Draft Peformance Work Statement - Off-Site Radiology.pdf

1. GENERAL:

1.1. Services Provided: The contractor shall provide radiology services offsite in accordance with the specifications contained herein to beneficiaries of the Department of Veterans Affairs (VA).

1.2. Place of Performance: Contractor shall furnish services at the (contractor’s facility).

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

1.4. Policy/Directives/Handbooks. Contractor shall comply with all relevant VA policies and procedures related to quality, access, patient safety, and performance, including but not limited to, the policies listed below. The policies listed below can be accessed electronically at the following: VA Publications and VHA Publications

1.1.1. VA Directive 1663: Health Care Resources (HCR) Contracting – Buying Title 38 U.S.C. 8153

1.1.2. VHA Directive 1003.04: VHA Patient Advocacy

1.1.3. VHA Directive 1088: Communicating Test Results to Providers and Patients

1.1.4. VHA Directive 1100.16: Health Care Accreditation of VHA Facilities and Programs

1.4.4 VHA Directive 1100.18: Reporting and Responding to State Licensing Boards

1.4.5 VHA Directive 1605.01: Privacy and Release of Information

1.4.6 VHA Directive 1900: VA National Standards of Practice

1.4.7 VHA Directive 1907.01: VHA Health Information Management and Health Records

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

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

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

1.5. 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 AAAHC: Accreditation Association for Ambulatory Health Care

1.5.2 ABA: American Board of Anesthesiology http://www.theaba.org/

1.5.3 AORN: Association of Operating Room Nurses

1.5.4 ASC: Ambulatory Surgery Center

1.5.5 AST: Association of Surgical Technicians

1.5.6 BAA: Business Associate Agreement

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 CMS: Centers for Medicare and Medicaid Services

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

1.5.11 CO: Contracting Officer – The person executing this contract on behalf of the VA with the authority to enter and administer contracts and make related determinations and findings.

1.5.12 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 VA. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken.

1.5.13 COS: Chief of Staff

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

1.5.15 CPARS: Contractor Performance Assessment Reporting System

1.5.16 CPT: Current Procedural Terminology

1.5.17 CRNA: Certified Registered Nurse Anesthetist

1.5.18 ED: Emergency Department

1.5.19 EHR: Electronic Health Records. Electronic health record system used by the VA.

1.5.20 EMR: Electronic Medical Record

1.5.21 FSMB: Federation of State Medical Boards

1.5.22 FTE: Full Time Equivalent: VA’s standard definition is for full time-working the equivalent of 80 hours every two weeks, 2080 hours per year. However, providers may propose using their standard FTE definition.

1.5.23 HHS: Department of Health and Human Services

1.5.24 HICPAC: Healthcare Infection Control Practices Advisory Committee - a federal advisory committee made up of 14 external infection control experts who provide advice and guidance to the CDC and the Secretary of HHS regarding the practice of health care infection control, strategies for surveillance and prevention and control of health care associated infections in United States health care facilities.

1.5.25 HIPAA: Health Insurance Portability and Accountability Act

1.5.26 HR: Human Resources

1.5.27 Implants: Implants are defined as any active medical device which is intended to be totally or partially introduced, surgically or medically, into the human body or by medical intervention into a natural orifice, and which is intended to remain after the procedure.

1.5.28 ISO: Information Security Officer

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

1.5.30 MOD: Medical Officer of the Day

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

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

1.5.33 NP: Nurse Practitioner

1.5.34 NPPES: National Plan and Provider Enumeration System

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

1.5.36 PA: Physician Assistant

1.5.37 POP: Period of Performance

1.5.38 PPD: Purified Protein Derivative

1.5.39 PWS: Performance Work Statement

1.5.40 QA/QI: Quality Assurance/Quality Improvement

1.5.41 QASP: Quality Assurance Surveillance Plan

1.5.42 QAPI: Quality Assessment and Performance Improvement

1.5.43 QM/PI: Quality Management/Performance Improvement

1.5.44 TJC: The Joint Commission

1.5.45 VA: Veterans Affairs

1.5.46 VHA: Veterans Health Administration

1.5.47 VISN: Veterans Integrated Services Network

1.5.48 VISTA: Veterans Integrated Systems Technology Architecture

2. QUALIFICATIONS: Contractor shall be duly licensed by the Department of Health and the State of Oklahoma to operate radiology equipment and shall be a qualified provider under the Medicare Program.

