Draft PWS _ On Call Vascular Surgery Physician Services Lebanon VAMC.pdf

Revision 05/10/2023 Page 1 of 37

VETERANS HEALTH ADMINISTRATION (VHA)

MEDICAL SHARING/AFFILIATE NATIONAL PROGRAM

OFFICE (MSO)

ONSITE GENERAL SURGERY PHYSICIAN SERVICES

MASTER PACKAGE

INCLUDES:

(1) SCHEDULE OF SERVICES (Page 2)

(2) PERFORMANCE WORK STATEMENT (PWS) (Page 8)

(3) QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

(Page 26)

Revision 05/10/2023 Page 2 of 37

SCHEDULE OF SERVICES

The Contractor shall furnish all key personnel to provide services necessary to perform onsite and on call Vascular Surgery Physician Services to eligible beneficiaries of the Department of Veterans Affairs (VA) Lebanon Medical Center. The Contractor’s physician(s)’ care shall cover the range of Vascular Surgery services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized national standards as established by the American Board of Surgery (ABS): http://www.absurgery.org/default.jsp?cc_gs Place of Performance: Services shall be provided onsite, Lebanon VA Medical Center (LVAMC), 1700 South Lincoln Ave, Lebanon, PA 17042.

The Contractor shall propose a minimum of 1 key personnel to be credentialed and be available for scheduling to meet the requirements of the contract.

http://www.absurgery.org/default.jsp?cc_gs

Revision 05/10/2023 Page 3 of 37

Period of Performance (POP): BASE YEAR: 9/28/2025 to 9/27/2026.

LIN SLIN Description Qty. Unit Unit Cost Total

Annual Cost

0001 None

Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday.

Hours

0001 None

Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630 through Monday 0800 and all Federal Holidays.

Board Certified VASCULAR SURGERY Physician Services

On-Call Vascular Services , Weekday In-house Coverage, up to 40 days per year.

KEY PERSONNEL

None 0001a

Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for after hour coverage 1630-0800, Revision 05/10/2023 Page 4 of 37

OPTION YEAR 1: 9/28/2026 to 9/27/2027

OPTION YEAR 2: 9/28/2027 to 9/27/2028

None 0001b

Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630

None 0001c

Board Certified VASCULAR SURGERY Physician Services

On-Call Vascular Services , Weekday In-house Coverage, TOTAL FOR BASE Hours

LIN SLIN Description Qty. Unit Unit Cost Total

Annual Cost

0001 None

Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday.

Hours

0001 None

Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services up to for all weekends, Friday 1630 through Monday 0800 and all Federal Holidays.

Hours

0001 None

Board Certified VASCULAR SURGERY Physician Services

On-Call Vascular Services , Weekday In-house Coverage, Revision 05/10/2023 Page 5 of 37

OPTION YEAR 3: 9/28/202 to 9/27/2029

Total

Annual Cost

0001 None

Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for after hour coverage 1630-0800, Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630

Board Certified VASCULAR SURGERY Physician Services

On-Call Vascular Services , Revision 05/10/2023 Page 6 of 37

OPTION YEAR 4: 9/28/2029 to 9/27/2030

Total

Annual Cost

0001 None

Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for after hour coverage 1630-0800, Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630

Board Certified VASCULAR SURGERY Physician Services

On-Call Vascular Services , Revision 05/10/2023 Page 7 of 37

Total

Annual Cost

0001 None

Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for after hour coverage 1630-0800, Board Certified VASCULAR SURGERY Physician Services

On Call Vascular Services for up to all weekends, Friday 1630

Board Certified VASCULAR SURGERY Physician Services

On-Call Vascular Services , Revision 05/10/2023 Page 8 of 37

PWS for Onsite General Surgery Physician Services

GENERAL:

1.1. Services Provided: The Contractor shall provide Board Certified Vascular Surgeon on-call and after hours coverage services, in accordance with the specifications contained herein to beneficiaries of the VA and the Lebanon VAMC. The proposed action will allow the LVAMC to maintain its Level Ib Surgical Complexity Level. It will provide on-call coverage in the event of a surgical emergency of a vascular nature.

1.2. Place of Performance: Contractor shall furnish services at the Lebanon VA Medical Center, 1700 South Lincoln Ave, Lebanon, PA 17042.

