Solicitation 36C26125Q0048 Enhanced Geriatric Case Management.pdf

PAGE 1 OF 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. UEI: EFT:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

640-25-1-344-0003

36C26125Q0048

6. SOLICITATION ISSUE DATE

11-18-2024

Tim Smith | Timothy.smith9de3@va.gov 916-923-4517 12-04-2024 1:00 pm PST

612MCP

Department of Veterans Affairs Network Contracting Office (NCO) 21

3237 Peacekeeper Way, Bldg 200 Suite 204 McClellan Park CA 95652

X

624190

$16 Million

N/A

X

See Performance Work Statement

612MCP

Department of Veterans Affairs Network Contracting Office (NCO) 21

3237 Peacekeeper Way, Bldg 200 Suite 204 McClellan CA 95652

Department of Veterans Affairs FMS VA-9(101) Financial Services Center

PO Box 149971 Austin TX 78714-9971

See CONTINUATION Page

Requirement for Enhanced Geriatric Case Management Services For VA Palo Alto Health Care System (VAPAHCS)

Period of Performance: 2/14/2025 - 2/13/2026

Note 1: Offerors shall follow the submission instructions specified in Addendum to FAR Provision 52.212-1 and 52.212-2 included in this solicitation. Failure to follow the instructions will result in an unfavorable evaluation and may not be considered for award

Note 2: All questions must be submitted no later than 11/25/2024 at 10:00 am PST to Timothy.smith9de3@va.gov

See CONTINUATION Page

X

Tim Smith Contracting Officer

36C26125Q0048

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 PRICE/COST SCHEDULE

ITEM INFORMATION

B.3 PERFORMANCE WORK STATEMENT

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL PRODUCTS

AND COMMERCIAL SERVICES (NOV 2023)

C.2 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.3 52.204-21 BASIC SAFEGUARDING OF COVERED CONTRACTOR

INFORMATION SYSTEMS (NOV 2021)

C.4 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.5 VAAR 852.201-70 CONTRACTING OFFICER'S REPRESENTATIVE (DEC 2022)

C.6 VAAR 852.203-70 COMMERCIAL ADVERTISING (MAY 2018)

C.7 VAAR 852.211-76 LIQUIDATED DAMAGES – REIMBURSEMENT FOR DATA

BREACH COSTS (FEB 2023) ALTERNATE I (FEB 2023)

C.8 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-

OWNED SMALL BUSINESS EVALUATION FACTORS (JAN 2023) (DEVIATION)

C.9 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (OCT 2019)

C.10 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS

(NOV 2018)

C.11 VAAR 852.237-74 NON-DISCRIMINATION IN SERVICE DELIVERY (OCT 2019)

C.12 VAAR 852.237-75 KEY PERSONNEL (OCT 2019)

C.13 VAAR 852.242-71 ADMINISTRATIVE CONTRACTING OFFICER (OCT 2020) . 41

C.14 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (MAY 2024)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

SECTION E - SOLICITATION PROVISIONS

E.1 52.201-1 ACQUISITION 360: VOLUNTARY SURVEY (SEP 2023)

E.2 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (SEP 2023)

E.3 ADDENDUM TO 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL

ITEMS

E.4 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB

1998)

E.5 52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS

AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

E.6 52.204-29 FEDERAL ACQUISITION SUPPLY CHAIN SECURITY ACT

ORDERS—REPRESENTATION AND DISCLOSURES (DEC 2023)

E.7 52.216-1 TYPE OF CONTRACT (APR 1984)

E.8 52.233-2 SERVICE OF PROTEST (SEP 2006)

E.9 VAAR 852.215-72 NOTICE OF INTENT TO RE-SOLICIT (OCT 2019)

E.10 VAAR 852.233-70 PROTEST CONTENT/ALTERNATIVE DISPUTE

RESOLUTION (OCT 2018)

E.11 VAAR 852.233-71 ALTERNATE PROTEST PROCEDURE (OCT 2018)

E.12 52.212-2 EVALUATION—COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES (NOV 2021)

E.13 52.212-2 EVALUATION—COMMERCIAL ITEMS (NOV 2021)

E.14 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—

COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES (MAY 2024)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C261 Department of Veterans Affairs Network Contracting Office (NCO) 21

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[X] 52.232-33, Payment by Electronic Funds Transfer—System For Award Management, or

[] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly []

b. Semi-Annually []

c. Other [X] Monthly

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

Presentment and Payment System – The FSC uses a third-party contractor, Tungsten, to transition vendors from paper to electronic invoice submission. Please go to this website:

http://www.tungsten-network.com/US/en/veterans-affairs/ to register and begin submitting electronic invoices, free of charge. The Department of Veterans Affairs Tungsten Number is:

AAA544240062 (this allows you to file invoices online for free.)

More information on the VA Financial Services Center is available at http://www.fsc.va.gov/einvoice.asp.

