J-1_SOD_06182015.docx

DOCX document 65 KB Posted

Attached to
2016 End Stage Renal Disease (ESRD) Networks Federal contract opportunity
Solicitation number
CMS-2016-ESRD-NETWORKS
Issued by
Department of Health and Human Services Centers for Medicare and Medicaid Services

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J-1 SOD

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Other files attached to 2016 End Stage Renal Disease (ESRD) Networks, newest first.
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ESRD_Amendment_000009_Cover_Letter_.pdf PDF
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ESRD_Amendment_000007_SF30.pdf PDF
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The Network shall submit all required reports and deliverables in accordance with the following schedule unless otherwise specified by CMS. CMS reserves the right to modify deliverable date(s) by up to 60 days beyond the dates listed in the deliverable chart below. CMS CORs, CO or other CMS designee shall authorize the changed deliverable date by listing the new deliverable date in an email to the contractor.

Days=Calendar Days, including holidays Business Days=Weekdays, excluding holidays IAW=In Accordance With DAGC=Days After Government Comments Electronically = ELT Quantity = QTY Hard copy = HC COR=Contracting Officer’s Representative CMS SME= CMS Subject Matter Expert ISSO=Information Systems Security Officer CO=Contracting Officer NCC=Network Coordinating Center

Item No.
SOW source
Item Description
Data Source
Method/Recipient
Due Date
Conduct Post-Award Meeting with OAGM/QIG
Network
ELT to COR

On or before January 31 of contract for base year only, unless instructed otherwise by OAGM

2
C.3.3A-E
Identification of NC, BOD, MRB, and PAC members
Network
ELT to COR
February 1 of each contract period
3
C.3.3
Bylaws
Network
ELT to COR
February 1 of each contract period
4
C.3.3F
Network staffing plan
Network
ELT to COR
February 1 of each contract period
5
C.3.18
Internal Quality Improvement (IQI) Plan
Network
ELT to COR
45 days after start of contract period
6
C.3.8
Network committee/LAN minutes
Network
ELT to COR
Available on request
7
C.3.4
Provide NEPOP Letter to NCC
Network
ELT to COR/NCC
February 1 of each contract period
8
C.3.7
COR Monthly Report:

Network to report the following:

1) Educational activities/effectiveness

2) Emergency Preparedness Activities

3) Security Incidents

4) NEPOP results/activities

5) SSA activities

6) Patient Engagement as part of Facility visits

7) Network/SSA Collaborations

8) Focused Audit results & interventions

9) Grievance Case review summary

10) Access –to-care summary

11) OCR Referrals

12) Facilities recommended for sanctions

13) Grievance QIA Activities

14) ICH CAHPS Activities

15) ICH CAHPS QIA activities

16) Grievance statistics

17) Access to care statistics

18) Vascular Access/LTC activities

19) Vascular Access reporting activities

20) Vascular Access Technical support

21) HAI LAN activities

22) NHSN Support activities

23) NHSN Monthly Data Check results

24) HAI BSI QIA activities

25) HAI Immunization QIA activities

26) AIM2 Project activities/attributes

27) QIP Activities

28) QIP QIA Activities

29) Data Quality QIA Activities

30) CrownWeb Activities

Network
ELT to COR
3 Business days prior to scheduled Monthly calls
9
C.3.7
Dashboard Input Form (DIF):

Network to report all QIA measures for:

1) Grievance QIA

2) ICH CAHPS QIA

3) Vascular Access LTC QIA

4) HAI BSI QIA

5) HAI Immunizations QIA

6) AIM2 QIA

7) AIM2 Hospitalization QIA (OY3/OY4)

8) QIP QIA

9) Data Quality QIA

ELT to COR
15th Calendar day of Month
10
C.3.7
Semi-Annual Cost Report
Network
ELT to COR / BOG

(Send report to COR and esrdnwreports@cms.hhs.gov ) 15th working day of the second calendar month after close of each semiannual cost reporting period; for the final period of the contract in OY4, the deliverable is due 12/31/20

11
C.3.7
Draft Annual Report of Network Activities
Network
ELT to COR
April 30 of each contract period
12
C.3.7
Final Annual Report of Network activities
Network
ELT to COR / CO / NCC

