36C26119Q0714-002.docx

PERFORMANCE WORK STATEMENT

RESIDENTIAL TREATMENT

A. GENERAL

1.1 DESCRIPTION OF SERVICE

Contractor shall provide Residential Treatment Substance Use Disorder services to eligible Veterans for treatment or mental illness, substance use disorder, therapeutic, and rehabilitative services, for the VA Pacific Island Healthcare System (VA PIHCS).

1.2 PLACE OF PERFORMANCE

Services shall be at a location on the Island of Oahu, Hawaii. It must be accessible by local public transportation or contractor provided transp01iation to the local VA facility and community resources and services. Performance will occur at the VA approved location.

1.3 AUTHORITY

Title 38 U.S.C. 8153, Health Care Resources (HCR) Sharing authority.

1.4 POLICY/HANDBOOKS

1.4.1 VHA Directive 2006-041 "Veterans' Health Care Services Standards" http://www.va.gov/vhapublications/ViewPublications.asp?pub ID=268

1.4.2 VHA Handbook 1100.18 Reporting And Responding To State Licensing Boards http://www.va.gov/vhapublicationsNiewPublications.asp?pub ID=l364

1.4.3. VHA Handbook 1907.01 Health Information Management and Health Record http://www.va.gov/vhapublicationsNiewPublications.asp?pub ID=2791

1.4.4. Privacy Act of 1974 (5. U.S.C. 5521) as amended http://www.justice.gov/oip/foia updates/Vol XVII 4/page2.htm

1.4.5. Infections Control in Health Care Personnel (as published in American Journal for infection Control-AJIC 1098;26;289-354 http://www.cdc.gov/hicpac/pdf/InfecControl.pdf

1.4.6. List of Excluded Individuals/Entities on the (HHS/OIG) http://oig.hhs. gov/exclusions/index.asp

1.4.7. Substance Abuse and Confidentiality: 42 CFR Part 2 http:www.ncse.org/sitecore/content/microsites/future-trends-2012/home/Privacy-and Technology/Substance-Abuse.aspx

1.4.8. 38 U.S.C. 7332- Confidentiality of Certain Medical Records http://www.law.come11.edu/uscode/text/38/7332

1.4.9. Limitations of use of assistance 38 CFR 17.707(b) http://www.gpo.gov/fdsys/pkg/CFR-l 998-title38-voll/pdf/CFR-l998-title38-voll-sec17- 707.pdf

1.5.0 VA Patient's Bill of Rights as set forth in 38 CFR l 7.34(a), Title 38, Code of Federal Regulations http://www.law.comell.edu/cfr/text/38.l 7.34

1.5.1. 5 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) http://www.gpo.gov/fdsys/granule/USCODE-20lO-title38-partIV-chap57-subchapl-sec5705

1.5.2. Title 5 U.S.C. 522a (Records Maintained on Individuals http://www.law.cornell.edu/uscode/text/5/552a

1.5.3. 45 C.F.R. Parts 160,162, and 164 (HIPAA) http://www.in.gov/judiciary/center/files/jedu-lib-general-hipaa-privacy.pdf

1.5.4. 45 C.F.R. 164.502 (e) - Uses and disclosures of protected health information: General Rules http://www.law.cronell.edu/cfr/text/45/164.502

1.5.5. Management and Health Records

http://www 1.va.gov/vhapublications/ViewPublications.asp?pub ID=2791

1.5.6 Release Medical Records or Health Information by 38 USC. 7332 http://www.gpo.gov/fdsys/granule/USCODE-20l l-title38/USCODE-2011-title38-partV chap73-subchapIII-sec7332/content-detai1.html

1.5 DEFINITIONS/ACRONYMS

ISO –

POP

PWS

PHI SUDP VA-

Information Security Officer Period of Performance Performance Work Statement Personal Health Information Substance Use Disorder Treatment Program Veteran Affairs

VAMC - Veteran Affairs Medical Center

VHA- CO-

Veterans Health Administration

Contracting Officer (CO): The CO is a VA employee who is assigned responsibility for the VA contract. The CO role is to ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO 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 as only the Contracting Officer is authorized to make commitments or issue changes that shall affect price, quantity or quality of performance of this contract. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor's performance.

