36C24523R0055 0001.pdf

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 NUMBERED 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 amendment, 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)

None

Department of Veterans Affairs VA Maryland Health Care System Crystal S. Hinton, Contracting Officer P.O. Box 1000, Bldg. 101, Room 4 Perry Point MD 21902

Department of Veterans Affairs VA Maryland Health Care System Crystal S. Hinton, Contracting Officer P.O. Box 1000, Bldg. 101, Room 4 Perry Point MD 21902

To all Offerors/Bidders

36C24523R0055

X

X 1

The purpose of this amendment is to update the PWS and CLIN line items. Please see page 2-59.

All other terms and conditions of the solicitation clauses and provisions remain the same.

Crystal S. Hinton Contracting Officer

Quantities listed are estimated only and are not guarantees.

Period of Performance: 4/01/2024-3/31/2029 with one six (6) month option period that we may or may not exercise.

Minimum Value: $155K

Estimated Maximum Value: $11,500,000.00

Subtotals of items 1-60 $_________

ITEM

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

0001 Contract Months 1-12

5 LPM Concentrator. Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 5 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate. HCPCS: E1390Code E1390

EA

0002 10 LPM Concentrator.

Rental concentrator with backup system consisting of compressed gas source, 20 EA $__________ $________________ regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 10 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

0003 Contract Months 1-12

M/H cylinder resupply.

(Primary/Backup Code E0443)

10 EA $___________ $________________

0004 Contract Months 1-12

Monthly rental of portable cylinder. Code E0431

72 EA $___________ $________________

0005 Contract Months 1-12

Set-up portable concentrator. Code

-- -- -- No Charge

0006 Contract Months 1-12

Monthly rental of portable concentrator. Code E1392

250 EA $___________ _$______________

0007 Contract Months 1-12

E cylinder resupply. Code E0443

733 EA $___________ $________________

0008 Contract Months 1-12

B cylinder resupply. Code

1196 EA $___________ $________________

0009 Contract Months 1-12

50 psi Air Compressor and supplies. Code E0565

4 EA $___________ $________________

0010 Contract Months 1-12

RT quarterly assessment of O2 patients. Code VA120

200 EA $___________ $________________

0011 Contract Months 1-12

Stationary liquid oxygen system. Code E0439

1 EA $___________ $________________

0012 Contract Months 1-12

Portable liquid oxygen system. Code E0444

3 EA $___________ $________________

0013 Contract Months 1-12

Liquid oxygen resupply.

Code E0444

357 LB $___________ $________________

0014 Contract Months 1-12

Consumables: Conserver/ Demand Pulsing nasal cannula

96 EA $___________ $________________

0015 Consumables:

Conserver/Oxygen

5 EA $___________ $________________

conserving device cannula

0016 Consumables: Oxygen Firesafe Valves/Oxysafe Valve. Code E1399

50 EA $___________ $________________

0017 Contract Months 1-12

Ventilator delivery & set-up.

Code VA 120

0018 Contract Months 1-12

RT monthly assessment of Ventilator patients. Code VA

0019 Contract Months 1-12

Monthly Ventilator Rental

0020 Contract Months 1-12

Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence.

-- EA $____________ No Charge

0021 Contract Months 1-12

Demand Nasal Cannula (e.g. Oximyzer) Reservoir or pendant/equivalent. VA111

75 EA $__________ $_______________

0022 Contracts Months 1-12

COVID Set-up for COVID positive veterans only

1 EA $___________ $_________________

Total

ITEM

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

1001 Contract Months 13-24

5 LPM Concentrator. Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 5 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

1002 10 LPM Concentrator.

Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 10 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

1003 Contract Months 13-24

(Primary/Backup Code E0443)

10 EA $___________ $________________

1004 Contract Months 13-24

1005 Contract Months 13-24

Set-up portable concentrator. Code

-- -- -- No Charge

1006 Contract Months 13-24

275 EA $___________ _$______________

1007 Contract Months 13-24

1008 Contract Months 13-24

1009 Contract Months 13-24

1010 Contract Months 13-24

1011 Contract Months 13-24

1012 Contract Months 13-24

1013 Contract Months 13-24

1014 Contract Months 13-24

Consumables: Conserver/

1015 Contract Months 13-24

Consumables:

Conserver/Oxygen conserving device cannula

5 EA $___________ $________________

1016 Contract Months 13-24

Consumables: Oxygen Firesafe Valves/Oxysafe Valve. Code E1399

50 EA $___________ $________________

1017 Contract Months 13-24

Ventilator delivery & set-up.

