Att K - SOW Template.docx

Attachment K

RFS 26-87982

STATEMENT OF WORK

I. EXECUTIVE SUMMARY

Hospice Services will provide interdisciplinary services for the palliation and management of terminal illness. At times Residents and families request Hospice Services in conjunction with the nursing services provided by Indiana Veterans’ Hospital (IVH). Due to the long-term nature of IVH, it is beneficial to enter into agreement with Hospice providers to provide relevant resident request services.

II. BACKGROUND AND CURRENT STATE

The Indiana Veterans’ Home is a state-owned long-term care (LTC) facility located in West Lafayette, IN providing long-term skilled nursing care, short-term rehabilitation, and memory care services to honorably discharged Indiana veterans, their spouses, and Gold Star Parents. The IVH is looking to establish relationships with hospice providers to provide care to residents. This procurement process is needed to ensure each party fully understands their role for services and billing (including Medicaid and VA billing) to meet state and federal regulations and requirements.

III. SCOPE OF WORK

a. Hospice Services include but are not limited to:

i. Nursing care and services by or under the supervision of a registered nurse

ii. Medical social services provided by a qualified social worker under the direction of a physician

iii. Physician services to the extent that these services are not provided by the attending physician;

iv. Counseling services, including bereavement, dietary and spiritual counseling

v. Physical, respiratory, occupational and speech therapy services

vi. Home health aide/homemaker services

vii. Medical supplies;

viii. Drugs and biologicals

ix. Use of medical appliances

x. Medical direction and management of the Hospice Patient.

xi. Hospice shall retain sole authority and responsibility to admit patients to Hospice's services. Neither Facility nor Facility personnel shall have authority to admit patients to Hospice services.

xii. Hospice shall perform an assessment of resident and shall notify Facility, either orally or in writing, whether such resident is authorized for admission as a Hospice Patient. Hospice shall maintain adequate records of all such authorizations of admission. Hospice shall have sole authority for assessing a Hospice Patient's continued eligibility for Hospice Services and for discharging a Hospice Patient from Hospice.

xiii. Hospice shall assume professional management responsibility for Hospice Services provided to Hospice Patients residing at Facility and their family units, pursuant to the Medicare Conditions of Participation for Hospice Care and state and local laws and regulations. This includes admission and/or discharge of patients, patient and family assessments, reassessments, establishment of the Plan of Care, authorization of all services and management of the care through Interdisciplinary Team (IDT) meetings. Hospice shall arrange for, and remain responsible for, any necessary continuous care or inpatient care related to a Hospice Patient's terminal illness and related conditions. Hospice acknowledges that it is responsible for providing Hospice Services to Hospice Patients residing at the Facility at the same level and to the same extent as Hospice Patients receiving care in their own homes.

xiv. Hospice shall retain professional management responsibility to ensure that Hospice Services are furnished in a safe and effective manner by qualified personnel in accordance with Hospice Patient's Plan of Care.

xv. Hospice shall retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care of Hospice Patients, which shall include coordination of Facility Services. Hospice's IDT shall communicate with Facility's designated IDT member, Facility's medical director, Hospice Patient's attending physician and other physicians participating in the care of a Hospice Patient as needed to coordinate Hospice Services with the medical care provided by other physicians. Methods used to evaluate the care may include: [a] periodic supervisory visits; [b] review of the qualifications of personnel providing Facility Services; [c] review of documentation; [d] evaluation of the response of a Hospice Patient to the Plan of Care; [e] discussion with patient and patient's caregivers; [f] patient evaluation surveys; and [g] quality improvement data.

xvi. Hospice shall provide orientation and ongoing hospice care training to Facility's personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and recordkeeping requirements.

xvii. For each Hospice Patient, Hospice shall designate a registered nurse who will be responsible for coordinating and supervising services provided to a Hospice Patient and be available twenty-four (24) hours per day, seven (7) days per week for consultation with Facility concerning a Hospice Patient's Plan of Care. In addition, for each Hospice Patient residing at Facility, Hospice shall designate a member of the Hospice Patient's IDT to provide overall coordination of care for such Hospice Patient. Such hospice representatives shall monitor Facility and be available to provide information to Facility regarding the provision of Facility Services and to coordinate the periodic evaluation of patient progress and outcomes of care upon request. Further, the hospice representative shall be responsible for communicating with Facility representatives and other health care providers who participate in the care of a Hospice Patient's terminal illness and related conditions to ensure quality of care for Hospice Patients and their families.

xviii. Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Facility Services under this Agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination.

b. OBJECTIVES OF ENGAGEMENT

i. Ensure compliant, high‑quality hospice services meeting state and federal standards.

ii. Improve coordinated care between hospice provider and facility staff.

iii. Establish consistent communication and documentation practices.

iv. Support continuity of care through structured interdisciplinary processes.

c. DELIVERABLES AND DEADLINES

d. PAYMENT MILESTONES

i. Routine Level of Services:

1. Hospice shall pay the Facility one hundred percent (100%) of the Medicaid daily reimbursement rate for room and board charges (“daily rate”) if Medicaid is responsible for room and board charges.

ii. VA Prevailing Rate:

1. IVH shall provide all medications for residents with Payer of VA prevailing rate, this charge shall not be included in the Hospice rate billed to VA by contractor.

