RFP 36C26220R0141 Amendment 0001.pdf

5. PROJECT NUMBER (if applicable)

CODE 7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

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6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER 3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

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PAGE OF PAGES

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10B. DATED

BPA NO. 1. CONTRACT ID CODE

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Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR

ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office. is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

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Prescribed by GSA - FAR (48 CFR) 53.243

(Type or print) (Type or print)

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(Number, street, county, State and ZIP Code)

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(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

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ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer)

0001 07-15-2020

NONE

36C262

Department of Veterans Affairs

Network Contracting Office 22

4811 Airport Plaza Drive

Suite 600

Long Beach CA 90815

36C262

Department of Veterans Affairs

Network Contracting Office 22

4811 Airport Plaza Drive

Suite 600

Long Beach CA 90815

To all Offerors/Bidders

36C26220R0141

07-15-2020

X

X 1

The purpose of Amendment 0001 is to answer questions received in response to RFP 36C26220R0141

VAGLAHS -PB HUD-VASH - Building 209.

Please see attahced documents.

RFP response is due by 7/30/2020 at 4:00pm PST.

Michael Kahyai

Question and Answers

RFP: 36C26220R0141

QUESTION: Page 18, #3.1 – Can the Team Supervisor and Lead Case Manager positions be considered in determining staffing patterns to fulfill the requirement of having access to case management services 24/7? (For example, the Team Supervisor and Lead Case Manager could perform case management functions during normal business hours, and Case Managers would perform this function on evenings, overnight and weekends.)

ANSWER: Per section 3.1 of the SOW, Veterans must have 24/7 access to case management in crisis intervention. The contractor shall establish the coverage/rotation as they see fit by someone who holds a case management position (Peers, SUDS, housing specialist would be excluded from this rotation). The person on call—should preferably be Licensed and /or have access to a licensed professional. Section 3.1 of the SOW has been updated to reflect this updated language.

QUESTION: Page 29, #5.2.3.-Please provide clarification on the Assigned Clinical Supervisor’s role. Can the Team Supervisor function as the Assigned Clinical Supervisor?

ANSWER: Yes. Sometimes the Team supervisor is a LMFT, which may not be appropriate to clinical supervise a MSW and Vice Versa. But in cases where it aligns, that is fine.

QUESTION: Page 30, #5.2.5 – This paragraph discusses the non-mandatory positions of

Certified Substance Abuse Counselor and Substance Use Disorder Specialist. Are you considering these two separate positions?

ANSWER: No, they are the same. The Substance Abuse Disorder Specialist is there to be used a definition.

B.4 STATEMENT OF WORK

Background:

HUD-VASH is a national program serving Veterans and their families throughout the country. This program continues to expand and has become one of the largest VA interventions to assist homeless

Veterans. It represents one of VA’s most significant efforts to achieve the President’s goal of ending homelessness among Veterans. The target population for the HUD-VASH program includes Veterans who are the most vulnerable and may have severe mental health and/or substance abuse problems targeting those who meet the chronic homeless definition (Reference Attachment C VHA HUD-VASH

Directive 1162.05).

This program also includes Veterans who may not be chronically homeless but who may fall into one of the priority groups (Reference Attachment C VHA HUD-VASH Directive 1162.05): women, women

Veterans with children, Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn

(OEF/OIF/OND) Veterans, and/or Veterans who have physical health problems and/or Substance Use

Disorders (SUD) with frequent emergency room visits, multiple treatment failures, and limited access to other social supports. Other priority groups per HUD Guidelines include; Chronically homeless, Homeless person with a disability with long periods of episodic homelessness and severe service needs, Homeless persons with disability with severe service needs, Homeless persons with disability coming from places not meant for human habitation, safe havens, or emergency shelters without severe service needs and/or Homeless person with a disability coming from transition housing. Reference Attachment C

VHA HUD-VASH Directive definition of Chronically Homeless. HUD Notice CPD-16-11, Notice on

Prioritizing Persons Experiencing Homelessness, VHA HUD-VASH DIRECTIVE 1162.05(1) at https://files.hudexchange.info/resources/documents/notice-cpd-16-11-prioritizing-persons-experiencing-chronic-homelessness-and-other-vulnerable-homeless-persons-in-psh.pdf.

The U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System (VAGLAHS) requires the Contractor to have demonstrated experience in the U.S. Housing and Urban Development

(HUD) and Veterans Affairs Supportive Housing (VASH) program to provide on-campus project-based case management and supportive services for Veterans who would benefit from onsite intensive case management due to the complexity and acuity of their needs. Intensive Case management is a team-based approach that offers a coordinated and brokered approach-delivering therapeutic services utilizing a strengths-based model of care.

Project Based Vouchers (PBVs) are a component of the Public Housing Authorities (PHAs) housing support program (Refer to Definitions Section of this Statement of Work (SOW). Under the PBV program, a PHA enters into an assistance contract with the owner of the property for a specified number of units and for a specified term. The assistance is tied to a unit. An individual/family who moves from a PBV unit does not have any right to continued housing assistance unless they are eligible to receive a Housing

Choice Voucher (HCV) when one becomes available.