1018 Contract Months 13-24

RT monthly assessment of

1019 Contract Months 13-24

1020 Contract Months 13-24

Delivery for re-supply and/or relocation of equipment due

1021 Contract Months 13-24

Demand Nasal Cannula

1022 Contract Months 13-24

COVID Set-up for COVID

Subtotals of items 1001-1022 $___________

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

2001 Contract Months 25-36

5 LPM Concentrator. Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 5 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

2002 10 LPM Concentrator.

Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 10 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

2003 Contract Months 25-36

(Primary/Backup Code E0443)

10 EA $___________ $________________

2004 Contract Months 25-36

2005 Contract Months 25-36

Set-up portable concentrator. Code

-- -- -- No Charge

2006 Contract Months 25-36

300 EA $___________ _$______________

2007 Contract Months 25-36

2008 Contract Months 25-36

2009 Contract Months 25-36

2010 Contract Months 25-36

RT quarterly assessment of

2011 Contract Months 25-36

2012 Contract Months 25-36

2013 Contract Months 25-36

2014 Contract Months 25-36

Consumables: Conserver/

2015 Contract Months 25-36

Consumables:

Conserver/Oxygen conserving device cannula

5 EA $___________ $________________

2016 Contract Months 25-36

Consumables: Oxygen Firesafe Valves/Oxysafe Valve. Code E1399

50 EA $___________ $________________

2017 Contract Months 25-36

2018 Contract Months 25-36

RT monthly assessment of

2019 Contract Months 25-36

2020 Contract Months 25-36

Delivery for re-supply and/or relocation of equipment due

2021 Contract Months 25-36

Demand Nasal Cannula

2022 Contract Months 25-36

COVID Set-up for COVID

Subtotals of items 2001-2022 $___________

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

3001 Contract Months 37-48

5 LPM Concentrator. Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 5 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

3002 10 LPM Concentrator.

backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 10 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

3003 Contract Months 37-48

10 EA $___________ $________________

(Primary/Backup Code E0443)

3004 Contract Months 37-48

3005 Contract Months 37-48

Set-up portable concentrator. Code

-- -- -- No Charge

3006 Contract Months 37-48

325 EA $___________ _$______________

3007 Contract Months 37-48

3008 Contract Months 37-48

3009 Contract Months 37-48

3010 Contract Months 37-48

3011 Contract Months 37-48

3012 Contract Months 37-48

Portable liquid oxygen

3013 Contract Months 37-48

3014 Contract Months 37-48

Consumables: Conserver/

3015 Contract Months 37-48

Consumables:

Conserver/Oxygen conserving device cannula

5 EA $___________ $________________

3016 Contract Months 37-48

Consumables: Oxygen Firesafe Valves/Oxysafe Valve. Code E1399

50 EA $___________ $________________

3017 Contract Months 37-48

3018 Contract Months 37-48

RT monthly assessment of

3019 Contract Months 37-48

3020 Contract Months 37-48

Delivery for re-supply and/or relocation of equipment due

3021 Contract Months 37-48

Demand Nasal Cannula

3022 Contract Months 37-48

COVID Set-up for COVID

Subtotals of items 3001-3023 $______________

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

4001 Contract Months 49-60

5 LPM Concentrator. Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 5 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

4002 10 LPM Concentrator.

backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 10 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

4003 Contract Months 49-60

M/H cylinder resupply.

(Primary/Backup Code E0443)

10 EA $___________ $________________

4004 Contract Months 49-60

4005 Contract Months 49-60

Set-up portable

-- -- -- No Charge concentrator. Code

4006 Contract Months 49-60

350 EA $___________ _$______________

4007 Contract Months 49-60

4008 Contract Months 49-60

4009 Contract Months 49-60

4010 Contract Months 49-60

4011 Contract Months 49-60

4012 Contract Months 49-60

4013 Contract Months 49-60

4014 Contract Months 49-60 96 EA $___________ $________________

Consumables: Conserver/

4015 Contract Months 49-60

Consumables:

