36C25226Q0636 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)

1 9

Department of Veterans Affairs 36C252 115 South 84th Street, Suite 101

Milwaukee WI 53214-1476

Department of Veterans Affairs 36C252 Great Lakes Acquisition Center - HC 115 South 84th Street, Suite 101 Milwaukee WI 53214-1476

To all Offerors/Bidders

36C25226Q0636

08-19-2026

X

X X

See CONTINUATION Page

X 1

The purpose of this amendment is to post questions received in response to this Solicitation along with their respective answers and to update the Statement of Work.

See Continuation Pages.

Robert Ruska Contracting Officer

RFQ Q&A

Solicitation 36C25226Q0636

On-site Survey Readiness Services (Physical Environment / Life Safety)

1. Please clarify whether the Government will consider the relevant experience and prior contracts of a proposed subcontractor or similarly situated certified SDVOSB/VOSB teaming partner toward the offeror’s minimum three-year experience and three-contract requirements, provided the offeror remains the prime contractor and complies with the applicable limitations on subcontracting.

A: Subcontractor experience will not satisfy the Governments’ requirement of demonstrating at a minimum, three (3) consecutive years’ experience.

2. If team-member experience may be considered, please also confirm whether the experience must be held by the same individual proposed as the surveyor, by the performing firm, or whether either may satisfy the requirement when adequately documented.

A: To satisfy the minimum five (5) years’ experience for the Surveyor under Section 6 of the Statement of Work, the experience must be held by the same individual.

3. Will the Government consider the documented Joint Commission Physical Environment and Life Safety experience of the individual who will personally perform the surveys toward the three-year experience requirement, where that experience was earned as a VHA executive rather than under contracts held by this firm? If the requirement is strictly a firm-level pass or fail gate, we would appreciate that confirmation so offerors can respond accordingly.

A: How the Offeror demonstrates the requirement of a minimum, three (3) consecutive years’ experience is ultimately up to the Offeror. Please keep in mind of the Government’s requirement that “Offeror shall provide at minimum three (3) examples of previous contracts that collectively appear to be of similar size and scope.” Government contract examples are preferred, but an Offeror will not be penalized for contracts submitted outside of the Federal Government. Subcontractor experience will not satisfy the Governments’ requirement of demonstrating at a minimum, three (3) consecutive years’ experience.

See 52.212-2 EVALUATION—COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES (NOV 2021) (DEVIATION OCT 2025) for how Offerors will be evaluated.

4. Does mock Joint Commission survey experience performed within VHA, in an official capacity across a VISN, count toward the five-year requirement in paragraph 6? Or does the Government require that the experience have been performed under contract?

A: As long as the Governments’ requirements in Section 6 of the Statement of Work are met and the Offeror is able to demonstrate at a minimum, three (3) consecutive years’ experience, this will satisfy the Government’s experience requirements. Please keep in mind of the Government’s requirement that “Offeror shall provide at minimum three (3) examples of previous contracts that collectively appear to be of similar size and scope.”

Government contract examples are preferred, but an Offeror will not be penalized for contracts submitted outside of the Federal Government.

5. Would the Government identify which healthcare certifications it considers qualifying, so that offerors can address paragraph 6 precisely?

A: Qualified individuals shall have expertise in Healthcare Safety and Health, demonstrated experience in conducting Healthcare Physical Environment surveys, and proficiency in evaluating the Joint Commission Physical Environment (Environment of Care) standards. These standards encompass safety, security, hazardous materials and waste, fire and life safety, equipment, and utilities management. Knowledge is evident through relevant training and education, as well as recognition as a subject matter expert. This includes designing programs, implementing regulatory standards and codes within a healthcare setting, and advising on improvements in engineering controls and program advancement.

STATEMENT OF WORK (SOW)

Department of Veterans Healthcare Administration (VHA)

On-site Survey Readiness Services (Physical Environment / Life Safety)

1. BACKGROUND: The Department of Veterans Affairs (VA) Facilities have been accredited for over 35 years. The accreditation process is a complex system of interrelated activities that ensures the VA maintains a constant state of regulatory readiness and a safe healthcare environment. These services shall support eight (8) medical facilities in establishing a continuous readiness program to achieve and maintain compliance with Joint Commission (JC) standards. This includes compliance with the JC Program, Physical Environment (PE), Life Safety (LS), and Emergency Management (EM) standards. The process encompasses pre-survey, survey, and post-survey activities, including effective communication.

