36C25622R0009.docx

36C25622R0009

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. NOV 2021)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

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

PAID VIA 1358

36C25622R0009 02-17-2022 Toni A. Clendenen 601-364-1373 02-16-2023

3:00 PM

CST

36C256 Department of Veterans Affairs

NETWORK CONTRACTING OFFICE (NCO 16)

715 S. PEAR ORCHARD RD.

RIDGELAND MS 39157

X 623110 $30 million N/A X 16/667/502

SEE PERFORMANCE WORK STATEMENT

MULTIPLE LOCATIONS PROJECTED

36C256 Department of Veterans Affairs

NETWORK CONTRACTING OFFICE (NCO 16)

715 S. Pear Orchard Rd Ridgeland MS 39157

SEE SECTION B FOR SPECIFIC INVOICING

INSTRUCTIONS

X See CONTINUATION Page

COMMUNITY NURSING HOME CARE SERVICES

OPEN & CONTINUOUS SOLICITATION X ONE (1) YEAR

OVERTON BROOKS VA MEDICAL CENTER (OBVAMC) SHREVEPORT, LA AND

ALEXANDRIA VA HEALTHCARE SYSTEM, PINEVILLE, LA

MULTIPLE VA FACILITY/MULTIPLE AWARD PER FACILITY PROJECTED

OFFERORS MUST IDENTIFY PARENT FACILITY AND PARISH/COUNTY

IN WHICH THEIR FACILITY IS LOCATED & INTENDS TO PROVIDE CARE

SEE SECTION B PAGE 6 AND FILL IN THE PARISH/COUNTY PROPOSED.

SEE SECTION E - INSTRUCTION TO OFFERORS, PG 62 FOR DETAILS

See CONTINUATION Page X X

ONE

Toni A. Clendenen

VA-VHA-2021-EABD9C35

Table of Contents

D.1 DVA COMMUNITY NURSING HOME PROGRAM LEVEL OF CARE DESCRIPTIONS

D.2 RUG III CLASSIFICATION & HIERARCHY

D.3 DoL WAGE DETERMINATION LINKS

D.4 QUALITY ASSURANCE SURVEILLANCE PLAN

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

b. GOVERNMENT: Toni A. Clendenen, Contracting Officer Department of Veterans Affairs Network Contracting Office 16 715 S. Pear Orchard Rd.

Ridgeland, MS 39157 Phone: (601) 206-0751 Email: toni.clendenen@va.gov

Overton Brooks VA Medical Center Latisha Robinson, Contracting Officer’s Representative (COR) Department of Veterans Affairs Overton Brooks VA Medical Center (OBVAMC) 510 E. Stoner Avenue Shreveport, LA 70019 Phone: (800) 935-8387 ext.67233 Email: latisha.robinson@va.gov

Alexandria VA Health Care System Shane Voohries, Contracting Officer’s Representative (COR) Department of Veterans Affairs Alexandria VA Health Care System 2495 Shreveport Highway Pineville, LA 73360 Phone: (318) 466-2431 Email: shane.voorhies@va.gov

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

See Performance Work Statement Page 20, # 23 for Invoicing Requirements

5. SECURE FAX: Please review VA Handbook 6500 that requires the following statement on all fax cover sheets be included:

“This fax is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this fax does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please notify this office immediately at the telephone number listed above.

6. The Contracting Officer will schedule a post award orientation for contract orientation purposes as required by VA Acquisition Manual, Part M842.502-70.

7. ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

36C25622R0009

Page 1 of Page 1 of

B.2 SUMMARY OF PRICE SCHEDULES:

1. The Contractor shall furnish all personnel to provide services necessary to perform community nursing home services to eligible beneficiaries of the Department of Veterans Affairs, VISN 16, for a multiple award fixed-unit price five (5) year Indefinite Delivery Contract (IDC) with Economic Price Adjustment (EPA), with Five (5) One (1) Year ordering periods from this solicitation. NAICS Code 623110, PSC/FSC Q402. All invoices submitted for review and payment shall include the LIN being invoiced for payment.