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

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

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

1.4.2. VHA Directive 1003.04: VHA Patient Advocacy

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

Group Practice

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

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

1.4.6. VHA Directive 1100.20: Credentialing of Health Care Providers

1.4.7. VHA Directive 1100.21: Privileging

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

Care Personnel

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

1.4.10. VHA Directive 1605.01: Privacy and Release of Information

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

Records

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

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

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

1.5. Acronyms/Definitions: Terms used in this contract shall be interpreted as follows unless the context expressly requires a different construction and/or interpretation. In case of a conflict in language between the Definitions and other sections of this contract, the language in this section shall govern.

1.5.1. ABS: American Board of Surgery http://www.absurgery.org/

1.5.2. ACGME: Accreditation Council for Graduate Medical Education

1.5.3. ACLS: Advanced Cardiac Life Support

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

Revision 05/10/2023 Page 9 of 37

1.5.4. AJIC: American Journal for Infection Control

1.5.5. AQL: Acceptable Quality Level

1.5.6. BAA: Business Associate Agreement

1.5.7. BBA: Balanced Budget Act

1.5.8. BLS: Basic Life Support

1.5.9. CDC: Centers for Disease Control and Prevention

1.5.10. CDR: Contract Deficiency Report

1.5.11. CEU: Certified Education Unit

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

1.5.13. CME: Continuing Medical Education

1.5.14. CMP: Civil Monetary Penalty

1.5.15. CMS: Centers for Medicare and Medicaid Services

1.5.16. CO: Contracting Officer: The person executing this contract on behalf of the

Government with the authority to enter into and administer contracts and make related determinations and findings.

1.5.17. COI: Conflict of Interest

1.5.18. COR: Contracting Officer’s Representative: A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance with and adheres to the specifications contained in the contract and to protect the interest of the Government. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken.

1.5.19. COS: Chief of Staff

1.5.20. CPARS: Contractor Performance Assessment Reporting System

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

1.5.22. DEA: Drug Enforcement Agency

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

1.5.24. EPA: Environmental Protection Agency

1.5.25. FAPIIS: Federal Awardee Performance and Integrity Information System

1.5.26. FAR: Federal Acquisition Regulation

1.5.27. FOIA: Freedom of Information Act

Revision 05/10/2023 Page 10 of 37

1.5.28. FPPE: Focused Provider Practice Evaluation

1.5.29. FSMB: Federation of State Medical Boards

1.5.30. 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.

1.5.31. HHS: Department of Health and Human Services

1.5.32. HICPAC: Hospital Infection Practices Advisory Committee

1.5.33. HIPAA: Health Insurance Portability and Accountability Act

1.5.34. IGRA: Interferon-gamma Release Assays

1.5.35. ISO: Information Security Officer

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

1.5.37. MRI: Magnetic Resonance Imaging

1.5.38. MST: Military Sexual Trauma

1.5.39. NPI: National Provider Identifier. NPI is a standard, unique 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).

1.5.40. NPPES: National Plan and Provider Enumeration System

1.5.41. NSO: National Surgery Office

1.5.42. OGC: Office of General Counsel

1.5.43. OIG: Office of Inspector General

1.5.44. OPPE: Ongoing Provider Practice Evaluation

1.5.45. OR: Operating Room

1.5.46. POP: Period of Performance

1.5.47. PPD: Purified Protein Derivative

1.5.48. PPIRS: Past Performance Information Retrieval System

1.5.49. PWS: Performance Work Statement

1.5.50. QA/QI: Quality Assurance/Quality Improvement

1.5.51. QM/PI: Quality Management/Performance Improvement

1.5.52. QASP: Quality Assurance Surveillance Plan

1.5.53. RFP: Request for Proposal

1.5.54. SCS: Specialty Care Services

1.5.55. SSAC: Sole Source Affiliate Contract

1.5.56. TJC: the Joint Commission

1.5.57. TST: Tuberculosis Skin Test

Revision 05/10/2023 Page 11 of 37

1.5.58. USC: United States Code

1.5.59. VA: Department of Veterans Affairs

1.5.60. VA-FSC: VA Financial Services Center

1.5.61. VAAR: VA Acquisition Regulation

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

1.5.63. VHA: Veterans Health Administration

1.5.64. VistA: Veterans Integrated Systems Technology Architecture

2. QUALIFICATIONS:

2.1. Staff/Facility

2.1.1. License: The Contractor’s physician(s) assigned by the Contractor to perform the services covered by this contract shall have a current license to practice medicine in any State, Territory, or Commonwealth of the United States or the District of Columbia) when services are performed onsite on VA property.

