Residential Rehabilitation PWS Updated.pdf

B.3 PERFORMANCE WORK SCHEDULE

1. GENERAL:

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).

1.1 Authority – Title 38 Code of Federal Regulations (CFR) 17.38 and 17.80 through 17.83, and FAR Part 12 – Acquisition of Commercial Items.

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

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

1.2.2 VHA Handbook 1605.1, “Privacy and Release of Information” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233

1.2.3 VHA Handbook 1907.01, “Health Information Management and Health Records” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088

1.2.4 VHA Directive 2009-038, “VHA National Dual Care Policy” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2058

1.1.1. Health Insurance Portability and Accountability Act of 1996 (HIPAA) https://www.govinfo.gov/content/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf

1.2.6 Patient Self Determination Act of 1990

https://www.congress.gov/bill/101st-congress/house-bill/4449/text

1.2.7. Privacy Act of 1974 (5 U.S.C. 552a) as amended

https://www.justice.gov/oip/blog/foia-update-freedom-information-act-5-usc-sect-552-amended-public-law-no-104-231-110-stat

1.2.8. VHA Handbook 1160.01, “Uniform Mental Health Services” http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762

1.2.9. VHA Handbook 1162.02, “Mental Health Residential Rehabilitation Treatment Program” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2354

1.2.10. VHA Handbook 1907.01, “Health Information Management and Health Records”

1.2.11. VHA Directive 1605.01, “Privacy and Release of Information”

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

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

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

1.3.1. ACLS: Advanced Cardiac Life Support

1.3.2. ADTP: Addictive Disorders Treatment Program

1.3.3. BAA: Business Associate Agreement

1.3.4. BBA: Balanced Budget Act

1.3.5. BLS: Basic Life Support

1.3.6. CARF: Commission on Accreditation of Rehabilitation Facilities

1.3.7. CDC: Centers for Disease Control and Prevention

1.3.8. CFR: Code of Federal Regulations

1.3.9. CLIN: Contract Line Item Number

1.3.10. CMP: Civil Monetary Penalty

DRAFT

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1364

1.3.11. CMS: Centers for Medicare & Medicaid Services

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

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

1.3.14. COS: Chief of Staff

1.3.15. CPARS: Contractor Performance Assessment Reporting System

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

1.3.17. CTS: Care, Treatment, and Services

1.3.18. DEA: Drug Enforcement Agency

1.3.19. DSN: Defense Switch Network

1.3.20. EDI: Electronic Data Interchange

1.3.21. ESRS: Electronic Subcontracting Reporting System

1.3.22. FAPIIS: Federal Awardee Performance and Integrity Information System

1.3.23. FAR: Federal Acquisition Regulation

1.3.24. FSC: Financial Service Center

1.3.25. HHS: Department of Health and Human Services

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

1.3.27. HIPAA: Health Insurance Portability and Accountability Act

1.3.28. ID: Identification

1.3.29. ISO: Information Security Officer

1.3.30. MD: Medical Doctor

1.3.31. MH RRTP: Mental Health Residential Rehabilitation Program

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

1.3.33. NICE: National Institute for Health and Care Excellence

1.3.34. NFPA: National Fire Protection Association

1.3.35. NPPE: National Plan and Provider Enumeration

1.3.36. OIG: Office of Inspector General

1.3.37. OSHA: Occupational Safety of Health Administration

1.3.38. PPIRS: Past Performance Information Retrieval System

1.3.39. PWS: Performance Work Statement

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

1.3.41. QA: Quality Assurance

1.3.42. QASP: Quality Assurance Surveillance Plan

1.3.43. QI: Quality Improvement

1.3.44. RFP: Request for Proposal

1.3.45. TIN: Tax Identification Number

1.3.46. TJC: The Joint Commission

1.3.47. TRP: Trauma Recovery Program

1.3.48. U.S.: United States

1.3.49. U.S.C: United States Code

1.3.50. VA: Veterans Affairs

1.3.51. VAAR: Veterans Affairs Acquisition Regulation

1.3.52. Veterans Affairs Medical Center (VAMC): The Veterans Health Administration is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VAMC’s, Outpatient Clinics, Community Based Outpatient Clinics, and VA Community Living Centers (VA Nursing Home) Programs. In reference to this PWS, VAMC is referring to Veterans Affair Pacific Islands Health Care System, 459 Patterson Road, Honolulu, Hawaii 96819.

