CNH Performance Work Statement (PWS)

Effective Date: 3/17/2025 Page 1 of 8

A. Overview

1. Federal Acquisition Regulation (FAR) – Indefinite Delivery Indefinite Quantity Contract (IDIQ). In accordance with FAR 16.504, Indefinite-Quantity Contracts, this is an IDIQ with an ordering period of up to five years beginning from the date of award. This requirement is being solicited under the authority of 38 CFR 17.4000, 38 U.S.C. 1710 and 38 U.S.C. 1720.

2. Veteran Placements. Placements may be issued by authorized VA medical center personnel to place Veterans in Nursing Homes. Contact for authorized VA medical center personnel information will be provided separately.

B. Introduction. The Community Nursing Home (CNH) program is a key component of the Veterans Health Administration (VHA) continuum of care. The Contractor agrees to provide in accordance with the terms and conditions stated herein to the U.S.

Department of Veterans Affairs Palo Alto Health Care System, in Palo Alto, CA at the prices specified in the section titled Schedule of Items of this IDIQ. Nursing home facilities in the CNH program shall cooperate with VA staff in referral of appropriate Veterans for care and accept Veterans of which they have the capability/capacity to care. The term, “facilities,” shall include but not be limited to rooms, wards, sections, eating areas, drinking fountains, entrances, and other like areas.

C. Requirements

1. General. Nursing home facilities in the CNH program shall ensure that care meets the health needs and promotes the maximum well-being of VA patients. Nursing home care will be furnished to ensure the total medical, nursing, and psychosocial needs of VA beneficiaries. All nursing home facilities in VA’s CNH program must have current Center for Medicare and Medicaid Services (CMS) certification (Medicare and/or Medicaid) and a state nursing home license. VA often has a particular need for specialty care services in the CNH program. The VA requires CNHs to have bed capacity to ensure their ability to take referrals when requested.

The CNH also must be able to accept VA referrals in a timely fashion (ideally within 24 hours of request). Provider visits will be available at the rate of one (1) visit per month. Laboratory, x-ray, and other special services will be available to VA patients as needed. In addition, the care provided will include room, meals, nursing care, and other services or supplies commensurate with the VA-authorized level of care, without extra charge. Duly authorized representatives of VA will provide quality oversight visits to Veterans placed to assure continuity of care and to assist in the Veterans’ transition back into the community. These visits do not substitute nor relieve the CNH in any way of the responsibility for the daily care and medical treatment of the Veteran. The per diem rate(s) established in this IDIQ will include the cost of primary medical care, one (1) provider visit per month and needed consultation, drugs and routine supplies, laboratory, x-ray, and other special services authorized by VA, unless otherwise specifically excepted (see Schedule of Items in this IDIQ for details regarding per diem rates and coverage). Full attention

Effective Date: 3/17/2025 Page 2 of 8 shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care.

2. Termination of Services. VA reserves the right to remove any or all VA patients from the CNH at any time when it is determined to be in the best interest of VA or the patients without additional costs to the Government.

3. VA Authorizations. Authorization for nursing home care will be submitted on VA Form 10-7078, “Authorization and Invoice for Medical and Hospital Services.” Each authorization validity period will be noted on the VA Form 10-7078 with a beginning and end date. Any extension to the original authorization validity period, regardless of the number of days, requires a new VA Form 10-7078.

4. Rate Basis. VA will use state Medicaid rates, with upward adjustments for case mix and the all-inclusive nature of VA’s contract rates, as a guide to determine negotiated rates. The negotiated rate will include the cost of medical care, routine medications, laboratory, x-ray, therapy(ies), and other special services authorized by VA, unless otherwise specifically exempted.

The Level of Care classification and associated per diem rates will remain in effect for each placement until and unless one of the following events takes place:

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

b. Need for more intensive therapy;

c. Significant change in condition; or

d. Classification changes may also occur based on a determination by VA.

Medicaid-Based Rates. The current State Medicaid rates may be used as a basis for determination of VA rates. The VA rate will include medical care, routine medications, laboratory, x-ray, therapy(ies), and other special services authorized by VA, unless otherwise specifically exempted.