2. OBJECTIVE: The objective of this contract is to provide Survey Readiness services for eight

(8) VHA healthcare facilities focused specifically on areas pertaining to the PE and LS sections of JC Accreditation Manual as well as the National Patient Safety Goals and all current Memoranda of Understanding (MOUs) and categorical waivers to certain requirements between VHA and the JC pertaining to PE and LS accreditation requirements.

a. Places of Performance:

Jesse Brown VA Medical Center (JB VAMC) 820 S Damen Ave., Chicago, IL 60612 Hours: Monday - Friday 8:00am – 4:30pm (Local)

Illiana Health Care System (IHCS) 1900 E Main St., Danville, IL 61832

Captain James A. Lovell Federal Health Care Center (FHCC) 3001 Green Bay Rd., North Chicago, IL 60064

Edward Hines, Jr. VA Medical Center (Hines VAMC) Roosevelt Road and 5th Ave., Hines, IL 60141

Oscar G. Johnson VA Medical Center (OGJ VAMC) 325 E H St., Iron Mountain, MI 49801

William S. Middleton VA Medical Center (Madison VAMC) 2500 Overlook Terrace, Madison, WI 53705

Tomah VA Medical Center (Tomah VAMC) 500 East Veteran St., Tomah 54660

Clement J. Zablocki VA Medical Center (Milwaukee VAMC) 5000 W National Ave., Milwaukee, WI 53295

b. Period of Performance: Performance shall begin within thirty (30) days after contract award. Performance shall be completed with one-hundred eighty (180) days after contract award.

3. DEFINITIONS AND TERMS: As used throughout this Statement of Work, the following terms shall have the meaning set forth below:

a. Physical Environment (PE) The objective of this chapter is to foster a safe, functional, and supportive environment within the hospital to ensure the preservation of quality and safety. The environment of care consists of three fundamental elements:

- The building or space, including how it is arranged and special features that protect patients, visitors, and staff.

- Equipment used to support patient care or to safely operate the building or space.

- People, including those who work within the hospital, patients, and anyone else who enters the environment, all of whom have a role in minimizing risks.

b. Fire Safety Management

Activities selected and implemented by the organization to assess and control the risks of fire, smoke, and other byproducts of combustion that could occur during the organization’s provision of care, treatment, or services.

c. Fire-Rated

Material that has undergone a test and is fire protection rated, or fire resistance rated.

Two examples of the concept of fire-rated include the following:

- fire resistance rating - The time, in minutes or hours, that materials or assemblies have withstood fire exposure, as determined by tests, or methods based on tests, prescribed by the National Fire Protection Association (NFPA).

- fire protection rating - A designation indicating the duration of fire test exposure to which a fire door assembly or fire window assembly was exposed and for which it met all the acceptance criteria, as determined in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, or NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies.

d. Fire Watch

The assignment of a person or persons to an area for the express purpose of protecting occupants from fire or similar emergencies. Examples of this protection include:

- Notifying the fire department, the building occupants, or both of an emergency.

- Preventing a fire from occurring.

- Extinguishing small fires.

e. Hazardous Materials and Waste

Materials whose handling, use, and storage are guided or defined by local, state, or federal regulations, such as the Occupational Safety and Health Administration’s Regulations for Bloodborne Pathogens regarding the disposal of blood and blood-soaked items and the Nuclear Regulatory Commission’s regulations for the handling and disposal of radioactive waste. This also includes hazardous vapors (for example, glutaraldehyde, ethylene oxide, nitrous oxide) and hazardous energy sources (for example, ionizing or nonionizing radiation, lasers, microwave, ultrasound). Although the JC considers infectious waste to fall within this category of materials, federal regulations do not define infectious or medical waste as hazardous waste.

f. Life Safety Code®

A set of standards for the construction and operation of buildings intended to provide a reasonable degree of safety during fires. These standards are prepared, published, and periodically revised by the National Fire Protection Association (NFPA) and adopted by JC to evaluate health care organizations under its life safety management program. The VHA adopts and uses the current edition of each NFPA code.

g. Utility Systems

Building systems that provide support to the physical environment, including electrical distribution and emergency power; vertical and horizontal transport; heating, ventilating, and air conditioning (HVAC); plumbing, boiler, and steam; piped gases; vacuum systems; and communication systems, including data exchange systems.