The purpose of this contract is to serve homeless Veterans with complex medical and psychiatric needs who have few resources and require long-term case management to either obtain and/or maintain permanent supportive housing. HUD-VASH follows the definition of “homeless” as authorized in 24

CFR 91.5, 38 U.S.C. 202(1) Reference Attachment C VHA HUD-VASH Directive 1162.05 and the

McKinney-Vento Homeless Assistance Act, as amended by S.896 the HEARTH Act of 2009

(https://files.hudexchange.info/resources/documents/HomelessAssistanceActAmendedbyHEARTH.pdf).

Scope:

https://files.hudexchange.info/resources/documents/notice-cpd-16-11-prioritizing-persons-experiencing-chronic-homelessness-and-other-vulnerable-homeless-persons-in-psh.pdf https://files.hudexchange.info/resources/documents/notice-cpd-16-11-prioritizing-persons-experiencing-chronic-homelessness-and-other-vulnerable-homeless-persons-in-psh.pdf https://files.hudexchange.info/resources/documents/HomelessAssistanceActAmendedbyHEARTH.pdf

Through the HUD-VASH program, the Contractor shall place Veterans into on campus Project Based housing while simultaneously providing case management and supportive services; and assist the Veteran in maintaining housing in the project-based unit. The contractor shall provide these services to a maximum of 54 Veteran patients, referred for placement in on campus HUD-VASH units provided by the

Housing Authority and City of Los Angeles (HACLA).

These Veterans will be placed in on campus housing due to complex medical/MH needs to promote accessibility of services; therefore, the contractor is expected to engage in frequent care coordination activities with VA and community providers working with the Veteran. The number of Veterans is expected to fluctuate over time. The facility is expected to accommodate a maximum of 54 Veterans. The

VA and Contractor may mutually agree to assign Veterans to the facility, at the same; price per voucher currently in effect as showing in the Price schedule.

The expectation is that all vouchers provided on this contract be utilized at 100% and that maximum effort from the contractor be made in respects to outreach and housing placement. VAGLAHS will support the contract with outreach and referrals to the best of their ability.

Through this contract, the VA seeks to expedite the placement of eligible HUD-VASH Veterans and their families in an on-campus, project-based, HUD-VASH housing.

Place of Performance: 11301 Wilshire Blvd. Building 209, Los Angeles, CA 90073.

1. General Requirements

1.1 Contractor shall work with Veterans who will be housed in the project-based units.

1.2 Contractor shall provide supportive services to Veterans which include, but are not limited to:

Resident Town Hall, Recovery groups, Recreational activities, Life Skills group, Substance Abuse

Groups, Bringing in community resources (e.g. Legal, Financial), Peer support groups, Religious/church services and/or Employment services/opportunities.

1.3 Contractor shall provide case management in accordance with Attachment BB HUD-VASH Case management and Attachment A Stages of Case Management and minimum visit requirements

Standard Operating Procedure with staffing ratios not to exceed twenty-five Veterans per case manager (25:1).

1.4 Contractor shall provide a team staff composition that is a mix of mental health and addiction treatment professionals, licensed social workers, licensed marital and family therapist/licensed mental health counselors, nurses, psychologist and housing and/or peer specialists. At least 50% of providers shall be master’s level per the qualifications outlined in section 5 of this Statement of Work (SOW).

1.5 Contractor shall provide 24/7 coverage for case management support as discussed in section 3 of this

SOW.

1.6 Contractor shall comply with HUD-VASH and GLA policy and procedures regarding documentation and evaluation standards for Veterans enrolled in HUD-VASH. Reference Attachment B HUD-VASH

Documentation SOP.

1.7 Contractor case management staff shall visit Veterans if in an institutionalized setting (hospital, assisted living, Board and Care, Community Nursing home, etc.). If Veterans are incarcerated, they should reach out to Veterans Justice Outreach (VJO) for coordination and collaboration of follow-up and services. Contractors shall also accompany Veterans to clinics, Emergency Rooms or other appointments as clinically indicated, while working with Veterans to foster independence and a sense of self- determination.

1.8 Contractor shall not discharge Veterans from case management services. If they leave the project-based voucher (PBV) initiative and begin to reside elsewhere. The Contractor shall establish alternative case management services prior to discharge.

1.9 Case Management visits to Veterans shall be conducted in accordance with Attachment C VHA HUD-

VASH Directive and Attachment A HUD-VASH Stages of Case Management and Minimum Visit

Requirements SOP.

1.10 Contractor staff shall ensure that when Veterans have achieved housing stability, the focus of the service support changes to community integration and other goals as discussed and agreed upon with

Veteran, and their contact with the Veteran does not diminish.

1.11 The Contractor shall meet the same performance measures set forth for the VA by the VHA

Homeless Program Office located in the technical manual “Performance Measures and Metrics” this requirement shall include any subsequent updates and/or revisions, to include standards set forth in the VA Supportive Housing Target and Business Rules (Reference Attachment C VHA HUD-VASH

Directive). Including the responsibility to update the Employment Tracker in the Homeless

Operations Management and Evaluation System (HOMES please refer to Definition section of this

SOW).