Conserver/Oxygen conserving device cannula

5 EA $___________ $________________

4016 Contract Months 49-60

Consumables: Oxygen Firesafe Valves/Oxysafe Valve. Code E1399

50 EA $___________ $________________

4017 Contract Months 49-60

4018 Contract Months 49-60

RT monthly assessment of

4019 Contract Months 49-60

4020 Contract Months 49-60

Delivery for re-supply and/or relocation of equipment due

4021 Contract Months 49-60

Demand Nasal Cannula

4022 Contract Months 49-60

COVID Set-up for COVID

Grand Total $__________________

Six Month Option Period, we may or may not exercise. 04/01/2029-09/30/2029

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

5001 Contract Months 61-66

5 LPM Concentrator. Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 5 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

5002 10 LPM Concentrator.

Rental concentrator with backup system consisting of compressed gas source, regulator, stand, nasal cannula, mask or trach collar, humidifier and fire safe valve when specified.

Includes delivery, setup, and education. Back up minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0 – 10 liters per minute.

If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly

5003 Contract Months 61-66

(Primary/Backup Code E0443)

10 EA $___________ $________________

5004 Contract Months 61-66

5005 Contract Months 61-66

Set-up portable concentrator. Code

-- -- -- No Charge

5006 Contract Months 61-66

350 EA $___________ _$______________

5007 Contract Months 61-66

5008 Contract Months 61-66

5009 Contract Months 61-66

5010 Contract Months 61-66

5011 Contract Months 61-66

5012 Contract Months 61-66

5013 Contract Months 61-66

5014 Contract Months 61-66

Consumables: Conserver/

5015 Contract Months 61-66

Consumables:

Conserver/Oxygen conserving device cannula

5 EA $___________ $________________

5016 Contract Months 61-66

Consumables: Oxygen Firesafe Valves/Oxysafe Valve. Code E1399

50 EA $___________ $________________

5017 Contract Months 61-66

5018 Contract Months 61-66

RT monthly assessment of

5019 Contract Months 61-66

5020 Contract Months 61-66

Delivery for re-supply and/or relocation of equipment due

5021 Contract Months 61-66

Demand Nasal Cannula

5022 Contract Months 61-66

COVID Set-up for COVID

B.3 DESCRIPTION/SPECIFICATION/PERFORMANCE WORK STATEMENT

1. SCOPE: This Performance Wort Statement (PWS) defines the effort required for the setup, installation, and management of Home Oxygen and Ventilation, in accordance with Joint Commission (JC) standards for Homecare, to Veteran beneficiaries serviced by Louis A.

Johnson VA Medical Center. This PWS includes the associated program management, human engineering, and logistic support planning requirements. The use of the terms, “beneficiary”, “Veterans”, “Patients”, and “Patient” are used interchangeably and refer to the recipient of required supplies, equipment, and services required under the contract.

1.1 BACKGROUND: The acquisition of Home Oxygen is being initiated to provide Home Oxygen to Veteran beneficiaries serviced by Louis A. Johnson VA Medical Center. The Louis A.

Johnson VA Medical Center does not have the capacity to provide these supplies, so a contract has been sought for the provision of home oxygen and all associated products and services.

1.2 VETERANS SERVED: The Department of Veterans Affairs Medical Centers (VAMC) at:

Louis A. Johnson VAMC currently serves an estimated 569 oxygen-using patients. The volumes or amounts shown in the solicitation are estimates only and impose no obligation on the VA. The contract shall be for the needs of the VA as determined and ordered by the VA during the life of the contract. The Contracting Officer’s Representative (COR) or designee shall provide (via encrypted email, fax, or VA approved portal) the contractor with notification to initiate individual Patient delivery requirements, including the Patient's oxygen prescription, equipment, supplies and incidental services to be provided including date and place of delivery.

The Contractor shall confirm receipt (via encrypted email, fax or through VA approved portal) of the request within one (2) working hour of notification; Per Facilities discretion the COR or designee shall also provide (via encrypted email, or fax or through VA approved portal) notification if VA owned equipment is to be provided; the COR or designee shall also provide notification (via encrypted email, or fax, or VA approved portal) to the contractor of VA initiated discontinuation of service. The discontinuation notifications shall be made (via encrypted email, or fax or VA approved portal) within 24 hours. The written documents shall include the authorizing official's signature, electronic or written.