Assigned CO: Network Contracting Office (NCO) 21 Contracting Officers Organization or Agency: Department of Veterans Affairs, VISN 21 Contracting

COR-

QASP-

Contracting Officer's Technical Representative (COR): The COR is responsible for technical administration of the contract as outlined in the COR Delegation of Authority issued by the CO. The COR shall assure proper Government surveillance of the contractor's performance and keep the CO informed of such. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Quality Assurance Surveillance Plan (OASP): The QASP is part of the contract and identifies the specific performance indicators and standards to be achieved by the contractor as outlined in the Performance Work Statement (PWS). The QASP review will be completed periodically by the COR and contractor's performance reported to the CO.

2. QUALIFICATIONS

2.1. STAFF

2.1.1 Licensing

Contract provider assigned by the Contractor to perform the services covered by this contract shall have, where duties require, and maintain current licenses in any State, Territory, or Commonwealth of the United Stated or the District of Columbia. All licenses held by the personnel working on this contract shall be full and unrestricted licenses. Personnel who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application will not be considered for the purposes of this contract. This includes but is not limited to personnel providing medical, psychiatric or specialist health and mental health services.

2.1.2 Credentialing and Privileging

The Contractor is responsible to ensure that employees/providers possess the requisite credentials enabling the granting of privileges.

2.1.3. Technical Proficiency

Contractor staff shall be technically proficient in the skills necessary to fulfill the Government's requirement, including the ability to speak, understand, read and write English fluently.

Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed. Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all contract physicians(s).

2.1.4 Training

The Contractor shall assign to this contract personnel who will receive initial and periodic training as required in the following areas. An annual training report will be submitted to the COR upon request.

2.1.4.1 Possess current certification in Basic Life Safety (BLS for Healthcare Providers including CPR and AED).

2.1.4.2. Have received extensive training on alcohol and substance use and familiarity with current treatment programs and approaches.

2.1.4.3. Have received training related to general mental health disorders, their characteristics, use of medications, and awareness of treatment approaches.

2.1.4.4. Have received training in maintaining client privacy and confidentiality in all verbal and written communications and interactions.

2.1.4.5. Adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPPA) of 1996. This includes both the Privacy and Security Rules published by the Department of Health and Human Services (HHS) regarding the use and disclosure of protected health information. Privacy training shall be completed annually.

2.1.4.6 Have training on Bloodborne Pathogen/Infection Control Procedures.

2.1.4.7 Have training on Crisis Prevention/ Intervention Training.

2.1.4.8 Have training on Emergency Disaster Preparedness and Policy Reviews

2.1.5. Standard Personnel Testing (PPD, etc.)

Contractor shall provide a statement that all required infection control testing is current and that the contractor is compliant with OSHA regulations concerning occupational exposure to blood borne pathogens. The Contractor shall also notify the VA of any significant communicable disease exposure and the VA will also notify the contractor of the same, as appropriate.

2.1.5.1 Contractor shall adhere to current Centers for Disease Control and Prevention/Healthcare Infection Control in Health Care Personnel. Contractor shall provide follow up documentation of clearance to return to the workplace prior to their return. Tests shall be current within the past year. '

2.1.6. Conflict of Interest

Contractor shall be responsible for identifying and communicating to the CO and COR any conflicts of interest and/or potential conflicts of interest during the entirety of contract perfo1111ance.

2.1.6.1. Contractor must disclose 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. Contractor must disclose the same information for any identified consultants 01· subcontractors who shall provide services.

2.1.6.2. Contractor must be able to demonstrate management capability, system or established plan to avoid or mitigate any actual or potential organizational conflicts of interest.

2.1.7. Citizenship related Requirements

The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S. Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Depa1iment of Veterans Affairs patient referrals.

2.1.7.1. 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.

2.1.7.2. If the Contractor fails to comply with any requirements outlined in the proceeding 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,

2.1.7.3. 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.

2.1.8. Annual Office of Inspector General (OIG) Statement

In accordance with HTPAA 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 patties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs.

2.1.8.1 Contractor shall review the (HHS/OIG) List of Excluded Individuals/Entities on the (HHS/OIG) web site to ensure that the proposed contract Contractor(s) is 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 reach 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.

