PWS - ACUTE DIALYSIS NURSING SERVICE.pdf

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PERFORMANCE WORK STATEMENT (PWS)

for

On-Site Acute Dialysis Nursing Service

1. GENERAL:

1.1. Services Provided: The Contractor shall provide Onsite Acute Dialysis Nursing Service in accordance with the terms, conditions, and specifications contained herein to beneficiaries of the Department of Veteran Affairs (VA), Sioux Falls VA Health Care System (VAHCS). Services will be provider on a 24-hour per day, seven days per week basis, including holidays and weekends. This will include maintaining the water treatment and dialysate systems in accordance with the manufacturer’s guidelines and standards of practice whenever they are on-site for acute hemodialysis nursing procedures. The Sioux Falls VAHCS will provide nurse oversight and retain ultimate authority over and responsibility for each patient’s care and treatment.

1.2. Place of Performance: Contractor shall furnish services at the Sioux Falls VAMC) 2501 W. 22nd Street, Sioux Falls, SD 57105.

1.3. Authority: Title 38 USC 8153, Health Care Resources (HCR) sharing Authority

1.4. Policy/Directives/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:

https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=969&FType=2

1.4.2. VHA Directive 1003.04: VHA Patient Advocacy:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5970

1.4.3. VHA Directive 1065: Productivity and Staffing Guidance for Specialty

Provider Group Practice:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9130

1.4.4. VHA Directive 1088(1) Communicating Test Results to Providers and Patients:

www.va.gov/vhapublications/viewpublication.asp?pub_id=3148

1.4.5. VHA Directive 1100.18: Reporting And Responding To State Licensing Boards:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9174

1.4.6. VHA Directive 1100.20 Credentialing of Health Care Providers:

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9444

1.4.7. VHA Directive 1192.01: Seasonal Influenza Prevention Program:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5472

1.4.8. VHA Directive 1220(1): Facility Procedure Complexity Designation Requirements to Perform Invasive Procedures In Any Clinical Setting:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8365

1.4.9. VHA Directive 1605.01: Privacy and Release of Information:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=969&FType=2 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5970 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Fvhapublications%2FViewPublication.asp%3Fpub_ID%3D9130&data=05%7C01%7C%7C8e30ab1c2724408fd8b908dabb69217a%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638028357445005912%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=nEyQZjaCRe9uO76Ysdmzbt%2B6eTSAaGHWlsT22NfQWJk%3D&reserved=0 http://www.va.gov/%E2%80%8Bvhapublications/%E2%80%8Bviewpublication.asp?pub_id=3148 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9174 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fvaww.va.gov%2Fvhapublications%2FViewPublication.asp%3Fpub_ID%3D9444&data=04%7C01%7C%7C5a2fc81d5c9e4c31696308d9ca3b3c47%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637763178024295633%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=g4iIWP0fMWV1ITn9%2F0vT4lpul7nFJAe%2FDMHlz4MTfT8%3D&reserved=0 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5472 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8365 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Fvhapublications%2FViewPublication.asp%3Fpub_ID%3D3233&data=05%7C01%7C%7C8e30ab1c2724408fd8b908dabb69217a%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638028357445162578%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=OSgtlRX4Np9LQE16y8y3W8udw0ZEIgPykhxCoprX530%3D&reserved=0

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1.4.10. VHA Directive 1907.01: VHA Health Information Management and Health Records:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235

1.4.11. VHA Handbook 1100.17: National Practitioner Data Bank Reports:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2135

1.4.12. VHA Handbook 1100.19: Credentialing and Privileging:

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

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

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

1.4.14. Joint Commission:

http://www.jointcommission.org/standards/

1.4.15. HHS OIG Website:

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

1.4.16. American Journal for Infection Control - AJIC 1998; 26:289-354:

http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

1.5. Acronyms/Definitions: 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. ABIM: American Board of Internal Medicine – Nephrology http://www.abim.org/certification/policies/internal-medicine-subspecialtypolicies/nephrology.aspx

