36C26319R0092-001.pdf

PAGE 1 OF 98 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. DUNS: DUNS+4:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

656-19-1-066-0002

36C26319R0092 4-30-19

Contract Specialist - Charles Morin 651-293-3035

5-28-19,10:00 AM CST

Department of Veterans Affairs

NCO 23 - St Paul

316 Robert Street N.

Attention: Charles Morin

St Paul MN 55101

X 0

$38.5 Million

X

N/A

X

St. Cloud VA Health Care System

4801 Veterans Dr.

Saint Cloud MN 56303

NCO 23 - St Paul

Attention: Charles Morin

316 Robert Street N.

St. Paul MN 55101

Y

Financial Services Center

PO Box 149971

Austin TX 78714-9971

See CONTINUATION Page

Mental Health Services for the

St. Cloud VA Health Care System

Period of Performance: 8/1/2019 - 7/31/2020

See Subsection B.2 Schedule of Services page 6

See Subsection B.3 Performance Work Statement page 13

X X

X ONE

36C26319R0092

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 SCHEDULE OF SERVICES

B.3 PERFORMANCE WORK STATMENT

B.4 IT CONTRACT SECURITY

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS

(OCT 2018)

C.2 52.204-21 BASIC SAFEGUARDING OF COVERED CONTRACTOR INFORMATION

SYSTEMS (JUN 2016)

C.3 52.216-18 ORDERING (OCT 1995)

(End of Clause)

C.4 52.216-19 ORDER LIMITATIONS (OCT 1995)

C.5 52.216-22 INDEFINITE QUANTITY (OCT 1995)

C.6 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.7 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

C.8 SUPPLEMENTAL INSURANCE REQUIREMENTS

C.9 52.232-19 AVAILABILITY OF FUNDS FOR THE NEXT FISCAL YEAR (APR 1984) 50

C.10 VAAR 852.203-70 COMMERCIAL ADVERTISING (MAY 2018)

C.11 VAAR 852.203-71 DISPLAY OF DEPARTMENT OF VETERAN AFFAIRS HOTLINE

POSTER (DEC 1992)

C.12 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (DEC 2009)

C.13 VAAR 852.219-9 VA SMALL BUSINESS SUBCONTRACTING PLAN MINIMUM

REQUIREMENTS (DEC 2009)

C.14 VAAR 852.219-71 VA MENTOR-PROTÉGÉ PROGRAM (DEC 2009)

C.15 VAAR 852.219-72 EVALUATION FACTOR FOR PARTICIPATION IN THE VA

MENTOR-PROTÉGÉ PROGRAM (DEC 2009)

C.16 VAAR 852.219-75 SUBCONTRACTING COMMITMENTS MONITORING AND

COMPLIANCE (JUL 2018)

C.17 VAAR 852.219-76 SUBCONTRACTING PLANS MONITORING AND COMPLIANCE

(JUL 2018)

C.18 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV

2012)

C.19 VAAR 852.237-7 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE

(JAN 2008)

C.20 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984)

C.21 SUBCONTRACTING PLAN--MONITORING AND COMPLIANCE (JUN 2011)

C.22 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.23 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (JAN 2019) ALTERNATE II (JAN

2019)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

D.1 List of Attachments

SECTION E - SOLICITATION PROVISIONS

E.1 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS (OCT 2018)

E.2 PROPOSAL SUBMITTAL INSTRUCTIONS

E.3 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (OCT 2015) 72

E.4 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (OCT 2018)

E.5 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014)

E.6 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL

ITEMS (OCT 2018)

E.7 52.216-1 TYPE OF CONTRACT (APR 1984)

E.8 52.217-5

E.9 52.233-2 SERVICE OF PROTEST (SEP 2006)

E.10 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB

1998)

E.11 VAAR 852.209-70 ORGANIZATIONAL CONFLICTS OF INTEREST (JAN 2008)

E.12 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-

OWNED SMALL BUSINESS EVALUATION FACTORS (JUL 2016)(DEVIATION)

E.13 VAAR 852.233-70 PROTEST CONTENT/ALTERNATIVE DISPUTE RESOLUTION

(OCT 2018)

E.14 VAAR 852.233-71 ALTERNATE PROTEST PROCEDURE (OCT 2018)

E.15 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN 2008) 98

E.16 VAAR

E.17 VAAR 852.271-70 NONDISCRIMINATION IN SERVICES PROVIDED TO

BENEFICIARIES (JAN 2008)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

(continuation from Standard Form 1449, block 18A.)