2.1.8.2. To ensure that the individuals providing services under the contract have not engaged in fraud or abuse regarding Sections 1128 and 1128A of the Social Security Act regarding federal health care programs, the Contractor is required to check the Health and Human Services- Office of Inspector General (HHS/OIG), List of Excluded Individuals/Entities on the OIG Website for each person providing services under this contract. The Contractor is required to certify in its proposal that all persons listed in the Contractor's proposal have been compared against the OIG list and NOT listed. During the performance of this contract the Contractor is prohibited from using any individual or business listed on the List of Excluded Individuals/Entities.

2.1.8.3 By submitting their proposal, the Contractor ce1iifies 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.

TECHNICAL DIRECTION

REFERRALS

The VA is responsible for determining eligibility of Veterans prior to referral to the Contractor for treatment. A written referral (hard copy, fax, or secured e-mail are acceptable) signed by an authorized VA ordering staff shall be provided to the Contractor for each Veteran referred for services under the contract.

2.2.1.1 A list of VA authorizing ordering staff for the contract shall be provided to the Contractor upon award of the contract. Ordering staff may be added or deleted from the list during the term of the contract at the discretion of the VA Substance Abuse Program Manager. The contractor shall be provided an undated list of authorized staff whenever such changes are made.

Contractor shall 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.

The initial referral period for a Veteran may be up to 28 days, depending upon the needs of the Veterans as mutually dete1mined by the Veteran, the Contractor's staff, and VA Program Manager or designee. An extension of the referral pe1iod up to a total of 45 days may be authorized by the VA Program Manager or designee, provided that funding is available.

THERAPEUTIC AND REHABILITATIVE SERVICES

Therapeutic and Rehabilitative Services dete1mined to be needed by each individual Veteran's referred for treatment as stated in the plan developed by the Contractor, with input from the Veteran and VA Program designee. Services which the contractor must be able to furnish shall include:

Structured group activities as appropriate per the veteran's treatment plan including but not limited to substance treatment, mental health support, medical self-care, case management, spiritual support, and familial connection and support. These and other related services will be provided 20 per week at minimum.

2.2.3.2 Individual counseling specific to the veteran's treatment plan will be provided 1 hour per week.

Collaboration with the VA designated program staff on the veteran's progress and discharge planning.

Assist the veteran as determined appropriate to develop responsible living patterns, to maintain an acceptable level of personal hygiene and grooming, and achieve a more adaptive level of psychosocial functioning, upgrade social skills, and improve personal relationships.

Support to the veteran for an alcohol/drug abuse- free lifestyle provided in an environment conducive to social interaction and fullest development of the resident's rehabilitative potential.

Assistance to gain and apply knowledge of the illness/recovery process in an environment supportive of recovery models.

A program that promotes community interaction.

Case records and data normally maintained and included in a medical record as a function of compliance with State or community licensing standards will be made available on a need to know basis to appropriate Department of Veteran Affairs staff members involved with the treatment program of the Veterans concerned.

ADMINISTRATIVE FUNCTIONS

2.2.4.1 ABSENCES Contractor shall notify the VA of unauthorized absences by a referred Veteran from the facility. Should a Veteran absent himself/herself from the Contractor's facility in an unauthorized manner, payment for services for that Veteran shall be continued for a maximum period of two days, provided there is an active outreach attempt on the part of the Contractor's staff to return the Veteran to the facility and there is a reasonable belief that the Veteran will return. Management of program dropout will be an element of quality assurance review of this program. Absences of the Veterans from the facility in excess of two days will not be reimbursable unless authorized in advance by the VA Program Manager.

2.2.4.2 VA Reserves the right to remove any or all Veterans from the facility at any time, without additional cost, when it is determined to be in the best interest of the VA or the Veteran.

2.2.4.3. 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 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 provided that VA authorization is obtained. If hospitalization of a nonemergency nature is required, it is agreed that admission to the appropriate VA facility will be accomplished promptly.

2.2.4.4. The Contractor shall notify the authorizing VA facility immediately of incidents involving veterans residing in the residential program. The contractor shalt notify the VA case manager by telephone during the hours of 8:00 A.M. and 4:30 P.M. For all incidents that occur after normal business hours, the contractor should notify the Administrator on Duty (AOD). The Contractor shall provide the SUDP case manager and the COR with a copy of the incident report within 24 hours. The contractor shall maintain a copy of the incident report in the Veteran's case record.

CONTRACTOR STAFF CONDUCT/COMPLAINTS HANDLING

Contractor personnel shall be expected to treat referred Veterans with dignity and respect and abides by standards of conduct minoring 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).

