Performance_Work_Statement_Draft.docx

1. GENERAL:

The Contractor shall be responsible for providing residential treatment to Veterans with various addiction and psychological issues as specified herein. All services shall be performed off-site at the Contractor’s facility. The Contractor shall provide professional and technical services to include materials, supplies, equipment and qualified supervision specified herein. The contract will be in support of VISN 8, which serves veterans within the following locations:

Including community based outpatient clinics administered by the facilities listed above.

0. Authority – Title 38 United States Code (U.S.C.), 1703 Contracts for Hospital Care and Medical Services in Non-Department Facilities, FAR Parts 12 – Acquisition of Commercial Items in conjunction with FAR Part 15 Contracting by Negotiation.

0. Policy/Handbooks - The contractor shall be subject to the following policies, including any subsequent updates during the period of performance:

1. 42 Code of Federal Regulations (CFR) Part 482 Conditions of Participation Hospitals, including Sub-part E Requirements for Specialty Hospitals. http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr;sid=aceca18b9fbe0110ffa37c08075c2b0e;rgn=div5;view=text;node=42%3A5. 0.1.1.1;idno=42;cc=ecfr

1. VA Directive 1663: Health Care Resources Contracting - Buying http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=347

1. VHA Handbook 1100.17: National Practitioner Data Bank Reports - http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2135

1. VHA Handbook 1100.18 Reporting And Responding To State Licensing Boards - http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1364

1. VHA Handbook 1605.1, Privacy and Release of Information http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1423

1. VHA Handbook 1907.01 Health Information Management and Health Records: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791

1. VHA Directive 2006-041 “Veterans’ Health Care Service Standards” (expired but still in effect pending revision) https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1443

1. VHA Directive 2009-038: VHA National Dual Care Policy http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2058

1. Health Insurance Portability and Accountability Act of 1996 (HIPAA) http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative- Simplification/HIPAAGenInfo/downloads/hipaalaw.pdf

1. Patient Self Determination Act of 1991: http://www.gpo.gov/fdsys/search/pagedetails.action?st=citation%3A42+USC+1395dd&gr anuleId=USCODE-2010-title42-chap7-subchapXVIII-partE- sec1395cc&packageId=USCODE-2010-title42&bread=true

1. Privacy Act of 1974 (5 U.S.C. 552a) as amended http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.hHm

1. VHA Handbook 1160.01: Uniform Mental Health Services in VA Medical Centers and Clinics as amended – reference attachment identified in section D of this solicitation

1. VA Publications: https://www.va.gov/vapubs/

1. VHA Publications: https://www.va.gov/vhapublications/publications.cfm?pub=2

0. Definitions/Acronyms: Terms used in this contract shall be interpreted as follows unless the context expressly requires a different construction and/or interpretation. In case of a conflict in language between the definitions and other sections of this contract, the language in this section shall govern.

2. ACLS: Advanced Cardiac Life Support

2. APA: American Psychological Association

2. BAA: Business Associate Agreement

2. BBA: Balanced Budget Act

2. BLS: Basic Life Support

2. CARF: Commission on Accreditation of Rehabilitation Facilities

2. CDC: Centers for Disease Control and Prevention

2. CFR: Code of Federal Regulations

2. CLIN: Contract Line Item Number

2. CMP: Civil Monetary Penalty

2. CMS: Centers for Medicare & Medicaid Services

2. COMM: Communications

2. Contracting Officer (CO): The person executing this contract on behalf of the Government with the authority to enter into and administer contracts and make related determinations and findings.

2. Contracting Officer’s Representative (COR): A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance with and adheres to the specifications contained in the contract and to protect the interest of the Government. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken.

2. COS: Chief of Staff

2. CRNA: Certified Registered Nurse Anesthetist

2. CPA: Canadian Psychological Association

2. CPARS: Contractor Performance Assessment Reporting System

2. Credentialing: Credentialing is the systematic process of screening and evaluating qualification and other credentials, including licensure, required education, relevant training and experience and current competence and health status.