1.12 Contractor’s case management services shall follow the principles and practices of the Pathways

Housing First Model (written by Sam Tsemberis). A copy of this book can be provided to the

Contractor by the VA.

1.13 Contractor staff shall participate in continuing education training related to Pathways Housing

First model, trauma informed care, motivational interviewing (refer to definitions section of this

SOW), relapse prevention, supported employment and supported education. The Contractor shall participate in all VA mandatory trainings for staff mentioned in section 1.23.1.4 and 3.20.5 of this

SOW. The VA shall also extend an invitation to Contract staff to participate in new trainings as approved throughout the year; if the Contractor chooses to provide their own similar trainings for staff, the contractor shall show that these trainings are performed by a certified trainer.

1.14 The Contractor shall provide full staffing in accordance with the requirements defined in this

SOW within 60 days of the contract award either through existing staff or new hires.

1.15 The Contractor shall maintain Basic Life Support (BLS) certification for all technical and professional staff; American Heart Association certification is preferred but not required. The

Contractor shall be removed from direct patient care if it expires or until it is obtained.

1.16 Contractor shall encourage Veterans to actively engage in healthcare and, when clinically indicated, mental health and or addiction services.

1.17 Contractor shall document in Homeless Operations Management and Evaluation (HOMES) within 3 business days of Veteran encounters and change of Veteran status as indicated. Reference

National policies from HOMES Main page. https://vaww.homes.va.gov/VAHomesNew.aspx

1.18 Contractor shall enter Veteran information (e.g. name, SSN), after obtaining a release of information into the Coordinated Entry System and Health Information Management System (HIMS) https://vaww.homes.va.gov/VAHomesNew.aspx

Reference Definition section of this SOW.

1.19 Veterans shall be assessed by the Contractor to determine if the Veteran meets the criteria for admission into the HUD-VASH program. The Contractor shall complete HOMES documentation, consistent with the HOMES Reporting Policy and VA Medical documentation, consistent with

Attachment B- HUD-VASH Documentation Standard Operating Procedure (SOP), which may include but not limited to changes to admission, housing, voucher, or employment status, encounter documentation, screening/admission notes, release of information forms, housing service agreements, suicide risk assessments, Advanced Directive Discussions, clinical reminders, treatment plans and safety plans. Contractor shall document using the appropriate template format for all clinical notes or appropriate templates and ensure all encounters are entered within 3 business days or on the same day in cases of crisis, in accordance with Attachment B- HUD-VASH Documentation Standard Operating

Procedure (SOP)

1.20 Contractor shall participate in and coordinate with the VA COR/Liaison during weekly case conferences regarding updates and changes in the Veteran’s care plans to foster a collaborative relationship with the VA and Contractor in meeting the Veteran’s needs. Case conferencing may be done in person or by telephonic conference calls as determined by the VA HUD-VASH Coordinator or his or her designee. All Veterans should be case conferenced once every quarter (no less than every

90 days) or as clinically indicated. All case conferences shall be documented in VA medical record system; additional providers-including primary care, specialty clinics, etc., shall be added as additional signers for awareness and collaboration. The Contractor shall involve other disciplines to participate in these case conferences based on providers working with the Veteran. VA COR/Liaison will review the case conferencing schedule presented by the contractor to ensure all Veterans are discussed no less than every 90 days. A case conferencing guide Attachment D- Case Conference

Guide, is attached for reference.

1.21 The Contractor shall work with the Veteran on obtaining and maintaining housing, developing independent living skills to include but no limited to budgeting, employment and/or assistance obtaining VA benefits.

1.22 The Contractor shall make every effort to communicate with the VA regarding this contract through the Network Contracting Office (NCO) 22, via the designated primary VA COR and/or at minimum when reaching out to Contracting office, include the COR/Liaison in the communication.

1.23 The Contractor shall demonstrate successful completion of the following tasks, validated by VA inspection, prior to initiating case management.

1.23.1 Tasks: The Contractor(s) shall:

1.23.1.1 Attend a post-award kick-off meeting within 10 days of contract award with the Contracting

Officer, COR, Program Manager and Others as agreed upon.

1.23.1.2 Process a Security/background investigation via National Agency Check with Written

Inquiries (NACI) and a Special Agreement Check (SAC) which includes electronic fingerprinting for case managers and their supervisor working with Veterans. In order to complete this background check, the Contractor shall provide staff member’s date of birth, social security number, hair color, eye color, address, phone number, and email addresses. U.S

Citizenship or legal resident status will be verified as part of this process.

1.23.1.3 In order for case managers and their supervisor to perform under this contract, they shall complete the credentialing process through the VA’s VetPro system in alignment with the

VetPro policies and operating procedures Reference VHA Handbook 1100.19 Credentialing and Privileging https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910.

VetPro is necessary for all licensed, registered or certified clinical staff members (e.g. LCSW, RN, CASAC.) and unlicensed case managers. Staff waiting to clear VetPro shall not perform duties at a lower level while awaiting credentialing. They may complete tasks that do not involve Protected Health Information (PHI, Refer to Definitions section of this SOW) or require Veteran contact.