Offeror shall submit offer(s) and pricing for location(s) of interest listed below for the catchment area(s) of interest.

Note: A separate offer must be provided for each site if multiple sites are proposed.

a. Louisiana – ___________________(City), ________________ (Parish).

b. Texas - ___________________(City), _____________(County).

RATE DETERMINATION

The per diem rate is established by the current Medicaid rate for Medicaid approved nursing homes plus a fair market amount (percentage) to cover the cost of supplies, services, and equipment above that provided under Medicaid established by the local state Medicaid agency (SMA). Rates established after the effective date of this contract will constitute a modification to the contract.

VA will use Medicaid rates for room, board, and routine nursing care.

For all levels of nursing care a percentage is added for routine ancillary services/supplies, such as drugs, nursing supplies, oxygen (occasional use), x-ray, laboratory, physician visits, and rental equipment.

Special equipment, e.g. clinitron bed, is/are not considered routine ancillary services (and may be provided by the VA).

Drug costs which comprise more than eight and one-half percent (8.5%) of the per diem rate are generally not considered routine ancillary supplies (and may be provided by the VA).

Rehabilitation therapies will be provided as a distinct level of care. Hospice Care and Dialysis are not included in the rate. VA or other payers may be used for Hospice and Dialysis, as determined by the veteran with VA approval.

ORDERING OFFICERS

Pursuant to VAAR 801.603-70, Ordering officers (OOs) will be authorized to place orders against this contract. The Contracting Officer (CO) will furnish the Contractor with the names of individuals authorized as OOs, by separate memorandum upon issuance of the contract.* When OOs are added after award, the CO will furnish the Contractor with the names of individuals authorized as OOs, by memorandum upon OO appointment. OOs are responsible for issuing and administering orders placed under this contract.

*OOs have no authority to modify any term of this basic contract. Any deviation from the terms of the basic contract must be approved in writing by the CO responsible for this contract. The Contractor shall accept orders against this contract only from the CO and/or authorized OOs. Fulfilling orders from persons other than the CO or OO may result in loss or delay in payment for supplies/services provided under such orders.

Order Limitations (See FAR 52.216-19, Section C) IDC Contract Limitations:

1. Contract IDC Minimum: The cost of one room for one veteran for one day.

2. Contract IDC Maximum: Maximum dollar value of the contract shall not exceed $20,000,000.00.

Ordering Period Task Order Limitations (See FAR 52.216-19, Section C)

1. Minimum Task Order: Minimum is met if one veteran consult is received for the ordering period.

1. Maximum Task Order: Maximum dollar of value of each task order shall not exceed $2.5 million.

B.3 PRICE/COST SCHEDULE

ITEM INFORMATION

VA Reduced Physical Functioning (PA1, PA2, PB1, PB2, PC1, PC2, PD1, PD2, PE1, PE2) Contract Period: Base POP Begin:

POP End:

Complete Fields:

Medicaid Rate $___________ x Proposed % above Medicaid __________ = VA Basic Rate $____________

Behavioral Symptoms and Cognitive Performance (BA1, BA2, BB1, BB2)

POP Begin:

POP End:

Complete Fields:

VA Basic Rate $___________ x Proposed % above Medicaid ___________ = Per Diem Rate $____________

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

POP Begin:

POP End:

Complete Fields:

Special Care Low (LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1)

POP Begin:

POP End:

Complete Fields:

Special Care High (HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1)

POP Begin:

POP End:

Complete Fields:

Extensive Services: (ES3, ES2, ES1)

POP Begin:

POP End:

Complete Fields:

Rehabilitation:

Ultra-high Rehab (RUC, RUB, RUA) Very-high Rehab (RVC, RVB, RVA) High Rehab (RHC, RHB, RHA) Medium Rehab (RMC, RMB, RMA) Low Rehab (RLB, RLA) Contract Period: Base POP Begin:

