36C25520R0016-006.docx

Capabilities Questionnaire Part 1 of 3 Patient Acceptance, Placement, Care

1. As of the date of this proposal, your facility’s capacity is %, of # of beds?

2. This solicitation requires performance of the following CMS categories of care. Some CNH facilities do not perform all care levels. Indicate which care levels (all RUG codes) your facility performs as a part of its day-to-day operations:

Performance Care Level Indicate with “Yes” if performed, blank if not performed.

a. CLIN 0001A - Reduced Physical Function

(PA1, PA2, PB1, PB2, PC1, PC2, PD1, PD2, PE1, PE2)

b. CLIN 0001B - Behavioral Symptoms & Cognitive Performance

(BA1, BA2, BB1, BB2)

c. CLIN 0001C – Clinically Complex

(CE2, CE1, CD1, CD2, CC2, CC1, CB2, CB1, CA2, CA1)

d. CLIN 0001D - Special Care (Low)

(LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1)

e. CLIN 0001E - Special Care (High)

(HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1)

f. CLIN 0001F - Extensive Services

(ES1, ES2, ES3)

g. CLIN 0001G - Rehabilitation Therapy

(RUC, RUB, RUA, RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, RLA)

h. CLIN 0001H – Rehabilitation Plus Extensive Services

(RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX)

3. If any level of care item above is not currently being performed in the day-to-day operations, is there an anticipation of performing the care levels if the VA’s beneficiaries have need for the level of care?

4. If 0001G or 0001H is performed, describe the type(s) of rehabilitation and therapy services that can be performed, noting any related equipment or resources to support rehabilitation and therapy services: Use separate sheet of paper if needed.

5. Is the facility Medical Director located at the facility?

a. If not, how often do physician visits occur per month?

6. If 0001B is performed, does the facility support the capability to provide those services, such as staff or visiting staff, facility features, etc.:

a. Alzheimer’s?

b. Dementia?

c. Other Behavioral-related patient-types?

Part 2 of 3 Past Performance – Government Business – last 3 years

1. Indicate any (up to 3) Federal Contracts, Agreements or similar patient placement arrangement held by, or entered into by the offeror’s nursing facility in the last 3 years, even if under different ownership than current ownership that involved the same or similar types of services described in this Request for Proposal, indicating:

- The Federal office or VA Medical Center locations:

- The contract, agreement or arrangement information (number, title, other identifier), period of services:

- The Contracting Officer or similar Representative contact information (name, phone, fax, address, e-mail):

Part 3 of 3 Past Performance – Non-Government Business – last 3 years

1. If NO Federal Contract, Agreement or similar patient placement arrangement has been held in the past, please indicate Non-Government Agency-related past performance information substantially the same as requested above within the past 3 years.

- Non-Government customers (e.g. hospital, physician group, etc.) Note – do not provide individual patient references:

- Non-Government customer arrangement information (number, title, other identifier) or period of services:

- The officials responsible for the arrangement(s) contact information (name, phone, fax, address, e-mail):