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer / Contract Specialist

Contracting Officer is Charles Hurry at charles.hurry@va.gov

Contract Specialist is Charles Morin at charles.morin@va.gov

Department of Veterans Affairs

NCO 23 – St. Paul

316 Robert Street N.

St. Paul MN 55101

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[X] 52.232-33, Payment by Electronic Funds Transfer—System For Award Management, or

[] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly []

b. Semi-Annually []

c. Other [X] Monthly, See Billing Instructions, PWS 6.2. Billing:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

5. ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

6. TYPE OF CONTRACT: Resultant contracts shall be a Fixed Price, Indefinite Delivery Indefinite

Quantity, (IDIQ), contract effective for the period stated in the Schedule of Services.

7. TERM OF CONTRACT: The contract period is effective August 1, 2019 through July 31, 2020 with four (4) option periods.

8. POINT OF CONTACT: The Contractor shall provide a point of contact (POC) who shall be responsible for the performance of the work under this contract. The POC shall have full authority to act for the Contractor on all matters relating to the daily operation of this contract. The POC may be a contract health care provider performing under this contract. An alternate may be designated, but the

Contractor shall identify, in writing, those times when the alternate shall act as the POC. The Contractor shall identify the POC and alternate in writing to the Contracting Officer’s Representative (COR) and

Contracting Officer (CO). The Contractor shall give written notification to the COR and CO of the time when the alternate will act as the POC. The POC shall be available by telephone Monday through Friday, 8:00 AM through 4:30 PM, excluding Federal holidays.

9. SECURE FAX: VA Handbook 6500 requires the following statement on all fax cover sheets be included: “This fax is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this fax does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribute on, or copying of this communication is prohibited. If you have received this fax in error, please notify this office immediately at the telephone number listed above.”

10. POST AWARD ORIENTATION: The Contracting Officer shall follow the guidance in FAR

Subpart 42.5 and note Information Letter (IL) 003A3-12-04 that provides documentation requirements for orientation conducted for such awards. A hyperlink to the IL is provided for your information.

http://www.va.gov/oal/docs/library/ils/il12-04.pdf http://www.va.gov/oal/docs/library/ils/il12-04.pdf

B.2 SCHEDULE OF SERVICES

SCHEDULE OF SERVICES

The Contractor shall furnish all personnel to provide services necessary to perform on-site, outpatient

Psychiatry Physician and Mental Health (MH) Advanced Practice Registered Nurse (APRN) Services to eligible beneficiaries of the St. Cloud VA Health Care System (hereinafter referred to as SCVAHCS).

Place of Performance: Services shall be provided on-site at SCVAHCS, 4801 Veterans Dr., St Cloud, MN

56303.

The Contractor shall furnish all personnel to provide services necessary to perform on-site On-Call

Mental Health Services to eligible beneficiaries of the Department of Veterans Affairs (VA), St. Cloud, MN VA Health Care System. The Contractor’s care shall cover the range of services as would be provided in a state-of-the-art health care medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized national standards.

Pricing Instructions:

Offerors must fill out the cells in the following columns in the Price Schedule for each Contract Line Item

Number (CLIN).

Affiliate Offerors shall include the “title” of the personnel submitted. Other commercial health care

Offerors shall identify by title/position or level of experience the key personnel submitted. Offerors may re-number sub-CLINs if adding or removing Key Personnel. The Offeror is instructed to include all other-than-price-and-cost information supporting the proposed price, as directed in Instructions to Offerors addendum to 52.212-1 and/or Section D- Contract Documents, Exhibits, or attachments.

For the Base Period, the Contractor shall propose 1.0 Full-Time Equivalent (FTE) or 2080 hours of

Psychiatry Physician Key Personnel and 1.0 FTE or 2080 hours of MH APRN Key Personnel to be credentialed and available for scheduling to meet the requirements of the contract. Contractor must provide an adequate amount of key personnel necessary to ensure adequate, continual coverage.

For Option Year One through Four, the Contractor shall provide 2.0 Full-Time Equivalent (FTE) or 4160 hours of Psychiatry Physician Key Personnel and 2.0 FTE or 4160 hours of MH APRN Key Personnel to be credentialed and available for scheduling to meet the requirements of the contract. Contractor must provide an adequate amount of key personnel necessary to ensure adequate, continual coverage.

