36C25819Q0001-001.docx

36C25819Q0001

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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

36C25819Q0001 03-04 -2019 Nonya Montano (nonya.montano@va.gov) 520-838-3600 03-02 -2020 11:00am EST Department of Veterans Affairs NCO22-Gilbert Network Contracting 3601 S. 6th Avenue Bldg. 45 Tucson AZ 85723 X 623110 X N/A X Department of Veterans Affairs Phoenix VA Healthcare System 650 E. Indian School Rd.

Phoenix AZ 85012 Department of Veterans Affairs NCO22-Gilbert Network Contracting 3601 S. 6th Avenue Bldg. 45 Tucson AZ 85723

Department of Veterans Affairs

ATTN: 136G

650 E. Indian School Rd.

Phoenix AZ 85012 602-277-5551 Ext. 2935 602-200-2375 See CONTINUATION Page Community Nursing Homes (CNH) for Maricopa and Gila Counties of Arizona in accordance with the Performance Work Statement

(PWS).

Procurement Authority: Title 38 U.S. Code § 1720.

X X X Carlos Acosta Table of Contents

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:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C258

Department of Veterans Affairs NCO22-Gilbert Network Contracting 3601 S. 6th Avenue Bldg. 45 Tucson AZ 85723

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.

Department of Veterans Affairs

ATTN: 136G

650 E. Indian School Rd.

Phoenix AZ 85012 ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

B.2 PRICE/COST SCHEDULE

“The guaranteed minimum award amount for this contract is one day of service care. The maximum aggregate value of orders that can be placed under this contract is $5,000,000.00. The Government does not guarantee that it will place any orders under this contract in excess of the guaranteed minimum award amount”.

ITEM INFORMATION

UNIT PRICE PER DAY

Respite Care Contract Period: Base POP Begin:

POP End:

Reduced Physical Function - Basic Care

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

Contract Period: Base

Behavioral & Cognitive Performance (BA1, BA2, BB1, BB2) (Dementia Care) Contract Period: Base

Clinically Complex

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

Contract Period: Base

Special Care Low

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

Contract Period: Base

Special Care High

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

Contract Period: Base

Extensive Services Trach (ES3) and/or Trach (ES2) Isolation for infectious disease (ES1)

Contract Period: Base

Rehabilitation Ultra-high Rehab (RUC, RUB, RUA) Very-high Rehab (RVC, RVB, RVA) High Rehab (RHC, RHB, RHA) Medium Rehab (RMC, RHB, RHA) Low Rehab (RLB, RLA)

Contract Period: Base

Rehabilitation Plus Extensive 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

Ventilator Care

Ventilator Care Plus Rehabilitation

Secure Behavior Unit Name:

Contract Period: Base

Secure Behavior

Contract Period: Base

Secure Behavior, High Acuity

Secure Behavior Plus Rehabilitation

HIV/AIDS

Bed Hold Per PWS Paragraph 11.2

Incidental Supplies in performance of care

Respite Care Contract Period: Option 1

Reduced Physical Function - Basic Care

Contract Period: Option 1

Behavioral & Cognitive Performance

Contract Period: Option 1

Clinically Complex

Contract Period: Option 1

Special Care Low

Contract Period: Option 1

Special Care High

Contract Period: Option 1

Extensive Services

Isolation for infectious disease (ES1)

Contract Period: Option 1

Rehabilitation

Very-high Rehab (RVC, RVB, RVA) High Rehab (RHC, RHB, RHA) Medium Rehab (RMC, RHB, RHA) Low Rehab (RLB, RLA)

Contract Period: Option 1

Rehabilitation Plus Extensive

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: Option 1

Ventilator Care

Ventilator Care Plus Rehabilitation

Secure Behavior

Contract Period: Option 1

Secure Behavior

Contract Period: Option 1

Secure Behavior, High Acuity

Secure Behavior Plus Rehabilitation

HIV/AIDS

Bed Hold Per PWS Paragraph 11.2

Incidental Supplies in performance of care

Respite Care Contract Period: Option 2

Reduced Physical Function – Basic Care

Contract Period: Option 2

Behavioral & Cognitive Performance

Contract Period: Option 2

Clinically Complex

Contract Period: Option 2

Special Care Low

Contract Period: Option 2

Special Care High

Contract Period: Option 2

Extensive Services

Isolation for infectious disease (ES1)

