Draft Performance Work Statement - Mental Health Residential Rehabilitation - Draft.pdf

1. GENERAL:

The Contractor shall be responsible for providing room, board and transportation to Veterans admitted to the G.V. (Sonny) Montgomery VA Medical Center’s Mental Health Residential Rehabilitation Treatment programs (MH RRTPs), as specified herein. MH RRTP treatment services are provided at the G.V. (Sonny) Montgomery VA Medical Center. Room, board, transportation and related services shall be provided at the Contractor’s facility. The Contractor shall provide all services to include materials, supplies, equipment, and qualified supervision specified herein. The contract will be in support of the G.V. (Sonny) Montgomery VA Medical Center, 1500 East Woodrow Wilson Avenue, Jackson, MS 39216.

1.1. Authority – Title 38 Code of Federal Regulations (CFR) 17.38 and 17.80 through 17.83, and FAR Part 12 – Acquisition of Commercial Items.

1.2. Policy/Handbooks - The contractor shall be subject to the following policies, including any subsequent updates during the period of performance:

1.2.1. VHA Handbook 1100.18, “Reporting And Responding To State Licensing Boards” http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1364

1.2.2. VHA Handbook 1605.1, “Privacy and Release of Information” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233

1.2.3. VHA Handbook 1907.01, “Health Information Management and Health Records” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088

1.2.4. VHA Directive 2009-038, “VHA National Dual Care Policy” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2058

1.2.5. Health Insurance Portability and Accountability Act of 1996 (HIPAA) https://www.govinfo.gov/content/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf

1.2.6. Patient Self Determination Act of 1990

https://www.congress.gov/bill/101st-congress/house-bill/4449/text

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

https://www.justice.gov/oip/blog/foia-update-freedom-information-act-5-usc-sect-552-amended-public-law-no-104-231-110-stat

1.2.8. VHA Handbook 1160.01, “Uniform Mental Health Services” http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762

1.2.9. VHA Handbook 1162.02, “Mental Health Residential Rehabilitation Treatment Program” https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2354

1.2.10. VHA Handbook 1907.01, “Health Information Management and Health Records”

1.2.11. VHA Directive 1605.01, “Privacy and Release of Information”

1.2.12. VA Publications: https://www.va.gov/vapubs/

1.2.13. VHA Publications: https://www.va.gov/vhapublications/publications.cfm?pub=2

1.3. Definitions/Acronyms: 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.

1.3.1. ACLS: Advanced Cardiac Life Support

1.3.2. ADTP: Addictive Disorders Treatment Program

1.3.3. BAA: Business Associate Agreement

1.3.4. BBA: Balanced Budget Act

1.3.5. BLS: Basic Life Support

1.3.6. CARF: Commission on Accreditation of Rehabilitation Facilities

1.3.7. CDC: Centers for Disease Control and Prevention

1.3.8. CFR: Code of Federal Regulations

1.3.9. CLIN: Contract Line Item Number

1.3.10. CMP: Civil Monetary Penalty

1.3.11. CMS: Centers for Medicare & Medicaid Services

1.3.12. Contracting Officer (CO): 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.

1.3.13. Contracting Officer’s Representative (COR): 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.

1.3.14. COS: Chief of Staff

1.3.15. CPARS: Contractor Performance Assessment Reporting System

1.3.16. Credentialing: Credentialing is the systematic process of screening and evaluating qualification and other credentials, including licensure, required education, relevant training and experience and current competence and health status.

1.3.17. CTS: Care, Treatment, and Services

1.3.18. DEA: Drug Enforcement Agency

1.3.19. DSN: Defense Switch Network

1.3.20. EDI: Electronic Data Interchange

1.3.21. ESRS: Electronic Subcontracting Reporting System

1.3.22. FAPIIS: Federal Awardee Performance and Integrity Information System

1.3.23. FAR: Federal Acquisition Regulation

1.3.24. FSC: Financial Service Center

1.3.25. HHS: Department of Health and Human Services

1.3.26. HICPAC: Healthcare Infection Control Practices Advisory Committee: A federal advisory committee made up of fourteen (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.