2. CTS: Care, Treatment, and Services

2. DEA: Drug Enforcement Agency

2. DSN: Defense Switch Network

2. EDI: Electronic Data Interchange

2. ESRS: Electronic Subcontracting Reporting System

2. FAPIIS: federal awardee performance and integrity information system

2. FAR: Federal Acquisition Regulation

2. FSC: Financial Service Center

2. HHS: Department of Health and Human Services

2. HICPAC: Healthcare Infection Control Practices Advisory Committee- a federal advisory committee made up of fourteen (14) external infection control experts who provide advice and guidance to the CDC and the Secretary of HHS regarding the practice of health care infection control, strategies for surveillance and prevention and control of health care associated infections in United States health care facilities.

2. HIPAA: Health Insurance Portability and Accountability Act

2. ID: Identification

2. ISO: Information Security Officer

2. MD: Medical Doctor

2. National Provider Identifier (NPI): NPI is a standard, unique ten (10)-digit numeric identifier required by HIPAA. The Veterans Health Administration must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers).

2. NICE: National Institute for Health and Care Excellence

2. NFPA: National Fire Protection Association

2. NPPE: National Plan and Provider Enumeration

2. OIG: Office of Inspector General

2. OSHA: Occupational Safety of Health Administration

2. PCSAS: Psychological Clinical Science Accreditation System

2. PHD: Doctor of Philosophy

2. PPIRS: Past Performance Information Retrieval System

2. PWS: Performance Work Statement

2. Privileging (Clinical Privileging): Privileging is the process by which a practitioner, licensed for independent practice; e.g., without supervision, direction, required sponsor, preceptor, mandatory collaboration, etc.; is permitted by law and the facility to practice independently, to provide specific medical or other patient care services within the scope of the individual’s license, based upon the individual’s clinical competence as determined by peer references, professional experience, health status, education, training and licensure. Clinical privileges must be facility-specific and provider-specific.

2. QA: Quality Assurance

2. QASP: Quality Assurance Surveillance Plan

2. QI: Quality Improvement

2. RFP: Request for Proposal

2. TIN: Tax Identification Number

2. TJC: The Joint Commission

2. U.S.: United States

2. U.S.C: United States Code

2. VA: Veterans Affairs

2. VAAR: Veterans Affairs Acquisition Regulation

2. Veterans Affairs Medical Center (VAMC): The Veterans Health Administration is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VAMC’s, Outpatient Clinics, Community Based Outpatient Clinics, and VA Community Living Centers (VA Nursing Home) Programs.

2. Veterans Health Administration (VHA): The central office for administration of the VA medical centers throughout the United States. The VHA is in Washington, D.C.

2. VISN: Veterans Integrated Service Network

0. BILLING DEFINITIONS

3. LENGTH OF STAY (LOS): The LOS is the period covered by the individual Unit Price. The LOS begins on the date of admission at the Contractor’s facility and will end upon the date of discharge from the Contractor’s facility. Additional days beyond the LOS for each CLIN will be reimbursed at the daily rate prescribed on the Price Schedule for each CLIN.

3. HCFA: Health Care Financing Administration

3. RESIDENTIAL CARE (FACILITY) AND PROFESSIONAL (PHYSICIAN) FEES: All professional, technical, institutional and ancillary charges necessary to cover all services associated with residential care during the LOS.

3. SELF-REFERRAL: Referring patients to Contractor’s facility for follow-up care. Contractor Personnel are prohibited from referring VA patients to their own practice(s).

1. QUALIFICATIONS

0. Staff/Facility

0. License: Contractor personnel assigned by the Contractor to perform services covered by this contract shall have a current license to practice medicine, psychology, social work and nursing, in any State, Territory, or Commonwealth of the United States or the District of Columbia. Contractor personnel must have a medical license and be individually registered with the DEA in the state where they will provide services under the contract. All licenses held by contractor personnel working on this contract shall be full and unrestricted licenses. Contractor personnel who have current, full and unrestricted licenses in one (1) or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application shall not be considered for the purposes of this contract.

0. Accreditation by the TJC or equivalent is required. CARF is evidence of internal quality assurance mechanisms and is desirable, but not required. Where applicable, the residential treatment setting must have a current occupancy permit issued by the authority having jurisdiction.

