36C26119Q0481-001.pdf

PAGE 1 OF 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. DUNS: DUNS+4:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

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

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

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

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 58

36C26119Q0481 04-09-2019

Nicole Do 8085391301 04-12-2019

1:00 PM HST

612MCP

Department of Veterans Affairs VA Sierra Pacific Network (VISN 21) VA Northern California HealthCare System 5342 Dudley Blvd, Bldg 209 McClellan CA 95652-2609

623110

X

N/A

X

VA Northern California Healthcare System 5342 Dudley Blvd., Bldg. 209

McClellan CA 95652

612MCP

Department of Veterans Affairs Department of Veterans Affairs VA Northern California HealthCare System 3230 Peacekeeper Way, Bldg. 209 McClellan CA 95652-1012

Department of Veterans Affairs FMS VA-9(101) Financial Services Center

PO Box 149971 Austin TX 78714-9971

This is a Request for Quote for Nursing Home Services.

Please fill in the price schedule by inputting percentages.

Please refer to FAR 52.212-1 Addendum to Instructions to Offerors for additional guidance on responding to this Request for Quote.

Please send any questions to nicole.do@va.gov and andrea.kaplan@va.gov.

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

IDIQ Period of Performance:

Ordering Period One: 5/01/19 - 4/30/20 Ordering Period Two: 5/01/20 - 4/30/21

X X

Nicole Do

VA-VHA-SAOW-2018-4BCE51EA

36C26119Q0481

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 SCHEDULE OF ITEMS

B.3 PRICE SCHEDULE

Contract Line Items:

B.4 PERFORMANCE WORK STATEMENT

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (OCT

2018)

C.2 52.216-18 ORDERING (OCT 1995)

C.3 52.216-19 ORDER LIMITATIONS (OCT 1995)

C.4 52.216-22 INDEFINITE QUANTITY (OCT 1995)

C.5 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.6 52.232-19 AVAILABILITY OF FUNDS FOR THE NEXT FISCAL YEAR (APR 1984) 28

C.7 VAAR 852.222-70 CONTRACT WORK HOURS AND SAFETY STANDARDS ACT—

NURSING HOME CARE FOR VETERANS (MAY 2018)

C.8 VAAR 852.237-7 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE

(JAN 2008)

C.9 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984)

C.10 MEDICARE/MEDICAID STANDARDS

C.11 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.12 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN 2008) 30

C.13 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (JAN 2019)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

D.1 See attached document: P07. WD D.2 See attached document: P09. Hale Nani QASP

SECTION E - SOLICITATION PROVISIONS

ADDENDUM TO FAR 52.212-1 INSTRUCTIONS TO OFFERORS - COMMERCIAL ITEMS

E.1 52.216-1 TYPE OF CONTRACT (APR 1984)

E.2 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB

1998)

E.3 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014)

E.4 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL

ITEMS (OCT 2018)

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: Brian Trahan 36C261 Contract Specialist: Andrea Kaplan

VA Sierra Pacific Network (VISN 21) VA Pacific Islands Healthcare System 3375 Koapaka Street Suite F250 Honolulu, HI 96819

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

[X] 52.232-33, Payment by Electronic Funds Transfer—System For Award Management, or

[] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly []

b. Semi-Annually []

c. Other [X] monthly

4. GOVERNMENT INVOICE ADDRESS: 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.

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 the VA Facility that authorized Care:

For patients authorized by the VA Pacific Islands Health Care System, the Government invoice address is:

Attn: GREC Center for Aging

459 Patterson Road

Honolulu, HI 96819

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

AMENDMENT NO DATE

B.2 SCHEDULE OF ITEMS

RUG-IV Case Mix Classification

0001. Reduced Physical Function:

Residents whose needs are primarily for support with activities of daily living and general supervision.

Applicable RUG-IV Scores: PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1

0002. Behavioral Symptoms and Cognitive Performance:

Residents satisfying the following conditions:

a) Having a maximum ADL dependency score of 5 or less.

b) 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

Applicable RUG-IV Scores: BB2, BB1, BA2, BA1

0003. 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

Applicable RUG-IV Scores: CE2, CE1, CD2, CD1, CC2, CC1, CB2, CB1, CA2, CA1

0004. Special Care Low:

Residents satisfying the following two conditions:

c) Having a minimum ADL dependency score of 2 or more.

d) 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

Applicable RUG-IV Scores: LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1

0005. Special Care High:

a) Having a minimum ADL dependency score of 2 or more.

b) 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 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

• Respiratory Therapy

Applicable RUG-IV Scores: HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1

0006. Extensive Services:

a) Having a minimum ADL dependency score of 2 or more.

b) While a resident, receiving complex clinical care and have needs involving: tracheostomy care, ventilator/respirator, and/or infection isolation.

