36C25926Q0188.docx

SUBJECT*

Psychiatric Step Down Short-Term Transitional Residential Care

GENERAL INFORMATION

Network Contracting Office

NCO 19

6162 South Willow Drive, Suite 300 Greenwood Village CO 80111

POINT OF CONTACT*

Contract Specialist Haylee Schrick-Ange haylee.schrick-ange@va.gov

PLACE OF PERFORMANCE

Rocky Mountain Regional VA Medical Center

1700 N. Wheeling Street

Aurora Colorado

ADDITIONAL INFORMATION

DESCRIPTION

THIS IS A SOURCE SOUGHT NOTICE / REQUEST FOR INFORMATION (RFI) ONLY. THIS IS NOT A REQUEST FOR PROPOSAL AND/OR QUOTE.

Disclaimer This Sources Sought is issued solely for the purpose identifying potential sources for a future requirement and does not constitute a solicitation. All information received in response to this notice that is marked as proprietary will be handled accordingly. Responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. Responders are solely responsible for all expenses associated with responding to this Sources Sought notice.

Synopsis This is not a solicitation announcement. This is a Sources Sought synopsis only. The purpose of this is to gain knowledge of potential qualified sources. A solicitation is not being issued at this time, and this notice shall not be construed as a commitment by the Government to issue a solicitation or ultimately award a contract, nor does it restrict the Government to a particular acquisition approach. Any information provided by industry to the Government as a result of this sources sought synopsis is strictly voluntary. Responses will not be returned. No entitlements to payment of direct or indirect cost or charges to the Government will arise as a result of contractor submission of responses or the Government's use of such information.

The Government is contemplating North American Industry Classification Systems (NAICS) 623220, Residential Mental Health and Substance Abuse Facilities (Size Standard: $19.0 Million). Comments on this NAICS and suggestions for alternatives must include supporting rationale.

Responses to this Sources Sought synopsis will be used by the Government to make appropriate acquisition decisions and are not considered adequate responses to a potential future solicitation announcement. After reviewing all responses to this synopsis, a solicitation announcement may be published via the Contracting Opportunities or GSA eBuy website.

The Department of Veterans Affairs (VA), Veterans Integrated Systems Network (VISN) 19 and the Network Contracting Office (NCO) 19 are performing market research to determine if there are Mental Health Transitional Living (MHTL) Homes within 60 miles of the Veterans Administration Medical Center.

Place of Performance: The contractor will provide services related to and must be currently licensed as an Mental Health Transitional Living (MHTL) Home (Level I or Level II) by the Colorado Behavioral Health Administration (CO BHA) or the Colorado Department of Human Services (CDHS) and the specific services indicated in the Statement of Work within 60-mile radius of the Rocky Mountain Regional VA Medical Center at 1700 N. Wheeling Street, Aurora, CO 80045.

Period of Performance: The Government is contemplating a period of performance for this contract of one (1) base year with four (4) option years, which may be exercised to extend the period of performance.

NAICS Code: 623220 - Residential Mental Health and Substance Abuse Facilities, PSC: Q519 – Medical – Behavioral and Mental Health, Small Business Size Standard: $19.0 Million

Responses Interested parties are requested to submit a statement of capability outlining past work that is related to this requirement listed above. The statement of capability shall include:

1. Vendor Name

2. Address

3. Point of Contact (POC)

4. Contact Phone Number(s)

5. Contact E-mail Address

6. CAGE Code

7. Business Category

8. Company's Business Size (i.e., annual revenues and employee size)

9. Brief Introduction of Company

10. Anticipated Teaming Arrangements (delineate between work accomplished by prime and work accomplished by teaming partners)

11. Description of Relevant Contract Experience (Government and Commercial)

a. Contract Number

b. Requirements Description

c. Total Contract Value (to include initial award amount and any modifications (description and value)

d. Place of performance

e. Organization to which contract is executed

i. POC Name

ii. Phone Number(s)

iii. E-mail address

12. Current price list for market research purpose only

13. Ability to meet VA requirement Again, any information submitted by the respondents to this source sought synopsis is strictly voluntary. The company's standard format is acceptable; however, the limit for all responses is not to exceed five (5) single-sided, 12 font size, 8 ½ x 11-inch pages. Capability must be submitted with enough detail for the Government to make an informed decision. The submitted information shall be UNCLASSIFIED.