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

1.3.54. VISN: Veterans Integrated Service Network

1.4. BILLING DEFINITIONS

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

2. QUALIFICATIONS

2.1 Staff/Facility

2.1.1 License: Any personnel assigned by the Contractor to perform clinical services covered by this contract (e.g., medication administration) shall have a current license to provide that service, as indicated by state/federal law. All licenses held by contractor personnel working on this contract shall be full and unrestricted licenses in any State, Territory, or Commonwealth of the United States or the District of Columbia. Contractor personnel who have current, full and unrestricted licenses in one (1) or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application shall not be considered for the purposes of this contract.

2.1.2 Facilities are expected to meet all applicable health, safety, and licensing standards outlined in VHA Handbook 1162, “Mental Health Residential Rehabilitation Treatment Program”, as well as all applicable TJC and CARF Standards. Formal independent accreditation by the TJC or CARF is evidence of internal quality assurance mechanisms and is desirable but is not required. Where applicable, the residential treatment setting must have a current occupancy permit issued by the authority having jurisdiction.

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

2.1.4 The facility must meet the following requirements:

2.1.4.1 Standards of the Life Safety Code NFPA # 101

2.1.4.2 Fire and safety code imposed by State law

2.1.4.3 City, State and Federal requirements concerning licensing and health codes

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

2.2 Board Certification/Staffing Credentials: Contractor clinical personnel must be currently certified in BLS, ACLS or equivalency. All continuing education courses required for maintaining certification must be kept up to date at all times. Documentation verifying current certification shall be provided by the Contractor to the VA COR when requested.

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

2.4 Technical Proficiency: Contractor Personnel shall be technically proficient in the skills necessary to fulfill the government’s requirements, including the ability to speak, understand, read and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed.

Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all Contractor Personnel when requested.

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

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

Tests shall be current within the past year.

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

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

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

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

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

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

2.12.1. Workers’ compensation

2.12.2. Professional liability insurance

2.12.3. Health examinations

2.12.4. Income tax withholding, and

2.12.5. Social security payments

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

Personnel) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

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

3.0 HOURS OF OPERATION:

3.1 WORK SCHEDULE: Services shall be available from the contractor twenty-four (24) hours per day, seven (7) days per week, including weekends and federal holidays.

Contractor shall provide coverage for all required shifts, including nights, weekends and holidays.

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

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

4.0 CONTRACTOR RESPONSIBILITIES

4.1 General: The Contractor shall be responsible for providing Therapeutic and Rehabilitative Services determined 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.

The services shall be furnished to beneficiaries for whom such care is specifically.

authorized by the VAMC. The type of Veterans to be cared for under this contract will normally require some care and services above the basic level of meals, room and board. Relevant care will include, but not be limited to:

4.1.1 Structure group activities as appropriate per the Veterans 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. Therapeutic, recreational and/or spiritual outings, structured and group activities and promote Healthy physical activities.

4.1.2 Active affiliation with community support groups

4.1.3 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.

4.1.4 Collaborate with the VA designated program staff of Veteran’s progress and discharge planning.

4.1.5 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.

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

4.1.7 Medication administration and monitoring

4.1.8 Transportation to/from the VAMC and to/from community locations

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

4.3 Clinical staff of the VA ADTP and TRP programs will determine who is eligible for housing under this contract. Length of stay at the facility will also be determined by VA staff.

4.4 Housing facility must be located either within the city limits of Honolulu or within twenty

(20) miles of the VAMC.

4.5 Contractors under this program must meet the following VA standards, based on regulations promulgated by Title 38 Code of Federal Regulations (CFR) Section 17.63.

