36C24124Q0229 0002.docx

5. PROJECT NUMBER (if applicable)

CODE

7.

ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF

PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE

OF YOUR

ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERE

D CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR

OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendmen t, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED

STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF

CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF

SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) Department of Veterans Affairs Network Contracting Office 1 (NE) Contracting Officer (90C) 940 Belmont Street Brockton MA 02301 Jeffrey S. Fleming jeffrey.fleming@va.gov Department of Veterans Affairs Network Contracting Office 1 (NE) Contracting Officer (90C) 940 Belmont Street Brockton MA 02301 To all Offerors/Bidders

36C24124Q0229 01-25-2024

X X 01/31/2024 14:00 hrs EST.

See CONTINUATION Page The purpose of this amendment is to:

1. Answer Questions:

Listed on page two (2)

2. updated PWS (Changes highlighted in yellow)

Jeffrey S. Fleming Contracting Officer

1. It is written that the work needs to be completed before TJCs survey window which Starts in February 2024 but being that this is not possible to complete before 2/1, what does the target Start date for this contract?

Answer:

February 12, 2024

1. Our team or Physicians and RNs will not be available until April 1st, 2024.Some of the duties in the scope of work can be done remotely but does not specify if some of the meetings, training and other tasks are permitted to be done remotely. Are any of these items can be performed remotely.

Answer:

We don’t permit remote work. This is also too late for us as we don’t know when the real team will arrive.

1. Can you please specify what the Pharmacy will need to be prepped on?

Answer:

The pharmacy will need the mock team to conduct an in person mock joint commission survey just as if they were the joint commission. This will include inpatient, outpatient, home care and clinic dispensing. Please include a pharmacist for outpatient home care and clinic dispensing. Thank you. We would need the pharmacy reviewed by policies, procedures, and storage.

Pharmacy needs a Review *Antibiotic Stewardship and Quality Control measures required, qualifications of pharmacist and staff, Look-like/sound alike drugs precautions/labeling and proper cleaning, maintenance of storage of equipment. Review Compounding Room, EOC and Policies and Procedures and staff competencies.

Probably could be done utilizing a combination of remote and 5 days onsite.

1. It is written that the work needs to be completed before TJCs survey window which Starts in February 2024 but being that this is not possible to complete before 2/1, what does the target Start date for this contract?

Answer:

02/14/24 Anticipated Start date

1. Some of the scope of work can be done remotely but does not specify if some meeting, training and other tasks are permitted to be done remotely. Are any of these items are able to be preformed remotely?

Answer:

Remote work is NOT authorized.

1. Why is a Pharmacist not included to review inpatient, outpatient, home care and clinic dispensing?

Answer:

Please include a pharmacist for outpatient home care and clinic dispensing.

*Antibiotic Stewardship and Quality Control measures required, qualifications of pharmacist and staff, Look-like/sound alike drugs precautions/labeling and proper cleaning, maintenance of storage of equipment.

Probably could be done utilizing a combination of remote and 5 days onsite.

1. Is remote work to reduce time onsite allowed before and after? It would allow better preparation for review with faster turn-around for identifying issues that will need to be addressed in a Corrective Action Plan. It would also reduce expenses.

Answer:

Remote work is NOT authorized.

1. Is remote work to reduce time onsite allowed before and after? It would allow better preparation for review with faster turn-around for identifying issues that will need to be addressed in a Corrective Action Plan. It would also reduce expenses.

Answer:

Remote work is NOT authorized.

Remote Examples below:

· Policy and procedures

· Previous TJC recommendations

· Review of PI Program

· Minutes from Critical Committee Meetings

· Personnel File Audits to Analyze for trends to allow HR Compliance time to correct issues

· Medical Records Delinquency Rates for Each facility

· Medical Staff, Medical Executive Committee, Infection Control Reports (if separate), Quality Reports

· Agenda of Board or CEO Reports

· TJC Compliance Critical Elements currently in process, if any

· Competency, Orientation, and Annual Evaluations Requirements

· Extensive Review of Life Safety with Logs of required documentation, Emergency Plans/Usage/Drills (3 Years), and Environment of Care.