2.2.5. l. The VA reserves the right to exclude Contractor staff members from providing services to Veterans under this contract based on breaches of conduct, including conduct that 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 Veterans or other staff members to designated Government representatives. The Contractor and Contracting Officer Representative shall deal with issues raised concerning contractor personnel conduct. The Contracting Officer shall be the final arbiter on questions of acceptability and in validating complaints.

2.3. NON-PERSONAL SERVICES

Personal services are prohibited under this contract.

2.3.1. No Employee Status

Contractor shall be responsible for protecting Contractor staff furnishing services. To carry out this responsibility, the Contractor shall provide or ce1tify that the following is provided for all their staff providing services under the resultant contract:

2.3.1. l. Workers' compensation

2.3.1.2. Professional liability insurance

2.3.1.3. Health examinations

2.3.1.4 Income tax withholding, and

2.3.1.5 Social security payments.

2.3.2 Tort Liability

The Federal Tort Claims Act does not cover Contractor or contract provider (s). When a Contractor or contract provider (s) has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor's (or contract Contractor (s)) action or nonaction shall be the responsibility of the Contractor <1nd/or insurance carrier.

2.3.3. Inherent Government Functions

Contractor and Contract provider (s) 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.

2.3.3. l. Contractor shall submit a listing of proposed key personnel performing technical delivery of services in the following format:

Contractor: ______________ Title/Rank: _____________

2.3.3.2. Curriculum Vitae and qualification documents of key personnel shall be submitted to the COR and maintained in the COR files.

2.3.4. Contingency Plan

Because continuity of care is an essential part of the VAPIHCS' medical services, the Contractor shall have a contingency plan in place to be utilized if the contractor (s) leaves Contractor's employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

2.3.5. Refusal/Dismissal

VAPIHCS reserves the right to refuse or dismiss contract personnel whose personal or professional conduct jeopardizes patient care or the regular and ordinary operation of the facility. Reasons for refusal or dismissal include, but are not limited to, unsatisfactory and performance prior to and/or during the term of the contract, failure to receive favorable adjudication during a VA background investigation, failure to satis(y the requirements of the contract, physical or verbal abuse to patients, staff: or visitors, intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, ethical misconduct,, conduct resulting in formal complaints by patients or other staff members, and any other valid reason considered objectionable.

2.4. KEY PERSONNEL

Contractor shall be expected to employ sufficient professional personnel to carry out all of the policies, procedures, and duties required for services delivery and administrative oversight.

Contractor shall assign to this contract personnel that by education and training (when required, certification or licensure) are qualified to provide the Basic Services and Supplemental Services required by this Performance Work Statement (PWS).

2.4.1. Contractor shall identify each person functioning as ''key personnel" under this contract and provide the VA with a copy of the employee resume (s) summarizing that person's relevant skills, experience where applicable. This information should be submitted with any formal proposal packages in response to this solicitation.

2.4.2. The requirements of the position hired and any security requirements or training. Contractor shall comply with the VA Patient's Bill of Rights as set forth in 38 CFR l 7.34(a), Title 38, Code of Federal Regulations. Contractor shall be responsible for maintaining Veterans' privacy and confidentiality and shall have systems in place that protect Veteran's identifying information and protected health information.

2.5. EMERGENCY SUBSTITUIONS

Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment. Contractor shall notify the CO in writing within 15 calendar days 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 15 calendar days prior to making any permanent substitutions, 2.5.l. Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitution, complete resumes for the proposed substitutes, an itemized cost breakdown supporting any change in price due to the proposed substitution, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications and faculty rank to those of the persons being replaced. The CO will notify the Contractor within fourteen (14) 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,

2.5.2. For temporary substitutions where the key person shall not be reporting to work for three

(3) consecutive work days or more, the Contractor shall provide a qualified replacement for the key person. The substitute shall have comparable qualifications to the key person. Any temporary and/or emergency substitution exceeding two weeks will require the procedure as stated above.

2.5.3. The CO and COR shall deal with issues raised concerning Contract provider (s) conduct. The final arbiter on questions of acceptability is the CO.

2.5.4. Contractor shall comply with the VA Patient's Bill of Rights as set forth in Title 38, Code of Federal Regulation and Section l 7.34(a). The Contractor shall be responsible for maintaining Veteran's privacy and confidentially and must have systems in place that protect Veteran1 s personal identifying information and protected health information.