All licenses held by the key personnel working on this contract shall be full and unrestricted licenses. Contractor’s physician(s) who have current, full and unrestricted licenses in one or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application will not be considered for the purposes of this contract.

2.1.2. Board Certification: All Contractor’s physician(s) shall be Board Certified by the ABS http://www.absurgery.org/, and 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 on an annual basis for each year of contract performance.

2.1.3. Credentialing and Privileging: Credentialing and privileging is to be done in accordance with the provisions of VHA Directive 1100.20 and VHA Directive

1100.21 referenced above. The Contractor is responsible to ensure that proposed physician(s) possesses the requisite credentials enabling the granting of privileges.

No services shall be provided by any Contractor’s physician(s) prior to obtaining approval by the Facility Medical Executive Board and Medical Center Director.

2.1.3.1. If a Contractor’s physician(s) and/or other contract provider(s) are not credentialed and privileged or has credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government.

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

Revision 05/10/2023 Page 12 of 37 of all educational and training experiences including any gaps in educational history for all Contractor’s physician(s) and Contractor’s physician(s) shall be responsible for abiding by the Facility's Medical Staff By-Laws, rules, and regulations (referenced herein) that govern medical staff behavior.

2.1.5. Continuing Medical Education (CME)/ Certified Education Unit (CEU) Requirements: Contractor shall provide the COR copies of current CMEs as required or requested by the facility. Contractor’s physician(s) registered or certified by national/medical associations shall continue to meet the minimum standards for CME to remain current. Contractor shall report CME hours to the credentials office for tracking. These documents are required for both privileging and re-privileging. Failure to provide shall result in loss of privileges for Contractor’s physician(s).

2.1.6. Training (ACLS, BLS, EHR and VA MANDATORY): Contractor shall meet all VA educational requirements and mandatory course requirements defined herein; all training must be completed by the contractor’s physician(s) as required by the VA.

Other training may become required. VA will communicate any changes to the training requirement to the contractor.

Training Frequency Annual Hours ACLS/BLS Yearly 1 hour

Active Threat Training N/A

Blood Administration:

Complications

N/A

EHR N/A

Government Ethics N/A

Hospice and Palliative Care for VA Clinicians

N/A

Military Sexual Trauma (MST) for Medical Providers

N/A

Moderate Sedation In- Service Training

N/A

PACT Act 2022 Toxic Exposure Screening (TES)

N/A

Patient Abuse N/A

Patient Rights N/A

Patient Safety N/A

Prevention/Management of Disruptive Behavior/Violence Prevention Level I

N/A

Prevention of Workplace Harassment/No Fear Act

N/A

Revision 05/10/2023 Page 13 of 37

Suicide Prevention: Suicide Risk Management Training for Clinicians

N/A

SUX Infection Control and Blood Borne Pathogens

N/A

VA Core Values Training (ICARE Recommitment)

N/A

VA Privacy and Information Security Awareness and Rules of Behavior

Yearly 1 hour

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

N/A

VHA Privacy and HIPAA Focused Training

Yearly 1 hour

VistA Imaging N/A

2.1.7. STANDARD INFECTION CONTROL MEASURES (PPD, IMMUNIZATIONS, ETC.):

Contractor shall provide proof of the following for physicians within five (5) calendar days after contract award and prior to the first duty shift to the COR and CO. Tests shall be current within the past year.

2.1.7.1. TUBERCULOSIS TESTING: Contractor shall provide proof of a negative Tuberculosis Skin Test (TST) or interferon-gamma release assays (IGRA) for all Contractor’s physician(s) upon hire in accordance with CDC guidance.

(This is applicable to all health care workers). A negative chest radiographic report for active tuberculosis shall be provided in cases of positive TST or IGRA results.

2.1.7.2. MEASLES, MUMPS, & RUBELLA TESTING: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}.

2.1.7.3. VARICELLA: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}.

2.1.7.4. ACELLULAR PERTUSSIS: Contractors shall provide proof of 1 dose of Tdap vaccination for all Contractor physicians {This is applicable to all health care workers}.

