VA263-17-R-1093-001.docx

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1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

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.

DUNS:

DUNS+4:

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 X

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. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

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

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

VA263-17-R-1093

Rosemary Malchow 651-293-3030 05-31-2019 Department of Veterans Affairs Network Contracting Office 23 Attn: Arlene Jorgensen Hillestad, CO 316 North Robert Street, Suite 506 St. Paul MN 55101 X 623110 $27.5 Million X N/A X Department of Veterans Affairs Network Contracting Office 23 316 North Robert Street, Suite 506 Attn: Rosemary Malchow, CS St. Paul MN 55101 Department of Veterans Affairs Network Contracting Office 23 Attn: Rosemary Malchow, CS 316 North Robert Street, Suite 506 St. Paul MN 55101

Y Department of Veterans Affairs Financial Services Center PO Box 149971 Austin TX 78714-9971 See CONTINUATION Page This is a MEDICARE solicitation for VISN 23 nursing home indefinite delivery indefinite quantity (IDIQ) contracts.

As a result of this Request for Proposal (RFP), the government anticipates awarding single or multiple IDIQ contracts.

USC 37.17-20 Authority for nursing home services(MEDICARE).

The list of requirements by State and County are in Section E.1 Instructions to Offerors.

$0.00 See CONTINUATION Page 1358 and medical services funds at time of awards.

X X X Arlene Jorgensen Hillestad Contracting Officer Table of Contents

B.3 SCHEDULE OF ITEMS - MEDICARE…………………………………………………..…13

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) – MEDICAID...................p. 33 D.2 WAGE DETERMINATION 01-10-2018………………………………………….…...…p. 37 List of Attachments: (See attached documents on FBO.gov and download a copy) See attached document on FBO: S02 RUGs IV Descriptions.

See attached document on FBO: Technical Capability Checklist - Medicaid 02.

See attached document on FBO: S02 MEDICARE PRICE SCHEDULE.

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:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C618 Department of Veterans Affairs Network Contracting Office 23 Attn: Arlene Jorgensen Hillestad, CO 316 North Robert Street, Suite 506 St. Paul MN 55101

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

3. INVOICES: Invoices shall be submitted in arrears:

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.

Department of Veterans Affairs Financial Services Center PO Box 149971 Austin TX 78714-9971

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

VA263-17-R-1093

Page 1 of Page 1 of

B.2 NURSING HOME PERFORMANCE WORK STATEMENT (PWS) –

MEDICARE

A. Overview

1. Federal Acquisition Regulation (FAR) – Indefinite Delivery Indefinite Quantity Contract (IDIQ). In accordance with FAR 16.504, Indefinite-Quantity Contracts, this is a IDIQ with five (5) yearly ordering periods starting with the date of award with a 6-month option to extend at the sole discretion of the Government.

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 authorized representative, the Contractor shall furnish all supplies and services herein described, at the per diem rates at the “Levels of Care” specified in the Schedule of Items of this IDIQ. The VA “Levels of Care” are defined in an attachment in Section D.1 of the solicitation and the IDIQ. VA is obligated only to the extent authorized placement of patients is made in accordance with this IDIQ.

3. Ordering. Orders will be issued by Ordering Officers to place Veterans in Nursing Homes, often on a sole source basis using an Exception to Fair Opportunity and utilizing the CPRS system and Standard Form 10-7078 at VA hospital sites (Reference FAR 16.505 (b)(2)(i)(B)). Ordering Officer Contact information is as follows:

Ordering Officer Name:

Address

Telephone number

E-mail address

Facsimile number

Agency task and delivery order ombudsman is included below (see 16.505(b)(8)) since multiple awards are being made. 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. 16.504(a)(4)(v).