One (1.0) FTE is defined by VA as a minimum of 80 hours every two weeks per year and does not include holidays.

On-Call Psychiatrist Services will not be performed co-current to regular duty day services, on-call hours provide coverage for before or after the duty day or on weekends. On-call contractor’s physician(s) must be available at all times for phone consultations with VA residents and physicians. Additionally, the on-call physician may be required to come in to the VA hospital while on-call. On-call coverage is performed on a rotational basis of about one week every two months per FTE. See the PWS for more detail on on-call coverage.

Contract Type: The Government intends to award a Fixed Priced Indefinite Quantity Contract.

• The guaranteed minimum contract quantity is $25,000.00. The Government is not required to place an order in excess of the guaranteed minimum.

• The maximum quantity/contract quantity/amount, including the base year and any option years exercised, shall not exceed $6,995,000.00.

• It is anticipated that a single contract will be awarded

Ordering Procedures:

• A task order will be placed by the Administrative NCO 23 Contracting Officer.

• Each ordering vehicle will document the quantity, and other pertinent data to ensure the services provide the appropriate level of patient care to the maximum order allowable under the resultant contract. No additional services are authorized without prior approval through the Administrative Contracting Officer and/or

Contracting Officer.

Period of Performance: Twelve (12) Month Base Period and four (4) 12-Month Option Years (to be exercised at the discretion of the Government)

Base Year: 8/1/2019 to 7/31/2020

Option Year 1 8/1/2020 to 7/31/2021

Option Year 2 8/1/2021 to 7/31/2022

Option Year 3 8/1/2022 to 7/31/2023

Option Year 4 8/1/2023 to 7/31/2024

CONTRACT TOTAL COST (BASE YEAR AND ALL OPTIONS)

Base Year Cost:

Option Year 1 Cost:

Option Year 2 Cost:

Option Year 3 Cost:

Option Year 4 Cost:

Total Contract Cost:

Period of Performance: BASE PERIOD: August 1, 2019 to July 31, 2020

CLIN

No.

SUB-

Description

Estimated

Quantity

Unit Unit Cost Total

Annual Cost

0001 None

Board Certified Psychiatrist Physician Services

(1.0 FTE)

2,080 Hours

0002 None

Board Certified Psychiatrist Physician Services -

Weekday On-Call (Mon 4:30 pm - Fri 8:00 am)

640 Hours

0003 None

Weekend On-Call (Fri 4:30 pm to Mon 8:00 am)

320 Hours

0004 None

Mental Health Advanced Practice Registered

Nurse (1.0 FTE)

2,080 Hours

KEY PERSONNEL

None 0001a

Board Certified Psychiatrist Physician

NAME:

TITLE:

2,080 Hours $______ /hr $______

None 0002a

640 Hours $______ /hr $______

None 0003a

320 Hours $______ /hr $______

None 0004a

Mental Health Advanced Practice Registered

Nurse

TITLE

TOTAL FOR BASE PERIOD:

OPTION YEAR 1: August 1, 2020 to July 31, 2021

Unit Unit Cost Total

1001 None

(2.0 FTE)

4,160 Hours

1002 None

1,280 Hours

1003 None

1004 None

None 1001a

None 1001b

None 1002a

None 1002b

None 1003a

None 1003b

None 1004a

Mental Health Advanced Practice Registered

None 1004a

Mental Health Advanced Practice Registered

TOTAL FOR OPTIONYEAT ONE:

OPTION YEAR 2: August 1, 2021 to July 31, 2022

Unit Unit Cost Total

2001 None

2002 None

2003 None

2004 None

None 2001a

None 2001b

None 2002a

None 2002b

None 2003a

None 2003b

None 2004a

Mental Health Advanced Practice Registered

None 2004a

Mental Health Advanced Practice Registered

TOTAL FOR OPTION YEAR TWO:

OPTION YEAR 3: August 1, 2022 to July 31, 2023

Unit Unit Cost Total

3001 None

3002 None

3003 None

3004 None

None 3001a

None 3001b

None 3002a

None 3002b

None 3003a

None 3003b

None 3004a

Mental Health Advanced Practice Registered

None 3004a

Mental Health Advanced Practice Registered

TOTA FOR OPTION YEAR THREE:

OPTION YEAR 4: August 1, 2023 to July 31, 2024

CLIN

No.