Please email capability statements to: Contract Specialist, Haylee Schrick-Ange at Haylee.schrick-ange@va.gov by 2:00 PM Mountain Standard Time on February 13, 2026. Telephone inquiries will not be accepted. Please note " Psychiatric Step Down Short-Term Transitional Residential Care- RMRVAMC" in the subject line of the email.

Potential offerors are responsible for monitoring System for Award Management (SAM) website for the possible release of the solicitation package.

Sources Sought Notice Sources Sought Notice All Contractors doing business with the Federal Government must be registered in SAM.gov.

Sources Sought Notice

Performance Work Statement Page 1 of Page 1 of

1. PURPOSE.

0. The Veterans Affairs Eastern Colorado Health Care System in Aurora, Colorado (“VA ECHCS”), requires contractors to provide services as part of its Inpatient Psychiatric and Residential Continuum of Care to vulnerable Veterans following discharge from the Inpatient Mental Health Unit or Residential Treatment.

0. The contractor shall provide short-term, transitional, residential care in Mental Health Transitional Living (MHTL) Homes (Level I or Level II). This service will be paid for by the Bed Day of Care defined as initiating at 12:00 pm and terminating at 11:59 am the following day. Community Mental Health Centers will be well-suited to providing this service because they are accustomed to using their assisted living residence resources for short-term housing and due to their mental health expertise.

1. BACKGROUND.

The 2023 Veterans Health Administration (VHA) Inpatient Mental Health Services Directive (VHA Directive 1160.06) states: “The primary goal of Inpatient Mental Health Services is to provide a safe and secure therapeutic environment to stabilize Veterans experiencing acute distress and improve their functional status, so they no longer require acute hospitalization. This is accomplished through the provision of Services based on the guiding principles listed above, and to facilitate smooth care transitions that connect Veterans to services and supports at a less intensive level of care and facilitate post-discharge engagement.”

C. SERVICES TO BE PROVIDED

1. Basic Services:

The Mental Health Transitional Living (MHTL) Homes) shall be certified by the Colorado Behavioral Health Administration (CO BHA) or the Colorado Department of Human Services (CDHS) at level I or level II and shall provide room, board and at a minimum the following:

a. Contractor shall provide transportation via contractor vehicle to pick up Veterans discharged from VA facilities.

b. Contractor shall provide a physical environment that is safe and designed to support Mental Health Transitional Residential Treatment services.

c. Contractor shall provide a secured (locked) medication room/area and medication administration to Veterans by Contractor’s technicians who are Colorado Qualified Medication Administration Persons (QMAP) or Registered Nurses (RN).

d. Contractor shall offer telephonic coordination of care and clinical updates on an as needed (when clinical care concerns arise) basis with the Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC) Inpatient Mental Health Point of Contact (INPT MH POC).

e. Contractor shall ensure staff presence in the Contractor facility on a 24-hour basis. This includes monitoring the needs of patients to ensure the residents receive the services and care necessary to protect their health, safety, and well-being.

f. Contractor staff shall provide verbal prompting to encourage Veterans to complete activities of daily living that include getting out of bed in the morning, daily hygiene, attending groups, following up with VA appointments, and appropriate social skills.

g. Contractor shall assess Veteran needs, develop residential service plans with guidance from RMRVAMC INPT MH POC, monitor veteran treatment progress, and plan discharge disposition in consultation with RMRVAMC Inpatient Mental Health POC.

h. Contractor shall provide Residential Program milieu management including verbal prompting for group participation, encouragement for hygiene and basic self-care, and prevention of disruptive behavior.

i. Contractor shall provide daily rehabilitative activities and or group activities in accordance with CO BHA/CDHS MHLT licensure requirements. These may include daily community meetings or other supportive content like stress coping skills instruction.

j. Contract shall ensure CO BHA/CDHS licensure of the Contractor Facility/Program and that the MHLT meets established standards for health and safety which include resident rights, protection from abuse, quality of residents’ lives, and quality of residents’ care through unannounced annual surveys and compliance inspections.

