36C26119Q1096-001.docx

36C26119Q1096

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

612-20-1-1999-0014 36C26119Q1096 08-28-2019 Felicia A. DeMita 925-372-2038 09-03-2019 10:00am Pacific

612MCP

Department of Veterans Affairs Network Contracting Office (NCO 21) 150 Muir Road, Bldg AB7, Rm 35 Martinez

CA

94553 X 623110 $27.5 Million N/A X Not applicable.

612MCP

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

CA

95652-1012

FMS VA-9(101) Financial Services Center PO Box 149971 Austin

TX

78714-9971 This is a request for quote for community nursing home services for veterans. Please complete the price schedule with requested rates for compensation for services.

Please also provide a copy of the current license and indicate the current number of veterans in care.

Please also include the latest VA inspection with the quote.

This solicitation will result in an Indefinite Delivery Indefinite Quantity (IDIQ) contract. Please refer to the price schedule for minimum and maximum contract value information.

This procurement is being done on a sole source basis.

All responsible sources may submit a capability statement, proposal, or quotation, which shall be considered by the agency.

Please send questions to felicia.demita@va.gov.

X Felicia A. DeMita

VA-VHA-SAOW-2018-2D91603A

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 36C261

Network Contracting Office (NCO 21) 150 Muir Road, Bldg AB7, Rm 35 Martinez

CA 94553

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 FMS VA-9(101) Financial Services Center

PO Box 149971 Austin TX 78714-9971 ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

36C26119Q1096

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SCHEDULE OF ITEMS

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: 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. Request for Rate adjustments must be accompanied by a justification for consideration by the Contracting Officer. 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. 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.

4. Medications: All Medications administered to VA-contracted Veterans residing in a CNH will be charged at the Average Wholesale Price (AWP) or according to the pharmacy bill, whichever is less. Medication costs up to 8.5% of billed care are included in the RUG rate pricing upon VA review and approval. 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 on a monthly basis. When a patient’s medication costs are determined to be in excess of the 8.5%, the VA must be promptly alerted to establish an appropriate course of action. This course of action may include the VA providing medication(s) to the CNH for the contracted Veteran 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. The VA also 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.

5. 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.

6. 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).

7. 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.

PRICE SCHEDULE

The guaranteed minimum award amount for this contract is one bed day. The maximum aggregate value of orders that can be placed under this contract is $3,500,000. The Government does not guarantee that it will place any orders under this contract in excess of the guaranteed minimum award amount.

The anticipated amount for the period of performance shown below is $1,500,000; however, that amount is only an estimate and in no way binds the government. Services will be reimbursed as shown by the percentages below:

(NOTE: The reference to the published rate means the date the rates are published and distributed, not the effective dates. In other words, if the rates are effective August 1, but they are not published until the subsequent March, then the rates for this contract would change in March.)

Ordering Period One: October 1, 2019 – September 30, 2020

Rate per day is based upon _____% of the Contractor's current published Medicaid rate.

_____% of applicable RUG IV Group Code 2 Rate is based on the current published RUG IV group code classification rate as determined by MDS assessment in accordance with Centers for Medicare and Medicaid Service (CMS) Guidelines and Procedures.

Rate per day is based on ______% of the Contractor's current published Medicaid rate.

Rate per day is based on ______% of the Contractor's current published Medicaid rate.

Rate per day is based on ______% of the Contractor's current published Medicaid rate

Ordering Period One: October 1, 2020 – September 30, 2021

Rate per day is based upon _____% of the Contractor's current published Medicaid rate.

_____% of applicable RUG IV Group Code 2 Rate is based on the current published RUG IV group code classification rate as determined by MDS assessment in accordance with Centers for Medicare and Medicaid Service (CMS) Guidelines and Procedures.

Rate per day is based on ______% of the Contractor's current published Medicaid rate.

Rate per day is based on ______% of the Contractor's current published Medicaid rate.

Rate per day is based on ______% of the Contractor's current published Medicaid rate

Ordering Period One: October 1, 2021 – September 30, 2022

Rate per day is based upon _____% of the Contractor's current published Medicaid rate.

_____% of applicable RUG IV Group Code 2 Rate is based on the current published RUG IV group code classification rate as determined by MDS assessment in accordance with Centers for Medicare and Medicaid Service (CMS) Guidelines and Procedures.