1.3 LOCATIONS: The Contractor shall provide Home Oxygen within a defined area of responsibility/jurisdiction to the patients’ residence, or other location as indicated on the order for Home Oxygen. Area of responsibility/jurisdiction for each VA facility includes the counties identified (See section A to define) below within this section for specific counties covered by each facility) as applicable to the area of responsibility/jurisdiction.

NOTE: (1) The Government reserves the right to purchase the services from the Contractor awarded a contract whose area of responsibility/jurisdiction includes the location of the patient’s place of residence. (2) Contractors must provide home oxygen to Veterans that are traveling in the contractor’s area of responsibility/jurisdiction as outlined in section 3.8.

A. LOUIS A. JOHNSON_VETERANS AFFAIRS MEDICAL CENTER (VAMC) LOCATED

IN CLARKSBURG, WEST VIRGINIA_AND CBOC’S IN BRAXTON, MONONGALIA,

TUCKER AND WOOD COUNTY: Contractor shall provide delivery, setup, installation, and management of Home Oxygen services to any Patients that are treated at the Louis A. Johnson VA Medical Center and all Community Based Outpatient Centers (CBOC’s) supported therein (Clinic of Jurisdiction/Primary Service Area COJ/PSA), regardless of their physical location. The listing of these counties does not exclude other counties.

This includes Patients who reside near bordering states catchment areas but prefer to be seen in Louis A. Johnson VAMC. Portable cylinders, regulators, regulator keys and 02 carriers shall be delivered to the Louis A. Johnson VAMC within one (1) business day of request to accommodate Home Oxygen beneficiaries who are visiting the VA or being discharged and require a tank of oxygen to go home. This shall be provided at no additional charge.

COUNTIES IN:

West Virginia: Barbour, Braxton, Calhoun, Clay, Doddridge, Gilmer, Harrison, Jackson, Lewis, Marion, Marshall, Monongalia, Nicholas, Pocahontas, Pleasants, Preston, Randolph, Ritchie, Roane, Taylor, Tucker, Tyler, Upshur, Webster, Wetzel, Wirt, Wood.

Ohio: Athens, Monroe, Noble, Belmont, Morgan, Washington.

Pennsylvania: Greene, Fayette, Westmoreland

Maryland: Garrett.

Patients in other counties of West Virginia and in the general vicinity of southwestern PA, eastern OH and western MD may be added to the program from time to time and Contractor will support these patients in accordance with the terms and conditions of this contract.

1.4 PORTABLE EQUIPMENT AT VA MEDICAL CENTERS

Two (2) portable oxygen concentrators shall be continuously maintained by the Contractor at the VA Medical Center. These portable oxygen concentrators shall be used for evaluation of patients to see if they qualify for these devices. This shall be provided at no additional cost to the Government for this service. Contractor shall be permitted access to the space and equipment when requested, by telephone, with 24 hours’ notice to the VA Medical Center’s Respiratory Therapy Department.

2. ORDERS, NOTIFICATION AND DELIVERY:

2.0 ORDERS: The Contracting Officer Representative (COR) or VA designee shall provide the Contractor with the orders/prosthetic consult, via facsimile, secured email or through VA approved portal in addition to phone contact to initiate individual patient service requirements.

This shall include patient’s oxygen prescription, oxygen prescription expiration date, equipment, supplies, and services to be provided including the date and place of delivery. The Contractor shall confirm receipt of the request within two (2) working hours of notification. Contractor shall confirm by facsimile, secure email or documentation in VA approved portal to VA designee/designated staff for all Home Oxygen initiations, plan of care changes, and discharges. The VA designee shall also provide notification of VA initiated discontinuance of service via facsimile, secured email, or entry in VA approved portal. All changes to patient care shall be confirmed in one of the above mechanisms. The prescription is terminated the day the patient expires.

