D.2 Attachment 2 Performance Work Statement.docx

Performance Work Statement

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 for the time period from the “Award Date” for one (1) Five-year base period.

2. Services Rendered at VA Per Diem Rates. Upon acceptance of a VA patient by the CNH, if and when requested by the VA Contracting Officer or Ordering Officer when delegated, the Contractor shall furnish all supplies and services herein described, at the per diem rates for the “Levels of Care” specified in the Schedule of Items of the IDIQ. The VA “Levels of Care” are outlined in this Performance Work Statement (PWS).

3. Ordering. Orders may be issued by Ordering Officers to place Veterans in Nursing Homes utilizing the CPRS system at VA hospital sites. Ordering Officer Contact information is as follows:

None of the orders will be placed utilizing the fair opportunity process because it has been determined that all orders will be subject to the relevant exceptions to the fair opportunity process.

4. Referrals to CNHs and placements: VA acknowledges that, depending on the availability of resources at a specific IDIQ holder facility, acceptance of a referral may be commercially impracticable for the IDIQ holder. In that event, the IDIQ holder may decline to accept that referral. If the IDIQ holder has determined that space is not available and will not accept the Veteran, the CNH program personnel will seek another IDIQ contract and a referral will be issued when a match is found. Only signed 10-7078s are considered authorized and complete orders.

Designated CNH program personnel will issue written authorizations for veterans to the IDIQ holder. In accordance with FAR 16.505(b)(2)(i)(A) or FAR 16.505(b)(2)(i)(B), VA has determined it is in the best interest of the Veteran to place the individual order without further competition because the need for these services is sometimes urgent and providing the opportunity to all IDIQ holders or other vendors would result in unacceptable delays in fulfilling that need. Location primarily will be selected based on the Veteran’s needs and proximity to the Veteran’s home.

B. Background

1. 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 services in accordance with the terms and conditions stated herein to the U.S. Department of Veterans Affairs Portland Health Care System, in Portland, Oregon 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, when applicable.

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 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.

NOTE: During the time period of this contract, the Medicare payment method MAY change to Patient Driven Patient Method (PDPM) or another system.

4. Medicare Rate Basis. VA will utilize the appropriate Resource Utilization Grouping (RUG) rate(s) as a guide to determine VA rates. The VA 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. VA will contract for appropriate categories of care using Resource Utilization Groups (RUGs-IV) as a reference or guide.

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.

5. Medicare Rate Determination. The per diem rate will be established by utilizing the current Medicare rate including the cost of supplies, services, and equipment above that which is provided under Medicare. Medicare rates established after the Effective Date of this IDIQ will require a modification to the IDIQ. The RUGS IV rates include room, board, and routine nursing care, rehabilitation therapy (including physical, speech and occupational therapy), respiratory therapy, oxygen therapy, medical and nursing supplies (including items such as urological and colostomy supplies), most oral medications, most items of durable medical equipment (excluding ventilators), x-rays, and routine laboratory tests (see Schedule of Items in this IDIQ for details on rates). Any additional requests for payment to the all-inclusive per diem rates must be pre-approved.

6. The CNH’s Minimum Data Set (MDS) Assessment for Medicare: The CNH’s Minimum Data Set (MDS) assessment will be completed on the same schedule as the current Medicare MDS-Scheduled assessments, including start of therapy (SOT) assessments and end of therapy (EOT) assessments. Classification changes will be approved by VA, dependent on projection for short-term or long-term residence, adhering to the most current MDS frequency guidelines from Medicare. The applicable per diem rate will continue until the next assessment. The RUG scores should be submitted on the MDS software that generates the RUG or on a Level of Care Authorization Form provided to the CNH.

7. 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).