Rate per day is based on ______% of the Contractor's current published Medicaid rate.

Rate per day is based on ______% of the Contractor's current published Medicaid rate.

Rate per day is based on ______% of the Contractor's current published Medicaid rate

VA NORTHERN CALIFORNIA HEALTH CARE SYSTEM

AGREEMENT

FOR THE FOLLOWING:

WINDSOR REDDING CARE CENTER

PERFORMANCE WORK STATEMENT

Overview

1. Federal Acquisition Regulation (FAR): Indefinite Delivery Contract (IDC). In accordance with FAR 16.504, Indefinite Delivery Contracts and based on VA Central Office wavier to use Care Meridian congregate living facility, this is an IDC from the “award date” and for a period of three years.

A. Service Rendered at VA Per Diem Rates: Upon acceptance of an authorized VA patient by the contracted Facility Windsor Redding Care Center, and if and when requested by the VA Contracting Officer, the Contracting Officer’s Representative or other VA authorized representative, the contractor shall furnish all supplies and services herein described, at the specifically approved, all-inclusive level of care of VA authorized placements, as specified in the Schedule of Items of this IDC. The VA Per Diem Rates are defined in the solicitation of this IDC. VA is obligated only to the specifically approved level of care for the specifically approved Veteran for the specifically approved time. Any adjustments or modifications to this obligation require written preauthorization.

B. Ordering: Orders for placement of Veterans in Nursing Homes will be made by the VA Contracting Officer, the Contracting Officer’s Representative or other VA authorized representative and the placement process will be facilitated through the CPRS system.

Background/Introduction: The Community Nursing Home Program (CNH) is a key component of the Veteran’s 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 Veteran’s Affairs Northern California Health Care System (VANCHCS) in California at the prices specified in the Schedule of Items in this IDC. Nursing Home facilities in the CNH Program shall cooperate with VA staff in the referral of preauthorized Veterans, for which they possess the immediate capability/capacity to care. The term “facilities” refers to rooms, wards, dining areas, drinking fountains, entrances and other like areas in which patient medical/psychosocial care and attention to wellbeing is conducted. VA shall have the right to inspect the Nursing Home facility and all components of the facility to ensure that the standard of care is acceptable and that the necessary care to maintain the wellbeing of the patient is being rendered.

1. Requirements (QASP Indicators 1, 2 & 8): Nursing Home facilities in the CNH Program shall ensure that all levels of care meet the health needs and promote the maximum wellbeing of VA beneficiaries. Nursing home care will be furnished based on interdisciplinary assessment to ensure the total medical, nursing, and psychosocial needs of VA beneficiaries are being met. 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 Veterans ambulatory, while achieving an optimal level of self-care and to coordinate discharge arrangements when clinically appropriate. All nursing home facilities in VA CNH Program must have the following:

A. Current and unrestricted Center for MediCare and Medicaid Services (CMS) certification B. Current and unrestricted State/Federal nursing home licensure and certification C. Liability insurance must be maintained and available for review VA has developed quality of care standards utilizing CMS inspection criteria, which is followed by the VA CNH Program Coordinators or other VA authorized designees during the process of selection and approval of nursing homes. See VHA Handbook 1143.2 “VHA Community Nursing Home Oversight Procedures” (June 02, 2004) a copy of this document is available at: http://www.va.gov/vhapublications/publications.cfm?pub=2

VA CNH Program often has a particular need for specialty level of care services. VA requires CNH to possess the capacity and capability to accept VA authorized referrals in a timely manner (ideally, within 24 hours of the request).

Provider visits will occur at a minimum, of one (1) visit per month; other services such as laboratory, x-ray and other special services will be available to VA patients as needed. Additionally, the all-inclusive authorization of care provided without extra charge will include the following: room, medications, meals, nursing care provider visits as needed and other VA authorized supplies/services commensurate with VA authorized levels of care, as specified in the Schedule of Items of this IDC.

Authorized VA representatives will conduct visits to the CNH in order to provide continuity of care and quality oversight to VA placed Veterans and to assist, when possible, with the Veteran’s transition back into the community. These visits do not substitute, nor alleviate the CNHs contracted responsibility for the daily care and medical treatment of the Veteran.