Vendor e-Invoice Set-Up Information:

If you have questions about the e-invoicing program or Tungsten, please contact the FSC at the phone number or email address listed below:

• Tungsten e-Invoice Setup Information: 1-877-489-6135

• Tungsten e-Invoice email: VA.Registration@Tungsten-Network.com

• FSC e-Invoice Contact Information: 1-877-353-9791

• FSC e-invoice email: vafsccshd@va.gov

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

B.2 PRICE/COST SCHEDULE

ITEM INFORMATION

ITEM

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

12.00 MO __________________ __________________

Provide 24x7 Geriatric Case Management Services in Accordance with the Performance Work Statement for up to 12 Veterans Contract Period: Base POP Begin: 02-14-2025 POP End: 02-13-2026 PRINCIPAL NAICS CODE: 624190 - Other Individual and Family Services PRODUCT/SERVICE CODE: G005 - Social - Geriatric

MANUFACTURER PART NUMBER (MPN): N/A

GRAND TOTAL __________________

B.3 PERFORMANCE WORK STATEMENT

PERFORMANCE WORK STATEMENT

GERIATRIC CASE MANAGEMENT SERVICES

PURPOSE

1. The Department of Veterans Affairs Palo Alto Health Care System (VAPAHCS), located at 795 Willow Rd. Menlo Park, CA 94025, is seeking a Contractor to provide 24/7 services for Veterans enrolled in the community-based Health Care for Homeless Veteran (HCHV) Enhanced Geriatric Services program. This is a service only contract. All services for this contract will be provided on site at one VA approved designated location where the Veterans will reside within Santa Clara County. The location of residences may change but will remain within the Santa Clara County. Contractors will be expected to assist Veterans with housing maintenance, geriatric support services and case management services. The goal of the HCHV program is to remove homeless Veterans from the street or habitation unfit for living and place them in community-based, residential environments with sufficient supportive services to meet their needs and ultimately facilitate the improvement of their housing situation. The period of performance of the resulting contract will be for a one year and no option periods. This contract represents a Firm Fixed-Priced contract. Costs not incorporated into the Contractor’s price will NOT be reimbursed by the Government. This contract is specifically for the geriatric population.

2. BACKGROUND

2.1. The Enhanced Geriatric Services program is an HCHV program to assist homeless

Veterans with ongoing medical, mental health, geriatric and other case management services while assisting Veterans in navigating housing barriers, completing housing requirements and in maintaining independent living while residing in community based permanent housing. All services for this contract will be provided at one location, on site, at Veteran residences, in a VA pre-approved designated location within Santa Clara County. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance use disorders, and other serious medical conditions. The purpose of this solicitation is to engage a Contractor to oversee a services only staffing contract to provide and facilitate the on-site, 24/7 supportive medical, mental health, geriatric and rehabilitative case management services to Veterans participating under this program. Through this contract initiative, Contractor(s) will ensure staff hired under this contract will support Veterans in maintaining housing while simultaneously providing case management and supportive services to assist Veterans’ medical and cognitive needs.

2.2. The target population for this contract are healthcare eligible high needs geriatric homeless Veterans that are participating in a homeless VA Palo Alto program that demonstrate the most need or vulnerability based on their unique clinical, medical and/or psychosocial circumstances.

2.3. Contractor will serve geriatric homeless Veterans who have little to no income and may fall below the 30% AMI for their county. Contractor will not be required to provide detoxification or other hospital level or licensed care treatment.

2.4. The Contractor shall meet all requirements in accordance with the items identified in the performance work statement The Contractor shall be responsible for maintaining compliance with this contract at all times.

3. SERVICES TO BE PROVIDED

3.1. Contractor shall provide all labor, supervision, material and supplies necessary to provide rehabilitative, medical, geriatric, therapeutic, mental health and supportive services to homeless Veterans. Services will be provided at a VA approved location, on-site within a Santa Clara County location where the Veteran resides. Services will be provided in accordance with all terms and conditions, provisions, and requirements listed herein. Prices provided in the Price Schedule shall be inclusive of all services listed in this section; prices do not include room and board. An office space will be provided to staff at the designated location.

3.1.1. Facilitate Room and Board: This is a service only contract. Prices do not include room and board.

3.1.2. Dietetic Services: Contractor will facilitate access to food for Veteran. This can include grocery shopping, Meals on Wheels, food kitchens, food stamps, facility provided meal service, or any other relevant resources related to nutrition for the Veteran. If medically indicated, Contractor will ensure Veterans with dietary restrictions requiring alternative meals (e.g., diabetic, renal, and soft mechanical diets) will have access to required food options.

3.1.3. Laundry Facilities: Contractor will ensure Veteran has access to laundry facilities. If no laundry facilities are on site, Contractor will provide assistance to Veterans on accessing laundry facilities. Should a Veteran have difficulty doing their own laundry, Contractor will provide guidance and support for Veteran to have laundry done at minimum one time per week. Should a Veteran refuse to wash his or her clothes, this will be addressed as a therapeutic opportunity.