0. The Contractor shall be duly licensed by the Department of Health of the State of Florida to operate a facility.

0. The facility must meet the following requirements:

0. Standards of the Life Safety Code NFPA # 101

0. Fire and safety code imposed by State law

0. City, State and Federal requirements concerning licensing and health codes

0. All residential treatment settings must be licensed as required for the particular setting under state and federal authority

0. Board Certification/Staffing Credentials: All psychiatrists must have a degree of Doctor of Medicine or osteopathy resulting from a course of education in medicine or osteopathic medicine. All social workers must have a Master’s degree in social work from a school of social work fully accredited by the Council of Social Work education. They must be licensed or certified by a state at the advanced practice level, which includes Association of Social Work Boards advanced generalist or clinical examination, to independently practice social work at the master’s degree level. All psychologists must have a doctoral degree in psychology from a graduate program in psychology accredited by APA, PCSAS, or the CPA at the time the program was completed. They must hold a full, current and unrestricted license to practice psychology at the doctoral level in a State, Territory, Commonwealth of the United States (e.g., Puerto Rico), or the District of Columbia. All other required disciplines must hold and maintain certifications throughout the duration of the contract period of performance. Contractor clinical personnel must be currently certified in BLS, ACLS or equivalency. All continuing education courses required for maintaining certification must be kept up to date at all times. Documentation verifying current certification shall be provided by the Contractor to the VA COR when requested.

0. Credentialing and Privileging: All Contractor Personnel who shall provide services under this contract must be appropriately credentialed and privileged, if required, according to the Bylaws and Rules of the contractor’s facility. If Contractor Personnel are not credentialed and privileged or have credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government.

0. Technical Proficiency: Contractor Personnel shall be technically proficient in the skills necessary to fulfill the government’s requirements, including the ability to speak, understand, read and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed. Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all Contractor Personnel when requested.

0. Training: Contractor shall meet all VA educational requirements. Contractor Personnel must meet mandatory course requirements as required by the Contractor’s facility.

0. Standard Personnel Testing/Infection Control: Contractor shall provide a statement with the proposal that all required infection control testing is current and that the contractor is compliant with OSHA regulations concerning occupational exposure to blood borne pathogens. The Contractor shall also notify the VA of any significant communicable disease exposures and the VA will also notify the contractor of the same, as appropriate. Contractor shall adhere to current CDC/HICPAC Guideline for Infection Control in health care personnel (as published in American Journal for Infection Control 1998; 26:289-354 http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf) for disease control. Tests shall be current within the past year.

0. National Provider Identifier (NPI): NPI is a standard, unique ten (10) - digit numeric identifier required by HIPAA. The VHA must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). The Contractor shall have or obtain appropriate NPI and if pertinent the Taxonomy Code confirmation notice issued by the CMS NPPE. The information shall be provided to the CO with the proposal.

0. Conflict of Interest: The Contractor is responsible for identifying and communicating to the CO and COR conflicts of interest at the time of proposal and during the entirety of contract performance. At the time of proposal, the Contractor shall provide a statement which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided. The Contractor shall also provide statements containing the same information for any identified consultants or subcontractors who shall provide services. The Contractor shall provide relevant facts that show how it’s organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest. These statements shall be in response to the VAAR provision 852.209-70 Organizational Conflicts of Interest (Jan 2008) and fully outlined in response to the subject attachment in Section D of the solicitation document.

2.9. Citizenship related Requirements: The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patients.

2.10. While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation of their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent Amendments, as well as applicable Federal Acquisition Regulations.

2.11. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S. Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patients; or other place where the Contractor provides services to Veterans who have been referred by VA physician(s) and shall form the basis for termination of this contract for breach.

2.12. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.

2.13. The Contractor agrees to obtain a similar certification from its subcontractors. The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document.

2.14. Annual Office of Inspector General (OIG) Statement: In accordance with HIPAA and the BBA of 1977, the HHS and OIG has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that proposed Contractor Personnel are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a CMP for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP’s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractor is and/or Contractor Personnel are not listed as of the date the offer was signed.

2.15. Non-Personal Healthcare Services: The parties agree that the Contractor and all Contractor Personnel shall not be considered VA employees for any purpose.