Unit Unit Cost Total

4001 None

4002 None

4003 None

4004 None

None 4001a

None 4001b

None 4002a

None 4002b

None 4003a

None 4003b

None 4004a

None 4004a

TOTALFOR OPTION YEAR FOUR:

Total for base performance period and options:

Contractor will only be paid for the actual hours of services provided.

B.3 PERFORMANCE WORK STATMENT

Performance Work Statement for Psychiatry and Mental Health APRN Services

1. GENERAL:

1.1. Services Provided: The Contractor shall provide Board Certified Psychiatry Physician Services and ANCC Certified Psychiatric-Mental Health Advanced Practice Nurses (PMH-APRNs) on site in accordance with the specifications contained herein to beneficiaries of the Department of

Veterans Affairs (VA) and the St. Cloud VA Health Care System (SCVAHCS).

1.2. Place of Performance - Contractor shall furnish services at the St. Cloud VA Health Care System, 4801 Veterans Drive, St. Cloud MN, 56303.

1.3. Authority: This contract is executed under the authority of Public Law 104-262, the Veterans

Health Care Eligibility Reform Act of 1996, and Title 38 USC 8153, Health Care Resources

(HCR) sharing Authority.

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

1.4.1. VA Directive 1663: Health Care Resources Contracting - Buying http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=347

1.4.2. VHA Directive 1003, VHA HB 1003.1, VHA HB 1003.2 and VHA Directive 1230 https://www.va.gov/vhapublications/index.cfm

1.4.3. VHA Directive 2010-018 “Facility Infrastructure”

www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2227

1.4.4. VHA Directive 1192 “Seasonal Influenza Prevention Program” https://www.publichealth.va.gov/docs/flu/VHA_Directive_1192_Sep

1.4.5. VHA Handbook 1100.17: National Practitioner Data Bank Reports -http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2135 http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=347 https://www.va.gov/vhapublications/index.cfm http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2227 https://www.publichealth.va.gov/docs/flu/VHA_Directive_1192_Sep http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2135

1.4.6. VHA Handbook 1100.18 Reporting and Responding to State Licensing Boards -http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1364

1.4.7. VHA Handbook 1100.19 Credentialing and Privileging -

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910

1.4.8. VHA Handbook 1907.01 Health Information Management and Health Records:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088

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

http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm

1.5. 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.

1.5.1. ABMS: American Board of Medical Specialties

1.5.2. ABPN: American Board of Psychiatry and Neurology is a member board of the American

Board of Medical Specialties

1.5.3. ACGME: Accreditation Council for Graduate Medical Education

1.5.4. ANCC: American Nurses Credentialing Center

1.5.5. AOD: Admitting Officer of the Day

1.5.6. APRN: Advanced Practice Registered Nurse

1.5.7. BLS: Basic Life Support

1.5.8. CCNE: Commission on Collegiate Nursing Education: www.aacn.nche.edu/accreditation

1.5.9. CDC: Centers for Disease Control and Prevention

1.5.10. CDR: Contract Discrepancy Report

1.5.11. CEU: Certified Education Unit

1.5.12. CME: Continuing Medical Education

1.5.13. CMS: Centers for Medicare and Medicaid Services

1.5.14. 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.

1.5.15. 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 non-compliance in order that appropriate action can be taken.

1.5.16. COS: Chief of Staff

1.5.17. CPARS: Contractor Performance Assessment Reporting System

1.5.18. CPRS: Computerized Patient Recordkeeping System- electronic health record system used by the VA.

1.5.19. 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.

1.5.20. DEA: Drug Enforcement Agency

1.5.21. DO: Doctor of Osteopathy

1.5.22. ED: Emergency Department

1.5.23. FSMB: Federation of State Medical Boards

1.5.24. HHS: Department of Health and Human Services

1.5.25. HIPAA: Health Insurance Portability and Accountability Act

1.5.26. HR: Human Resources

1.5.27. ISO: Information Security Officer

1.5.28. MD: Medical Doctor

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1364 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088 http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm http://www.aacn.nche.edu/accreditation

1.5.29. Medical Emergency - a sudden onset of a medical condition manifesting itself by acute symptoms of enough severity that the absence of immediate medical attention could reasonably result in: Permanently placing a patient's health in jeopardy, causing other serious medical consequences, causing impairments to body functions, or Causing serious or permanent dysfunction of any body-organ or part.