The VA Ombudsman for task/delivery orders is the Associate Deputy Assistant Secretary (ADAS) for Procurement Policy, Systems, and Oversight (PPSO). The address and e-mail address for the Ombudsman follows:

Department of Veterans Affairs ADAS for Procurement Policy, Systems, and Oversight Risk Management and Compliance Service 810 Vermont Avenue, NW Washington, DC 20420 e-mail: VARiskManagement@va.gov

Note: Ordering officers will be authorized to place orders against this contract. The Contracting Officer will furnish the Contractor with the names of individuals authorized as ordering officers, by separate memorandum upon issuance of the contract. When ordering officers are added after award, the Contracting Officer will furnish the Contractor with the names of individuals authorized as ordering officers, by memorandum upon ordering officer appointment. Ordering officers are responsible for issuing and administering orders placed under this contract. Ordering officers have no authority to modify any term of this basic contract. Any deviation from the terms of the basic contract must be approved in writing by the Contracting Officer responsible for this contract. The Contractor shall accept orders against this contract only from the Contracting Officer and/or authorized ordering officers. Fulfilling orders from persons other than the Contracting Officer or ordering officer may result in loss or delay in payment for supplies/services provided under such orders.

4. Referrals to CNHs and placements. VA acknowledges that, depending on the availability of resources at specific IDIQ holder facilities at specific times, acceptance of a referral may be commercially impracticable for the IDIQ holder. In that event, the IDIQ holder may decline to accept an authorization. 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 an authorization will be issued when a match is found.

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 in accordance with the terms and conditions stated herein to the U.S. Department of Veterans Affairs [Site] Health Care System, in [City, State] 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. 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 Veteran is rendered.

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 Veterans. 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 and annual and ongoing quality reviews. See VHA Handbook 1143.2, “VHA Community Nursing Home Oversight Procedures (June 4, 2004) a copy of which is available at: http://www.va.gov/vhapublications/publications.cfm?pub=2. 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 (The CNH also must be able to accept VA referrals within 24 hours of request). Primary care/provider (medical doctor, nurse practitioner, and/or physician assistant) visits will be available at the Medicare frequency requirements. Laboratory, x-ray, and other special services will be available to Veterans 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. Authorized VA representatives will provide quality oversight visits to Veterans to assure satisfaction, quality, and continuity of care and may assist in the Veterans’ transition back into the community. These visits do not substitute nor relieve the CNH in any way of the responsibility for the daily care and medical treatment of the Veteran. The per diem rate(s) established in this IDIQ will include the cost of nursing care, room and board, meals, primary medical care which includes provider visits, 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 Veterans to achieve and maintain independence in the activities of daily living. Each Veteran must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

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

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

4. Medicare-Based Rates. The Resource Utilization Grouping (RUG) rate(s) will include the cost of medical care, medications, laboratory, x-ray, therapy (ies), and other special services authorized by VA, unless otherwise specifically exempted (Refer to Table A in the schedule of items). VA will contract for appropriate Medicare categories of care using Resource Utilization Groups (RUGs-IV) as a reference. A description of the RUGs-IV systems can be found in 42 CFR Parts 409, et al.

5. Medicare Rate Determination. The per diem rate is determined by the Medicare based approved rates including the cost of supplies, services, and equipment that is provided under 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) and end of therapy (EOT) assessments. Classification changes will be approved by VA, 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 (usually section Z) 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 Veteran care; arranging easy access to 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 will be individual therapy, rather than group therapy, unless otherwise ordered by the authorizing VA facility. Therapy evaluation must be completed and sent to the VA CNH office for approval of services. 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 Veteran’s disability or dysfunction and designed to specifically address each problem identified in the evaluation; design of a plan of care addressing the Veteran’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 Veteran 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 CNH physician’s orders. 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 MPLS VA HCS Home and Community Care Department at 612-467-3824. 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 VA and compliance with these requirements.

12. Corrective Action Plan (QASP Indicator #2): The CNH will cooperate with timely development of Corrective Action Plans (CAPs) related to identified deficiencies and related to State, 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.

13. Life Safety Code. The CNH’s building shall conform to the most recent standards of the Life Safety Code (National Fire Protection Association Standard) in effect on the date of the IDIQ award and compliance with all applicable Federal, State and local regulations. The administrator of the CNH is required to notify the VA Contracting Officer 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 which were in existence at the time this IDIQ became effective. The VA Contracting Officer will notify the VA Safety Manager responsible for the Life Safety Code inspection of the CNH and he/she will review (inspect the facility if required) the proposed changes and provide necessary approval or disapproval of the CNH to house veterans during and/or after the proposed changes. These changes may include but are not limited to:

a. Interior changes requiring VA notification. Some examples of facility changes that require the VA Contracting Officer notification are as follows: interior finish, corridor partitions/walls, patient room doors, linen or trash chutes, exits, emergency lighting, fire alarm systems, automatic sprinklers, smoke barrier walls or doors, oxygen systems, compressed gas storage, HVAC, electrical and fuel gas systems;

b. Automatic sprinkler system. All VA contracted CNH facilities are to be fully-equipped with a fully-automatic sprinkler system installed in accordance with the National Fire Protection Association’s (NFPA) standards and be 100% sprinkled; (notably the NFPA standard may change so sprinkler system could require updating).