1.5.2. ACGME: Accreditation Council for Graduate Medical Education

1.5.3. ACLS: Advanced Cardiac Life Support

1.5.4. AOD: Admitting Officer of the Day

1.5.5. BLS: Basic Life Support

1.5.6. CCNE: Commission on Collegiate Nursing Education:

www.aacn.nche.edu/accreditation

1.5.7. CDC: Centers for Disease Control and Prevention

1.5.8. CDR: Contract Discrepancy Report

1.5.9. CEU: Certified Education Unit

1.5.10. CME: Continuing Medical Education

1.5.11. CMP: Civil Monetary Penalty

1.5.12. CMS: Centers for Medicare and Medicaid Services

1.5.13. CO: Contracting Officer – 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.

1.5.14. COR: Contracting Officer’s Representative – A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2135 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910 http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm http://www.jointcommission.org/standards/ http://oig.hhs.gov/exclusions/index.asp http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf http://www.abim.org/certification/policies/internal-medicine-subspecialtypolicies/nephrology.aspx http://www.abim.org/certification/policies/internal-medicine-subspecialtypolicies/nephrology.aspx http://www.aacn.nche.edu/accreditation

Revision 03/09/2023 Page 10 of 36 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.

1.5.15. COS: Chief of Staff

1.5.16. COVID-19: Coronavirus Disease 2019

1.5.17. CPARS: Contractor Performance Assessment Reporting System

1.5.18. DEA: Drug Enforcement Agency

1.5.19. ED: Emergency Department

1.5.20. ECMO: Extracorporeal Membrane Oxygenation

1.5.21. EHR: Electronic Health Record - electronic health record system used by the

VA

1.5.22. EMR: Electronic Medical Record

1.5.23. FSMB: Federation of State Medical Boards

1.5.24. FTEE: Full Time Equivalency Employee is defined by VA as a minimum of 80 hours every two weeks and does not include holidays

1.5.25. HHS: Department of Health and Human Services

1.5.26. HIPAA: Health Insurance Portability and Accountability Act

1.5.27. HR: Human Resources

1.5.28. ISO: Information Security Officer

1.5.29. 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).

1.5.30. NLNAC: National League for Nursing Accrediting Commission.

www.nlnac.org

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

1.5.32. NP: Nurse Practitioner

1.5.33. NPPES: National Plan and Provider Enumeration System

1.5.34. OSHA: Occupational Safety and Health Administration

1.5.35. OIT: Office of Information and Technology

1.5.36. OPM: Office of Personnel Management

1.5.37. OPPE: Ongoing Provider Practice Evaluation

1.5.38. OR: Operating Room

1.5.39. PA: Physician Assistant

1.5.40. PIV: Personal Identity Verification

1.5.41. POP: Period of Performance

http://www.nlnac.org/

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1.5.42. PPD: Purified Protein Derivative

1.5.43. PWS: Performance Work Statement

1.5.44. QASP: Quality Assurance Surveillance Plan

1.5.45. RFP: Request for Proposal

1.5.46. VAMC: Veterans Affairs Medical Center

1.5.47. 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.

1.5.48. 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 the purpose of this contract, this term shall mean the Sioux Falls VA Medical Center.

2. QUALIFICATIONS:

2.1. Staff/Facility – The contractor shall identify a minimum of two (2) Acute Dialysis Nurses (Registered Nurses) to provide contract coverage for On-Site Acute Dialysis Nursing Services at the Sioux Falls VAHCS.

2.1.1. License: All licenses held by the personnel working on this contract shall be full and unrestricted license to the services covered by this contract issued in any State, Territory, or Commonwealth of the United States or the District of Columbia. Contract personnel shall submit evidence of current, full and unrestricted licenses, registration, certification, and/or other relevant credentials for verification prior to appointment and throughout the employment process, as requested by the COR. Contractor is responsible for keeping the COR informed of anything that would adversely affect or otherwise limit their clinical privileges. Failure to meet this requirement may result in termination of the contract.

2.1.2. Board Certification: The contractor’s employees and any subcontractors shall have all licenses, permits, and certifications as required by law and this contract. Contractor personnel assigned to perform services covered by this contract shall be certified Registered Nurses and meet the requirements for appointment to the Medical Staff, Sioux Falls VAHCS, as outlined in the Medical Staff Bylaws. The services to be performed by contractor personnel will be performed within the VA policies and procedures and the regulations of the Medical Staff Bylaws of the VAHCS.

Documentation verifying current certification shall be provided to the COR on an annual basis for each year of contract performance.

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2.1.3. Credentialing and Privileging: Contract Dialysis Registered Nurses fulfilling the conditions of the contract shall be subject to all bylaws, rules and regulations of the VAMC. Each Dialysis Registered Nurse shall be credentialed and privileged prior to providing services and must be found acceptable by the Medical Executive committee and Governing Body.