TThe per diem rate(s) established in this IDC will include the cost of primary medical care, at a minimum, one (1) provider visit per month (including needed consultation, medications and routine supplies, laboratory, x-ray, and other, VA authorized specialty services, unless otherwise and specifically excluded). See the Schedule of Items for details regarding per diem rates, inclusions and exclusions. Every effort will be made to help patients achieve and maintain the highest possible quality of life. CNH staff shall direct their full attention to keeping the patients ambulatory as well as educating and motivating patients to achieve and maintain independence in the activities of daily living (ADLs) as well as the optimal level of self-care.

2. Termination of Services: VA reserves the right to remove any/all placements of VA patients from CNH when it is determined to be in the best interest of VA or the Veterans and to do so without incurring additional cost to the government.

3. VA Authorizations: Authorization for all levels of nursing home care will be submitted on VA Form 10-7078, “Authorization & Invoice for Medical & Hospital Services.” Each authorization will contain both the beginning and end date of the approval period as well as the specific all-inclusive level of care authorized. Any/all adjustment(s) to the period of approval or changes in the level of care must be specifically requested and receive written approval/authorization prior to services being rendered.

4. Medicare Based Rates: The Resource Utilization Grouping (RUG) rate(s) is all-inclusive rate(s) which includes the following costs: room, meals, medications, medical care, wound care, tracheostomy and supplies, ventilator and supplies, physicians visits, laboratory, x-ray, therapy(ies), equipment, supplies and other special services authorized by VA, unless otherwise specifically excluded. VA will contract for appropriate Medicare categories of care using Resource Utilization Groups (RUGs IV) as a reference and prior written approval for specific RUG “Levels of Care” are required. A description of the RUG systems may be found in 42 CFR Parts 409, et al.

5. Medicare-Rate Determination: The current, per diem rate for Medicare-approved nursing homes including the cost of supplies, services, and equipment. Any adjustments to established rates requested after the effective date of this IDC will require a written contract modification. The RUG IV rates include: room, meals, routine nursing, medical and wound care, physicians visits, laboratory, x-ray, rehabilitation therapy (including physical, speech and occupational), respiratory and oxygen therapy, nursing supplies (including items such as urological and colostomy supplies), tracheostomy, ventilator, items of durable medical equipment and other special services authorized by VA, unless otherwise specifically excluded. Any and all adjustment(s) to the RUG level of care or additional requests for payment to the all-inclusive per diem rate must be specifically requested and receive written approval/authorization prior to services being rendered.

6. The CNH’s Minimum Data Set (MDS) Assessment for Medicare: The CNH’s Minimum Data Set (MDS) assessment will be completed on the same schedule as the current Medicare MDS-Scheduled assessments, including close of therapy (COT) assessments. Classification changes will be approved by VA, dependent on projection for short-term or long-term residence, and adhering to the most current MDS frequency guidelines from Medicare. The applicable per diem rate will continue until the next assessment. Any and all adjustment(s) to the RUG level of care or additional requests for payment to the all-inclusive per diem rate must be specifically requested and receive written approval/authorization for a specific period of time and prior to services being rendered. VA will make the determination whether classification changes require readmission to VA. VA staff will audit MDS assessments as needed, as determined by VA.

7. Level of Care: The Level of Care classification and associated per diem rate(s) will remain in effect for each individual, specifically approved Veteran for a specifically approved period of time, unless one of the following events takes place:

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

B. Need for more intensive therapy;

C. Significant change in condition; or D. Classification changes may also occur based on a determination by VA.

8. Primary Medical Coverage: The assigned CNH provider is the patient’s primary medical provider during the nursing home stay and this individual is responsible for writing and/or approving admission and all other orders from the time the veteran arrives at the CNH. The CNH provider calls and arranges for timely provider back-up according to OBRA guidelines (42 CFR 483.40), as well as 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 in accordance with CMS Guidelines.

9. Rehabilitation Criteria: All therapy provided under this IDC will be individual therapy, rather than group therapy, unless otherwise ordered and authorized by 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.