Applicable RUG-IV Scores: ES3, ES2, ES1

0007. Rehabilitation:

Residents receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.

Applicable RUG-IV Scores: RUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLB

0008. Rehabilitation Plus Extensive Services:

Residents satisfying all of the following three conditions:

a) Having a minimum activity of daily living (ADL) dependency score of 2 or more.

b) Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.

c) While a resident, receiving complex clinical care and have needs involving tracheostomy care, ventilator/respirator, and/or infection isolation.

Applicable RUG-IV Scores: RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX, 0009. Bed Hold: For re-hospitalizations or therapeutic passes, VA may pay a bed hold upon CNH request with prior VA approval and best interest of VA or Veteran to do so. When deemed appropriate, VA will reimburse the CNH applicable per diem rate for bed hold not to exceed two (2) days per episode, four (4) days total per month (see Schedule of Items for applicable per diem rate).

Also, see Bed Hold in the Performance Work Statement for additional details regarding Bed Hold circumstances.

0010. Ventilator Care: 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).

0012. One-on-One Observation Care: Defined as an assigned Certified Nursing Assistant dedicated to being at the Veteran’s side nonstop for duration of determined time, to assist with care needs of a Veteran diagnosed with Dementia with behavioral disturbances, Alzheimer’s with behavioral disturbances, Traumatic Brain Injuries, or Impulse Control Disorders. The key design is to reduce agitation or elopement risk and safety concerns for self or others and are NOT placed in a locked facility/unit. Other diagnoses may be considered but must have behavioral issues warranting such need of one-on-one care by VA CNH Program staff and is typically determine prior to placement.

Advanced approval is required.

One-on-one care may also include escorts; accompanying the Veteran to VA referred appointment, for those Veterans that cannot clearly communicate their needs/concerns to the Provider performing the services and is approved for Special Mode Transportation arrangements to attend these appointments. No Veteran should be accompanied to any such appointment with more than one staff in total.

B.3 PRICE SCHEDULE

1. Rate Determination: The VA is seeking preferred rates, based on patient care need. 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 Medicare or State Medicaid rates as a reference, VA rates are independent of those payment systems and governed by the terms of this IDC. The per diem rate utilizes the Medicaid Resident Assessment Instructions (RAI)/Minimum Data Set (MDS) assessment and RUGS score as the reference for rates. Assessment schedules identical to Medicaid will be used; in addition, the VA reserves the right to request a resident re-assessment at any time during the coverage period.

2. Rate Adjustments: Rates will apply throughout the term of the IDC and are reflected as stated percentages above the Medicare/Medicaid rate(s), which are negotiated to cover the all-inclusive nature of the agreement and will not be negotiated. The rates will be computed and added to the published Medicaid rate for each level of care item. The Government will reimburse for the current Medicaid rate known to the Government but no retroactive adjustments will be made. The contractor must provide notice to the Government of any Medicaid rate changes. The rate change will be effective from the date on which Government and contractor execute a contract modification. The contractor shall furnish proof of its Medicare/Medicaid rate as furnished by the State of Hawaii.

3. Rehabilitation Therapy: Any type of rehabilitation therapy (physical therapy, occupational therapy, speech therapy, etc.) requires the pre-approval of the VA before the initiation of therapy. Contractor shall provide Nursing home services in accordance with the attached performance work statement. Period of Performance is from date of award through two years and includes 2 ordering periods.

4. Medications: The VA reserves the right to deny payment for medication, which at its sole discretion, is determined by the VA to be of no clinical benefit to the veteran. The rate(s) shall be established at the Order Level. Medications, which comprise more than 8.5% of the monthly per diem rate are excluded from the rate(s) established here. Medication costs which exceed 8.5% of the monthly per diem will be billed as a separate line item in addition to the applicable RUG rate(s). All calculations will be made monthly. 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 medication by the VA., or requiring an acceptable alternative medication be substituted. If for any reason the VA provides patient medications, the rate of reimbursement will be decreased by an agreed upon amount. It is recommended that the accepting CNH request sufficient quantities of medication from the institution that the patient is being transferred from for the convenience and the ease of transition of the patient. Any externally provided medications will not be refilled unless specifically authorized by the patient’s primary care provider.