2.1.7.5. INFLUENZA: Contractors shall provide proof that all Contractor physicians have received the annual Influenza vaccine unless it is contraindicated. If the Contractor physician has a medical contraindication to the vaccine they shall be required to wear a mask during the Influenza season. {This is applicable to all health care workers}.

2.1.7.6. COVID-19: Vaccination required or request an exemption.

2.1.7.7. OSHA REGULATION CONCERNING OCCUPATIONAL EXPOSURE TO

BLOODBORNE PATHOGENS: Contractor shall provide evidence of completing and passing generic self-study blood-borne pathogen training for

Revision 05/10/2023 Page 14 of 37 all Contractor’s physician(s) {This is applicable to all health care workers};

provide their own Hepatitis B vaccination series and hepatitis B surface antigen test results following the hepatitis B vaccination series; maintain an exposure determination and control plan; maintain required records; and ensure that proper follow-up evaluation is provided following an exposure incident.

2.1.7.8. The facility shall notify the Contractor of any significant communicable disease exposures as appropriate. Contractor shall adhere to current CDC/HICPAC Guideline for Infection Control in health care personnel (as published in American Journal for Infection Control - AJIC 1998; 26:289-354 http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf) for disease control.

Contractor shall provide follow up documentation of clearance to return to the workplace prior to their return.

2.1.8. NPI: NPI is a standard, unique 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 NPPES be provided to the CO with the proposal.

2.1.9. DEA: Contractor shall provide copy of current DEA certificate.

2.1.10. Conflict of Interest (COI): The Contractor and all Contractor’s physician(s) are responsible for identifying and communicating to the CO and COR conflicts of interest at the time of proposal and during the entirety of contract performance. At the time of proposal, the Contractor shall provide a statement which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided.

The Contractor shall also provide statements containing the same information for any identified consultants or subcontractors who shall provide services. The Contractor must also provide relevant facts that show how it’s organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest. These statements shall be in response to the VAAR provision 852.209-70 Organizational Conflicts of Interest and fully outlined in response to the subject attachment in Section D of the solicitation document.

2.1.11. Citizenship related Requirements:

2.1.11.1. The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to VA patient referrals.

2.1.11.2. While performing services for the VA, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

Revision 05/10/2023 Page 15 of 37

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 FAR.

2.1.11.3. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the VA may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services VA patient referrals; or other place where the Contractor provides services to veterans who have been referred by the VA; and shall form the basis for termination of this contract for breach.

2.1.11.4. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.

2.1.11.5. The Contractor agrees to obtain a similar certification from its subcontractors.

The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document.

2.1.12. Annual OIG Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the HHS OIG has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs.

2.1.12.1. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed Contractor’s physician(s) are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a Civil Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP’s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries.

2.1.12.2. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractors are and/or firm is not listed as of the date the offer/bid was signed.

2.2. Clinical/Professional Performance: The qualifications of Contractor personnel are subject to review by facility COS or his/her clinical designee and approval by the Medical Center Director as provided in VHA Directive 1100.20 and VHA Directive

1100.21. Clinical/Professional performance monitoring and review of all clinical personnel covered by this contract for quality purposes will be provided by the facility COS and/or the Chief of the Service or his designee. A clinical COR may be appointed, however, only the CO is authorized to consider any contract modification request and/or make changes to the contract during the administration of the resultant contract.

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

Revision 05/10/2023 Page 16 of 37

2.3. Non Personal Healthcare Services: The parties agree that the Contractor and all Contractor’s physician(s) shall not be considered VA employees for any purpose.

2.4. Indemnification: The Contractor shall be liable for, and shall indemnify and hold harmless the Government against, all actions or claims for loss of or damage to property or the injury or death of persons, arising out of or resulting from the fault, negligence, or act or omission of the Contractor, its agents, or employees.

2.5. Prohibition against Self-Referral: Contractor’s physicians are prohibited from referring VA patients to contractor’s or their own practice(s).

2.6. Inherent Government Functions: Contractor and Contractor’s physician(s) shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees (outside a clinical context), selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy.