1.3.27. HIPAA: Health Insurance Portability and Accountability Act

1.3.28. ID: Identification

1.3.29. ISO: Information Security Officer

1.3.30. MD: Medical Doctor

1.3.31. MH RRTP: Mental Health Residential Rehabilitation Program

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

1.3.33. NICE: National Institute for Health and Care Excellence

1.3.34. NFPA: National Fire Protection Association

1.3.35. NPPE: National Plan and Provider Enumeration

1.3.36. OIG: Office of Inspector General

1.3.37. OSHA: Occupational Safety of Health Administration

1.3.38. PPIRS: Past Performance Information Retrieval System

1.3.39. PWS: Performance Work Statement

1.3.40. Privileging (Clinical Privileging): 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.

1.3.41. QA: Quality Assurance

1.3.42. QASP: Quality Assurance Surveillance Plan

1.3.43. QI: Quality Improvement

1.3.44. RFP: Request for Proposal

1.3.45. TIN: Tax Identification Number

1.3.46. TJC: The Joint Commission

1.3.47. TRP: Trauma Recovery Program

1.3.48. U.S.: United States

1.3.49. U.S.C: United States Code

1.3.50. VA: Veterans Affairs

1.3.51. VAAR: Veterans Affairs Acquisition Regulation

1.3.52. Veterans Affairs Medical Center (VAMC): The Veterans Health Administration is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VAMC’s, Outpatient Clinics, Community Based Outpatient Clinics, and VA Community Living Centers (VA Nursing Home) Programs. In reference to this PWS, VAMC is referring to the G.V. (Sonny) Montgomery VA Medical Center, 1500 East Woodrow Wilson Avenue, Jackson, MS 39216.

1.3.53. Veterans Health Administration (VHA): The central office for administration of the VA medical centers throughout the United States. The VHA is based in Washington, D.C.

1.3.54. VISN: Veterans Integrated Service Network

1.4. BILLING DEFINITIONS

1.4.1. LENGTH OF STAY (LOS): The LOS is the period covered by the individual Unit

Price. The LOS begins on the date of admission to the VAMC MH RRTPS (and the Contractor’s housing facility) and will end upon the date of discharge from the VAMC MH RRTPS (and the Contractor’s housing facility). Additional days beyond the LOS for each CLIN will be reimbursed at the daily rate prescribed on the Price Schedule for each CLIN.

2. QUALIFICATIONS

2.1 Staff/Facility

2.1.1 License: Any personnel assigned by the Contractor to perform clinical services covered by this contract (e.g., medication administration) shall have a current license to provide that service, as indicated by state/federal law. All licenses held by contractor personnel working on this contract shall be full and unrestricted licenses in any State, Territory, or Commonwealth of the United States or the District of Columbia. Contractor personnel who have current, full and unrestricted licenses in one (1) or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application shall not be considered for the purposes of this contract.

2.1.2 Facilities are expected to meet all applicable health, safety, and licensing standards outlined in VHA Handbook 1162, “Mental Health Residential Rehabilitation Treatment Program”, as well as all applicable TJC and CARF Standards. Formal independent accreditation by the TJC or CARF is evidence of internal quality assurance mechanisms and is desirable but is not required. Where applicable, the residential treatment setting must have a current occupancy permit issued by the authority having jurisdiction.

2.1.3 The Contractor shall be duly licensed by the Department of Health of the State of Mississippi to operate a facility.

2.1.4 The facility must meet the following requirements:

2.1.4.1 Standards of the Life Safety Code NFPA # 101

2.1.4.2 Fire and safety code imposed by State law

2.1.4.3 City, State and Federal requirements concerning licensing and health codes

2.1.4.4 All residential treatment settings must be licensed as required for the particular setting under state and federal authority

2.2 Board Certification/Staffing Credentials: Contractor clinical personnel must be currently certified in BLS, 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 when requested.

2.3 Credentialing and Privileging: All Contractor Personnel who shall provide services under this contract must be appropriately credentialed and privileged, if required, according to the Bylaws and Rules of the contractor’s facility. If Contractor Personnel are not credentialed and privileged or have credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government. Copies of all credentialing forms will be provided to the COR on request.

2.4 Technical Proficiency: Contractor Personnel shall be technically proficient in the skills necessary to fulfill the government’s requirements, including the ability to speak, understand, read, and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed.

Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all Contractor Personnel when requested.

2.5 Training: Contractor shall meet all VA educational requirements. Contractor Personnel must meet mandatory course requirements as required by the Contractor’s facility.

2.6 Standard Personnel Testing/Infection Control: Contractor shall provide a statement with the proposal that all required infection control testing is current and that the contractor is compliant with 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 will 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 1998; 26:289-354 http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf) for disease control.