Contract Period: Option 2

Rehabilitation

Very-high Rehab (RVC, RVB, RVA) High Rehab (RHC, RHB, RHA) Medium Rehab (RMC, RHB, RHA) Low Rehab (RLB, RLA)

Contract Period: Option 2

Rehabilitation Plus Extensive

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: Option 2

Ventilator Care

Ventilator Plus Rehabilitation

Secure Behavior

Contract Period: Option 2

Secure Behavior

Contract Period: Option 2

Secure Behavior, High Acuity

Secure Behavior Plus Rehabilitation

HIV/AIDS

Bed Hold Per PWS Paragraph 11.2

Incidental Supplies in performance of care

Respite Care Contract Period: Option 3

Reduced Physical Function – Basic Care

Contract Period: Option 3

Behavioral & Cognitive Performance

Contract Period: Option 3

Clinically Complex

Contract Period: Option 3

Special Care Low

Contract Period: Option 3

Special Care High

Contract Period: Option 3

Extensive Services

Isolation for infectious disease (ES1)

Contract Period: Option 3

Rehabilitation

Very-high Rehab (RVC, RVB, RVA) High Rehab (RHC, RHB, RHA) Medium Rehab (RMC, RHB, RHA) Low Rehab (RLB, RLA)

Contract Period: Option 3

Rehabilitation Plus Extensive

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: Option 3

Ventilator Care

Ventilator Care Plus Rehabilitation

Secure Behavior

Contract Period: Option 3

Secure Behavior

Contract Period: Option 3

Secure Behavior, High Acuity

Secure Behavior Plus Rehabilitation

HIV/AIDS

Bed Hold Per PWS Paragraph 11.2

Incidental Supplies in performance of care

Respite Care Contract Period: Option 4

Reduced Physical Function – Basic Care

Contract Period: Option 4

Behavioral & Cognitive Performance

Contract Period: Option 4

Clinically Complex

Contract Period: Option 4

Special Care Low

Contract Period: Option 4

Special Care High

Contract Period: Option 4

Extensive Services

Isolation for infectious disease (ES1)

Contract Period: Option 4

Rehabilitation

Very-high Rehab (RVC, RVB, RVA) High Rehab (RHC, RHB, RHA) Medium Rehab (RMC, RHB, RHA) Low Rehab (RLB, RLA)

Contract Period: Option 4

Rehabilitation Plus Extensive

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: Option 4

Ventilator Care

Ventilator Care Plus Rehabilitation

Secure Behavior

Contract Period: Option 4

Secure Behavior

Contract Period: Option 4

Secure Behavior, High Acuity

Secure Behavior Plus Rehabilitation

HIV/AIDS

Bed Hold Per PWS Paragraph 11.2

Incidental Supplies in performance of care

**Secure Behavior Unit constitutes those individuals whose rates are not included in the above structure due to severity of behaviors and the need for higher level of care than can be safely accommodated utilizing the standard rate structure. **

B.3 PERFORMANCE WORK STATEMENT

Performance Work Statement Community Nursing Home

A. INTRODUCTION

1. The Community Nursing Home (CNH) program is a key component of the Veterans Health Administration (VHA) continuum of care under authority 38 U.S. Code § 1720. The Contractor agrees to provide in accordance with the terms and conditions stated herein to the U.S. Department of Veterans Affairs, Phoenix Veterans Administration Health Care System, in the following approximate geographic areas: Maricopa County, Arizona and Gila County, Arizona. Other counties in the State of Arizona may be considered at the government’s discretion.

2. 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.