h. Acronyms Applicable to this Statement of Work:

COR - Contracting Officers Representative PE - Physical Environment LS - Life Safety NFPA - National Fire Protection Association JC - Joint Commission

4. TASKS TO BE ACCOMPLISHED: The Contractor shall provide all necessary resources to the VA Medical Centers listed above to provide Survey Readiness Services. The Contractor shall provide a limited range of survey readiness services (Mock Joint Commission/Physical Environment standard/LS Survey) to include accreditation-related services that are offered and conducted on a scheduled basis in the areas of PE and LS. There are currently eight (8) medical facilities that will be reviewed. Elements to be reviewed shall include, but are not limited to, the following.

a. Joint Commission Physical Environment (JC/PE):

I. Plan (current JC/PE standard) II. Implement

i. Safety and Security (current JC/PE standard)

ii. Hazardous Materials and Waste (current JC/PE standard)

iii. Fire Safety (current JC/PE standard)

iv. Medical Equipment (current JC/PE standard)

v. Utilities (current JC/PE standard)

vi. Other Physical Environment Requirements (current JC/PE standard)

III. Staff Demonstrate Competence (current JC/PE standard) IV. Monitor and Improve (current JC/PE standard)

b. Life Safety: (current edition of the NFPA/LSC)

I. Administrative Activities

i. Statement of Conditions (current JC/PE standard)

ii. Interim Life Safety Measures (current JC/PE standard)

II. Health Care Occupancy

i. All Health Care Occupancy Buildings

1. General Building Requirements (current JC/PE standard)

2. Means of Egress Requirements (current JC/PE standard)

3. Protection (current JC/PE standard)

(a) Fire Alarm (current JC/PE standard)

(b) Extinguishment (current JC/PE standard)

4. Special Provisions (current JC/PE standard)

5. Building Services (current JC/PE standard)

6. Operating Features (current JC/PE standard)

III. Ambulatory Health Care Occupancy

i. All Ambulatory Health Care Occupancy Buildings

1. General Building Requirements (current JC/PE standard)

2. Means of Egress Requirements (current JC/PE standard)

3. Protection (current JC/PE standard)

(a) Fire Alarm (current JC/PE standard)

(b) Extinguishment (current JC/PE standard)

4. Special Provisions (current JC/PE standard)

5. Building Services (LS.03.01.50)

6. Operating Features (current JC/PE standard)

A. The Contractor shall provide:

i. On-site Survey Readiness Services (Mock PE/LS Survey) for the eight (8) VHA medical facilities, focusing on the areas of PE and LS. Standards interpretation services shall be provided as necessary, including education and review of all applicable MOUs.

ii. The purpose of the mock surveys is to identify performance improvement opportunities and to maintain continual readiness to achieve and maintain compliance with the current JC Hospital Accreditation Standards Manual and other specialty manuals for the 2027 unannounced JC triennial surveys for the eight (8) medical facilities.

iii. Mock PE surveys shall be conducted prior to the beginning of Fiscal Year 2027 (OCTOBER 1, 2027) at each of the eight (8) medical facilities. The surveys shall include developing a survey agenda and reviewing the seven (7) Management Plans, performance improvement activities, annual evaluations, Statement of Conditions, and other pertinent PE/LS documents. The Contractor shall assess the documentation covering fire safety, medical equipment, and utility systems. A review of related PE/LS documentation from each facility’s Community-Based Outpatient Clinic (CBOC) is also required. PE/LS documentation for the CBOCs shall be provided by the VA. Inspection of the CBOCs is not required.

(a) The contractor shall provide a surveyor for twenty-one (21) days as listed below for the Mock PE/LS surveys. (Actual dates are to be mutually determined by Contractor and the Contracting Officer’s Representative (COR).

(1) JB VAMC 3 days

(2) IHCS 2 days

(3) FHCC 3 days

(4) HINES VAMC 3 days

(5) OGJ VAMC 2 days

(6) MADISON VAMC 2 days

(7) TOMAH VAMC 2 days

(8) MILWILWAUKEE VAMC 4 days

(b) A brief needs assessment shall be conducted with each facility prior to the surveys to determine focus areas to include: a review of hospital policies/procedures, Safety/EOC Committee training, improvement performance activities and goals, discussions with department heads, the building maintenance program, or any other area of weakness identified by the facility.