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

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

4.7.1 One (1) administrative staff member, or designee of equivalent professional capability (with the authority to make decisions regarding the facility and residents, or with contact information for an offsite administrator in case of emergency), accessible by VA staff 24 hours a day, 7 days a week.

4.7.2 Sufficient nursing personnel to administer medications (incl. controlled substances) at a frequency indicated by Veteran’s VA prescriptions, including daytime, nighttime, weekend and as-needed dosages. Medications must be dispensed within 10 minutes of prescribed dosing schedule. PRN medication must be dispensed within 30 minutes of Veteran’s request.

4.7.3 An on-site or on-call licensed independent medical provider (RN or MD) that will be able to provide assessment, consultation and assistance for both emergency and non-life-threatening medical and psychiatric incidents.

4.7.4 Sufficient food service, maintenance and janitorial staff to provide adequate nutrition and a clean, safe housing environment.

4.7.5 At least one (1) contractor employed staff member will be on-site and available in an emergency during each shift, twenty-four (24) hours per day, seven (7) days per week. In facilities with multiple buildings, floors or wings, a staff member must be physically present in each building/floor/wing, at all times Veterans are present in the area. The VA will provide Health Technician positions to help the contractor meet the 24/7 supervision requirement. Hiring, supervision, determination of work hours/leave time and all other personnel matters related to VA positions will be handled by the VA. Staffing requirements not met by these positions will be the responsibility of the contractor. Contractor is responsible for communicating and coordinating with VA Health Technician supervisor to ensure adequacy of 24/7 staffing. Staff providing onsite supervision of Veterans must be trained in management of disruptive behaviors, first aid, Basic Life Support and use of emergency equipment.

4.8 Contractor shall provide resumes for all key personnel; if substitutions of key personnel are need, substitution must be submitted at least fifteen (15) days prior to the proposed date substitution is to occur. The Contracting Officer (CO) or Contracting Officer

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

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

4.10 The Contractor shall:

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

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

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

4.10.4 Provide housing up to twenty-four (24) hours a day for Veteran placements.

Housing will be provided for up to three (3) Veterans at a time. Atmosphere will be consistent with a typical American home in terms of cleanliness, furnishings, and décor. Environment should promote an individual sense of well-being, optimism, recovery, and integration with the surrounding community (as opposed to a hospital- or dormitory-like dwelling).

4.10.5 Provide three (3) daily nutritious meals and reasonable accommodation for special dietary needs.

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

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

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

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

4.10.10 Provide an adequately-sized work station for two (2) VA staff assigned to the facility. The VA will provide all computer equipment needed by VA staff. Work station must afford secure storage of personal staff belongings and confidential documents.

5.0 STANDARDS OF CARE:

5.1 Housing and Services. The Contractor’s housing and other services shall be of a quality, meeting or exceeding currently recognized national standards as established by:

5.1.1 The professional standards of the TJC or equivalent

http://www.jointcommission.org/standards_information/hap_requirements.aspx.

Even if the facility is not accredited by TJC, the TJC standards for Behavioral

Health Care for Substance Use Disorders must be met or exceeded.

5.1.2 CARF

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

5.1.3 NICE guidelines

5.1.4 The requirements contained in this PWS

5.2 MEDICAL RECORDS

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

164 (HIPAA).

5.2.2 Generally, electronic medical records are maintained by VA staff and are not accessible to contractor. A hard copy medication administration record shall be developed by VA staff and utilized to track medication administration occurring at both the VAMC and contractor facility.

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

5.4. Disclosure: Contractor Personnel shall obtain permission from the VA before disclosing any patient information. The VA will provide the Contractor with a copy of VHA Handbook 1907.01, Health Information Management and Health Records and VHA Directive 1605.01, Privacy and Release of Information through links included in section

1.2 herein. The penalties and liabilities for the unauthorized disclosure of patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

5.5. Professional Standards for Documenting Care: Care shall be appropriately documented in medication administration records in accordance with standard commercial practice and guidelines established by VHA Handbook 1907.01 Health Information Management and Health Records (link included in Section 1.2 herein) and all guidelines provided by VAMC. Medication administration entries shall be legible and maintained in detail consistent with good medical and professional practices so as to facilitate internal and external peer reviews, medical audits and follow-up treatments.