Radiology equipment refers to medical imaging devices and associated systems used for diagnostic purposes, designed to produce images of internal body structures through technologies such as X-rays, ultrasound, magnetic resonance, computed tomography, and nuclear medicine techniques. This includes, but is not limited to, X-ray machines, CT scanners, MRI systems, ultrasound units, and related accessories. All equipment shall comply with applicable federal and state regulations, safety standards, and Medicare program requirements.

2.1. Facility:

2.1.1 The contracted facility shall meet or exceed health care accreditation requirements of VHA Directive 1100.16 or Accreditation Requirements for Ambulatory Health Care. Documentation verifying accreditation requirements shall be provided by the contractor on an annual basis.

2.1.2 The contractor’s facility shall meet all federal, state, and local fire and life safety codes and shall be accessible and convenient for wheelchair patients and other handicapped or disabled Veterans.

http://www.nlnac.org/

2.2. Staff:

2.2.1 Board Certification: All contract physician(s) shall be Board Certified. 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.

2.2.2 Contractor staff shall meet state licensure requirements and all licenses held by contractor’s staff working on this contract shall be full and unrestricted licenses.

Contractor staff who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action, or denied upon application shall not provide services under this contract.

2.2.3 Contractor shall have written policies and procedures regarding staff credentials and privileges. All contractor staff shall be appropriately credentialed and privileged according to those policies and procedures and practice within the scope of their privileges.

2.2.4 Contractor staff shall be technically proficient in the skills necessary to fulfill the VA’s requirements, including the ability to speak, understand, read, and write English fluently.

2.2.5 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. Contract 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 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 physician(s).

2.2.6 Contractor staff qualifications, licenses, and certifications shall be maintained in good standing throughout the contract period of performance. 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. In the event that contractor staff is not directly employed by the treating facility, documentation shall be provided to the COR to ensure adequate certification.

2.2.7 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 contract physician(s) as required by the VA.

Training Frequency Annual Hours

TBA TBA TBA

TBA TBA TBA

2.2.8 Contractor shall provide statement that all required infectious disease testing for personnel is current and that the contractor is compliant with all applicable laws to include OSHA regulations concerning occupational exposure to blood borne pathogens. The contractor shall also notify the VA of any significant communicable disease exposures and the VA shall also notify the contractor of the same, 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 https://www.cdc.gov/hicpac/pdf/InfectControl98.pdf) for disease control. If personnel are absent from work secondary to infectious disease, then contractor shall provide follow up documentation of clearance prior to return to the workplace.

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

2.3. Conflict of Interest: The contractor and all contractor’s personnel 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 shall 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. Attach in Section D and remove this instruction prior to submitting.

2.4. Citizenship Related Requirements:

2.4.1 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 laws and regulations that are enforced by the Department of Homeland Security and the Department of Labor as these may relate to undocumented noncitizens and/or non-immigrant foreign nationals working under contract or subcontract for the contractor while providing services to Department of Veterans Affairs.

2.4.2 While performing services for the Department of Veterans Affairs, the contractor shall not knowingly employ, contract, or subcontract with an undocumented noncitizen or foreign national non-immigrant who is in violation their status, because 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 (including FAR Subpart 22.18).

2.4.3 If the contractor fails to comply with any requirements outlined in the preceding paragraphs or above referenced laws and regulations, the Department of https://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

Veterans Affairs may, at its discretion, require that the undocumented noncitizen or foreign national who has failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by the Department of Homeland Security and/or the 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 may form the basis for termination of this contract for breach.

2.4.4 The contractor acknowledges that this certification concerns a matter within the jurisdiction of an agency of the United States. The contractor further acknowledges that this certification is subject to Title 18, United States Code, Section 1001, and, as such, a false, fictitious, or fraudulent certification may render the offeror subject to criminal, civil, or administrative penalties, including prosecution.

2.4.5 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. Attach in Section D and remove this instruction prior to submitting.

2.5. Annual Office of Inspector General (OIG) Statement: In accordance with The Health Insurance Portability and Accountability Act (HIPAA) and the Balanced Budget Act (BBA) of 1977, the VA 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.

2.5.1 Therefore, all contractors shall review the OIG List of Excluded Individuals/Entities (LEIE) on the OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed Contract staff and/or firm(s) are not listed. Contractors 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 or entity 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 Contract staff and entities that employ or enter contracts with excluded individuals or entities to provide items or services to Federal program beneficiaries.

