Attachments.pdf

D.1 RUGs IV DESCRIPTIONS

1. Rehabilitation Plus Extensive Services: Residents satisfying all of the following three conditions:

Having a minimum activity of daily living (ADL) dependency score of 2 or more. Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. While a resident, receiving complex clinical care and have needs involving tracheostomy care, ventilator/respirator, and/or infection isolation.

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

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

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

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

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

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

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

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Covenant Care Carson LLC

(dba Carson Nursing and Rehabilitation) April 22, 2021 – April 21, 2022

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

What will be monitored How monitoring will take place Who will conduct the monitoring How monitoring efforts and results will be documented

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the Government may review and revise it on a regular basis.

However, the Government shall coordinate changes with the contractor. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned Contracting Officer (CO): Latasha Winston Assigned Contract Specialist: Cynthia Diezel Organization or Agency: U.S. Department of Veterans Affairs

b. Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR(S): Dixie Langus, CNH PSA/COR and Georgiann Waters, GEC Admin Asst

c. Other Key Government Personnel

Melissa Peterson, RN - CNH Coordinator Jennifer Duran, LCSW - CNH Program Administrator

(dba Carson Nursing and Rehabilitation) April 22, 2021 – April 21, 2022

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager – As assigned by facility

b. Other Contractor Personnel - As assigned by facility

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

QUALITY ASSURANCE SURVEILLANCE PLAN

Nursing Home Care

No. Paragraph in PWS

Indicator/Performance Standard

Standard for

Quality Level

Acceptable Quality Level

Method of Surveillance1

Incentive

1 (C) (11) Nursing Home shall provide VA with copies of all State / Federal licensures, certifications, and investigations reports when requested.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

2 (C) (12) The Contractor shall cooperate in developing plans of corrective action according to outlined criteria in the Performance Work Statement.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

3 (C) (15) Notice of veteran being hospitalized within 72 hours and notice of any veteran death within 24 hours or immediately the first business day after a weekend or holiday.

100% 95% Periodic Reviews and spot checks

Positive past performance rating

1 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

(dba Carson Nursing and Rehabilitation) April 22, 2021 – April 21, 2022

QUALITY ASSURANCE SURVEILLANCE PLAN

Nursing Home Care

No. Paragraph in PWS

Indicator/Performance Standard

Standard for

Quality Level

Acceptable Quality Level

Method of Surveillance2

Incentive

4 (C) (17) Notice of all reportable events on VA contract veterans and all facility sentinel events within 24 hours or immediately the first business day after a weekend or holiday.

100% 100% Periodic reviews

Positive past performance rating

5 (C) (19) All medical records concerning the veteran's care in the nursing home a) will be readily accessible to VA, and b) within acceptable standards and practice.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

6 (C) (23) Invoices shall be timely and accurate for all items billed.

100% 95% -100% Periodic Reviews and spot checks

Positive past performance rating

5. INCENTIVES/RATING STANDARDS

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance.

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION

c. USER SURVEY

d. VALIDATED USER/CUSTOMER COMPLAINTS

e. INSPECTION

f. PERIODIC SAMPLING

g. RANDOM SAMPLING

h. PROGRESS OR STATUS MEETINGS

i. ANALYSIS OF CONTRACTOR’S PROGRESS REPORTS

2 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

(dba Carson Nursing and Rehabilitation) April 22, 2021 – April 21, 2022

7. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

8. DOCUMENTING PERFORMANCE

a. Acceptable Performance

The Government shall document positive OR NEGATIVE performance. Any report may become a part of the supporting documentation for any contractual action.

b. Unacceptable performance

When unacceptable performance occurs, the COR shall work with the Contracting Officer (CO) inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication.

In any case, the COR shall document the discussion and place it in the COR file. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the COR will work with the contractor to increase performance to an acceptable level.

When the COR and CO determines formal written communication is required, the COR and CO shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

See above Acceptable Quality Level & Method of Surveillance located in QASP

(dba Carson Nursing and Rehabilitation) April 22, 2021 – April 21, 2022

b. Frequency of Performance Assessment Meetings

The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Representative

REGISTER OF WAGE DETERMINATIONS UNDER | U.S. DEPARTMENT OF LABOR

THE SERVICE CONTRACT ACT | EMPLOYMENT STANDARDS ADMINISTRATION

By direction of the Secretary of Labor | WAGE AND HOUR DIVISION

| WASHINGTON D.C. 20210

| Wage Determination No.: 1973-0130

Daniel W. Simms Division of | Revision No.: 58

Director Wage Determinations| Date of Last Revision: 07/16/2019

Note: Under Executive Order (EO) 13658, an hourly minimum wage of $10.60 for calendar year 2019 applies to all contracts subject to the Service Contract Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2015. If this contract is covered by the EO, the contractor must pay all workers in any classification listed on this wage determination at least $10.60 per hour (or the applicable wage rate listed on this wage determination, if it is higher) for all hours spent performing on the contract in calendar year 2019. The EO minimum wage rate will be adjusted annually. Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts.