Copies of received medical information shall be authenticated (signed) copies.

5.6. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. In the case of the VA authorizing the Contractor to release patient information, the Contractor in compliance with VA regulations, and at his/her own expense, shall use VA Form 3288, Request for and Consent to Release of Information from Individual’s Records, to process “Release of Information Requests.” The VA’s Release of Information Section shall provide the Contractor with assistance in completing forms. Completed Release of Information requests shall be forwarded to the VA Privacy Officer at the applicable VAMC. The VA Privacy Officer information shall be provided at the time of task order award.

5.7. Site Visits: The VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this contract, through one

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

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

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

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

6. ADMINISTRATIVE:

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

6.2. Staff Meetings/Rounds: Contractor Personnel shall attend staff meetings as required by the MH RRTP program managers and Contractor’s establishment.

6.3. QA/QI documentation: Contractor Personnel shall complete the appropriate QA/QI documentation pertaining to care as requested by RRTP program managers or other VA representatives.

6.4. Patient Safety Compliance and Reporting: Contractor Personnel shall follow all established patient safety and infection control standards of care. Contractor Personnel shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breeches of patient safety shall be reported to the

COR in accordance with the VA Safety Policy as soon as practicable (but within twentyfour

(24) hours). Contractor Personnel shall notify the COR of the incident and submit to the COR a Patient Safety Report, following up with the COR as required or requested. A copy of the Patient Safety Report will be provided when needed.

7. PERFORMANCE STANDARDS, QUALITY ASSURANCE AND QUALITY IMPROVEMENT

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

7.1.1. Performance Standards:

7.1.1.1 Measure: Non-Clinical Information Return (Deviation from Routine Care) Performance Requirement: Clinical information is provided back to the respective residential program (TRP or ADTP).

Standard: Information is provided within twenty-four (24) hours of the event.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection, coinciding with ongoing reviews of 36C25620D0003 maintenance and repair logs during routine facility inspection visits.

Frequency: Periodic Inspection

7.1.1.2 Measure: Access (Bed Availability)

Performance Requirement: An adequate number of beds will be available in a ready state to accommodate TRP and ADTP admissions.

Standard: Empty beds will be ready for occupancy within two (2) hours of notification by TRP or ADTP.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection, observed through monthly reports from contractor.

Frequency: Monthly

7.1.1.3 Measure: Accreditation

Performance Requirement: Contractor will work with VA MH RRTP in their efforts to maintain accreditation standards of Joint Commission on Accreditation Facilities (CARF), as relevant to contracted services.

Standard: Contractor will comply with Joint Commission and CARF standards as they relate to the VA MH RRTP unit. Contractor will facilitate inspections of the facility and relevant records as requested. Contractor will be responsive to request for corrective action resulting from inspections.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection, by both VA staff and external accrediting bodies (e.g., Joint Commission, CARF).

Frequency: Periodic Inspection

7.1.1.4 Measure: Staff Qualifications

Performance Requirement: Staff employed by the contractor will have continuing education relevant to addictions and trauma.

Standard: Staff will receive a minimum of ten (10) Continuing Education Units per year in areas of substance abuse and trauma. Veteran care staff hired by the contractor will not have participated in a TRP or ADTP residential program within the past two (2) years.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection of staff training and employment records.

Frequency: Periodic Inspection

7.1.1.5 Measure: Veteran Safety - Reporting

Performance Requirement: Veteran safety incidents reported to the respective treatment program (TRP or ADTP) or on-call psychiatrist.

Standard: All incidents reported within one (1) hour of the incident.

Acceptable Quality Level: 90% Surveillance Method: Direct observations and periodic inspection, observed through communication and residential treatment records.

Frequency: Periodic Inspection

7.1.1.6 Measure: Veteran Safety – Incident Resolution

Performance Requirement: All Veteran safety incidents are investigated, confirmed, and resolved.

Standard: Contractor will consult with the appropriate program manager within one (1) business day of the event.