POP End:

Complete Fields:

Rehabilitation + Extensive Services:

Ultra-high Rehab + Ext Svs (RUX, RUL) Very-high Rehab + Ext Svs (RVX, RVL) High Rehab + Ext Svs (RHX, RHL) Medium Rehab + Ext Svs (RMX, RML) Low Rehab + Ext Svs (RLX) Contract Period: Base POP Begin:

POP End:

Complete Fields:

VA HIV/ +AIDS:

POP Begin:

POP End:

Complete Fields:

Pharmacy Greater than 8.5%

POP Begin:

POP End:

Rate: Actual Cost above 8.5%

Ancillary Services

POP Begin:

POP End:

Rate: Actual Cost

GRAND TOTAL

B.4 PERFORMANCE WORK STATEMENT

A. Overview

1. Federal Acquisition Regulation (FAR) – Indefinite Delivery Contract (IDC). In accordance with FAR 16.504, Indefinite-Quantity Contracts, this requirement is a twelve month, open and continuous solicitation for Community Nursing Home Care Services throughout the catchment areas listed in the paragraphs below:

The Overton Brooks VA Medical Center (OBVAMC) Shreveport, LA has multiple needs for Nursing Home Services in the surrounding State of Louisiana parishes of Caldwell, Franklin, Madison, Jackson, Ouachita, Union, Moorehouse, West Carroll, East Carrol, Richland, Tensas to Caddo, Bossier, Webster, Claiborne, Lincoln, Bienville, and the State of Texas counties of Red River, Sabine, Desoto and Natchitoches encompassing the catchment area of Shreveport to Monroe, LA and their surrounding suburbs and rural areas.

The Alexandria VA Health Care System has multiple needs for Nursing Home Services in the surrounding State of Louisiana parishes of Sabine, Desoto, Natchitoches, Vernon, Beauregard, Allen, Evangeline, Jefferson Davis, Calcasieu, Winn, Grant, LaSalle, Catahoula, Avoyelles, Rapides, St. Landry, Acadia, Lafayette, St. Martin and Iberia encompassing the catchment area of Alexandria LA and their surrounding suburbs and rural areas.

Please be aware all Federal, State and local labor laws will be applicable to this procurement including, federal minimum wage as provided in Section 6(a)(1) of the Fair Labor Standards Act. If you have specific questions regarding labor laws, you should contact your local Federal Department of Labor representative.

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 Summary of Schedules of Items included in this IDC. The VA “Levels of Care” are defined as 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 Delegated 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) and VA Acquisition Regulation (VAAR) 801.603-70)). Ordering Officer Contact information for each medical center is as follows:

Overton Brooks VA Medical Center (OBVMC) (667/122)

Community Nursing Home Coordinator (006) 510 E. Stoner Ave Shreveport, LA 71101

Community Nursing Home Coordinator (006) 510 E. Stoner Ave Shreveport, LA 71101

Alexandria VA Health Care System (502/122)

2495 Shreveport Hwy 71 N Pineville, LA 71360-4044

A. 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 Overton Brooks VA Medical Center (OBVAMC) (OBVHCS), in Shreveport, LA and/or the Alexandria VA Health Care System (AVHCS) in Pineville, LA at the prices specified in the section titled Summary of Schedules 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.

B. Requirements

1. General. OBVAMC and AVHCS are requesting multiple facilities throughout their catchment areas as needs arise. 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 Office of Community Care Field Guidebook (FGB) Specialty Programs, a copy of which is available at: https://dvagov.sharepoint.com/sites/VHAOCC/CNM/CI/OCCFGB/SitePages/FGB.aspx

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.

Patients who require continued nursing home stay post termination of a VA contract and require implementation of a new payer source such as Medicaid, will be the responsibility of the nursing care facility’s social worker. The nursing home’s social worker will assist patients/families with completing the necessary arrangements, including any and all applications for nursing care, payment and benefits. VA staff will be available as consultants during this transition period.