States: Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New

Mexico, Oregon, Utah, Washington, Wyoming

Area: Arizona Statewide

California Statewide

Colorado Statewide

Hawaii Statewide

Idaho Statewide

Montana Statewide

New Mexico Statewide

Nevada Statewide

Oregon Statewide

Utah Statewide

Washington Statewide

Wyoming Statewide

**Fringe Benefits Required Follow the Occupational Listing**

Employed on contract for Nursing Home services.

OCCUPATION CODE - TITLE FOOTNOTE RATE

(not set) - Kitchen Helper 7.25

(not set) - Laundry Worker 7.25

(not set) - Maid/Porter 7.25

(not set) - Nursing Aide/Orderly 7.25

Note: Executive Order (EO) 13706, Establishing Paid Sick Leave for Federal Contractors, applies to all contracts subject to the Service Contract Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2017. If this contract is covered by the EO, the contractor must provide employees with 1 hour of paid sick leave for every 30 hours they work, up to 56 hours of paid sick leave each year. Employees must be permitted to use paid sick leave for their own illness, injury or other health-related needs, including preventive care; to assist a family member (or person who is like family to the employee) who is ill, injured, or has other health-related needs, including preventive care; or for reasons resulting from, or to assist a family member (or person who is like family to the employee) who is the victim of, domestic violence, sexual assault, or stalking. Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts.

ALL OCCUPATIONS LISTED ABOVE RECEIVE THE FOLLOWING BENEFITS:

HEALTH & WELFARE: $4.54 per hour, up to 40 hours per week, or $181.60 per week or

$786.93 per month

HEALTH & WELFARE EO 13706: $4.22 per hour up to 40 hours per week, or $168.80 per week, or $731.47 per month*

*This rate is to be used only when compensating employees for performance on an SCA-covered contract also covered by EO 13706, Establishing Paid Sick Leave for Federal Contractors. A contractor may not receive credit toward its SCA obligations for any paid sick leave provided pursuant to EO 13706.

VACATION: 1-week paid vacation after 1 year of service with a contractor or successor; and 2 weeks after 2 years. Length of service includes the whole span of continuous service with the present contractor or successor, wherever employed and with the predecessor contractors in the performance of similar work at the same Federal facility. (Reg. 29 CFR 4.173)

HOLIDAYS: A minimum of four paid holidays per year: New Year's Day, Labor Day, Thanksgiving Day, and Christmas Day. (A contractor may substitute for any of the named holidays another day off with pay in accordance with a plan communicated to the employees involved.) (See 29 CFR 4.174)

HEALTH & WELFARE (Hawaii): $1.94 per hour, up to 40 hours per week, or $77.60 per week, or $336.27 per month for all employees on whose behalf the contractor provides health care benefits pursuant to the Hawaii prepaid Health Care Act. For those employees who are not receiving health care benefits mandated by the Hawaii prepaid Health Care Act, the new health and welfare benefit rate will be $4.54 per hour, up to 40 hours per week.

HEALTH & WELFARE (Hawaii EO 13706): $1.63 per hour, up to 40 hours per week, or $65.20 per week, or $282.53 per month for all employees on whose behalf the contractor provides health care benefits pursuant to the Hawaii prepaid Health Care Act. For those employees who are not receiving health care benefits mandated by the Hawaii prepaid Health Care Act, the new health and welfare benefit rate will be $4.22 per hour, up to 40 hours per week. *

*This rate is to be used only when compensating employees for performance on an SCA-covered contract also covered by EO 13706, Establishing Paid Sick Leave for Federal Contractors. A contractor may not receive credit toward its SCA obligations for any paid sick leave provided pursuant to EO 13706.

** UNIFORM ALLOWANCE **

If employees are required to wear uniforms in the performance of this contract (either by the terms of the Government contract, by the employer, by the state or local law, etc.), the cost of furnishing such uniforms and maintaining (by laundering or dry cleaning) such uniforms is an expense that may not be borne by an employee where such cost reduces the hourly rate below that required by the wage determination. The Department of Labor will accept payment in accordance with the following standards as compliance:

The contractor or subcontractor is required to furnish all employees with an adequate number of uniforms without cost or to reimburse employees for the actual cost of the uniforms. In addition, where uniform cleaning and maintenance is made the responsibility of the employee, all contractors and subcontractors subject to this wage determination shall (in the absence of a bona fide collective bargaining agreement providing for a different amount, or the furnishing of contrary affirmative proof as to the actual cost), reimburse all employees for such cleaning and maintenance at a rate of $3.35 per week (or $.67 cents per day). However, in those instances where the uniforms furnished are made of "wash and wear" materials, may be routinely washed and dried with other personal garments, and do not require any special treatment such as dry cleaning, daily washing, or commercial laundering in order to meet the cleanliness or appearance standards set by the terms of the Government contract, by the contractor, by law, or by the nature of the work, there is no requirement that employees be reimbursed for uniform maintenance costs.