1.5.30. MOD: Medical Officer of the Day

1.5.31. PMH_APRN: Psychiatric-Mental Health Advance Practice Registered Nurses

1.5.32. National Provider Identifier (NPI): NPI is a standard, unique 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).

1.5.33. NLNAC: National League for Nursing Accrediting Commission. www.nlnac.org

1.5.34. Non-Contract Provider - any person, organization, agency, or entity that is not directly or indirectly employed by the Contractor or any of its subcontractors

1.5.35. NP: Nurse Practitioner

1.5.36. NPPES: National Plan and Provider Enumeration System

1.5.37. PA: Physician Assistant

1.5.38. PALS: Pediatric Advanced Life Support

1.5.39. POP: Period of Performance

1.5.40. PPD: Purified Protein Derivative

1.5.41. PWS: Performance Work Statement

1.5.42. Privileging (Clinical Privileging): Privileging is the process by which a practitioner, licensed for 8independent 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.

1.5.43. Provider: Physician or Advanced Practice Registered Nurse

1.5.44. QA/QI: Quality Assurance/Quality Improvement

1.5.45. QM/PI: Quality Management/Performance Improvement

1.5.46. QASP: Quality Assurance Surveillance Plan

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

1.5.48. Veterans Integrated Services Network (VISN): The regional oversight for the VA medical centers.

1.5.49. VISTA (Veterans Integrated Systems Technology Architecture): A PC based system that will capture and store clinical imagery, scanned documents and other non-textual data files and integrates them into patient’s medical record and with the hospital information system.

1.5.50. VetPro: a federal web-based credentialing program for healthcare providers.

1.5.51. Veterans Affairs Medical Center (VAMC): Unless identified with the name of a different

VA medical Center, for purposes of this contract, this term shall mean the St. Cloud VA

Medical Center.

http://www.nlnac.org/

2. QUALIFICATIONS:

2.1. Staff/Facility

2.1.1. License – The Contractor’s physician (s) assigned by the Contractor to perform the services covered by this contract shall have a current license to practice medicine in any

State, Territory, or Commonwealth of the United States or the District of Columbia) when services are performed onsite on VA property.

All licenses held by the personnel working on this contract shall be full and unrestricted licenses. Contractor’s physician (s) who have current, full and unrestricted licenses in one or more states, but 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.

2.1.2. Board Certification - All contractor’s physician(s) shall be Board Certified by the

American Board of Medical Specialties (ABMS)/American Board of Psychiatry and

Neurology (ABPN), and be currently certified in Basic Life Support (BLS). All continuing education courses required for maintaining certification must be kept up to date at all times. Documentation verifying current certification shall be provided by the Contractor to the VA COR on an annual basis for each year of contract performance.

2.1.3. Credentialing and Privileging –Credentialing and privileging is to be done in accordance with the provisions of VHA Handbook 1100.19 referenced above. The Contractor is responsible to ensure that proposed physician(s) possesses the requisite credentials enabling the granting of privileges. No services shall be provided by any contractor’s physician(s) prior to obtaining approval by the St. Cloud VA MEDICAL CENTER

(SCVAMC) Professional Standards Board, Medical Executive Board and Medical Center

Director.

2.1.3.1. If a contractor’s physician(s) is not credentialed and privileged or has credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government.

2.1.4. Technical Proficiency - Contractor’s physician(s) 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’s physician(s) and contractor’s physician(s) shall be responsible for abiding by the Facility's Medical Staff By-Laws, rules, and regulations (referenced herein) that govern medical staff behavior.

2.1.5. Continuing Medical Education (CME)/ Certified Education Unit (CEU)

Requirements: Contractor shall provide the COR copies of current CMEs as required or requested by the VAMC. Contractor’s physician(s) registered or certified by national/medical associations shall continue to meet the minimum standards for CME to remain current. Contractor shall report CME hours to the credentials office for tracking.

These documents are required for both privileging and re-privileging. Failure to provide shall result in loss of privileges for contractor’s physician(s).

