36C79118R0022-015.docx

ATTACHMENT 6

PAST PERFORMANCE QUESTIONNAIRE

NOTICE TO OFFERORS

Contained herein, is a draft letter and questionnaire that shall be used to solicit past performance comments from up to three (3) of your references, identified in your response to the solicitation requirements.

The Contracting Officer, in the interest of expediency, will start collecting past performance data before the due date. Offeror references are requested to submit their past performance information in advance of the proposal due date. This past performance questionnaire is for offerors to send to their current and/or previous references with instructions to return the completed questionnaire to the Government. Failure of the references to submit the completed questionnaires shall not be a cause for rejection of the proposal nor shall it be reflected in the Government's evaluation of the offeror's past performance.

Offerors are encouraged to submit the attached letter and questionnaire to up to three of their references and request the return of the questionnaire to the Contracting Officer/Contract Specialist as soon as possible prior to the established closing date of the solicitation. Offerors will have to complete the heading and paragraphs 1 through 6 of the questionnaire for each reference. Past Performance Questionnaires received directly from the offeror will not be considered.

MEMORANDUM FOR PROJECT REFERENCES

FROM: David Little, VA Contracting Officer David.Little@va.gov

SUBJECT: Request for Performance Information for Department of Veteran Affairs Solicitation, 36C79118R0022, Nationwide Dialysis Services

You have been identified as a point of contact for a past and/or present performance evaluation of the company listed on the attached questionnaire. I request that you complete the attached questionnaire, providing detailed information on the performance history of the company identified. Kindly identify the name of the prime contractor in block 1 of the form. If your evaluation is being submitted on a sub-contractor, kindly identify the prime contractor for this project in block 1 of this form.

It is essential that I receive your official response not later than November 8, 2018. You may send your response ALYSSA.URQUHART@VA.GOV and DAVID.LITTLE@VA.GOV or send via mail to Department of Veteran Affairs, Commodities & Services Acquisition Service, 555 Corporate Circle, Golden, CO 80401.

I appreciate your assistance in this matter. Please contact me with any questions you may have.

Sincerely, //SIGNED//

David Little Contracting Officer

1. Contractor Name, Address & Phone Number:

2. Contract Number(s):

3. Contract Value (Base plus Options):

4. Period of Performance:

5. Type of Contract(s) Used: (Check all that apply)

[ ]FP

[ ]FPI

[ ]CR

[ ]T&M [ ]Labor Hour [ ]8(a) [ ]Sealed Bid [ ]Negotiated

[ ]TO/DO

[ ]SB Set-Aside [ ]Competitive [ ]Non-Competitive [ ]Requirements [ ]Supplies/Equipment [ ]Services [ ]Commercial Items Acquisition

6. Description of Requirement:

7. Ratings: After commenting, score, in column to the right, using 1 for Unsatisfactory, 2 for Marginal, 3 for Satisfactory, 4 for Very Good and 5 for Exceptional. (See page 6 for explanation of categories and rating scale) (Circle)

Quality

2-M

3-S

4-VG

5-E

Compliance with CMS, Federal, and State Regulations for Dialysis

2-M

3-S

4-VG

5-E

Timeliness of Performance

2-M

3-S

4-VG

5-E

Business Relations/Customer Satisfaction

2-M

3-S

4-VG

5-E

Total Score (Sum of scores from each area)

Mean Score (Sum of scores divided by total number of areas

36C79118R0022 VA’s Nationwide Dialysis Solicitation

9. Would you select this firm again? [ ]Yes [ ]No Comments:

10. Was the contractor committed to customer satisfaction?

Comments:

11. Respondent’s Identification:

Name:

Position/Title:

Address & Phone Number:

Relationship and Time Involved with Program/Contract:

Date of Evaluation:

INSTRUCTIONS FOR COMPLETING THE PAST PERFORMANCE QUESTIONNAIRE

Block 1: Name, address and phone number of the contract being evaluated. Identify the specific division being evaluated if there is more than one.

Block 2: Contract number(s) used to evaluate performance.

Block 3: Contract value, including option periods. The value in this block should reflect any increases or decreases affected during the life of the contract.

Block 4: Dates in which the contractor being evaluated performed work for the evaluator.

Block 5: Check all blocks that apply to contracts with the contractor being evaluated.

Block 6: Brief description of the work performed by the contractor.

Block 7: Indicate the contractor’s rating in the far right column. In the comment areas, provide rationale for the rating. Indicate the contract requirements that were exceeded (when a value of 5 is given) and those that were not met (when a value of 1 or 2 is given) by the contractor. Also calculate the total and mean scores for the ratings.

Block 8: Identify major subcontractors, team partners and joint ventures and include their work responsibilities. List key personnel employed during the contract that played a major role in the performance rating. Do not list key personnel not employed long enough to effect performance. In some cases, more than one individual may have served in a key position.

Block 9: Explain why you would or would not select the contractor for this contract again.

Block 10: State your opinion as to whether or not the contractor is committed to customer satisfaction.

Block 11: Provide your vital information as requested.

VA791-12-Q-0045

RATING GUIDELINES FOR PAST PERFORMANCE QUESTIONNAIRE

Use the following as guidance in making evaluations for the Past Performance Questionnaire.

-Accuracy of reports -Appropriateness of personnel -Technical excellence -Compliance with all CMS Medicare Program, federal and state regulations -Reports adverse or sentinel events timely -Attentive to overall patient health and safety needs

-Meets timelines for reporting -Reliable -Responsive to technical direction -Completed on time, including wrap-up and contract administration -Claims timely and correct -Effective management -Business-like correspondence -Responsive to contract requirements -Prompt notification of problems -Reasonable/cooperative -Flexible, pro-active, effective -Recommended viable solutions -Effective small/small disadvantaged business subcontracting program

-Does not report adverse or sentinel events -Not attentive to patient health and safety needs

-Many late deliveries -Non-responsive to requests for information -Non-compliance with claims submission requirements and timelines

-Delinquent responses -Lack of cooperative spirit -Unsatisfied user; unable to improve relations -Significantly under subcontracting goals -Excessive, unnecessary change proposals to correct poor management -Significantly untimely definitization of change proposals

-Ineffective corrective actions -Not in compliance with some regulations -Inadequate corrective action plans -Untimely reporting of adverse or sentinel events -Not attentive to patient health and safety needs -Some late deliveries; no corrective actions -Incorrect or late claims submissions -Late resubmission/correction of claims -Unprofessional -Low responsiveness -Low user satisfaction; no attempts to improve relations -Unsuccessful in meeting subcontracting goals -Unnecessary change proposals -Untimely definitizations

-Minor problems with satisfactory corrective actions -Complies with required regulations -Reports adverse or sentinel events timely -Attentive to overall patient health and safety needs -On-time deliveries -Minor problems which did not affect deliveries -Claims timely and accurate -Responsive to requests -Professional and responsive -Met expectations -Adequate user satisfaction -Met subcontracting goals -No untimely change proposals

-Reports adverse or sentinel events in less time than required -Attentive to all specific patient health and safety needs -On-time delivery/some early deliveries to the Government’s benefit -Claims timely and accurate -Professional and responsive -Exceeded expectations and user satisfaction -Exceeded subcontracting goals

- Timely response to change proposals

-Expedient response to and reporting of any adverse or sentinel events -Attentive to all patient needs for safety, health and comfort -On-time deliveries with many early deliveries to the Government’s benefit -Reports all incidents/events in less time than required.

-Claims timely and accurate -Highly professional, responsive and proactive -Significantly exceeded expectations -High user satisfaction -Significantly exceeded subcontracting goals -Timely response to change proposals