3.1.4. Case Management Services: This contract requires that Contractor maintain a minimum staffing ratio of one dedicated, full time, on-site primary daytime medical and/or nursing case manager per a maximum of 12 Veterans. Written requests for exceptions may be granted by the VA Liaison. There will also be secondary medical case management staff coverage for all remaining day, night, and weekend hours. At a minimum, the primary daytime medical case manager must be an LVN level of care or higher and be required to work normal business hours Monday through Friday. For all secondary day, night and weekend staff, they must have qualifications of, at minimum, an experienced caregiver with 5 or more years of caregiver experience and/or CNA level of care or higher. (See “personnel 6.1 for more details on specific requirements for staffing).

3.1.4.1. Check Ins: The primary medical case manager will provide structured individual case management, including counseling on self-care skills, adaptive coping skills, financial planning, permanent housing maintenance, written care plan, referral for financial benefits, socialization, managing medical issues and all other needs as applicable. The primary medical case manager will be required to have daily check ins during their normal tour of duty times. The secondary daytime and night and weekend medical case managers will ensure Veteran basic needs are being met and continuity of care through daily check ins, medication oversight and documented case management follow up as outlined by the primary case manager. For High-Risk Veterans (Veterans with high cognitive deficits and/or high safety concerns), all medical case managers may be required to have more frequent check ins which will include, at minimum, once during the day shifts and once during the evening shifts (e.g. 8 am and 6pm daily).All staff shall log after each shift any incidents, concerns and follow up needed for the next case manager to refer to as they begin their shift.

The primary case manager is responsible for ensuring any pending items over the night and weekend are resolved or followed up on at beginning of their scheduled shift. Additionally, the primary medical case manager shall provide the following:

3.1.4.2. Informational Packets: All Veterans must receive an informational packet within 72 business hours which includes, at minimum, the following information:

3.1.4.2.1. Description of services

3.1.4.2.2. Grievance Policy

3.1.4.2.3. Emergency procedures

3.1.4.2.4. Patient rights and Reasonable Accommodation

3.1.4.2.5. Ombudsmen contact information in accordance with state regulation.

3.1.4.3. A thorough assessment of Veteran’s psychosocial needs and written individualized care plan (ICP) will be developed within seven business days of admission for each Veteran. Information from the assessment will be integrated into the Veteran’s ICP. ICPs will also include an assessment of Veteran Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)’s and possible crisis situations for the Veteran, such as elder abuse, harm to self, verbal abuse or acts of violence or any other medical or psychiatric crisis. Contracted staff will take proactive measures to address any issues in the ICPs and work to prevent these instances to avert crisis to keep these incidents at a minimum. Contractor will be proactive to ensure staff are trained in de-escalation techniques. Contractor will be a mandated reporter.

3.1.4.4. Collaboration and coordination with VA program staff will include coordination of supportive psychosocial services as needed. Coordinated efforts must be made with the Liaison around medical, mental health, admission, and housing support needs. Contractor is expected to coordinate all appointments including, but not limited to, chemotherapy appointments, dialysis appointments, and wound care appointments.

Contractor will be expected to accompany Veterans to their appointments when medically, cognitively, or psychiatrically indicated per the liaison and/or Contractor’s clinical judgement. Contractor’s staff will make active efforts to establish relationships with key stakeholders, providers, and partners in the VA Health Care and Benefits Administration Systems to work closely and collaboratively with the interdisciplinary treatment team.

Contractor will be required to work on longer term housing goals as needed. Examples of this include Cal Vet Homes, Skilled Nursing Facilities, Memory Care, Assisted Living and/or Coordination with family and Caregivers for long term care support.

3.1.4.5. Ongoing ICP coordination will be expected between the Case Manager(s) and VA Liaison (or Designee). The Case Manager(s) will be expected to coordinate with the VA Liaison (or Designee) to ensure Veteran’s goals, as expressed in both the agency and VA Liaison’s (or Designee’s) intake, are reflected in the ICPs.

3.1.4.6. Every 60 days, the primary case manager will also coordinate a meeting with the Veteran and the VA Liaison (or Designee) for bi-monthly ICP update meetings for the first six months after admission. If stabilization is evident, meetings may be every 180 days as stabilization continues.

These meetings may need to be more frequent than 60 days or may revert to 60 days if the Veteran de-stabilizes.

3.1.4.7. The primary case manager is expected to meet with the VA Liaison (or Designee) for case management update meetings every 30 days. If the Veteran de-stabilizes, meetings may need to be more frequent than 30 days. Contractor will provide proper documentation verifying services and case management efforts by all team members including, but not limited to nursing staff, case management staff, benefit specialists, and program management staff. Notes must be written professionally in a format that utilizes the clear settings of goals and documents progress towards those goals (e.g. SNAP, SOAP, or SMART notes).