2.5.2 By submitting their proposal, the contractor certifies that the OIG LEIE has been reviewed and that the contractor and its subcontractors are not listed as of the date the proposal was signed. In addition, the contractor will review the OIG LEIE annually to verify compliance.

2.6. Non-Personal Services: The parties agree that the contractor, contract staff, agents and sub-contractors shall not be considered VA employees for any purpose. All individuals that provide services under this resultant contract and are not staff of the contractor shall be regarded as subcontractors. The contractor shall be responsible and accountable for the quality of care delivered by all its subcontractors. The contractor shall be responsible for strict compliance of all contract terms and conditions without regard to who provides the service.

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

2.7. Indemnification: The contractor shall be liable for, and shall indemnify and hold harmless the VA 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.

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

2.9. Inherently Governmental Functions Prohibited: This includes, but is not limited to, determination of agency policy, determination of federal program priorities for budget requests, direction and control of VA employees, selection or non-selection of individuals for federal VA 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.

2.10. Contract Personnel: The contractor shall be responsible for protecting contractor’s personnel furnishing services. To carry out this responsibility, the contractor shall provide or certify that the following is provided for all contract staff providing services under the resultant contract:

2.10.1 Workers’ compensation

2.10.2 Professional liability insurance

2.10.3 Health examinations

2.10.4 Income tax withholding, and

2.10.5 Social security payments.

2.11. Tort Liability: The Federal Tort Claims Act does not cover contractor personnel. When a contracted provider has been identified as a provider in a tort claim, The contractor’s provider shall notify the contractor’s legal counsel and/or insurance carrier. Any settlement or judgment arising from a contractor’s personnel action or non-action is the responsibility of the contractor and/or insurance carrier.

3. HOURS OF OPERATION/SCHEDULING:

3.1. BUSINESS HOURS: Mon-Fri 0800-1600

3.2. FEDERAL HOLIDAYS: The following holidays are observed by the Department of Veterans Affairs:

• New Year’s Day

• President’s Day

• Martin Luther King’s Birthday

• Memorial Day

• Juneteenth

• Independence Day

• Labor Day

• Columbus Day

• Veterans Day

• Thanksgiving

• Christmas

• Any day specifically declared to be a national holiday.

4. CONTRACTOR RESPONSIBILITIES:

4.1. The contractor shall be responsible for supervising the daily services provided under this contract by the contractor’s support staff.

4.2. Contractor shall be responsible for all equipment, supplies, disposables, or one-time use items necessary to perform radiology services at the contractor’s facility. This includes radiology equipment required for imaging studies. VA shall not provide equipment for offsite services.

4.3. Standards of Practice: Contractor shall meet or exceed VA and AAAHC (or equivalent) standards.

4.4. Professional Services: Estimated 97% of the time will be devoted to professional radiology services performed offsite. The Contractor shall be responsible for:

4.4.1 Scope of Services: The Contractor’s physician(s) shall provide diagnostic interpretation of imaging studies and timely reporting, including but not limited to consultative support for Interventional Radiology, image review, and procedure planning as required by the VA facility. All interpretations shall meet VA standards of care and comply with applicable ACR guidelines. Contractor shall deliver images and reports to VA on DICOM-compatible physical media (CD/DVD) as specified by VA. Delivery must meet VA standards for security and timeliness.

4.4.2 Applicable CPT Codes: The following CPT codes represent the imaging studies covered under this contract:

• CPT 72202 XR Sacoiliac Joints

• CPT 73020 XR Shoulder 1 View

• CPT 72081 XR Scoliosis

• CPT 71111 XR Ribs

• CPT 72220 XR Sacrum

• CPT 73502 XR Hip 2 View

• CPT 73030 XR Shoulder 2 View

• CPT 73562 XR Knee 3 View

• CPT 72100 XR Lumbar Spine 3 View

• CPT 73552 Femur 2 View

• CPT 73000 XR Clavicle

• CPT 73610 XR Ankle 3 View

• CPT 73080 XR Elbow 3 View

• CPT 73600 XR Ankle 2 View

• CPT 73620 XR Foot 2 View

• CPT 73110 XR Wrist 3 View

• CPT 73120 XR Hand 2 View

• CPT 73564 XR Knee 4 View

• CPT 72110 XR Lumbar spine W/ OBL

• CPT 71046 XR Chest 2 View

• CPT 73060 XR Humerus

• CPT 73630 XR Foot 3 View

• CPT 73130 XR Hand 3 View

• CPT 77073 XR Bone Length

• CPT 74018 XR Abdomen 1 View

• CPT 73560 XR Knee <3 Views

• CPT 73590 XR Tib/Fib

• CPT 72170 XR Pelvis

• CPT 73552 XR Femur MIN 2 View

• CPT 72070 XR Thoracic Spine 2 View

• CPT 70030 XR Orbits

• CPT 73070 XR Elbow 2 View

• CPT 71045 XR Chest 1 View

• CPT 73660 XR Toe(s)