1.23.1.4 Ensure staff performing on this contract complete the VA’s online Information Security and

Privacy Awareness Training Course and the Privacy Policy Awareness Training Course for case managers and their supervisors working directly with Veterans under this contract. The

Privacy Awareness Training requirement may be fulfilled under additional privacy awareness training options. In order to complete online VA Privacy and Information Security Training, Contractor staff shall set up a VA Employee Education System account. This shall be done online. This requirement is in addition to any other training that may be required of the

Contractor(s) and any sub-contractor(s).

1.23.1.5 The Contractor shall not commence performance on the tasks in the awarded contract until the

Contracting Officer (CO) has conducted a kickoff meeting or has advised the contractor that a kickoff meeting has been waived.

1.24 Post Award Conference

1.24.1 The contractor shall meet face to face or via Teleconference quarterly through the life of the award with the Contracting Officer, COR, Program Manager, and others to ensure that the

Contract performance requirements are being met.

2 Admission/Referrals

2.1 Veterans enter the HUD-VASH program by being identified as meeting HUD-VASH admission criteria (Reference Attachment C VHA Directive 1162.05 HUD-VASH Program) and/or referred by the VA as eligible for the program or through community outreach conducted by the Contractor.

2.2 The Contractor shall conduct screenings, including an interview with the Veteran, VA medical record system chart review, and HOMES assessment (Reference Attachment M HOMES Forms) as appropriate to determine VASH eligibility based on the homeless and chronic homeless criteria.

2.3 The Contractor shall also conduct a basic screening for healthcare eligibility that shall include a review of the Veteran’s DD214 by obtaining access to SQUARES (see definition section of SOW).

2.4 Contractors shall admit Veterans to the HUD-VASH program without VA approval after completing necessary screenings, however, the Contractor shall notify the VA COR by email within 24-hours of the Veterans admission and add the Veteran to the Agency list. Note: Admission is by clinical decision of HUD-VASH Staff, or, if indicated, in more complex situation, with consultation of homeless program leadership or other appropriate service. Contractors shall maintain a list of

Veterans who do not meet the eligibility criteria and provide those Veterans with a copy of

Attachment N-HUD VASH Denial letter. Veterans must be informed that they have a right to file an appeal within 60 days from receipt of the denial letter by following the process noted in the letter.

Veterans shall also be provided with alternate resources for housing. An example of resource handout

(attachment X) is attached.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910

2.5 If Veteran was previously screened and denied by VA, as evidence by screening note in VA Medical record, contractor shall contact VA COR/Liaison to consult prior to completing their screening and/or admission into program.

2.6 Contractor shall provide simultaneous housing and case management services for Veterans under their care.

2.7 Veterans are considered admitted into HUD-VASH when accepted for case management. Admission decisions shall occur within 24 hours or one business day of a completed referral interview with the appropriate documentation in HOMES.

2.8 In the case of a two-Veteran household, the individual identified as head of household with the primary need for case management is the voucher holder. If both Veterans require case management, there shall be two separate entries in HOMES showing that they are case managed although one

Veteran has a HUD-VASH Voucher issued.

2.9 Contractor Housing Placement & Stabilization Duties: The Contractor shall perform Housing

Placement & Stabilization Duties that include the following:

2.9.1 Identify and enroll Veterans who meet criteria for program admission:

2.9.1.1 To be eligible for the HUD-VASH program, a Veteran must be:

2.9.1.1.1 Eligible for VA health care as determined by the local VA medical center

2.9.1.1.2 Determined to be homeless based on national HUD-VASH Policies and Practices with every effort made to identify and serve the most chronically homeless and vulnerable Veterans.

2.9.2 Contractor shall assist Veteran in completing and submitting PHA and other Federal, local, and state entitlement program paperwork (e.g. Social Security, food stamps, utility assistance, etc.)

2.9.3 Advocate with landlords on behalf of the Veteran to maintain a lease and advise any potential landlords that the contractor shall be providing assistance and case management services to the

Veteran in order to help the Veteran remain successfully housed. Contractor shall assist Veterans with all inspections required for move-in (Reference Attachment DD Pre-inspection checklist).

Contractor shall ensure that the Veteran has completed the VA release of permitted information so communication between the landlord, Contractor, and VA can occur as needed.

2.9.4 Assist with developing a budget and assist the Veteran in securing necessary funding for recurrent monthly expenses.

2.9.5 Assist the Veteran in making calls to utility providers to ask questions and resolve issues

(including turning off or transferring utilities), ensure the Veteran is paying rent and utility bills in a timely manner and provide budgeting/money management assistance as needed.

2.9.6 Assist Veteran in applying for all eligible benefits, both VA and non-VA, including but not limited to; Veteran’s Benefits Administration (VBA), Employment Development Department

(EDD), Social Security Administration (SSA).