2.1 NOTIFICATION TO VA REGARDING STATUS OF DELIVERY OF HOME OXYGEN

SERVICES:

a. The contractor shall notify the appropriate VA designee and/or COR monthly of initial delivery of home oxygen equipment by sending copies of individual delivery tickets via FEDEX/UPS/USPS or similar. The delivery ticket shall be signed and dated by the patient or their designated representative. This notification shall be made when patient requires changes in medical equipment or equipment switch-outs.

b. The Contractor shall notify the appropriate VA designee and/or COR by secure email or facsimile within one (1) working day if expected delivery of medical equipment is not completed. This notification shall include reason/explanation as to why the delivery was not able to be completed; and a plan of action to resolve delivery failure.

c. The Contractor shall notify the appropriate VA designee and/or COR by secure email or facsimile or documentation in VA approved portal within one (1) working day if the patient refuses delivery of medical equipment and/or signs the Contractor’s AMA form. Copy of the AMA form signed by patient shall be included in this notification.

2.2 DELIVERY OF MEDICAL EQUIPMENT:

a. The Contractor shall deliver and set up in the patient’s residence all equipment and supplies ordered. This contract is a full-service contract. Set-up shall include establishment of operational parameters of equipment to VA prescription, ensures purity of O2, Veteran training on system operations, review of safety checks and discussion of home safety issues. Services are required to be provided 24 hours a day, seven (7) days a week, including holidays, including all emergency service calls. Contract prices are all-inclusive.

The Contractor shall not be reimbursed for costs incurred in excess of the contract prices in the Schedule of Supplies/Services for services provided in accordance with the Schedule of Supplies/Services.

b. Patients shall be notified of expected delivery times by the Contractor. Veterans shall be provided with a four (4) hour delivery time window for expected time of delivery.

c. Deliveries of medical equipment and supplies shall be made in full. If the contractor is unable to fulfill the full prescribed medical equipment and supplies list, they may choose partial delivery. Contractor shall notify the VA Designee and/or COR via secured email or facsimile or entry in VA approved portal within one (1) calendar day in the event of a partial delivery. In such cases where a partial delivery is made, the remainder of the delivery will be made within one (1) calendar day. Payment shall only be issued for full deliveries.

Contractor shall maintain sufficient stock (or have available) to ensure all deliveries can be made within the contractual timeframes. The cost for additional deliveries to complete the order shall be at no additional cost to VA.

d. The Contractor shall deliver portable oxygen equipment to previously established and new patients being discharged to their home from non-VA Facilities and other facilities as requested by VA Staff per the needs of the Veteran. Equipment shall be delivered within four (4) hours of the request.

2.3 EXCESS DELIVERY: The Contractor shall not deliver supplies and/or equipment in excess of those prescribed, and the Contractor shall not be paid for any excess deliveries.

SERVICE SPECIFICATIONS:

3.0 PRESCRIPTION CHANGES: The Contractor shall not change or alter a patient’s oxygen prescription or equipment requirements without a new prescription from the patient’s VA physician. A request to change tank size does not require a Physician’s signature, as long as liter flow rate is not altered.

3.1 HOME VISITS:

a. The Contractor shall visit patients’ residences for regularly scheduled maintenance visits in performance of this contract by appointment only; between the hours of 7:00 a.m. and 7:00 p.m. Exceptions shall be made in the cases of emergencies.

b. The Contractor is responsible for scheduling the appointments to the patient’s home 24-48 hours prior to the appointment.

c. On each scheduled set-up/delivery the Contractor shall reassess the need to instruct the patient on the use and care of the equipment and supplies as necessary. The Contractor shall perform and document a home safety assessment that will include assessing for fall risk, evidence of smoking around oxygen equipment, working smoke detectors, posted “No Smoking” signs in addition to all other JC requirements for home safety assessments.

d. Contractor shall re-instruct patient, family or caregivers as necessary without formal order from the VA.

3.2 INITIAL SET-UPS: Initial set-ups are services provided to those patients who have not been provided a VA authorized oxygen therapy delivery system to their place of residence on a previous occasion or have not used such a system continuously for the past 60 days. Once initial set-up has been completed, the Contractor shall develop a regular delivery schedule for home oxygen and supplies to patients. All Initial 50 PSI setups shall include all disposables, large bore tubing, large volume nebulizers, drain bags and masks.

a. Initial set-ups shall be completed within eight (8) hours of request. Failure to deliver within the required time shall result in the VA obtaining oxygen from another source. Any costs in excess of contract pricing for services provided shall be billed to contractor or credited to next invoice at the discretion of the ordering facility. The Contractor shall notify the appropriate VA designee and/or COR via secured email, facsimile, or documentation in within one (1) calendar day if expected delivery is not completed. This notification shall include reason why delivery was unable to be completed.