• CPT 72114 XR Lumbar Spine W/obl + flex/ext

• CPT 72120 XR Lumbar Spine flex/ext ONLY

• CPT 73090 XR Forearm

• CPT 73501 XR Hip 1 View

• CPT 74019 XR Abdomen flat/upright

• CPT 73100 XR Wrist 2 View

• CPT 72052 XR Cervical Spine flex/ext

• CPT 72072 XR Thoracic Spine 2View W/swimmers

• CPT 73140 XR Finger(s)

• CPT 74022 XR Acute Abdomen Series

• CPT 72040 XR Cervical Spine 3 View

4.5. Medical Records- Medical Records are the property of the contractor, but copies shall be provided to the VA for each VA patient on a DICOM compatible CD/DVD. The report and images will need to be sent to the VA by contractor bringing to the VINITA VA clinic so that Lab Courier and deliver to VA for downloading and placement into the patient’s chart.

4.5.1 Authorities: Contractor shall comply with the Privacy Act of 1974 (as amended by 5 U.S.C. 552a), 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 (Health Insurance Portability and Accountability Act) for medical records created as a result of services contractor provides under this contract.

4.5.2 HIPAA: This contract and its requirements meet exception in 45 C.F.R.

164.502(e) and does not require a BAA 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. Treatment and administrative patient 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’ (24VA19). 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 are available for immediate transmission when requested by the VA. Records identified for review, audit, or evaluation by VA representatives and authorized federal and state officials, shall be accessed on-site during normal business hours or mailed by the contractor at their expense. Contractor shall deliver all final patient records, correspondence, http://www.rms.oit.va.gov/SOR_Records/24VA19.asp http://www.rms.oit.va.gov/SOR_Records/24VA19.asp and notes to the VA within twenty-one (21) calendar days after the contract expiration date.

4.5.3 Disclosure: Contractor’s personnel may have access to patient medical records;

however, contractor shall obtain permission from the VA before disclosing any patient information. Subject to applicable federal confidentiality or privacy laws, the contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over contractor, may have access to VA’s records, at VA’s place of business on request during normal business hours, to inspect and review and make copies of such records.

The VA shall provide the contractor with a copy of VHA Directive 1907.1, Health Information Management and Health Records, VHA HIM Health Record Documentation Program Guide, 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 and its subcontractors.

4.5.4 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.

4.5.5 Release of Information: The VA shall maintain control of releasing any VA patient medical information. Contractor shall refer veterans to Eastern Oklahoma Veterans Healthcare Services (EOVHCS). Release of Information section to request copies of records.

4.5.5.1. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

4.5.5.2. In accordance with 36 C.F.R. 1222.32, all data created for VA use and delivered to, or falling under the legal control of, the VA are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and shall be managed and scheduled for disposition only as permitted by statute or regulation.

4.5.5.3. In accordance with 36 C.F.R. 1222.32, contractor shall maintain all records created for VA use or created in the course of performing the contract and/or delivered to, or under the legal control of the VA and shall be managed in accordance with Federal law. Electronic records and associated metadata shall be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

4.5.5.4. The VA and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation.

Records may not be removed from the legal custody of VA or destroyed except for in accordance with the provisions of the agency records http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469 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=3088 http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1423 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, contractor shall report to VA. The agency shall report promptly to NARA in accordance with 36 C.F.R. 1230.

4.5.5.5. The contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records, or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract]. The contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected.

The contractor shall not remove material from VA facilities or systems, or facilities or systems operated or maintained on the VA’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to VA control, or the contractor shall hold it until otherwise directed. Items returned to the VA shall be hand carried, mailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the [contract]. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph 4.7.5.4.

4.5.5.6. The contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The contractor (and any sub-contractor) is required to abide by VA and VA guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

4.5.5.7. The contractor shall not create or maintain any records containing any non-public VA information that are not specifically tied to or authorized by the contract.