1. The Contractor shall comply with applicable requirements of the Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part II) and the Confidentiality of Certain Medical Records (38 USC 7332).

1. The Contractor shall comply with the principles listed in 38 CFR 17.707(b) to provide housing and supportive services in a manner that is free from religious discrimination.

D. ADDITIONAL CONTRACT REQUIREMENTS

1. Contractor agency shall be currently licensed as a Mental Health Transitional Living (MHTL) Home (Level I or Level II) by the Colorado Behavioral Health Administration (CO BHA) or the Colorado Department of Human Services (CDHS)

1. The Contractor’s facility must be located within a 60-mile radius of the Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC) to ensure easy transportation of patients between the facilities. The RMRVAMC is located at 1700 N. Wheeling Street in Aurora, CO 80045.

1. Personnel All services under this contract shall be performed by qualified staff including:

i. Residential Counselors, Residential Program Managers, and Registered Nurses

ii. Any staff administering medications shall be certified in Qualified Medication Administration Person (QMAP).

iii. Staff shall be proficient and trained yearly in patient rights and Basic Life Support (BLS) certification.

E. KEY PERSONNEL- DUTIES AND RESPONSIBILITIES

1. MHTL Step-Down Unit Program Manager shall:

· Supervise Residential Counselors in the facility

· Have thorough awareness of the expectations of this Statement of Work (SOW)

· Ensure emergency notification of the VA occurs for critical incidents

· Ensure timely response to VA referrals and phone contact and full review of admission packets

· Contractor will acknowledge receipt of admissions request within (2) hour of receipt and provide a decision on accepting the referral within (1) business day of the referral.

2. Residential Counselors shall:

· Provide observation and redirection of residents of the facility in accordance with CO BHA/CDHS guidelines.

· Administer Veterans medications in accordance with QMAP rules.

· Ensure that incident reports are written and given to the program manager for review.

F. REFERRALS

1. Referrals from the VA to the Step-Down MHTL will occur during regular business hours Monday through Friday from 8am to 4:30pm and will be accompanied by a call to the MHTL office and a follow-up faxed admission packet for review. Admission packet will include:

· Veteran name, age, diagnosis

· Name and date of next placement/housing plan

· Medical Clearance Statement

· Signed Veteran Understanding of Step-down Rules and Consequences

· Step Down may specify their own needed referral questions

2. The VA and the Contractor will each establish primary and secondary points of contact (POCs) and emergency contacts with phone numbers and email addresses for referrals, care coordination, and emergency notification for critical incidents after the contract has been awarded.

3. Response by the Contractor to the VA on admission referrals shall be prompt and complete with acknowledgment of receipt of the admission packet within one business day of VA faxing/secure message. The physical transport and admission of the Veteran to the Contractor facility must be completed within 3 business days of receiving the admission packet if the Veteran is accepted.

4. A list of authorized VA ordering officials for the contract shall be provided to the Contractor upon award of the contract. Ordering officials may be added or deleted from the list during the term of the contract at the discretion of VA Contracting Officer. The Contractor shall be provided an updated list of authorized VA ordering officials whenever such changes are made.

5. It is understood that the Contractor will not be paid for care provided to a referred Veteran beyond the period authorized in the referral, unless an extension of the authorization is provided in writing by the VA.