3. HOURS OF OPERATION

3.1. BUSINESS HOURS

3.1.1 DEPARTMENT OF VETERANS AFFAIRS

8:00AM -4:30PM

Monday through Friday (excluding weekends and Federal holidays)

3.1.2. CONTRACTOR

24 hours a day/seven days per week/365 days per year.

Monday through Friday (excluding weekends and Federal holidays)

3.1.3. FEDERAL HOLIDAYS

Federal law (5.U.S.C. 6103) establishes the following public holidays for Federal employees.

New Year's Day Birthday of Martin Luther King, Jr.

Washington's Birthday Memorial Day Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Day Christmas Day

3.1.4 Contractor shall provide service to veterans on State and Federal holidays without increased expense to the VA.

3.1.5. EMERGENCY COVERAGE

Contractor shall have availability for emergency telephone calls twenty-four hours a day seven days a week. Contractor shall not be required to provide off-hour coverage.

3.1.6. CANCELLATION POLICY

Unless a state of emergency has been declared, the Contractor shall be responsible for providing services,

4. CONTRACTOR RESPONSIBILIES

4.1. STANDARD AMENITIES

Contractor shall comply with the principles listed in the Tentative eligibility determinations - 38 CRF 17.707(6) to provide housing and supportive services in a manner that is free from religious discrimination. The director services will be monitored as denoted in the Quality Assurance Surveillance on regular basis.

4.2. PERSONNEL

Contractor shall employ sufficient personnel to carry out the policies, responsibilities, and the program for the facility. There must be, at a minimum, one administrative staff member 24/7, or designee on duty on the premises or residing at the house and available for emergencies.

4.3. VA COORDINATION

Contractor shall be expected to collaborate regularly with the identified VA Liaison and other VA providers as necessary to ensure proper coordination of care, services, and resources for the benefit of individual Veterans.

4.4. COMMUNICATIONS

Contractor shall be expected to have a reliable, working phone line for VA inquiries. Messages left for the program by VA Staff are expected to be returned as soon as possible during normal business hours Monday through Friday. This includes calls from VA proper or the liaison to the program. Written correspondence, such as eligibility authorizations, extension requests, incident reports, and discharge rep01ts shall be promptly delivered as denoted in their respective sections below. The program may also be asked to provide evidence of completion of Substance Use Disorder Treatment in order to satisfy requirements for Veterans court-ordered to complete such treatment.

4.5. GROUP ACTIVITIES

Structured group activities will be available to Veterans admitted to the program. At a minimum, Veterans should plan to attend, Alcoholics Anonymous, Narcotics, Anonymous, or Vocational Counseling,

4.6. TRANSPORTATION

Contractor shall support the Veterans with finding solutions for their local transpo1tation needs (e.g., to schedule meetings, appointments, etc.). At a minimum, the Contractor shall be expected to help the Veterans by providing information and instructions necessary to enable Veterans to utilize public transportation. If VA or contractor staff determines that adequate public transportation is not available or appropriate for a Veteran, the Contracto1· shall arrange for alternative transport by car,

4.7. RECOVERY

The program environment shall be conducive to positive social interaction and the fullest development of the Veteran's rehabilitative potential. The Contractor is expected to support the Veteran in gaining and applying knowledge of the recovery process, and to provide individual and group sessions focusing specifically on the treattr1ent of mental health and substance use disorders, as well as providing other supports as needed to facilitate progress in the individual's overall recovery effort.

4.8. FACILITY

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:

4.8.1. Have a current occupancy pem1it issued by the local and state governments in the jurisdiction where the facility is located.

4.8.2. Be in compliance with existing standards of State safety codes and local, and/or State health and sanitation codes.

4.8.3. Be licensed under State or local authority.

4.8.4. Where applicable, be accredited by the State.

4.8.5. Be equipped with operational air conditioning/heating systems.

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

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

4.8.8. Have windows and doors that can be opened and closed in accordance with manufacture!' standards.

4.9. FIRE SAFETY

4.9.1. Contractor facility shall meet fire safety requirements as followed:

4.9.2. The building must meet the requirements of the applicable residential occupancy chapters of the current version of NFPA 101, National Fire Protection Association's Life Safety Code. Any equivalencies or variances must be approved by the appropriate Veterans Health Administration and the Veterans Integrated Service Network (VISN) Director.