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

B. SCOPE

Nursing home care will be furnished to ensure the total medical, nursing, and psycho-social needs of VA beneficiaries. The nursing home shall ensure that care meets the health needs and promotes the maximum well-being of VA patients. Physician visits, laboratory, x-ray, and other special services for VA patients will be at the same frequency as that provided to other patients at the nursing home receiving the same or comparable level of care. 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. All therapy services will be provided by a licensed professional staff and follow the Medicare regulation and procedures of progress toward identified goals. The per diem rate(s) established in this contract will include the cost of primary medical care, drugs and routine supplies, laboratory, x ray, and other special services authorized by VA, unless otherwise specifically accepted.

Full attention shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living, to the maximum extent possible. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care.

The nursing home shall accept referral of and shall provide all services specified in this contract for any person determined eligible by the VA Under Secretary for Health or his/her designee, regardless of the race, color, religion, sex, or national origin of the person for whom such services are ordered. In addition, the nursing home warrants that subcontracting will not be resorted to as a means of circumventing this provision. Additionally, the nursing home shall not maintain nor provide dual or segregated patient facilities which are segregated on the basis of race, creed, color, or national origin. The nursing home shall neither require such segregated use by written or oral policies, nor tolerate such use by local custom. The term facilities shall include but not be limited to rooms, wards, sections, eating areas, drinking fountains, entrances, and other like areas.

C. PERIOD OF PERFORMANCE: In accordance with FAR 16.504, Indefinite-Quantity Contracts, each indefinite delivery contract awarded shall be for a period of one (1) base year with four (4) options.

D. REQUIREMENTS

1.0 Level of Care The contractor shall provide one or more specific levels of care defined in the following paragraphs. Level of care determinations are based on the VA Resource Utilization Groups (RUGS-IV) case-mix, the industry standard. See 42 CFR Parts 411 and 489. A case-mix system categorizes patients into groups according to their level of care needs. RUGS-IV, like other case-mix systems, defines patients for clinical and reimbursement purposes.

Respite Care: This level of care is designed to provide short term, limited use (not to exceed 14 days per episode and 30 days per calendar year) services for veterans with chronic illness not in need of acute care services and who are not better accounted for in the RUG case mix. This is designed to provide temporary relief to the primary care giver to help the veteran to continue residing in their primary residence. It is designed to accommodate referrals with minimum care needs. Referrals with more complex care needs would be accommodated under the RUG case mix classification system. Rates for Respite Care will be based on negotiated fair and reasonable negotiated rates set forth in the contract. Determination of which level of care rate is applicable will be made on a case-by-case basis based on the level of care required by the patient(s) at the time of Respite Care Placement.

Reduced Physical Function: Residents whose needs are primarily for support with activities of daily living and general supervision. Calculations identify residents who are receiving restorative nursing services as recorded on the MDS and include: urinary and/or bowel training program, passive and/or active range of motion, amputation/prosthesis, training, splint or brace assistance, dressing or grooming training, eating or swallowing training, transfer training, bed mobility and/or walking training, communication training.

Behavioral Symptoms and Cognitive Performance: Residents satisfying the following two conditions: Having a maximum ADL dependency score of 5 or less. Having behavioral or cognitive performance symptoms, involving any of the following: difficulty in repeating words, temporal orientation, or recall (score on the Brief Interview for Mental Status <=9), difficulty in making self-understood, short term memory, or decision making (score on the Cognitive Performance Scale >=3), hallucinations, delusions, physical behavioral symptoms toward others, verbal behavioral symptoms toward others, other behavioral symptoms, rejection of care, or wandering.

Clinically Complex: Residents receiving complex clinical care or have conditions requiring skilled nursing management, interventions or treatments involving any of the following: pneumonia, hemiplegia with ADL dependency score of 5 or more, surgical wounds or open lesions with treatment, burns, chemotherapy while a resident, oxygen therapy while a resident, IV medications while a resident, or transfusions while a resident.