G. ABSENCES AND CANCELLATION

1. The contractor shall notify the VA of unauthorized absences by a referred Veteran from the facility.

2. The contractor shall notify the authorizing VA facility immediately when a medical emergency occurs that requires hospitalization of a referred Veteran. It is agreed that the Veteran will be admitted to the appropriate VA facility when possible. When such admission is not feasible because of the nature of the emergency, it is agreed that hospitalization in a non-federal hospital may be accomplished if VA authorization is obtained. If hospitalization of a non-emergency nature is required, it is agreed that admission to the appropriate VA facility will be accomplished promptly.

3. The contractor shall notify the authorizing VA facility immediately of any critical incidents involving Veterans residing in the residential program. The contractor shall notify the VA INPT MH POC by telephone during the hours of 8:00am and 4:30pm on weekdays. For all incidents that occur after normal business hours, the contractor should notify the Medical Center Administrative Officer on Duty (AOD).

4. In addition to notification of the VA for critical incidents, the VA grants the Contractor Program the right to discharge the Veteran in care in consultation with the VA for significant infractions or concerns.

i. Critical Incidents requiring notification which may also result in discharge from the program include the following:

1. Absences without leave for greater than 12 hours.

2. Confirmed use of alcohol or illegal substances.

3. Significant disruptive behavior that cannot be redirected such as, threats, physical assaults, significant sexual or racially harassing behavior.

4. Medical problems requiring hospitalization for which the Contractor program is not able to provide aftercare.

H. CONTRATOR STAFF CONDUCT/COMPLAINTS HANDLING

Contractor personnel shall be expected to treat referred Veterans with dignity and respect and abide by standards of conduct mirroring those prescribed by current federal personnel regulations. The Contractor shall comply with the VA Patient's Bill of Rights as set forth in 38 CFR 17.34a (copy available upon request).

I. TRANSPORTATION

The Contractor shall provide all Veterans with transportation from the RMR VAMC Medical Center at the point of discharge to the Contractor facility at the agreed upon date and time after admission acceptance.

J. FACILITY

2. It is the responsibility of the Contractor to properly maintain its facilities and the VA shall have no responsibility for paying or reimbursing the Contractor for such expenses. The contract facility must:

a. Have a current occupancy permit and Mental Health Transitional Living (Level I or Level II) License issued by the local and state governments in the jurisdiction where the facility is located. (CO BHA/CDHS).

b. Tax Identification Number

c. Comply with existing standards of State safety codes and local, and/or State health and sanitation codes (Sanitary License from Environmental Health)

d. Have handicapped accessibility by ADA Law Authority.

e. Where applicable, be accredited by the State to be equipped with operational air conditioning /heating systems

f. Be kept clean free of dirt, grime, mold, or other hazardous substances and damaged noticeably detract from the overall appearance.

g. Be equipped with first aid equipment and an evacuation plan in case of emergency

h. Have windows and doors that can be opened and closed in accordance with manufacturer standards.

2. The contractor facility must meet fire safety requirements, as follows:

a. Fire exit drills must be held at least quarterly. Residents must be instructed in evacuation procedures when the primary and/or secondary exits are blocked. A written fire plan for evacuation in the event of fire shall be developed and reviewed annually. The plan shall outline the duties, responsibilities and actions to be taken by the staff and residents in the event of a fire emergency. This plan shall be implemented during fire exit drills.

b. A written policy regarding tobacco smoking in the facility shall be established and enforced.

c. Portable fire extinguishers shall be installed at the facility. Use NFPA 10, Portable Fire Extinguishers, as guidance in selection and location requirements of extinguishers.

K. Facility Safety Requirements

1. Contractor shall strictly follow all facility safety requirements as outlined throughout:

a. Building Construction:

(1) If the facility is in the same building with other occupancies, the facility cannot have a sole means of egress or means of escape that passes through nonresidential or non-health care occupancy in the same building.

(2) If the board and care occupancy is located above nonresidential or non-health care occupancy, the board and care occupancy and exits shall be separated from the nonresidential or non-health care occupancy by construction having a minimum 2-hour fire resistance rating.

b. Means of Escape:

(1) All designated means of escape shall be continuously maintained free of all obstructions or impediments to enable instant use in case of fire or emergency.