Tests shall be current within the past year.

2.7 National Provider Identifier (NPI): NPI is a standard, unique ten (10) - digit numeric identifier required by HIPAA. The VHA must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). The Contractor shall have or obtain appropriate NPI and if pertinent the Taxonomy Code confirmation notice issued by the CMS NPPE. The information shall be provided to the CO with the proposal.

2.8 Conflict of Interest: The Contractor is 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 (e.g., 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 provide relevant facts that show how its 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 (Jan 2008) and fully outlined in response to the subject attachment in Section D of the solicitation document.

2.9. Annual Office of Inspector General (OIG) Statement: In accordance with HIPAA and the BBA of 1977, the HHS and 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. 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 proposed Contractor Personnel 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 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. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractor is and/or Contractor Personnel are not listed as of the date the offer was signed.

2.10. Non-Personal Healthcare Services: The parties agree that the Contractor and all Contractor Personnel shall not be considered VA employees for any purpose.

2.11. Inherent Government Functions: Contractor and Contractor Personnel 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.

2.12. No Employee status: The Contractor shall be responsible for protecting Contractor Personnel 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:

2.12.1. Workers’ compensation

2.12.2. Professional liability insurance

2.12.3. Health examinations

2.12.4. Income tax withholding, and

2.12.5. Social security payments

2.13. Tort Liability: The Federal Tort Claims Act does not cover Contractor or Contractor Personnel. When a Contractor or Contractor Personnel 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 Personnel) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

2.14. Contingency Plan: Because continuity of care is an essential part of SERVICES, the Contractor shall have a contingency plan in place to be utilized if Contractor Personnel Leave Contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

3.0 HOURS OF OPERATION:

3.1 WORK SCHEDULE: Services shall be available from the contractor twenty-four (24) hours per day, seven (7) days per week, including weekends and federal holidays.

Contractor shall provide coverage for all required shifts, including nights, weekends, and holidays.

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 Jr’s Birthday Memorial Day Juneteenth Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Christmas Any day specifically declared by the President of the United States to be a national holiday.

4.0 CONTRACTOR RESPONSIBILITIES

4.1 General: The Contractor shall be responsible for providing room, board, medication administration, and transportation to Veterans admitted to the MH RRTP. This includes Veterans with the following presenting problems: substance use and post-traumatic stress disorder, often co-occurring with psychotic disorders, bipolar disorders, obsessive- compulsive disorders, major depression, other mood disorders, anxiety disorders, homelessness, justice involvement, and other various psychosocial issues. The services shall be furnished to beneficiaries for whom such care is specifically authorized by the VAMC. The type of Veterans to be cared for under this contract will normally require some care and services above the basic level of meals, room, and board. Relevant care will include, but not be limited to:

4.1.1 Supervised alcohol and drug free environment

4.1.2 Active affiliation with community support groups

4.1.3 Structured individual and group activities

4.1.4 Healthy physical activities

4.1.5 Family involvement

4.1.6 Therapeutic, recreational, and/or spiritual outings

4.1.7 Medication administration and monitoring

4.1.8 Transportation to/from the VAMC and to/from community locations

4.2 The beneficiaries receiving care under this contract shall receive basic health and personal hygiene maintenance, monitoring of medications, and any other service or supplies normally provided in a residential home setting. The rate established shall be an all-inclusive rate.

4.3 Clinical staff of the VA MH RRTP will determine who is eligible for housing under this contract. Length of stay at the facility will also be determined by VA staff.

4.4 Housing facility must be located either within the city limits of Jackson or within twenty

(20) miles of the VAMC.

4.5 Contractors under this program must meet the following VA standards, based on regulations promulgated by Title 38 Code of Federal Regulations (CFR) Section 17.63.

4.6 Licenses and Accreditation: The residential treatment settings must be licensed as required for the particular setting under State and federal authority.

4.7 Staff: Sufficient staff shall be provided (i.e., in numbers and position qualifications) to carry out the policies, responsibilities, and therapeutic activities of the residential treatment program. The Contractor shall assign to this contract personnel that by education and/or training (and, when required, certification or licensure) are qualified to provide the services required by this PWS. Contractor shall ensure that all contract staff meet any training or certifications as required by VA. Contractor may be required to supply resume(s) summarizing relevant skills and experience of any/all key personnel upon request. Minimum Key Personnel requirements are as follows:

4.7.1 One (1) administrative staff member, or designee of equivalent professional capability (with the authority to make decisions regarding the facility and residents, or with contact information for an offsite administrator in case of emergency), accessible by VA staff 24 hours a day, 7 days a week.

