Mock Life Safety-Joint Commission Survey SOW DRAFT.docx

PERFORMANCE WORK STATEMENT (PWS) ACCREDITATION READINESS JOINT COMMISSION SURVEY

Bay Pines VA Healthcare System

DATED: 5/26/2026

I. GENERAL

The following terms discuss the requirements of Contractor delivery of Mock Survey Services. A Mock The Joint Commission (TJC) survey and/or Ascellon shall be conducted at each Bay Pines VA Healthcare System facility to assist in the continuous process improvement and readiness efforts. The Mock Survey process shall be conducted in accordance with “The Joint Commission, Survey Activity Guide for Health Care Organizations All Accreditation Programs,” dated January 2026 or most current version. These surveys shall focus on frequently cited standards, problematic standards, the high-risk areas of, but not limited to, environment of care, life safety and any topics pertinent and chosen by the facility. The survey process shall identify important organizational, and systems issues related to safety, quality of care, and services and interfaces between such processes.

This single survey shall be a 5-day survey. Bay Pines will be allowed 1 Life Safety consultative visit.

Consultants shall use the most recently published TJC Standards, Ascellon standards and other appropriate standards for Hospital, Behavioral Health, Long Term Care, and Home Care.

Each facility shall supply the surveyor with accurate information describing the scope of services provided. The facility shall provide access to those staff members who shall normally be involved in the survey process to allow adequate assessment of standards compliance.

II. OBJECTIVES

a. TJC Standards Compliance including Environment of Care and Life Safety standards.

b. Enhance Continuous Readiness (CR) state.

c. Support concepts of continuous process improvement and High Reliability

d. Enhance staff accreditation survey process knowledge.

e. Increase patient safety.

III. SCOPE

The purpose of this procurement action is to acquire CR services also known as Continuous Readiness standards compliance. The Department of Veterans Affairs (VA) health care facilities have been accredited by TJC for over 35 years. The accreditation process is a complex system of related and interdependent activities which enable the VA to maintain a constant state of regulatory readiness and maintain a safe health care environment. These services shall support Bay Pines (See Attachment A) facilities to enable a CR program to achieve and continue compliance with TJC standards including but not limited to compliance with TJC Program, Environment of Care, and Life Safety standards.

IV. PERFORMANCE PERIOD: One Year

V. LOCATIONS: See Attachment A

VI. DEFINITIONS:

· Contractor: A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

· Contracting Officer: A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

· Contracting Officer's Representative (COR): An employee of the U.S. Government appointed by the contracting officer to administer the contract. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

· Defective Service: A service output that does not meet the standard of performance associated with the Performance Work Statement.

· Deliverable: Anything that can be physically delivered but may include non-manufactured things such as meeting minutes or reports.

· Physical Security: Actions that prevent the loss or damage of Government property.

· Quality Assurance: The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

· Quality Assurance Surveillance Plan (QASP): An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

· Quality Control: All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

VII. ACRONYMS:

· CO - Contracting Officer

· COR - Contracting Officer Representative

· FAR - Federal Acquisition Regulation

· HIPAA - Health Insurance Portability and Accountability Act of 1996

· POC - Point of Contact

· PWS - Performance Work Statement

· QA - Quality Assurance

· QAP - Quality Assurance Plan

· QASP - Quality Assurance Surveillance Plan

· QC - Quality Control

· QCP - Quality Control Program

· TJC - The Joint Commission

· VA - Department Of Veterans Affairs

· VHA - Veterans Health Administration

· VISN - Veteran Integrated Service Network

VIII. CONSULTANT QUALIFICATIONS

a. The Contractor and their Consultants shall possess knowledge of TJC standards, Ascellon standards, and VHA regulations which apply to accreditation bodies.

b. The Consultant shall have experience, education, and knowledge of Life Safety processes.

c. The Consultant shall have a minimum of three years of surveying experience.

d. Consultants shall use the most recently published TJC standards, Ascellon standards and other appropriate standards for Long Term, Care, Behavioral Health, and Home Care.

e. The consultant shall possess the appropriate qualifications of surveyor and consultant experience to include Admin/Life Safety Specialist with previous experience serving as TJC surveyors/consultants and credentials for conducting the surveys. They shall have surveyor/consultant experience and be knowledgeable of the unique challenges faced by VA Medical Centers. The Consultants’ expertise in Ascellon, Hospital, Behavioral Health, and Life Safety and is required. Previous VA experience is preferred. No substitution in surveyors will be permitted without first consulting with the VA contracting officer. If contractors’ performance is less than satisfactory, the VA reserves the right to request a substitute contractor at no additional cost to the VA.

IX. SPECIFIC MANDATORY TASKS AND ASSOCIATED DELIVERABLES

a. Surveys shall be conducted in accordance with “The Joint Commission, Survey Activity Guide for Health Care Organizations All Accreditation Programs,” dated January 2026, or the most current version.

b. Mock Survey shall consist of a 5-day survey as specified by the facility.

c. Date of the survey shall be as directed by each facility.

d. The facility surveys shall be coordinated with the designated point of contact at each site.

e. The survey schedule for each facility and changes shall be provided to the COR in advance.

f. Each facility shall supply the surveyor with accurate information describing the scope of services provided by the facility.

g. The surveyor shall inform facility’s designated point of contact of the activity they will be conducting each day.

h. The facility shall provide access to those staff members who shall normally be involved in the survey process to allow adequate assessment of standards compliance.

i. Each survey shall include an exit briefing.

j. For the five-day survey, 30 minutes shall be scheduled towards the end of each day (except the last) for surveyors to conduct either Special Issue Resolution or engage in surveyor planning or team meeting activity.

