36C25525Q0562 SS.pdf

Contract Opportunity Sources Sought Notice

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Q510

Interoperative Monitoring Services for the Columbia VAMC

66048

36C25525Q0562

09/08/2025 17:00 CENTRAL TIME, CHICAGO, USA

N

621399

Department of Veterans Affairs Network Contracting Office (NCO) 15 3450 S 4th Street Trafficway

Leavenworth KS 66048

Contracting Officer Jason Condiff Jason.Condiff@va.gov 913-946-1113

Harry S. Truman Memorial Veterans’ Hospital Columbia VAMC 800 Hospital Dr.

Columbi, MO

65201

USA

Jason.Condiff@va.gov

This is a SOURCES SOUGHT NOTICE. This notice is a market survey and is for information only, to be used for preliminary planning purposes. No proposals are being requested or accepted with this notice.

THIS IS NOT A SOLICITATION FOR QUOTES AND NO CONTRACT SHALL BE AWARDED FROM

THIS NOTICE.

The VA NCO 15 Contracting Center has been tasked to solicit for and award on-site Interoperative Monitoring Services for the Columbia, MO VAMC. Potential sources are responsible for the complete performance of the technical aspects of Intraoperative Neuromonitoring (neurophysiology) services. The proposed project is anticipated to be a firm, fixed-price requirement. The type of solicitation to be issued will depend upon the responses to this notice. No reimbursement will be made for any costs associated with providing information in response to this notice or any follow up information requested. The purpose of this notice is to gain knowledge of interest, capabilities and qualifications of various members of the Business Community to include Small Business or Large Business, Veteran Owned Small Business, Service-Disabled Veteran-Owned Small Business (SDVOSB), HUBZONE, 8(a), etc., to complete and perform a Firm, Fixed-Price contract. After review of the responses to this sources sought announcement, a synopsis and/or solicitation announcement may be published at a later time. The Government must ensure there is adequate competition among the potential pool of responsive contractors.

The duration of the requirement is for a base period (start-TBD and end TBD) with four each, one-year option periods. The North American Industrial Classification System (NAICS) Code applicable to this acquisition is 621399. The Small Business Size Standard for this acquisition is $10.0M.

Please limit your response to this synopsis to five pages and please include the following information:

- Your company's name, addresses, point of contact, phone number, and email address.

- Your company's interest in submitting a proposal on the solicitation when it is issued.

- Your company's capability to meet the requirements.

- Your company's capability to perform a contract of this type and comparable work performed within the past three years to include a brief description of the project, customer's name, phone number and address, period of performance, and dollar value of the project.

- Your company's Business Size (Large or Small) and Socioeconomic Status (Veteran Owned, SDVOSB, HUBZONE, 8(a), etc.).

- Your company's Joint Venture information (if applicable and include copy of agreement) - existing and potential

Please provide a capability statement addressing your organization's ability to perform as a prime contractor the work described in the draft PWS (below). Index your firm's capabilities to the tasks in the draft PWS so that your firm's capabilities can be readily assessed. This is not a request for proposal and in no way obligates the Government to award any contract. Interested companies are asked to respond to this Sources Sought Notice no later-than 5:00 PM (CST) on 09/08/2025. All interested companies must be registered for all award types in SAM (http://www.sam.gov/) to be eligible for award of government contracts. Please email your response to: Contracting Officer Jason Condiff, Email Address: Jason.Condiff@va.gov. Please reference the following solicitation number in the subject line of all correspondence submitted: 36C25525Q0562.

DRAFT: Performance Work Statement

1. GENERAL:

1.1. Services Provided: The Contractor shall provide VA and Joint Commission Certified Interoperative Monitoring services in accordance with the specifications contained herein to beneficiaries of the Department of Veterans Affairs (VA) and Harry S. Truman Memorial Veterans' Hospital.

1.1.1. Place of Performance: - Contractor shall furnish services at the Harry S. Truman Memorial Veterans' Hospital, 800 Hospital Dr. Columbia, MO 65201.

1.2. Scope: - The Contractor shall provide as needed and case-by-case service that enables

COLUMBIA VAMC to offer IONM options for patients under the direct medical care within the operating room. The IONM Contractor must be experienced and available to cover scheduled and emergency cases 24/7/365, within one hour of notification (onsite technical and online or in person professional services). Contractor Electro Neurophysiologic Technologist (s) shall provide interoperative neuromonitoring services. Contractor Neurologists shall provide comprehensive clinical guidance during the entire surgical procedure.