(COR checks Network website) June 15 of each contract period

13
C.3.8
Submit title(s), objective(s), and list of attendees for annual QualityNet conference, LAN meetings, and/ or other conferences
Network
ELT to COR
30 days prior to scheduled meeting
14
C.3.11
Recommend sanctions for recalcitrant facilities
CROWNWeb for clinical outcomes; PCU for information on IVD/IVT/failure to place
ELT to COR

ELT to SA as directed by CMS

15a
C.3.13
Identify and develop MOA with back-up Network
Network
ELT to COR/CMS SME / Back-up Network
1/31 of each contract period
15b
C.3.13
Provide copy of Emergency Preparedness plan
Network
ELT to CO/KCER
On or before February 15th of each contract period
15c
C.3.13
Participate in annual emergency preparedness drill in conjunction with the NCC and conduct a self-assessment of performance
Network
ELT to COR / CMS SME / NCC
30 days after completion of activity
16a
C.3.15-16
Log of daily incremental back-up and weekly full backup Tape Validation and Rotation Schedule
Network
ELT as directed by the CMS QualityNet ISSO COR

ELT to CMS QNet ISSO Available on request

16b
C.3.15-16
Log of offsite storage of back-up media and rotation schedule
Template will be provided by CMS QNet ISSO; logs maintained locally by IT staff/SPOC
ELT as directed by the CMS QualityNet ISSO COR

ELT to CMS QNet ISSO Available on request

16c
C.3.15-16
List of assigned Network Information Technology (IT) staff with required information
Template will be provided by CMS QNet ISSO
ELT as directed by the CMS QualityNet ISSO COR

ELT to CMS QNet ISSO January 24 of each contract period

16d
C.3.15-16
Completion of Remedy ticket assignments
Remedy
Remedy AR System COR , HCQIS Infrastructure Contractor
As assigned to Network IT staff through Remedy Action Request (AR) System; Must be completed within the designated timeframe
16e
C.3.15-16
Maintenance of systems and software in compliance with applicable configuration requirements
Memorandums or Remedy AR System COR, HCQIS Infrastructure Contractor
As released
16f
C.3.15-16
Update Remedy inventory for all procured and received Government Property (including hardware and software) Maintain HHS-22 process within Remedy
Submit HHS-22 for approval via Remedy; updated record in Remedy Inventory Module. COR, CMS Government Property Administrator
As requested (i.e., when Government Property, including hardware and software, is transferred, retired, or disposed)
16g
C.3.15-16
List of all purchased and leased equipment in HHS-565 submission Final Report

ELT to CMS Government Property Administrator

ELT to CO October 31 of each contract period or upon request, upon contract termination or normal contract conclusion

16h
C.3.15-16
Update Remedy inventory for all Government Property (including hardware and software) transferred. Maintain HHS-22 process within Remedy
Submit HHS-22 for approval via Remedy; update record in Remedy Inventory Module to COR, CMS Government Property Administrator
As requested (i.e., when Government Property, including hardware and software, is transferred, retired, or disposed)
16i
C.3.17
Network System Security Plan (SSP) and Information Security (IS) Risk Assessment (RA)
Template will be provided by CMS QNet ISSO
ELT to CMS QNet ISSO
May 28 of each contract period; also, within 15 days of any change
16j
C.3.17
Network annual CMS Security Assessment and Authorization (SA&A)
Template will be provided by CMS QNet ISSO
ELT to CMS QNet ISSO
Annually; Date TBD
16k
C.3.17
Business Continuity and Contingency Plan (BCCP) that demonstrates how the organization shall establish, maintain, and effectively implement plans for emergency response, back-up operations, and post-disaster recovery for organizational information systems to ensure the availability of critical information resources and continuity of operations in emergency situations
Template will be provided by CMS QNet ISSO
ELT as directed by the CMS QNet ISSO COR

ELT to CMS QNet ISSO May 28 of each contract period; also within 15 days of any change

16l
C.3.17
List of active and inactive QNet user accounts with required data
Logs maintained locally; template will be provided by CMS QNet ISSO
ELT as directed by the CMS QNet QualityNet ISSO to COR