4.9.3. All residents in the facility must be mentally and physically capable of leaving the building, unaided, in the event of an emergency.

4.9.4. Fire exit drills must be held at least quarterly. Residents must be instructed in evacuation procedures when the primary and/or secondary exists 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 take1i by the staff and residents in the event of a fire emergency. This plan shall be implemented during fire exist drills.

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

4.9.6. Po1iable fire extinguishers shall be installed at the facility. Use NFPA I 0, Portable Fire Extinguishers, as guidance in selection and location requirements of extinguishers.

4.9.7 Requirements for fire protection equipment and systems shall be in accordance with NFPA IO I. All fire protection systems and equipment, such as the fire alarm system, smoke detectors, and portable extinguishers, shall be inspected, tested, and maintained in accordance with the applicable NFPA fire codes and the results documented.

4.9.8. The annual inspection by a VA team required by paragraph 7 shall include a fire and safety inspection conducted at the facility unless a review of past Department of Veterans Affairs inspections or inspections made by the local authorities indicates that a fire and safety inspection would not be necessary in which case the fire and safety inspection maybe waived by the VA

4.10. ROOM AND BOARD

Room and Board shall be accessible to the Veteran 7 days a week and 24 hours per day. Accommodations will include a bed and linens (towels and bed sheets\ as well as other furnishing such as a dresser or other means of secure storage. At least three nutritious meals, 7 days a week will provide for Veterans.

4.10.1. Suitable alternative meal options must be made available to reasonably accommodate those with special, medically required dieta1·y restrictions. In addition, nutritious snacks of nourishing quality (e.g. fruits), should be available between meals and before bedtime for those requiring or desiring additional food, when it is not medically contraindicated.

4.10.2. There will not be more than a 14 hour span between evening meal and breakfast of the following day. Food shall be prepared, served and stored under sanitary conditions. The Contractor shall provide storage space in an on-site refrigerator for Veterans to store personal food. The Contractor shall establish and maintain sanitary procedures for washing dishes1 cleaning equipment and work areas and disposing of waste.

4.1 l. LAUNDRY Laundry facilities or services shall be available at no cost for residents to tend to their laundry needs.

4.4. MEDICAL RECORDS

4.4.1, AUTHORITIES

Contractors providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the U.S.C.551 a (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),

4.4.2. 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.

4.4.2.1. Any 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, released1 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 01· 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.

4.4.3. DISCLOSURE

Subject to applicable federal confidentiality or privacy laws, the Contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over Contractor, may have access to VA 's records, at VA's place of business on request during normal business hours, to inspect and review and make copies of such records. The VA will provide the Contractor with a copy of VHA Handbook J 907. I, Health Information management and Health Records and VI-IA Handbook l 605.1, 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.

4.4.4. 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 1907.0 I Health Information Management and Health Records and all guidelines provided by the VAPICHS.

4.4.5. RELEASE OF INFORMATION

The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. In the case of the VA authorizing the Contractor to release patient information, the Contractor in compliance with VA regulations, and at his/her own expense, shall use VA Form 3288, Request for and Consent to Release of Information from Individual's Records, to process "Release of Information Requests." In addition, the Contractor shall be responsible for locating and forwarding records not kept at their facility. The VNs Release of Information Section shall provide the Contractor with assistance in completing forms. Additionally, the Contractor shall use VA Form I 0-5345, Request for and Authorization to Release Medical Records or Health Information, when releasing records protected by 38 U.S.C, 7332. Treatment and release records shall include the patient's consent form. Completed Release of Information requests will be forwarded to the VA Privacy Officer.

4.5. COMPUTERIZED PATIENT RECORD SYSTEM (CPRS)

Contract personnel are not authorized to enter patient care information into CPRS.

4.6. PERFORMANCE STANDARDS, QUALITY ASSURANCE AND QUALITY IMPROVEMENT

4.6.1 In accordance with VA regulations, a record-keeping system will be established and maintained by the COR to ensure contract compliance.

4.6.2. Upon verification of services, payment will be authorized by the COR.

4.6.3. The services specified herein may be changed by mutual written agreement of the parties in accordance with the terms and conditions set forth herein.

5. GOVERNMENT RESPONSILITITIES

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 pe1iaining to contract administration. The Contracting Officer is authorized to make commitments or issue changes that shall affect price, quantity or quality of performance of this contract.