2.9.7 Perform site visits of HUD-VASH apartments to ensure that Veterans reside in healthy residences in accordance with Attachment C VHA Directive 1162.05 HUD-VASH Program and Attachment

A HUD-VASH Stages of Case management and minimum visit requirements SOP. Veterans in these units have been identified as psychiatrically and medically complex and it is the expectation of the VA that the Contractor shall visit Veterans monthly with the Lead case manager making at least quarterly face to face contact with the Veteran.

2.10 The Veteran is entitled to Portability of his/her voucher. Portability provides Veterans the opportunity to transfer their HCV to live in the community of their choice, within certain limits.

In addition to local VA guidelines, Federal Register Notice of May 6, 2008 addresses portability in HUD-VASH. The Notice can be found at:

https://www.federalregister.gov/documents/2014/06/18/2014-14167/section-8-housingchoice-vouchers-revised-implementation-of-the-hud-va-supportive-housing-program NOTE: This linked document is outside VA control and may or may not conform to Section 508 of the Rehabilitation

Act.

3 Case Management Duties:

3.1 The Contractor shall have procedures in place to ensure Veterans have access to case management services through a licensed professional, twenty-four (24) hours per day, seven (7) days per week, which shall include crisis management and referrals (Attachment BB HUD-VASH Case Management).

3.2 The Contractor shall ensure consistency of case management services to enhance staff ability to engage and form relationships with Veterans and provide consistent and highly skilled interventions in keeping with the Housing First (HF) model.

3.2.1 Housing First is an approach that centers on providing homeless individuals with housing quickly, and then providing services and treatment as needed. The primary focus of the Housing

First approach is to identify an immediate need for housing and helping individuals and families quickly access and sustain permanent housing. Housing First programs share four (4) critical elements:

3.2.1.1 Focus on helping individuals and family’s access and sustain rental housing as quickly as possible and ensure the housing is permanent;

3.2.1.2 A variety of services delivered primarily following a housing placement to promote housing stability and individual well-being;

3.2.1.3 Time-limited or long-term services depending upon the individual need;

3.2.1.4 Housing is not contingent on compliance with services. Participants must comply with a standard lease agreement and are provided with the services and supports necessary to help them to obtain and maintain housing and reintegrate into the community.

3.2.1.5 Contractor staff shall support the Veteran’s family (Refer to the Definitions section of this SOW) members who may be residing with the Veteran by assisting them in obtaining medical and mental health care if needed as well as assisting with school registration.

3.2.1.6 Contractor staff shall provide the documented needs of Veterans and make home visits consistent with the needs of the Veterans and in accordance with Attachment A HUD-VASH

Stages of Case management and minimum visit requirements SOP and Attachment E Mental

Health Treatment.

https://www.federalregister.gov/documents/2014/06/18/2014-14167/section-8-housing-choice-vouchers-revised-implementation-of-the-hud-va-supportive-housing-program https://www.federalregister.gov/documents/2014/06/18/2014-14167/section-8-housing-choice-vouchers-revised-implementation-of-the-hud-va-supportive-housing-program https://www.federalregister.gov/documents/2014/06/18/2014-14167/section-8-housing-choice-vouchers-revised-implementation-of-the-hud-va-supportive-housing-program

3.2.1.7 The identified Contractor shall also apply Harm Reduction interventions when working with

Veterans.

3.3 The Contractor shall have space available at the project-based site for the staff to conduct group meetings with the Veterans under contract care. This space must provide Veterans with privacy.

3.4 The Contractor shall also have the ability to place Contractor staff at VA facilities to provide access to Veterans as clinically appropriate.

3.5 Contractor shall submit a monthly tracking sheet (commonly referred to as White Board) approved by the COR that provides status updates for Veterans receiving services under this contract regarding change in the level of care, milestones met, employment/benefits, potential discharges, and other fields as approved by the COR/Liaison.

3.6 Contractor(s) shall ensure that sufficient staff are available to provide services to meet the documented needs of the Veterans as well as to make home visits consistent with the level of care each Veteran is being treated at in addition to the following:

3.6.1 Create a Mental Health treatment plan (MHTP) Attachment E-Mental Health Treatment Plan and

Attachment W Mental Health Suite Treatment Planning) within two weeks of program admission.

(This plan will be documented in the VA medical record). For MHTP entry time frames-reference

Attachment B- HUD-VASH Documentation SOP.

3.6.2 Review and update the Treatment Plan with the Veteran every six months or when there is a significant change in Veteran’s functioning level or circumstances that calls for a change in his/her treatment and document the review and any changes to the plan in the VA medical record.

The Contractors Lead Case Manager or Supervisor shall act as the Mental Health Treatment

Coordinator if the Veteran does not have a VA mental health provider. This Lead Case Manager or Supervisor shall be a clinically licensed staff member.

3.6.3 Comply with additional documentation and/or data reporting for the Housing First demonstration as required by VAGLAHS based on changing or subsequent local, VISN, or national HUD-

VASH requirements.

3.6.4 Engage the Veteran in the HUD-VASH screening process and perform interviewing, counseling, and case management of identified Veterans who are at risk; providing psychosocial assessments

(see sample attachment Y) to identify service and treatment needs which affect Veteran’s housing stability, recovery/community reintegration.