3.1.4.8. Special attention will be made to address High Suicide Risk (HSR) Veterans as identified by the VA Liaison (or Designee), VA Mental Health Staff and/or the contracted Case Manager. Contractor will avail themselves to be contacted by the suicide prevention coordinator immediately should a Veteran miss an appointment and his/her safety must be verified. On a weekly basis, the contracted case manager will be required to update the VA Liaison (or Designee) on Veteran safety concerns for HSR Veterans. Contracted case manager will review the HSR Safety Plans with the Veteran on a bi-weekly basis until clinically indicated (this can include until the HSR flag is removed by the VA). HSR Safety Plan reviews and a copy of the Veteran’s Safety Plan will be documented in the chart. All Veterans will be referred to the VA for Primary Care and Mental Health appointments and Contractor will support Veterans in making initial and subsequent appointments. Particular efforts will be made for Veterans who are identified by Liaison to be highly acute.

Efforts will be documented in the Veterans ICP and reviewed by the VA Liaison (or Designee), at least monthly or as clinically indicated.

3.1.4.9. If Contractor determines a Veteran who has not been identified as an HSR Veteran to have expressed suicidal ideation, Contractor must follow their agency and VA incident and safety protocols. If the identified Veteran does not have a safety plan, Contractor will create an agency safety plan with the Veteran and make increased efforts to connect the Veteran to mental health services. Contractor safety plan will be forwarded to the VA Liaison (or Designee), as well as information on all efforts to connect the Veteran to mental health services. All procedures applied to HSR Veterans must be followed for the non-flagged HSR Veteran until the Veteran can be evaluated by a MH provider and/or Suicide Prevention Coordinator.

3.1.4.10. Contractor must be in close communication with the liaison for any missing Veterans due to the high acuity of the target population.

Contractor must file missing person’s report should the Veteran be considered at risk.

3.1.4.11. Contractor’s staff will maintain a professional relationship with internal and external partners. As such, Contractor must work together with the VA Liaison and other VA staff to resolve issues around quality of care with respect and professionalism.

3.1.4.12. Medical Case Management Services: Contractor shall provide life skills education and assistance to Veterans. Contractor will assist Veterans with the following: scheduling medical and mental health appointments, providing customized education for medical diagnosis and medication management, memory cues, and arranging appropriate transportation to and from all appointments. Contractor will make referrals to community-based organizations when health and/or psychosocial condition(s) indicate need for appropriate referral(s) and make sure all medications prescribed are reconciled to prevent duplication of orders among providers. Contractor will promote clear communication among treatment providers by ensuring awareness regarding Veteran’s medical needs and prescribed medication. Contractor will provide coordination of care by meeting with Veterans and medical staff to determine goals and recovery targets for identified conditions. Contractor will assist Veterans with medication management by monitoring Veterans’ compliance issues and providing extensive medication education to improve compliance.

Contractor will teach appropriate medical interventions regarding wound care, self-care, and management of medical diagnosis. Contractor will offer cues to Veterans to facilitate self-care. Staff providing this education must be qualified professionals to offer this service and education to Veterans. Contractor will facilitate connections to non-VA entities and coordinate care and transportation for Adult Day Health Centers and other Geriatric Services. Contractor will provide housing support and coordination to a higher level of care if needed and will facilitate applications and all medical documentation. Contractor will be expected to assist in researching and filing applications for VA and Non-VA medical benefits that the Veteran may be eligible for, which can include HHA/IHSS/Medi-Cal/Medi-Care/Senior Advantage and other services.

Contractor may be required to provide light ADL assistance and operate within their scope.

3.1.4.13. Contractor Housing and Stabilization Case Management Duties:

Contractor will be expected to enroll and provide on-site services to the low and/or no income Veterans enrolled under this contract. Contractor will work with involved agencies (i.e. Public Housing Authority, Office of Supportive Housing, etc.) to facilitate the timely access to the housing vouchers available for Veterans enrolled in this program (when applicable). The Contractor duties may include: Assist veteran with the veteran in securing vital documents, such as a DD-214, a birth certificate, a social security card, income verification, etc. required to obtain the housing voucher; Accompany Veteran to any housing appointments including annual certifications, briefings, and interim appointments.

Contractor shall assist Veteran in completing and submitting housing vouchers and other Federal, local and state entitlement programs.

Advocate with landlords on behalf of the Veteran to maintain their lease and to work with Veteran and landlord on payment options or other financial assistance programs to increase Veteran income if Veteran is at risk of being discharged or denied entry into this program due to income deficiencies, delays in rental payment or other concerns. Contractor shall ensure that the Veteran has completed the VA release of information so communication between the landlord, Contractor, and VA COR/Liaison can occur as needed. Assist the Veteran in making calls to utility providers to ask questions and resolve issues (including restoring, turning on, turning off or transferring utilities); As applicable, if higher level of care housing placements or inpatient residential treatments are clinically indicated, Contractor will provide case management around obtaining higher level housing options will be required. Examples of this may be researching future housing options, connecting to local resources, discussing how to maintain/pay for housing over long term, adult day health referrals Cal Vet homes, skilled nursing, and licensed assisted living facilities and/or other community long-term supports.