5. Primary Medical Coverage. The assigned CNH provider is the primary medical provider during the nursing home stay and is responsible for writing or approving admission and all other orders as soon as the Veteran arrives at the CNH. The CNH provider is responsible for general medical care, urgent evaluation and intervention.

Provider visits will be according to the Center for Medicare and Medicaid Services (CMS) guidelines. The assigned nursing home provider will provide timely care following the most current CMS guidelines; arranging 24/7 access for patient care;

arranging easy access to VA staff for consultation; providing timely response to calls and arranging for timely provider back-up according to OBRA guidelines (42 CFR 483.40, OBRA Guidelines).

6. Emergency Care; Financial Responsibility; Advanced Directives.

Veterans may have coverage for emergency care when the CNH alerts the VA within 24 hours of the care. The CNH will qualify for VA reimbursement of https://www.va.gov/vaforms/medical/pdf/VHA-10-7078-fill.pdf https://www.va.gov/vaforms/medical/pdf/VHA-10-7078-fill.pdf https://www.va.gov/vaforms/medical/pdf/VHA-10-7078-fill.pdf https://www.va.gov/vaforms/medical/pdf/VHA-10-7078-fill.pdf

Effective Date: 3/17/2025 Page 3 of 8 emergency care and ancillary transportation, provided that the CNH or private hospital contacts the VA Health Care System (VAHCS) within 72-hours of admission or first business day following a weekend or holiday. This includes the cost of necessary transportation for such care. Use of a VA or VA network medical facility is preferred.

7. HIPAA Compliance. HIPAA compliance is required. The Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the national Standards to Protect the Privacy and Security of Protected Health Information (PHI). As required by HIPAA, the Department of Health and Human Services (HHS) has promulgated rules governing the security and use and disclosure of protected health information by covered entities, including the Department of Veterans Affairs (VA). In accordance with HIPAA, the Contractor may be required to enter into a Business Associate Agreement (BAA) with VA, but VACO has recognized CNH Facilities as an entity that does not require a BAA as long as they are conducting health care on VA’s behalf. The CNH care program qualifies as a medical service, so no BAA is required.

8. Quality Expectations for CNH’s:

a. All CNHs in the CNH Program must be certified by CMS under Title XVIII (Medicare) or Title XIX (Medicaid) or have received special approval from the Office of Geriatrics and Extended Care (GEC) Office. CNHs are responsible to the state of jurisdiction and CMS for the care provided. VA does not regulate the care or inspect CNHs. VA acts as an informed purchaser of care in order to purchase quality services for Veterans and enhance the Veterans’ experience in the home.

b. The CNH must maintain a current and unrestricted state license to operate as a skilled nursing facility or mental health rehabilitation center (MHRC). Changes in the status of the licensure will be immediately reported to VAPAHCS Community Nursing Home Program staff at 650-493-5000 ext. 68424 or ext.

62207. VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this IDIQ.

(QASP Indicator #1) The CNH shall cooperate fully with VA’s quality improvement or quality assurance program functions relating to this IDIQ. Authorized VA medical center personnel shall make all final determinations as to the Contractor’s reasonable cooperation with VA and compliance with these requirements.

9. Corrective Action Plan. (QASP Indicator #2).

The CNH will cooperate with timely development of Corrective Action Plans (CAPs) related to identified deficiencies and related to State or Medicare surveys. The CNH will provide copies of CAPs to VA.

Effective Date: 3/17/2025 Page 4 of 8

10. Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veterans; CNH Responsibility for Veteran’s Belongings or Personal Effects (QASP Indicator #3). VA beneficiaries who begin to require more than the level of care authorized by VA will be readmitted to an appropriate VA facility, as determined and authorized by VA.

a. When such an admission is not feasible because of the nature of the emergency, hospitalization in a non-Federal facility may be accomplished provided VA authorization is obtained. VA authorization must be obtained within 72-hours of admission of the patient to a non-Federal facility and notice of any Veteran death within 24-hours or immediately upon the first business day after a weekend or holiday. If hospitalization of a non-emergency nature is required, readmission to a VA Medical Center may be accomplished as soon as the patient’s condition is sufficiently stabilized to permit admission to a VA Medical Center.

