C03 36C25926C0057 Psychiatry Services signed.pdf

36C25926C0057

Table of Contents

SECTION A ....................................................................................................... Error! Bookmark not defined.

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES ............................................................. Error! Bookmark not defined.

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 SCHEDULE OF SERVICES

B.3 PERFORMANCE WORK STATEMENT

B.4 IT CONTRACT SECURITY

SECTION C - CONTRACT CLAUSES

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

COMMERCIAL SERVICES (NOV 2023)

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

C.3 TYPE OF CONTRACT (NOV 2025)(DEVIATION)

C.4 52.222-90 ADDRESSING DEI DISCRIMNATION BY FEDERAL CONTRACTORS

(DEVIATION APR 2026))

C.5 52.240-91 INFORMATION AND INFORMATION SYSTEMS SECURITY (FEB 2023)

C.6 52.240-92 SECURITY REQUIREMENTS (DEVIATION) (NOV 2025)………………………48

C.7 VAAR 852.204-71 PERSONNEL VETTING AND CREDENTIALING (DEVIATION) (MAR

2026)

C.8 VAAR 852.204-72 PERSONNEL VETTING AND CREDENTIALING (DEVATION) (MAR

2026)

C.9 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV 2018) . 58

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

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

a. CONTRACTOR: Strength of Minds Jodie Seitz 918-342-2622 jseitz@strengthofmind.com

b. GOVERNMENT: Contracting Officer 36C259 Department of Veterans Affairs Network Contracting Office

NCO 19

6162 South Willow Drive, Suite 300 Greenwood Village CO 80111

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 in arrears

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.

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

AMENDMENT NO DATE

5. Federal Acquisition Regulations (FAR) require all contractors doing business with the Government to register and maintain registration in two separate and individual online databases:

a. CONTRACTOR PERFORMANCE ASSESSMENT REPORTING SYSTEM (CPARS) - as prescribed in FAR Part 42.15, the Department of Veterans Affairs (VA) evaluates contractor past performance on all contracts that exceed the simplified acquisition threshold. Additional information is found in section 4.9 of the Performance Work Statement (PWS).

b. SYSTEM FOR AWARD MANAGEMENT (SAM) - all prospective awardees shall be registered and maintain active registration in the SAM database prior to award, during performance, and through final payment of any contract resulting from this solicitation. After initial registration, the contractor is required to update registration data as changes occur and must re-register annually. Noncompliance will preclude the exercising of any option periods that may be included herein and may be cause for termination of the contract. Refer to FAR Clause 52.212-4(t) for more details.

6. SECURE FAX: In accordance with VA Handbook 6500, the following statement is required on all fax cover sheets; if it is determined the ordering process will include a fax: “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, distribution 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.

7. MANDATORY WRITTEN DISCLOSURES: Mandatory written disclosures required by FAR clause 52.203-13 to the Department of Veterans Affairs, Office of Inspector General (OIG) must be made electronically through the VA OIG Hotline at OIG Hotline (va.gov) and clicking on "FAR clause 52.203-13 Reporting." If you experience difficulty accessing the website, call the Hotline at 1-800-488-8244 for further instructions.

8. FAR DEVIATION FEB 2025 Instructions: System updates may lag policy updates. The System for Award Management (SAM) may continue to require entities to complete representations based on provisions that are not included in agency solicitations.

B.2 SCHEDULE OF SERVICES

The Contractor shall furnish all key personnel to provide services necessary to perform onsite Psychiatry Physician Services to eligible beneficiaries of the Department of Veterans Affairs, Eastern Oklahoma VA Healthcare System (EOVAHCS). The Contractor’s physician(s) care shall cover the range of Psychiatry services. The standard of care shall be of a quality, meeting or exceeding currently recognized national standards as established by the American Board of Psychiatry and Neurology.

https://www.abpn.org

Place of Performance: Services shall be provided on site, Jack C. Montgomery VAMC 1011 Honor Heights Drive, Muskogee, OK 74401 and opening June 1, 2026, James M. Inhofe VAMC 440 S. Houston Ave. Tulsa, OK 74127.