Acceptable Quality Level: 90% Surveillance Method: Reviewed during analysis of critical incidents, routine site inspections, and any accreditation surveys.

Frequency: Periodic Inspection

7.1.1.7 Measure: Veteran Satisfaction

Performance Requirement: Contractor assesses patient satisfaction and solicits complaints and suggestions regarding the quality of care.

Standard: Contractor representative attends monthly stakeholder meeting to receive and respond to feedback. Veteran satisfaction survey is administered by contractor, with results tallied and reported to TRP and ADTP on at least a quarterly basis.

Acceptable Quality Level: 90% Surveillance Method: Attendance at stakeholder meeting. User survey and quarterly roll-up reports that include any qualitative statements from veterans.

Frequency: Periodic Inspection

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

7.3. The Government reserves the right to refuse acceptance of any Contractor Personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility.

Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall handle issues raised concerning Contractor Personnel conduct. The final arbiter on questions of acceptability is the CO.

7.4. Quality Management reports shall be submitted to VAMC on a Quarterly basis.

Reports shall include performance improvement and quality control activities relating to the Contractor’s facility. The COS should be notified of sentinel events as defined by TJC or equivalent, immediately upon occurrence.

7.5. Deliverables: The contractor shall provide the following deliverables as required:

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

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

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

7.5.3.1 Access to the facility(ies) will be restricted to a single access-controlled entrance. Closed circuit video surveillance with recording and review capacity will be utilized to monitor access points and public areas, including any inside or outside locations utilized by Veterans, as requested; does not include private bedrooms or bathrooms. The contractor will provide video surveillance and access-control equipment to meet this requirement. The contractor will be responsible for maintaining and repairing this equipment.

7.5.3.2 All unit entry/egress doors are controlled by keyless entry locks or automatically locking/alarmed doors or overseen by a dedicated individual. The contractor will be responsible for providing and maintaining this equipment.

7.5.3.3 MH RRTP unit signage will be current, visible and will contain visitor, weapon, CCTV, and illicit drug and alcohol policies. The MH RRTP unit will also display current Veteran Crisis Line posters and phone number stickers. The contractor will be responsible for providing and maintaining VA approved signage.

7.5.3.4 The contractor will be responsible for ensuring that parking lots and walkways have adequate lighting and are free of obstructions and hazards.

7.5.3.5 All Veterans shall be provided clean, safe, and sanitary housing. Contractor will provide adequate space and privacy in bedrooms, bathrooms and other areas for up to twenty-seven (27) Veterans. Each bedroom will have adequate space to comfortably accommodate up to two (2) Veterans and will have an insuite bathroom. Bedrooms and bathrooms should be lockable by Veterans (e.g., with a key card or user defined code) but also immediately accessible to VA staff in case of emergency (e.g., via master key or override system). Environment should demonstrate attention to safety & security needs throughout (e.g., handrails in showers; non-slip bathroom mats).

7.5.3.6 Provisions will be made to house at least eight (8) women at a time (minimum four (4) rooms in total, no more than two (2) female Veterans per room). Rooms housing female Veterans must be within line of sight of the VAMC worker’s station. Female bathroom doors will be locked when accessible from unit hallways or other public spaces.

7.5.3.7 Facility will provide at least two (2) bedrooms/bathrooms designed for wheelchair access (e.g. roll-in shower with folding seat; maneuvering space at bedside).

7.5.3.8 Empty beds will be clean and ready for occupancy within two (2) hours of notification by TRP or ADTP staff.

7.5.3.9 Flooring throughout the unit should be hard and non-porous, not carpeted.

7.5.3.10 Furniture will include, at minimum: a standard (twin size) bed and bed frame, nightstand, closet, desk and medication locker for each Veteran. Bed frames should be manufactured out of metal or plastic (not wood), to reduce bed bug risk. Closets and locker should be lockable by Veterans (e.g., with a user defined code) but also immediately accessible to VA staff in case of emergency (e.g., via master key or override system). It is the responsibility of the contractor to maintain all bedroom furniture and to fix or replace anything in disrepair.