Special Care High: Residents satisfying the following two conditions: Having a minimum ADL dependency score of 2 or more. Receiving complex clinical care or have serious medical conditions involving any one of the following: comatose, septicemia, diabetes with insulin injections and insulin order changes, quadriplegia with a higher minimum ADL dependence criterion (ADL score of 5 or more), chronic obstructive pulmonary disease (COPD) with shortness of breath when lying flat, fever with pneumonia, vomiting, weight loss, or tube feeding meeting intake requirement, parenteral/IV feeding, or respiratory therapy.

Special Care Low: Residents satisfying the following two conditions: Having a minimum ADL dependency score of 2 or more. Receiving complex clinical care or have serious medical conditions involving any of the following: cerebral palsy with ADL dependency score of 5 or more, multiple sclerosis with ADL dependency score of 5 or more, Parkinson’s disease with ADL dependency score of 5 or more, respiratory failure and oxygen therapy while a resident, tube feeding meeting intake requirement, ulcer treatment with two or more ulcers including venous ulcers, arterial ulcers or Stage II pressure ulcers, ulcer treatment with any Stage III or IV pressure ulcer, foot infections or wounds with application of dressing, radiation therapy while a resident, or dialysis while a resident.

Extensive Services: Residents satisfying the following two conditions: Having a minimum ADL dependency score of 2 or more. While a resident, receiving complex clinical care and have needs involving: tracheostomy care, ventilator/respirator, and/or infection isolation.

Rehabilitation: Residents receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. Therapy must be ordered by a VA physician for a specific period of time, not to exceed one month. Orders may be recertified. A copy of the therapy notes will be sent to the VA facility each month.

Rehabilitation Plus Extensive Services: Residents satisfying all of the following three conditions: Having a minimum activity of daily living (ADL) dependency score of 2 or more. Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. While a resident, receiving complex clinical care and have needs involving tracheostomy care, ventilator/respirator, and/or infection isolation.

Ventilator Dependent Care: Level of care is self-explanatory. This level of care is used in cases which cannot be covered by other case mix classifications outlined above. Veterans requiring the use of a ventilator will only be placed in a CNH-trained and equipped for those types of specialty patients. The CNH must be inspected and approved by the VA prior to any placements in the ventilator-designated room. Rates for ventilator care will be detailed in the pricing schedule and will be an all-inclusive per diem rate (including ventilator and supplies).

Ventilator Plus Rehabilitation: Level of care is self-explanatory. This level of care is used in cases with a combination of ventilator care plus rehabilitation. Veterans requiring the use of a ventilator will only be placed in a CNH-trained and equipped for those types of specialty patients. The CNH must be inspected and approved by the VA prior to any placements in the ventilator-designated room. Rates for ventilator care will be detailed in the pricing schedule and will be an all-inclusive per diem rate (including ventilator and supplies). Residents receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. Therapy must be ordered by a VA physician for a specific period of time, not to exceed one month. Orders may be recertified. A copy of the therapy notes will be sent to the VA facility each month.

Secure Behavior Unit: Individuals whose rates are not included in the above case-mix classifications due to severity of behaviors and the need for a higher level of care than can be safely accommodated utilizing the standard rate structure. Specialized behavioral support services must be reflected in the Individualized Care Plan to include appropriate behavior monitoring, reporting, and intervention strategies. Psychiatric and Psychological services are included in the negotiated rate. All services necessary for the clinically appropriate care are considered included and the facility will maintain adequate staffing to ensure the safety of residents, to include provision of 1:1 coverage if clinically indicated.

Secure Behavior Plus Rehabilitation: Veterans on a secure behavior unit that receive rehabilitation services.

HIV+/AIDS Care: Specialized services for HIV+ and/or AIDS patients. May be specialized program care of an individual patient. (Per diem rates shall be negotiated on a case by case basis).

2.0 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 and approval of the extension by the placing VA facility.

3.0 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. As with Medicare, a description of the RUG-IV systems can be found in 42 CFR Parts 409, et al.

3.1 RATE DETERMINATION VA rates are an all-inclusive per diem rate. The per diem rate(s) will apply throughout the term of this Indefinite Delivery Contract (IDC). While the VA uses State Medicaid rates as a reference, VA rates are independent of those payment systems and governed by the terms of this IDC.