· We have 2 individuals to identify each area non-compliant. *Oral recommendations of Imminent Threat to Life are made onsite, especially for Suicide Precautions Onsite:

· Peer Review and Sentinel Event Issues would need to be onsite for Privacy

· Validation of Medical Staff Credentialing

· Physician Meetings at each campus or centralized

· Extensive Review of Life Safety, Emergency Plans/Usage, and Environment of Care. We have 2 individuals to identify each area non-compliant. Oral recommendations of Imminent Threat to Life are made onsite, especially for Suicide Precautions

· Patient Safety

· Need top 10 diagnosis in each service area, and least used for low volume

· Meet with Chief of Staff, CNOs, CEOs/Leadership, Safety Officer/s, Managers, and others to provide update on new 2024 standards

· Exit reviews with our staff and leadership (determined by VA)

· We use crosswalk with both Medicare Conditions of Participation and The Joint Commission Standards.

· Our tools are designed for maximum review of High Risk Areas.

· We meet at the end of each work day to validate the need to look for trends of issues identified.

· We provide a full report in 10 business days with Correction Action Plans.

· We are available to do Video Conference to present Report/corrective Action Plans so a Q&A can be done.

1. We assign time oriented goals with Severity Index to allow top. Will VAMC provide any additional requirements to insert into our survey tools at least 30 days prior to onsite review Answer:

No

B.2 PERFORMANCE STATEMENT OF WORK Revision 1 Revisions are highlighted in yellow.

1. Objective:

· The purpose of this Performance Statement of Work (PWS) is for a mock Consultation for Joint Commission (JC) readiness with a goal to assist in survey preparation. This is including but not limited to the Contractor is to provide a Continuous Readiness Assessment JC Survey and/or Education for the purpose of performance improvement, improving system effectiveness, and achieving and maintaining compliance with JC standards for the selected facility, residential programs and its CBOC’s. The assessment will be inclusive of the three TJC programs: Hospital, Home Care, and Behavioral Health. The focus review should include a comprehensive review of:

a. Standards

b. Accreditation Requirements

c. Compliance requirements

d. Survey guides

· Product delivery will be the responsibility of the Vendors working with the Bedford VAMC project management POC, the Vendor will be responsible for coordinating and performing the delivery, implementation, and training for the devices.

2. Background:

The objective is to complete a mock survey of the facility to prepare the facility for an upcoming Joint Commission Survey.

3. Scope

· Complete a Mock survey of areas that are surveyed by The Joint Commission including the laboratory, pharmacy, SPS, and mental health areas throughout the facility.

4. Specific Tasks:

a. Conduct a mock TJC Survey

b. Review Environment of Care

c. Documentation

d. Policies and Procedure evaluation to provide Bedford VA with rapid response to policy development processes.

e. Review all the VHA Bedford prior Joint Commission Survey Findings to ensure we are in compliance. Please see below:

i. Include the following categories that the standards fall under:

5. Training:

· Prepare our facility staff members in standards expected by TJC.

· Provide recommendation and training on identified areas where improvement is needed.

6. Installation:

N/A

7. Performance Monitoring:

HCQA shall monitor the performance of this contract. This shall be accomplished by monitoring the needs of the facility and being available for inquiries the facility may ask after the visit.

8. Government-Furnished Equipment (GFE)/Government-Furnished Information (GFI):

None

9. Other Pertinent Information or Special Considerations:

The A&A requirements do not apply, and that a Security Accreditation Package is not required.

10. Place of Performance:

Bedford, VAMC 200 Springs Road Bedford, MA 01731

Gloucester VA Clinic 199 Main Street Gloucester, MA 01930-6029

Haverhill VA Clinic 209 Summer Street Haverhill, MA 01830-6315

Lynn VA Clinic 225 Boston Street, Suite 107 Lynn, MA 01904-3123

Crescent House Transitional Residence Program 15 Veterans Way Lynn, Ma 01940

Visiting Nurse Home Care Visits in the Bedford VA Catchment Area

11. Delivery Schedule:

Deliver a verbal and written daily out brief to assigned Hospital staff related to any Joint Commission survey related findings or need for correction.

Deliver a full written report within 5 business days of the completion of the survey. The written report should state all findings and a plan of correction for the facility.

12. Period of Performance:

HCQA shall have available dates that are accommodating to the facility. The laboratory time frame would need to occur ASAP and prior to TJC arrival which is expected any time beginning 02/2024

13. Additional Requirement:

· N/A

14. Records Management:

· The following standard items relate to records generated in executing the contract and should be included in a typical procurement contract:

· Citations to pertinent laws, codes, and regulations such as 44 U.S.C chapters 21, 29, 31 and 33; Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part 1228.

