Capabilities Questionnaire.pdf
PDF 20 KB Posted
- Attached to
- Q402--Community Nursing Home-VISN15
- Solicitation number
- 36C25521R0016
About this file
This document contains a capabilities questionnaire for a community nursing home care services contract opportunity with the Department of Veterans Affairs. The questionnaire requests information from offerors such as the facility's bed capacity, which categories of care it provides including reduced physical function, behavioral symptoms and cognitive performance, clinically complex patients, special care levels, extensive services, and rehabilitation therapy services. Additional questions address whether the facility medical director is on site, capabilities for Alzheimer's, dementia, and other behavioral patient types, and anticipated ability to provide care levels needed by VA beneficiaries. The related federal contract opportunity is a continuous solicitation to award multiple IDIQ contracts for nursing home care services to VA medical centers in VISN 15, which includes parts of Kansas, Missouri, Arkansas, Illinois, Indiana and Kentucky.
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Other files
| File | Type | Posted |
|---|---|---|
| Subcontracting Plan Template_A0002.pdf | ||
| 36C25521R0016 0002.pdf | ||
| 36C25521R0016 0001.pdf | ||
| SubcontractingPlan.pdf | ||
| CapabilitiesQuestionnaire.pdf | ||
| Sample QASP.pdf | ||
| Supplement to Invoices.pdf | ||
| INFORMATION ON WAGE DETERMINATION.pdf | ||
| Contract Deficiency Report.pdf | ||
| VISN 15 Placement.pdf | ||
| Sample UB-04.pdf | ||
| Subcontracting Plan.pdf | ||
| AOR Maps.pdf | ||
| 36C25521R0016_3.pdf |
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Text version
Attachment 9, Capabilities and Performance Questionnaire
Part 1 of 3 Patient Acceptance, Placement, Care
Offeror Name: CNH Facility Name:
Facility City: Facility County:
1. As of the date of this proposal, your facility’s capacity is %, of # of beds?
2. This solicitation requires performance of the following CMS categories of care. Some CNH facilities do not perform all care levels. Indicate which care levels (all RUG codes) your facility performs as a part of its day-to-day operations:
Performance Care Level Indicate with “Yes” if performed, blank if not performed.
a. CLIN 0001A - Reduced Physical Function
(PA1, PA2, PB1, PB2, PC1, PC2, PD1, PD2, PE1, PE2)
b. CLIN 0001B - Behavioral Symptoms & Cognitive Performance
(BA1, BA2, BB1, BB2)
c. CLIN 0001C – Clinically Complex
(CE2, CE1, CD1, CD2, CC2, CC1, CB2, CB1, CA2, CA1)
d. CLIN 0001D - Special Care (Low)
(LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1)
e. CLIN 0001E - Special Care (High)
(HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1)
f. CLIN 0001F - Extensive Services
(ES1, ES2, ES3)
g. CLIN 0001G - Rehabilitation Therapy
(RUC, RUB, RUA, RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, RLA)
h. CLIN 0001H – Rehabilitation Plus Extensive Services
(RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX)
3. If any level of care item above is not currently being performed in the day-to-day operations, is there an anticipation of performing the care levels if the VA’s beneficiaries have need for the level of care?
4. If 0001G or 0001H is performed, describe the type(s) of rehabilitation and therapy services that can be performed, noting any related equipment or resources to support rehabilitation and therapy services: Use separate sheet of paper if needed.
5. Is the facility Medical Director located at the facility?
a. If not, how often do physician visits occur per month?
6. If 0001B is performed, does the facility support the capability to provide those services, such as staff or visiting staff, facility features, etc.:
a. Alzheimer’s?
b. Dementia?
c. Other Behavioral-related patient-types?
Bethesda Long Term Care, Inc. Bethesda Dilworth
Oakland St. Louis
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
259100
No
VHALEADUNMIG
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