3.6.5 Utilize case management strategies to include crisis intervention and case management including both short and long-term services working toward long range independent housing and community reintegration. Contractor shall provide services as needed based on Veterans’ needs, acuity level and preferences for care. Veterans needs to be reassessed on a regular basis, no less than quarterly and in accordance with local policy for changes in their needs, acuity level and preferences for care.

3.6.6 Screen each Veteran for suicidal and homicidal risk with each contact. This screening shall be documented in progress notes, suicide risk assessments, and safety plans. Contractor shall document the aforementioned in the VA medical record.

3.6.7 If the Veteran is a danger to him/herself or others, the Contractor shall take immediate steps to provide appropriate intervention per Attachment O CERS Procedure for Medical and Psychiatric

Emergency Response in the Community and Attachment F CERS Management and Escalation of

Health Status Concerns.

3.6.8 Crisis management shall be coordinated and executed by the contractor and shall be reported to the VA COR and other VA staff in accordance to Attachment F CERS Management and

Escalation of Health Status Concerns and Attachment G CERS Incident-Death Reporting

Manual.

3.6.9 Contractor is responsible for reporting Requirements located in the U.S. Department of Housing and Urban Development Public and Indian Housing Notice PIH 2011-53(HA), issued

09/20/2011; https://www.hud.gov/sites/documents/pih2011-53.pdf this requirement shall include any subsequent changes, updates, or revisions to the PIH Notice.

3.6.10 Facilitate the Veteran’s involvement in supportive employment and other restoration programs, intervening and advocating on behalf of the Veteran.

3.6.11 Assess and promote engagement with appropriate healthcare, especially mental health and addiction care when clinically indicated. Reference Attachment H CERS Primary Care

Engagement SOP

3.6.12 Formulate case-management treatment goals and plans with Veteran, that address identified needs, stressors and problems.

3.6.13 Actively involve the Veteran and their family or significant others in coordination with the team members, based on the psychosocial assessments, to develop a treatment plan with the Veteran using his/her language whenever possible, ensuring he/she has a copy of the plan including goals for clinical treatment and discharge from case management.

3.7 Contractors shall provide direct mental health and substance abuse counseling within the scope of practice of these disciplines and assist in securing available VA services including but not limited to the use of tele-mental health services.

3.8 Contractor shall integrate Housing stabilization planning with relevant VA health and mental health services. The Housing stabilization plan provides a case management and supportive services framework for the Veteran’s sustainability in HUD-VASH and identifies the Veteran’s goals with steps to achieve those goals.

3.9 Contractor shall have procedures in place to ensure clients have 24/7 access to live person-to-person case management services which shall include crisis management and referral.

3.10 The Contractor shall visit each Veteran face-to-face at the intervals required by Attachment C

HUD-VASH Directive and Attachment A Stages of Case Management and Minimum Visit

Requirements.

3.11 Visits, while not required to take place in the Veterans home, are encouraged to be done in the home at least on a quarterly basis to assess conditions of the home and at least once a month, if the

Veteran is in the intensive stage of case management. Visits can also take place in the community, at the Contractor agency, or a place mutually agreed upon by the Veteran and Case Manager.

https://www.hud.gov/sites/documents/pih2011-53.pdf

3.12 Phone contacts, while an acceptable way to communicate with the Veteran, are not considered visits in meeting the minimum visit requirements for any acuity level. In the event the Contractor is unable to locate the Veteran for the required number of visits, the Contractor shall document face-to-face attempts, phone calls, and letters sent to the Veteran including dates and times in the VA medical record system as verification of services rendered and to show that due diligence has been exercised.

Note: phone calls and letters do not qualify as attempts.

3.12.1 DUE DILIGENCE STANDARDS-The intent of this section is to provide directions to the

Contractor regarding:

3.12.1.1 Required clinical interventions for Veterans who cannot be located or contacted, and

3.12.1.2 What constitutes acceptable efforts in completing those steps for monthly invoicing purposes.

It is understood that homeless and formerly homeless Veterans may be difficult to reach, fail to keep appointments, and/or abscond from services at unexpected times. VA places high emphasis on incorporating a sense of urgency and accountability in following up with

Veterans to assure their safety and wellbeing. This is referred to as “due diligence.”

3.12.1.3 Clinical Due Diligence:

3.12.1.3.1 At any time, any urgent or emergent concerns about a Veteran’s health and safety by the

Contractor or the VA require immediate consultation with the Contractor supervisor and notification to the VA COR/Liaison. Contractor staff is expected to use clinical judgement and collaborate with the VA COR/Liaison in determining appropriate next steps in any emergent situation.

3.12.1.3.2 Clinical due diligence consists of multiple steps to reach a Veteran to ensure the Veteran’s well-being and follow up with appropriate case management and services. Visits should be scheduled with the Veteran when possible. Unscheduled visits may occur but will not be considered as non-compliance with case management on the part of the Veteran. Scheduled visits are defined as the Veteran having been contacted in advance and agreed to the appointment date, time, and location. When a Veteran is absent from a scheduled visit or meeting without notice, the following steps must be taken to contact the Veteran and/or determine the Veteran’s whereabouts.