2.1.5.1. Psychiatrist shall have experience in the following:

2.1.5.1.1. Adult patients;

2.1.5.1.2. Substance use in adults;

2.1.5.1.3. Geriatrics;

2.1.5.1.4. Inpatient and Outpatient experience, including triage and disposition of patients in mental health crisis;

2.1.5.1.5. Teamwork; and

2.1.5.1.6. Medication management.

2.1.6. APRN Certification and Experience – All contractor’s Advanced Practice Registered

Nurses (APRN) shall be ANA Certified in Psychiatry-Mental Health from an accredited school by the National League for Nursing Accrediting Commission. www.nlnac.org and be currently certified in Basic Life Support (BLS). All continuing education courses required for maintaining certification must be kept up to date at all times. Documentation verifying current certification shall be provided by the Contractor to the VA COR on an annual basis for each year of contract performance.

2.1.6.1. APRN must have experience in adult or geropsychiatry. Graduate Psychiatric APRN with post-graduate residencies in adult or geropsychiatry preferred.

2.1.7. Training (BLS, CPRS and VA MANDATORY): Contractor shall meet all VA educational requirements and mandatory course requirements defined herein; all training must be completed by the contractor’s physician(s) as required by the VA. Other training may become required. VA will communicate any changes to the training requirement to the contractor. This training will be completed during duty hours.

Training (The following training is mandatory per VHACO for Contracted

Physicians)

Frequency (once a year, etc.)

Annual Hours

Active Threat Training One-time requirement within 90 days

1 hour

Military Sexual Trauma (MST) for

Medical Providers

One-time requirement within 90 days

2.50 hours

Prevention of Workplace Harassment/No

Fear Act

90 days and every 2 years

1.50 hours

VA Core Values Training (ICARE

Recommitment)

Annually 0.50 hour

VA Privacy and Information Security

Awareness and Rules of Behavior

ASAP and annually thereafter

1 hour

VHA Privacy and HIPAA Focused

Training

Within 30 days and annually thereafter

1 hour

BLS ASAP and every 2 years

4 hours

Patient Safety Annually 0.50 hour

Patient Rights Annually 0.50 hour

Patient Abuse Annually 0.50 hour

Prevention/Management of Disruptive

Behavior/Violence Prevention Level I

Level II

Level III

One-time requirement within 90 days

90 days of hire and every 2 years

90 days of hire and every 2 years

1.50 hours

4 hours

4 hours

Suicide Prevention: Suicide Risk

Management Training for Clinicians

90 days and annually 1 hour http://www.nlnac.org/

CPRS At time of hire- as needed

Varies based upon skills and knowledge of individual hired

VISTA Imaging One-time requirement within 90 days

1 hour

Other Training per local facility:

MH Environment of Care Annually 1 hour

2.1.8. Standard Personnel Testing (PPD, etc.): Contractor shall provide proof of the following tests for physicians within five (5) calendar days after contract award and prior to the first duty shift to the COR and Contracting Officer. Tests shall be current within the past year.

2.1.8.1. TUBERCULOSIS TESTING: Contractor shall provide proof of a negative

Tuberculosis Skin Test (TST) or interferon-gamma release assays (IGRA) for all

Contractor’s physician (s) {This is applicable to all health care workers}. A negative chest radiographic report for active tuberculosis shall be provided in cases of positive

TST or IGRA results. The TST or IGRA testing shall be repeated annually.

2.1.8.2. MEASLES, MUMPS, & RUBELLA TESTING: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}.

2.1.8.3. VARICELLA: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}.

2.1.8.4. ACELLULAR PERTUSSIS: Contractors shall provide proof of 1 dose of Tdap vaccination for all Contractor physicians {This is applicable to all health care workers}.

2.1.8.5. INFLUENZA: Contractors shall provide proof that all Contractor physicians have received the annual Influenza vaccine unless it is contraindicated. If the Contractor physician has a medical contraindication to the vaccine, they shall be required to wear a mask during the Influenza season. {This is applicable to all health care workers}.

2.1.8.6. OSHA REGULATION CONCERNING OCCUPATIONAL EXPOSURE TO

BLOODBORNE PATHOGENS: Contractor shall provide evidence of completing and passing generic self-study blood-borne pathogen training for all Contractor’s physician (s) {This is applicable to all health care workers}; provide their own

Hepatitis B vaccination series and hepatitis B surface antigen test results following the hepatitis B vaccination series; maintain an exposure determination and control plan;

maintain required records; and ensure that proper follow-up evaluation is provided following an exposure incident.