Pricing Instructions: The offeror is instructed to edit the Line-Item Number (LIN) number to correspond with the number of key personnel submitted for the LIN. 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. Also, renumber LINs if adding or removing Key Personnel.

The Contractor shall propose a minimum of two (2) key personnel to be credentialed and be available for scheduling to meet the requirements of the contract.

Hourly Billing: Contractor shall prepare monthly invoices by calculating the total number of hours worked during the billing period and rounding the monthly total to the nearest whole hour. The rounded total shall be used as the basis for invoicing. Partial hours should not be billed separately; instead, they should be included in the monthly total prior to rounding and in timesheets. Any fractional amounts should be rounded in accordance with standard rounding rules (i.e., amounts of 0.50 (:30) or greater rounded up to the next hour; amounts less than 0.50 (:30) rounded down).

Period of Performance: 06/18/2026 to 10/31/2026

LIN Description Qty. Unit Unit Cost Total

Annual Cost

0001 Face-to-face rounding on Weekends & Weekdays (as needed) 513 Hours $208.09/hr. $106,750.17

0002 Face-to-face rounding on Holidays 32 Hours $289.39/hr. $9,260.48

TOTAL CONTRACT VALUE $116,010.65

https://www.abpn.org/

B.3 PERFORMANCE WORK STATEMENT

1. GENERAL:

1.1. Services Provided: The Contractor shall provide Board Certified /Board Eligible Physician

Services on site in accordance with the specifications contained herein to beneficiaries of the Department of Veterans Affairs (VA) and the Eastern Oklahoma VA Healthcare System.

Place of Performance: Contractor shall furnish services at the Jack C. Montgomery VAMC 1011 Honor Heights Drive, Muskogee, OK 74401 and James M. Inhofe VAMC 440 S. Houston Ave.

Tulsa, OK 74127.

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

1.3. Policy/Directives/Handbooks The contractor shall be subject to the following policies, including any subsequent updates during the period of performance. The policies listed below can be accessed electronically at the following: VA Publications VHA Publications

1.3.1. VA Directive 1663: Health Care Resources (HCR) Contracting – Buying Title 38 U.S.C.

8153:

1.3.2. VHA Directive 1003.04: VHA Patient Advocacy

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

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

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

1.4.6. VHA Directive 1100.21: Privileging

1.4.7. VHA Directive 1100.20 Credentialing of Health Care Providers

1.4.8. VHA Directive 1192.01: Seasonal Influenza Vaccination Program for VHA Health Care Personnel

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

1.4.10. VHA Directive 1605.01: Privacy and Release of Information

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

1.4.12. VHA Handbook 1100.17: National Practitioner Data Bank (NPDB) Reports

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

1.5. 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. ABPN: American Board of Psychiatry and Neurology

1.5.2. ACGME: Accreditation Council for Graduate Medical Education

1.5.3. ACLS: Advanced Cardiac Life Support

1.5.4. BLS: Basic Life Support

1.5.5. CDC: Centers for Disease Control and Prevention

https://www.va.gov/vapubs/ https://www.va.gov/vhapublications/index.cfm http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm

1.5.6. CEU: Certified Education Unit

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

1.5.8. CME: Continuing Medical Education

1.5.9. CMS: Centers for Medicare and Medicaid Services

1.5.10. 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.

1.5.11. COR: Contracting Officer’s Representative: 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.

1.5.12. COS: Chief of Staff

1.5.13. CPARS: Contractor Performance Assessment Reporting System

1.5.14. Credentialing: Credentialing is the process of obtaining, verifying, and assessing the qualifications of a health care provider to provide care or services in or for the VA health care system. Credentials are documented evidence of licensure, education, training, experience or other qualifications.

1.5.15. DEA: Drug Enforcement Agency

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

1.5.17. FSMB: Federation of State Medical Boards

1.5.18. FTE: Full Time Equivalent. VA’s definition for full time-working is the equivalent of 80 hours every two weeks, 2080 hours per year. In calculating FTE, any hours not worked on national holidays shall not be included.