4.7.2 Sufficient nursing personnel to administer medications (including controlled substances) at a frequency indicated by Veteran’s VA prescriptions, including daytime, nighttime, weekend and as-needed dosages. Medications must be dispensed within ten (10) minutes of prescribed dosing schedule. PRN medication must be dispensed within thirty (30) minutes of Veteran’s request.

4.7.3 An on-site licensed independent medical provider (RN or MD) that will be able to provide assessment, consultation and assistance for both emergency and non-life-threatening medical and psychiatric incidents.

4.7.4 Sufficient food service, maintenance, housekeeping, and janitorial staff to provide adequate nutrition and a clean, safe housing environment.

4.7.5 At least one (1) contractor employed staff member will be on-site and available in an emergency during each shift, twenty-four (24) hours per day, seven (7) days per week. In facilities with multiple buildings, floors or wings, a staff member must be physically present in each building/floor/wing, whenever Veterans are present in the area. The VA will provide Therapy Assistant positions to help the contractor meet the

24/7 supervision requirement. Hiring, supervision, determination of work hours/leave time, and all other personnel matters related to VA positions will be handled by the VA. Staffing requirements not met by these positions will be the responsibility of the contractor. Contractor is responsible for communicating and coordinating with VA Health Technician supervisor to ensure adequacy of 24/7 staffing. Staff providing on- site supervision of Veterans must be trained in management of disruptive behaviors, first aid, Basic Life Support and use of emergency equipment.

4.8 Contractor shall provide resumes and credentialing documents for all key personnel; if substitutions of key personnel are needed, substitution must be submitted at least fifteen (15) days prior to the proposed date substitution is to occur. The Contracting Officer (CO) or Contracting Officer Representative (COR) will notify the contractor within fifteen (15) calendar days after receipt of all required information if the VA is able to accept the proposed substitute key personnel. Temporary substitutions of key personnel shall be permitted in accordance with the contractor’s contingency plan. The contractor’s contingency plan shall be utilized if personnel leave the contractor’s employment or are unable to continue performance in accordance with the terms and conditions of the resulting contract. The contingency plan shall be submitted to the CO as a part of the proposal package. The CO is the ultimate authority on acceptable length for temporary substitution of key personnel.

4.9 The VA reserves the right to refuse or revoke acceptance of any key personnel if personal, professional conduct, lack of required skills or experience jeopardizes patient care or interferes with the regular and ordinary operation of the facility and the VA Residential Program Objectives.

4.10 The Contractor shall:

4.10.1 Identify, by name, the key management and technical personnel who shall work under a contract with VAMC representatives at the time the service is being provided. The contractor shall submit a listing of names, position and telephone numbers of all personnel. In the event a key person on the list becomes unavailable, it is the contractor’s responsibility to inform the Contracting Officer Representative (COR) immediately so that there will be no lapse of communication.

4.10.2 Assist Veterans requiring emergency services (medical or psychiatric) with quickly accessing appropriate care from a VA or community facility, as appropriate.

4.10.3 Provide secure, separate housing and bathroom accommodations for males and females; common use of kitchen facilities, dining rooms and recreational areas is acceptable.

4.10.4 Provide housing up to twenty-four (24) hours a day for Veteran placements.

Housing will be provided for up to twenty-seven (27) Veterans at a time, with no more than two (2) Veterans per room. The atmosphere will be consistent with a typical American home in terms of cleanliness, furnishings and décor. The environment should promote an individual sense of well-being, optimism, recovery and integration with the surrounding community (as opposed to a hospital- or dormitory-like dwelling). At least fifty (50) percent of these rooms must meet standards for housing Veterans subject to the Americans With Disabilities Act

(ADA).

4.10.5 Provide three (3) daily nutritious meals and reasonable accommodation for special dietary needs.

4.10.6 Provide a means for Veterans in the program to wash their own clothes or otherwise tend to laundry at no additional cost to the Veteran.

4.10.7 Provide secure, appropriate storage for both the Veteran’s belongings and medication (if applicable).

4.10.8 Maintain a minimum of one (1) staff member on-site at all times to ensure appropriate responses to matters involving Veterans safety.

4.10.9 Provide a working phone line for Veteran use, ensuring reasonably prompt communication with the VA is possible at all times to ensure they are able to communicate to manage their appointments with the VA.