(2) All door assemblies that are required to swing in the direction of exit travel shall be operating properly.

(3) Every sleeping room and living area shall have a primary means of escape that provides a safe path of travel, to the outside.

(4) If sleeping rooms or living areas are above or below the level of exit discharge, the primary means of escape shall comply with item i, ii, iii, or iv below:

i. The primary means of escape is an exterior stair, or

ii. The primary means of escape is a horizontal exit, or

iii. The primary means of escape is a fire escape stair, or

iv. The primary means of escape is an interior stair meeting 1, 2, or 3 below:

1. A stair, enclosed with 30-minute construction including 20-minute self or automatic closing fire doors, provided that all portions of the primary means of escape are separated from all occupied or furnished spaces on lower floors with 30-minute construction, or

2. In buildings 3 stories or less, protected throughout by QR or residential sprinklers, a stair, open on the 3rd floor (only), provided that all portions of the primary means of escape are separated from all occupied or furnished spaces on lower floors with 30-minute construction, or

3. An open stair in buildings 2 stories or less in height that are protected throughout by QR or residential sprinklers.

(5) All doors shall be at least 32 inches wide.

(6) Closet doors shall be designed to allow opening from the inside.

(7) Bathroom doors shall be designed to allow opening from the outside during an emergency.

(8) All doors in the means of escape (except those meeting delayed egress or access-controlled egress locks) shall not be locked in the direction of egress.

c. Protection

(1) Exterior stairs shall be reasonably protected by distance, arrangement, or protection of openings exposing the stairs so that blockage by fire of the exterior and interior means of escape simultaneously is unlikely.

(2) All hazardous areas on the same floor need to be protected by a primary means of escape and sleeping rooms need to be protected by a smoke partition that shall be located between the hazardous areas and the sleeping rooms or primary escape route, with a self or automatic closing door.

[Note: Hazardous areas include areas for corrugated cardboard storage, food or household maintenance items in wholesale or institutional type quantities and concentrations, or mass storage of residents’ belongings.] [Note: Hazardous areas that are not on the same floor as, and those that are not in or abutting, a primary means of egress or sleeping room are permitted to be protected by sprinklers alone.]

(3) The corridor walls constructed as smoke partitions shall be capable of resisting the passage of smoke.

(4) Corridor doors shall have latches or other mechanisms suitable for keeping the doors closed.

(5) Corridor doors shall be arranged so that nothing prevents the occupant from being able to close the door.

(6) Fire alarm systems shall be installed with manual pull boxes at the exit doors.

(7) The fire alarm system shall provide occupant notification with audible and visible appliances that operate throughout the building.

(8) The fire alarm panel shall be attended 24/7 protected by a smoke detector or smoke alarm.

(9) Interconnected AC-powered smoke alarms shall be installed in all sleeping rooms, and placed on all levels, including basements, with additional smoke alarms installed in living areas including living rooms, dens, dayrooms and similar spaces shall be audible in all sleeping areas.

[Note: Systems detectors installed in these spaces are permitted in place of the smoke alarms.]

d. Utilities

(1) Stoves and combustion heaters shall be located so they do not block escape in case of fire caused by malfunction of the stove or heater.

e. Operating Features

(1) There shall be a written fire emergency plan for protecting all persons in the event of fire, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating persons from the building when necessary and; the plan shall address unusual needs of residents (deafness, blindness, or other physical limitations).

(2) Residents shall be trained in the proper actions to take in event of a fire and this training shall include what to do if the primary escape route is blocked.

(3) Emergency egress and relocation drills shall be conducted at least 6 times per year (bimonthly) with at least two of these drills at night when residents are sleeping.

(4) Emergency egress and relocation drills shall involve the actual evacuation of residents to a designated assembly area and residents are required to use the designated means of egress during the drills.

(5) There shall be staff on duty and in the facility at all times when residents require evacuation assistance.

(6) Smoking regulations shall be established for the facility; and where smoking is permitted, shall be noncombustible safety-type ashtrays or receptacles provided in convenient locations.