ELT CMS QNet QualityNet ISSO

ELT to QNet Security Team Date TBD

16m
C.3.17
Corrective Action Plan (CAP)

(Also known as a Performance Improvement Plan, PIP)

Template will be provided by CMS QNet ISSO
ELT as directed by the COR and CMS QNet ISSO
Within 30 days after audit or finding
16n
C.3.17
Plan of Action and Milestone
Template will be provided by CMS QNet ISSO
ELT as directed by the COR and CMS QNet ISSO
Within 15 days of approval of CAP: monthly thereafter until CAP is closed.
16o
C.3.17
QNet Security Awareness Training (SAT)
Logs maintained locally by IT staff/SPOC with required data and artifacts; template will be provided by CMS QNet ISSO
ELT as directed by the CMS QualityNet ISSO COR

ELT to CMS QNet ISSOCOR QNet Before Network employee receives a QNet User Account and on request

16p
C.3.17
QNet Security Awareness Training (SAT) Certification Letter
Template will be provided by CMS QNet ISSO
ELT to CMS QNet ISSO

Submit additional artifacts on request.

Date TBD

16q
C.3.17
Record of security incident response
ELT to COR
Within 24 hours of occurrence to COR; Report on Monthly COR Report
16r
C.3.19
Performance Improvement Plan (PIP)
Network
ELT as directed by the COR
Within 5 working days of notification

AIM-1 Better care for the ESRD Individual

17
C.4.1.A.1
Provide 25% of facilities located in the Network area with patient representative forms to identify 15 patients to participate in activities
Network
ELT to COR/ AIM CMS SME
On or before January 31st
18
C.4.1A.1
Provide list of 15 Patient SMEs, if different than PAC member list
Network
ELT to COR/AIM CMS SME
On or before February 15 of each contract period, if applicable
19
C.4.1.A.1
Develop a summary report of PE activities and learning resulting from the activity in preparation for next contract year
Network
ELT to COR/AIM CMS SME
November 30 of each contract period
20
C.4.1.A.3
Provide list of 5 patients working with NCC Patient Engagement LAN
Network
ELT to COR/AIM CMS SME/NCC
On or before February 15 of contract award
21
C.4.1.A.3
Provide an update on the number of participants who remain active in patient-and family-engagement activities, including the N-PFE LAN and QIAs
Network
ELT to COR/AIM CMS SME
Last business day of each quarter for each contract period
22
C.4.1.B.1
Notify COR of all QoC cases which are referred to State Agency (SA)
Network
ELT to COR/AIM CMS SME/SA
Within one working day of identification
23
C.4.1.B.1
Networks will submit patient data for those who have agreed to participate in Grievance Survey to the NCC.
PCU Query
ELT to NCC
By fifth day of month
24
C.4.1.B.1
Provide Grievance QIA Template for review
PCU
ELT to COR/AIM CMS SME
3/31 for Base year, 1/31 for Option years
25
C.4.1.C.1
Provide ICH CAHPS QIA Short Form for review
Network
ELT to COR/AIM CMS SME
3/31 for Base year; 1/31 for Option years
26
C.4.1.D.3
Provide HAI BSI QIA Short Form for review
Network
ELT to COR/AIM CMS SME
3/31 for Base year; 1/31 for Option years
27
C.4.1.D.4
Provide HAI Immunizations QIA Short Form for review
Network
ELT to COR/AIM CMS SME
3/31 for Base year; 1/31 for Option years
28
C.4.1.A-D
Networks shall provide updated QIA target facility/populations lists to the NCC for the subsequent contract period
Network
ELT to NCC
Last working day in November

AIM-2 Better Health for the ESRD Population

29a
C.4.2.B
Identify AIM 2 Innovation Pilot Project topic and disparity
Network/

CW Data ELT to COR/

AIM CMS SME

Last business day in February, 1/31 for Option years

29b
C.4.2.B
Finalize proposal with baseline data collection and analysis
Network/