4.10.10 Provide an adequately-sized work station for two (2) VA staff assigned to the facility. The VA will provide all computer equipment needed by VA staff. The work station must afford secure storage of personal staff belongings and confidential documents.

5.0 STANDARDS OF CARE:

5.1 Housing and Services. The Contractor’s housing and other services shall be of a quality, meeting or exceeding currently recognized national standards as established by:

5.1.1 The professional standards of the TJC or equivalent

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

Even if the facility is not accredited by TJC, the TJC standards for Behavioral Health Care for Substance Use Disorders must be met or exceeded.

5.1.2 CARF

http://www.carf.org/Programs/BH/

5.1.3 NICE guidelines

5.1.4 The requirements contained in this PWS

5.2 MEDICAL RECORDS

5.2.1 Authorities: Contractor Personnel providing healthcare services to patients shall be considered as part of the Department Healthcare Activity and shall comply with the U.S.C.551a (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).

5.2.2 Generally, electronic medical records are maintained by VA staff and are not accessible to contractor. A hard copy medication administration record shall be developed by VA staff and utilized to track medication administration occurring at both the VAMC and contractor facility. Within six (6) months of the awarding of the contract, the Contractor will be able to access Veteran electronic Medical Records and use supportive software such as Bar Code Me3dication Administration (BCMA).

5.2.3 Given the necessity of having electronic medical record available at the contracted site, the following stipulations will be enforced for this contract

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.

2. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government 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 must be managed and scheduled for disposition only as permitted by statute or regulation.

3. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law.

Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

4. G.V. Sonny Montgomery VAMC (GVSMVAMC) 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 [Agency] or destroyed except for in accordance with the provisions of the agency records 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 must report to [Agency]. The agency must report promptly to NARA in accordance with 36 CFR 1230.

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 vehicle]. 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 Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. Contractor personnel shall sign VA Form 10-0708 “Employee Clearance from Indebtedness” before resigning or termination from Contractor working for GVSMVAMC and Facility Records Officer must sign form. A copy of completed signed VA Form 10-0708 (Contractor personnel and Facility Records Officer signatures) shall be place in each competency folder. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to [Agency] control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the [contract vehicle]. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

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 Government and [Agency] guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

7. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with GVSMVAMC policy.

8. The Contractor shall not create or maintain any records containing any non-public GVSMVAMC information that are not specifically tied to or authorized by the contract.

9. 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.

10. The GVSMVAMC 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. Government for which GVSMVAC 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 must be identified as required by FAR 52.227-11 through FAR 52.227-20.

11. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take [Agency]-provided records management training.

The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training. TMS (Talent Management System) course VA 4192704: “Records Management for Everyone” [Note: To the extent an agency requires contractors to complete records management training, the agency must provide the training to the contractor.]

12. Flow-down of requirements to subcontractors:

a. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this [contract vehicle], and require written subcontractor acknowledgment of same.

b. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.

5.3. HIPAA: This contract and its requirements meet the exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to a health care provider for treatment. Based on this exception, a BAA is not required for this contract. Treatment and administrative patient records generated by this contract or provided to the Contractor by the VA are covered by the VA system of records entitled ‘Patient Medical Records-VA’ (24VA19). Medication administration logs (and any other 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 his/her expense. Contractor shall deliver all final patient records, correspondences, and notes to the VA within twenty-one (21) calendar days after the contract expiration date.

5.4. Disclosure: Contractor Personnel shall obtain permission from the VA before disclosing any patient information. The VA will provide the Contractor with a copy of VHA Handbook 1907.01, Health Information Management and Health Records and VHA Directive 1605.01, Privacy and Release of Information through links included in section

1.2 herein. The penalties and liabilities for the unauthorized disclosure of patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

5.5. Professional Standards for Documenting Care: Care shall be appropriately documented in medication administration records in accordance with standard commercial practice and guidelines established by VHA Handbook 1907.01 Health Information Management and Health Records (link included in Section 1.2 herein) and all guidelines provided by VAMC. Medication administration entries shall be legible and maintained in detail consistent with good medical and professional practices so as to facilitate internal and external peer reviews, medical audits and follow-up treatments.

Copies of received medical information shall be authenticated (signed) copies. Within six (6) months of the contract being awarded, the contractor will have the capability of completing all documentation including medication administration in the VA electronic medical record.