Credentialing and privileging are to be completed in accordance with VHA Handbook 1100.19 and VHA Directive 1100.20 referenced above. The ability for an individual Dialysis Registered Nurse to continue to render services under the contract shall be dependent upon demonstration of clinical competence. Clinical competency shall be assessed on an ongoing basis, is true for all Dialysis Registered Nurses, and to the reported as provider specific practice information at the time or an accreditation body with equal or better standards Joint Commission.

2.1.3.1. At the time of the award the contractor shall provide all information necessary to comply with VA requirements for credentialing and/or privileging of contracted personnel. If a contract personnel(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: Contract 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 contract personnel and contract personnel 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. Contract personnel 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 credential’s office for tracking. These documents are required for both privileging and re-privileging. Failure to provide shall result in loss of privileges for contract personnel(s).

2.1.6. Training (ACLS, BLS, EHR and VA MANDATORY): Contractor shall meet all VA educational requirements and mandatory course requirements defined herein; all training must be completed by the contractor personnel as required by the VA. Other training may become required. VA will communicate any changes to the training requirement to the contractor.

NOTE: Acute Dialysis Nurses are required to provide evidence of current BLS Training (or equivalent to include CPR/AED Training or VA Heart Saver Class). Training classes are offered at the Sioux Falls VAHCS at no cost to the contractor. Contact the COR for registration instructions.

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Training Frequency Duration

Blood Administration: Complications TMS 8562

(SUX-246)

Annual 1 hour

Blood Product Administration TMS 8563 (SUX-245) Annual 1 hour

VA Privacy and Information Security Awareness and Rules of Behavior TMS 10176 DVA 001 Annual 1 hour

Privacy and HIPAA TMS 10203 DVA 002 Annual 1 hour

Prevention and Management of Disruptive Behavior Reporting Requirement Part 1 TMS VA 37659 (SUX- 236)

Annual 1 hour

Prevention and Management of Disruptive Behavior Reporting Requirement Part 1 Refresher TMS VA

37659 (VHA 168)

Annual 0.5 hours

Computerized Patient Record System (CPRS) Tab by Tab Update TMS 8512 One-Time 1.5 hours

VISTA Imaging Training TMS 3940847 (SUX-068) One-Time 0.5 hour

Service Line Specific Training (to be identified) Varies Varies

2.1.7. 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.

2.1.7.1. 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) upon hire in accordance with CDC guidance. (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.

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

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

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

2.1.7.5. 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

Revision 03/09/2023 Page 14 of 36 contraindication to the vaccine, they shall be required to wear a mask during the Influenza season. {This is applicable to all health care workers}.

2.1.7.6. COVID-19: Contractors shall comply with VHA Supplemental Contract Requirements for Combatting COVID-19 {This is applicable to all health care workers}. – See Section D attachment.

2.1.7.7. 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.

2.1.7.8. The facility 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.

2.1.8. National Provider Identification (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 provided to the Contracting Officer with the proposal.

2.1.9. Conflict of Interest: The Contractor and all contract personnel(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 and fully outlined in http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

Revision 03/09/2023 Page 15 of 36 response to the subject attachment in Section D of the solicitation document.

2.1.10. Citizenship related Requirements:

2.1.10.1. 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.

2.1.10.2. 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.

2.1.10.3. 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.

2.1.10.4. 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.

2.1.10.5. 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.

2.1.11. 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

Revision 03/09/2023 Page 16 of 36 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.

2.1.11.1. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site referenced above to ensure that the proposed contract 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.

2.1.11.2. 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 and VHA Directive 1100.20. Clinical/Professional performance monitoring and review of all clinical personnel covered by this contract for quality purposes will be provided by the facility 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 contract personnel(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 Contract personnel(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.

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2.7. No Employee status: The Contractor shall be responsible for protecting Contract personnel(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 to include:

2.7.3.1. Annual TB Skin Test and recent chest X-ray if there is a history of positive TB skin test

2.7.3.2. Evidence of Hepatitis B immunity (hepatitis immune titer, if the individual has had the series of shots; if no immunity, evidence that the individual has started the Hepatitis B vaccination series

2.7.3.3. Evidence of a Hepatitis C titer

2.7.3.4. Varicella titer if contracted employee has not had chicken pox

2.7.4. Income tax withholding, and

2.7.5. Social security payments

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

2.9. Key Personnel:

2.9.1. The contractor shall identify/provide a minimum of two (2) Registered Nurses, licensed, trained, and certified, to provide On-Site Acute Dialysis Nursing Services.