4.5.5.8. The contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

4.5.5.9. The VA owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. VA for which VA shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any contractor rights in the data or deliverables shall be identified as required by FAR 52.227-11 through FAR 52.227-20.

4.6. 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 radiology staff is unable to continue performance in accordance with the terms and conditions of the resulting contract.

4.7. It is the expectation that the performance of contracted services shall meet basic principles of risk reduction, safety, staff competence, and performance improvement.

4.8. Contractor shall follow the American College of Radiology and maintain documentation of appropriate peer review statistics as needed for quality management and credentialing.

4.9. The contractor shall provide documents such as policies and procedures to demonstrate prevention and management of safety risks; and, upon request, reports of incidents involving care, treatment and/or services of VA patients.

4.10. Patient Safety Compliance and Reporting: Contractor’s staff shall follow all established patient safety and infection control standards of care. Contractor’s staff(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 breaches of patient safety shall be reported to the COR.

As soon as practicable (but within 24 hours) contractors shall notify COR of incident and submit to the COR the Patient Safety Report, following up with COR as required or requested

4.11. PROCEDURES:

4.11.1 Contractor shall comply with any regulatory guidance applicable to the type of procedure being performed.

4.11.2 Standard of Care should be equal to that provided by VA.

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

IMPROVEMENT (QI)

4.12.1 Quality Management/Quality Assurance Surveillance: Contractor staff 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 shall be monitored by the VA 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.

4.12.2 The VA reserves the right to refuse acceptance of any contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care. 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 VA 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.

4.13. Performance Standards:

4.13.1 Measure: Privacy, Confidentiality and HIPAA

Performance Requirement: Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality

Standard: All (100%) Contractor’s support staff comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA

Acceptable Quality Level: 100% compliance

Surveillance Method: Periodic Inspection; Contractor shall provide evidence of annual training required by the facility, reports violations per VA Handbook 6500.6.

Frequency: Annually

4.13.2 Measure: Timely Delivery of Images and Reports

Performance Requirement: All images and reports delivered to VA within 24 hours of interpretation

Standard: 100% compliance

Acceptable Quality Level: 100% compliance

Surveillance Method: Periodic inspection and audit of delivery logs

Frequency: Monthly

4.14. Registration with Contractor Performance Assessment Reporting System

4.14.1 As prescribed in Federal Acquisition Regulation (FAR) Part 42.15, the Department of Veterans Affairs (VA) evaluates contractor past performance on all contracts that exceed the Simplified Acquisition Threshold and shares those evaluations with other Federal VA contract specialists and procurement officials.

The FAR requires that the contractor be provided an opportunity to comment on past performance evaluations prior to each report closing. To fulfill this requirement VA uses an online database, CPARS, which is maintained by the Naval Sea Logistics Center in Portsmouth, New Hampshire. CPARS has connectivity with the Past Performance Information Retrieval System (PPIRS) database, which is available to all Federal agencies. PPIRS is the system used to collect and retrieve performance assessment reports used in source selection determinations and completed CPARS report cards transferred to PPIRS.

CPARS also includes access to the federal awardee performance and integrity information system (FAPIIS). FAPIIS is a web-enabled application accessed via CPARS for contractor responsibility determination information.

4.14.2 Each contractor whose contract award is estimated to exceed the Simplified Acquisition Threshold requires a CPARS evaluation. A VA Focal Point shall register your contract within thirty days after contract award and, at that time, you shall receive an email message with a User ID (to be used when reviewing evaluations). Additional information regarding the evaluation process can be found at www.cpars.gov or if you have any questions, you may contact the Customer Support Desk @ DSN: 684-1690 or COMM: 207-438-1690.

http://www.cpars.gov/

4.14.3 For contracts with a period of one year or less, the contracting officer shall perform a single evaluation when the contract is complete. For contracts exceeding one year, the contracting officer shall evaluate the contractor’s performance annually. Interim reports shall be filed each year until the last year of the contract, when the final report shall be completed. The report shall be assigned in CPARS to the contractor’s designated representative for comment.

The contractor representative shall have sixty (60) business days to submit any comments and re-assign the report to the CO.

4.14.4 Failure for the contractor’s representative to respond to the evaluation within those sixty (60) business days shall result in the VA’s evaluation being placed on file in the database with a statement that the contractor failed to respond; the contractor’s representative shall be “locked out” of the evaluation and may no longer send comments.