4. Medicaid-Based Rates. The current State Medicaid rates may be used as a basis for determination of VA rates. The VA rate will include medical care, routine medications, laboratory, x-ray, therapy (ies), and other special services authorized by VA, unless otherwise specifically exempted. VA will contract for appropriate Medicaid categories of care using Resource Utilization Groups (RUG-IV) as a guide. A description of the RUG-IV systems can be found in 42 CFR Parts 409, et al. 42 CFR §409 Hospital Insurance Benefits - Code of Federal Regulations (ecfr.io)

The category of care classification and associated per diem rate will remain in effect for each placement until and unless one of the following events takes place:

a. The recipient is discharged and subsequently qualifies for a new admission assessment; and/or

b. The nursing home submits an assessment requesting a change in the level of care classification and VA approves it. Classification changes may also occur based on a determination by VA. VA will make the determination whether classification changes require readmission to VA.

5. 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 42 CFR §483 Requirements For States And Long Term Care Facilities - Code of Federal Regulations (ecfr.io)).

6. 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 requires 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.

7. 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.

8. 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.

9. 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 responsible VHA Healthcare System Community Nursing Home Coordinator (See # 3 above for contact information). 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 immediately once received 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.

10. 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:

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

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

e. 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;

f. 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

g. Provide dates when corrective action will be completed.

11. 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 (Current Edition 2021) and compliance with all applicable Federal, State and local regulations NFPA 101®: Life Safety Code®. 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% sprinkled;

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 time of renovation or alteration.

12. 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.

13. 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-ours 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.

14. Prescription Medication. Drug costs which comprise more than eight and one-half percent (8.5%) of the per diem rate are generally not considered routine ancillary supplies and may be reimbursed by the VA. The nursing home must complete the Notification and Request for Reimbursement of Medication Costs Exceeding 8.5%, along with pharmacy bill and Medication Administration Record (MAR). Approved requests for reimbursement of medication costs should be added to the monthly invoice. High drug costs will be determined or priced using the Average Wholesale Price (AWP). All calculations will be made on a monthly basis. When a high-cost drug patient is identified, the Contract Nursing Home Coordinator must be advised promptly so that a drug cost analysis is conducted. The nursing home is responsible for forwarding to the VA on admit of the Veteran to the nursing home and by the first day of each month, an update of the patient’s medication profile with drug cost for analysis. Once completed, the nursing home will be notified by the VA Contract Nursing Home Coordinator of high-cost drugs to be reimbursed or provided by the VA. A copy of this notice and subsequent updates should be kept in the Veteran’s medical record for review by the Community Health Nurse and Social Worker at 30-day follow-up visits.

15. Leave of Absence (LOA) – Bed-Hold Statement. For re-hospitalizations or therapeutic passes, VA will pay a bed hold. 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:

1. 2 days/episode, pre-approved by VA when in the best interest of the Veteran and VA. Exceptions 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.

16. Reportable Events (QASP Indicator #3). VA requires CNHs to report to the CNH Coordinator at VA any of the following events within 24-hours or by 10:00 a.m. 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.

17. 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.

18. VA Staff Access to CNH Records (QASP Indicator #4). 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.

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

20. VA Health Care System Consultation/Resources.

20a. Overton Brooks VA Medical Center:

(a). Telephone Care Communications Systems (TCCS): For non-urgent scheduled clinic appointments/consultations, call the Overton Brooks VA Medical Center and ask to be transferred to the needed specialty clinic (i.e. cardiology, urology, etc.) at 1-800-863-7441 between 9 a.m. and 3 p.m. Monday through Friday, excluding holidays. If a same day appointment is anticipated; please call as early as possible.

(b). Admissions Conference: For non-emergency consultation or/evaluation for admission to the Overton Brooks VA Medical Center (after initial evaluation or intervention by the nursing home physician), send Veteran to nearest ER and follow the community emergency room notification process. If the CNH physician is coordinating a direct admission to the VA with a VA specialty clinic provider/physician, please follow the instructions provided by the VA specialty clinic provider/physician.