2.7. No Employee status: The Contractor shall be responsible for protecting Contractor’s physician(s) furnishing services. To carry out this responsibility, the Contractor shall provide or certify that the following is provided for all their staff providing services under the resultant contract:

2.7.1. Workers’ compensation

2.7.2. Professional liability insurance

2.7.3. Health examinations

2.7.4. Income tax withholding, and

2.7.5. Social security payments.

2.8. Tort Liability: The Federal Tort Claims Act does not cover Contractor or Contractor’s physician(s). When a Contractor or Contractor’s physician(s) has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor’s (or Contractor’s physician(s)) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

2.9. Key Personnel:

2.9.1. The VA Full Time Equivalent (FTE) for the services required is 2. (enter the number of VA FTE that the resultant contract will provide hours of service coverage for example 2080 hours = 1.0 VA FTE).

2.9.2. The minimum number of Board Certified Vascular SURGERY physicians required to be onsite daily is 1 to be onsite as defined in paragraph Hours of Operation in this section.

2.9.3. The Contractor shall be responsible for providing coverage to the VA during periods of vacancies of the Contractor’s personnel due to sick leave, personal leave, vacations and additional coverage as required. In the event a scheduled physician is unable to complete an assigned shift, the Contractor shall

Revision 05/10/2023 Page 17 of 37 provide replacement physician coverage within 2 hours and notify the COR immediately of the schedule change.

2.9.4. Personnel Substitutions: During the first ninety (90) calendar days of performance, the Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment.

The Contractor shall notify the CO, in writing, within 15 calendar day(s) after the occurrence of any of these events and provide the information required below.

After 90 days, the Contractor shall submit the information required below to the CO at least 15 calendar days prior to making any permanent substitutions.

2.9.4.1. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO will notify the Contractor within 15 calendar days after receipt of all required information of the decision on the proposed substitutes.

The contract will be modified to reflect any approved changes of key personnel.

2.9.4.2. For temporary substitutions where the key person shall not be reporting to work for 3 consecutive workdays or more, the Contractor shall provide a qualified replacement for the key person. The substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above.

2.9.4.3. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. Should the VA COS or designee show documented clinical problems or continual unprofessional behavior/actions with any Contractor’s physician(s), s/he may request, without cause, immediate replacement of said Contractor’s physician(s). The CO and COR shall deal with issues raised concerning Contractor’s physician(s) conduct.

The final arbiter on questions of acceptability is the CO.

2.9.4.4. Contingency Plan: Because continuity of care is an essential part of Facility’s medical services, The Contractor shall have a contingency plan in place to be utilized if the Contractor’s physician(s) leaves Contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

3. VA HOURS OF OPERATION/SCHEDULING:

3.1. VA Business Hours: On Call Vascular Services: after hour coverage 1630-0800, up to 5 days per week, Monday through Friday, all weekends, Friday 1630 through Monday 0800 and all Federal Holidays and Weekday In-house Coverage, up to 40 days per year.

OR Schedule: On Call services only as outlined in 3.1.

Revision 05/10/2023 Page 18 of 37

3.1.1. If an emergency Vascular event arises as identified by a staff physician;

phone contact will be made within 15 minutes to the contract Vascular Surgeon/s on-call. It is required that the contract provider be on site within 60 minutes of receipt of the phone call. Upon stabilization of the patient and assessment of further needed intervention, the contract provider may decide to transfer the patient to a Non-VA facility for provision of an advanced level of patient care..

3.1.2. Contractor’s physician(s) shall be available and present in clinic during normal Lebanon VAMC clinic hours if needed, which will be established, and may be revised, as deemed appropriate for patient care by the ACOS.

Currently, normal clinic hours are Monday through Friday 8:00 am to 4:30 pm.

1.1. Off-hours Coverage: On Call Vascular Services: after hour coverage 1630-0800, up to 5 days per week, Monday through Friday, all weekends, Friday 1630 through Monday 0800 and all Federal Holidays and Weekday In-house Coverage, up to 40 days per year.

1.1.1.1. On-call Contractor’s physician(s) must be available at all times for phone consultations with VA residents and physicians.

1.1.1.2. On-call providers must be available within 15 minutes by phone and onsite within 60 minutes.

1.2. Federal Holidays: The following holidays are observed by the VA:

• 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.

1.3. Cancellations: If a clinic cancellation is needed, Contractor will provide a contingency plan to see clinic patients withing 5 busines days.

2. CONTRACTOR RESPONSIBILITIES:

Revision 05/10/2023 Page 19 of 37

2.1. Clinical Personnel Required: The Contractor shall provide Contractor’s physician(s) who are competent, qualified per this performance work statement and adequately trained to perform assigned duties.