b. In the event of a death of any Veteran, the Contractor agrees to notify VA immediately of the death. In the event a death of a VA beneficiary while receiving nursing home care under this IDIQ, the CNH will promptly notify the VA facility which authorized admission and immediately assemble, inventory, and safeguard the patient’s personal effects. The funds, deposits, and effects left by the VA patients upon the premises of the CNH shall be delivered by the CNH to the person(s) entitled thereto under the laws currently governing the CNH for making disposition of funds and effects left by patients, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.

c. When disposition has been made, the itemized inventory with annotation as to the disposition of the funds and effects will be immediately forwarded to the VA facility that authorized admission. Should a deceased patient leave no will, heirs, or next of kin, his/her personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases, the CNH will forward an inventory of any such property and funds in its possession to the VA facility authorizing admission and will hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition. CMS regulations require retention of records for five (5) years when there is no requirement in State law.

11. Leave of Absence (LOA) – Bed-Hold Statement. For re-hospitalizations or therapeutic passes, VA will pay a bed hold. Therapeutic passes will be authorized by the CNH staff based on individual patient needs but are generally limited to two (2) times per month and should be pre-approved. VA will cover bed holds and the number of covered bed-hold days shall be determined by the VA CNH Coordinators on a case-by-case basis.

Effective Date: 3/17/2025 Page 5 of 8

Bed-hold will begin the date the resident leaves the CNH and full per diem will resume on the date of readmission to the CNH.

12. Reportable Events (QASP Indicator #4). VA requires CNHs to report to the CNH Coordinator at VA any of the below events within 24-hours or immediately upon the first business day after a weekend or holiday. Reporting shall include date of occurrence and patient disposition and outcome.

a. Sentinel events;

b. When there is a change of ownership of the CNH;

c. When there is a change of nursing home administrator or Director of

Nursing/Director of Nursing Service;

d. substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH Veterans or property;

e. Elopements of CNH Veterans pursuant to state regulations;

f. Infectious outbreaks;

g. Resident to resident or resident to staff altercations involving a CNH Veteran resulting in any injury that is other than minor;

h. Copies of annual surveys or substantiated complaint investigations conducted by a State oversight agency; and

i. Adverse events.

A sentinel event may include, but is not limited to the following:

1. A fall resulting in death or injury;

2. Elopement resulting in a missing patient;

3. Patient abuse confirmed or under suspicion;

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

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

6. Death related to an unconfirmed or suspicious cause.

When an adverse event occurs involving a CNH Veteran which is not determined to be a Sentinel Event (but that the State requires that the occurrence be reported to the State), such event is also to be reported to VA’s CNH program office. Some adverse events, such as minor medication errors without catastrophic outcomes, are managed by the CNH in the context of their quality improvement programs. It is not necessary for nursing homes to report such incidents to the CNH program office.

13. VA Actions Regarding Serious Quality of Care Deficiencies. In cases of serious deficiencies affecting the health or safety of Veterans or in cases of continued uncorrected deficiencies, VA will take one or more of the following actions in accordance with the terms and clauses of the IDIQ and applicable procurement regulations:

a. Increase VA staffing monitoring until the State survey agency clears the deficiency;

b. Suspend placement of Veterans in the CNH;

Effective Date: 3/17/2025 Page 6 of 8

c. Remove or transfer Veterans under the IDIQ from the subject CNH;

d. Not renew the IDIQ; and/or

e. Terminate the IDIQ.

14. VA Staff Access to CNH Records (QASP Indicator #5). All medical records concerning the Veteran’s care in the CNH shall be readily accessible to VA.

Selected VA staff will be provided access to the CNH electronic health record for each Veteran. Upon discharge or the death of a patient, medical records will be retained by the CNH for a period of at least five (5) years following termination of care. Patient records will be maintained in conformance with the Privacy Act of 1974 (5 U.S.C. § 552a). A medical record shall be maintained for each patient in accordance with CMS standards in 42 CFR 483.

15. Specialty Care Services. The CNH will assume responsibility for arranging specialty care for Veterans (e.g. dental care, podiatry, and ophthalmology).

16. Contact Information for VA Appointments/Admissions/Specialty Care.

a. For urgent same-day outpatient specialty care or for non-urgent scheduled clinic appointments/consultations, phone number 1-855-632-8262 between 8am and 4:30pm. Monday through Friday, excluding holidays. If a same-day appointment is anticipated; please call as early as possible.

b. For non-emergency medical consultation or /evaluation for admission to the

VA Palo Alto Health Care System (after initial evaluation or intervention by the nursing home physician) call phone number 650-496-2591.