(7) New draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant per NFPA 701.

f. Disaster Plan.

(1) Facility is to have a written disaster plan in coordination with the emergency management entity responsible for the locality in which the project resides. The plan encompasses natural and manmade disasters. NOTE: It is not the intent of this regulation to require a certification from a local emergency management entity rather that the contractor access and utilize information from local emergency management office.

The purpose of the plan is to ensure that there are procedures that promote safety during emergency situations. The plan must prepare Program staff and Veterans as to how to respond during a disaster. The review of the plan should take into consideration the setting of the program (i.e., apartment with supportive services versus congregate site with program staff on site). NOTE: Contractor are encouraged to consult with local emergency management organizations within their community as a resource for planning purposes.

g. Additional Requirements:

(1) No more than four participants per room.

(2) Each room shall have an area of at least 100 sq. ft. for lodging one veteran or 80 sq. ft. for more than one participant.

L. INSPECTION OF FACILITY AND PROGRAM

1. The Contractor will be in good standing with the Colorado Department of Public Health and Environment (CO BHA/CDHS) and abide by all inspections demonstrating compliance with state regulations.

The CO BHA/CDHS Process for Licensing Mental Health Transitional Living resident care, staffing, environment, and compliance with regulations. Key details and summaries of elements are show below:

Licensing and Certification:

All Colorado Mental Health Transitional Living (MHTL) programs must be licensed by the CO BHA/CDHS to operate. They can also be certified by the Centers for Medicare and Medicaid Services (CMS) or the Colorado Department of Healthcare Policy and Financing (HCPF) to receive reimbursement for services provided to eligible residents.

Types of Inspections:

· Annual Surveys: These are typically unannounced and take place roughly every 12 months.

· Complaint Investigations: These are conducted in response to formal regulatory-related complaints.

Inspection Process:

· Unannounced Annual Surveys:

· CO BHA/CDHS surveyors conduct these inspections, often over multiple days, observing the facility and interviewing residents and staff.

· The Government reserves the right to conduct unannounced inspection at anytime.

Review of Records:

Surveyors review medical records, facility policies, and other relevant documents.

Compliance Evaluation:

The inspection team evaluates the facility's compliance with state and federal regulations.

Identifying Deficiencies:

If a facility fails to meet regulatory requirements, deficiencies may be cited.

Deficiencies are categorized by scope and severity, indicating the level of harm and the pervasiveness of the deficient practice.

Plans of Correction:

Facilities are required to develop and implement a plan of correction to address any deficiencies identified during the inspection.

The plan of correction outlines how the facility will remedy the deficiencies.

Public Access to Inspection Results:

Inspection results, including citations, regulation text, and plans of correction, are often available to the public through the CO BHA/CDHS's website.

M. CONTRACT CHANGES/TECHNICAL DIRECTIONS.

1. The Contracting Officer is the only person authorized to approve changes or modify any of the requirements of this contract. The Contractor shall communicate with the Contracting Officer on all matters pertaining to contract administration. Only the Contracting Officer is authorized to make commitments or issue changes that shall affect price, quantity or quality of performance of this contract.

2. IN THE EVENT THE CONTRACTOR AFFECTS ANY SUCH CHANGE AT THE DIRECTION OF ANY PERSON OTHER THAN THE CONTRACTING OFFICER WITHOUT AUTHORITY, NO ADJUSTMENT SHALL BE MADE IN THE CONTRACT PRICE TO COVER AN INCREASE IN COSTS INCURRED AS A RESULT THEREOF.

3. The COR will be responsible for the overall technical administration of this contract as outlined in the COR Delegation of Authority, including monitoring of the Contractor’s performance.

N. QUALITY OF SERVICE REQUIREMENTS:

1. Quality Control Program:

The contractor, not the government, is responsible for management and quality control actions to meet the terms of the contract. Contractor shall provide an adequate quality control plan which addresses organizational, personnel, process controls, documents/records, incident tracking, assessments, process improvements, and facilities and safety mechanisms.