3.1.4.14. Financial Planning: Contractor will assist Veteran in increasing income by applying for all eligible benefits, both VA and non-VA (e.g. Veteran’s Benefits Administration (VBA), Social Security Administration (SSA), SSI, SSDI, SNAP benefits, utility assistance, NSC pension, GA, Aid and Attendance, Medi-Cal, etc.). Evaluate and assist the Veteran with budgeting education to promote the ability to manage expenses including those related to housing while also assisting the Veteran with locating both community and Government resources. Verify whether the Veteran is paying rent and utility bills in a timely manner and provide budgeting/money management assistance as needed. Case Managers will document all structured activities that support Veterans in developing a short and long-term plan to understand and address their current financial situation and how to improve it. Each Veteran must apply for Medi-Cal, Medi-Care, and aid and attendance (if eligible) if they do not have this benefit. Financial benefits must be applied for within 60 days of housing stability. Case management services must be provided to evaluate and increase a Veteran’s income to provide the most opportunities for success. Contractor will assist Veteran in negotiating landlord disputes.

3.1.4.15. If applicable, Case Manager will refer Veteran to all relevant legal services which would benefit the Veteran’s housing stability. Case Managers will document all activities and education that support a Veteran’s legal needs.

3.1.5. Medication Monitoring: Contractor will provide Veteran with medication reminders, prompting, medication education, and assistance with organizing medication as therapeutically indicated. Education will include best practice for storage from manufacturer and comply with physician’s orders.

3.1.5.1. All primary and secondary medical case management staff providing Veteran care will be required to, at minimum, have received the required medication training if not already included in the staff member’s license. As a result of this training, all staff should be able to provide medication prompts to the Veterans, as needed, when the primary medical case manager is not on duty. This training will need to be completed within 90 days after contract award. The certificate(s) of the medication training and the times/days and hours of the person(s) covering will be provided to the VA Liaison to keep on file. A list of these staff members and their schedules will be requested at start of contract.

3.1.5.2. Contractor will also be responsible for providing education for non-licensed providers on when an on-call or higher level of care consultation is necessary.

3.1.6. Grievance Procedures: Contractor must have an internal grievance process that Veterans can use to resolve conflicts within the program. Contractor must have written policies and procedures for resolving grievances, including a statement regarding the Veteran’s right to request reasonable accommodation, and must post them in a conspicuous place and be accessible to Veteran. In addition, each Veteran receiving services shall receive a copy of the grievance policies and procedures at intake and prior to any discharge decisions.

3.1.7. Timeliness of Response: Contractor must have a dedicated phone line for VA inquiries and Veteran self-referrals. Return calls from Contractor are expected within 4 hours during business hours Monday through Friday. Calls, referrals, emails, or other correspondence from community agencies, VA staff, Veterans or VA Liaisons (or Designees), are also expected to be addressed within 4 business hours Monday through Friday.

3.1.8. Critical Incident Reporting: All critical incidents will be reported within 24 hours. This includes the following:

o Falls o Assault (to Veteran or Staff) o Elderly/dependent adult abuse or neglect o Missing Persons o Sexual assault o Fire (Veteran involved) o Medical/psychiatric emergency (911 Calls) o Hospitalization o Suicide or suicide attempt o Homicide o Significant change in mental status o Death o Infectious control (TB, COVID, etc.)

o Active substance abuse on Contractor property o Observation/ possession of weapons o Grave disability

3.1.8.1. Critical Incidents: Contractor shall notify the authorizing VA facility immediately of any incidents involving Veterans in the Enhanced Geriatric Service contract. Contractor shall notify the VA liaison by telephone or email during the hours of 8:00am and 4:30pm. For all incidents that occur after normal business hours, Contractor should notify the HCHV Staff the following business day. Contractor shall provide the HCHV liaison and the COR with a copy of the incident report within 24 business hours. Contractor shall maintain a copy of the incident report in the Veteran’s case record.

3.1.8.2. Medical Emergencies: For emergency hospitalizations, if possible, a request for Veteran to be transported to the nearest VA facility is expected; however, if such admission is not feasible because of the nature of the emergency, it is agreed that hospitalization in a non-federal facility is acceptable. If hospitalization of a non- emergent nature is required, it is agreed that admission to the appropriate VA facility will be accomplished promptly. Contractor will arrange for admission and support the Veteran with any transportation issues that may arise.