8. Rehabilitation Criteria. All therapy provided under this IDIQ will be individual therapy, rather than group therapy, unless otherwise ordered by the authorizing VA facility. Therapy shall require pre-approval by VA before services are provided. Medical Restorative criteria will be used for physical therapy, occupational therapy, and speech therapy. Therapy must be skilled, relate to safety and be restorative according to Medicare criteria.

a. Description of Rehabilitative Therapy. The concept of rehabilitative therapy includes recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, or decrease in severity, or justification for an optimistic outlook to justify continued treatment. Covered therapy services shall be rehabilitative therapy services unless they meet the criteria for maintenance therapy requiring the skills of a therapist.

b. Evaluations/re-evaluations should consider the following: Establishment of treatment goals specific to the patient’s disability or dysfunction and designed to specifically address each problem identified in the evaluation; design of a plan of care addressing the patient’s disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment; continued assessment and analysis during implementation of the services at regular intervals; instruction leading to establishment of compensatory skills; selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short-term training on use of the device or system); and patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family should be ongoing.

9. Emergency Care; Financial Responsibility; Advanced Directives. In emergencies, nursing home staff will utilize the 911 local emergency systems as for any resident. Advance directives or living wills shall be adhered to according to the CNH physician’s orders. When private hospitalization or emergency services are required, the patient, spouse, financial guardian or insurer is financially responsible. Service-connected veterans may qualify for VA coverage of emergency care provided the VA Health Care System (VAHCS) is contacted by the private hospital provider within 72-hours of admission on the first business day following a weekend or holiday. This includes the cost of necessary transportation for such care.

10. 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.

11. State Licensure; Access to CNH Quality of Care Reports (QASP Indicator #1). The CNH must maintain a current and unrestricted state license to operate as a skilled nursing facility. Changes in the status of the licensure will be immediately reported to the Portland VA Home and Community Care Department. The VA will monitor the professional care and administrative management of services provided to VA beneficiaries, through one or any combination of the following methods: reviews of State agencies reports; on-site inspection of the CNH by VA staff, and/or on-site monitoring of Veterans. The CNH shall provide VA with copies of all State agency reports when requested and cooperate fully with VA’s quality improvement or quality assurance program functions, including VA’s on-site inspection and monitoring. The VA Contracting Officer shall make all final determinations as to the Contractor’s reasonable cooperation with the VA and compliance with these requirements.

12. Nursing Home Star Rating (QASP Indicator #2). The nursing home must maintain a 3-star overall rating or higher or a 2-star overall rating with 4-stars or higher in quality. These ratings are calculated by the Centers for Medicaid & Medicare and are publicly available on the Nursing Home Compare website (https://www.medicare.gov/nursinghomecompare/search.html?). If a nursing home does not meet this quality criteria, the COR or designee can determine if a waiver request is appropriate.

13. Corrective Action Plan. (QASP Indicator #3). The CNH will cooperate with timely development of Corrective Action Plans (CAPs) related to identified deficiencies and related to State, Federal or VA surveys. The CNH will develop in the time period specified by VA timely and appropriate CAPs for VA surveys or investigation of complaints related to quality of care or sentinel events. The CNH will also supply related documents or data as specified by VA. The CAPs will include but are not limited to the following criteria and shall:

a. Contain elements detailing how the CNH will correct the deficiency as it relates to the individual;

b. Indicate how the CNH will act to protect residents in similar situations;

c. Include the measures the CNH will take or systems that will be altered to ensure that the problem will not recur. The CNH must look at the system and determine if a change to the existing system will work, if a new system is necessary, or if a system does not exist and must be developed;

d. Indicate how the CNH plans to monitor performance to make sure that solutions are permanent. The CNH must develop a quality assurance tool for ensuring that correction is achieved and sustained. This tool must be implemented. Failure to implement a quality assurance tool to sustain compliance will reflect that the CNH has an ineffective quality assurance system; and

e. Provide dates when corrective action will be completed.

14. Acceptable Safety and Sanitation Practices. Acceptable safety and sanitation practices shall be observed throughout the facility. The CNH will address employee and patient safety practices through staff orientation, training and adherence to related policy or procedures to provide a safe and clean environment.

15. Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veterans; CNH Responsibility for Veteran’s Belongings or Personal Effects. 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 a VA beneficiary, while receiving nursing home care, the CNH 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.

16. 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 based on the following plan:

1. When deemed appropriate, VA will reimburse the CNH 70% of applicable per diem rate for bed hold not to exceed two (2) days per episode, four (4) days total per month.

