson VA Medical Centers Community Nursing Home program 304-623-7651. VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this IDC, 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 relating to this IDC, 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 and related to 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: interior finish, 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% sprinklered;

c. Natural disasters. In the event of a natural disaster (flood, tornado, etc.), the CNH shall communicate all action plans to VA. 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 the 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. Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veterans; CNH Responsibility to Veteran’s Belongings or Personal Effects (QASP Indicator #3). VA beneficiaries who begin to require more than the level of care authorized by VA will be readmitted to an appropriate VA facility, as determined and authorized by VA.

a. When such an admission is not feasible because of the nature of the emergency, hospitalization in a non-Federal facility may be accomplished provided VA authorization is obtained. VA authorization must be obtained within 72-hours of admission of the patient to a non-Federal facility and notice of any veteran death within 24-hours or immediately the first business day after a weekend or holiday. If hospitalization of a non-emergency nature is required, readmission to a VA Medical Center may be accomplished as soon as the patient’s condition is sufficiently stabilized to permit admission to a VA Medical Center.

b. In the event of a death of any veteran, the Contractor agrees to notify VA immediately of the death. In the event a death of a VA beneficiary while receiving nursing home care under this IDC, the CNH will promptly notify the VA facility which authorized admission and immediately assemble, inventory, and safeguard the patient’s personal effects. The funds, deposits, and effects left by the VA patients upon the premises of the CNH shall be delivered by the CNH to the person(s) entitled thereto under the laws currently governing the CNH for making disposition of funds and effects left by patients, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.

c. When disposition has been made, the itemized inventory with annotation as to the disposition of the funds and effects will be immediately forwarded to the VA facility authorizing admission. Should a deceased patient leave no will, heirs, or next of kin, his/her personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases, the CNH will forward an inventory of any such property and funds in its possession to the VA facility authorizing admission and will hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition. CMS regulations require retention of records for five (5) years when there is no requirement in State law.

16. Leave of Absence (LOA) – Bed-Hold Statement. For re-hospitalizations or therapeutic passes, VA will pay a bed hold. Any bed-hold charge shall not exceed the number of bed-hold days allowed by state regulations. Therapeutic passes will be authorized by the CNH staff based on individual patient needs but are generally limited to two (2) times per month and should be pre-approved. VA will cover bed holds based on the following plan:

The host VA medical center will select one of the following options:

a. 3 days/episode, pre-approved by the Louis A. Johnson VAMC when in the best interest of the Veteran and VAMC. Exceptions will be approved at VAMC level Bed-hold will begin the date the resident leaves the CNH and full per diem will resume on the date of readmission to the CNH. Absences of fifteen (15) consecutive calendar days or more, whether in a VA or in a non-Federal facility require a new authorization agreement. The nursing home is responsible to notify the family if a bed hold is required for a longer period. The family would then make arrangements with the home to hold the bed.

17. 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 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 veterans or 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.

18. 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 in accordance with the terms and clauses of the IDC and applicable procurement regulations:

a. Increase VA staffing monitoring until the State survey agency clears the deficiency;

b. Suspend placement of veterans in the CNH;

c. Remove or transfer veterans under the IDC from the subject CNH;

d. Not renew the IDC; and/or

e. Terminate the IDC.

19. 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. VAHCS Referral Package to the CNH:

1. Copy of Physician Orders for Nursing Home Care; CPRS Notes; Discharge Summary including History & Physical information with Medication List; Rehabilitation Progress Notes; and Veteran Demographic Record which includes next of kin information.

2. Copy of Authorization Agreement (VAF 10-7078).

b. Nursing Home Clinical Record: The CNH must maintain clinical records on each veteran in accordance with accepted professional standards and practice. The clinical record must be: complete, accurately documented, readily accessible, systematically organized, and legible. Clinical records must contain at a minimum:

1. Sufficient information to identify the resident;

2. A record of the veteran’s assessments, including those assessments performed by services under the IDC with the CNH;

3. The plan of care and services including medication administration, provided by CNH staff and services provided under the IDC with the CNH;

4. Interdisciplinary progress notes to include effect of care provided, veterans’ response to treatment, change in condition, and changes in treatment;

5. Medical practitioner orders which are signed and dated;

6. Allergies;

7. Person to contact in an emergency situation;

8. Name of attending medical practitioner; and

9. Advanced directives if available.

c. 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.

20. Specialty Services. The CNH will assume responsibility for arranging specialty care for veterans (e.g., dental care, podiatry and ophthalmology).

21. VA Medical Center Consultation/Resources.

(a) When Veteran requires ambulance transport to a Community Hospital Emergency Department

a. During work hours: Contact Care in the Community at 304-623-3461 ext. 2640

b. After work hours: Contact Administrative Officer of the Day (AOD) at 304-623-3461 ext. 3215

c. The Transferring nursing home is to inform the receiving emergency department the patient is a Veteran and following stabilization the Veteran is to be transported to the closest VA medical center. If not the LAJVAMC, then we are to be notified.

(b) When Veteran requires admission to a Community Hospital

a. Follow above protocol

(c) When the Veteran requires ambulance transport to this VAMC

a. Follow above protocol

b. NOTIFY VAMC EMERGENCY DEPARTMENT STAFF OF REASON FOR TRANSPORT AND EXPECTATIONS OF CARE.

22. 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.

23. CNH Billing (QASP Indicator #6). Invoices for board, 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, RUG category (ies), and agreed upon RUG rate (s). Failure to include this information may result in delayed payment.

a. Pre-approved services billed by CMS procedures or CPT codes: All services which are pre-approved by VA as additional to the all-inclusive per diem rate must be billed according to CMS procedures or CPT codes. The CNH will be reimbursed based on local guidelines and VA pricing schedules.

b. High cost drugs: All requests for additional reimbursement for high cost drugs and corresponding billing are due as soon as possible, but no later than 90 calendar days after use of products.

c. Invoices: Corrected invoices must be submitted for additional payment of any ancillary costs or changes to the original billing. All corrected invoices must include all items that are affected by the change.

Any rate adjustment shall not exceed the Medicare rate.

24. Minimum Quantities; VA Payment. The guaranteed minimum quantity to be awarded under this contract is one (1) night stay per veteran and the maximum quantity to be awarded under this contract is $5,000,000.00. 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.

25. 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.

a) Vendors who bill electronically using the HIPAA-compliant claims transactions must submit claims through the VA clearinghouse, Emdeon, using payer ID number 12115 for medical claims.

b) Vendors who are not able to use the HIPAA-compliant transactions are not required to do so. Supporting information for monthly invoices will be mailed to:

LAJVAMC

Attn: Community Nursing Home Program-Rosebud Plaza One Medical Center Drive Clarksburg, WV 26301

B.6 PRICE/COST SCHEDULE

*The guaranteed minimum quantity to be awarded under this contract is one (1) night stay per veteran and the maximum quantity to be awarded under this contract is $5,000,000.00. *

**The period of performance will be added prior to award of contract**

Medicare RUGS IV Pricing Schedule

Discount Medicare Per Diem Rate

+ RU Criteria – ADL 7-15

+ RV Criteria – ADL 16-18

+ RV Criteria – ADL 7-15

+ Rehab High Criteria - ADL 7-12

+ RM Criteria – ADL 7-15

6-10

2-5

15-16

15-16

11-14

11-14

B.1 ACCEPTABLE SAFETY AND SANITATION PRACTICES

Acceptable safety and sanitation practices shall be observed throughout the facility. The building shall conform to the standards of the Life Safety Code ( National Fire Protection Association Standard #101) in effect on the date of contract award.

B.2 MEDICARE/MEDICAID STANDARDS

The contractor is required to follow Medicare/Medicaid standards for all VA placements, except Life Safety. Medicare and Medicaid clinical and program standards are found in 42 CFR 483

4. INVOICES

Invoices shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered. All invoices must include the full name and address of the nursing home and shall reflect the patient's name, social security number, number of days billed, level of care category, and per diem rate. Failure to include this information may result in delayed payments.

5. AUTHORIZATIONS

Authorizations for nursing home care will be accomplished on VA Form 10-7078, Authorization and Invoice for Medical and Hospital Services. Each authorization validity period will be from the initial effective date to disposition. Any extension to the original authorization validity period, regardless of the number of days, requires a new VA Form 10-7078.

6. ANCILLARY COSTS

Ancillary costs are pre-approved costs for supplies or services not identified as included in the all-inclusive rate or any other pre- authorized rate or schedule or payment for items or services provided under this agreement. Ancillary costs such as medications, and special equipment, may not be added to any invoice without written permission of the VA medical center placing the veteran. If permission is received, the nursing home must also submit the physician's order for the medication/supply, the dispensing log, the supplier and the cost charged by the supplier to the nursing home, and what the nursing home is charging the VA.

B.3 ECONOMIC PRICE ADJUSTMENT

This provision does not apply to ancillary services that may be added or deleted from the agreement.

The per diem rate(s) will apply throughout the term of this contract, including extension period(s). The rate(s) may be adjusted only to reflect a change in a Medicaid rate as authorized by the SMA. Normally, this will be on an annual basis. The negotiated percentage above the Medicaid rate, to cover the all inclusive nature of the contract, will not be renegotiated; but will be applied and added to the new Medicaid rate for the adjusted per diem rate for each level of care item. This clause does not apply to rates for non Medicaid nursing homes. In this regard, new rates will be negotiated requiring a modification to the contract. Each per diem price adjustment under this clause is subject to the following limitations:

Any adjustment shall be limited to the effect of increases or decreases in the approved SMA's patient care components within the affected Medicaid groups.

Adjustments will occur no more frequently than those issued by the SMA.

No adjustments will be made until the Contracting Officer receives an SMA authenticated copy of the new rate, signed and dated in a conspicuous area at the top right of the document by the authorized nursing home official. Within ten days after this occurs, the Contracting Officer will execute an approval signature and date at the approximate location of the nursing home official's signature, the action of which will serve as the effective date of the adjusted rate. A copy of the fully executed document will be sent to the nursing home official for record keeping purposes.

**** CO should establish multi level care rates wherever possible regardless of whether the local state has only a unitary care rate program, as the multi level care rate approach can better approximate the actual cost of care for individual patients. The levels of care can be either the VA version (use also for private care CNHs) as shown on the Community Nursing Home Website; state version; or any combination thereof. In this regard, indicate "VA" or "state" in the description column of the Price Schedule for each level of care listed. All levels of care required for the contract period, including the option period(s), should be listed whenever possible. This will eliminate or minimize the need for modifications. A list of VA levels of care is contained in the Sample Price Schedule shown in the Description of Care column below. Definitions of the VA levels of care, displayed on the CNH Website are listed as Attachment 1 as referenced in Section E of this format. Attachment 1 should be included when VA levels of care are included. ****

B.4 TERMINATION OF SERVICES

VA reserves the right to remove any or all VA patients from the nursing home at any time, when it is determined to be in the best interest of VA or the patients.

B.5 PAYMENTS

36C24520R0022 Payments made by VA under this contract constitute the total cost of nursing home care. No additional charges will be billed to Medicare Part B, the beneficiary or his/her family, either by the nursing home or any third part 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 contractor will not solicit contributions, donations, or gifts from patients or family members.

SECTION C - CONTRACT CLAUSES

ADDENDUM to FAR 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS Clauses that are incorporated by reference (by Citation Number, Title, and Date), have the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available.

The following clauses are incorporated into 52.212-4 as an addendum to this contract:

C.1 52.203-16 PREVENTING PERSONAL CONFLICTS OF INTEREST DEC 2011

(a) Definitions. As used in this clause— "Acquisition function closely associated with inherently governmental functions" means supporting or providing advice or recommendations with regard to the following activities of a Federal agency:

(1) Planning acquisitions.

(2) Determining what supplies or services are to be acquired by the Government, including developing statements of work.

(3) Developing or approving any contractual documents, to include documents defining requirements, incentive plans, and evaluation criteria.

(4) Evaluating contract proposals.

(5) Awarding Government contracts.

(6) Administering contracts (including ordering changes or giving technical direction in contract performance or contract quantities, evaluating contractor performance, and accepting or rejecting contractor products or services).

(7) Terminating contracts.

(8) Determining whether contract costs are reasonable, allocable, and allowable.

"Covered employee" means an individual who performs an acquisition function closely associated with inherently governmental functions and is—

(1) An employee of the contractor; or

(2) A subcontractor that is a self-employed individual treated as a covered employee of the contractor because there is no employer to whom such an individual could submit the required disclosures.

"Non-public information" means any Government or third-party information that—

(1) Is exempt from disclosure under the Freedom of Information Act (5 U.S.C. 552) or otherwise protected from disclosure by statute, Executive order, or regulation; or

(2) Has not been disseminated to the general public and the Government has not yet determined whether the information can or will be made available to the public.

"Personal conflict of interest" means a situation in which a covered employee has a financial interest, personal activity, or relationship that could impair the employee's ability to act impartially and in the best interest of the Government when performing…