Services are “technical only” and shall include intraoperative, preoperative, postoperative neurophysiologic monitoring services and evoked potential testing for neurosurgery patients.

Contractor shall provide interoperative neuromonitoring services. Intraoperative monitoring modalities needed include: SSEPS, TcMEP, S-EMG, T-EMG, spinal cord mapping including D- Waves, DNEPs, NMEPs, Cortical, motor, sensory, language mapping, white matter tract and brainstem nuclei mapping, brainstem auditory evoked responses, visual evoked potentials, cranial nerve monitoring, and intraoperative EEG. Specialized cases are procedures requiring advanced IONM techniques or advanced skills including the following: cortical SSEP mapping, direct cortical stimulation mapping of motor cortex, language mapping, brainstem nuclear mapping, cerebral white matter mapping, cases requiring measurement of lateral spread, brachial plexus cases and selective dorsal root rhizotomies.

Services are to be conducted in the operating room on a per case basis as determined by the Chief of Surgical Service. The Surgical Chief shall notify the OR Manager or appropriate designee in Surgical Service when monitoring services are needed for a neurosurgical patient.

The OR Manager or appropriate designee will contact the Contractor with the request for monitoring. All changes to the proposed monitoring, to include date/time, type of monitoring, etc., will be conveyed by the OR Manager or appropriate designee to the Contractor.

2. QUALIFICATIONS:

2.1. Staff/Facility

2.1.1. License: Neurologists assigned by the Contractor to perform the services covered by this contract shall have a current license to practice medicine in the state of Missouri. All licenses held by the personnel working on this contract shall be full and unrestricted licenses. Contractor’s Neurologists who have current, full, and unrestricted Missouri licenses, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application may not be considered for the purposes of this contract.

2.1.2. Board Certification: - All Contractor provided Neurologists shall be Board Certified/Board Eligible as Neurologists by the American Board of Neurological Surgery. 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 on an annual basis for each year of contract performance.

2.1.2.1. All Contractor provided Electro Neurophysiologic Technologists who perform on-site

IONM services shall be accredited and registered through the American Board of Registered Electro Neurophysiologic Technologist (http://www.abret.org). This technical certification is intended for Technologists who work under supervision by a Neurophysiologist or Neurologist. 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 Contracting Officer Representative (COR) within the first thirty (30) days of contract award and shall provide on an annual basis for each year of contract performance.

2.1.2.2. All On-site Contractor provided personnel shall be certified in Basic Life Support (BLS). 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 on an annual basis for each year of contract performance.

2.1.3. National Provider Identifier (NPI): NPI is a standard, unique 10-digit numeric identifier required by HIPAA. This is applicable to contracted Neurologists providing services. The Veterans Health Administration must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). The Contractor shall have appropriate NPI and if pertinent, the Taxonomy Code confirmation notice issued by the Centers for Medicare and Medicaid Services (CMS) National Plan and Provider Enumeration System (NPPES). NPI’s must be provided to the Contracting Officer with the quote.

2.1.4. Conflict of Interest: The Contractor and all contractor’s providers of care are responsible for identifying and communicating to the CO and COR conflicts of interest at the time of quote and during the entirety of contract performance. At the time of quote, 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 must also 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.

2.1.5. Citizenship related Requirements:

2.1.5.1. 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 patient referrals;

2.1.5.2. 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 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.

2.1.5.3. 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 patient referrals; or other place where the contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.

2.1.5.4. 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.

2.1.5.5. The contractor agrees to obtain a similar certification from its subcontractors. The certification shall be made as part of the Contractors response to the RFQ using the subject attachment in Section D of the solicitation document.

2.1.6. Annual Office of Inspector General (OIG) Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the Department of Health and Human Services (HHS) Office of Inspector General (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.

2.1.6.1. 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 the proposed contractor’s providers of care 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 Civil Monetary Penalty (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.

2.1.6.2. By submitting their quote, the contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the contractors are and/or firm is not listed as of the date the offer/bid was signed.

2.2. Clinical/Professional Performance: The qualifications of contractor personnel are subject to review by VA Medical Center COS or his/her clinical designee and approval by the Medical Center Director as provided in VHA Handbook 1100.19. Clinical/Professional performance monitoring and review of all clinical personnel covered by this contract for quality purposes will be provided by the COLUMBIA VAMC COS and/or the Chief of the Service or his designee. A COR will be appointed, however, only the CO is authorized to consider any contract modification request and/or make changes to the contract during the administration of the resultant contract.