5. Private Rooms: Beneficiaries or their representatives may elect to pay separately for a private room.

If a private room is requested, the VA beneficiary shall be obligated to pay the difference between the standard rate and the private room rate. This agreement should be in writing between the facility and the beneficiary or their legal representative, with a copy to the COR. No additional private room charge to the VA will be permitted. A private room rate for the management of 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 Ordering Official. No additional private room charge will be allowed in the following circumstances:

a. where the CNH only maintains private rooms; no double-occupancy rooms are available; and

b. for ventilator-dependent patients with prior-negotiated rates.

If the contractor elects to place a VA beneficiary in a private room without a formal request, then the VA is only obligated to pay the rate for the beneficiary’s current level of care under the terms of this contract.

6. 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.

7. Transportation: Medically necessary transportation to and from the VA hospitals for clinics, evaluation or hospitalization will be arranged and paid by the VA hospital for Authorized CNH patients only and only when requested by the CNH facility with at least 48 business hours advanced notice. For transportation appointments, notify the VA Travel Designee/CNH Program Coordinator.

Contract Line Items:

VISN 21 anticipates awarding a single-award Indefinite Delivery Indefinite Quantity (IDIQ) contracts to responsible offeror(s) whose offer(s) conform(s) to the solicitation and will be most advantageous to the Government for a period two (2) years and the possibility of a 6-month extension.

Please provide your most favored customer/preferred rates. Rates are an all-inclusive per diem rate based on a percentage above your State Medicaid rate. Please indicate your proposed percentage (addition to State Medicaid rate) in the attached price schedule.

Note: Indefinite Delivery, Indefinite Quantity Contract is being used because it is impossible to determine with any certainty the exact amount of services that will be required under this contract.

The guaranteed minimum, for the contract is one room for one veteran for one day. The maximum of the contract, inclusive of ordering periods, shall not exceed $3,000,000. The Government does not guarantee that it will place any orders under this contract in excess of the guaranteed minimum award amount.

Ordering Period One: May 1, 2019 – April 30, 2020

1 Current Published Medicaid Rates will be used. Please provide a copy of your State Medicaid Agency letter establishing your rate.

2 VA Base Rate is the basic per diem rate for Veterans receiving long term care in accordance with this PWS.

3 For States that establish (and publish) a separate Bed Hold Rate, that established State Medicaid Rate shall be used.

4 For States whose State Medicaid Agencies establish a separate rate for Ventilator Care, please quote a % (above your established State Medicaid Ventilator rate) to provide ventilator care in accordance with this PWS. If your state does not establish a separate Medicaid Rate, Ventilator Care shall be invoiced at Extensive Services or Rehabilitation Plus Extensive Services as appropriate. If you do not provide Ventilator Care, please put N/A under the Unit Price for this CLIN.

5 Additional % to be applied to the applicable RUG IV Case Mix Classification (based on the level of care required) for treating veterans with HIV/AIDS. The application of this supplemental line item must be pre-approved by the VA CNH Program Staff prior to beginning care.

Number Description Payment Methodology Percent Quoted

0001 Reduced Physical Function = State Medicaid Agency Rate1 + %; this will be your

VA BASE RATE2

0002 Behavioral Symptoms and Cognitive Performance

= MEDICAID + X%

0003 Clinically Complex = MEDICAID + X%

0004 Special Care Low = MEDICAID + X%

0005 Special Care High = MEDICAID + X%

0006 Extensive Services = MEDICAID + X%

0007 Rehabilitation = MEDICAID + X%

0008 Rehabilitation Plus Extensive Services = MEDICAID + X%

0009 Bed Hold3

= State Medicaid bed hold rate – no supplement

0010 Ventilator4

= State Medicaid Agency Rate + %

0011 HIV/AIDS Care5 Supplemental %

Ordering Period Two: May 1, 2020 – April 30, 2021

Number Description Payment Methodology Percent Quoted

1001 Reduced Physical Function = State Medicaid Agency Rate7 + %; this will be your

VA BASE RATE8

1002 Behavioral Symptoms and Cognitive Performance

= MEDICAID + X%

1003 Clinically Complex = MEDICAID + X%

1004 Special Care Low = MEDICAID + X%

1005 Special Care High = MEDICAID + X%

1006 Extensive Services = MEDICAID + X%

1007 Rehabilitation = MEDICAID + X%

1008 Rehabilitation Plus Extensive Services = MEDICAID + X%

1009 Bed Hold9

= State Medicaid bed hold rate – no supplement

1010 Ventilator10

= State Medicaid Agency Rate + %

6 One-on-One Observation Care must be pre-authorized by VA CNH Program Staff prior to proceeding with this type of care.

7 Current Published Medicaid Rates will be used. Please provide a copy of your State Medicaid Agency letter establishing your rate.