5.6. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. In the case of the VA authorizing the Contractor to release patient information, the Contractor in compliance with VA regulations, and at his/her own expense, shall use VA Form 3288, Request for and Consent to Release of Information from Individual’s Records, to process “Release of Information Requests.” The VA’s Release of Information Section shall provide the Contractor with assistance in completing forms. Completed Release of Information requests shall be forwarded to the VA Privacy Officer at the applicable VAMC. The VA Privacy Officer information shall be provided at the time of task order award.

5.7. Site Visits: The VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this contract, through one

(1) or a combination of the following methods: reviews of State agenciy reports; on-site inspection of the facility by VA staff; and/or on-site monitoring of VA patients. The facility shall provide the VA with copies of all state agency reports when requested and cooperate fully with VA’s QI or QA program functions relating to the contract, including VA’s onsite inspection and monitoring. The VA CO shall make all final determinations as to the Contractor’s reasonable cooperation with VA compliance with these requirements.

5.8. The Contractor shall designate an individual who can be contacted for any clinical problems or issues that arise during the performance of this contract. The designees for the Government will be the COR’s for this contract.

5.9. Notification of Death of Veterans: In the event of a death of any Veteran, the Contractor agrees to notify VA immediately of the death. In the event a death of a VA beneficiary while receiving care under this contract, the facility shall promptly notify the VA facility which authorized admission and immediately assemble, inventory, and safeguard the patient’s personal effects. The funds, deposits, and effects left by the VA patients upon the premises of the facility shall be delivered by the facility to the person(s) entitled thereto under the laws currently governing the facility for making disposition of funds and effects left by patients, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.

5.10. When disposition has been made, the itemized inventory with annotation as to the disposition of the funds and effects shall be immediately forwarded to the VA facility authorizing admission. Should a deceased patient leave no will, heirs, or next of kin, his/her personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases, the facility shall forward an inventory of any such property and funds in its possession to the VA facility authorizing admission and shall hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition. CMS regulations require retention of records for five (5) years when there is no requirement in State law.

6. ADMINISTRATIVE:

6.1. Quality Improvement Meetings: Contractor Personnel shall participate in continuous quality improvement activities and meetings with committee participation as required by the MH RRTP program managers and Contractor’s establishment.

6.2. Staff Meetings/Rounds: Contractor Personnel shall attend staff meetings as required by the MH RRTP program managers and Contractor’s establishment.

6.3. QA/QI documentation: Contractor Personnel shall complete the appropriate QA/QI documentation pertaining to care as requested by RRTP program managers or other VA representatives.

6.4. Patient Safety Compliance and Reporting: Contractor Personnel shall follow all established patient safety and infection control standards of care. Contractor Personnel 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 reported to the COR in accordance with the VA Safety Policy as soon as practicable (but within twenty-four (24) hours). Contractor Personnel shall notify the COR of the incident and submit to the COR a Patient Safety Report, following up with the COR as required or requested. A copy of the Patient Safety Report will be provided when needed.

7. PERFORMANCE STANDARDS, QUALITY ASSURANCE AND QUALITY IMPROVEMENT

7.1. Quality Management/Quality Assurance Surveillance: Contractor performance will be monitored by the Government using the standards as outlined in this PWS and methods of surveillance detailed in the QASP. The QASP is included as an attachment to this solicitation in Section D and define the methods and frequency of surveillance conducted.

7.1.1. Performance Standards:

7.1.1.1 Measure: Non-Clinical Information Return (Deviation from Routine Care)

Performance Requirement: Clinical information is provided back to the respective residential program (TRP or ADTP).

Standard: Information is provided within twenty-four (24) hours of the event.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection, coinciding with ongoing reviews of maintenance and repair logs during routine facility inspection visits.

Frequency: Periodic Inspection

7.1.1.2 Measure: Access (Bed Availability)

Performance Requirement: An adequate number of beds will be available in a ready state to accommodate MH RRTP admissions.

Standard: Empty beds will be ready for occupancy within two (2) hours of notification by TRP or ADTP.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection, observed through monthly reports from contractor.

Frequency: Monthly

7.1.1.3 Measure: Accreditation

Performance Requirement: Contractor will work with VA MH RRTP in their efforts to maintain accreditation standards of Joint Commission on Accreditation Facilities (CARF), as relevant to contracted services.