3.1.9. Therapeutic and Rehabilitative Services:

3.1.9.1. Milieu: Contractor will cultivate a milieu of trust and safety. This includes a tolerance for relapses, regression, and personal unpredictability. As a part of the engagement strategy, Veterans will be connected to and invited to participate in activities of everyday life, including recreation activities and socializing. Such opportunities will be offered, not required nor demanded. A Harm Reduction Model will be utilized. Adherence to this model may be assessed at any time by the liaison. It is expected that Contractor will assist with self-care including, but not limited to, offering adult briefs and providing cues for hygiene, medication, and eating. It will be understood that the target population in this contract is going to need intense assistance in getting completing activities of daily living. While Contractor is not expected to offer licensed level care, Contractor will support Veterans who show a decline in daily functioning. As such, the administrator for this contract must be RCFE administrator certified.

3.1.9.2. Recovery: This contract uses a Housing First approach with a focus on Harm Reduction. Support for a healthy lifestyle needs to be provided in an environment conducive to social interaction and to the fullest development of the resident’s rehabilitative potential. Pursuant to these principles, abstinence only policies and drug testing may not be used to discharge or discipline a Veteran. Drug testing may only be used as a clinical intervention to modify behavior or assess behavioral issues in agreement with the Veteran’s treatment goals.

3.1.10. Transportation: Contractor shall assist Veteran with round trip transportation to scheduled meetings, medical appointments, and hospital visits as needed. Should the Veteran need added assistance for his appointments, Contractor will be expected to accompany Veteran to the appointment to ensure Veteran meets with the provider.

3.1.11. Occupancy: Contractor is expected to enroll and admit Veterans in a timely manner to maintain an occupancy of 90%. Admission decisions are a joint decision between Contractor and VA. Final decision on admission is determined by the VA Liaison.

3.1.12. Documentation: An individual case record will be created for each referred Veteran. Contractor shall document treatment and, if applicable, discharge planning, reflecting the Veteran’s health, social, cognitive, and mental health needs. Documentation should also include any involvement of the Veteran, the VA staff, and appropriate community resources in resolving problems and setting goals. Case records shall be maintained in a secure and confidential manner as required by the Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR part 2) and the Confidentiality of Certain Medical Records (38 USC 7332). Case records and data normally maintained and included in a medical record as a function of compliance with State or community licensing standards will be made available on a need-to-know basis to the appropriate Department of Veterans Affairs staff members. Contractor shall comply with applicable requirements of the Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part II) and the Confidentiality of Certain Medical Records (38 USC 7332). The files shall include:

Reasons for referral

All essential identifying data relevant to Veteran and his/her family, including a socio-cultural assessment, weekly progress reports or notes, and documentation of any case management interventions or patient care conferences.

Copies of any medical prescriptions issued by physicians, including orders, if any, for medications to be taken. Contractor must comply with HCHV inspection requirements.

Case management notes written in a professional manner (i.e. SMART, SOAP, SNAP) and will include the following: 1) a written and thorough Housing Maintenance Assessment, 2) a written, standardized Socialization Assessment, 3) a Financial Plan, 4) a Discharge Plan, and

5) an Individual Care Plan with attendant goals and documented activity indicating Veteran and Case Manager are actively working on identified goals.

Daily sign in and administrative logs for the purpose of verifying Veteran’s participation in the program, safety checks, absences and Contractor services. These logs must be submitted to the VA Liaison monthly.

QASP Compliance Tool and all attendant supporting documentation demonstrating Contractor compliance with Contract.

Final summaries on each resident who leaves the program, which includes reasons for leaving, the Veteran’s future plans, and follow-up locator information.

Waivers, Corrective Action and Incident Reports as appropriate.

Contractor shall comply with the principles listed in 38 CFR 17.707(b) to provide housing and supportive services in a manner that is free from religious discrimination.

3.1.13. Rules, Policies And Procedures: Contractor shall have reasonable rules governing day-to-day life and activities. The purpose of these rules is to promote stability, safety, cleanliness, and dignity. Rules should not set up Veteran for failure and should be presented in a manner that is the least intrusive and punitive. Infraction of rules will be seen as a therapeutic opportunity, not responded to punitively. Should any rule prove to be a barrier to service, then the rule must be reviewed with the Liaison and possibly changed to ensure continuous engagement and accessibility to the program.

Response to rule infractions should be approached with leniency and further engagement as appropriate to the Veteran’s participation in the program. The focus of the rules should be around the safety of Veteran residing at the facility.