8 VA Base Rate is the basic per diem rate for Veterans receiving long term care in accordance with this PWS.

9 For States that establish (and publish) a separate Bed Hold Rate, that established State Medicaid Rate shall be used.

10 For States whose State Medicaid Agencies establish a separate rate for Ventilator Care, please quote a % (above your established State Medicaid Ventilator rate) to provide ventilator care in accordance with this PWS. If your state does not establish a separate Medicaid Rate, Ventilator Care shall be invoiced at Extensive Services or Rehabilitation Plus Extensive Services as appropriate. If you do not provide Ventilator Care, please put N/A under the Unit Price for this CLIN.

0012 One-on-one Observation Care6

Hourly rate Please Quote Hourly Rate

1011 HIV/AIDS Care11

Supplemental %

1012 One-on-one Observation Care12

Hourly rate Please Quote Hourly Rate

11 Additional % to be applied to the applicable RUG IV Case Mix Classification (based on the level of care required) for treating veterans with HIV/AIDS. The application of this supplemental line item must be pre-approved by the VA CNH Program Staff prior to beginning care.

12 One-on-One Observation Care must be pre-authorized by VA CNH Program Staff prior to proceeding with this type of care.

B.4 PERFORMANCE WORK STATEMENT

Performance Work Statement (PWS)

Community Nursing Home Services for the Veterans Affairs Pacific Islands Healthcare System (VAPIHCS)

April 1, 2019 A. Overview

1. Services Rendered at VA Per Diem Rates. Upon acceptance of a VA patient by the

Community Nursing Home (CNH) program, if and when requested by the VA Contracting Officer or authorized representative, the Contractor shall furnish all supplies and services herein described, at the per diem rates for the ”Levels of Care” specified in the Schedule of Items of this IDC. The VA “Levels of Care” are defined in an attachment in Section D.1 of the solicitation and the IDC. VA is obligated only to the extent authorized placement of patients is made in accordance with this IDC.

2. Background/Introduction. The 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 Pacific Island Health Care System (PIHCS), in Honolulu, Hawaii at the prices specified in the section titled Schedule of Items of this IDC. Nursing home facilities in the CNH program shall cooperate with VA staff in referral of appropriate veterans for care and accept veterans of which they have the capability/capacity to care. The term, “facilities,” shall include but not be limited to rooms, wards, sections, eating areas, drinking fountains, entrances, and other like areas. VA shall have the right to inspect the CNH and all appurtenances by authorized VA representative(s) to ensure that acceptable standards are maintained and that the necessary care to maintain the well-being of the patient is rendered.

B. Requirements

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

http://www.va.gov/vhapublications/publications.cfm?pub=2. VA often has a particular need for specialty care services in the CNH program. The VA requires CNHs to have bed capacity to ensure their ability to take referrals when requested. The CNH also must be able to accept VA referrals in a timely fashion (ideally within 24 hours of request). Provider visits will be available at the rate of one (1) visit per month.

Laboratory, x-ray, and other special services will be available to VA patients as needed. In addition, the care provided will include room, meals, nursing care, and other services or supplies commensurate with the VA-authorized level of care, without extra charge. Duly authorized representatives of VA will provide quality oversight visits to veterans placed to assure continuity of care and to assist in the veterans’ transition back into the community. These visits do not substitute nor relieve the CNH in any way of the responsibility for the daily care and medical treatment of the veteran. The per diem rate(s) established in this IDC will include the cost of primary medical care, one (1) provider visit per month and needed consultation, drugs and routine supplies, laboratory, x-ray, and other special services authorized by VA, unless otherwise specifically excepted (see Schedule of Items in this IDC for details regarding per diem http://www.va.gov/vhapublications/publications.cfm?pub=2 rates and coverage). Full attention shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care.

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

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

4. 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.

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).