2.3. Non-Personal Healthcare Services: The parties agree that the contractor and all contractor’s Neurologists and Electro Neurophysiologic Technologist shall not be considered VA employees for any purpose.

2.4. Indemnification: The contractor shall be liable for, and shall indemnify and hold harmless the

Government against, all actions or claims for loss of or damage to property or the injury or death http://oig.hhs.gov/exclusions/index.asp of persons, arising out of or resulting from the fault, negligence, or act or omission of the contractor, its agents, or employees.

2.5. Prohibition Against Self-Referral: Contractor’s contracted personnel are prohibited from referring VA patients to contractor’s or their own practice(s)

2.6. Inherent Government Functions: Contractor and contractor’s providers of care 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.

2.7. No Employee status: The contractor shall be responsible for protecting the contractor’s providers of care 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:

• Workers’ compensation

• Professional liability insurance

• Health examinations

• Income tax withholding, and

• Social security payments.

2.8. Tort Liability: The Federal Tort Claims Act does not cover the contractor’s providers of care.

When a contractor or contractor’s contracted personnel have 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’s Neurologists or Electro Neurophysiologic Technologist) action or non-action shall be the responsibility of the contractor and/or insurance carrier.

2.9. Key Personnel:

2.9.1. Clinical Personnel Required: The contractor shall provide contracted Neurologists who are competent, qualified per this Performance Work Statement and adequately trained to perform assigned duties. Required to be available daily will be two (2) as defined in the Hours of Operation section.

2.9.2. Clinical Personnel Required: The minimum number of Board Certified/Board Eligible Electro Neurophysiologic Technologist required to be available daily will be two (2) as defined in the Hours of Operation section.

2.9.3. At all times during procedures in the operating room, the ratio of contracted staff to patient will be at a minimum, 1 to 1.

2.9.4. Personnel Substitutions: During the first ninety (90) calendar days of performance, the contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment. The contractor shall notify the CO, in writing, within three (3) calendar day(s) after the occurrence of any of these events and provide the information required below. After 90 days, the contractor shall submit the information required below to the CO at least 30 calendar days prior to making any permanent substitutions.

2.9.4.1. The contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO will notify the Contractor within ten (10) calendar days after receipt of all required information of the decision on the proposed substitutes. The contract will be modified to reflect any approved changes of key personnel.

2.9.4.2. For temporary substitutions where the key person shall not be reporting to work for three consecutive workdays or more, the contractor shall provide a qualified replacement for the key person. The substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above.

2.9.4.3. 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. Should the VA COS or designee show documented clinical problems or continual unprofessional behavior/actions with any Contractor’s Neurologist(s) or Technologist(s), s/he may request, without cause, immediate replacement of said Contractor’s Neurologist(s) or Technologist(s). The CO and COR shall deal with issues raised concerning Contractor’s Neurologist(s) or Technologist(s) conduct. The final arbiter on questions of acceptability is the CO.

2.9.4.4. Contingency Plan: Because continuity of care is an essential part of COLUMBIA

VAMC’s medical services, The contractor shall have a contingency plan in place to be utilized if the Contractor’s Neurologist(s) or Technologist(s) leaves contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

3. HOURS OF OPERATION

3.1. VA Business Hours: Normal hours of operations are 7:30 am – 5:00 pm, Monday through

Friday. The operating room is open 24 hours/day and a contractor shall be available for procedures 365 days/year, 24/7.

3.1.1. Contractor’s services shall be available and present for all hours of possible scheduled operations, which will be established, and may be revised, as deemed appropriate for patient care by the Chief of Staff. Currently normal operating room hours are 7:30 am – 5:00 pm, Monday through Friday.

3.1.1.1. During normal business hours of operation, contracted staff shall be onsite and ready to perform services 45 minutes prior to the start of surgery. Equipment and Technologist shall be cleared through biomed and SPS 45 minutes prior to surgical procedure.

3.1.2. Contracted personnel shall be available for procedures outside of normal hours of operations, including evenings, weekends and holidays.

3.1.2.1. Outside of normal business hours, contracted staff should report to the operating room within 60 minutes of being called for surgery.

3.2. Federal Holidays: The following holidays are observed by the Department of Veterans Affairs:

• New Year’s Day

• President’s Day

• Martin Luther King’s Birthday

• Memorial Day

• Juneteenth

• 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.

3.3 Cancellations: contractor will not cancel service for any reason.

3.3.1. Unless a state of emergency has been declared or clinics are otherwise cancelled by the COLUMBIA VAMC, the contractor shall be responsible for providing services.