1.5.19. HHS: Department of Health and Human Services

1.5.20. HIPAA: Health Insurance Portability and Accountability Act

1.5.21. ISO: Information Security Officer

1.5.22. Key Personnel: The individuals specified in this contract who are essential to work performance.

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

1.5.24. POP: Period of Performance

1.5.25. PPD: Purified Protein Derivative

1.5.26. PWS: Performance Work Statement

1.5.27. QA/QI: Quality Assurance/Quality Improvement

1.5.28. QASP: Quality Assurance Surveillance Plan

1.5.29. QM/PI: Quality Management/Performance Improvement

1.5.30. VETPro: is VHA’s mandatory credentialing software platform to document the credentialing of VHA health care providers. This system facilitates completion of a uniform, accurate, and complete credentials file.

1.5.31. VHA: Veterans’ Health Administration

1.5.32. VISN: Veterans Integrated Services Network

1.5.33. VistA: Veterans Information Systems Technology Architecture

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 key 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 /Board Eligible by the American Board of Psychiatry and Neurology http://www.abpm.org/, and be currently certified in Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) or equivalency. All continuing education courses required for maintaining certification must be kept up to date at all times. Documentation verifying current certification shall be provided by the Contractor to the VA COR 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 1100.20 and VHA Directive 1100.21 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 Facility 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.

http://www.abpm.org/

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 facility. 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).

2.1.6. 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’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.

Training Frequency Annual Hours

ACLS/BLS 1x yearly 1

V19 MRI Safety: Level One 1x yearly 1

VA Privacy and Information Security Awareness and Rules of Behavior

1x yearly 1

VHA Privacy and HIPAA Focused Training

1x yearly 1

Government Ethics 1x yearly 1

Suicide Prevention: Suicide Risk Management Training for Clinicians

1x yearly 1

SUX Infection Control and Blood Borne Pathogens

1x yearly 1

VA Core Values Training (ICARE Recommitment)

1x yearly 1

VHA MRI Safety Training Level 1 Training (all who enter MRI suites)

1x yearly 1

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 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. 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.

2.1.7.7. 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 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 facilities). 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. DEA: Contractor shall provide copy of current DEA certificate.

2.1.10. 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 and fully outlined in response to the subject attachment in Section D of the solicitation document.

2.1.11. Citizenship related Requirements:

2.1.11.1. The Contractor certifies that the Contractor shall comply with all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf 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;

2.1.11.2. 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.

2.1.11.3. 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.

2.1.11.4. 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.

2.1.11.5. 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.

2.1.12. 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.

2.1.12.1. 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.

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

Facility Director as provided in VHA Handbook 1100.20 and VHA Directive 1100.21.

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 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.

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) for the services required is 2.

2.9.2. The minimum number of Board Certified /Board Eligible Psychiatry physicians required to be on site as needed is 2.

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 is unable to complete an assigned shift, the contractor shall provide replacement physician coverage within 2 hours and notify the Contracting Office 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 15 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 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 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.

2.9.4.3. 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 Facility’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. VA HOURS OF OPERATION/SCHEDULING

3.1. VA Business Hours: The Psychiatry Department is open Monday – Friday from 8:00am to 4:30pm excluding recognized federal holidays

3.2. Clinic or OR Schedule: The contractor shall be assigned as needed 7 days per week coverage for the inpatient psychiatric unit and emergency department plus holiday and back up coverage during regular working hours. Not to exceed 8 hours per shift unless authorized. This will include 8 hour coverage on all Federal Holidays. One provider specializing in mental health or Board- Certified/Board eligible Psychiatrist Physicians required to be on-call daily can be one of the following: PA, APRN, or Psychiatrist Physician to be available as needed for consultation. No cost variances for the different provider certifications. .

3.2.1. Patients must be seen by a Contractor’s physician(s) on-site at the facility 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.

3.2.2. Contractor’s physician(s) shall be available and present in clinic during normal facility clinic hours, which will be established, and may be revised, as deemed appropriate for patient care by the Chief of Staff. Currently, normal clinic hours are Monday – Friday from 8:00am to 4:30pm excluding recognized federal holidays.