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 may require pre-approval by VA before services are provided. Medical Restorative criteria will be used for physical therapy, occupational therapy, and speech therapy. Therapy must be skilled, relate to safety and be restorative according to Medicare criteria.

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

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

7. Respite Care Criteria. This level of care is designed to provide short term, limited use (not to exceed 30 days per episode or 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 caregiver 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.

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.

8. 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.

9. 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.

10. State Licensure; Access to CNH Quality of Care Reports (QASP Indicator #1). The CNH must maintain a current and unrestricted Hawaii state license to operate as a skilled nursing facility. Changes in the status of the licensure will be immediately reported to the VA PIHCS CNH Coordinator at 808- 433-0269. VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this IDC, through one or any combination of the following methods: reviews of State agencies reports; on-site inspection of the CNH by VA staff; and/or on-site monitoring of VA patients. The CNH shall provide VA with copies of all State agency reports when requested, and cooperate fully with VA’s quality improvement or quality assurance program functions relating to this IDC, including VA’s on-site inspection and monitoring. The VA Contracting Officer shall make all final determinations as to the Contractor’s reasonable cooperation with VA and compliance with these requirements.

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

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

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

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

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

e. Provide dates when corrective action will be completed.

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

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

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

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

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

13. 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.

14. Re-admission to the VA or Community 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 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 authorized Medical Center may be accomplished as soon as the patient’s condition is sufficiently stabilized to permit admission to an approved 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.

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 when deemed appropriate. VA will reimburse the CNH 70% of applicable per diem rate for bed hold not to exceed five (5) days per episode. 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 #4). VA requires CNHs to report to the CNH Coordinator at VA any of the following events within 24-hours or immediately the first business day after a weekend or holiday:

1. Sentinel events;

2. When there is a change of ownership of the CNH;

3. When there is a change of nursing home administrator or Director of Nursing/Director of Nursing

Service;

4. substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH veterans or property;

5. Elopements of CNH veterans pursuant to state regulations;

6. Infectious outbreaks;

7. Resident to resident or resident to staff altercations involving a CNH veteran resulting in any injury that is other than minor;

8. Copies of annual surveys or substantiated complaint investigations conducted by a State oversight agency; and

9. Adverse events. Reporting shall include date of occurrence and patient disposition and outcome.

A sentinel event may include, but is not limited to the following:

1. A fall resulting in death or injury;

2. Elopement resulting in a missing patient;

3. Patient abuse confirmed or under suspicion;

4. A medication error resulting in patient illness or injury;

5. Death or patient injury related to restraint (including side rails) use; or

6. Death related to an unconfirmed or suspicious cause.

When an adverse event occurs involving a CNH Veteran which is not determined to be a Sentinel Event (but that the State requires that the occurrence be reported to the State), such event is also to be reported to VA’s CNH program office. Some adverse events, such as minor medication errors without catastrophic outcomes, are managed by the CNH in the context of their quality improvement programs. It is not necessary for nursing homes to report such incidents to the CNH program office.

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

a. VAHCS Referral Package to the CNH:

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

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

b. Nursing Home Clinical Record: The CNH must maintain clinical records on each veteran in accordance with accepted professional standards and practice. The clinical record must be:

complete, accurately documented, readily accessible, systematically organized, and legible.

Clinical records must contain at a minimum:

1. Sufficient information to identify the resident;

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

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

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

5. Medical practitioner orders which are signed and dated;

6. Allergies;

7. Person to contact in an emergency situation;

8. Name of attending medical practitioner; and

9. Advanced directives if available.

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

19. Specialty Services. The CNH will assume responsibility for arranging specialty care for veterans (e.g., dental care, podiatry and ophthalmology). When determined appropriate, CNH Staff will alert VA Staff in the CNH Program that attending MD has provided orders for consultation for specialty care for a veteran resident. CNH Program will notify the advising VA MD of the request who will transcribe the request for specialty care through VA system to either provide the care through VA providers or utilization of the VA program authorizing care in the community. This will include transportation to approved specialty care appointments.

20. 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.

21. CNH Billing (QASP Indicator #6). Invoices for board, care and ancillary services shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered. The Contractor 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) (See Attachment A RUGS). 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: Prescription medications that are equal to or greater than 8.5% of the monthly per diem rate(s) are billable using the provided invoice form (See Attachment B). All requests for reimbursement for high cost drugs and monthly invoices are due as soon as possible, but no later than 90 calendar days after the last date of the billing month.

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

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

23. 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:

Community Nursing Home…