2.9.2. 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 provider is unable to complete an assigned shift, the contractor shall provide replacement provider coverage within 2 hours and notify the Contracting Office Representative (COR) immediately of the schedule change.

2.9.3. Contractor shall provide the names of contract personnel assigned to the performance of this contract:

Key Personnel/Substitute Name(s) Official/Professional Title

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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 15 calendar days after the occurrence of any of these events and provide the information required below.

After 90 days, the Contractor shall submit the information required below to the CO at least 15 calendar days prior to making any permanent substitutions.

2.9.4.1. 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 15 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 (3) consecutive workdays or more, the Contractor shall provide a qualified replacement for the key person.

The substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above.

2.9.5. 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 contract personnel(s), s/he may request, without cause, immediate replacement of said contract personnel(s).

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

2.9.7. Contingency Plan: Because continuity of care is an essential part of the Facility’s medical services, The Contractor shall have a contingency plan in place to be utilized if the contract personnel(s) leaves Contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

2.9.8. Note: Evidence of completion of required licensure, credentials, required training, current competencies and background investigations must be validated for all contractor personnel referred to perform services under this contract prior to providing direct patient care. Contractor shall not have any personnel report to duty until written notification is received from the Contracting Officer advising that the candidate (s) presented has met all requirements for contract performance.

Revision 03/09/2023 Page 19 of 36

3. VA HOURS OF OPERATION/SCHEDULING:

3.1. Work Schedule: Coverage hours are continuous, 24 hours a day, seven (7) days a week, including weekends and Federal Holidays.

3.2. It is required that one (1) Dialysis Nurse be on-call for 24 hours a day, seven (7) days a week including all Federal Holidays, who can report to the Sioux Falls VAHCS within 60 minutes of notification to support emergent cases.

3.2.1. On-call service is considered part of the contract service and will not be paid separately. Any procedure performed during an on-call status for an emergency procedure shall be paid the same rate as the regular procedure.

3.3. Dialysis procedures shall be performed in the designated Dialysis Room or in

Intensive Care Unit (ICU) at the Sioux Falls VAHCS.

3.4. The Sioux Falls VAHCS will notify the contractor one (1) business day in advance of the procedure date for recurring and routine requirements.

3.5. Disaster/Emergency Coverage. Unless a state of emergency has been declared or services are otherwise cancelled by the Sioux Falls VAHCS, the Contractor shall be available and present during scheduled procedure day/time.

3.6. Standards of Care. The Standards of Care should be equal to that provided by the VA if the VA were capable of providing the services required at their location. The contractor shall provide competent, quality Dialysis Service Nurses to required patients of the Sioux Falls VAHCS, in the performance of contract requirements.

Contractor shall provide all services specified in this contract for any VA beneficiary.

3.7. Absences. Appropriate coverage shall be provided in accordance with the contract terms and conditions and must be supplied by the contractor. The contractor’s employee must be present at the Sioux Falls VAHCS and must be able to perform the required service(s) for the period specified in the contract. Back-up coverage is required at all times.

3.8. Cancellation.

3.8.1. The VA must be informed at least 72 hours in advance if there will be a significant change in contractor’s ability to perform to allow for planning of service coverage and workload distribution.

3.8.2. The VA will notify the contractor when patient substitutions are used to prevent a cancellation. In the event a patient substitution cannot be utilized, the VA will inform the contractor at least 72 hours in advance

4. CONTRACTOR RESPONSIBILITIES:

4.1. Clinical Personnel Required: The Contractor shall provide contract personnel(s) who are competent, qualified per this performance work statement and adequately trained to perform assigned duties.

4.1.1. Contract personnel(s) shall be responsible for signing in and out when in attendance. Time sheets will be used by the COR to confirm hours/day and services provided against the contractor’s invoices.

4.2. Standards of Care: The contract personnel(s)’ care shall cover the range of Perfusionist/Autotransfusion 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:

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4.2.1. American Board of Nephrology:

http://www.abim.org/certification/policies/internal-medicine-subspecialtypolicies/nephrology.aspx

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 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

4.2.5. The requirements contained in this PWS

4.3. MEDICAL RECORDS

4.3.1. Authorities: Contract personnel(s) providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the 5 U.S.C.552a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts 160, 162, and 164 (HIPAA).