2.16. Inherent Government Functions: Contractor and Contractor Personnel shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees (outside a clinical context), selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy.

2.17. No Employee status: The Contractor shall be responsible for protecting Contractor Personnel furnishing services. To carry out this responsibility, the Contractor shall provide or certify that the following is provided for all their staff providing services under the resultant contract:

2.17.1. Workers’ compensation

2.17.2. Professional liability insurance

2.17.3. Health examinations

2.17.4. Income tax withholding, and

2.17.5. Social security payments

2.18. Tort Liability: The Federal Tort Claims Act does not cover Contractor or Contractor Personnel. When a Contractor or Contractor Personnel has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor’s (or Contractor Personnel) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

2.19. Contingency Plan: Because continuity of care is an essential part of VISN 8, the Contractor shall have a contingency plan in place to be utilized if Contractor Personnel Leave Contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

3.0 HOURS OF OPERATION:

3.1 WORK SCHEDULE: Services shall be available from the contractor twenty-four (24) hours per day, seven (7) days per week, including weekends and federal holidays. Contractor shall provide coverage for all required shifts, including nights, weekends and holidays.

3.2 In residential treatment settings, there must be, at a minimum, a full-time staff member or designee available for emergencies 24 hours per day, seven (7) days per week.

3.3 Onsite supervision of residential settings is required 24 hours per day, seven (7) days per week. An employee of the contractor must be physically present in the unit, at all times, Veterans are in the unit. In buildings with multiple floors, a staff member must be physically present on each floor in the building, at all times, Veterans are present on the floor.

3.4 FEDERAL HOLIDAYS: The following holidays are observed by the Department of Veterans Affairs:

New Year’s Day President’s Day Martin Luther King Jr’s Birthday Memorial Day Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Christmas Any day specifically declared by the President of the United States to be a national holiday.

4.0 CONTRACTOR RESPONSIBILITIES

4.1 General: The Contractor shall be responsible for providing residential treatment to Veterans, including those with the following presenting problems: substance abuse, psychotic disorders, bipolar disorders, obsessive compulsive disorders, major depression, other mood disorders, anxiety disorders, post-traumatic stress disorder, homelessness, justice involvement, and other various psychosocial issues. The services shall be furnished to beneficiaries for whom such care is specifically authorized by the applicable facility within VISN 8. The type of Veterans to be cared for under this contract will normally require care and services above the level of meals, room and board. Relevant care will include, but not be limited to:

4.1.1 Supervised alcohol and drug free environment

4.1.2 Active affiliation with community support groups

4.1.3 Structured and group activities

4.1.4 Healthy physical activities

4.1.5 Individual counseling

4.1.6 Group counseling

4.1.7 Family involvement

4.1.8 Assistance with housing resources

4.1.9 Coordination with legal systems

4.1.10 Case management, as required

4.2 The beneficiaries receiving care under this contract shall receive basic health and personal hygiene maintenance, monitoring of medications, and any other service or supplies normally provided in a residential treatment setting. The rate established shall be an all-inclusive rate.

4.3 Length of stay at the facility will be initially authorized for up to sixty (60) days. The contractor may not be provided compensation for a period in excess of that stated in the length of treatment contracted, unless such extension of the authorization is provided in writing by the Contracting Officer Representative or authorized VA representative from VISN 8. Upon award of the contract, the VA will provide a list of authorized personnel who has the authority to authorize the extension for veterans at this facility.

4.4 Contractors under this program must meet the following VA standards, based on regulations promulgated by Title 38 Code of Federal Regulations (CFR) Section 17.53b:

4.5 Licenses and Accreditation:

4.6 The residential treatment settings must be licensed as required for the particular setting under State and federal authority.

4.7 Staff:

4.8 Sufficient staff shall be provided (i.e., in numbers and position qualifications) to carry out the policies, responsibilities, and therapeutic activities of the residential treatment program. The Contractor shall assign to this contract personnel that by education and/or training (and, when required, certification or licensure) are qualified to provide the services required by this PWS. Contractor may be required to supply resume(s) summarizing relevant skills and experience of any/all key personnel upon request. Minimum Key Personnel requirements are as follows:

4.9 One (1) administrative staff member, or designee of equivalent professional capability (with the authority to make decisions regarding the facility and residents, or with contact information for an offsite administrator in case of emergency), on duty on the premises or providing awake supervision of residents and staff 24 hours a day, 7 days a week.