REQUEST FOR AUTHORIZATION OF ADDITIONAL CLASSIFICATION AND WAGE RATE Standard Form

1444 (SF-1444)

Conformance Process:

The contracting officer shall require that any class of service employee which is not listed herein and which is to be employed under the contract (i.e., the work to be performed is not performed by any classification listed in the wage determination), be classified by the contractor so as to provide a reasonable relationship (i.e., appropriate level of skill comparison) between such unlisted classifications and the classifications listed in the wage determination. Such conformed classes of employees shall be paid the monetary wages and furnished the fringe benefits as are determined (See 29 CFR 4.6(b)(2)(i)). Such conforming procedures shall be initiated by the contractor prior to the performance of contract work by such unlisted class(es) of employees (See 29 CFR 4.6(b)(2)(ii)). The Wage and Hour Division shall make a final determination of conformed classification, wage rate, and/or fringe benefits which shall be retroactive to the commencement date of the contract (See 29 CFR 4.6(b)(2)(iv)(C)(vi)). When multiple wage determinations are included in a contract, a separate SF-1444 should be prepared for each wage determination to which a class(es) is to be conformed.

The process for preparing a conformance request is as follows:

1) When preparing the bid, the contractor identifies the need for a conformed occupation(s) and computes a proposed rate(s).

2) After contract award, the contractor prepares a written report listing in order the proposed classification title(s), a Federal grade equivalency (FGE) for each proposed classification(s), job description(s), and rationale for proposed wage rate(s), including information regarding the agreement or disagreement of the authorized representative of the employees involved, or where there is no authorized representative, the employees themselves. This report should be submitted to the contracting officer no later than 30 days after such unlisted class(es) of employees performs any contract work.

3) The contracting officer reviews the proposed action and promptly submits a report of the action, together with the agency's recommendations and pertinent information including the position of the contractor and the employees, to the Wage and Hour Division, U.S. Department of Labor, for review (See 29 CFR 4.6(b)(2)(ii)).

4) Within 30 days of receipt, the Wage and Hour Division approves, modifies, or disapproves the action via transmittal to the agency contracting officer, or notifies the contracting officer that additional time will be required to process the request.

5) The contracting officer transmits the Wage and Hour decision to the contractor.

6) The contractor informs the affected employees.

Information required by the Regulations must be submitted on SF-1444 or bond paper.

When preparing a conformance request, the "Service Contract Act Directory of Occupations" (the Directory) should be used to compare job definitions to ensure that duties requested are not performed by a classification already listed in the wage determination. Remember, it is not the job title, but the required tasks that determine whether a class is included in an established wage determination.

Conformances may not be used to artificially split, combine, or subdivide classifications listed in the wage determination.

** OCCUPATIONS NOT INCLUDED IN THE SCA DIRECTORY OF OCCUPATIONS **

Kitchen Helper

Performs one or more of the following unskilled kitchen duties: Cleans worktables, meat blocks, refrigerator, and grease trays; sweeps, mops kitchen floors; obtains and distributes supplies and utensils; and watches and stirs cooking foods to prevent burning. Carries dirty utensils to be washed and returns cleaned utensils and polished silver to proper place in kitchen. Cleans pots and kitchen utensils.

Washes dishes by hand or machine. Carries out garbage. Delivers food trays to patients on resident floor and collects dirty dishes from trays. Assists in setting up trays. Dishes up food. Cuts, peels, and washes fruits and vegetables. Makes toast and beverages.

Laundry Worker

Performs one or a combination of the nonsupervisory duties required to operate the establishment's laundry facilities. Examples of such duties are: Operating washing or dry-cleaning machines; pressing garment or flat-work by hand or machine;

operating an extractor to remove moisture from material; and marking and sorting garments of flat-work.

Maid/Porter

Cleans and services establishment premises. Performs one or more of the following duties: Cleans, mops, and waxes floors. Dusts furniture and equipment. Cleans window sills, empties trash baskets, and arranges furniture and equipment in an orderly fashion. Scours and polishes, bathtubs, sinks, mirrors, and similar equipment, replenishing supplies of soap and towels. Polishes brass and cleans and polishes glass panels in doors and partitions. Keeps utility storage rooms in good order by cleaning lockers and equipment, arranging supplies, and sweeping and mopping floors. Performs a variety of related duties.

Nursing Aide/Orderly

Performs routine duties in the care of patients (or residents) usually under the supervision of a registered or practical nurse. Duties involve most of the following: Bathing bed patients or assisting them in bathing; caring for patient's hair and nails; feeding or assisting patients in eating and bringing patients between-meal nourishment; assisting patients with bedpans and urinals; keeping records of patients' food intake and output as directed; assisting patients in dressing and undressing; assisting patients in walking and transporting patients by wheelchair and stretcher; and cleaning and sterilizing instruments and equipment.

May clean rooms, make occupied or unoccupied beds, and take and record temperature, pulse, and respiration rate.