For non-emergency and emergency mental health consultation or evaluation for admission to the VAPAHCS (after initial evaluation or intervention by the CNH physician) call the Emergency Department at 650-493-5000 ext. 65490 or 65470, Palo Alto campus.

c. For urgent referrals or consultation after hours, weekends and holidays, call the Officer of the Day at 650-493-5000 ext. 60462, Palo Alto campus.

d. For transportation to and from the VA facility and VA affiliated appointments, evaluation, or hospitalization, call Travel Office at 650-493-5000 ext. 65686, Palo Alto campus. Transportation will be arranged and paid by the VA for CNH patients when requested.

17. Soliciting Charitable Contributions. The CNH will not directly solicit contributions, donations, or gifts from Veteran patients or a Veteran’s family members. CNH-wide charitable fundraising activities such as United Way are allowed.

Effective Date: 3/17/2025 Page 7 of 8

18. CNH Billing (QASP Indicator #6). Invoices for board, care and ancillary services shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered. The CNH will promptly notify the VA CNH Coordinator regarding any change in Veteran status:

discharge, transfer, against medical advice (AMA), hospitalization, death and/or any changes in payer source and any ability to complete timely billing. All invoices must include the full name and address of the CNH and shall reflect the patient’s name, social security number, number of days billed, case mix classification if applicable, and agreed upon rate(s). Failure to include this information may result in delayed payment.

a. Pre-approved services billed by CMS procedures or CPT codes: All services which are pre-approved by VA as additional to the all-inclusive per diem rate must be billed according to CMS procedures or CPT codes. The CNH will be reimbursed based on local guidelines and VA pricing schedules.

b. High-cost drugs: All requests for additional reimbursement for high-cost drugs and corresponding billing are due as soon as possible, but no later than 90 calendar days after use of products.

c. Invoices: Corrected invoices must be submitted for additional payment of any ancillary costs or changes to the original billing. All corrected invoices must include all items that are affected by the change and should include the CNH corrected claim form.

19. Minimum Quantities; VA Payment. It is impossible to determine the exact or estimated amount, which will be expended under this IDIQ. No obligation will be incurred by VA under this IDIQ, until authorizations are issued for nursing home care of specific beneficiaries. VA agrees to make payment on a timely basis for services rendered in accordance with such authorizations upon receipt of proper invoices submitted by the CNH as outlined in this IDIQ. VA will make payment for the day a recipient enters the CNH but not the day the recipient leaves a CNH unless entrance and departure are on the same day, then payment will be made for one (1) day.

20. VA Payments. Payments made by VA under any contract pursuant to this IDIQ, constitute the total cost of nursing home care. No additional charges will be billed to Medicare (with the exception of hospice), Medicaid, or private insurance, the beneficiary or his/her family, either by the CNH or any third-party furnishing services or supplies required for such care, unless and until specific prior authorization in writing is obtained from the VA facility authorizing placement. The patient, family, and any other entitlement programs (e.g., Medicare, Medicaid, etc.) will not be billed for uncovered services or costs during the VA contract period. This constitutes double-billing and Federal fraud.

Effective Date: 3/17/2025 Page 8 of 8

a. Vendors who bill electronically using the HIPAA-compliant claims transactions must submit claims through the VA clearinghouse, Emdeon, using payer ID number 12115 for medical claims.

b. Vendors who are not able to use the HIPAA-compliant transactions are not required to do so. Supporting information for monthly invoices will be forwarded via the means below:

• Secure Email only to: VHAPALCNHProgram@va.gov

• Fax: to number 650-849-0382, Attn: Victoria Gledhill, LCSW COR and

Graciela Valencia Ruezga, Program Support Assistant

• Mail:

VAPAHCS – CNH Program Attn: Victoria Gledhill, LCSW, COR; Deirdre McNamara, LCSW, COR;

and Graciela Valencia Ruezga, Program Support Assistant 3801 Miranda Avenue - PAD 122 Palo Alto, CA 94304 mailto:VHAPALCNHProgram@va.gov