· Contractor shall treat all deliverables under the contract as the property of the U.S. Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.

· Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records.

· Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the Freedom of Information Act.

· Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.

· The Government Agency owns the rights to all data/records produced as part of this contract.

· The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractor must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data.

· Contractor agrees to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974. These policies include the preservation of all records created or received regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.].

· No disposition of documents will be allowed without the prior written consent of the Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules.

· Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, this contract. The Contractor (and any sub-contractor) is required to abide by Government and Agency guidance for protecting sensitive and proprietary information.

15. Deliverables:

The vendor SHALL provide the following:

1. Provide an optional on-site educational program for Environment of Care (EOC)/Life Safety including Annual Workplace Evaluation (AWE)/Emergency Management, Home Care, Behavioral Health and Nursing and Rehabilitation at the DC VAMC.

2. Provide on-site educational programs for 2019 JC Standards and National Patient Safety Goals, Workplace Violence and Physical Security, H&P Requirements to Care Planning, Pain Management and Care Planning, Patient Education and Care Planning, Infection Control, Medication Management (optional, if agreed upon by both parties).

Provide announced mock surveys inclusive of the four TJC programs: Hospital to include pharmacy with antibiotic Stewardship and Quality Control measures required, qualifications of pharmacist and staff, Look-like/sound alike drugs precautions/labeling and proper cleaning, maintenance of storage of equipment, policies and staff competencies. Review of the morgue, outpatient clinics such as urgent care, mental health, primary care, podiatry and women’s health; Home Care, Behavioral Health (including Opioid), and Nursing and Rehabilitation.

1. Provide announced mock surveys at the five identified VISN 5 Medical Center and potentially one CBOC to cover the four TJC programs: Hospital, Home Care, Behavioral Health (including Opioid), and Nursing and Rehabilitation.

2. End-of-day strategic sessions with leadership to discuss the key findings of the day and to provide time for questions.

3. Provide a comprehensive exit briefing to the facility and VISN leadership at the end of the facility announced/unannounced mock surveys, where applicable.

4. Within two-weeks of the completions of the Readiness Assessment, contractor will provide a detailed report, which identifies areas of non-compliance. Contractor will provide best practices and recommendations designed to bring the VISN 5 facilities into compliance with the TJC standards. The report will include description of findings and a recommended action plan when deficiencies have been identified. A written and electronic copy of the report will be provided.

5. Physician(s) with qualifications and experience required to perform a methodical in-depth quality assessment for total of fourteen (14) business days for no less than eight (8) hrs./day.

6. Registered nurse(s) with qualifications and experience required to perform a methodical in-depth quality assessment for total of fourteen (14) business days for no less than eight (8) hrs./day.

7. Environmental consultant(s) with expertise in Life Safety Codes with qualifications and experience required to perform a methodical in-depth quality assessment for a total of fourteen (14) business days for no less than eight (8) hrs./day. Both parties will have to agree on this prior to any follow up visit.

8. Review specified Community Based Outpatient Clinic to be determined.

9. Environmental consultant(s) with expertise in Life Safety Codes with qualifications and experience required to perform a methodical in-depth quality assessment for a total of ten (10) business days for no less than eight (8) hrs./day. Both parties will have to agree on this prior to any follow up visit.

10. Registered nurse(s) with qualifications and experience required to perform a methodical in-depth quality assessment for total of ten (10) business days for no less than eight (8) hrs./day.

16. Qualifications and Credentials:

a. The surveyor must possess the appropriate qualifications and credentials for conducting the surveys. The surveyor will be an expert on EC and LS matters, and have specific health care certifications, or equivalent. The surveyor must have at least five years’ experience in conducting mock TJC surveys on the whole range of Environment of Care, Life Safety, and Emergency Management-related issues. Experience on national committees or authoring articles on EC/LS related issues is preferred. Previous VA experience is preferred. If surveyor performance is less than satisfactory, the VA reserves the right to request a substitute surveyor at no additional cost to the VA.

b. The surveyor will use the most current TJC Standards published in the Hospital Accreditation Standards Manual, Environment of Care Essentials for Health Care, and other related publications as enforced by the VHA.

c. Have experience in providing a mock survey at a VA hospital in the past 36 months.

17. Travel Expenses:

All travel expenses associated with providing services under this contract are the responsibility of the contractor.

Amendment 0002 to 36C24124Q0229 image4.png image5.png image1.png image2.png image3.png