Rules regarding substance use, chores, engagement in treatment, and general rule compliance, shall be as flexible as is necessary to carry out the functions of this contract and to maximize Veteran engagement. Any rule or policy that proves problematic to the active, effective, and ongoing engagement of Veteran shall be addressed by the VA and program management team, subject to immediate review and repeal upon the request of the VA Liaison. Examples of rules that may not be appropriate to this setting are: mandatory breathalyzing, mandatory sobriety, and mandatory meetings (e.g. house meetings, AA, NA, SUD treatment meetings). Veteran will be provided a copy of the rules at intake and/or upon Veteran’s request. In addition, Contractor will post the rules in a location readily visible to Veterans and visitors. These rules must include detailed Patient Rights and the procedures that Contractor has in place to protect the Veteran’s rights and dignity. Veteran must be permitted to exercise these rights without fear of reprisal. If requested, Contractor must reasonably accommodate Veterans whose compliance with program rules is limited by the Veterans’ physical or mental disabilities, in accordance with the Americans with Disabilities Act, the Federal Fair Housing Amendments Act, Section 504 of the Rehabilitation Act, including those requirements covering reasonable accommodations for disabilities and the use of assistance and companion animals, and the California Fair Employment and Housing Act of 1973, and all other applicable State or Federal laws. Contractor must equally apply all rules, policies, and procedures to Veteran, unless Veteran has asked for a reasonable accommodation due to his/her disability.

3.1.14. The Contractor shall respect and maintain the basic rights of patients, demonstrating concern for personal dignity and human relationships. The Contractor shall respect the cultural and personal values, beliefs, and preferences of each Veteran.

4. REFERRALS, ADMISSIONS, ELIGIBILITY, AND DISCHARGE

4.1. Referrals and Admissions: Prioritization will be based on the acuity of the

Veteran’s abilities (or lack thereof) to live independently.

Indicators may include:

Failure to thrive in HUD-VASH or other permanent supportive housing program

Frequency of hospitalizations Frequency of emergency department visits Level of ability to perform basic activities of daily living (ADLs) Continuous need for reminders for important tasks, such as managing medications, appointments, meals, and bathing Mental status.

4.1.1. Liaisons will have the final decision for admissions and discharges to the program.

4.1.2. Contractor will provide verbal and written notification that is readily accessible to all individuals including the VA liaison, upon request, of reasons for non- acceptance.

4.1.3. Contractor must have formal appeal procedures through which Veteran may appeal unfavorable admission or eligibility decisions and a copy of the policy for appeals is to be given to Veteran at screening or intake. For highly symptomatic Veterans, a waiver for admission and intake procedures can be requested through the VA Liaison (or Designee).

4.1.4. Arranging the meeting between the Liaison and the Veteran is Contractor’s responsibility.

4.2. Eligibility: The VA is responsible for determining eligibility and appropriateness of Veterans prior to acceptance by Contractor for services. The VA is responsible for identification of Veterans for units and the VA makes the final decision of Veterans who are served by the Enhanced Geriatric Services Contract. If there is an interest list for this program, this list needs to be reviewed jointly by the VA and Contractor to determine best fit for the program.

4.2.1. Written documentation of eligibility verification, signed by an authorized VA Staff, shall be obtained by Contractor as soon as possible for each Veteran referred for services under the contract for inclusion in the Veteran’s program file.

4.2.2. A list of authorized VA Staff for the contract shall be provided to Contractor upon award of the contract. VA Staff may be added or deleted from the list during the term of the contract at the discretion of VA Contracting Officer.

Contractor shall be provided an updated list of authorized VA Staff whenever such changes are made.

4.2.3. It is understood that the type of Veterans to be cared for under this contract will require care and treatment services over and above the level of basic room and board. It is also understood that Veterans may need more intensive case management than the general population. The level of intensity of services required will be part of an ongoing conversation with Liaison. To be eligible for admission to the Enhanced Geriatric Services contract, all Veterans must be homeless and be eligible and registered for VA healthcare services. While the contract is intended for Veterans over age 50, Liaison may grant admission to Veterans under the age of 50 based on needs and acuity. Contractor may provide services to Veteran populations, such as but not limited to the following: medically compromised Veterans, Veterans with cognitive disorders, geriatric Veterans, Veterans with sex offender status, Veterans who may have a mental illness, Veterans who have abused drugs or alcohol for many years, and/or Veterans who have been involved with the legal system.

4.2.4. If applicable, at least quarterly, the contractor will reconcile data with the COR/Liaison to determine that status of all vouchers. This includes any vouchers that are being used by Veterans who have graduated from the program.

4.2.5. Voucher Reconciliation with Santa Clara County (If applicable): At least quarterly, the contractor will reconcile data with the COR/Liaison to determine that status of all vouchers. This includes any vouchers that are being used by Veterans who have graduated from the program.

4.3. Denial of Services: Unless determined clinically appropriate by VA liaison, Veterans cannot be denied based solely upon length of current abstinence from alcohol or non-prescribed controlled substances, active use, the number of previous treatment episodes, the time interval since the last program entry, the use of prescribed controlled substances, disability, income, gender, or legal history. The screening process must consider each of these special circumstances and determine whether the program can meet the individual Veteran's needs while maintaining the program's safety, security, and integrity. Contractor must employ a harm reduction approach. Contractor will provide verbal and written notification that is readily accessible to all individuals including VA liaison, upon request, of reasons for non-acceptance.