3.3. 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

• Juneteenth

• Independence Day

• Labor Day

• Columbus Day

• Veterans Day

• Thanksgiving

• Christmas

• Any day specifically declared to be a national holiday.

Cancellations: The contractor shall ensure that qualified backup providers are available to provide coverage during scheduled and unscheduled absences of the primary contract provider. The contractor shall ensure that all backup providers participate in the Credentialing and Privileging and Training processes.

4. CONTRACTOR RESPONSIBILITIES

4.1. Clinical Personnel Required: The Contractor shall provide Contractor’s physician(s) who are competent, qualified per this performance work statement 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.

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 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. The American Board of Psychiatry and Neurology (ABPN): https://www.abpn.org .

4.2.2. The professional standards of The Joint Commission (TJC):

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

4.2.3. The standards of the American Hospital Association (AHA):

http://www.hpoe.org/resources?show=100&type=8 and;

4.2.4. The requirements contained in this PWS

4.3. Medical Records

https://www.abpn.org/ http://www.jointcommission.org/standards_information/hap_requirements.aspx http://www.hpoe.org/resources?show=100&type=8

4.3.1. 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 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 of VA patients. 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 Privacy Act 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 4.4.4.

4.3.3. Disclosure: Contractor’s physician(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 1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

4.3.4. 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 and all guidelines provided by the facility.

4.3.5. Release of Information: The VA shall maintain control of releasing any copies of patient health information or health records 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.

Direct Patient Care: An estimated 90 percent of the time will be involved in direct patient care.

Contractor shall be responsible for providing contract prescriber(s) who are competent, qualified per this performance work statement, and adequately trained to perform assigned duties. Contract personnel shall be able to report to the facility within 2 hours while on duty if needed or requested.

4.3.7. Scope of Care: Contractor’s physician(s) shall be responsible for:

4.3.7.1. Inpatient Care: All psychiatrists will be required to work in collaboration with Mental Health staff who are part-time or full time salaried by the VA for inpatient care duties including but not limited to:

4.3.7.1.1. Operating and collaborating physician’s patients

4.3.7.1.2. Seeing 1C/1D Psychiatry Service - Ward Patients.

4.3.7.1.3. Admitting

4.3.7.1.4. Diagnosis of patients

4.3.7.1.5. Developing Treatment Plans

4.3.7.1.6. Managing, including the performance of timely treatment

4.3.7.1.7. Discharge/Transfer

4.3.7.1.8. Including all needed medical record documentation

4.3.7.1.9. Outpatient Care

4.3.7.1.10. Seeing all new patient referrals with accompanying medical records

4.3.7.1.11. Seeing severely mental ill patients

4.3.7.1.12. Evaluation disposition E-consult

4.3.7.1.13. Post-discharged follow up

4.3.7.1.14. Patients must be seen by provider in 30 days

4.3.8. Clinic and Residential Care: Contractor’s physician(s) shall provide clinical psychiatry services. Clinical duties include direct patient care. Contractor’s physician (s)shall operate the clinic, examine patients, and interpret reports as required by the VA. Contractor’s physician(s) shall be present and on time for any scheduled clinics as documented by physical presence in the clinic. The contractor's employees will be required to work with VA staff. Should clinic hours need to be changed, VA will provide the contractor a thirty-day advanced notice of the change. Approximate case load is as follows:

4.3.8.1. 6 to 6.5 patient bookable hours per day.

4.3.8.2. 6 patients for an hour each or roughly 12 patients for one half-hour each; or any combination of one-hour and one-half hour appointment per day totaling 6 to 6.5 bookable patient hours per day.”

4.3.9. Peer Review: The contractor shall provide professional Psychiatry Service with Mental expertise for peer review of selected cases. This shall include, but not be limited to tort claims, patient family complaints, Mental Health case reviews, peer reviews, and Health case reviews, peer reviews, and benefit appeals.