4. CONTRACTOR RESPONSIBILITIES

4.1. The Contractor shall furnish all supplies, accessories, equipment, consumables, transportation, delivery, training, and services. The Contractor shall provide 24/7 case coverage and scheduling 365 days/year by Key Personnel who are on the key personnel roster. Electro Neurophysiologic Technologists must be available for onsite coverage before and during surgery. Contractor shall coordinate provision of services with the attending surgeon or designee. Contractor shall complete all administrative tasks and required documentation immediately following the procedures.

4.2. Contractors must comply with appropriate and applicable policies, procedures and regulations of the COLUMBIA VAMC as well as with centers for Medicare and Medicaid services (CMS) requirements and complete medical record deficiencies within policy guidelines. Services must meet Joint Commission clinical quality standards for intraoperative monitoring and be FPIS compliant. Quality reports required for quality assurance need to be JHACO certified.

4.3. The Contractor shall provide, transport, install, participate in the simulations, be available in live surgical cases and test the medical equipment prior to utilization.

4.4. Intraoperative Neuromonitoring (neurophysiology) services: The Electro Neurophysiologic

Technologist shall be under direction of the OR Surgeon and shall perform multiple modality evoked potentials on patients in the operating room at the COLUMBIA VAMC. Procedures may include stimulate screws and stimulate nerves. The Electro Neurophysiologic Technologist will be responsible for setting up all necessary OR equipment and supplies necessary for neurophysiological intraoperative monitoring and the placement of suitable electrodes on predetermined measured positions on the patient’s body. Technologist must accurately apply all recording and stimulating electrodes. Once connected to the machine in the operating room, data can be interpreted by the Neurophysiologist (on-site) or remotely where the data is transmitted using a secure HIPAA compliant internet connection.

4.5. Intraoperative monitoring modalities needed include: SSEPS, TcMEP, S-EMG, T- EMG, spinal cord mapping including D-Waves, DNEPs, NMEPs, Cortical, motor, sensory, language mapping, white matter tract and brainstem nuclei mapping, brainstem auditory evoked responses, visual evoked potentials, cranial nerve monitoring, and intraoperative EEG.

Specialized cases are procedures requiring advanced IONM techniques or advanced skills including the following: cortical SSEP mapping, direct cortical stimulation mapping of motor cortex, language mapping, brainstem nuclear mapping, cerebral white matter mapping, cases requiring measurement of lateral spread, brachial plexus cases and selective dorsal root rhizotomies.

4.6. Contractor shall interpret the intraoperative monitoring recording and make recommendations regarding action or consequence to the attending Neurosurgeon. The Electro Neurophysiologic Technologist will recognize artifacts in the data differentiate them from evoked potential patterns and take appropriate steps to eliminate them. They will obtain patient medical information when requested and will translate test results from computer files to a hard copy report for VA Neurophysiologic Technologist’s interpretation.

Contractor must be proven capable of identifying monitored waveforms and any variation from baseline.

Contractor must demonstrate an understanding of anesthetic techniques and physiologic changes that can affect the waveforms being monitored.

4.7. The Contractor will establish communication protocols with the surgical team to report monitoring activity. The Neuromonitoring team will provide all resources required to ensure a smooth transition in accordance with the contract requirements.

4.8. The Electro Neurophysiologic Technologist will be sufficiently knowledgeable and test equipment prior to use and to make any adjustments in the equipment settings that are required. The Electro Neurophysiologic Technologist will select predetermined electrode combinations as well as non-standard assortments as necessary. The Electro Neurophysiologic Technologist will obtain standard recordings and report on-going status of patient’s nervous system to the surgeon.

4.9. The Electro Neurophysiologic Technologist will recognize artifacts in the data differentiate them from evoked potential patterns and take appropriate steps to eliminate them. They will obtain patient medical information when requested and will translate test results from computer files to a hard copy report for Neurologists interpretation. The Electro Neurophysiologic Technologist staff will also be responsible for removing electrodes post procedure and returning equipment if COLUMBIA VAMC to specified locations or remove the contractor’ supplied equipment from the operating room upon completion of each procedure.

4.10. On-site Contracted personnel shall be responsible for signing in and out when in attendance in the operating room. Attendance rosters shall be used for verification of worked performed by the COR. Failure to sign in and out on the attendance log may delay payment for services being rendered.

4.11. QA/QI documentation: The contractor’s neurologists shall complete the appropriate documentation pertaining to all procedures, complications and outcome of examinations by secure communication within 24 hours following procedure.

