Performance Work Statement Montana Community Nursing Homes.pdf

PERFORMANCE WORK STATEMENT (PWS) - Attachment 7

1. Background/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 Montana VA Health Care System in Fort Harrison, Montana at the prices specified in the section titled Schedule of Items of this contract.

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. VA shall have the right to inspect the CNH and all appurtenances by authorized VA representative(s) to ensure that acceptable standards are maintained and that the necessary care to maintain the well-being of the patient is rendered.

2. 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 developed quality of care standards utilizing CMS inspection criteria that are followed by VA in its selection of nursing homes, which includes a review of the

Medicare Care Compare ratings on which the CNH is evaluated based on local policy and directives established by the Medical Center and the Office of Geriatrics and Extended Care.

Reference of VHA Notice 2019-22 dated October 24, 2019 and the VHA Office of

Community Care Field Guide Book Specialty Programs dated July 9, 2020.

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). The per diem rate(s) established in this contract will include the cost of primary medical care, one (1) CNH provider visit every 30 days and/or per Medicare guidelines for mandated provider visits and as-needed for consultation, medications and routine supplies, laboratory, x-ray and other special services authorized by VA, unless otherwise specifically excepted (see Schedule of Items in this contract for details regarding per diem rates and coverage). In addition, the care provided will include room, meals, nursing care, and other services or supplies-to include continuous oxygen- 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 appropriate. 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.

3. Services Rendered at VA Per Diem Rates. Upon acceptance of a VA patient by the CNH, if requested by the VA Contracting Officer or authorized representative, the Contractor shall furnish all supplies and services herein described. VA is obligated only to the extent authorized placement of patients is made in accordance with this PWS.

4. 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. If a veteran no longer meets clinical eligibilities, the

CNH will work with VA on an appropriate discharge plan.

5. VA Authorizations. Authorization for CNH care will be submitted in CPRS using the following template, “Community Care-GEC Community Nursing Home Consult” or another electronic format used by the VA. Each authorization validity period will be noted on the

Community Care-GEC Community Nursing Home Consult with a beginning and end date.

Any extension to the original authorization validity period, regardless of the number of days can be added as an addendum to the original authorization.

6. Patient Placement. The CNH Coordinator/Contracting Officer Representatives (COR)/or

Point of Contact (POC) will coordinate the placement of patients to the Nursing Homes utilizing the Computerized Patient Record System (CPRS) system at VA hospital sites

(Reference FAR 16.505 (b)(2)(i)(B)). COR/POC Contact information will be identified in the post-award conference letter.

7. VA acknowledges that, depending on the availability of resources at specific CNH facilities at specific times, acceptance of a referral may be commercially impracticable for the CNH.

Therefore, the VA will coordinate care with an alternate CNH facility.

8. Designated VA CNH program personnel will issue written authorizations for Veterans to the contracted CNH. The determination to place a Veteran at a CNH is based on program needs determined by the VA.

9. 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. As with Medicare, a description of the RUG-IV systems can be found in 42 CFR Parts 409, et al. The level of care classification and associated per diem rate will remain in effect for each placement until and unless one of the following events takes place:

a. The recipient is discharged and subsequently qualifies for a new admission assessment.

b. The nursing home submits an assessment requesting a change in the level of care classification and VA approves it. Classification changes may also occur based on a determination by VA.

10. Primary Medical Coverage. The assigned CNH provider is the primary medical provider during the CNH 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 CNH 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).

11. Rehabilitation Criteria. All therapy provided under this PWS will be individual therapy, rather than group therapy, unless otherwise ordered by the authorizing VA facility. Therapy will require pre-approval by VA before services are provided. Medical Restorative criteria https://www.acquisition.gov/far/current/html/Subpart%2016_5.html#wp1095799 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. 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. The Contractor shall submit all Progress Reports to the VAMC upon request.

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.

12. Emergency Care; Financial Responsibility; Advanced Directives. In emergencies, CNH staff will utilize the 911 local emergency systems as for any resident. Advance directives or living wills shall be adhered to according to CNH physician’s orders. When private hospitalization or emergency services are required, the patient, spouse, financial guardian or insurer is financially responsible. A Veteran authorized by the VA to be in a CNH facility may qualify for VA coverage of emergency care provided the VA Health Care System

(VAHCS) if 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.

13. 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 if they are conducting health care on VA’s behalf.

The CNH care program qualifies as a medical service, so no BAA is required.

14. State Licensure; Access to CNH Quality of Care Reports (Performance Objective #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

VA Home and Community Care Department and the Contracting Officer. VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this contract, 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 VA patients. 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 relating to this contract, 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 VA and compliance with these requirements.

15. Corrective Action Plan (Performance Objective #2). 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.

16. Life Safety Code. The CNH’s building shall conform to the most recent standards of the Life

Safety Code (National Fire Protection Association Standard #101) and remain in compliance with all applicable Federal, State and local regulations. The administrator of the CNH is required to notify the COR/POC in writing at least thirty (30) calendar days prior to any planned facility changes that could impact the Life Safety Code and other safety features of the facility.

17. Acceptable Safety and Sanitation Practices. Acceptable safety and sanitation practices shall be observed throughout the CNH 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.

18. Re-admission to the VA Hospital and Emergency Care; Notification of Death of

Veterans; CNH Responsibility to Veteran’s Belongings or Personal Effects

(Performance Objective #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 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. Absences of fifteen (15) consecutive calendar days or more, whether in a

VA or in a non-Federal facility, require a new authorization.

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, 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 authorizing 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.

19. 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 limited to 6 overnights per calendar year, typically at 24-48 hours per each event and will be pre-approved. VA will cover bed holds and will reimburse according to the prevailing State Medicaid guidelines.