CW Data ELT to COR/

AIM CMS SME

Last business day in March

29c
C.4.2.B
Reporting of the final project target facilities to the NCC
Network/

CW Data ELT to COR/

AIM CMS SME

Second business day in April

30
C.4.2.D (A3)
Identify AIM2 National Hospital Care Coordination project population and disparity
Network/

CW Data ELT to COR/

AIM CMS SME

Second business day in April for OY3 & OY4

AIM-3 Reduce Costs of ESRD Care

31
C.4.3.A
Provide MAH Updates quarterly, if needed
Network
ELT to COR/ QMHAG CMS SME/QIP contractor (parrotte@med.umich.edu)
By COB tenth working day of the first month of each quarter
32
C.4.3.A
QIP QIA Report on facilities selected
Network
ELT to COR/AIM CMS SME
Last business day in January
33
C.4.3.A
Provide QIP QIA Short Form for review
Network
ELT to COR/AIM CMS SME
Last business day in March
34
C.4.3.A
Provide QIP QIA facility list of 10 or more facilities
QIP File provided by NCC
ELT to COR/

AIM CMS SME

Last business day in January each contract period and as within five business days of each new facility being added to the QIA

35
C.4.3.A
Provide QIP QIA facility RCAs
QIP QIA Template
ELT to COR/

AIM CMS SME

Last business day in March of each contract period and within 10 business days of adding a facility

36
C.4.3.A
ESRD QIP QIA Results Report
QIP QIA Template
ELT to COR/

AIM CMS SME

Monthly, if applicable, on or before 15th calendar day of the month

37A
C.4.3.B
Provide technical support to oversee the timely submission and completion of the 2744 Annual ESRD Facility Survey and provide notification to CMS of successful completion of this survey
CROWNWeb
ELT to COR/CMS SME
Provide notification of validation that all facilities have successfully completed and submitted 2744A forms by First Friday in May
37B
C.4.3.B
Provide technical support to oversee the timely submission and completion of the 2744 Annual ESRD Facility Survey and provide notification to CMS of successful completion of this survey
CROWNWeb
ELT to COR/CMS SME
Report successful completion of the ESRD Facility survey by providing a signed confirmation by the second Friday in May.
38
C.4.3.B
Complete Bi-Annual Data Quality QIA survey results
CDC will provide template
ELT to COR/

AIM CMS SME

Twice per contract period to be determined by CMS

39
Entire SOW
Networks shall provide updated QIA target facility/populations lists
Networks
ELT to NCC
by the last working day in November for the subsequent contract period

Table 2 – Conflict of Interest Schedule of Deliverables: ESRD Network Schedule of Deliverables for the Performance Period of December 1, 2015, through November 30, 2016

Item No.

Item Description
Recipient and Reporting Mechanism
Due Date(s)
Data Source
Evaluation

(of Deliverable) Notes

Conflict of Interest Identification

1
Submission of proposed contract or other agreement with provider of services or health plan for services related to the proposed provider or health plan’s Medicare reimbursement

H.11.C.3(c) CO and CIS

ELT COR

At least 30 days prior to the planned execution date of the agreement

2
Submission of report listing the agreements entered into with a provider of services or health plan and with federal, state or local government agencies

H.11.3.C.3 (d) CO and CIS

April 1, 2016

3
Submission of documentation that Network’s subcontractors have mitigated any conflict or potential conflict

H.11.C.4 CO and CIS

At least 30 days prior to the planned execution date of the agreement

Conflict of Interest Disclosure

4
Submit Organizational Conflicts of Interest Certificate in accordance with H.11.D.1 and H.11.D.2 (a)

CO and CIS

Upon submission of technical proposal

Upon request for revisions from CO

Updates included in April 1, 2016 report

45 days before any change in the information submitted in accordance H.4.2

5.
Submit Ownership Interest Information H.11.D.1(g)
ELT COR

With Technical Proposal

Updates included in April 1, 2016 report

Personnel Changes Requiring Conflict of Interest

6.
Submission of resume or CV and additional information in accordance with paragraph H.11.F
CO and CIS

Prior to engaging the services of the replacement personnel in accordance with paragraph H.6

Start-Ups, Acquisitions and Affiliations

7.
Provide notification of intent to start-up acquire or affiliate with or be acquired by another business

H.11.G CO and CIS

As soon as possible but no case later than 60 days before the projected start-up date

Refresh SOW Schedule of Deliverables (SOD): Base through OY4

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