4.10 Sufficient case management/counseling personnel to provide direct services to Veteran residents. Case managers should have some training and experience working with homeless individuals and the Housing First approach; experience working with individuals dealing with chronic medical, mental health and substance abuse problems is highly desirable. Staff working with Veterans should be able to assess, anticipate, and effectively refer Veterans experiencing crises for additional support as appropriate

4.11 At least one (1) staff or security member with Cardiopulmonary Resuscitation (CPR) certification will be on-site and available in an emergency during each shift, 24 hours per day.

4.12 Contractor shall provide resumes for all key personnel; if substitutions of key personnel are need, substitution must be submitted at least 15 days prior to the proposed date substitution is to occur. The Contracting Officer (CO) or Contracting Officer Representative (COR) will notify the contractor within fifteen (15) calendar days after receipt of all required information if the VA is able to accept the proposed substitute key personnel. Temporary substitutions of key personnel shall be permitted in accordance with the contractor’s contingency plan. The contractor’s contingency plan shall be utilized if personnel leave the contractor’s employment or are unable to continue performance in accordance with the terms and conditions of the resulting contract. The contingency plan shall be submitted to the CO as a part of the proposal package. The CO is the ultimate authority on acceptable length for temporary substitution of key personnel.

4.13 The VA reserves the right to refuse or revoke acceptance of any key personnel if personal, professional conduct, lack of required skills or experience jeopardizes patient care or interferes with the regular and ordinary operation of the facility and the VA Residential Program Objective.

4.14 The Contractor shall:

4.15 Identify, by name, the key management and technical personnel who shall work under a contract with VISN 8 representatives at the time the service is being provided. The contractor shall submit a listing of names, position and telephone numbers of all personnel. In the event a key person on the list becomes unavailable, it is the contractor’s responsibility to inform the Contracting Officer Representative (COR) immediately so that there will be no lapse of communication.

4.16 Assist Veterans requiring emergency services (medical or psychiatric) with quickly accessing appropriate care from a VA or community facility, as appropriate.

4.17 Medical and Psychiatric Stabilization: Vital signs and laboratory data shall be consistent with facility standards for discharge of acute and/or residential patients. The standard shall meet CTS.04.01.01 of the Joint Commission 2016 Guidelines.

4.18 Provide secure, separate housing and bathroom accommodations for males and females; common use of kitchen facilities and dining rooms is acceptable.

4.19 Provide services twenty-four (24) hours a day for Veteran placements lasting up to sixty (60) days per Veteran. Extensions beyond initial sixty (60) days should be authorized in writing by VA Liaison; extensions beyond six (6) months must be prior-approved by the Social Work Service Contract Coordinator/ COR;

4.20 Provide three (3) daily nutritious meals and reasonable accommodation for special dietary needs;

4.21 Provide a means for Veterans in the program to wash their own clothes or otherwise tend to laundry at no additional cost to the Veteran.

4.22 Provide secure, appropriate storage for both the Veteran’s belongings and medication (if applicable).

4.23 Provide quality case management services that utilize a Housing First approach and includes elements of motivational interviewing, harm reduction, critical time intervention, and other best practices that focus on the Veteran obtaining permanent housing

4.24 Maintain a minimum of one (1) staff member on-site at all times to ensure appropriate responses to matters involving Veterans safety

4.25 Provide a working phone line for Veterans, ensuring reasonably prompt communication with the VA is possible at all times to ensure they are able to communicate to manage their appointments with the VA.

5.0 Standards of Care: The Contractor’s personnel(s) care shall cover the range of Community Based Residential Treatment for Substance Use Disorders as would be provided in a state-of-the-art civilian treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized national standards as established by:

5.1.1 The American Psychiatric Association Standards

5.1.2 The professional standards of the TJC or equivalent http://www.jointcommission.org/standards_information/hap_requirements.aspx. Even if the facility is not accredited by TJC, the TJC standards for Behavioral Health Care for Substance Use Disorders must be met or exceeded.