c. Natural disasters. In the event of a natural disaster (flood, tornado, etc.), the CNH shall communicate all action plans to VA. The action plans will at a minimum identify temporary transfers of location, dates, and names of Veterans transferred; and

d. Major construction; additions; and renovations. SHALL MEET latest NFPA Life/Safety Code requirements as well as any additional VA CNH construction standards in place at time of renovation or alteration.

14. Acceptable Safety and Sanitation Practices. Acceptable safety and sanitation practices shall be observed throughout the facility. The CNH will address employee and Veteran 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 to 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 Health Care System (VAHCS), 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 Veteran to a non-Federal facility. If hospitalization of a non-emergency nature is required, readmission to a VA Health Care System may be accomplished as soon as the Veteran’s condition is sufficiently stabilized to permit admission to a VAHCS.

b. In the event of 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 Veteran’s personal effects. The funds, deposits, and effects left by the VA Veterans 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 Veterans, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.

c. Should a deceased Veteran 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 itemized inventory with annotation as to the disposition of the funds and effects of any such property and funds in its possession to the VA facility of jurisdiction 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 nursing home records for five (5) years when there is no requirement in State law.

16. Bed-Hold Policy for hospitalizations and approved therapeutic passes.

Hospitalizations do not require a pre-authorization, but VAHCS must be notified as soon as possible (no later than one business day after hospitalization). Therapeutic passes are to be limited and pre-authorized by the VAHCS.

a. HOSPITALIZATIONS The VAHCS will select one of the following options:

1. Two days per hospitalization reimbursed at the current per diem rate.

2. The first two days of hospitalization reimbursed at 70% of current per diem rate.

3. According to the prevailing State Medicaid guidelines at the bed hold rate determined by the State.

b. THERAPEUTIC PASSES (pre-authorized only) The VAHCS will select one of the following options:

1. Two days per month, reimbursed at the current per diem rate. More than 2 days per month must be pre-approved by VAHCS.

2. Two days per month, reimbursed at 70% of the current per diem rate.

Bed-hold begins the date the Veteran departs the CNH and the current per diem rate resumes the date of readmission. Absences of fifteen (15) consecutive days requires the VAHCS to discharge the Veteran from the current CNH authorization. A new authorization is required upon readmission to a CNH. The CNH is responsible to notify the Veteran / family of any financial responsibility for bed hold days not paid by the VA, arrangements may then be made between the Veteran / family and the CNH beyond the VAHSC authorized (two) days.

17. Reportable Events (QASP Indicator #3). VA requires CNHs to report to the CNH Coordinator at VA any of the following events within 24 hours or immediately the first business day after a weekend or holiday: 1) sentinel events; 2) substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH Veterans or property; 3) elopements of CNH Veterans pursuant to state regulations; 4) infectious outbreaks; 5) resident to resident or resident to staff altercations involving a CNH Veteran resulting in any injury that is other than minor; 6) copies of annual surveys or substantiated complaint investigations conducted by a State oversight agency; and 7) adverse events. Reporting shall include date of occurrence and Veteran disposition and outcome. Other Reportable Events that should be reported timely, but not necessarily immediately are: 1) when there is a change of nursing home administrator or Director of Nursing/Director of Nursing Service; or 2) when there is a pending change of ownership of the CNH.

A sentinel event may include, but is not limited to the following: 1) a fall resulting in death or injury; 2) elopement resulting in a missing resident; 3) resident abuse confirmed or under suspicion; 4) a medication error resulting in resident illness or injury; 5) death or resident injury related to restraint (including side rails) use; or 6) death related to an unconfirmed or suspicious cause. When an adverse event occurs involving a CNH Veteran which is not determined to be a Sentinel Event (but that the State requires that the occurrence be reported to the State), such event is also to be reported to VA’s CNH program office. Some adverse events, such as minor medication errors without catastrophic outcomes, are managed by the CNH in the context of their quality improvement programs. It is not necessary for nursing homes to report such incidents to the CNH program office.