4.3.10. Scheduling: Contractor and VA Chief of Mental Health shall prepare monthly call schedules for coverage of Mental Health emergencies. A draft schedule shall be submitted to the contracting office within five (5) working days prior to the end of each month.

4.3.11. Communication of Test Results: Mechanisms must be in place to provide notification of test results for patients receiving care in accordance with VHA Directive 1088, Communicating Test Results to Providers and Patients.

4.3.12. Medications: Contractor’s physician(s) shall follow all established medication policies and procedures. No sample medications shall be provided to patients.

4.3.13. Discharge education: Provide discharge education and follow up instructions that are coordinated with the next care setting for all emergency department patients.

4.3.14. ADMINISTRATIVE: An estimated 10% of time will not be involved in direct patient care.

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

4.3.14.2. 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.

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

4.3.14.4. 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 VA Patient Safety Reporting System, following up with COR as required or requested.

4.4. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY

IMPROVEMENT(QI)

4.4.1. 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 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.

4.4.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints.

If 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.

4.4.3. 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. The CO and COR shall deal with issues raised concerning Contractor’s conduct. The final arbiter on questions of acceptability is the CO.

4.4.4. Performance Standards: The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in the QASP shall be used to determine the level of contractor performance in the elements defined. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards. The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

4.4.4.1. Measure: Provider Quality Performance

Performance Requirement: All Contractor’s physician(s) shall perform in accordance with clinical standards

Standard: OPPE documentation for all (100%) staff providing services under the contract. All staff (100%) meet Standards.

Acceptable Quality Level: 100% meet standards.

Surveillance Method: OPPE data pertinent to care performed for each provider working under this contract. OPPE data will review the following elements:

A. Patient Care Performance B. Medical/Clinical knowledge C. Practiced Based Learning and Improvement D. Interpersonal and Communication Skills E. Professionalism F. System Based Practice

Frequency: Quarterly

4.4.4.2. Measure: Qualifications of Key Personnel

Performance Requirement: All Contractor’s physician(s) shall be Board Certified /Board Eligible in accordance with ABPN Standards for psychiatry.

Standard: All (100%) Contractor’s physician(s) s are board certified/board eligible.

Acceptable Quality Level: 100%

Surveillance Method: Periodic Inspection or Random Sampling of qualification documents

Frequency: Quarterly

4.4.4.3. Measure: Scope of Practice/Privileging

Performance Requirement: Contractor’s physician(s) perform within their individual scopes of practice/privileging.

Standard: All (100%) Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time.

Acceptable Quality Level: 100% Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time.

Surveillance Method: Random sampling of records.

Frequency: Quarterly

4.4.4.4. Measure: Patient Access

Performance Requirement: The Contractor shall provide Contractor’s physician(s) in accordance with the operating hours, and VA clinical schedule outlined in this PWS.

Standard: All (98%) Contractor’s physician(s) are on time and available to perform services.

Acceptable Quality Level: Contractor’s physician(s) are on-time and available to perform services 98% of the time.

Surveillance Method: Periodic Inspection of Time and Attendance Sheets

Frequency: Quarterly

4.4.4.5. Measure: Patient Safety

Performance Requirement: Patient safety incidents shall be reported using VA Patient Safety Reporting System. All incidents reported immediately (within 24 hours.)

Standard: All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

Acceptable Quality Level: 95% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

Surveillance Method: Periodic inspection or random sampling

Frequency: Quarterly

4.4.4.6. Measure: Maintains licensing, registration, and certification

Performance Requirement: Updated Licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current.

Standard: All (100%) licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current.

Acceptable Quality Level: 99% licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.

Surveillance Method: Periodic Inspection or Random Sampling

Frequency: Quarterly

4.4.4.7. Measure: Mandatory Training

Performance Requirement: Contractor shall complete all required training on time per facility policy

Standard: All (100%) of required training is complete on time by Contractor’s physician(s)

Acceptable Quality Level: 99% completions.

Surveillance Method: Periodic Inspection or Random Sampling

Frequency: Quarterly

4.4.4.8.