5. VA RESPONSIBILITIES:

5.1. The VA shall provide radiology testing guidelines that conform to ACR and Medicare standards.

5.1.1 Basic Radiology, e.g., chest X-ray, plain X-rays, and other imaging as clinically indicated.

5.2. The VA shall provide to the contractor policies, procedures, and processes necessary to allow cooperative functioning between the agency and the facility. Updates and refreshers shall be provided to the contractor upon request and when policy procedures or process changes.

5.3. All follow up care shall be accomplished at the VA facility. Contractor shall not advise patient(s) to come back to their facility for follow-up. Patients shall be instructed to contact the VA providing care for all follow-up.

5.4. VA shall be responsible for ensuring procedure follow-up and care once the procedure report and all supporting documentation signed by the performing VA physician is received.

6. SPECIAL CONTRACT REQUIREMENTS:

6.1. Reports/Deliverables: The contractor shall be responsible for complying with all reporting requirements established by the contract. The contractor shall be responsible for assuring the accuracy and completeness of all reports and other documents as well as the timely submission of each. The contractor shall comply with contract requirements regarding the appropriate reporting formats, instructions, submission timetables, and technical assistance as required.

6.2. The following are brief descriptions of required documents that shall be submitted by contractor: upon award; weekly; monthly; quarterly; annually, etc. identified throughout the PWS and is provided here as a guide for contractor convenience. If an item is within the PWS and not listed here, the contractor remains responsible for the delivery of the item.

6.2.1 Invoice requirements and supporting documentation: Payment to the contractor shall be made monthly, in arrears, upon receipt of a properly prepared invoice.

Payment for services shall be at the rates specified in the Schedule of Supplies/Services. The contractor shall submit invoices using CMS Uniform Billing (UB-04) forms covering the services performed under this contract. The invoices shall contain the following information:

• Name and Address of Contractor.

• Invoice Date and invoice Number.

• Contract Number and Purchase Order Number.

• Date of Service.

• Name of Beneficiary and last four digits of the Social Security number.

• Itemized statement of services rendered by CPT Code and Rates.

• Total price.

6.3. Vendor Electronic Invoice Submission Method: Invoices will be electronically submitted to the Tungsten website at https://www.tungstenautomation.com/. Tungsten Automation direct vendor support number is 877-489-6135 for VA contracts. The VA-FSC pays all associated transaction fees for VA orders. During Implementation (technical set-up) Tungsten Automation will confirm your Taxpayer ID Number with the VA-FSC. This process can take up to 5 business days to complete to ensure your invoice is automatically routed to your Certifying Official for approval and payment. To successfully submit an invoice to VA-FSC please review “How to Create an Invoice” within the how to guides. All invoices submitted through Tungsten Automation to the VA-FSC should mirror the current submission of Invoice. Clarification of additional requirements should be confirmed with your Certifying Official (your CO or buyer).

Payment will only be made for actual services rendered. Payments shall be made monthly in arrears. The VA-FSC requires specific information in compliance with the Prompt Pay Act and Business Requirements. The contractor shall be reimbursed upon receipt of a proper invoice. For additional information, please contact:

Tungsten Support Phone: 1-877-489-6135 Website: https://www.tungstenautomation.com/

Department of Veterans Affairs Financial Service Center https://www.fsc.va.gov/einvoice.asp

6.4. Payments in Full/No Billing VA beneficiaries: The contractor shall accept payment for services rendered under this contract as payment in full. VA beneficiaries shall not under any circumstances be charged nor their insurance companies charged for services rendered by the contractor, even if VA does not pay for those services. This provision shall survive the termination or ending of the contract.

6.4.1 To the extent that the Veteran desires services which are not a VA benefit or covered under the terms of this contract, the contractor shall notify the Veteran that there shall be a charge for such service and that the VA shall not be responsible for payment.

6.4.2 The contractor shall not bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against, any person or entity other than VA for services provided pursuant to this contract. It shall be considered fraudulent for the contractor to bill other third-party insurance sources (including Medicare) for services rendered to VA beneficiaries under this contract.

6.5. Contractor Security Requirements: In accordance with Acquisition Policy Flash! 24- 03 COs shall ensure solicitations and contracts account for all VA’s overarching security policy, to include, but not limited to, VA Handbook 6500.6, VA Directive 0710, VA https://www.tungstenautomation.com/ https://www.tungstenautomation.com/ https://www.fsc.va.gov/einvoice.asp

Handbook 0710, VAAR 804.1303, VAAR 804.1903, and VAAR 804.1970. Please work with your ISO, privacy officer and legal to select appropriate language.