b. Switch-outs are services provided to those patients who are presently using an oxygen delivery system or have used such a system continuously within the past 60 days. The Contractor shall provide equipment switch-outs by staff with documented competency training on the manufacturer’s recommended assembly, use, and maintenance of the equipment used under this contract.

c. Switch outs are to be completed within two (2) calendar days. Failure to complete switch out within the required time shall result in the VA obtaining oxygen from another source. Any costs in excess of contract pricing for services provided shall be billed to contractor or credited to next invoice at the discretion of the ordering facility.

d. Failure to perform the switch-outs as prescribed by VA prescription shall result in no cost to the government. Payment shall be made once switch-outs are completed as prescribed.

Payments shall be assessed based on the provider’s established rate and pro-rated from set-up date. Medical equipment switch-out requested to increase the patient’s quality of life or due to changes in the patient’s oxygen requirement shall be made at no additional charge to the government.

e. Set-up of Home Oxygen includes setting up and ensuring the appropriate oxygen system is operational, instruction and training of patient, and/or caregiver and home environment safety check. Failure to deliver within the required time shall result in the VA obtaining oxygen from another source. Any costs in excess of contract pricing for services provided shall be billed to contractor or credited to next invoice at the discretion of the ordering facility.

f. The Contractor is responsible for establishing appointments with patients when initiating set-ups, switch-outs, and deliveries.

3.3 ASSESSMENT REQUIREMENTS:

a. The Contractor shall perform an assessment of the patient’s home and environment in accordance with Joint Commission (JC) accreditation standards for Homecare and maintain documentation of assessments in the individual patient file or folder. Contractor will perform Quarterly Assessments and provide documentation to the VA designee and/or COR.

b. The Contractor shall notify the VA designee and/or COR during the home visit if the Contractor’s staff determines that the presence of oxygen in the home presents such a danger that the oxygen must be removed, or in the case of an initial set-up, not placed in the home.

c. The Contractor shall notify the VA designee and/or COR by telephone or email within two

(2) hours if any unsafe conditions are observed in the patient’s home that preclude the installation or continuance of oxygen service. Unsafe conditions shall include fire safety hazards, oxygen safety hazards, patient abuse by family or caregivers, or any instance that places the patient or Contractor’s staff in immediate danger. The Contractor shall provide written documentation of the safety hazard to the VA designee and/or COR within one (1) business day of incident.

d. The Contractor shall check the adequacy of the electrical outlets in the patient’s home and while still in the patient’s residence, report any unsafe conditions to the VA designee and/or COR during the initial assessment. VA shall not be responsible or liable for any unsafe electrical conditions caused by the Contractor. Any alterations to the patient’s residence shall be the responsibility of the patient. If ordered equipment cannot be safely installed, the VA designee and/or COR shall provide an alternative oxygen delivery system after VA physician’s approval until new prescription can be obtained. If no alternative is available, the prescribing VA physician shall be notified by the VA designee and/or COR.

3.4 PATIENT EDUCATION REQUIREMENTS:

a. The Contractor shall provide education to each patient at the time of set-up, and every six

(6) months thereafter, and assess the need for reinforcement during visits. This information shall be presented verbally, in demonstration and material covered shall be in written form to be left with the patient/caregiver. The written material shall be in English as well as the foreign language of the patient, should the patient not speak English. In the case of such an occurrence the Contractor is to advise the VA facility to facilitate adequate instructions. All patient education material must be presented in written form to VA designee and/or COR for approval prior to distribution to patients. The Contractor shall implement any new or revised education material as directed by the VA designee and/or COR. The VA shall determine whether the Contractor shall use his/her forms or forms supplied by the VA for documentation of services provided to patients. Regardless of whether the VA provides a VA Patient Rights & Responsibilities document and/or forms to the Contractor, and/or the Contractor uses his/her VA Patient Rights & Responsibilities and/or forms, the Contractor is responsible for duplication of the documents/forms when copies are needed to give to patients.

b. Patients shall be provided a copy of VA Patient Rights & Responsibilities, and Advance Directives as appropriate. The Contractor shall document that the patient/caregiver has been instructed in accordance with JC Standards for Homecare.