Bed-hold will begin the date the resident leaves the CNH if VA is notified of absence and bed-hold is requested at the time of notification. 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. The CNH 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.

20. Reportable Events (Performance Objective #4). VA requires CNHs to report to the CNH

Coordinator/COR/POC at VA for any of the following events within 24-hours or immediately the first business day after a weekend or holiday:

a. Sentinel events; 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.

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

c. When there is a change of CNH 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. Reporting shall include date of occurrence and patient disposition and outcome. 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 CNHs to report such incidents to the CNH program office.

21. 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 identified through the CMS Medicare Nursing Home Care Compare, the

Government will take one or more of the following actions in accordance with the terms and conditions of the IDC 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 IDC from the subject CNH;

d. Not renew the IDC; and/or

e. Terminate the IDC.

22. VA Staff Access to CNH Records (Performance Objective #5). The Contractor shall ensure that all medical records concerning the veteran’s care in the CNH will be readily accessible to VA. 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).

The contractor shall maintain a medical record for each patient, which includes at least the following:

a. VAHCS 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 Community Care-GEC Community Nursing Home Consult

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 the

CNH;

3) The plan of care and services including medication administration, provided by CNH staff and services provided by 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.

23. Specialty Services/Specialized Prosthetics Equipment (e.g. Specialty bed). All Specialty

Services must be pre-approved through the VA Consult process. The CNH will assume responsibility for arranging specialty care for veterans (e.g., dental care, podiatry and ophthalmology). Veterans may be eligible for Specialized Prosthetic Equipment if clinically indicated. Pre-approval is required by the VA.

24. VA Health Care System Consultation/Resources. If emergency hospitalization is needed after evaluation by the CNH physician, contact VA at 406-447-6801 to speak to MOD

(Medical Officer on Duty) to determine feasibility of transfer to VA Hospital. All other ER visits and/or hospitalizations are to be reported to Office of Community Care, Payment

Operations and Management (POM) Office at 1-844-724-7842. A message may be left after hours and on weekends.

25. 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.

26. CNH Billing (Performance Objective #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, RUG category(ies), and agreed upon RUG rate (s). Failure to include this information may result in delayed payment. All invoices must be submitted using the UB04 form. Claims over one year will need to be submit through the claims process in accordance with the

Federal Acquisition Regulation.

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. Ancillary costs may not be added to any invoice without written permission of the VA medical center. Ancillary services defined as supportive or diagnostic measures a physician may use to treat a patient. Anything that does not include room and board or direct care by a physician or nurse is considered ancillary. If permission is received, the nursing home must submit the physician’s order for the medication/supply, the dispensing log, the supplier and the cost charged by the supplier to the nursing home. The CNH will be reimbursed based on local guidelines and

VA pricing schedules.

b. High cost medications: All Medications administered to VA-contracted Veterans residing in a CNH will be charged at the Average Wholesale Price (AWP) or according to the pharmacy bill, whichever is less. Medication costs up to 8.5% of billed care are included in the RUG rate pricing. If Medication costs exceed 8.5% of the monthly per diem a medication exception should be requested through the Community Nursing Home

Program. The MTVAHCS pharmacy will establish a course of action to compensate for the excess cost of medications. The course of action may include the provision of the high cost medications through the VA pharmacy as defined as any medication that exceeds $2500/month, recommendation to provide an acceptable alternative medication or reimbursement for the amount of the high cost medications in excess of 8.5%. The course of action will be documented in the Veterans medical records and entered in the

CNH consult. All calculations will be made on a monthly basis. The VA reserves the right to deny payment for medication, which at its sole discretion, is determined by the

VA to be of no clinical benefit to the Veteran. All pre-authorized requests for reimbursement for high cost drugs and corresponding billing are due as soon as possible, but no later than 30 calendar days after use of products. Invoices for pharmacy reimbursement will be sent directly to:

HCBS/CNH Program, PO Box 1500, Mail Code 182H

Fort Harrison, MT 59636-1500

c. Private Rooms. A private room rate for clinical concerns such as communicable diseases or infections (e.g., MRSA, VRE), or other pertinent clinical needs may be charged above the negotiated RUG rate for that facility with prior approval by the VA CNH Coordinator or designated VA staff. However, no additional private room charge will be allowed in the following circumstances: where the private room is strictly veteran or family preferred; where the CNH only maintains private rooms; no double-occupancy rooms are available; and for ventilator-dependent patients with prior-negotiated rates.

d. 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. For information related to submitted claims please see:

• VA Community Care Contact Center at 1- 877-881-7618

• For claim status: Customer Engagement Portal (CEP) https://www.cep.fsc.va.gov

• FAX to 406-447-7645 Attention: CNH Coordinator

27. Authorization for Patient Care: It is impossible to determine the exact or estimated amount, which will be expended by the CNH. No obligation will be incurred by VA until authorizations are issued for CNH care of specific beneficiaries. However, under this IDC, there is a guaranteed minimum. 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 IDC. 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.

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cep.fsc.va.gov%2F&data=04%7C01%7C%7C1b0396eb393c4bec337808d91f9da036%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637575584116379911%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=YH3Eb9tAldqAlZRqc%2FhHbTxlMWIm%2Fp1gQMXaEEiEm%2Bc%3D&reserved=0

28. VA Payments. Payments made by VA under any contract constitute the total cost of CNH care. No additional charges will be billed to Medicare (with the exception of hospice services), 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.

a. Contractors who are not able to use the HIPAA-compliant transactions are not required to do so. Supporting information for monthly invoices will be mailed or faxed to:

Department of Veteran Affairs

HCBS/CNH Program, PO Box 1500, Mail Code 182H

Fort Harrison, MT 59636-1500 or

ATTN: CNH coordinator

FAX: 406-447-7645

END PERFORMANCE WORK STATEMENT