(c) The surveyor shall conduct a building tour, which shall include visits to patient care settings and other areas likely to be visited by JC. The surveyor shall provide consultation on the best methods to meet the standards and propose solutions to identify issues.

(d) The surveyor shall conduct one or more informal on-site educational sessions as needed, during scheduled survey dates, addressing shortcomings identified during the document review or building tour, or a general overview session for interested staff. These sessions shall be tailored to address the unique needs of each facility and the backgrounds of the attendees.

(e) The surveyor shall submit a written report by JC standard within fifteen (15) working days after each site visit. The report shall cite the applicable standard of noncompliance, provide a narrative assessment of noncompliance, and include specific recommendations for compliance. Any findings that may result in a finding of noncompliance shall be clearly identified in the report, along with a recommendation on how best to resolve the noncompliance. Findings of noncompliance and partial compliance shall be identified in the report. The report shall be submitted electronically in Microsoft Word to the Medical Center Director and the VISN Safety and Health Manager.

(f) The contractor shall provide an aggregated VISN-wide written report for VA

Leadership at the time of the VISN summation session. The summary report shall include facility findings, facility recommendations, general strengths and weaknesses, trends across the VISN, and general and site-specific recommendations.

5. Deliverables: The contractor shall provide the following deliverables:

a. Mock PE surveys at each of the eight (8) medical facilities.

b. An electronic report of findings shall be provided to the medical facility within fifteen (15) working days after the survey has been completed, citing the specific standard of noncompliance to be in Microsoft Word format, submitted to the Medical Center Director, and VISN Safety and Health Manager.

c. An electronic copy of the aggregated VISN-wide report of findings shall be provided to VISN prior to the summation conference to include facility findings, recommendations by facility, general strengths and weaknesses by facility, trends across the VISN, and general and site-specific recommendations to be in Microsoft Word format, submitted to the VISN Network Director and VISN Safety and Health Manager.

d. The surveyor shall conduct a summation conference, approximately two (2) hours with VISN Leadership (VISN Safety and Health Manager) at the end of all surveys to discuss findings and trends.

6. Qualifications: Qualified individuals shall have expertise in Healthcare Safety and Health, demonstrated experience in conducting Healthcare Physical Environment surveys, and proficiency in evaluating the Joint Commission Physical Environment (Environment of Care) standards. These standards encompass safety, security, hazardous materials and waste, fire and life safety, equipment, and utilities management. Knowledge is evident through relevant training and education, as well as recognition as a subject matter expert. This includes designing programs, implementing regulatory standards and codes within a healthcare setting, and advising on improvements in engineering controls and program advancement.

The Surveyor shall be an expert in PE and LS matters and have at least five (5) years’ experience in conducting mock JC surveys on the whole range of Physical Environment, Life Safety, and Emergency Management-related issues. Experience on national committees or authoring articles on PE/LS related issues is preferred. If the surveyor's performance is less than satisfactory, the VA reserves the right to request a substitute surveyor at no additional cost to the VA.

a. The surveyor shall use the most current JC Standards published in the Hospital Accreditation Standards Manual, Physical Environment Essentials for Health Care, and other related publications as enforced by the VHA.

7. Schedules and Coordination: All surveys shall be coordinated with the Safety and Health Manager.

a. Schedules for all contract services shall be approved/finalized as soon as possible after contract award, with a minimum of a two-week lead time from approval to scheduled task.

b. All contract services shall be completed within 180 days of the award.

c. Each facility survey shall be completed on consecutive days during normal business hours and not to be continued over a weekend. No services shall be provided on weekends or federal holidays.

d. The expectation is that the same surveyor shall survey all VISN medical facilities. No substitutions among surveyors shall be permitted without first consulting with the COR and Contracting Officer (CO).

8. Travel Expenses: All travel expenses associated with providing services under this contract are the Contractor's responsibility. The Contractor shall offer an all-inclusive price. The Government will not reimburse any travel expenses.

9. DOCUMENTATION AND BILLING CLARIFICATION: The actual cost for PE and LS surveys is based on the number of consultants and the length of the consultation. Required consultation days may vary based on changes in the size and complexity (square footage and services);

however, it is generally anticipated that a 2-day or 3-day review will be performed based on size.