3.1.1 The per diem rate is established by the current Medicaid rate for Medicaid approved nursing homes plus a negotiated fair market amount (percentage) to cover the providers actual cost of supplies, services, and equipment above that provided under Medicaid established by the local Centers for Medicare & Medicaid Services (CMS). Rates established after the effective date of this contract will constitute a modification to the contract.

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

3.1.3 For all levels of nursing care, the negotiated per diem rate includes routine ancillary services/ supplies, such as drugs, nursing supplies, oxygen (occasional use), x-ray, laboratory, physician visits, and rental equipment.

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

3.1.5 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).

3.1.6 Rehabilitation therapies will be provided as a distinct level of care. Rehabilitation visits will be authorized by VA based on actual services provided and typically in 10-day pre-approved increments.

3.1.7 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. Hospice and Dialysis services are billed and authorized separately.

3.1.8 The per diem rate(s) will apply throughout the term of this agreement, including extension period(s). The rate(s) may be adjusted upon review.

3.2 Rate Adjustments: Rate adjustments may be requested by either the VA or the Contractor’s authorized Community Nursing Home (CNH) representative during the term of this IDC. Adjustments will occur no more frequently than those issued by the CMS. Normally, this will be in conjunction with the annual Option renewal review.

3.2.1 Request for Rate adjustments must be accompanied by a justification for consideration by the Contracting Officer. No adjustments will be made until the Contracting Officer receives a CMS 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.

3.2.2 If approved, the IDC must be modified and signed by both the Contractor and the VA Contracting Officer. The effective date of the rate adjustment will be the actual “Effective Date” as indicated on the IDC or the modification.

3.3 Level of Care Classification Effective Records: The level 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:

3.3.1 The recipient is discharged and subsequently qualifies for a new admission assessment.

3.3.2 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.

4.0 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

5.0 ORAL MEDICATIONS. Oral medications, which comprise more than 8.5% of the per diem rate on a monthly basis, are excluded from that rate. High drug costs will be determined or priced using the Average Wholesale Price (AWP) of the drugs plus a transaction fee, not to exceed 3% per month, to cover providers actual cost. All calculations will be made on a monthly basis. When a high cost drug patient is identified, VA staff must be advised promptly to establish an appropriate course of action, which may include the provision of the medications by VA.

6.0 Private Rooms: A private room rate for clinical concerns such as communicable diseases or infections (e.g., MRSA, VRE), or other pertinent clinical needs may be charged above the negotiated RUG rate for that facility with prior approval by the VA CNH Coordinator or designated VA staff. However, no additional private room charge will be allowed in the following circumstances: where the CNH only maintains private rooms; no double-occupancy rooms are available; and for ventilator-dependent patients with prior-negotiated rates.

7.0 Specialized Prosthetics Equipment (e.g., special bed and/or bariatric equipment: Veterans may be eligible for specialized equipment when clinically indicated. Pre-approval required by VA.

8.0 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). The provider must be a licensed physician; no other substitutions are authorized.

9.0 Rehabilitation Criteria. All therapy provided 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.

9.1 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.

9.2 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.

10.0 Transportation to and from the VA hospital for outpatient and admission appointments can be provided by the VA. The VA, however, does not insist that transportation be provided by the VA in all cases. Those patients who have family or others capable of transporting and providing supervision to the veteran in the outpatient area at the VA are encouraged to do so. If no other means are available, the VA will be responsive to requests by the nursing home for transportation.

11.0 Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veterans; CNH Responsibility to Veteran’s Belongings or Personal Effects. 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.

11.1 Veterans receiving care under this agreement, who begin to require acute hospital care, will be readmitted to an 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 VA authorization is obtained. VA authorization must be 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 patient's condition is sufficiently stabilized to permit admission to VA.

11.2 If a veteran is re-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 patient and the VA; or the patient may be responsible for making these arrangements. The number of covered bed hold days will be determined by VA on a case-by-case basis, but will not exceed the number of bed hold days allowed by state Medicaid regulations. Payment will follow state Medicaid regulations.