4.4. Absences and Missing Persons: Contractor shall notify the VA of unauthorized/unscheduled absences and/or scheduled absences within 24 hrs. of Veteran’s absence. All scheduled and unscheduled absences will be clearly documented on the daily sign in log, including reason for any scheduled absence (e.g. medical needs).

4.4.1. Absences: Authorized scheduled absences will be logged on the attendance log. Authorized absences must meet the following conditions:

(a) be pre-planned, consistent with and support the Veteran’s individual service plan (e.g., family reunification, short term medical, substance use disorder (SUD) or psychiatric treatment), (b) have a reason that is documented in the individual Veteran’s case file, treatment record, or service plan.

4.4.2. Unscheduled absences: For unscheduled absences, the absence is logged on the attendance log and the following conditions are required to be met: (a) Contractor must notify the VA liaison of the absence and document the absence on the sign in log. Contractor must provide active outreach efforts to locate and reengage the Veteran. Efforts to locate the Veteran will be documented in the Veteran’s individual case file, treatment record, or service plan, (b) Contractor will discuss discharge of Veteran if there is reason to believe the Veteran will not return to the facility and will follow appropriate housing procedures. At least three attempts to locate the Veteran will occur with all unscheduled absences.

4.4.3. During intake, the emergency contact information must be acquired from Veteran and a discussion of whom Veteran will go to if they leave their unit without notifying staff. This information needs to be documented in Veteran’s file for reference in case of emergency or missing persons. Contractor is required to do daily check ins. During check in, Contractor shall notify VA Liaison of any Veteran unplanned absences within 24 hours or at next check

in. For High-Risk Veterans (Veterans which high cognitive deficits and/or high safety concerns), if the Veteran is absent after 4 hours (and/or as clinically determined by discussion with VA liaison), a missing person’s report will need to be filed and VA liaison notified.

4.4.3.1. Missing Persons: For Veterans determined to be High Risk, if Veteran has an unplanned absence for over 4 hours from last check in (and/or as clinically determined by discussion with VA liaison) and all efforts to locate Veteran are unsuccessful, Contractor must file a missing person’s report immediately and then notify the VA Liaison. For all other instances, with absences over 24 hours, efforts should be made by Contractor to locate Veteran. Efforts will include contacting Veteran and the Veteran emergency contact, VA Liaison, calling local jails, and contacting local hospitals. If every effort to locate Veteran has been unsuccessful, a missing person’s report is expected to be filed.

Contractor is expected to attempt and document at least 3 attempts to locate Veteran over the next 72 hours.

4.4.4. Contractor shall notify the authorizing VA facility immediately of any Critical Incidents involving Veterans participating in the Enhanced Geriatric Services program. Contractor shall notify VA liaison by telephone or email during the hours of 8:00am and 4:30pm. For all Critical Incidents that occur after normal business hours, Contractor should notify the HCHV Staff the following business day. Contractor shall provide the HCHV case manager and the COR with a copy of the Critical Incident report within 24 business hours after incident. Contractor shall maintain a copy of the Critical Incident report in Veteran’s case record. Please see Case Management Services for details regarding what constitutes Critical Incident reporting.

Contractor will support Veteran with any admission documentation, referral and transportation issues that may arise.

4.4.5. VA reserves the right to discontinue any or all Veterans from the program at any time, without additional cost, when it is determined to be in the best interest of the VA or Veteran.

4.5. Basic Rights and Protection Against Discrimination: Contractor must protect the rights and dignity of Veteran in all phases of service delivery. At a minimum, Contractor must afford each Veteran the following rights and protections. Veterans must be permitted to exercise these rights without fear of reprisal.

4.5.1. Veterans are entitled to enjoy a safe and healthful environment in the program.

4.5.2. Veterans are entitled to be treated in a manner that respects their dignity, privacy, and individuality.

4.5.3. Veterans with disabilities are entitled to reasonable accommodations under Fair Housing laws when such accommodations are necessary because of their disability.

4.5.4. Veterans are entitled to remain in the program and not be involuntarily removed without reasonable notice, good cause, and just procedures.

4.5.5. Veterans are entitled to reasonable privacy and confidential treatment of personal, social, financial, medical, mental, and behavioral health records, except as necessary to further treatment, information and referral services and in compliance with the Veteran’s consent to release information.

4.5.6. Veterans are entitled to the full exercise of their civil, constitutional, and legal rights.

4.5.7. Veterans will have on-going opportunities to voice opinions, to participate in program operation and programming, and to make suggestions regarding programming and rules.

4.5.8. Veterans’ rights must be protected against all forms of discrimination, including those based on race, religious creed, color, national origin, ancestry, language, disability (physical or mental health), medical condition, marital status, familial status, age, gender, sexual preference, source of income, or political affiliation.

4.5.9. Veterans will receive a written policy indicating that harassment of clients and staff on the basis of race, religious creed, color, national origin, ancestry, language, disability (physical or mental health), medical…