2. Hospice shall pay the Facility the daily rate for residents with a Payer of VA Prevailing Rate, this charge will be billed by facility to VA directly.

iii. General Inpatient Level of Services:

1. Hospice shall pay the Facility $659.01/day, representing the 2024 Medicaid Settlement Rate. Rate to be adjusted annually per FSSA approval.

iv. Respite Level of Services:

1. Hospice shall pay the Facility $700.17/day, representing the 2026 Daily Rate effective 7/1/2026. Rate to be adjusted annually effective 7/1.

IV. INDEPENDENT VALIDATION AND VERIFICATION

If the State decides to add Independent Verification & Validation (IV&V) services as part of this Contract, the Contractor will copy the Indiana Department of Administration (IDOA) – IV&V Team member(s) on all project related communications (emails, meeting invites, collaboration tools, etc.) and will grant access to all documents and deliverables throughout the term of the Contract. If IDOA elects to deploy IV&V services in connection with this engagement, the IV&V Team will review and assess all deliverables to determine compliance with the State’s requirements set forth in the Contract including the Statement of Work. For contracts entered into, renewed, or amended after June 30, 2026, the IV&V Team shall serve as an approving authority, and no payment shall be issued to the Vendor unless and until IV&V has provided such approval.

V. COMPLIANCE REQUIREMENTS

a. HIPAA Compliance

i. Services and activities subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Contractor covenants that it will appropriately safeguard Protected Health Information (defined in 45 CFR 160.103), and agrees that it is subject to, and shall comply with, the provisions of 45 CFR Subpart E regarding use and disclosure of Protected Health Information.

ii. The HIPPAA Business Associate Agreement is attached as Exhibit A.

VI. KEY PERFORMANCE INDICATORS

The State will use Key Performance Indicators (KPIs) to measure performance and outcomes of the Contract. The specific KPIs and their targets will be defined and agreed upon by the State and the Contractor during the initial phases of the requirements under the Contract. At a minimum, on time delivery at quality standards of the scope provided within the budget set forth in the Contract will each be measured. Additionally, the State will collect a modified Net Promoter Score from customers to this Contract in its discretion. Low ratings on the modified Net Promoter Score or failure to meet any other KPIs may be deemed, at the discretion of the State, to constitute default under the Contract.

Exhibit A HIPAA Business Associate Agreement

A. Health Insurance Portability and Accountability Act (HIPAA)

1. In the performance of the services listed in this Contract, the Contractor may have access to confidential identifiable medical information known as Protected Health Information (PHI).

2. The Contractor agrees that in connection with its services performed on behalf of the State, the Contractor is a Business Associate and shall comply with the Business Associate requirements of HIPAA as described in Section B.

B. HIPAA Business Associate

Name of Business Associate Incident # (number assigned by reporting entity)

Type of Incident Date and Time of Report (Date and time incident was initially reported) Date and Time of Incident (Date and time incident occurred) Time potential breach was identified

Name and Title of Person Reporting Incident Contact Information (of person reporting incident)

Summary of Incident (Include pertinent information regarding the potential security breach)

Description of Protected Health Information Involved (Include number of participants records involved)

Action Taken Name of Person(s) Conducting Preliminary Investigation Contact Information (of individual responsible for Issue Analysis) Date Investigation started Action(s) Taken (include dates, times, and names of agencies notified of the Incident)

Conclusion Date Investigation ended Findings Measures taken to address issue, and prevent any reoccurrences

If the Contractor is unable to reach the IVH HIPAA Officer at the above phone number, then report successful breaches of security to the IVH Superintendent by calling (765) 497-8501 within the same timeframes indicated above. In the event a successful breach is discovered outside of normal business hours, leaving a voice message at the above listed numbers is sufficient verbal notification; however, the Contractor shall still comply with the electronic reporting requirement stated above.

DEFINITIONS FOR USE IN THIS ADDENDUM

“Designated Record Set” shall mean a group of records maintained by or for the covered entity that is (a) the medical records and billing records about individuals maintained by or for the covered entity, (b) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (c) used, in whole or in part, by or for the covered entity to make decisions about individuals. As used herein the term “Record” means any item, collection, or grouping of information that includes protected health Information and is maintained, collected, used, or disseminated by or for the covered entity.

“Protected Health Information (PHI)” shall mean individually identifiable health information that is (a) transmitted by electronic media, (b) maintained in any medium constituting electronic media; or (c) transmitted or maintained in any other form or medium. “Protected Health Information” shall not include (a) education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. §1232g and (b) records described in 20 U.S.C. §1232g(a)(4)(B)(iv).

“Security Incident” shall mean the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system." (45 CFR §164.304) The parties agree that all terms in this attachment not otherwise defined shall be defined by reference to the same terms in the HIPAA and its implementing regulations.