Q--CNH Martinsburg - Virginia counties
Department of Veterans Affairs, VA Maryland Health Care System | Published September 8, 2015 - Deadline September 14, 2015
Nursing Home Performance Work Statement (PWS)
1. TERM OF CONTRACT:
a. Federal Acquisition Regulation (FAR) - Basic Ordering Agreements. In accordance with FAR 16.703, Basic Ordering Agreements, this is a Basic Ordering Agreement (BOA) for the time period of (1 year) from date of award plus (4) one year options. A contract is formed, in accordance with the terms and conditions of this BOA, when the Department of Veterans Affairs (VA) agrees to place a patient in the Community Nursing Home (CNH) and the CNH agrees to accept the patient. Upon acceptance by the Contractor of beneficiaries of VA, all clauses and terms and conditions of this BOA shall apply and become a part of the resultant contract during such time as a VA patient remains in that CNH at the expense of VA.
b. Orders. VA personnel designated in writing will issue written authorizations for Veterans to the contractor. Location primarily will be selected based on the Veteran's needs and proximity to the Veteran's home.
c. A BOA shall be changed only by modifying the agreement itself and not by individual orders issued under it. Modifying a basic ordering agreement shall not retroactively affect orders previously issued under it. See FAR 16.703(c)(2).
d. 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 for the services specified on the MEDICARE PRICING Table in the Schedule of Items of this BOA. VA rates are generally based on CMS RUGs rates. See Section D.1 (Contract Documents, Exhibits or Attachments) for RUGs Descriptions. VA is only obligated to pay for patients that are placed in accordance with this BOA.
a. The services specified in the Sections entitled Schedule of Supplies/Services and Special Contract Requirements may be changed by written modification to this contract. The services to be performed by the contractor will be performed in accordance with VA policies and procedures and the regulations of the medical staff by laws of the VA facility.
a. 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 VA Martinsburg Health Care System, in Martinsburg, WV at the prices specified in the section titled Schedule of Items of this BOA. 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 provide care. The term, "facilities," shall include but not be limited to rooms, wards, sections, eating areas, drinking fountains, entrances, and other like areas. VA shall have the right to inspect the CNH and all appurtenances by authorized VA representative(s) to ensure that acceptable standards are maintained and that the necessary care to maintain the well-being of the patient is rendered.
DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK
1. Under the authority of Public Law 104-262 and 38 USC § 1720, the contractor agrees to provide Health Care Resources in accordance with the terms and conditions stated herein, to furnish to the Martinsburg Veterans Affairs Medical Center, the services and prices specified in the section titled Schedule of Items of this agreement. Nursing Homes in the CNH program shall ensure that care meets the health needs and promotes the maximum well-being of VA patients. Nursing home care will be furnished to ensure the total medical, nursing, and psychosocial needs of VA beneficiaries. Full attention shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care
2. All nursing homes in VA's CNH program must have current Center for Medicare and Medicaid Services (CMS) certification (Medicare and/or Medicaid) and must maintain a current and unrestricted state nursing home license. Changes in the status of the licensure will be immediately reported to the Martinsburg VA Medical Center Home and Community Programs at 304-263-0811 ext. 3268. The CNH also must report immediately to the Martinsburg VAMC the following conditions:
(a) De-certification for Medicare and Medicaid Programs;
(b) SSA findings of CNH not in substantial compliance with standards
3. 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 Martinsburg VA Home and Community Care Department at 304-263-0811 ext. 3268. 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 VA patients. The CNH shall provide VA with copies of all State agency reports when requested, and cooperate fully with VA's quality improvement or quality assurance program functions, 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.
a. It is agreed that the CNH shall provide VA with copies of all state agency reports when requested, and cooperate fully with VA's quality improvement/quality assurance program functions relating to this agreement, 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.
4. 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
5. VA often has a particular need for specialty care services in the CNH program. The VA requires CNHs to have bed capacity to ensure their ability to take referrals when requested. The CNH also must be able to accept VA referrals in a timely fashion (ideally within 24 hours of request).
6. The nursing home shall accept referrals and shall provide all services specified in this contract for any person determined eligible by the VA Under Secretary for Health regardless of race, color, religion, sex or national origin of the person for whom such services are ordered.
7. Primary care/provider (medical doctor, nurse practitioner, and/or physician assistant) visits will be available at the rate of one (1) visit per month. Laboratory, x-ray, and other special services will be available to VA patients as needed. In addition, the care provided will include room, meals, nursing care, and other services or supplies commensurate with the VA-authorized level of care, without extra charge. Duly authorized representatives of VA will provide quality oversight visits to veterans placed to assure continuity of care and to assist in the veterans' transition back into the community. 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 BOA will include the cost of nursing care, room and board, meals, primary medical care, one (1) provider visit per month and needed consultation, drugs and routine supplies, laboratory, x-ray, and other special services authorized by VA, unless otherwise specifically excepted (see Schedule of Items in this BOA for details regarding per diem rates and coverage). Full attention shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care.
8. Primary Medical Coverage. The assigned CNH provider is the primary medical provider during the nursing home stay and is responsible for writing or approving admission and all other orders as soon as the veteran arrives at the CNH. The CNH provider is responsible for general medical care, urgent evaluation and intervention. Provider visits will be according to the Center for Medicare and Medicaid Services (CMS) guidelines. The assigned nursing home provider will provide timely care following the most current CMS guidelines; arranging 24/7 access for patient care; arranging easy access to 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). The CNH physician visits are part of the all-inclusive CNH rate.
9. Provider visits, laboratory, x-ray, and other special services for VA patients will be at the same frequency as that provided to other patients at the CNH receiving the same or comparable level of care. 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.
10. VA developed quality of care standards utilizing CMS inspection criteria that are followed by VA in its selection of nursing homes. See VHA Handbook 1143.2 which outlines threshold standards and VA exclusionary criteria that must be met which includes: evaluation of data provided by the Centers for Medicare and Medicaid's (CMS) On-Line Survey Certification and Retrieval System (OSCAR) and the Minimum Data Set (MDS) Nursing Home Quality Indicator (QI) Profile, and CNH staffing levels. These data elements are reported in CMS' Nursing Home Compare at http://www.medicare.gov/nhcompare/home.asp. Current quality measure and current individual MDS information will be made available by the contractor to the VAMC. The VA will use an exclusionary review tool developed by VHA. The standards of the exclusionary review state that a contracted community nursing homes are to be excluded from our program when they fail four of our(7) criteria. The failure criteria includes: (3) or more tags with an Oscar Level of G-L or the equivalent of scores of 3 or higher on Medicare compare; total health care deficiencies are greater than twice the state average; Oscar levels of E-L or nursing home compare scores of 2 or higher on any of the following tags: F221, F222, F223, F225, F226, F241 and F491; RN hours per resident per day are below the state average; total number of staffing hours are below the state average; Oscar levels E-L or nursing home compare scores of (2) or higher found under any of the following tags: F353, F495, F496, F497, F498, F499; and (4) or more CMS quality measures are greater than the state average.
11. 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. A sentinel event may include but is not limited to the following: 1) a fall resulting in death or injury; 2) elopement resulting in missing patient; 3) patient abuse confirmed or under suspicion; 4) medication error resulting in patient illness or injury; 5) death or patient injury related to restraint (including side rails) use; or 6) death related to unconfirmed or suspicious cause. 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
e. provide dates when corrective action will be completed.
12. In those cases of serious deficiencies affecting the health or safety of Veterans, or in cases of continued uncorrected deficiencies, VHA will take one or more of the following actions in accordance with the terms and conditions of the BOA and applicable procurement regulations:
a) Increase VA staffing monitoring until the state survey agency clears the deficiency;
b) Suspend placement of Veterans to the nursing home;
c) Remove or transfer Veterans under VA agreement from the nursing home;
d) Not renew the BOA;
e) Terminate the BOA.
13. Termination of Services. VA reserves the right to remove any or all VA patients from the CNH at any time when it is determined to be in the best interest of VA or the patients without additional costs to the Government.
14. Emergency Care; Financial Responsibility; Advanced Directives. In emergencies, nursing home staff will utilize the 911 local emergency systems for any resident. Advance directives/living wills shall be adhered to according to CNH physician's orders. While under VA contract, Service connected Veterans may qualify for VA coverage of emergency care provided by the Martinsburg VA Medical Center when contacted by the nursing home within 48 hours of being sent out via 911. This includes the cost of necessary transportation for such care.
15. 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.
16. Life Safety Code. The CNH's building shall conform to the most recent standards of the Life Safety Code (National Fire Protection Association Standard #101) in effect on the date of the BOA 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 BOA 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 approval. 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;
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. Major construction including building additions or other renovations which may affect physical plant integrity; SHALL MEET latest NFPA 101 Life/Safety Code requirements as well as any additional VA CNH construction standards in place at time of renovation or alteration.
17. Acceptable Safety and Sanitation Practices. Acceptable safety and sanitation practices shall be observed throughout the facility. The CNH will address employee and patient safety practices through staff orientation, training and adherence to related policy or procedures to provide a safe and clean environment.
18. Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veterans; CNH Responsibility to Veteran's Belongings or Personal Effects (QASP Indicator #3). VA beneficiaries who begin to require more than the level of care authorized by VA will be readmitted to an appropriate VA facility, as determined and authorized by VA.
a. When such an admission is not feasible because of the nature of the emergency, hospitalization in a non-Federal facility may be accomplished provided VA authorization is obtained. VA authorization must be obtained within 48 hours of admission of the patient to a non-Federal facility. If hospitalization of a non-emergency nature is required, readmission to a VA Medical Center may be accomplished as soon as the patient's condition is sufficiently stabilized to permit admission to a VA Medical Center.
b. In the event of a death of any veteran, the Contractor agrees to notify VA immediately of the death. In the event a death of a VA beneficiary while receiving nursing home care, the CNH will promptly notify the VA facility which authorized admission and immediately assemble, inventory, and safeguard the patient's personal effects. The funds, deposits, and effects left by the VA patients upon the premises of the CNH shall be delivered by the CNH to the person(s) entitled thereto under the laws currently governing the CNH for making disposition of funds and effects left by patients, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.
c. When disposition has been made, the itemized inventory with annotation as to the disposition of the funds and effects will be immediately forwarded to the VA facility authorizing admission. Should a deceased patient leave no will, heirs, or next of kin, his/her personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases, the CNH will forward an inventory of any such property and funds in its possession to the VA facility authorizing admission and will hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition. CMS regulations require retention of nursing home records for five (5) years when there is no requirement in State law.
19. Leave of Absence (LOA) - Bed-Hold Statement. To hold the CNH bed for the Veteran, VA may authorize up to 5 days while the Veteran is hospitalized; however, if the Veteran is not expected to return within 5 days, only if the VAMC is notified, will 48 hours of bed hold be granted. If the Veteran returns to the facility and the CNH places the Veteran under his Medicare, the CNH will not be eligible to receive a bed hold. The CNH physician may authorize a pass (days away from the nursing home) from the CNH according to the CNH policies for long-term placements. The leave must be part of a therapeutic plan and approved by VA. Leave days at VA expense are limited to two days within a calendar month. Leave days at VA expense are limited to 6 days per calendar year. Exceptions may be approved by the VA facility Geriatric and Extended Care designee
a. Bed-hold will begin the date the resident leaves the CNH and full per diem will only resume on the date of readmission to the CNH. Absences of fifteen (15) consecutive calendar days or more, whether in a VA or in a non-Federal facility require a new authorization from VA. The nursing home is responsible to notify the family if a bed hold is required for a longer period. The family would then make arrangements with the home to hold the bed. VA will reimburse the CNH 70% per day of the lowest RUG rate for bed hold and LOA.
20. Reportable Events (QASP Indicator #4). 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) when there is a pending change of ownership of the CNH; 3) when there is a change of nursing home administrator or Director of Nursing/Director of Nursing Service; 4) substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH veterans or property; 5) elopements of CNH veterans pursuant to state regulations; 6) infectious outbreaks; 7) resident to resident or resident to staff altercations involving a CNH veteran resulting in any injury that is other than minor; 8) copies of annual surveys or substantiated complaint investigations conducted by a State oversight agency; and 9) adverse events. Reporting shall include date of occurrence and patient disposition and outcome.
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 patient; 3) patient abuse confirmed or under suspicion; 4) a medication error resulting in patient illness or injury; 5) death or patient injury related to restraint (including side rails) use; or 6) death related to an unconfirmed or suspicious cause. 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.
21. VA Actions Regarding Serious Quality of Care Deficiencies. In cases of serious deficiencies affecting the health or safety of veterans or in cases of continued uncorrected deficiencies, 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 BOA from the subject CNH;
d. Terminate the BOA.
It is agreed that duly authorized representatives of VA will provide supervisory visits to Veterans placed to assure the continuity of care and to assist in the Veteran's transition back into the community. It is understood that these visits do not substitute nor relieve the nursing home in anyway of their responsibility for the daily care, medical treatment of the Veteran, and transitioning Veterans back into the community.
22. VA Staff Access to CNH Records (QASP Indicator #5). All medical records concerning the veteran's care in the CNH will be readily accessible to VA. The CNH is required to provide VA staff access to information in the electronic medical record of the Veteran if requested. Upon discharge or the death of a patient, medical records will be retained by the CNH for a period of at least five (5) years following termination of care. Patient records will be maintained in conformance with the Privacy Act of 1974 (5 U.S.C. § 552a). A medical record shall be maintained for each patient, which includes at least the following:
a. 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).
23. The VA beneficiary will be provided nursing home care at the expense of the VA for a period not in
excess of that stated in the nursing care and treatment plan received from the VA unless an extension
of the authorization is provided in writing by the placing VA facility. The authorization agreement, VA
Form 10-7078 will terminate whenever a VA patient is hospitalized for fifteen (15) calendar days or more, whether in a VA or in a non-Federal facility. A new authorization agreement will be required for the return of the patient to the CNH.
a. Level of Care Classification Effective Records: The level of care classification and associated per diem rate will remain in effect for each placement until and unless one of the following events takes place:
1. The recipient is discharged and subsequently qualifies for a new admission assessment.
2. The nursing home submits an assessment requesting a change in the level of care classification and VA approves it. Classification changes may also occur based on a determination by VA. VA will make the determination whether classification changes require re-admission to VA.
24. 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 BOA with the CNH;
3) Minimum Data Set (MDS) information
4) The plan of care and services including medication administration, provided by CNH staff and services provided under the BOA with the CNH;
5) Interdisciplinary progress notes to include effect of care provided, veterans' response to treatment, change in condition, and changes in treatment;
6) Medical practitioner orders which are signed and dated;
8) Person to contact in an emergency situation;
9) Name of attending medical practitioner; and
10) Advanced directives if available.
a. 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.
25. VA Health Care System Consultation/Resources. For assistance with VHA non-urgent clinic or specialty appointments/consultations, Admissions and transportation needs, please contact the VA Community programs office at 304-263-0811 ext. 3268 . For after hours assistance, please contact the VAMC Administrator on duty 304-263-0811.
26. Charitable Contributions. The CNH will not solicit contributions, donations, or gifts from patients or family members. Note: Established charitable fundraising activities of a CNH fall outside the scope of this language.
27. Minimum Quantities. It is impossible to determine the exact or estimated amount, which will be expended under this BOA. No obligation will be incurred by VA under this BOA, 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 BOA. VA will make payment for the day a recipient enters the CNH but not the day the recipient leaves a CNH unless entrance and departure are on the same day, then payment will be made for one (1) day.
28. 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. 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.
29. Medicare Rate Determination. The per diem rate is established by the current Medicare rate for Medicare- approved nursing homes including the cost of supplies, services, and equipment. Rates established after the Effective Date of this BOA will require a modification to the BOA. 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 BOA for details on rates). Any additional requests for payment to the all-inclusive per diem rates must be pre-approved.
30. 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 close of therapy (COT) assessments. Classification changes will be provided to and approved by VA, dependent on projection for short-term or long-term residence, and adhering to the most current MDS frequency guidelines from Medicare or as requested. The applicable per diem rate will continue until the next assessment. VA will make the determination whether classification changes require readmission to VA. This request should be submitted on the Level of Care Authorization Form provided to the facility. VA staff will audit approximately 20% of the MDS assessments.
The Level of Care classification and associated per diem rates will remain in effect for each placement until and unless one of the following events takes place:
a. Re-hospitalization that may be associated with a change in level of care;
b. Need for more intensive therapy;
c. Significant change in condition; or
d. Classification changes may also occur based on a determination by VA.
31. Rehabilitation Criteria. All therapy provided will be individual therapy, rather than group therapy, unless otherwise ordered by the authorizing VA facility. Therapy services requires pre-approval by VA before services are provided. Medical criteria will be used for physical therapy, occupational therapy, and speech therapy. Therapy must be skilled, related 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 skilled rehabilitative therapy services requiring the skills of a licensed therapist.
b. Evaluations/re-evaluations should consider the following: Establishment of treatment goals specific to the patient's disability or dysfunction and designed to specifically address each problem identified in the evaluation; design of a plan of care addressing the patient's disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment; continued assessment and analysis during implementation of the services at regular intervals; instruction leading to establishment of compensatory skills; selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short-term training on use of the device or system); and patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family should be ongoing.
32. VA Payments. Payments made by VA under any contract pursuant to this BOA, constitute the total cost of nursing home care. No additional charges will be billed to Medicare (with the exception of hospice), Medicaid, or private insurance, the beneficiary or his/her family, either by the CNH or any third party furnishing services or supplies required for such care, unless and until specific prior authorization in writing is obtained from the VA facility authorizing placement. The patient, family and any other entitlement programs (e.g., Medicare, Medicaid, etc.) will not be billed for uncovered services or costs during the VA contract period. This constitutes double-billing and Federal fraud.
33. CNH Billing (QASP Indicator #6). Invoices for board, care and ancillary services shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered. The CNH will promptly notify the VA CNH Coordinator and/or VA CNH staff regarding any change in Veteran status: discharge, transfer, against medical advice (AMA), hospitalization, death and/or any changes in payer source and any ability to complete timely billing.
All invoices must include the full name and address of the CNH and shall reflect the patient's name, social security number, number of days billed, dates of services, RUG category(ies), and agreed upon RUG rate (s). Failure to include this information may result in delayed payment. Invoices shall be sent on the UB-04 forms along with appropriate supporting clinical documentation to the Martinsburg VAMC Non VA Care (NVCC)/Fee 510 Butler Ave. Martinsburg, WV 25405
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: VHA community programs office should be contacted regarding Medications exceeding $1500 per month. Payment for these medications will require pre-authorization or may be provided by the VAMC. The contractor may be required to provide additional documentation regarding rationale for the prescription. The VA reserves the right to deny payment for medication when it is determined by the VA that the medication is of no clinical benefit to the Veteran and if VA preapproval was not requested and obtained prior to the administration of such medication.
c. Invoices: Corrected invoices must be submitted for additional payment of any ancillary costs or changes to the original billing. All corrected invoices must include all items that are affected by the change and should include the CNH corrected
END DESCRIPTION/SPECIFICATION/STATEMENT OF WORK