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:

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 #4). All medical records concerning the Veteran’s care in the CNH will be readily accessible to VA. Upon discharge or the death of a Veteran, medical records will be retained by the CNH for a period of at least five (5) years following termination of care. Veteran 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 Veteran, 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 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 or ophthalmology).

[THE FOLLOWING PARAGRAPH SHOULD BE TAILORED AT TIME OF AWARD TO SUIT EACH SITE:]

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 (Phone#) 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 Phone #:

For non-emergency consultation or /evaluation for admission to the [FACILITY NAME]VA Health Care System (after initial evaluation or intervention by the nursing home physician).

(c) After hours, weekends and holidays: For urgent referrals or consultation contact the Admission Conference Call System number [PHONE #].

(d) 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. For clinic appointments, call [PHONE #].

22. Charitable Contributions. The CNH will not solicit contributions, donations, or gifts from Veterans 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 after generation of Medicare RAI/MDS RUG Scores and not later than 30 days following the end of the month in which services were rendered. The CNH will promptly notify the VA CNH program 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 Veteran’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 whenever it is found that the original invoice was not correct. All corrected invoices must include all items that are affected by the change.

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 Veteran enters the CNH but not the day the Veteran 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 is obtained from the VA facility authorizing placement. The Veteran, 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 insure the service is not covered by VA, then make arrangements with Veteran / family for private pay.

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

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

Non-VA Payment (routing# 17A-2) MPLS VA Health Care System 1 Veterans Dr.

Mpls, MN 55417

The contractor, their personnel, and their subcontractors 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.

END PERFORMANCE WORK STATEMENT

B.3 SCHEDULE OF ITEMS - MEDICARE

1. Rate Determination: The VA is seeking preferred rates, based on patient care need. VA rates are an all inclusive per diem rate. Items generally included or excluded in the per diem rate are listed in Table A, although some variances may apply in coverage. The per diem rate(s) will apply throughout the term of this Indefinite Quantity Contract (IDIQ). While the VA uses Medicare or State Medicaid rates as a reference, VA rates are independent of those payment systems and governed by the terms of this IDIQ. The per diem rate utilizes the Medicare RAI/MDS assessment and RUGS score as the reference for rates. Assessment schedules identical to Medicare will be used; in addition, the VA reserves the right to request a resident re-assessment at any time during the coverage period.

2. Rate Adjustments: Rate adjustments are made in accordance with the proper State agency regulatory standard and in accordance with the IDIQ as mutually agreed upon by both parties. Rate adjustments are not effective until the IDIQ modification is signed by both the Contractor and the VA Contracting Officer. The effective date of the rate adjustment will be the actual “Effective Date” as indicated on the IDIQ or the modification.

Table A

Pre-approval required (Paragraph 3) of this Schedule of Items

Pre-approval required (Paragraph 3) of this Schedule of Items

Pre-approval required (Paragraph 3) of this Schedule of Items

Pre-approval required for additional visits

Paragraph 4 of this Schedule of Items

Durable medical Equipment

Specialized beds

Hospice Care

Dialysis

Transportation

UC/ER visits

Hospitalizations

Psychology Services

TPN/IV Therapy

Dental Care

Audiology Care

Eye Care

Custom Prosthetics

Specialized Wound Care

See Paragraph 5 of this Schedule of Items

See Paragraph 6 of this Schedule of Items

3. Rehabilitation Therapy: Any type of rehabilitation therapy (physical therapy, occupational therapy, speech therapy, etc) requires the pre-approval of the VA before the initiation of therapy.

4. Medications: All Medications administered to VA-contracted Veterans residing in a CNH will be charged according to Average Warehouse Price (AWP) or the State Medicaid rate or Pharmacy bill, whichever is less. Medication costs up to 8.5% of billed care are included in the RUG rate pricing. Medication costs which exceed 8.5% of the monthly per diem will be billed as a separate line item in addition to the applicable RUG rate(s). All calculations will be made on a monthly basis. When a patient’s medication costs are determined to be in excess of the 8.5%, the VA must be promptly alerted to establish an appropriate course of action. This course of action may include the VA providing medication(s) to the CNH for the contracted Veteran or requiring an acceptable alternative medication be substituted. If for any reason the VA provides patient medications, the rate of reimbursement will be decreased by an agreed upon amount. The VA also 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.