5.1.3 CARF http://www.carf.org/Programs/BH/

5.1.4 NICE guidelines

5.1.5 The requirements contained in this PWS

5.2 MEDICAL RECORDS

5.2.1 Authorities: Contractor Personnel providing healthcare services to patients shall be considered as part of the Department Healthcare Activity and shall comply with the U.S.C.551a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts 160, 162, and 164 (HIPAA).

5.2.2 An individual medical record shall be developed with the assistance of VA staff and maintained by Contractor Personnel staff on each Veteran receiving healthcare treatment. All medical records concerning the Veteran’s care will be readily accessible to the VAMC facility. The medical record maintained by the contractor shall include the following:

5.2.2.1 Reason for referral

5.2.2.2 Essential identifying data relevant to the Veteran and Veteran’s family

5.2.2.3 Data relating to the Veteran’s admission to include the targeted individual goals for constructive changes which are to be attained during the Veteran’s stay at the contractor’s facility

5.2.2.4 Record or log of medical prescriptions issued by physicians

5.2.2.5 Reports of periodic re-evaluation by program staff, to include any measures of movement towards rehabilitation goals

5.2.2.6 Discharge summaries on each Veteran who leaves the program to include a description of beneficial changes realized during the residential period, reasons for leaving, the Veteran’s future plans, housing status and if possible, follow-up locator information

5.2.2.7 Treatment plan and treatment plan reviews. When requested, the contractor shall provide copies of each Veteran’s treatment plan/review to the VAMC

5.2.2.8 It is agreed that the VA may readily have access to all medical records on all VA beneficiaries. Records shall be retained by the contractor for a period of at least five (5) years following termination of care.

5.3. HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to: a health care provider for treatment. Based on this exception, a BAA is not required for this contract. Treatment and administrative patient records generated by this contract or provided to the Contractor by the VA are covered by the VA system of records entitled ‘Patient Medical Records-VA’ (24VA19). Contractor generated Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services are available for immediate transmission when requested by the VA. Records identified for review, audit, or evaluation by VA representatives and authorized federal and state officials, shall be accessed on-site during normal business hours or mailed by the Contractor at his/her expense. Contractor shall deliver all final patient records, correspondences, and notes to the VA within twenty-one (21) calendar days after the contract expiration date.

5.4. Disclosure: Contractor and Contractor Personnel may have access to patient medical records; however, Contractor and Contractor Personnel shall obtain permission from the VA before disclosing any patient information. Subject to applicable federal confidentiality or privacy laws, the Contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over Contractor, may have access to VA’s records, at VA’s place of business on request during normal business hours, to inspect and review and make copies of such records. The VA will provide the Contractor with a copy of VHA Handbook 1907.1, Health Information management and Health Records and VHA Handbook 1605.1, Privacy and Release of Information through links included in section 1.3 herein. The penalties and liabilities for the unauthorized disclosure of patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

5.5. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Handbook 1907.01 Health Information Management and Health Records (link included in Section 1.3 herein) and all guidelines provided by VISN 8 facilities. Medical record entries shall be legible and maintained in detail consistent with good medical and professional practices so as to facilitate internal and external peer reviews, medical audits and follow-up treatments. Copies of received medical information shall be authenticated (signed) copies.

5.6. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. In the case of the VA authorizing the Contractor to release patient information, the Contractor in compliance with VA regulations, and at his/her own expense, shall use VA Form 3288, Request for and Consent to Release of Information from Individual’s Records, to process “Release of Information Requests.” In addition, the Contractor shall be responsible for locating and forwarding records not kept at their facility. The VA’s Release of Information Section shall provide the Contractor with assistance in completing forms. Additionally, the Contractor shall use VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information when releasing records protected by 38 U.S.C. 7332, Confidentiality of Certain Medical Records. Treatment and release records shall include the patient’s consent form. Completed Release of Information requests shall be forwarded to the VA Privacy Officer at the applicable VAMC. The VA Privacy Officer information shall be provided at the time of task order award.