4.3.2. HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to: a health care provider for treatment. Based on this exception, a BAA is not required for this contract. Health records generated by this contract or provided to the Contractors by the VA are covered by the VA system of records entitled ‘Patient Medical Records-VA’ (24VA10A7). Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services provided to VA patients are captured in the VA electronic health record system as required by VA policy as discussed in 4.3.4.

4.3.3. Disclosure: Contract personnel(s) may have access to patient medical records for the purpose of providing medical care and services to VA patients and performing services under the contract; however, Contractor shall obtain permission from the VA before disclosing any patient information outside VA. VA authorizes the Contractor to discuss patient health information for coordination of care with community health care providers in compliance with VA regulations, HIPAA and VHA Directive 1605.01, Privacy and Release of Information. The VA will provide the Contractor with a copy of VHA Directive 1907.01, Health Information Management and Health Records and VHA Directive 1605.01, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

4.3.4. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Directive 1907.01 Health Information Management and Health Records:

http://www.abim.org/certification/policies/internal-medicine-subspecialtypolicies/nephrology.aspx http://www.abim.org/certification/policies/internal-medicine-subspecialtypolicies/nephrology.aspx http://www.jointcommission.org/standards_information/standards.aspx http://www.hpoe.org/resources?show=100&type=8 http://www.rms.oit.va.gov/SOR_Records/24VA19.asp https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233

Revision 03/09/2023 Page 21 of 36 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 and all guidelines provided by the Facility.

4.3.5. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. Contractor will not release or disclose copies of records and will refer all such requests to the Release of Information Department at the VA facility were assigned.

4.3.6. Management for Medical Records: National Archives and Records Administration record disposition requirements are found in RCS 10-1 Chapter 6, 6000 series.

4.3.7. Confidentiality: VA will provide the contract personnel(s) access to pertinent patient medical information, within the existing privacy rules and regulations, for the purpose of providing coordinated comprehensive primary care. Contract personnel(s) shall ensure the confidentiality of all patient information and shall be held liable in the event of the breach of confidentiality.

4.3.8. Personal Identity Verification (PIV): Contract personnel(s) shall participate in computer security and documentation training as is all personnel practicing within the VA Medical Center. Contract personnel(s) shall comply with facility requirements to obtain personal security investigations, installation access and participate in the computer security and documentation training.

4.3.9. Contract personnel(s) shall provide medical record documentation in accordance with rules and regulations of the medical staff and medical staff by laws. Reference Policy Memorandum No. 136-1, Change 2 to Appendix B dated Sept. 29, 2000, Control of Medical Records and in accordance with Policy Memorandum 136-1, Change 2 to Appendix A dated September 29, 2000, Completion of Medical Records.

4.3.10. Records created by contract personnel(s) in the course of treating VA patients under this agreement are the property of the VA and shall not be accessed, released, transferred or destroyed except in accordance with applicable federal law and regulations. Contract personnel(s) shall maintain computer access and prepare for cases the following day by obtaining the patient information and record within the current electronic health record system for review.

4.3.11. Contract personnel(s) shall participate in quality improvement projects, initiatives, and reporting as requested.

4.3.11.1. VA utilizes a fully automated electronic medical record. The EMR consists of two primary components. The first is the Veterans Health Information System and Technology Architecture (VISTA), which consists of commercial hardware and software developed by the VA.

VISTA is a collection of over 100 applications that make up a comprehensive hospital information system. It includes both medical records and clinical applications or packages such as order entry, progress note, laboratory, radiology, and scheduling/admission-discharge-transfer and discharge summary. The present VISTA packages combined comprise an estimated 80 percent of the information maintained in the EMR. Contract personnel(s) shall be responsible for viewing the patient record within the EHR and will not be utilizing the VISTA system.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235

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4.3.11.2. Upon transfusion of components, the Perfusionists are responsible for completing the required information on the SF-518 form (Record of Transfusion on the Standard Form 518) to include pre-transfusion data and post-transfusion data. The completed original SF-518 shall be scanned into the patient's chart, and a copy of the SF-518 shall be placed in the designated location for return to the Blood Bank.

Under no circumstances will the SF-518 be discarded.

4.3.11.3. The second component uses optical disk imaging technology to meet the remaining 20 percent of the EMR information needs such as advance directive/guardianship papers, medical record documentation from non- VA facilities and informed consents.

4.3.11.4. VA will provide the necessary training to contract personnel(s) on the proper use and operation of the current computerized medical records system (Electronic Health Record - EHR). Contractor agrees and shall instruct their employees in signing computer security access agreements and is bound by confidentiality and release of information restrictions. For purposes of clarity, where the VA Forms reference “Contracted Employee Name” it shall mean “Contractor’s Employee Name.”