2. Contractor’s Quality Improvement Monitors shall:

a. Ensure timely responses for Admission referrals

b. Ensure transportation at the point of discharge to the Contractor Facility

c. Ensure confidentiality of patient record information.

d. Monitor the completeness and accuracy of financial records.

e. Assess the treatment outcome at periodic intervals.

f. Evaluate the residential treatment setting's ability to consistently ensure the presence of staff capable of providing services required under the terms of the contract.

The quality control program is the driver for quality. The contractor is required to develop a comprehensive program of inspections and monitoring actions. The first major step to ensuring a “self-correcting” contract is to ensure that the quality control program, approved at the beginning of the contract, provides the measures needed to lead the contractor to success.

3. Performance Requirement Summary (PRS)

A Contract Discrepancy Report (CDR) will be issued for performance below the AQL. The Contractor will have One week to provide a response that includes an improvement strategy for addressing the issues. 30 days after issuing the CDR, the Contractor will be re-rated. If performance does not comply with PWS, the CO will be notified, the performance record will be documented.

A Contract Discrepancy Report (CDR) will be issued for performance below the AQL. The Contractor will have One week to provide a response that includes an improvement strategy for addressing the issues. 30 days after issuing the CDR, the Contractor will be re-rated. If performance does not comply with PWS, the CO will be notified, the performance record will be documented.

A Contract Discrepancy Report (CDR) will be issued for performance below the AQL. The Contractor will have One week to provide a response that includes an improvement strategy for addressing the issues. 30 days after issuing the CDR, the Contractor will be re-rated. If performance does not comply with PWS, the CO will be notified, the performance record will be documented.

A Contract Discrepancy Report (CDR) will be issued for performance below the AQL. The Contractor will have One week to provide a response that includes an improvement strategy for addressing the issues. 30 days after issuing the CDR, the Contractor will be re-rated. If performance does not comply with PWS, the CO will be notified, the performance record will be documented.

O. NUTRITION

The facility management must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.

a. Staffing. The contractor must employ a cook on a full-time basis that follows the guidelines by the Commission on Dietetic Registration of the American Dietetic Association.

The Government reserves the right to inspect and modify menu items as needed to meet the above guidelines. A Government Nutritionist will perform announced and unannounced visits and/or inspections for quality assurance.

b. Sufficient Staff. The contractor must employ sufficient support personnel competent to carry out the functions of the dietary service.

c. Menus and Nutritional adequacy. Menus must:

Meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Science; be prepared in advance; and be followed.

d. Food. Each resident receives and the facility provides:

(1) Food prepared by methods that conserve nutritive value, flavor, and appearance.

(2) Food that is palatable, attractive, and at the proper temperature.

(3) Food prepared in a form designated to meet individual needs; and

(4) Substitutes offered of similar nutritive value to residents who refuse food served.

(5) Therapeutic diets. Therapeutic diets must be prescribed by the Government’s Primary Care Physician.

e. Frequency of meals.

(1) Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.

(2) There must be no more than 14 hours between a substantial evening meal and breakfast the following day, exceptions as provided in paragraph 4 of this section.

(3) The facility staff shall offer snacks at bedtime daily.

(4) When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day, if a resident group agrees to this meal span, and a nourishing snack is served.

f. Sanitary conditions. The facility must:

(1) Procure food from sources approved or considered satisfactory by Federal, State, or local authorities.

(2) Store, prepare, distribute, and serve food under sanitary conditions; and

(3) Dispose of garbage and refuse properly

P. LIVING SPACES

The contractor must ensure:

1. The facility is free from overwhelming unpleasant odor.

2. The facility appears clean and well-kept.

3. The temperature in the facility is comfortable for residents.

4. The facility has good lightning.

5. Noise levels in the dining room and other common areas are comfortable.

6. Smoking is not allowed or may be restricted to certain areas of the facility.

7. Furnishings are sturdy, yet comfortable and attractive.

8. There are hand washing supplies in all sinks of the facility

9. There are quiet areas where residents can have visits with friends and family.

Q. RESIDENCE APPEARANCE

The contractor must ensure residents are clean, appropriately dressed for season or time of day, and well groomed.