(c). After hours, weekends and holidays: Go to nearest ER and follow the community emergency room notification process.

(d). Transportation: Necessary transportation to and from the VA hospital for clinics, evaluation or hospitalization will be arranged and paid by the VA hospital business office special transportation section for CNH patients when requested. CNH facilities should not schedule their own transportation and send VA the bill. VA special transportation must be contacted in advance at Ext 5131 and special transportation will arrange the transportation at VA’s expense. For clinic appointments, call 318-990-5131. For questions after hours call 318-990-5116.

20b. Alexandria VA Health Care System:

(a) Telephone Care Communications Systems (TCCS): For urgent same-day outpatient specialty care or for non-urgent scheduled clinic appointments/consultations, phone 318-483-5083 between 9 a.m. and 3 p.m. Monday through Friday, excluding holidays. If a same-day appointment is anticipated; please call as early as possible.

(b) Admissions Conference Call Systems phone number Phone #: 318-466-4402 For non-emergency consultation or /evaluation for admission to the Southeast Louisiana Veterans Health Care System (after initial evaluation or intervention by the nursing home physician).

(c) After hours, weekends and holidays: For urgent referrals or consultation contact the Admission Conference Call System number 318-466-4402.

(d) Transportation: Necessary transportation to and from the VA hospital for clinics, evaluation or hospitalization will be arranged and paid by the VA hospital for CNH patients when requested. For Clinic appointments, call 318-466-2424.

21. 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.

22. 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, special equipment, rehabilitation therapies, etc., 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.

23. CNH Billing (QASP Indicator #5). Invoices for board, care and ancillary services shall be submitted promptly to the authorizing facility by close of business on the 15th calendar day following the end of the month in which services were rendered. Invoices should be accurate for all items billed. 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-approves 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: Invoices must include the contract line item number that corresponds to the Medicaid RUG IV rate being invoiced. 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.

24. 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:

Overton Brooks VA Medical Center 510 E. Stoner Ave # 122 Shreveport, LA 71101 Attn: Budget Tech (122)

Alexandria VA Health Care System P. O. Box 69004 Alexandria, LA 71306-9004 ATTN: Josephine Izzo (122)

25. Emergency Preparedness Plans. The nursing home shall submit a copy of the facility’s Emergency Preparedness Plan and the cover letter received from the State of Louisiana’s Office of Emergency Preparedness acknowledging receipt of the facility’s plan to the Community Nursing Home Care Coordinator. This plan is due no later than two weeks after award of a contract and by March 1st of each year thereafter.

CNH PHARMACY INVOICES

CNH DOCUMENTS REQURED (mail/fax):

Pharmacy Bill Spreadsheet (See Below for Template, Medications & Amount) Medication Administration Record (MAR, to include all medications listed in the invoice) Pharmacy Bill (Pharmacy used by CNH) Line Item Number (LIN) from Price Schedule being billed

SAMPLE

MONTHLY PER DIEM IS $5000

PHARMACY BILL SPREADSHEET $650

$5000 X 8.5% = $425 $650 - $425 = $225 $225 + $6.75 (3% transaction fee) = 231.75 (TOTAL AMOUNT OWED TO CNH)

PLEASE USE THIS TEMPLATE FOR INVOICES (see attachment on next page)

INFORMATION THAT NEEDS TO BE INPUT IN SPREADSHEET

· Nursing Home Information

· Resident Information

· VA Per Diem Rate

· Start Date & End Date

· Line Item Number (LIN)

If there are 2 RUGs use the second lines for the following

· VA Per Diem Rate (if 2 RUGs rates are used in the month)

· Start Date & End Date

· Line Item Number (LIN)

THERE IS NO NEED SEND BILLS THAT DO NOT EXCEED 8.5% OF MONTHLY PER DIEM

EXCEPTIONS

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