3.12.1.3.3 Missed initial scheduled meeting: If the Veteran does not answer the door or is not present at the meeting location at the scheduled time, the Contractor shall attempt to contact the Veteran by phone while on the premises. (NOTE: This would not be considered a separate attempt to contact the Veteran because it is part of the scheduled appointment. This attempt to meet in person and contact the Veteran by phone shall be documented in one note in the medical record.) If the Veteran does not have a phone, the Contractor shall consult with the VA

COR/Liaison for alternatives based on the Veteran’s unique circumstances.

3.12.1.3.4 If the Contractor reaches the Veteran by phone and the Veteran is safe and well, the importance of a face-to-face meeting within 24 hours of the initial scheduled event must be emphasized with the Veteran and the visit / meeting should be rescheduled to occur as quickly as possible. This should be documented in the same note in the medical record. If the

Contractor is unable to reach the Veteran by phone, the VA COR/Liaison must be notified.

The Contractor is advised to consider taking the following steps (not necessarily in sequential order) in consultation with the contractor’s clinical case manager supervisor to locate the

Veteran:

3.12.1.3.4.1 Review VA medical record remote data (medical and other appointments or scheduled VA appointments) and Vista Web.

3.12.1.3.4.2 Contact all VA assigned medical providers (or non-VA medical providers if known).

3.12.1.3.4.3 Contact the Veteran's listed emergency contacts

3.12.1.3.4.4 Contact the Veteran's landlord or other collateral with whom there is a completed Release of Information

3.12.1.3.4.5 Check local shelter system roster (if assigned to a shelter, contact the shelter staff)

3.12.1.3.4.6 Utilize hospital registry, prisons, and inmate lookup websites

3.12.1.3.4.7 Contact the local police precinct closest to the Veteran’s home to request a and welfare check (police make visit to Veteran's apartment)

3.12.1.3.4.8 Make an unannounced visit to Veteran's home (if the missed meeting was scheduled for an alternate location)

3.12.1.3.4.9 Contact the city morgue

3.12.1.4 All steps taken to locate the Veteran shall be clearly documented in the clinical record. If the

Veteran is located and/or contacted during any of these steps, an appropriate plan and follow up shall be determined based on the Veteran’s disposition (i.e., home visit rescheduled; visit to other location such as hospital or shelter; etc.). This plan shall be reviewed by the case managers supervisor and documented in the VA medical record including any supervisory recommendations and timeframes for next steps.

3.12.1.5 If the Veteran has not been located and/or contacted upon completion of these steps, the

Contractor shall ensure that the case has been discussed with the VA COR/Liaison and the agreed upon plan for next steps has been documented in a progress note and entered into VA medical record system on the same day as the activity occurred.

3.12.1.6 Second attempt to meet with the Veteran after a missed appointment: If a Veteran has not been located and/or contacted after the steps listed in section 3.12.1.3 have been completed, a second attempt to meet with the Veteran shall be made within 24 hours of the initial scheduled meeting. At minimum, a second attempt must include a phone call to the Veteran. If the

Veteran does not have a phone, the Contractor shall consult with the VA COR/Liaison for alternatives based on the Veteran’s unique circumstances. If the Contractor reaches the

Veteran by phone, the importance of a face-to-face meeting within 24 hours of the initial scheduled event must be emphasized with the Veteran. This shall be documented as a separate administrative note. An in-person home visit is required. Phone contact is not an acceptable substitute. In the case of concerns about a Veteran’s safety, an unannounced home visit must be attempted as soon as possible. In either case, the Case manager shall consult their supervisor and notify the VA COR/Liaison. The VA COR/Liaison shall be consulted at any time for planning purposes based on the Veteran’s unique circumstances.

3.12.1.7 If the Veteran is located and/or contacted during any of these steps, an appropriate plan and follow up shall be determined based on the Veteran’s disposition (i.e., home visit rescheduled;

visit to other location such as hospital or shelter; etc.). This plan shall be reviewed with the case managers supervisor and documented in the VA medical record including any supervisory recommendations and timeframes for next steps.

3.12.1.8 If the Veteran has not been located and/or contacted upon completion of these steps, the

Contractor shall ensure that the case has been discussed with the VA COR/Liaison, and the agreed upon plan for next steps has been documented in a progress note and entered into VA medical record system on the same day as the activity occurred. Also, the contractor is required to include other providers working with the Veteran as signers on notes for awareness if the Veteran cannot be located/contacted and there are safety concerns.

3.12.1.9 Third attempt to meet with the Veteran after a missed appointment: If the Veteran still has not been contacted or located after the steps in 3.12.1.6-8 have been completed, the third attempt must be an unannounced home visit. This attempt should occur within 24 hours of the second attempt to reach the Veteran. If there is no response the Contract HUD-VASH Clinical

Supervisor and VA COR/Liaison must be notified and consulted regarding an appropriate plan based on the Veteran’s unique clinical circumstances. In addition, a certified letter should be mailed to the Veteran. The letter should include:

3.12.1.9.1 All telephone numbers used in prior attempts to reach the Veteran

3.12.1.9.2 Dates of those attempts

3.12.1.9.3 Case manager’s and supervisor’s contact information with

3.12.1.9.4 Specific request that the Veteran call to schedule an appointment

3.12.1.9.5 This should be documented as a separate administrative note in VA medical record system to include the tracking number of the certified mail.