5. 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 CNH only maintains private rooms; no double-occupancy rooms are available; and for ventilator-dependent patients with prior-negotiated rates.

6. Ventilator Care: Veterans requiring the use of a ventilator will only be placed in a CNH-trained and equipped for those types of specialty patients. The CNH must be inspected and approved by the VA prior to any placements in the ventilator-designated room. Rates for ventilator care will be detailed in the rate table and will be an all-inclusive per diem rate (including ventilator and supplies).

7. Specialized Prosthetics Equipment (e.g., special bed and/or bariatric equipment): Veterans may be eligible for specialized equipment when clinically indicated. Pre-approval required by VA.

8. Minimum and Maximum Amounts for this IDIQ. An administrative fee of $50.00 will be obligated at the time of contract award. The maximum amount for this IDIQ shall not exceed $10 million dollars.

9. Economic Price Adjustment. Medicare pricing changes by law annually, and rate modifications are accomplished under the contract by bilateral modification.

SECTION C - CONTRACT CLAUSES

C.1 52.216-18 ORDERING (OCT 1995)

(a) Any supplies and services to be furnished under this contract shall be ordered by issuance of delivery orders or task orders by the individuals or activities designated in the Schedule. Such orders may be issued from the effective date of the contract through the end of the effective period.

(b) All delivery orders or task orders are subject to the terms and conditions of this contract. In the event of conflict between a delivery order or task order and this contract, the contract shall control.

(c) If mailed, a delivery order or task order is considered "issued" when the Government deposits the order in the mail. Orders may be issued orally, by facsimile, or by electronic commerce methods only if authorized in the Schedule.

(End of Clause)

C.2 52.216-19 ORDER LIMITATIONS (OCT 1995)

(a) Minimum order. When the Government requires supplies or services covered by this contract in an amount of less than $50.00, the Government is not obligated to purchase, nor is the Contractor obligated to furnish, those supplies or services under the contract.

(b) Maximum order. The Contractor is not obligated to honor—

(1) Any order for a single item in excess of $10 million dollars;

(2) Any order for a combination of items in excess of $10 million dollars; or

(3) A series of orders from the same ordering office within 30 days that together call for quantities exceeding the limitation in paragraph (b)(1) or (2) of this section.

(c) If this is a requirements contract (i.e., includes the Requirements clause at subsection 52.216-21 of the Federal Acquisition Regulation (FAR)), the Government is not required to order a part of any one requirement from the Contractor if that requirement exceeds the maximum-order limitations in paragraph (b) of this section.

(d) Notwithstanding paragraphs (b) and (c) of this section, the Contractor shall honor any order exceeding the maximum order limitations in paragraph (b), unless that order (or orders) is returned to the ordering office within 30 days after issuance, with written notice stating the Contractor's intent not to ship the item (or items) called for and the reasons. Upon receiving this notice, the Government may acquire the supplies or services from another source.

(End of Clause)

C.3 52.216-22 INDEFINITE QUANTITY (OCT 1995)

(a) This is an indefinite-quantity contract for the supplies or services specified, and effective for the period stated, in the Schedule. The quantities of supplies and services specified in the Schedule are estimates only and are not purchased by this contract.

(b) Delivery or performance shall be made only as authorized by orders issued in accordance with the Ordering clause. The Contractor shall furnish to the Government, when and if ordered, the supplies or services specified in the Schedule up to and including the quantity designated in the Schedule as the "maximum." The Government shall order at least the quantity of supplies or services designated in the Schedule as the "minimum."

(c) Except for any limitations on quantities in the Order Limitations clause or in the Schedule, there is no limit on the number of orders that may be issued. The Government may issue orders requiring delivery to multiple destinations or performance at multiple locations.

(d) Any order issued during the effective period of this contract and not completed within that period shall be completed by the Contractor within the time specified in the order. The contract shall govern the Contractor's and Government's rights and obligations with respect to that order to the same extent as if the order were completed during the contract's effective period; provided, that the Contractor shall not be required to make any deliveries under this contract after the end of the contract period.

(End of Clause)

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

The Government may require continued performance of any services within the limits and at the rates specified in the contract.