3.5 DISCONTINUATION OF SERVICE:

a. The Government shall notify the Contractor in the event of an order to discontinue oxygen service to any patient covered under this contract as soon as identified. Notification shall be by via secured email or facsimile. At least two (2) weeks prior to the scheduled termination of prescription the Contractor shall notify the VA designee and/or COR via secured email or facsimile, if removal of home oxygen may be detrimental to the patient.

Payment shall be pro-rated based upon the notification date of discontinuance of service. In the event that the contractor is notified that a patient has moved out of the service area, or is deceased, the Contractor shall notify the VA designee and/or COR within one (1) business day of this discovery.

b. The Contractor shall remove equipment from the patient’s residence at the earliest possible time but no later than five (5) business days after notification of Discontinuation of Service (DC) unless approved by the VA Designee and/or COR. The date and time of equipment pickup shall be coordinated with the patient and/or next of kin and/or significant other. The Contractor shall make every effort to meet the patient’s or patient’s families’ requests for pickup times. The Contractor shall honor family’s requests pickup equipment before or after funerals or family gatherings relative to patient funerals. The Contractor shall treat such requests with the utmost courtesy and give such requests the highest priority. In the event the patient refuses to release the equipment the Contractor shall immediately notify the VA designee and/or COR. Billing of services ends at time of VA-issued notification to discontinue order and/or date of patient’s death.

3.6 EMERGENCY SERVICES:

a. The Contractor shall provide emergency services on a 24-hour basis, and the contractor shall provide services at the patient’s home no more than four (4) hours of receiving a call. If the Contractor is unable to respond to an emergency service call within four (4) hours, the Contractor shall be responsible for making arrangements with another supplier to provide oxygen, and the Contractor shall be responsible for any excess cost above the contract reimbursed price. A written explanation of why the Contractor was unable to respond to the emergency must be provided to the VA Designee and/or COR within one (1) business day.

b. An emergency exists if the VA Designee and/or COR informs the Contractor that he/she considers the situation an emergency, or if the patient states in a telephone call to the Contractor that an emergency exists in regard to the function of the home oxygen equipment or use of the equipment. The Contractor shall provide written details of the patient emergency to the VA Designee and/or COR within one (1) business day of notification by the patient. This written report shall contain time of initial call and time contractor arrived at the patient’s house.

c. The Contractor shall maintain a telephone number for emergency purposes so that the

VA and patients who have been authorized to receive home oxygen may contact the Contractor outside of normal business hours. The Contractor shall provide the telephone number to the patients.

d. The Contractor shall notify the VA designee and/or COR immediately in the event of a disaster, natural or otherwise, that may affect the services covered under this contract.

e. The Contractor shall be prepared to provide services on an emergency basis. Contractor shall provide initial setups and emergency service seven (7) days a week, twenty-four

(24) hours a day, this includes holidays. Patient discharges requiring initial setups after 7:00 pm shall be completed that same day.

3.7 SIGNAGE: The Contractor shall provide the patient signs for all entrances into the patient’s residence, stating “Warning Oxygen in Use, No Smoking” or other verbiage that No Smoking is allowed due to oxygen being present and document that the Patient/Caregiver is instructed in the safe use of oxygen and equipment per OSHA regulations. The Contractor shall attach patient education and expectations placard to all concentrators and liquid oxygen stationary systems. In the event the Veteran refuses the signage, the contractor shall notify the VA Designee and/or COR immediately after the visit, for documentation purposes by the VA.

3.8 TRAVELING PATIENTS:

a. The Contractor shall be responsible for coordinating all home oxygen for patients who travel both within and outside their respective contracted area of responsibility/jurisdiction, unless otherwise indicated. The VA designee and/or COR shall be responsible for notifying the Contractor where/when the patient is traveling to and the mode of transportation. The Contractor is responsible for coordinating with the patient when travel has been completed.

b. Traveling patients shall be provided with a Federal Aviation Administration (FAA) approved portable concentrator for travel purposes at the request of the VA designee and/or COR.

These units shall not be standard for long term use.

c. Invoices for travel patients shall be provided to the VA with the next monthly invoice.

d. Patients traveling within the Contractor’s area of responsibility/jurisdiction shall be provided all home oxygen under the contract at the contract rate. Patients traveling within contracted areas of responsibility/jurisdiction covered under other VA contracts for home oxygen, but not within the Contractor’s area of responsibility/jurisdiction, shall be provided all required oxygen services at whatever contract rate that applies to the area the patient is traveling.