2.1.1. Contractor’s physician(s) shall be responsible for signing in and out when in attendance. Time sheets will be used by the COR to confirm hours/day and services provided against the contractor’s invoices.

2.2. Standards of Care: The Contractor’s physician(s)’ care shall cover the range of Vascular Surgery services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized the Joint Commission (TJC), VA and national standards as established by:

2.2.1. The ABS http://www.absurgery.org/

2.2.2. The professional standards of TJC:

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

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

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

2.2.4. The requirements contained in this PWS

2.3. Medical Records:

2.3.1. Authorities: Contractor’s physician(s) providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the 5 U.S.C.552a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts 160, 162, and 164

(HIPAA).

2.3.2. HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to: a health care provider for treatment of VA patients. Based on this exception, a BAA is not required for this contract.

Health records generated by this contract or provided to the Contractors by the VA are covered by the VA Privacy Act system of records entitled ‘Patient Medical Records-VA’ (24VA10A7). Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations.

Contractor shall ensure that all records pertaining to medical care and services provided to VA patients are captured in the VA electronic health record system as required by VA policy as discussed in 4.4.4.

2.3.3. Disclosure: Contractor’s physician(s) may have access to patient medical records for the purpose of providing medical care and services to VA patients and performing services under the contract; however, Contractor shall obtain permission from the VA before disclosing any patient information outside VA.

VA authorizes the Contractor to discuss patient health information for coordination of care within community health care providers in compliance with VA regulations, HIPAA and VHA Directive 1605.1, Privacy and Release of Information. The VA will provide the Contractor with a copy of VHA http://www.absurgery.org/ http://www.jointcommission.org/standards_information/standards.aspx http://www.hpoe.org/resources?show=100&type=8 http://www.rms.oit.va.gov/SOR_Records/24VA19.asp http://www.rms.oit.va.gov/SOR_Records/24VA19.asp http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1423 http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1423

Revision 05/10/2023 Page 20 of 37

Directive 1907.01, Health Information Management and Health Records and VHA Directive1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

2.3.4. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Directive 1907.01 Health Information Management and Health Records:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 and all guidelines provided by the facility.

2.3.5. Release of Information: The VA shall maintain control of releasing any copies of patient health information or health records and will follow policies and standards as defined, but not limited to Privacy Act requirements. The Contractor will not release or disclose copies of records and will refer all such requests to the Release of Information Department at the VA facility where assigned.

2.3.6. Management for Medical Records: National Archives and Records Administration record disposition requirements are found in RCS 10-1 Chapter 6, 6000 series.

2.4. Direct Patient Care: Estimated ___% of the time involved in direct patient care.

Contractor shall be responsible for

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

VASCULAR SURGERY Physician care, including, but not limited to:

2.4.1.1. Clinic Responsibilities: Contractor physician(s) shall be present on time for any scheduled clinics/surgeries start times as documented by physical presence in the clinic or OR at the scheduled start time.

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

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

2.4.1.4. Discharge education: Provide discharge education and follow up instructions that are coordinated with the next care setting for all GENERAL SURGERY clinical or surgical patients.

2.4.2. ADMINISTRATIVE: Estimated 0% of time not involved in direct patient care

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

List all meetings, associated time and frequency.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235

Revision 05/10/2023 Page 21 of 37

Meeting Frequency (once a year, etc.)

Annual Hours

Case Conference Monthly, as needed, to present case.

2.4.2.2. Staff Meetings: The Contractor’s physician(s) shall attend staff meetings as required by the facility Chief of Service, COS, or designee. Contractor to communicate with COR on this requirement and report any conflicts that may interfere with compliance with this requirement.

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

2.4.2.4. Patient Safety Compliance and Reporting: Contractor’s physician(s) shall follow all established patient safety and infection control standards of care. Contractor’s physician(s) shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breeches of patient safety shall be documented in the medical record of those impacted and disclosed to the patient or surrogate. As soon as practicable (but within 24 hours) Contractors shall notify COR of incident and submit an entry in the VA Patient Safety Reporting System, following up with COR as required or requested.

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

IMPROVEMENT(QI):

2.5.1. Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance: Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE). Contractor performance will be monitored by the government using the standards as outlined in this PWS and methods of surveillance detailed in the QASP. The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted.

2.5.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. If the Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse.

2.5.3. 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.

Revision 05/10/2023 Page 22 of 37

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.