3.13 The Contractor shall provide evidence of contacts with individuals and agencies engaged to support the Veteran’s housing and recovery needs. Specific documentation and implementation of services completed in the VA medical record system and HOMES charting record must be completed, with an approved, assigned licensed independent clinical provider signing off on all notes if the staff member providing direct services to the Veteran is not independently licensed.

3.14 Clinical Documentations that shall be completed by a master’s in social work intern under appropriate supervision or MSW or a person with equivalent or higher education are:

3.14.1 Comprehensive Suicide Risk Evaluation (CSRE) and Columbia-Suicide Severity Rating Scale

(C-SSRS) to include when necessary, Safety Plan.

3.14.2 Clinical reminders

3.14.3 Mental Health Treatment Assessment and Treatment Plan

3.14.4 Stage of Case management template

3.14.5 The Contractor shall create and retain records (by use of Attachment Z Dept of VA medical record system) that provide evidence of contacts with individuals and agencies engaged to support Veteran’s housing and recovery needs.

3.15 Registered master level interns may supplement case management staff with completion of documentation in accordance with the intern’s learning plan and oversight by clinical supervisor. All interns are required to have their clinical supervisor as their additional signer on notes. No task that falls within the intern’s scope of practice under the jurisdiction of the state licensing board may be completed by the Contractors bachelor’s level personnel.

3.16 Bachelor’s level Case Managers may be maintained as an integral part of the interdisciplinary case management team (Refer to the Definitions section of this SOW). Bachelor’s level Case Manager’s tasks must remain within scope of a Bachelor Level Social Worker and with direct supervision of a licensed independent clinical provider per Attachment J CERS Documentation Oversight of Direct

Service Personnel SOP. The supervision may also include shared visits depending upon the complexity. All other disciplines who are members of the Interdisciplinary case management team must only work within the scope of their trained field of practice.

3.17 Contractor shall comply with the huddle expectations described in Attachment K HUD-VASH

Huddle SOP. Contractor staff shall participate in at least one huddle per week, lasting two hours or two huddles per week, lasting one hour each. Any time remaining would be best used for more in-depth case consultation. The purpose of huddle is to discuss immediate needs/issues and create an action plan for assigned Veterans. Veterans who are currently in crisis and require immediate intervention (i.e. present as dangerous to self or others, have severe and/or acute unmet medical needs or housing related time sensitive matters such as: eviction, landlord/tenant issues jeopardizing housing or Public Housing Authority (PHA) requirements) should be discussed first.

3.18 Life Skills: Contractor shall provide life skills education and assistance to Veterans that include:

3.18.1 Budgeting/Money Management Assistance

3.18.2 Locating local food banks

3.18.3 How to use coupons

3.18.4 Budget billing for utilities

3.18.5 Advice on how to maintain a clean and safe residence

3.18.6 Socialization

3.18.7 Spirituality – where and how to access these services if desired

3.18.8 Schedule of free/low cost community activities

3.18.9 Planned evening and weekend Psychosocial events

3.18.10 Community volunteer opportunities

3.18.11 Peer/tenant support group

3.18.12 Instruction on how to be a good neighbor/tenant

3.18.13 Mental Health Wellness Self-Management / mental health recovery living skills (if applicable)

3.18.14 Relapse prevention and harm reduction (if applicable)

3.18.15 Healthy lifestyle/living

3.18.16 Access to community resources

3.18.17 Parenting/family living skills (if applicable)

3.18.18 Family reunification and/or development of relevant social support networks

3.18.19 Assist with obtaining legal assistance-free/low cost resources such as:

3.18.19.1 Obtaining a driver’s license

3.18.19.2 Locating child support

3.18.19.3 Identifying the local liaison with VJO (Veterans Justice Outreach) program,

3.18.19.4 Locating the local specialty or treatment court

3.18.19.5 Assistance with light house cleaning, shopping, and cooking.

3.19 Transportation: The contractor shall provide transportation for Veterans to medical and other VA appointments and/or appointments that would assist the Veteran in obtaining housing.

3.19.1 Contractor shall refer and provide transportation to VA Medical Facilities, VA Regional Offices, and community-based agencies for services that may include health care, entitlements, vocational assistance, education, recreation, and any other needed assistance.

3.19.2 The Contractor shall make every effort to connect the Veteran with existing public transportation networks or other community provided transportation.

3.19.3 In cases where the Veteran is unable to access or use existing public transportation networks or other community provided transportation, the Contractor shall provide transportation for the

Veterans to attend appointments at the VA, SSA, PHA, benefits agencies, landlords etc.

Transportation may include bus passes, transit cards, or subsidized transportation services such as

Access, and other identified needed services and entitlements.

3.19.4 The Contractor shall accompany Veteran to any public housing authority…