5.7. Site Visits: The VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this contract, through one (1) or a combination of the following methods: reviews of State agencies reports; on-site inspection of the facility by VA staff; and/or on-site monitoring of VA patients. The facility shall provide the VA with copies of all state agency reports when requested, and cooperate fully with VA’s QI or QA program functions relating to the contract, including VA’s onsite inspection and monitoring. The VA CO shall make all final determinations as to the Contractor’s reasonable cooperation with VA compliance with these requirements.

5.8. Discharge education: The contractor is the primary agency responsible for discharge planning. Discharge planning shall begin upon admission. Discharge planning shall address and coordinate appropriate follow up services, housing needs, economic stability, support networks, and other relevant needs of the Veteran. The contractor shall attempt, and document, follow up with Veterans that unexpectedly leave the program. Contractor shall notify the VA COR or designee immediately if any patient unexpectedly leaves the program.

5.9. Contractor Personnel shall keep the referring VA Physician informed verbally on a weekly basis of the VA patient’s progress, or more frequently up to daily if requested by VA.

5.10. The Contractor shall designate an individual who can be contacted for any clinical problems or issues that arise during the performance of this contract. The designees for the Government will be the COR’s for this contract.

5.11. VISN 8 will pay for the patient’s care and treatment as outlined in the terms of the contract until the VA patient is transferred or discharged.

5.12. Notification of Death of Veterans: In the event of a death of any veteran, the Contractor agrees to notify VA immediately of the death. In the event a death of a VA beneficiary while receiving care under this contract, the facility shall promptly notify the VA facility which authorized admission and immediately assemble, inventory, and safeguard the patient’s personal effects. The funds, deposits, and effects left by the VA patients upon the premises of the facility shall be delivered by the facility to the person(s) entitled thereto under the laws currently governing the facility for making disposition of funds and effects left by patients, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.

5.13. When disposition has been made, the itemized inventory with annotation as to the disposition of the funds and effects shall be immediately forwarded to the VA facility authorizing admission. Should a deceased patient leave no will, heirs, or next of kin, his/her personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases, the facility shall forward an inventory of any such property and funds in its possession to the VA facility authorizing admission and shall hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition. CMS regulations require retention of records for five (5) years when there is no requirement in State law.

1. ADMINISTRATIVE:

0. Quality Improvement Meetings: Contractor Personnel shall participate in continuous quality improvement activities and meetings with committee participation as required by the Contractor’s establishment

0. Staff Meetings/Rounds: Contractor Personnel shall attend staff meetings as required by the Contractor’s establishment.

0. QA/QI documentation: Contractor Personnel shall complete the appropriate QA/QI documentation pertaining to care as needed.

0. Patient Safety Compliance and Reporting: Contractor Personnel shall follow all established patient safety and infection control standards of care. Contractor Personnel shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breeches of patient safety shall be reported to the COR in accordance with the VA Safety Policy. As soon as practicable (but within twenty-four (24) hours). Contractor Personnel shall notify the COR of the incident and submit to the COR a Patient Safety Report, following up with the COR as required or requested. A copy of the Patient Safety Report will be provided when needed.

1. PERFORMANCE STANDARDS, QUALITY ASSURANCE AND QUALITY IMPROVEMENT

1. Quality Management/Quality Assurance Surveillance: Contractor performance will be monitored by the Government using the standards as outlined in this PWS and methods of surveillance detailed in the QASP. The QASP is included as an attachment to this solicitation in section D and define the methods and frequency of surveillance conducted.

1. Patient Complaints: The CO will resolve complaints concerning Contractor relations with Government employees or VA patients. The CO is the final authority on validating complaints. In the event that Contractor Personnel are involved and named in a validated VA patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse.

1. The Government reserves the right to refuse acceptance of any Contractor Personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall handle issues raised concerning Contractor Personnel conduct. The final arbiter on questions of acceptability is the CO.

1. Quality Management reports shall be submitted to the VISN 8 Quality Management Department on a Quarterly basis. Reports shall include morbidity and mortality data, performance improvement and quality control activities relating to the Contractor’s facility and VA patients referred by the applicable facility to the Contractor. The COS should be notified of sentinel events as defined by TJC or equivalent, immediately upon occurrence.