The Contractor currently providing home oxygen shall work with the VA designee and/or COR, the Home Oxygen Coordinator, and the Prosthetic Representative to notify and arrange for home oxygen with the contractor whose area the patient is traveling.

e. For patients traveling outside the areas of responsibility/jurisdiction covered by other VA contracts for home oxygen, and/or temporarily relocating, the Contractor shall arrange for home oxygen from an area provider. The Contractor shall obtain pre-approval from the Contracting Officer or designee on pricing if it is above the contract price on the Contractor’s contract. If approved, the Contractor shall be reimbursed the contract rate plus the additional cost incurred for providing appropriate home oxygen. The Contractor shall provide the VA designee and/or COR evidence of any additional costs involved in providing the services outside the areas of responsibility / jurisdiction covered by other VA contracts for home oxygen.

f. Home oxygen for travel outside of the continental USA, overseas travel, and cruises are the responsibility of the patient.

g. Patients not travelling but are permanently relocating outside of established contracted area of coverage will be provided up to 90 days of continuation of services.

EQUIPMENT SPECIFICATIONS AND ASSOCIATED REQUIREMENTS:

4.0 EQUIPMENT MAINTENANCE:

a. Twice annually or as recommended by the equipment manufacturer, whichever occurs most often, the Contractor shall visit the patient to inspect equipment, checking for proper functioning and prompting patients to replace disposables, such as filters, tubing and nasal cannula as needed. During the visit the Contractor shall also reassess equipment compliance, provide educational needs, perform equipment inspection and maintenance in accordance with manufacturer’s recommendations and perform an environmental survey.

All equipment ordered shall be inspected. A written report shall include at minimum the following data:

1. Name and last four digits of social security number (SSN) of patient using the equipment.

2. Monitor compliance on prescription (Liters Per Minute (LPM), hours per day). Report will reflect hours of all equipment ordered.

3. Type of equipment, hours on concentrator (Serial numbers for the rented equipment shall be the Contractor’s responsibility and kept on file in the Contractor’s main office).

4. Inspection results of liter flow rate in monitoring patient compliance (as compared to prescription).

5. Inspection compliance of intake filters (exchange or clean by patient); follow-up education and/or reinforcement of compliance documented.

6. Revised plan of service as needed.

7. A delivery report shall be developed by the Contractor, signed and dated by the contract staff and the patient/care giver and a copy shall be left with the patient. The reports shall be legible and attached to the invoice. All reports shall be submitted to the VA designee and/or COR in alphabetical order, with the monthly invoices by the 10th business day of the month following service. The report must include a patient list and associated scanned delivery/maintenance receipts with patient’s signatures, patient signed patient education notes and clinical notes associated with plan of care changes. The report shall be submitted by the Contractor in both hard copy and on electronic media (DVD or CD). Format to be approved by VA. Changes to the format shall not constitute a need for a contract modification.

4.1 NECESSARY EQUIPMENT AND SERVICES:

a. In accordance with the prescription received from the VA facility, the Contractor shall provide the patient with the following items:

1. Humidifiers and water traps, when the liter flow is equal to or greater than four (4) liters per minute, or if prescribed. The number of humidifiers must be sufficient to ensure that they are not depleted between re-supply visits. The number of traps shall be based on the patient’s flow rate. Humidifiers and water traps are changed every two-weeks with a supply in reserve at all times sufficient to last until the contractor’s next visit.

2. Twelve (12) disposable oxygen cannulas on hand for a change every two (2) weeks with a supply in reserve at all times until the Contractor’s next scheduled visit.

3. Twelve (12) disposable masks for change/wash every two (2) weeks with a supply in reserve at all times (when masks are prescribed in lieu of nasal cannulas).

4. 25-50 feet of oxygen connecting tubing shall be replaced every 30 days with an equivalent section of tubing in reserve at all times (to be included in initial setup) until the Contractor’s next scheduled visit.

5. Tracheotomy collar and accessories (e.g. tubing and large volume nebulizer, drain bag) with a supply on hand allowing for change every three (3) days and a supply of five (5) each in reserve at all times until the Contractor’s…