7.5.3.11 Mattresses – Contractor will provide a standard, twin size mattress for each Veteran. Contractor will be responsible for replacing mattresses every four (4) years or sooner, as needed and for developing processes to ensure cleanliness of mattresses for each Veteran. Mattresses and box springs should both be encased in a vinyl or other bed-bug proof cover that is kept in good repair (no holes).

7.5.3.12 Pillows & Bedding - Contractor will be responsible for providing clean and comfortable pillows and bedding. Contractor will replace pillows every one (1) year or sooner, as needed. Contractor will replace bedding (i.e., mattress cover, pillow cases, fitted sheet, sheet, and comforter) every two (2) years or sooner, as needed.

7.5.3.13 Towels – The contractor will maintain an adequate supply of clean bathroom towels (minimum four (4) full length body towels and four (4) wash cloths per week for each Veteran) for use by the Veterans. New towels will be purchased by the contractor every one (1) year, or sooner as needed.

7.5.3.14 Contractor will be responsible for laundering bed/bath linens once per week or more often if requested or upon admission of a new resident.

7.5.3.15 Veterans will have access to a minimum of one (1) common kitchen area for storing and preparing personal food items. At minimum, the kitchen area will include two (2) full size (i.e., at least eighteen (18) cubic feet) refrigerators, a microwave, water/ice machine, coffee maker and basic kitchen cutlery (disposable forks, spoons and knives). Contractor will check fridges, freezers, water/ice machines (and other appliances as indicated) will be checked daily to ensure they are clean, functional and maintaining safe and appropriate temperatures.

7.5.3.16 Contractor will provide secure storage of patient medications, including any controlled medications that are authorized by the Medical Director of ADTP or TRP. This includes both patient lockers (lockable and accessible to both Veterans and staff) and a secure medication storage/dispensing area accessible only to staff (e.g., appropriate for storage of refrigerated medications, narcotics).

7.5.3.17 Veterans will have access to at least four (4) well-functioning computers with Internet access and up-to-date word processing software and operating systems, as well as to at least one (1) working fax machine and at least two (2) printers. Contractor will be responsible for maintaining an adequate supply of printer/fax paper, and all necessary supplies to maintain proper working order (e.g., ink). Contractor will be responsible for repair and replacement of computers, faxes and printers. Computers must be no older than five (5) years.

7.5.3.18 Contractor will provide high speed wireless internet access to accommodate twenty-seven (27) simultaneous users. Contractor shall use up-to-date site blocking and monitoring software for all internet access to prevent inappropriate computer use.

7.5.3.19 All Veterans will have access to recreational, fitness and lounging areas that provide access to sports, fitness and activities such as billiards, ping-pong, table, card and board games.

7.5.3.20 An indoor fitness & recreation area will include a minimum of six (6) cardio machines (e.g., treadmill, elliptical, stationary bikes), a set of free weights/dumbbells, weight bench and a full-body workout machine (e.g., weight cage, bowflex). Contractor will ensure all fitness and weight machines are maintained and serviced as needed to ensure safety. Fitness equipment must be serviced a minimum of once a year by a certified professional, verifiable by written records and/or stickers on machines. Indoor space and supplies must also be available to facilitate wellness interventions like Yoga, Tai Chi and stretching. Space will include floor/yoga mats and access to a TV and DVD player to facilitate Veteran use of exercise/wellness instructional videos.

7.5.3.21 An outdoor recreation area will include at minimum a basketball hoop, court and basketballs. Access to other activities and recreational supplies is encouraged (e.g., horse shoes, frisbee, football, walking track, volleyball, bean bag toss).

7.5.3.22 A minimum of two (2) common areas will be provided for watching TV or movies. Additional common areas may be necessary depending on the layout of the facility. Each common area shall be large enough to comfortably accommodate at least fifteen (15) Veterans, as well as a 48-inch or larger television, and at least one (1) card table with chairs to promote socialization.

Contractor will provide comfortable furniture, televisions (at least 48-inches of diagonal screen size), DVD players and…