1. This contract requires establishment and documentation of treatment goals specific to the patient’s condition and designed to specifically address each problem identified in the evaluation; design of a plan of care addressing the patient’s disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment; continued assessment and analysis during implementation of the services at regular intervals. Assessment and analysis includes but is not limited to measurement-based outcomes using standardized assessments at regular intervals.

1. Although status is reported weekly, progress must be shown over the preceding two (2)-week period toward meeting the goals as determined by measurement-based outcomes used by the facility. If a patient has not shown progress toward goals in the preceding two (2)-week period, the treatment plan should be reviewed with input from the VA referring provider. Lack of progress toward goals over a four (4) -week period may be grounds to discontinue Contractor services for that Veteran at the discretion of the VA.

1. Deliverables:

6. The contractor shall provide the following deliverables as required:

6. Contractor shall submit a Quality Control Business Plan that supports the program objectives and associated tasks. The CO shall review and comment as necessary to ensure that contract goals are met.

6. Contractor shall provide a detailed staffing and service plan. Plan should demonstrate that sufficient professional personnel are employed to carry out the policies, responsibilities, and services required under this contract. The Contractor must identify each person functioning as “Key Personnel” under this contract, and provide the VA with a description of the services to be provided by each person. The Contractor shall assign to this contract personnel that by education and/or training (and, when required, certification or licensure) are qualified to provide the services required by this PWS. Contractor may be required to supply a resume(s) summarizing relevant skills and experience of any/all key personnel upon request.

6. Contractor shall provide written documentation constituted by the individual Veteran case record that verifies the provision of all supportive services required under this contract for each Veteran participant.

6. The written plan of care shall be completed and entered into the individual Veteran case record no later than day 14 days after being admitted to the program. An individual clinical record will be developed with the assistance of the VA staff and maintained by the contractor on each Veteran placed under this contract

6. All case records shall be maintained with such security and confidentiality as required, and shall be made available on a need-to-know basis to appropriate VA staff members involved with the care of the Veterans concerned. The clinical record maintained by the contractor will include:

6. Reasons for referral;

6. Essential identifying data relevant to the Veteran and Veteran's family;

6. Data relating to the Veteran's admission to include medical condition and housing needs.

6. Record or log of medical prescriptions issued by physicians;

6. Reports of periodic re-evaluation by program staff, to include any measures of movement toward recovery goals and establishing independent housing.

6. Discharge summaries on each Veteran who leaves the program to include a description of the Veteran’s housing plan/status, the Veteran's future plans, and if possible, follow-up locator information.

6. The VA may readily have access to all medical records concerning the Veteran’s care with the contractor. Upon discharge or death of the Veteran, medical records on all VA beneficiaries will be retained by the contractor for a period of at least five years following termination of care.

6. The following is a list of mandatory tasks and associated deliverables:

6. All Veterans shall be provided clean, safe, and sanitary housing. Each occupant shall be provided one single bed, storage space, and one dresser with at least two drawers. All Veterans will have access to indoor and outdoor recreational and lounging areas.

6. Veteran dietary needs shall be met in accordance with sound medical care and shall include the following:

6. At least three (3) nutritious meals served daily at regular times with no more than a fourteen (14) hour span between evening and breakfast of the following day. Between-meal or bedtime snacks of nourishing quality shall be offered.

6. Food must be prepared, served, and stored under sanitary conditions.

6. Sanitary procedures established and maintained for washing dishes, cleaning equipment and work areas, and proper waste disposal.

6. The contractor shall provide laundry facilities and laundry detergent, at no cost to the Veteran.

6. The contractor shall maintain a participant handbook that includes program guidelines and a grievance policy. At the time of admission, each Veteran shall be provided a copy of the program handbook. The grievance procedure shall be posted and remain available to Veterans.

6. The contractor shall provide therapeutic and rehabilitative services that include the following:

6. The contractor shall provide structured activities that include Veteran participation in group sessions, individual sessions, and other clinical interventions. Individualized treatment goals and interventions will be based on a combination of Veteran input and recommendations of clinical staff. VA staff may also participate in treatment planning.

6. The contractor shall provide a variety of group activities, including healthy recreational and leisure activities, healthy physical activities, and participation in community events.

6. The contractor shall address health and personal hygiene maintenance.

6. Medications including controlled substances shall be properly stored and controlled.