10. Emergency Care; Financial Responsibility; Advanced Directives: In emergencies, CNH staff will utilize the local 911 emergency systems as for any resident. The Nursing Home must contact the VA CNH Coordinator or VA authorized representative upon transfer of the contracted Veteran to an outside facility and provide, at a minimum, the following information: Identifying information of Veteran; Date of transfer; Reason for transfer and the transfer location. 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.

11. 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, 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 Program qualifies as a medical service, so no BAA is required.

12. State Licensure; Access to CNH Quality of Care Reports (QASP Indicator No. 1): The CNH must, at all times, 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 VANCHCS CNH Program Coordinator or VA authorized representative. VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this IDC, through one or a 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 and/or quality assurance program functions relating to this IDC, including VA’s on-site inspection and monitoring. The VA Contracting Officer or VA authorized representative shall make all final determinations as to the Contractor’s reasonable cooperation with VA and compliance with these requirements.

13. Corrective Action Plan(s) (QASP Indicator No. 3): The CNH will cooperate with timely development of a Corrective Action Plan(s) (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 CAP(s) for VA surveys or investigation of complaints related to quality of care or sentinel events. The CNH will also supply documents and data as specified by VA. The Corrective Action Plan will include but will not be limited to the following criteria and shall:

A. contain elements detailing how the CNH will correct the deficiency(ies) as it relates to the identified deficiency(ies);

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

C. include the measures the CNH will take or systems/processes that will be altered to ensure the problem will not recur. It is the CNHs responsibility to evaluate 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 currently 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 the 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(s) will be completed.

14. Life Safety Code: The CNH’s building shall conform to the most recent standards of the Life Safety Code (National Fire Protection Association Standard No.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 or other VA authorized representative 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 or other VA authorized representative will notify the VA Safety Manager responsible for the Life Safety Code inspection of the CNH and will review (inspect the facility if required) the proposed changes and provide necessary approval/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 fully equipped with functional automatic sprinklers;

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

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

15. 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.

16. Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veteran(s); CNH Responsibility to Veterans’ Belongings or Personal Effects (QASP Indicators No. 6 & 7): VA beneficiaries who begin to require more than the level of care authorized by VA will be readmitted to an appropriate VA facility, as determined and authorized by VA.

A. The nursing home shall notify the authorizing VA facility when a medical emergency requiring rehospitalization occurs, (within 24 hours or the first business day after a weekend or holiday). The veteran shall be readmitted to an appropriate VA facility. When such readmission is not feasible because of the nature of the emergency, hospitalization in a non-federal hospital may be accomplished provided VA authorization is obtained from the Utilization Review Nurse or other VA within 72 hours of admission.

B. In the event of a death of a VA beneficiary occurs while receiving nursing home care under this IDC, the CNH is required to promptly notify the authorizing VA facility within 24 hours or on the first business day following a weekend or holiday 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, heir(s), or next of kin, 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.

17. Leave of Absence (LOA) – Bed-Hold Statement: 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. 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 may cover bed holds based on the following:

The host VA medical center may select and approve one of the following options upon CNH request for bed hold: Up to 5 days/hospital transfer, pre-approved by VA when in the best interest of the Veteran and VA. Exceptions approved at VAMC level:

A. 1) Follow Medicare: no bed holds; 2) Follow Medicaid : rule would differ by State;

B. 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);

C. VA may reimburse according to the prevailing State Medicaid guidelines.

Authorized bed-hold may begin the date the resident leaves the CNH and applicable 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 agreement of authorization. It is the CNH’s responsibility to notify the family if a bed hold is required for a longer period. The family would then arrange with the CNH to hold the bed.

18. Reportable Events (QASP Indicator #4): VA requires CNHs to report to the VA CNH Coordinator or authorized VA representative of any of the following events within 24-hours or the first business day after a weekend or holiday: VANCHCS Appointment Line at: (800) 382-8387. Reporting (see above for Reportable Events) shall include date of occurrence, patient disposition and outcome. A sentinel event may include, but is not limited to the following:

A. A fall resulting in death or injury;

B. Elopement resulting in a missing patient;

C. Patient abuse confirmed or under suspicion;

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

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

D. 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 the State requires that the occurrence be reported), such event is also to be reported to VA CNH Coordinator or other VA authorized representative. 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 CNH to report such incidents to the VA CNH Coordinator.