11.2.1 VA payment amounts for “bed hold” days will be at 75% of the applicable level of care the respective patient is receiving at the time of leave or transfer

11.2.2 Bed hold will be considered if the facility overall bed occupancy is at 90% or greater

11.2.3 Bed hold days for recipients admitted to a hospital for a short stay are limited to 12 days per contract year

11.2.4 Exceptions will be considered on a case by case basis

11.2.5 Therapeutic leave days are limited to 9 per calendar year

11.2.6 The VA facility will include payment for these "bed hold" days only when the conditions above are met.

11.2.7 Payment may be denied for any absences not properly authorized by VA

11.3 The VA facility will approve leave days (days away from the nursing home) for long-term placements. The leave must be part of a therapeutic plan and pre-approved approved by VA. Leave days at VA expense are limited to 9 days per calendar year. Payment will follow state Medicaid regulations. Exceptions may be approved by the VA facility director or designee.

11.4 Patients receiving care under this contract, 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. 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 VA authorization is obtained. VA authorization must be obtained within 72 hours of admission of the patient to a non-Federal facility. If hospitalization of a non-emergency nature is required, it is agreed that readmission to a VA Medical Center will be accomplished as soon as the patient's condition is sufficiently stabilized to permit admission to VA.

11.5 In the event a VA beneficiary receiving nursing home care under this contract dies, the nursing home will promptly notify the VA office authorizing admission and immediately assemble, inventory, and safeguard the patient's personal effects pending further guidance by VA. With the concurrence of the VA office authorizing admission, the nursing home will:

11.5.1 All funds, deposits, and effects left by VA patients upon the premises of the nursing home shall be delivered by the nursing home to the person or persons entitled thereto under the laws currently governing the nursing home 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.

11.5.2 When disposition has been made, the itemized inventory with a notation as to the disposition of the funds and effects will be immediately forwarded to the VA office authorizing admission.

11.5.3 Should a deceased patient have 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 nursing home will forward inventory of any such property and funds in its possession to the VA office authorizing admission, and will hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition.

12 VETERANS VOLUNTARILY ABSENCE

12.1 In the event a VA beneficiary receiving nursing home care under this contract decides to leave the facility, as soon as possible the nursing home will, but not to exceed 48 hours, notify the VA that the VA beneficiary has voluntarily left the facility.

12.2 In the event a VA beneficiary receiving nursing home care under this contract desires to leave the facility for 24 hours or more [excludes scheduled appointment and off-site medical treatment] on a pass, the nursing home must obtain approval from the VA office authorizing admission BEFORE the VA beneficiary is granted a pass and allowed to leave the facility.

12.3 The nursing home is responsible for supervising VA beneficiaries housed at their facility whether the beneficiary is at the facility, or has been transported to a clinic or other treatment facility, to the doctor, of the VAMC.

12.3.1 The nursing home is responsible for complying with all the 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.

12.3.2 If a veteran is sent to an outpatient appointment at the VA (or admission exam where admission is not a certainty) the nursing home must make a judgment as to whether the veteran needs physical assistance due to disability or oversight due to confusion. The nursing home must assure that adequate oversight is provided during the trip to the VA or while in the outpatient clinic.

12.3.3 Oversight can be provided by a family member, clergy person, volunteer or any other person who, in the judgment of the nursing home can responsibly and capably provide the necessary oversight. However, someone from the facility or a family member or volunteer must be with a resident who evidences any mental confusion or who would have a problem negotiating his/her way through the outpatient clinic process.

12.3.4 In the absence of any other person, the nursing facility should send a staff member to assure protective oversight. This judgment is made by the nursing home and does not preclude “dropping off” a mentally alert and physically capable resident for a medical appointment or some other activity, to be picked up at a later time.

12.3.5 When the veteran is in the outpatient clinic at the VA, s/he still is considered a resident of the nursing facility that is thereby responsible to provide physical assistance and protective oversight. The VA’s responsibility in the outpatient clinic is for treatment only.

