36C24218R0185-004.pdf

PAST PERFORMANCE EVALUATION

CONTRACTOR’S NAME:

The past performance evaluation factors will be rated as acceptable, unacceptable or neutral. Past performance will be evaluated based on quality of service, recent and relevant contracts, State inspection, and Medicare Star rating.

Definition The offeror meets or exceeds the (acceptability) standard.

The offeror fails to meet the (acceptability) standard.

Determination Acceptable Unacceptable Neutral The offeror had no past performance.

Proposals that lack any past performance will receive a neutral rating.

1. Is the contractor an incumbent VA-contracted facility?

YES NO

ACCEPTABLE UNACCEPTABLE

CONTRACT NUMBER:

NEUTRAL

2. Review of the nursing home’s most recent State inspection report including any Statement of Deficiencies and Plan of Correction

ACCEPTABLE UNACCEPTABLE NEUTRAL

3. Medicare Star Rating A Medicare Star rating of 3 is preferred but not required

ACCEPTABLE UNACCEPTABLE NEUTRAL

COMMENTS:

THE OFFEROR’S OVERALL PAST PERFORMANCE IS RATES AS:

ACCEPTABLE UNACCEPTABLE NEUTRAL

EVALUATOR’S SIGNATURE

D.11 ATTACHMENT