2.1.8.7. The VAMC shall notify the Contractor of any significant communicable disease exposures 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- AJIC 1998; 26:289-354 http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf) for disease control. Contractor shall provide follow up documentation of clearance to return to the workplace prior to their return.

2.1.9. National Provider Identifier (NPI): NPI is a standard, unique 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). The Contractor shall have or obtain appropriate NPI and if pertinent the Taxonomy Code confirmation notice issued by the Centers for Medicare and

Medicaid Services (CMS) National Plan and Provider Enumeration System (NPPES) be http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf provided to the Contracting Officer with the proposal.

2.1.10. DEA - Contractor shall provide copy of current DEA certificate.

2.1.11. Conflict of Interest: The Contractor and all contractor’s physician(s) are 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 must also provide relevant facts that show how it’s organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest. These statements shall be in response to the VAAR provision 852.209-70 Organizational Conflicts of Interest (Jan 2008) and fully outlined in response to the subject attachment in Section D of the solicitation document.

2.1.12. Citizenship related Requirements:

2.1.12.1. The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended;

its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the

Contractor while providing services to Department of Veterans Affairs patient referrals;

2.1.12.2. While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United

States. Additionally, the Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent

Amendments, as well as applicable Federal Acquisition Regulations.

2.1.12.3. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the

U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.

2.1.12.4. This certification concerns a matter within the jurisdiction of an agency of the United

States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.

2.1.12.5. The Contractor agrees to obtain a similar certification from its subcontractors. The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document.

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

(HHS) Office of Inspector General (OIG) has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the

Medicare and Medicaid programs.

2.1.13.1. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed contractor’s physician(s) are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a Civil

Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP’s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries.

2.1.13.2. By submitting their proposal, the Contractor certifies that the HHS OIG List of

Excluded Individuals/Entities has been reviewed and that the Contractors are and/or firm is not listed as of the date the offer/bid was signed.

2.2. Clinical/Professional Performance: The qualifications of Contractor personnel are subject to review by VA Medical Center COS or his/her clinical designee and approval by the Medical

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

2.3. Non-Personal Healthcare Services: The parties agree that the Contractor and all contractor’s physician(s) shall not be considered VA employees for any purpose.

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

Government against, all actions or claims for loss of or damage to property or the injury or death of persons, arising out of or resulting from the fault, negligence, or act or omission of the

Contractor, its agents, or employees.

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

2.6. Inherent Government Functions: Contractor and Contractor’s physician(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.

2.7. No Employee status: The Contractor shall be responsible for protecting Contractor’s physician(s) 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:

2.7.1.Workers’ compensation

2.7.2.Professional liability insurance

2.7.3.Health examinations

2.7.4.Income tax withholding, and

2.7.5.Social security payments.

http://oig.hhs.gov/exclusions/index.asp

2.8. Tort Liability: The Federal Tort Claims Act does not cover Contractor or contractor’s physician(s). When a Contractor or contractor’s physician(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 contractor’s physician(s)) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

2.9. Key Personnel:

2.9.1. The VA Full Time Equivalency (FTE): FTE is defined by VA as a minimum of 80 hours every two weeks and does not include holidays.

2.9.2. The minimum number of Psychiatry physicians and Psych-MH APRNs to staff the Mental

Health Service Line locations, located within the St. Cloud VA Health Care System, on a daily basis (be on site) is two Psychiatry M.D./D.O. s and 2 Psych-MH APRNs as defined in paragraph Hours of Operation in this section.

2.9.3. The Contractor shall be responsible for providing coverage to the VA during periods of vacancies of the Contractor’s personnel due to sick leave, personal leave, vacations and additional coverage as required. In the event a scheduled physician or Psych-MH

APRN is unable to complete an assigned shift, the contractor shall provide replacement physician coverage and notify the Contracting Office Representative

(COR) at the St. Cloud VA Medical Center immediately of the schedule change.

2.9.4. Personnel Substitutions: During the first ninety (90) calendar days of performance, the

Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment. The Contractor shall notify the CO, in writing, within five calendar day(s) after the occurrence of any of these events and provide the information required below. After 90 days, the Contractor shall submit the information required below to the CO at least 45 calendar days prior to making any permanent substitutions.

2.9.4.1. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO will notify the Contractor within 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.

2.9.4.2. For temporary substitutions where the key person shall not be reporting to work for three 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 period exceeding two weeks will require the procedure as stated above.