2.5.4. Performance Standards:

2.5.4.1. Measure: Provider Quality Performance

Performance Requirement: All Contractor’s physician(s) shall perform in accordance with clinical standards Standard: OPPE documentation for all (100%) staff providing services under the contract. All staff (100%) meet Standards AQL: 100% meet Standards Surveillance Method: OPPE data pertinent to care performed for each provider working under this contract. OPPE data will review the following elements:

A. Patient Care Performance B. Medical/Clinical knowledge C. Practiced Based Learning and Improvement D. Interpersonal and Communication Skills E. Professionalism F. System Based Practice Frequency: _Every 12 months__________

2.5.4.2. Measure: Qualifications of Key Personnel

Performance Requirement: All Contractor’s physician(s) shall be Board Certified in accordance with ABS Standards for General Surgery Standard: All (100%) Contractor’s physician(s) are Board Certified.

AQL: 100%

Surveillance Method: Periodic Inspection or Random Sampling of qualification documents Frequency: Every 12 months

2.5.4.3. Measure: Scope of Practice/Privileging

Performance Requirement: Contractor’s physician(s) perform within their individual scopes of practice/privileging Standard: All (100%) Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time AQL: 100% Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time Surveillance Method: Random Sampling of records Frequency: Every 12 months

2.5.4.4. Measure: Patient Access

Revision 05/10/2023 Page 23 of 37

Performance Requirement: The Contractor shall provide Contractor’s physician(s) in accordance with the operating hours and VA clinical schedule outlined in this PWS Standard: All (100%) Contractor’s physician(s) are on time and available to perform services AQL: Contractor’s physician(s) is on-time and available to perform services 100% of the time Surveillance Method: Periodic Inspection of Time and Attendance Sheets Frequency: Monthly

2.5.4.5. Measure: Patient Safety

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

Standard: All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident AQL: 100% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident Periodic Inspection or Random Sampling Frequency: Quarterly

2.5.4.6. Measure: Maintains licensing, registration, and certification Performance Requirement: Updated licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current Standard: All (100%) licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current AQL: 100% licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.

Surveillance Method: Periodic Inspection or Random Sampling Frequency: Every 12 months

2.5.4.7. Measure: Mandatory Training

Performance Requirement: Contractor shall complete all required training on time per facility policy Standard: All (100%) of required training is complete on time by Contractor’s physician(s) AQL: 100% completions Surveillance Method: Periodic Inspection or Random Sampling Frequency: Every Quarter

2.5.4.8. Measure: Privacy, Confidentiality and HIPAA

Revision 05/10/2023 Page 24 of 37

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 physician(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

AQL: 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: Every 12 Months

2.5.5. Registration with Contractor Performance Assessment Reporting System

2.5.5.1. As prescribed in FAR Part 42.15, the VA evaluates Contractor past performance on all contracts that exceed the Simplified Acquisition Threshold and shares those evaluations with other Federal Government 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.

2.5.5.2. Each Contractor whose contract award is estimated to exceed the Simplified Acquisition Threshold requires a CPARS evaluation. A government Focal Point will register your contract within thirty days after contract award and, at that time, you will 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.

2.5.5.3. For contracts with a period of one year or less, the CO will perform a single evaluation when the contract is complete. For contracts exceeding one year, the CO will evaluate the Contractor’s performance annually. Interim reports will be filed each year until the last year of the contract, when the final report will be completed. The report shall be assigned in CPARS to the Contractor’s designated representative for comment. The Contractor representative will have sixty (60) days to submit any comments and re-assign the report to the CO.

2.5.5.4. Failure for the Contractor’s representative to respond to the evaluation within those sixty (60) days, will result in the Government’s evaluation http://www.cpars.gov/

Revision 05/10/2023 Page 25 of 37 being placed on file in the database with a statement that the Contractor failed to respond; the Contractor’s representative will be “locked out” of the evaluation and may no longer send comments.

3. GOVERNMENT RESPONSIBILITIES:

3.1. VA Support Personnel, Services or Equipment: Laptop if needed to maintain remote access.

3.2. Contract Administration/Performance Monitoring: After award of contract, all inquiries and correspondence relative to the administration of the contract shall be addressed to: (enter contract administration if not already listed in another area- list the title (not name) and contact information for COR, Clinical point of contact, and any other relevant personnel involved).

3.2.1. CO…