5.1. VAPICHS RESPONSIBILITIES

5.1.1. The Contracting Officer Representative will be responsible for the overall technical administration of this contract as outlined in the Contracting Officer Representative's Delegation of Authority, including monitoring of the Contractor's performance.

5.1 .3. The Contracting Officer shall resolve complaints concerning Contractor relations with the Government employees or patients. The Contracting Officer is f1nal authority on validating complaints. In the event the Contractor effects 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.

5.1.4. In the event that contracted services do not meet quality and/or safety expectations, the best remedy will be implemented, to include but not limited to a targeted and time limited performance improvement plan; increased monitoring of the contracted services; consultation or training for Contractor personnel to be provided by the VA; replacement of the contract personnel and/or renegotiation of the contract terms or termination of the contract.

6. SPECIAL CONTRACT REQUIREMENTS

6.1. Invoicing

Contractor shall provide monthly invoicing to the government within l 0 days of the encl of each month for vvhen services were provided. Subsequent changes or corrections shall be submitted by separate invoice. In addition to information required for submission of a "'proper" invoice in accordance with VAAR 852.232-72 Electronic submission of payment requests, and shall include the following at a minimum:

6.1.1. Name and Address of Contractor

6.1.2. Invoice Date and Invoice Number

6.1.3. Contract Number and Purchase/Task Order Number

6.1.4. Date of Service

6.1.5. Homeless Beds

6.1.6. Daily Bed Rate

6.1.7. Total Bed Days

6.1.8. Total price

6.1.9. Invoices rendered by the Contractor to Financial Service Center for service furnished under this agreement will be invoiced in full for each month in which services were performed. No advance payments will be authorized.

6.1.10. Invoices submitted must show the total number of individual and group sessions. Client signature pages must be submitted for actual sessions worked by the psychologist/social worker.

6.2. VENDOR ELECTRONIC INVOICE SUBMISSION METHODS

Facsimile, e-mail, and scanned documents arc not acceptable forms of submission for payment requests. Electronic form means an automated system transmitting information electronically according to the accepted electronic data transmission methods.

6.3, VENDOR E"INVOICE SET-UP INFORMATION

Submit your electronic invoices to the VA Financial Services Center for payment processing via the OB10 system http://ob10.com/us/en/veterans-affairs-us/, free of charge. If you have questions about the e-invoicing program or OB l 0, please contact the FSC at the phone number or email address listed below:

OB 10 e-Invoice Setup Information: 1-877-489-6 I 35 OB10 e-Invoice email: VA.Registration@obl0.com FSC e-Invoice Contact Information: 1-877-353-9791 FSC e-Invoice email: vafsccshd@va.gov

6.4. NO DIRECT BILLING OF VA BENEFICIARIES

Contractor shall accept payment for services rendered under this contract as payment in full. VA beneficiaries shall not under any circumstances be charged nor their insurance companies charged for services rendered by the Contractor, even if VA does not pay for those services. This provision shall survive the termination or ending of the contract.

6.4.1. To the extent that the Veteran desires services which are not a VA benefit or covered under the terms of this contract, the Contractor shall be required to notify the Veteran that there will be a charge for such service and that the VA will not be responsible for payment.

6.4.2. The Contractor shall not bill, charge, collect a deposit from, seek compensation, remuneration, oi reimbursement from, or have any recourse against, any person or entity other than VA for services provided pursuant to this contract. It shall be considered fraudulent for the Contractor to bill other third party insurance sources (including Medicare) for services rendered to VA beneficiaries under this contract.

6.4.3. Payment is due within 30 business days upon receipt of a valid Clean Claim. A Clean Claim means a claim in which the information in the possession of VA PIHCS reasonably indicated that

(i) the claim is for authorized and Covered Services provided; (ii) the claim has no material defect or impropriety; (iii) there is no dispute regarding the amount claimed; and (iv) VA PIHCS has no reasonable reason to believe that the claim was submitted fraudulently.

B. IT CONTRACT SECURITY

Note: This contract does not include, require or allow Contractor physical access to VA information or VA information systems.

1.GENERAL

Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

a. 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.

b. 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.

c. 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.

d. Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services ary 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.

e. 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.

3. VA INFORMATION CUSTODIAL LANGUAGE

a. 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).

b. 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.

c. 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.

d. 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.