VA263-17-R-1093-002.docx

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Technical Capability Checklist Open and Continuous Solicitation No. VA263-17-R-1093 (Medicare)

Nursing Home Name: _____________________________ County and State: _______________ A. Technical Capability – Technical capability to meet the Government’s requirements:

1) Regulatory and Compliance. Nursing home facility will meet all Federal and State regulatory requirements and industry practices, as applicable, and be in compliance with such regulations and standards.

(*Please respond to the criteria below by circling “yes” or “no”; provide brief, detailed explanation for any answer.)

a. Facility is in compliance with most recent standards of Life Safety Standards – National Fire Protection Association Standard and applicable Federal, State and local regulations.

Yes / No ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b. Facility must be 100% sprinkled and can demonstrate evidence of this fact upon request.

Yes / No ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

c. Facility has current Center for Medicare and Medicaid Services (CMS) certification (Medicare and/or Medicaid) and State license.

Yes / No ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

d. Facility has Medical Liability Insurance/Professional Liability Insurance at the minimum level as required by the State and VAAR 852.237-7, Indemnification and Medical Liability.

Yes / No ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

e. Facility meets 3 or less of 7 exclusionary criteria related to VA quality of care standards as outlined in VHA Handbook 1143.2, “VHA Community Nursing Home Oversight Procedures” (June 4, 2004) as evidenced by the latest CMS survey.

*Note: For the following state averages, see the Nursing Home Compare website: http://www.medicare.gov/NHCompare/Include/DataSection/Questions/ProximitySearch.asp?bhcp=1 **Note: For facilities meeting 4 or more of the exclusionary criteria, VISN 23 has established a waiver review process for facilities in geographic/rural areas with scarce resources or needed specialized services.

i. Three (3) level “G” or worse deficiencies in the current survey; reference CMS Nursing Home Compare Standard: Score of 3 or higher.

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ii. Total number of health deficiencies are twice the State average in current survey; reference CMS Nursing Home Compare website.

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

iii. A level “E” or higher deficiency in the current survey in one of the following areas: Restraints (Federal Tag, F221 or F222); Abuse – F223; Staff Treatment of Patients (includes background check) – F225 or F226; Dignity – F241; or, Licensure – F491; reference CMS Nursing Home Compare Standard: Fails when score of 2 or higher in any measure.

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

iv. RN hours per resident day are below the State average; reference Nursing Home Compare website (Please supply your average___, to be compared with your State’s average, as applicable);

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

v. Total nursing hours per resident day are below the State average; reference Nursing Home Compare website. Please supply your average___, to be compared with your State’s average, as applicable);

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

vi. A level “E” or higher deficiency in the current survey in one of the following areas: Nursing Services – F353; Nursing Aide Training – F494 or F495 or F496; Regular In-Service Training – F497; Proficiency of Nursing Aides – F498; or Staff Qualifications – F499; reference CMS Nursing Home Compare Standard: Fails when score of 2 or higher found in any measure;

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

vii. Six (6) or more of the CMS Quality Measures listed in the Nursing Home Compare website fall above the State average; reference CMS Nursing Home Compare Standard: Fails when six or more CMS Quality Measures listed are greater than State average.

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Quality Control. Nursing home facility demonstrates, if applicable, that its remedial actions meet standards and are accepted by State licensing and certification officials to promote acceptable quality of care for veterans.

a) Facility can show upon request evidence that its latest plan of correction, if applicable, is approved by the State for any pending deficiencies.

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Management Approach. Nursing home will demonstrate timely access to care and resources.

a) Facility has bed capacity to ensure their ability to take referrals when requested (i.e. Long-Term Care beds) Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b) Facility is able to accept VA referrals in a timely fashion (VA standard is within 24 hours of request).

Yes / No ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signed by Administrator or ______________________________

Signature: _______________________________ Date: _____________ Printed Name: ___________________________