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

Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated

Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. Should the VA COS or designee show documented clinical problems or continual unprofessional behavior/actions with any

Contractor’s physician (s), s/he may request, without cause, immediate replacement of said Contractor’s physician (s). The CO and COR shall deal with issues raised concerning Contractor’s physician (s) conduct. The final arbiter on questions of acceptability is the CO.

2.9.4.4. Contingency Plan: Because continuity of care is an essential part of the St. Cloud VA

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

3. HOURS OF OPERATION

3.1.1. VA Business Hours: The general assignment will be five (5) days per week, but may change depending on workload. The normal work schedule will be Monday through

Friday from 8:00am to 4:30pm., with a ½ hour non-paid lunch break. Federal holidays are excluded from normal work schedule hours of operation. Contract provider will generally work (8) hours per day (40) hours per week. The Clinical Director for Mental Health

Services, or designee, will provide the work assignments for these positions and will provide clinical direction. Patients must be seen by a contractor’s physician(s) on-site at the St. Cloud VA Health Care System in a timely manner in accordance with VA Rules and Regulations on clinic wait times and consult completion. Contractor shall notify the

COR at least monthly about any obstacles to meeting this performance measure.

3.1.2. Contractor’s Physician(s) and Psych-MH APRNs shall be available and present in clinic during normal SCVAMC clinic hours, which will be established, and may be revised, as deemed appropriate for patient care by the Service Line Director or Chief of Staff.

Currently, normal clinic hours are 8:00am to 4:30pm, Monday through Friday.

3.1.3. Off-hours Coverage: The Psychiatrist will provide on-call for off-tour hours, weekends and holiday psychiatric coverage on a scheduled/rotating basis with other psychiatrists on staff.

3.1.3.1. Psychiatry weekend call would begin at 4:30 pm on Friday and run through 8:00 am the following Monday. This would be an estimated one weekend every 1-2 months.

Note: No premium payment will be made for working federal holidays.

3.1.3.2. Contractor’s Physician will provide on-call evening psychiatric coverage on a scheduled/rotating basis with other psychiatrists on staff. This would be from 4:30 pm in the evening to 8:00 am the following day during the business work week

(Monday-Thursday). This would be about once a week.

3.1.3.3. When on call, the Psychiatrist is referred to as the Mental Health Medical Officer of the Day (MHOD) and is on duty 24 hours a day. The Psychiatrist scheduled for evening/weekend/holiday call must be available and report on station four (4) hours on Saturday and four (4) hours on Sunday, and eight (8) hours for a Holiday. The patient must be seen and evaluated within 24 hours of admission. The Psychiatrist must also be available by telephone if the Medical Officer of the Day (MOD) has issues/concerns about psychiatry patients.

3.1.3.4. When on-call the contractor’s physician(s) must be available at all times for phone consultations with VA physicians, nursing or the MOD.

3.1.3.5. Patients must be seen within 60 minutes of the page when medically indicated.

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

• New Year’s Day

• President’s Day

• Martin Luther King’s Birthday

• Memorial Day

• Independence Day

• Labor Day

• Columbus Day

• Veterans Day

• Thanksgiving

• Christmas

• Any day specifically declared to be a national holiday.

3.3. Cancellations:

3.3.1. Unless a state of emergency has been declared or clinics are otherwise cancelled by the

VAMC, the Contractor shall be responsible for providing services.

4. CONTRACTOR RESPONSIBILITIES

4.1. Clinical Personnel Required: The Contractor shall provide contractor’s physician(s) who are competent, qualified per this PWS and adequately trained to perform assigned duties.

4.1.1. Contractor’s physician (s) shall be responsible for signing in and out when in attendance.

These sign in/sign out sheets will be used by the COR to confirm hours/day provided against the contractor’s invoices.

4.2. Standards of Care: The contractor’s physician(s) care shall cover the range of Psychiatry services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized national standards as established by:

4.2.1. American Psychiatric Association Practice Guidelines, https://psychiatryonline.org/guidelines

4.2.2. VA Standards: VHA Directive 2006-041 “Veterans’ Health Care Service Standards”

(expired but still in effect pending revision) https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1443

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

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

4.2.5. The requirements contained in this PWS

4.3. Reserved.

4.4. MEDICAL RECORDS

4.4.1. Authorities: Contractor’s physician(s) providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the

U.S.C.551a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C.

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