R. STAFF

1. The contractor must ensure the relationship between the staff and the residents appears to be compassionate, kind, polite, and respectful.

2. The contractor will communicate that all staff must wear name tags.

3. The contractor will ensure staff knocks on doors before entering a resident's room and refer to resident by name.

S. POLICY/PROCEDURE MANUAL

The contractor shall ensure:

1. The written patient care policies and procedures are established and implemented.

2. Policies and manual include accidents and incidents (falls and missing patient).

T. NURSING: MEDICATION MANAGEMENT & NARCOTICS

1. Contractor shall ensure the medication cabinet is locked.

2. Contractor shall have double locks for narcotics.

3. Contractor shall ensure medication is recorded daily.

4. Contractor shall ensure emergency supplies are checked per policy.

U. RECORDS AND REPORTS

1. An individual progress record must be safely maintained by the Contract Mental Health Transitional Living Program for each Veteran admitted. This progress record maintained by the Contract Residential Program must include:

a. Reasons for referral

b. Data relating to the veteran’s admission and anticipated length of stay in the residential program to include the targeted individual goals for constructive changes which are to be attained during the veteran’s stay at the residential setting.

c. Record or log of medical prescriptions issued by VA physicians

d. Reports of periodic reevaluation by program staff, to include any measures of movement toward rehabilitation goals.

e. Data relevant to the veteran's admission and anticipated length of stay.

f. Copies of physician’s orders (if applicable).

g. Weekly progress notes to measure progress toward service plan goals.

V. IN SERVICE EDUCATION PROGRAM

Contractor shall ensure staff has training in:

1. Infection Control – management and prevention of infectious disease

2. CPR – basic life support procedures

3. Crisis Management – verbal de-escalation

W. SITE VISITS

The CO BHA/CDHS will perform annual and periodic unannounced site inspection visits or inspections for cause. The Government also reserves the right to unannounced inspections at any time.

X. INFORMATION SECURITY CHECK

The C & A requirements do not apply; therefore, a security accreditation package is not required.

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY GENERAL

The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract.

ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

1. A Contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

1. All Contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for Contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

1. Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness.

1. Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the Contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor.

1. The Contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the Contractor or subcontractor’s employ. The Contracting Officer must also be notified immediately by the Contractor or subcontractor prior to an unfriendly termination.

VA INFORMATION CUSTODIAL LANGUAGE

1. Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

1. VA information should not be co-mingled, if possible, with any other data on the Contractors/subcontractor’s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the Contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct on-site inspections of Contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

1. Prior to termination or completion of this contract, Contractor/subcontractor must not destroy information received from VA, or gathered/created by the Contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a Contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the Contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

1. The Contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract.

1. The Contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on Contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the Contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

1. If VA determines that the Contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the Contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

1. If a VHA contract is terminated for cause, the associated BAA must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship.

1. The Contractor/subcontractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated.

1. The Contractor/subcontractor’s firewall and Web services security controls, if applicable, shall meet or exceed VA’s minimum requirements. VA Configuration Guidelines are available upon request.

1. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the Contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA’s prior written approval. The Contractor/subcontractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response.

1. Notwithstanding the provision above, the Contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the Contractor/subcontractor is in receipt of a court order or other requests for the above mentioned information, that Contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response.

1. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the Contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COTR.

SECURITY INCIDENT INVESTIGATION

a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

b. To the extent known by the Contractor/subcontractor, the Contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the Contractor/subcontractor considers relevant.

c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

d. In instances of theft or break-in or other criminal activity, the Contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The Contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The Contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

TRAINING

a. All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

b. Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems;

c. VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training;

d. Successfully complete the appropriate VA privacy training and annually complete…