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. Absences of fifteen (15) consecutive calendar days or more, whether in a VA or in a non-Federal facility require a new authorization agreement. The nursing home is responsible to notify the family if a bed hold is required for a longer period. The family would then make arrangements with the home to hold the bed.

17. 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. substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH veterans or property;

c. Elopements of CNH veterans pursuant to state regulations;

d. Infectious outbreaks;

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

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

g. Adverse events.

Other Reportable Events that should be reported timely, but not necessarily immediately are:

a. Change of nursing home administrator or Director of Nursing/Director of nursing service.

b. Pending change of ownership of the CNH.

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

a. A fall resulting in death or injury;

b. Elopement resulting in a missing patient;

c. Patient abuse confirmed or under suspicion;

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

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

f. 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.

18. 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;

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

d. Not renew the IDIQ; and/or

e. Terminate the IDIQ.

19. 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. If CNH has an electronic medical record, VA staff shall be granted remote access. 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, which includes at least the following:

a. VA Referral Package to the CNH:

1. Copy of Physician Orders for Nursing Home Care; CPRS Notes; Discharge Summary including History & Physical information with Medication List; Rehabilitation Progress Notes; and Veteran Demographic Record which includes next of kin information.

2. Copy of Authorization Agreement (VAF 10-7078).

b. Nursing Home Clinical Record: The CNH must maintain clinical records on each veteran in accordance with accepted professional standards and practice. The clinical record must be: complete, accurately documented, readily accessible, systematically organized, and legible. Clinical records must contain at a minimum:

1. Sufficient information to identify the resident;

2. A record of the veteran’s assessments, including those assessments performed by services under the IDIQ with the CNH;

3. The plan of care and services including medication administration, provided by CNH staff and services provided under the IDIQ with the CNH;

4. Interdisciplinary progress notes to include effect of care provided, veterans’ response to treatment, change in condition, and changes in treatment;

5. Medical practitioner orders which are signed and dated;

6. Allergies;

7. Person to contact in an emergency situation;

8. Name of attending medical practitioner; and

9. Advanced directives if available.

c. Clinical Record Safeguards: The CNH must safeguard clinical record information against loss, destruction, or unauthorized use. If the CNH maintains a veteran’s record by computer, electronic signatures are acceptable. If attestation is done on computer records, safeguards to prevent unauthorized access and to provide for reconstruction of information must be in place.

20. Specialty Services. The CNH will assume responsibility for arranging specialty care for veterans (e.g., dental care, podiatry and ophthalmology). Specialty care service must be preapproved by the VA.

21. VA Health Care System Consultation/Resources.

(a) Telephone Care Communications Systems (TCCS): For urgent same-day outpatient specialty care or for non-urgent scheduled clinic appointments/consultations, phone number 503-220-8262 follow prompts for scheduling between 9 a.m. and 3 p.m. Monday through Friday, excluding holidays. If a same-day appointment is anticipated; please call as early as possible.

(b) Admissions Conference Call Systems phone number: No Direct hospital admissions from nursing home for urgent or non-urgent care. If the veteran has an urgent need please call 911 for transport to local hospital for emergency room service. For non-emergency consultation or /evaluation for admission to the Portland VA Health Care System (after initial evaluation or intervention by the nursing home physician).

(c) Transportation: Necessary transportation to and from the VA hospital for clinics, evaluation or hospitalization will be arranged and paid by the VA hospital for CNH patients when requested. Please call 503-273-5020 for transportation. To make, change or cancel Clinic appointments, call 503-273-5201 and follow the prompts.

22. Charitable Contributions. The CNH will not solicit contributions, donations, or gifts from patients or family members. Note: Established charitable fundraising activities of a CNH fall outside the scope of this language.

23. CNH Billing. 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, RUG category(ies), and agreed upon RUG 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.

24. 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.

25. 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. Should Veteran / family choose to have a service not authorized by VA, i.e., private room when double room available or therapy when VA has reviewed and deemed not medically indicated, the CNH will first contact VA to ensure the service is not covered by VA, then make arrangements with Veteran / family for private pay. Invoicing will be conducted electronically.

The contractor and their personnel shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract.