36C10G21R0018.docx

COMBINED SYNOPSIS / SOLICITATION 36C10G21R0018

Combined Synopsis/Solicitation Notice

SUBJECT* Request for Proposal (RFP) for Surveys of VA Community Living Centers (CLC) and State Veterans Homes (SVH).

GENERAL INFORMATION

USA

OPAL | Strategic Acquisition Center 10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

POINT OF CONTACT*

Contracting Officer Mr. Twillie L Curry III twillie.curry@va.gov

PLACE OF PERFORMANCE

ADDRESS See Attachment

COMBINED SYNOPSIS / SOLICITATION 36C10G21R0018

SEE ATTACHED COMBINED SYNOPSIS / SOLICITATION 36C10G21R0018

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SECTION A

A.1 COMBINED SYNOPSIS/SOLICITATION FOR COMMERCIAL ITEMS

Posted Date:

Original Response Date:

Current Response Date:

A.2 GENERAL INFORMATION

Contracting Office Address:

Office of Procurement, Acquisition and Logistics (OPAL) Strategic Acquisition Center (SAC) 10300 Spotsylvania Ave, Suite 400 Fredericksburg, VA 22408

Description:

This is a combined synopsis/solicitation for commercial services prepared in accordance with the format in Federal Acquisition Regulation (FAR) subpart 12.6, “Streamlined Procedures for Evaluation and Solicitation for Commercial Items,” as supplemented with additional information included in this notice. This announcement constitutes the only solicitation; proposals are being requested, and a written solicitation document will not be issued.

The associated North American Industrial Classification System (NAICS) code for this procurement is 541611, with a small business size standard of $16.5M.

This solicitation is a Request for Proposals (RFP). The solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular (FAC) 2021-05 published in the Federal Register on March 10, 2021.

Type of Contract:

The Government will award a single vendor a Firm-Fixed Price (FFP) Requirements Contract FAR 16.503.

Number of Contracts to be Awarded:

The Government intends to select one contractor for this acquisition. However, the Government reserves the right not to award a contract at all, depending on the quality of the proposals and prices submitted and the availability of funds.

All interested companies shall provide proposal for the following Surveys for Community Living Centers (CLC) and State Veterans Homes (SVH):

SECTION B

B.1 CONTRACT ADMINISTRATION DATA

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

a. CONTRACTOR: TBD

b. GOVERNMENT: Contracting Officer 36C10G U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center 10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

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.

U.S. Department of Veterans Affairs Financial Services Center

PO BOX 149971

Austin TX 78714-8917

5. FSC MANDATORY ELECTRONIC INVOICE SUBMISSION: Contractors are required to submit payment requests in electronic form in accordance with the submission instructions on next page.

TUNGSTEN ELECTRONIC INVOICE SUBMISSION

FSC e-INVOICE PROGRAM THRU AUSTIN PORTAL

FSC MANDATORY ELECTRONIC INVOICE SUBMISSION FOR AUSTIN PAYMENTS

Contracting POC: <insert contact info here> COR (Contracting Officers Representative): <insert contact info here> Contract/Task Order Number: <insert contract info here> Purchase Order Number: <insert purchase order info here>

a. Vendor Electronic Invoice Submission Methods:

Facsimile, e-mail, and scanned documents are not acceptable forms of submission for payment requests. Electronic form means an automated system transmitting information electronically according to the accepted electronic data transmission methods below.

1. VA’s Electronic Invoice 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 begin submitting electronic invoices, free of charge.

2. A system that conforms to the X12 electronic data interchange (EDI) formats established by the Accredited Standards Center (ASC) chartered by the American National Standards Institute (ANSI). The X12 EDI Web site (http://www.x12.org)

b. Vendor e-invoice Set-Up Information:

Please contact Tungsten at the phone number or email address listed below to begin submitting your electronic invoices to the VA Financial Services Center for payment processing, free of charge. If you have question about the e-invoicing program or Tungsten, please contact the FSC at the phone number or email address listed below.

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

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

3. FSC e-Invoice Contact Information: 1-877-353-9791

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

See https://www.fsc.va.gov/einvoice.asp for more information.

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

COMBINED SYNOPSIS / SOLICITATION 36C10G21R0018

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B.2 PERFOMANCE WORK STATEMENT

A. GENERAL INFORMATION

A.1.0 Title of Project: Surveys of VA Community Living Centers (CLC) and State Veterans Homes (SVH).

The Department of Veterans Affairs (VA) has established that a vendor shall conduct surveys at VA Community Living Centers and State Veterans Homes. The vendor shall utilize the Centers for Medicare and Medicaid Services (CMS) process with elements specifically established for State Veterans Homes according to federal regulations. The survey process shall be performed for each CLC and each SVH, and five (5) Spinal Cord Injury/Disorders (SCI/D) Long Term Centers at least annually according to the schedule outlined in the PWS.

The skill set required of the vendor personnel surveying CLCs includes long-term care surveyor experience or expertise to include either state or CMS survey experience in conducting surveys of nursing homes, Quality Measures (QM) generated by the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS); the ability to utilize and correlate CMS surveys to the operations of federally owned and operated CLCs. The selected vendor will conduct surveys and will require the qualifications necessary to review activities at nursing homes, and assure it operates within federal guidelines providing high quality care to residents and recommend areas to improve as necessary. Training credentials, licenses, and years of experience in clinical and life safety and National Fire Protection Association (NFPA) fire protection surveyor positions with emphasis on CMS expertise shall be included for all lead survey personnel.

The skill set required of the vendor’s personnel surveying SVHs includes long-term care surveyor experience or expertise to include either; state, or CMS survey experience in conducting surveys of nursing homes; Quality Measures generated by the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS); and the ability to utilize and correlate CMS surveys to the state owned and operated homes governed by Federal Regulations for nursing home, domiciliary and adult day health care programs. The selected vendor will conduct all types of surveys and will require the qualifications necessary to review activities at nursing homes, domiciliary or adult day health care programs and assure they operate within state and federal regulations providing high quality care to residents and recommend areas to improve as necessary. Training credentials, licenses and years of experience in clinical and life safety and National Fire Protection Association (NFPA) fire protection surveyor positions with emphasis on CMS expertise shall be included for all lead survey personnel. The vendor will be responsible for reviewing and scoring all clinical, §51.210, §51.390. §51.475 Administration, §51.480 Transportation, resident personal funds protected in §51.70(c)(1-6), obtain all required VA forms and life safety standards in 38 CFR Part 51: “Per Diem for Nursing Home, Domiciliary, or Adult Day Health Care of Veterans in State Homes. “The ratings per federal regulation are Met or Not Met. The associated survey forms for the nursing home, domiciliary and adult day health care programs are attached: Nursing Home Survey Report (Attachment A), Domiciliary Survey Report (Attachment B), and Adult Day Health Care Survey Report (Attachment C). The survey reports may be edited or altered through the course of this contract and provided to vendor by the GEC Program Office.

A.2.0 Background/Scope of Work

2.1 There are 135 VA CLCs and 5 SCI/D Long Term Centers across the United States and Puerto Rico. (Attachment D) Additional CLCs and/or SCI/D Long Term Centers may be added during the lifetime of this contract; any new CLCs and/or SCI/D Long Term Centers that are opened during the performance period will also need to be surveyed and will be added via bi-lateral modification of the task order. The CLCs offer an array of services including, but not limited to:

• short stay services such as hospice, respite, skilled nursing and rehabilitation;

• long stay services such as dementia care;

• care for veterans with spinal cord injury and disorders; and

• mental health recovery care for eligible veterans.

2.2 There are currently 158 State-Owned and Operated Veterans Homes across the United States; this includes all 50 states, territories, tribal lands and possessions of the United States, and the Commonwealth of Puerto Rico. (Attachment E) Additional SVHs may be added during the lifetime of this contract. The State-Owned and Operated Veterans Homes provide three levels of care to include nursing home care, domiciliary care, and adult day health care. The SVHs offer an array of services including, but not limited to:

· short stay services such as hospice and palliative care, skilled nursing and rehabilitation;

· long stay services such as dementia care;

· Wound care;

· Mental health services.

2.3 VA has a commitment to ensure the VA CLCs, SCI/D Centers and SVHs maintain high quality standards. VA has implemented the survey program modeled upon the CMS surveys to provide direct oversight of VA CLC and SCI/D care and to assess SVH compliance with title 38 CFR Part 51. The community standard of assessing level of performance against standards includes an annual survey by a state agency under the auspices of CMS. SVHs do not receive F-tags or K-tags.

2.4 The CMS survey process is specific to nursing homes. The CLC and SCI/D on site surveys are unannounced. The majority of SVHs are unannounced for annual and for cause but some are not. Both survey teams for CLCs, SCI/D and SVHs begin with offsite preparation including reviewing and studying the Quality Measures generated by the Resident Assessment Instrument/Minimum Data Set (RAI/MDS), last survey report, and any state survey report applicable to a CMS certified SVH and selecting the observation population prior to the survey based on this review. The facility 802 and Resident Roster are to be provided at the beginning of the survey. On site, or through a virtual modality, survey teams will focus on observation of direct care including but not limited to medication administration, actual care delivery, and resident and staff interviews, medical record review and assessment of the physical environment and fire protection. VA require services of conducting surveys at SVHs to identify compliance with VA standards in title 38 Code of Federal Regulations (CFR), Parts 51 applicable to the level of care.

The survey report cites specific deviations from professional or community standards of care and federal regulations.

2.5 On a national level, this type of survey process assures that standards are indeed being met. Furthermore, the CMS survey process is considered a standard best practice for nursing homes in the United States.

Based on any potential national public health emergency, the survey process modality is determined for each CLC, SCI or SVH by the GEC Program Office and will be one of two survey options: 1.) On site review, or 2.) a full virtual modality. For virtual surveys, observations of direct care or resident and staff interactions at the CLC, SCI or SVHs, will be collaborative utilizing all available technology components. Read access to any form or type of electronic health record from a CLC or SVH, will require the execution of a Business Associate Agreement with the Veterans Health Administration.

The number and type of surveyors (clinical, administrative or life safety) and duration of survey will be determined based on the size of the facility to include the census and the program/level of care being surveyed. The table in Attachment F will be used, unless directed otherwise by the COR. The COR can adjust the number of surveyors and days based on circumstances at the facility related to any national pandemic (i.e. decrease number of surveyors with an increase in number of days)

Modality 1: Full Virtual Concept: The entire survey team conducts the survey away from the CLC or SVH, whereby CLC or SVH staff are responding to the reviewers and using technology to show direct care observations and physical structure of the building as well as providing needed documents.

Vendor has access to Quality Measures in advance.

A Pre- Survey Conference is conducted 1 week in advance of survey to review technology, make staff liaison assignments, and coordinate survey agenda.

Vendor needs to pre-select possible areas for review based on MDS quality measure data, latest Care Compare report and last annual survey report.

Vendor to prepare and distribute assignments to other reviewers at entrance conference.

Reviewers to observe the CLC, or SVH direct care and conduct interview of residents, family members and staff using electronic device (e.g., iPad, smartphone, laptop, etc.). Reviews will be completed via use of an application, such as Zoom, MS Teams, WebEx, etc., to complete the observations and interviews.

Vendor clinical reviewers will each initially select three sample residents for review. The team will request the most recent comprehensive and quarterly Minimum Data Set (MDS); the most recent history and physical evaluation; current, active provider orders; and the most recent history and physical for each resident in the sample. These documents should be provided electronically no later than the end of the first day of the survey.

A building tour or unit tours are conducted via an electronic device (e.g., iPad, smartphone, laptop, etc.) using an application, such as Zoom, MS Teams, WebEx, etc., to complete the observations. The facility staff would be available with basic knowledge of the building, access to basic tools (i.e. ladder, flashlight, keys to locked rooms and a tape measure).

Vendor needs to supply a list of the documents that the team needs to be sent electronically for review.

The facility would be required to timely send reviewers relevant information, such as the applicable policies and procedures and medical records if read access not possible in a method that meets VHA privacy and security requirements.

The reviewers need a method to discuss what they discovered for the day. Choice of technology to be Zoom, WebEx, MS Teams or conference call.

The entrance briefing, daily briefing and exit briefing with the facility needs to be established electronically such as Zoom or MS Teams or conference call.

Vendor may be able to talk with residents and families by telephone.

Modality 2: On-Site (Unannounced, unless otherwise indicated by the COR) Concept: At minimum, members of the survey team are only on site as needed. If the Fiscal portion of the survey can be accomplished remotely then it is authorized. Contracted vendor will only send staff as needed.

Vendor has access to Quality Measures.

The facility escort with the life safety reviewer is limited to 1.

The facility escort with clinical reviewers is limited to 1 per reviewer.

The reviewers need a method to discuss what they discovered for the day if necessary, for an outbreak or national pandemic. Choice of technology to be Zoom, WebEx, MS Teams, or conference call or with CDC acceptable distancing in a room.

The entrance briefing, daily briefing and exit briefing with the facility could be established electronically such as Zoom or MS Teams or conference call or with CDC acceptable distancing in a room.

All reviewers are always to observe social distancing.

Vendor Surveyors may be able to talk with residents and families by telephone.

The vendor must provide all necessary personal protective equipment (PPE) recommended by the Center for Disease Control, prior to performing any on site or with sufficient quantities for all reviewers during the entire survey. Any testing or vaccination will be completed by the vendor prior to the surveyor entering the facility and the surveyor will be able to produce evidence.

The vendor must have a plan to actively screen surveyors daily for disease as well as testing and vaccination plan.

The vendor must request a PIV card for all reviewers and obtain a va.gov email address. This requirement is to assure all surveyors can create and fully utilize the Microsoft Teams platform and share file for a necessary full virtual survey.

The vendor is required to request access to the VA Austin server to pull all MDS Quality Measure Reports prior to the start of any CLC or SVH survey. The contractor survey team is to review the quality measure reports prior to the first day of any survey.

2.6 Therefore, VA has a requirement to contract with a vendor with the appropriate CMS survey expertise to conduct surveys for VA CLCs, SVHs and SCI/D Long Term Centers. The purpose of these surveys is to:

a. Identify serious concerns with quality of care through direct observations, either in person or utilizing a virtual modality.

b. To provide consultative services on best practices and the standards of care.

c. To educate and reinforce VA CLC, SCI/D and SVH staff on Veteran-centered care; and

d. Recognize SVHs and certify SVHs annually for compliance to the federal regulations to continue to receive federal per diem payments.

2.7 The SCI/D surveys will be independent of CLC surveys within the same VAMC. However, the SCI/D will be completed adjacent to the CLC surveys being conducted in VAMCs that have both services provided. This will allow utilization of the same survey staff to conduct both surveys during the same visit and thereby reduce travel costs.

2.8 The domiciliary and adult day healthcare survey will be independent of the nursing home survey within the same SVH. However, the domiciliary and adult day healthcare surveys will be completed adjacent to the nursing home program survey in a SVH that offers multiple levels of care.

2.9 Quality Assurance: The Government’s procedures to verify services being performed by the Contractor are performed according to acceptable performance objectives and AQLs.

2.10 Quality Assurance Plan (QAP): The QAP must demonstrate that the offeror’s plan effectively measures the accuracy, quality, and reliability of data throughout the survey process. The offeror shall provide a detailed description of the management and operational strategy that sequences the events that this organization shall employ to ensure prompt and efficient delivery of the products and services required.

A.3.0 Period of Performance

3.1 The period of performance shall be a twelve (12) month base period from date of award, with four (4) twelve (12) month options.

A.4.0 Type of Contract

4.1 This is a Firm-Fixed Price (FFP) Requirements Contract FAR 16.503 that will be most advantageous to the Government, price and other factors considered.

A.5.0 Place of Performance

5.1 All work completed under this PWS shall take place at the Contractor’s facility, at the designated VA CLC and SCI Center locations or at the SVHs or by virtual modality as described above.

5.2 Initiation of a virtual survey will be at the request of the Government through the Contractor and/or COR.

A.6.0 Deliverables Schedule

6.1 If for any reason the scheduled time for a deliverable cannot be met, the contractor is required to explain why (include the original deliverable due date) in writing to the COR within one business day before the deliverable date including a firm commitment of when the work shall be completed. This notice to the COR shall cite the reasons for the delay, and the impact on the overall project. The COR will then review the facts and issue a response two business days in accordance with applicable regulations.

A. CONTRACT AWARD KICK-OFF MEETING

The COR shall specify dates, locations (can be virtual), and prepare an agenda which will be provided to all attendees at least five (5) calendar days prior to the meeting), and shall provide meeting minutes (provided to all attendees within three (3) calendar days following the meeting). The COR shall invite the CO, Contract Specialist (CS), and the CLC/SVH VA National Program Managers. Additional Government attendees shall be provided to the Contractor via the COR.

The Contractor shall not commence performance of the tasks in this PWS until after the kickoff meeting or until the CO has formally advised the Contractor of a notice to proceed.

Deliverable 1 – Attend Kick-off meeting

B. SPECIFIC MANDATORY TASKS AND ASSOCIATED DELIVERABLES

C.1.1 Tasks/Activities/Deliverables

Task 1 – Surveys (either Virtual on On-Site) This project shall require the vendor to conduct surveys for VA CLCs, SCI/D Centers and SVHs as identified in the Pricing Schedule, utilizing CMS process standards of care and elements of the title 38 CFR Part 51 regulations for SVHs.

Any new CLCs or SCI/D Long Term Centers that are opened during the performance period will also need to be surveyed and will be added via bilateral modification of the task order.

This project shall also require the vendor to conduct a recognition survey for any new, annex, branch, enlargement, expansion, or relocation of a SVH. A state may request, and the vendor will schedule and conduct the survey in the requested month or week by the state. New state Veterans homes must undergo recognition, a process whereby the state applies to VA for per diem payments for care provided to eligible Veterans in their respective state. State Veterans homes must undergo the recognition process for newly constructed homes, renovations, relocations or increases in the numbers of beds and levels of care. Facilities requesting recognition must meet all VA standards to receive a passed recognition status. States are notified at the exit conference if the survey passed or failed. If a survey failed, another recognition survey is scheduled.

All surveys require off-site preparation including the review of the last previous surveys, sentinel events, the MDSQM report, Care Compare for any CMS survey and Resident Level Summary. All CLC and SCI/D surveys shall include an entrance and exit briefing/conference with appropriate Veterans Integrated Service Network (VISN), facility, and CLC and SCI/D Center management. All SVH surveys shall include an entrance, daily briefing and exit briefing/conference with SVH facility management. All virtual surveys will include SVH facility management and SVH VISN Liaisons. The entrance and exit briefings are a requirement and recognized part of all surveys.

Upon arrival at the facility or at the initiation of a virtual survey, the survey team shall contact the Director of the VA Medical Center or SVH Administrator. An Entrance Letter is prepared and presented to the SVH Administrator as to the type of survey, survey dates and survey team members. At the entrance briefing the survey team shall meet with the appropriate staff to announce the survey, request certain documents, and agree on protocols. At the exit briefing the surveyors shall provide the leadership and staff and the VA Medical Center or the SVH Administrator a verbal summary of key findings in general terms in preparation for receiving the final written report. No final ratings, or scope or severity, or specific federal regulation will be given at the exit briefing. The vendor should have an identified subject matter expert or Director to contact during any survey for questions, guidance, clarification, or direction in an unforeseen situation. That subject matter expert or Director will define or develop a process to contact or alert the VA COR as to such issues as they arise as necessary.

The schedule for conducting surveys will be based on the following established criteria. Each CLC and SCI/D will have a grouping assigned, but regardless of grouping, the survey will occur annually within 11-13 months.

• Group 1 CLCs and SCI/D Centers– CLC and SCI/Ds in this group will have no G or above deficiency, or no repeat deficiencies in the current contract year compared to the previous contract year. Repeat survey occurs within 11-13 months (execution of repeat surveys is contingent on the exercise of task order options).

• Group 2 CLCs and SCI/D Centers– CLC and SCI/Ds in this group have repeat deficiencies in any area that are below the scope and severity of a G level. Repeat survey occurs within 11-13 months (execution of repeat surveys is contingent on the exercise of task order options).

• Group 3 CLCs and SCI/D Centers– CLC and SCI/Ds in this group have a G level finding. Repeat survey occurs within 11-13 months (execution of repeat surveys is contingent on the exercise of task order options).

• Group 4 CLCs and SCI/D Centers– CLC and SCI/Ds in this group have multiple G level deficiencies, have one or more repeat G level deficiencies in the same are in the current contract year compared to the previous contract year or has an increase of 5 or more additional deficiencies in the contract year compared to the previous year. Repeat survey occurs within 11-13 months (execution of repeat surveys is contingent on the exercise of task order options).

• Group 5 CLCs and SCI/D Centers– CLC and SCI/Ds in this group have an H level or above finding. Repeat survey occurs within 11-13 months (execution of repeat surveys may be contingent on the exercise of task order options).

The vendor will be on site/virtual within 15 business days after official notification is made by GEC to the VA medical center for a For-Cause Survey. A For-Cause Survey may be authorized by GEC to review a major or significant specific concern, or a series of incidents, complaints, deficiencies or events that may jeopardize the health or safety of residents. This is a full survey but focuses on the specific events or acts that prompted the survey. The decision to initiate a For-Cause Survey is an unannounced survey and is determined by GEC based on all available information, trends, reports and recommendations made by the Medical Center Director.

Deliverable 2: CLC Surveys (inclusive of SCI/D if applicable) Deliverable 3: CLC (inclusive of SCI/D if applicable) For Cause Surveys Deliverable 7: Final CLC Survey Report Deliverable 11: Final SCI/D Centers Survey Report Deliverable 31: CLC and SCI/D De-identified Survey Reports

The schedule for conducting SVH surveys will be based on the following criteria:

· The vendor will be given from the COR, via government email, a spreadsheet of VA surveyor’s preferences from those at the VA Medical Facility of Jurisdiction. The spreadsheet will include the SVHs to be surveyed by month and selected survey modality.

· VA surveyor preferences are provided to the vendor of those designated VA Medical Facility Representatives and VA Fiscal Representatives from the VA Medical Facility of Jurisdiction.

· The vendor shall provide a list of all individual surveys scheduled in any given month according to the recognized month by each SVH or other factors determined by the government by electronically sending a calendar of individual surveys listed with proposed survey dates and surveyor names, surveyor emails and type of surveyor to the COR one month (30 days) in advance of the survey.

· The vendor shall schedule all surveys (Annual, Recognition or For Cause) in collaboration with the VA COR from the VA Office of Geriatrics and Extended Care and in coordination with the availability of the designated VA Medical Facility of Jurisdiction representatives.

· The vendor will be on site/virtual within 15 business days after official notification is made by GEC to the VA medical facility of jurisdiction for a For-Cause Survey. A For-Cause Survey may be authorized by GEC to review a major or significant specific concern, or a series of incidents, complaints, deficiencies or events that may jeopardize the health or safety of residents. This is a full survey but focuses on the specific events or acts that prompted the survey.

· The decision to initiate a For-Cause Survey is determined by GEC based on all available information, trends, reports and recommendations made by the SVH VISN liaison and Director, VA medical facility of jurisdiction. This is an unannounced survey to the SVH.

· The COR will approve all survey schedules.

A final report of survey findings will be forwarded to the Office of GEC Program within 10 business days of completion of survey. The final survey report will describe and fully document survey findings, survey ratings and a determination of the scope and severity of the findings. The report will identify the CLC medical director and CLC nurse leader. The final report will also include the following for each unit of the CLCs being surveyed:

a. Medication error rate

b. Current census

A final report of SVH survey findings will be forwarded to the Office of GEC Program within 10 business days of completion of survey. The survey report will include a copy of the completed life safety checklist pertinent to that specific level of care (Attachments G-I). The life safety checklists are only a guide and not to be provided to the SVH facility management. The final survey report will describe and fully document survey findings per federal regulation, survey ratings and a determination of the scope and severity of the findings. No recommendations or notes are given with a Met rating. Ratings are either Met or Not Met.

All survey reports will be reviewed by the Program Office and any corrections/comments furnished to the vendor 5 business days after receipt. Following revisions, the vendor will submit final edited reports within 5 business days to the Program Office. A final report is required for each individual site survey level of care.

The vendor will provide de-identified reports for each program 30 days after the final report.

Deliverable 4: SVH (inclusive of all levels of care as applicable) Annual Surveys Deliverable 5: SVH (inclusive of all levels of care as applicable) For Cause Surveys Deliverable 6: SVH (inclusive of all levels of care as applicable) Recognition Surveys Deliverable 8: Final SVH Survey Reports Deliverable 31: SVH De-identified Survey Reports

Task 2 – Project Work Plan The vendor will provide the necessary resources to address a strategy documented in a work plan for:

a. Integrating the CMS survey approach including but not limited to utilizing the RAI/MDS;

b. Observation of direct resident care, including but not limited to meals, medication passes, and dressing changes and pressure ulcer care;

c. Pre-and onsite preparation such as review of prior survey and quality data and other pertinent information; and

d. Assessing progress with implementation of the principles of person-centered care/ culture transformation (CLC only).

The work plan shall specify the number and discipline of surveyors, including a life safety surveyor, assigned to the surveys, the number of days spent at each CLC or SVH, if applicable, the timeframe for the facilitation of a virtual survey, and the length of time for each visit. The SVH monthly survey schedule must be approved by the COR. All virtual surveys will include a 1-hour Pre-Survey Conference in advance of the Entrance survey call with the GEC Program Office, CLC leadership, or SVH facility management; survey team and VISN staff for necessary technological plans and agenda for survey.

The Quality Assurance Plan (QAP) shall be submitted per the solicitation and be based on the Performance Requirements Summary (PRS), outcomes, and identify how the Performance Objectives will be achieved. It shall address all the personnel, specific tasks in the PWS, and remedial actions.

Deliverable12: Project Work Plan Deliverable 13: Monthly Updates to Work Plan Deliverable 32: Quality Assurance Plan (QAP)

Task 3 – Levels H, I, J, K and L findings (High Risk and Immediate Jeopardy (IJ) Findings) During the CLC or SCI/D survey, the surveyors shall notify the VA Medical Center Leadership and VHA Office of Geriatrics and Extended Care (GEC) if any findings are rated Levels H, I, J, K or L in the Scope and Severity Matrix utilized by CMS (attachment K). Findings in Levels H and I are not immediate jeopardy but result in actual harm due to substandard care. Findings in Levels J, K and L constitute immediate jeopardy. During a SVH survey, surveyors shall notify the Project Manager of a potential IJ if any regulations are suspected to be rated at Levels J, K, or L in the Scope and Severity Matrix. The Project Manager is to immediately notify GEC of the situation, the finding, level, federal regulation, and when SVH management has been notified. An IJ may be called when a potential deficiency is identified that causes or had the potential to cause harm to the resident’s health or safety. The survey team is to immediately notify the SVH facility management in requesting an abatement plan to correct the situation. The Project Manager is to immediately notify the GEC COR when the abatement plan is received and approved. In addition, a copy of that abatement plan is to be sent to the GEC COR. The vendor surveyors will participate in a conference call with the GEC Program Office and VA Medical Center of jurisdiction to discuss and review the IJ and the abatement plan that was accepted. Call to be arranged by GEC Program Office.

The surveyors remain on site when immediate jeopardy is determined and ensure that the CLC/SVH corrects the deficiency immediately with a written abatement plan. If survey is virtual, the surveyors will remain in contact with the facility leadership until it has been demonstrated the deficiency has been corrected with a written abatement plan.

The vendor shall provide in writing to the VHA Office of GEC Program a preliminary report for findings rated H, I, J, K or L in the Scope and Severity Matrix for CLC and those rated J, K or L in the Scope and Severity Matrix for SVHs within 1 working day of the finding.

Deliverable 14: CLC and SCI/D Notification and correction of immediate jeopardy findings Deliverable 15: SVH Notification and correction of immediate jeopardy findings Deliverable 16: Preliminary report for Levels H, I, J, K and L findings in CLCs and SCI/D Deliverable 17: Preliminary report for Levels J, K and L findings in SVHs

Task 4 – Feedback Mechanism

The vendor shall provide a mechanism for the VA CLCs, SVHs and SCI/D Centers to provide, at minimum, both positive and negative feedback of all phases of the survey process, and for correction of problems in a timely fashion after they are reported. Examples include problems with Vendor’s staff or surveyor performance and questionable citations. The Vendor shall also provide a process for regular reporting of feedback to the COR. A mechanism for reporting of feedback shall be submitted to the COR within 30 days of the contract award date.

Deliverable 18: Feedback Mechanism

Task 5 – Summary Survey Data Reports

The vendor shall submit a Summary Survey Data Report of the CLC and separate SVH survey findings and separate Summary SCI/D Report of the SCI/D survey findings quarterly and a cumulative summary report for the year. The Summary CLC and SVH Survey Data Reports and Summary SCI/D Survey Data Report shall include statistical analysis for the survey program at both the VISN and facility level, as well as individual community living centers and state veterans’ homes, and must include the following:

Federal tags – Average number cited nationally

Most frequently cited nationally

Average number cited by VISN

Most frequently cited by VISN

Number cited by facility

Standards cited by facility

Federal regulations for SVHs

Deliverable 19: Quarterly CLC Summary Survey Data Reports Deliverable 20: Quarterly SVH Summary Survey Data Reports Deliverable 21: Yearly CLC Summary Survey Data Reports Deliverable 22: Yearly SVH Summary Survey Data Reports Deliverable 23: SCI/D Quarterly Summary Survey Data Report Deliverable 24: Yearly SCI/D Summary Survey Data Report

Task 6 – Ad Hoc Reporting and Communication Plan The vendor must have the flexibility to provide simple reports (i.e., CLCs that have a particular finding) at the request of the program office.

Communication is an essential part of the survey process between the Vendor’s staff and Office of Geriatrics and Extended Care (GEC) Program COR. A communication plan shall be submitted to the COR within 30 days of date of award of contract and implemented within 10 days of notification by COR of approval.

The vendor will participate and submit written feedback and responses to the COR when requested in a timely manner, related to information necessary regarding an informal dispute on a survey report or a concern or complaint to a surveyor. Vendor shall participate in further investigation or explanation with written rationale as to why a citation was given or how the explanatory statements were derived when requested by the GEC Program Office.

The vendor shall submit status reports to the COR monthly. Status reports shall include, at a minimum, the following information in a VA provided format no later than the fifth business day of each month. The vendor must participate and respond no later than 5 calendar days to any request from the GEC Program Office with explanation as to how and why a deficiency was written against a federal regulation, or why the Scope and Severity was selected as a result of a facility executing the GEC Informal Dispute Resolution Process.

a. Work accomplished

b. Work planned for the next month including the team leader, survey team members, survey team contact information and anticipated number of days at the facility.

c. Status of milestones including slippage and proposed revision of target date(s) when appropriate

d. Old issues

e. New issues and problems

Deliverable 25: Ad-hoc simple reports Deliverable 26: Communication Plan Deliverable 27: Monthly status reports

Task 7 - National Education

Contractor will provide monthly national education to CLC, SCI/D and SVH staff via 60-minute conference calls/webinars (i.e. via adobe connect, MS team, etc.). There will be no need to access any government system. Topics will be developed with and approved by the COR.

Deliverable 28: CLC and SCI/D National Training Plan Deliverable 29: SVH National Training Plan

C. PERFORMANCE METRICS

At the end of each assessment period, the assessment will be reviewed by the Program Managers and CO. The COR / CO will notify the Contractor of the results no later than fifteen (15) working days after the end of the assessment period. The Contracting Officer’s Representative (COR) will perform quarterly assessments. The Performance Based Service Assessment Survey, or other method, may be used to document this assessment.

The table below defines the Performance Metrics associated with this effort:

Performance Objective

Performance Standard

Acceptable Performance

requirements

2. Efficient and effective in meeting requirements Plan for virtual as well as face to face surveys is evident

3. Meets technical needs and mission requirements

4. Offers quality services/products Satisfactory or higher

2. Products completed, reviewed, delivered in timely manner

3. Notifies customer in advance of potential problems Satisfactory or higher

2. Personnel possess necessary knowledge, skills, and abilities to perform tasks Satisfactory or higher

2. Services/products delivered were of desired quality Satisfactory or higher

The Government will utilize a Quality Assurance Plan (QAP) provided by the contractor throughout the life of the contract to ensure that the Contractor is performing the services required by this PWS in an acceptable manner. The COR will determine if the performance of the Contractor is below a metric standard and deem it unacceptable. The COR will then notify the Contracting Officer.

The Contractor will be monitored and assessed throughout the period of performance of the contract / order as to either meeting or not meeting the performance thresholds stated in the Performance Metrics and the Performance Requirements Summary sections of the PWS. The Contracting Officer’s Representative (COR) will perform quarterly assessments. The Performance Based Service Assessment Survey, or other method, may be used to document this assessment.

D. PERFORMANCE REQUIREMENTS SUMMARY

Applicable

PWS

Paragraphs (Paragraph #) Required Service (Performance requirements) Standard- (performance Standards)

(Quality Assurance) Remedies

C.1.1 Task 1 Deliverables; 4,5,15,17

Unannounced Surveys

b. Random sample of 50% of survey inspection reports

a. Vendor provided feedback on survey performance and request plan of correction if necessary

b. Vendor to correct/re- work; noted on CPARS

C.1.1 Task 1 Deliverable; 18

Survey Reports

d. Random sample of 50% of inspection reports

e. Vendor provided feedback on timeliness requirement and request plan of correction if necessary

f. Vendor to correct/re- work; noted on CPARS

C.1.1 Task 2

Deliverable; 19, 20

Delivery of Project Work Plan

Vendor to correct/re- work; noted on CPARS

C.1.1 Task 3

Deliverable; 19, 20

Notification and correction of immediate jeopardy findings VHA GEC Program Office and COR are notified timely of all findings rated Levels H, I, J, K and L for CLC and SCI programs and in the Scope and Levels I, J, K Severity Matrix for SVH programs.

VHA GEC Program Office and COR are notified timely of the preliminary report

C.1.1 Task 4

Deliverable: 25

Feedback Mechanism

C.1.1 Task 5

Deliverables: 26, 27, 30

Quarterly Survey Summaries

C.1.1 Task 6

Deliverable: 32

Ad Hoc Reporting