Standard: Contractor will comply with Joint Commission and CARF standards as they relate to the VA MH RRTP unit. Contractor will facilitate inspections of the facility and relevant records as requested. Contractor will be responsive to request for corrective action resulting from inspections.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection, by both VA staff and external accrediting bodies (e.g., Joint Commission, CARF).

Frequency: Periodic Inspection

7.1.1.4 Measure: Staff Qualifications

Performance Requirement: Staff employed by the contractor will have continuing education relevant to addictions and trauma.

Standard: Staff will receive a minimum of ten (10) Continuing Education Units per year in areas of substance abuse and trauma. Veteran care staff hired by the contractor will not have participated in a MH RRTP program within the past two (2) years.

Acceptable Quality Level: 90% Surveillance Method: Periodic inspection of staff training and employment records.

Frequency: Periodic Inspection

7.1.1.5 Measure: Veteran Safety - Reporting

Performance Requirement: Veteran safety incidents reported to the respective treatment program (TRP or ADTP) or on-call psychiatrist.

Standard: All incidents reported within one (1) hour of the incident.

Acceptable Quality Level: 90% Surveillance Method: Direct observations and periodic inspection, observed through communication and residential treatment records.

Frequency: Periodic Inspection

7.1.1.6 Measure: Veteran Safety – Incident Resolution

Performance Requirement: All Veteran safety incidents are investigated, confirmed, and resolved.

Standard: Contractor will consult with the appropriate program manager within one (1) business day of the event.

Acceptable Quality Level: 90% Surveillance Method: Reviewed during analysis of critical incidents, routine site inspections, and any accreditation surveys.

Frequency: Periodic Inspection

7.1.1.7 Measure: Veteran Satisfaction

Performance Requirement: Contractor assesses patient satisfaction and solicits complaints and suggestions regarding the quality of care.

Standard: Contractor representative attends monthly stakeholder meeting to receive and respond to feedback. Veteran satisfaction survey is administered by contractor, with results tallied and reported to TRP and ADTP on at least a quarterly basis.

Acceptable Quality Level: 90% Surveillance Method: Attendance at stakeholder meeting. User survey and quarterly roll-up reports that include any qualitative statements from veterans.

Frequency: Periodic Inspection

7.2. Patient Complaints: The COR on an informal level will resolve complaints concerning Contractor relations with Government employees or VA patients. If complaint is not resolved on an informal level, the COR will notify the CO of the complaint officially through a contract report. The CO is the final authority on validating complaints. In the event that Contractor Personnel are involved and named in a validated VA 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.

7.3. 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 handle issues raised concerning Contractor Personnel conduct. The final arbiter on questions of acceptability is the CO.

7.4. Quality Management reports shall be submitted to VAMC on a Quarterly basis.

Reports shall include performance improvement and quality control activities relating to the Contractor’s facility. The COS should be notified of sentinel events as defined by TJC or equivalent, immediately upon occurrence.

7.5. Deliverables: The contractor shall provide the following deliverables as required:

7.5.1.Contractor shall submit a Quality Control Business Plan that supports the program objectives and associated tasks. The CO shall review and comment as necessary to ensure that contract goals are met.

7.5.2.Contractor shall provide a detailed staffing and service plan. Plan should demonstrate that sufficient professional personnel are employed to carry out the policies, responsibilities, and services required under this contract. The Contractor must identify each person functioning as “Key Personnel” under this contract and provide the VA with a description of the services to be provided by each person. The Contractor shall assign to this contract personnel that by education and/or training (and, when required, certification or licensure) are qualified to provide the services required by this PWS. Contractor may be required to supply a resume(s) summarizing relevant skills and experience of any/all key personnel upon request.

7.5.3.The following is a list of mandatory tasks and associated deliverables:

7.5.3.1 Access to the facility(ies) will be restricted to a single access-controlled entrance. Closed circuit video surveillance with recording and review capacity will be utilized to monitor access points and public areas, including any inside or outside locations utilized by Veterans, as requested; does not include private bedrooms or bathrooms. The contractor will provide video surveillance and access-control equipment to meet this requirement. The contractor will be responsible for maintaining and repairing this equipment.

7.5.3.2 All unit entry/egress doors are controlled by keyless entry locks or automatically locking/alarmed doors or overseen by a dedicated individual. The contractor will be responsible for providing and maintaining this equipment.

7.5.3.3 MH RRTP unit signage will be current, visible and will contain visitor, weapon, CCTV, and illicit drug and alcohol policies. The MH RRTP unit will also display current Veteran Crisis Line posters and phone number stickers.