k. For three-day surveys, the surveyor will schedule a daily kick-off meeting with organization participants which shall be scheduled for a 30-minute period, where the surveyor shall summarize the events of the previous day and communicate observations according to the standards or areas that may or may not lead to findings.

l. After the facility survey is completed, the surveyor shall schedule an exit conference with the Facility Director and other leadership staff to discuss findings and trends.

m. The survey shall include a survey report preparation session lasting 60-120 minutes in a conference room supplied by the facility, which will include a conference table, power outlets, telephone, and internet access.

n. The survey shall include an Exit Brief lasting 10-15 minutes to discuss the survey findings report.

o. The Government will provide Joint Commission Standards policies and results of previous survey reports.

p. The Contractor shall submit a written report by TJC standard and/or Ascellon within fifteen (15) working days after the site visit. The report shall cite the specific standard of noncompliance, a narrative assessment of noncompliance and specific recommendations for compliance. Any findings that may result in a finding of noncompliance must be clearly identified in the report, along with a recommendation on how best to resolve it. Findings of noncompliance and partial compliance shall be identified in the report. The report shall be submitted in an electronic format in Microsoft Word simultaneously to the Medical Center Director, and the surveyed VISN Quality Management Officer team.

q. The Contractor shall conduct survey business at the facility between the hours of 7:00AM and 5:00PM Monday thru Friday, except federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government-directed facility closings.

All employees of the Contractor shall not be considered VA employees. Survey Team member working on VA property shall be subject to the same rules and regulations as all contracted employees.

The Contractor must maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS when the Government facility is not closed for the above reasons. VA Staff will issue a temporary ID badge to the contracted Surveyor, who will properly display the badge while working onsite. The VA reserves the right to refuse any Surveyor access to the VA property for any or no reason.

The Contractor shall not release, publish, or disclose sensitive information to unauthorized personnel, and shall protect such information in accordance with provisions of 18 U.S.C. 641 (Criminal Code; Public Money, Property or Records) and any other pertinent laws and regulations governing the confidentiality of sensitive information.

X. CONFLICT OF INTEREST

A conflict of interest is defined as the existence of financial or other relationship between the Contractor, (including any of the employees, agents, subcontractors, or representatives) and a party involved under this contract. The Contractor shall promptly notify the presiding official whenever there is a potential or actual conflict of interest between the Contractor and such party. If a potential or actual conflict of interest is reported by the Contractor, the CO reserves the right to have the have the Contractor supply another qualified candidate from their agency to serve as a backup or fill-in replacement surveyor and the Contractor shall bear the full cost of replacing the contracted representative.

XI. QUALITY ASSURANCE SURVEILLANCE PLAN

Determining Performance

Government shall use the monitoring methods cited below to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

Reporting

At the end of the survey the Designated Point of Contact will prepare a written report for the Bay Pines COR and CO summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s final exit brief and will become part of the QA documentation. This will enable the VA to demonstrate whether the contractor is meeting the stated objectives and/or performance standards including cost/technical/scheduling objectives.

Reviews and Resolution

The Bay Pines COR may require the contractor’s project manager, or a designated alternate, to meet with the Bay Pines COR and Designated Point of Contact to discuss performance evaluation for the Contractor, due to the length of each survey. The Contractor performance evaluation will then be provided to the Contracting Officer for inclusion in the CO file.

Contract Oversight

The Bay Pines COR (subject to CO approval), will be responsible for verifying contract compliance. The Bay Pines COR will designate appropriate VA personnel to assist in monitoring services rendered through one or a combination of the following mechanisms:

a. Facilities Designated Point of Contacts will monitor Contractor Performance to ensure that services ordered have been rendered in a timely manner. Any incidents of Contractor noncompliance as evidenced by the monitoring procedures will be forwarded to the Bay Pines COR and administering CO for performance evaluation consideration.

b. Facility Designated Point of Contacts shall provide a written statement at the completion of each survey to the Bay Pines COR to include a summary of contractor actions and a statement that all requirements of the contract have been fulfilled as agreed. This summary evaluation will be submitted within 10 days of the completion of a facility survey.

c. Documentation of services performed will be reviewed prior to certifying payment. Bay Pines COR contract monitoring, and recordkeeping procedures will be sufficient to ensure proper payment and allow audit verification that services were provided.

XII. Performance Standards

The chart below outlines performance objective, standards, quality levels, and surveillance methods that serve as a basic rubric for Contractor Performance evaluation under this contract. Confirmation of these delinquent performances will be made known to the Contractor immediately upon discovery.

of weakness identified

XIII. SECURITY REQUIREMENTS

a. The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract. The position sensitivity for this effort has been designated as LOW.

b. A National Business Associate Agreement (BAA) is required for this contract when awarded.

Attachment A

Bay Pines VA Healthcare System

C.W. Bill Young VAMC 10000 Bay Pines Blvd Bay Pines, FL 33744

(727) 398-6661

(888) 820-0230

North Pinellas CBOC 26286 US Hwy 19 N Clearwater, FL 33761

(727) 734-5276

St Petersburg CBOC 840 Dr MLK Jr St N St. Petersburg, FL 33705

(727) 502-1700

Bradenton CBOC 5520 State Rd 64, #101 Bradenton, FL 34208

(941) 721-0649

Sarasota CBOC 5682 Bee Ridge Rd, #100 Sarasota, FL 34233

(941) 371-3349

Sebring CBOC 2931 New Life Way Sebring, FL 33870

(863) 471-6227

Port Charlotte CBOC 4161 Tamiami Trail, Suite 401 Port Charlotte, FL 33952

(941) 235-2710

Lee County Healthcare Center 2489 Diplomat Pkwy E.

Cape Coral, FL 33909

(239) 652-1800

Naples CBOC 800 Goodlette Rd N, #120 Naples, FL 34101

(239) 659-9188