19. 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 veteran(s) from the CNH;

D. Not renew the IDC; and/or E. Terminate the IDC.

20. VA Staff Access to CNH Records (QASP Indicator No. 5). All medical records (including electronic) 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 a minimum, 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).

21. 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:

A. Sufficient information to identify the resident;

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

C. Veteran’s MDS Assessment (if available);

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

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

F. Medical practitioner orders which are signed and dated;

G. Allergies;

H. Person to contact in an emergency situation;

I. Name of attending medical practitioner; and J. Advanced directives (if available).

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

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

24. VA Health Care System Consultation/Resources.

(A) Telephone Care Communications Systems (TCCS): For urgent same-day outpatient specialty care or for non-urgent scheduled clinic appointments/consultations, call VANCHCS Appointment Line at: (800) 382-8387, between 9 a.m. and 3 p.m. Monday through Friday, excluding holidays.

If a same-day appointment is anticipated, please call as early as possible.

(B) Admissions: For admissions/non-emergency consultations or evaluations for admission to VANCHCS (after initial evaluation or intervention by the nursing home physician) please call:

VANCHCS Appointment Line at: (800) 382-8387;

(C) After hours, weekends and holidays: For urgent referrals or consultation contact VANCHCS Advice Line at: (800) 382-8387;

(D) Transportation: Necessary transportation to and from the VA hospital for previously scheduled and authorized appointments will be arranged by the VA hospital for CNH patients when requested. For scheduling clinic appointments, call VANCHCS Appointment Line at: (800) 382-8387and contact the CNH Coordinator or authorized VA representative for transportation/travel requests

24. 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.

25. CNH Billing (QASP Indicator No. 9): Invoices for board, care and ancillary services shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered. The CNH will promptly notify the VA CNH Coordinator or VA authorized representative 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 proper invoices must accurately include the full name and address of the CNH, and shall accurately reflect the patient’s name, social security number, beginning and end date of services rendered, number of days billed, authorized/approved RUG category(ies), and the level of care provided/established RUG rate(s). Failure to include this information may result in delayed payment. NOTE: All invoiced services must receive prior VA authorization.

A. Pre-approved services billed by CMS procedures or CPT codes: All VA pre-approved services, which are provided in addition 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, as authorized by VA;

B. High cost drugs: All requests for high cost medications not included in the all-inclusive per diem rate must be specifically requested by the CNH provider or authorized designee and must be specifically authorized by VA;

C. Invoices: Invoices will be sent on the CMS-1450 (red invoice). The invoices must include the same information as provided to Medicare. Payment will be made monthly, thirty (30) days in arrears, following receipt of a properly prepared invoice. A properly prepared invoice shall include the RUG level and assessment reference date. All services provided must be itemized (listed separately) on the invoice. Separate invoices will be submitted for each Veteran approved for services under this agreement.

26. Minimum Quantities; VA Payment. It is inadvisable for the government to determine the exact amount, which may be expended under this IDC. No obligation will be incurred by VA under this IDC, until pre-approved VA authorizations are issued for nursing home care of specific beneficiaries. VA agrees to make payment on a timely basis for specifically pre-approved services rendered in accordance with FAR 32.905, after receipt of proper invoice. 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 occur on the same day, then payment will be made for one (1) day.

27. 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 written authorization, is obtained from the authorizing VA facility. The Veteran, family and/or 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:

VA Northern California Health Care System Mare Island Outpatient Clinic Fee Basis/Purchased care (04F/MI) 201 Walnut Avenue Vallejo, CA 94592

Records Management Language for Contracts Required The following standard items relate to records generated in executing the contract and should be included in a typical Electronic Information Systems (EIS) procurement contract:

1. Citations to pertinent laws, codes and regulations such as 44 U.S.C chapters 21, 29, 31 and 33; Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part 1228.

1. Contractor shall treat all deliverables under the contract as the property of the U.S. Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.

1. Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records.

1. Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the Freedom of Information Act.

1. Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.

1. The Government Agency owns the rights to all data/records produced as part of this contract.

1. The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractor must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data.

1. Contractor agrees to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974. These policies include the preservation of all records created or received regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.].

1. No disposition of documents will be allowed without the prior written consent of the Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules.

1. Contractor is required to obtain the…