4.12. The contractor shall submit an equipment service report to the COR within 24 hours of the completion of the surgical case.

4.13. Contractor’s Neurologists shall follow all established patient safety and infection control standards of care. Contractor’s Neurologists shall make every effort to prevent surgical complications 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 as soon as practicable (but within 24 hours). Contractors shall notify COR of incident and submit to the COR the patient safety report, following up with COR as required or requested.

4.14. Equipment: COLUMBIA VAMC will not procure, or provide separate compensation for contractor’s use of, any equipment required to perform services or necessary accessories/supplies under this contract. Contractor may utilize existing COLUMBIA VAMC monitoring equipment and software or may provide and utilize its own equipment and software if preferred, so long as its efficacy and reliability can be evidenced. The COLUMBIA VAMC will not be responsible for the contractor’s equipment for costs of repairs and or replacements of such equipment, technology, or software. Contractor has full responsibility of using its own technology to conduct IONM services. the contractor shall abide by all COLUMBIA VAMC policies and procedures regarding the maintenance, use and safety of any clinical equipment utilized by the Technologist in the or at COLUMBIA VAMC.

4.14.1. Contractor shall be responsible for computer networking assistance reasonably necessary for the technologist to perform IONM services at its own expense if using company owned equipment.

5. STANDARDS OF CARE: The Contractor and contractor’s providers of care shall cover the range of Neurological services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized national standards as established by:

• Certification in American Board of Psychiatry and Neurology http://www.abpn.com

• Neurophysiologic Intraoperative Monitoring (CNIM) from the American Board of Registered

Electro Neurophysiologic Technologist (http://www.abret.org)

• This technical certification intended for technologists who work under supervision by a neurophysiologist or neurologist. American Board of Neurophysiologic Monitoring (ABNM) certification (http://abnm.info)

• The American College of Neurology (ANN): https://www.aan.com/policy-and-guidelines/guidelines/

• The professional standards of the Joint Commission (TJC) http://www.jointcommission.org/standards_information/hap_requirements.aspx

• The standards of the American Hospital Association (AHA) http://www.hpoe.org/resources?show=100&type=8 and;

• The requirements contained in this PWS.

6. MEDICAL RECORDS

6.1. Authorities: Contractor and contractor’s providers of care providing healthcare services to VA 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).

6.2. 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.

6.3. Patient records: Treatment and administrative patient records generated by this contract or provided to the contractors by the VA are covered by the VA system of records entitled ‘Patient Medical Records-VA’ (24VA19). Contractor generated VA 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 expense. Contractor shall deliver all final patient records, correspondence, and notes to the VA within twenty-one (21) calendar days after the contract expiration date.

6.4. Disclosure: Contractor and contractor’s providers of care may have access to patient medical records; however, contractor 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 http://www.abpn.com/ http://www.abret.org/ http://abnm.info/ https://www.aan.com/policy-and-guidelines/guidelines/ https://www.aan.com/policy-and-guidelines/guidelines/ http://www.jointcommission.org/standards_information/hap_requirements.aspx http://www.hpoe.org/resources?show=100&type=8 http://www.rms.oit.va.gov/SOR_Records/24VA19.asp http://www.rms.oit.va.gov/SOR_Records/24VA19.asp 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. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the contractor.

6.5. Confidentiality of Patient Records:

6.5.1. The Contractor, as a VA provider, will assist in the provision of health care to patients seeking such care from or through VA. As such, the Contractor is considered as being part of the Department health care activity. Contractor is considered to be a VA provider for purposes of the Privacy Act, Title 5 U.S.C. 552a. Further, for the purpose of VA records access and patient confidentiality, Contractor is considered to be a VA contractor for the following provisions: Title 38 U.S.C. 5701, 5705, and 7362. Therefore, Contractor may have access, as would other appropriate components of VA, to patient medical records, including patient treatment records pertaining to drug and alcohol abuse, HIV, and sickle cell anemia, to the extent necessary to perform its contractual responsibilities. However, like other components of the Department, and not withstanding any other provisions of the contract, the Contractor is restricted from making disclosures of VA records, or information contained in such records, to which it may have access, except to the extent that explicit disclosure authority from VA has been received. The Contractor is subject to the same penalties and liabilities for unauthorized disclosures of such records as VA

6.5.2. The records referred to above shall be and remain the property of VA and shall not be removed or transferred from VA except in accordance with 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), and federal laws, rules and regulations. 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.

6.6. 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:

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791 and all guidelines provided by the COLUMBIA VAMC.

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469 http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1423 http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1423 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791