4.4. Direct Patient Care: 90 % of the time involved in direct patient care.

4.4.1. Scope of Care: Contract personnel (as appropriate and within scope of practice/privileging) shall be responsible for providing Acute Dialysis care, including, but not limited to:

4.4.1.1. Medications: Medications prescribed as part of the hemodialysis treatment will be administered by the contract personnel. Drugs will be furnished by the Sioux Falls VAMC. Contractor personnel shall follow all established medication policies and procedures.

4.4.1.2. The Autotransfusionist is responsible to check the OR schedule daily for surgical procedures requiring Autotransfusionist services; coordinate scheduled periodic preventative maintenance and repair calls for VA owned equipment and maintain a record of such; assure a minimum of four complete sets of supplies for open heart and Autotransfusion cases are available at any given time; sets up and operates Autotransfusion pump for surgical procedures other than open heart. Also, generates a record during each surgical case to include the surgical time of the procedure and the amount of autotransfused blood given to Anesthesiology for delivery to the patient and handle breakdown of disposable within autotransfusion pump after completion of each procedure.

4.4.1.3. Reporting Information for Treatment: Access to the VA EHR shall be provided to the contract personnel, including the ability to printout a report of those services provided by contract personnel. A detailed treatment plan which includes an initial assessment, recommended plan of treatment and expected outcomes will be entered in the patient's clinical record within twenty-four hours of initiating treatment and at a minimum contain the following information:

• Patient’s name and identification number

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• Treating Physician's name and telephone number for follow-up questions

• Pertinent History

• Physical Findings

• Summary of the Recommended Treatment Plan

• Date treatment was initiated or is planned

• Anticipated or actual date that treatment was completed

• Follow-up Recommendations/Results of the Treatment

• Instructions given to the patient

4.4.1.4. It is the contract employee’s responsibility to view the patient record within the current electronic health record prior to the surgery to review the surgeon’s plan of care.

4.5. ADMINISTRATIVE: estimated 10% of time not involved in direct patient care.

4.5.1. Quality Improvement Meetings: The Contractor’s Representative shall participate in continuous quality improvement activities and meetings with committee participation as required by the VAMC Chief of Service, Chief of Staff, or designee.

4.5.2. Staff Meetings: The Contractor’s physician(s) shall attend staff meetings as required by the facility Chief of Service, Chief of Staff, or designee. Contractor to communicate with COR on this requirement and report any conflicts that may interfere with compliance with this requirement

Meeting Frequency Annual Hours

Acute Dialysis Committee Monthly 12 hours

4.5.3. QA/QI documentation: The Contractor’s personnel shall complete the appropriate QM/PI documentation pertaining to all procedures, complications and outcome of examinations.

4.5.4. Patient Safety Compliance and Reporting: Contractor’s physician(s) shall follow all established patient safety and infection control standards of care. Contractor’s physician(s) 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 documented in the medical record of those impacted and disclosed to the patient or surrogate. As soon as practicable (but within 24 hours) Contractors shall notify COR of incident and submit an entry in the Patient Safety Reporting System, following up with COR as required or requested.

4.6. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) SURVEILLANCE PLAN

AND QUALITY IMPROVEMENT(QI)

4.6.1. Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance: Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE). Contractor performance will be monitored

Revision 03/09/2023 Page 24 of 36 by the government using the standards as outlined in this Performance Work Statement (PWS) and methods of surveillance detailed in the Quality Assurance Surveillance Plan (QASP). The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted. Contract monitoring will be accomplished through a record keeping system (attendance log) maintained by the Chief, Surgical Service in order to reconcile payments.

Contractor’s employees shall sign in and sign out of the attendance log indicating the dates and times worked. Procedure documentation shall be maintained by the contractor and shall be signed by the contractor’s employee(s). The Chief, Cardio- Thoracic Section shall certify the actual number of procedures completed. Copies of the procedure documentation sheets shall be forwarded to the Chief, Surgical Service for review and concurrence. The Chief, Surgical Service is responsible for monitoring the professional components of the contract. All adverse actions shall be reported to the Contracting Officer immediately. The Contracting Officer and COR shall examine methodologies and quality control procedures during the contract term. All activities shall comply with Joint Commission standards and the policies and procedures of the VAMC.

4.6.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. In the event that the Contractor is involved and named in a validated 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.

4.6.3. 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.