13 MEDICAL RECORDS

13.1 All medical records concerning the veteran's care in the nursing home will be readily accessible to VA. Upon discharge or death of the patient, medical records will be retained by the nursing home for a period of at least three 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 that includes at least the following:

a) Admission identification records

b) Admitting evaluation (including diagnosis by nursing home physician).

c) Physician orders.

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

e) Special reports (laboratory, x ray, activity, etc.).

f) Minimum Data Set (MDS) information, provided to VA upon admission and every six months thereafter

14 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.

14.1 The authorization agreement, VA Form 10-7078, for the affected patient will terminate whenever a VA patient is re-hospitalized for 15 calendar days or more, whether in a VA or in a non-Federal facility. A new authorization agreement will be required at the time the patient returns.

15.0 PAYMENTS

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. VA will make payment for the day a recipient enters the facility but not the day the recipient leaves a facility unless entrance and departure are on the same day then payment will be made for one day.

16.0 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.

16.1 GOVERNMENT INVOICE ADDRESS

All Invoices from the contractor shall be submitted in accordance with NNPO Non-VA medical Care and Local Fee procedures. Invoices may be mailed or faxed to the facility for processing; invoices must specify “Contracted Nursing Homes.”

Department of Veterans Affairs

ATTN: 136G

650 E. Indian School Rd.

Phoenix, AZ 85012 Phone: (602) 277-5551 ext 2935 Fax: (602) 200-2375

17.0 REGULATIONS

17.1 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.

17.2 State Licensure and Insurance. 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 Contracting Officer and Contracting Officer’s Representative. The contractor shall provide the Contracting Officer an updated license and insurance certificate annually.

17.3 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) 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. The VA Contracting Officer will notify the VA Safety Manager responsible for the Life Safety Code inspection of the CNH. These changes may include but are not limited to:

a. Interior changes and/or building modifications. 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; and

c. Evacuation Plan. In the event of a natural disaster (flood, tornado, etc.) and/or facility failure that could negatively affect patient lives, 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.

17.4 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.

17.5 The C & A requirements do not apply and a Security Accreditation Package is not required.

E. QUALITY CONTROL

18.0 Quality Control

18.1 REVIEWS/INSPECTIONS

18.1.1 VA developed quality of care standards utilizing Center for Medicare and Medicaid Services (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.

A. The CNH shall maintain three stars or better shown on the Center for Medicare/ Medicaid Nursing Home Compare website.

B. It is agreed that VA will have the right to on-site reviews of the nursing home 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. It is further agreed that the VA will have the right to inspect the contractor’s personnel files.

C. It is agreed that duly authorized representatives of VA will provide follow up supervision visits to veterans placed to assure the continuity of care and to assist in the veteran's transition back to the community. It is understood that these visits do not substitute for nor relieve the nursing home in any way of the responsibility for the daily care and medical treatment of the veteran.

D. The VA, at its sole option, will monitor the professional care and administrative management of services provided to VA beneficiaries under this agreement, through one or any combination of the following methods; reviews of state agencies reports, on-site review of the Nursing Home by VA staff, and/or on-site monitoring of VA patients. It is agreed that the Nursing Home shall provide VA with copies of all state agency reports when requested, and cooperate fully with VA's quality improvement-quality assurance program functions relating to this agreement, including VA's on-site review and monitoring. It is further agreed that the VA will have the right to inspect contractor’s employee personnel files. The VA contracting Officer shall make all final determinations as to the contractor's reasonable cooperation with VA and compliance with these requirements.

E. If at any time the contract nursing home receives a Notice of Non-Compliance or a Notice of Sub-Standard Care resulting from the federal survey, the contract nursing home will notify the Community Nursing Home Care Coordinator by telephone within 24 hours of the receipt of such assignment. In the absence of the Community Care Coordinator, The Chief, Associate Chief of Staff for Geriatrics and Extended Care and the Associate Chief Nurse Geriatrics and Extended Care at the VA will be notified by telephone.