Mock_Surveys_PWS_(1).pdf

PERFORMANCE WORK STATEMENT

OPERATIONAL ASSESSMENT FOR ARMED FORCES RETIREMENT HOMES (AFRH)

in Washington, DC and Gulfport, MS

1. INTRODUCTION

1.1 The Armed Forces Retirement Home has a requirement of an Operational Assessment (Mock Survey) to be conducted in accordance with current Joint Commission standards, for the Ambulatory Care (Outpatient Care), Home Care (Independent Living Pus), Nursing Care, Life Safety/Environment of Care, Assisted Living Services, Long Term Care Services and Memory Support Services to the Armed Forces Retirement Home. This Mock Survey will also need to provide an Overall Facility Review of procedures, practices and an assessment of, as it relates to, clinical and safety processes.

2 . BACKGROUND

2.1 The Armed Forces Retirement Home (AFRH) with campuses in Washington, DC and in Gulfport, Mississippi is a Continuing Care Retirement Community (CCRC). In 1991, the AFRH became an independent Federal agency under the Executive Branch with the enactment the Defense Authorization Act, Public Law 101-510. This modern retirement community offers Independent Living, Independent Living Plus (Home Care), Assisted Living, Long Term Care and Memory Support to our Nation’s Veterans.

2.2 The AFRH campus in Gulfport, Mississippi provides nursing home services within a single location with a total bed capacity of 600, Assisted Living services up to 38 residents, Long Term Care services up to 24 residents, Memory Support services up to 17 residents, and Independent Living Plus services (Home Care) up to 28 residents.

2.3 The AFRH campus in Washington, DC provides nursing home services within a single location with total bed capacity of 276, Assisted Living services for up to 60 residents, Long Term Care services up to 36 residents, Memory Support services up to 24 residents, and Independent Living Plus services (Home Care) up to 15 residents.

3 . S C O P E

3.1 The vendor shall conduct an On-Site Survey and provide a structured findings report and recommendations in relation to the AFRH’s preparation for Joint Commission Accreditation at the Washington DC, and Gulfport, MS campus locations with a focus on:

• Nursing Care Center,

• Environment of Care/Life Safety,

• Home Care

• Ambulatory Healthcare

• Infection Prevention and Control Program

• Assisted Living

3.2 Services shall include: An assessment of organizational compliance in areas such as leadership, patient safety, infection prevention and control, medication management, emergency management, waived testing, dental services, use of data, and medical staff.

3.3 After mock accreditation survey results have been received by the respective AFRH campus, the vendor will review the facility action plans for mitigation and propose any needed changes to the plan or educational materials needed to better understand the associated standards.

4. REQUIRED SERVICES

4.1 The contractor will conduct an operational assessment (Mock Survey) to prepare AFRH for Joint Commission accreditation in the Ambulatory Care (Outpatient Care), Home Care (Independent Living Plus), Nursing Care, Life Safety/Environment of Care, Assisted Living Services, Long Term Care Services and Memory Support Services. A Mock Survey Findings Report, including identified gaps and recommendations for corrective action, shall be provided upon completion of the mock survey. The assessment shall include:

4.1.1 Compliance with current Joint Commission standards for Nursing Care Centers including additional requirements for Veterans Affairs Community Living Centers (CLCs), the current Comprehensive Accreditation Manual for Ambulatory Care, Assisted Living, and the current Comprehensive Accreditation Manual with Home Care.

4.1.2 Evaluation of current health care operations in relationship to meeting organizational goals of quality and patient safety. This may include virtual/off-site facility and procedural reviews, webinars, telephone conferences, document review and email support.

4.1.3 Utilization of individual and system tracer methodology for evaluation of determined areas of focus and to review direct care processes, across services and disciplines, in key inpatient and outpatient clinical areas and the environment. Information may be gathered by making observations, conducting interviews and reviewing selected documents.

4.1.4 Review of processes, with focus on identified risk points, and development of strategies to minimize these risks.

4.1.5 Identification of important organizational and systems issues related to safety, quality of care, treatment and services and interfaces between those processes.

4.1.6 A written summary of mock survey findings and recommendations will be provided upon completion.

5. STAFFING AND SERVICE REQUIREMENTS

5.1 Staffing - Offeror shall provide names and resumes of Key Personnel proposed to meet the contractual operational assessment services. Resumes shall demonstrate experience, qualifications and years of experience.

5.2 Staffing-Offeror shall provide names and resumes of key personnel proposed to meet the contractual operational assessment services. Resumes shall demonstrate experience and qualifications.

6. PERSONNEL QUALIFICATIONS

6.1 Personnel must be thoroughly knowledgeable in the current Joint Commission standards survey approach developed and tested for application of Nursing Care Services, Ambulatory Care Services, Assisted Living, and Home Care Services to include Life Safety standards.

7. HEALTH REQUIREMENT

7.1 Contractor personnel performing services at AFRH under this contract shall be free of communicable disease. A purified protein derivative test for tuberculosis (PPD) shall be required. If the PPD is negative, a Chest X-ray shall not be required. If the PPD is positive, a Chest X-ray shall be required. The Contractor shall submit documentation of passed procedures. The Contractor shall pay the expenses for all physical examinations/tests required under the provisions of this contract. Copies of employee health records with immunization for Hepatitis, influenza or refusal to obtain such will be made available to AFRH if requested.

8. REQUIRED SERVICES

8.1 Contractor shall not exceed the scope as outlined in this PWS.

8.2 The Contractor staff shall have effective oral and written communications skills in the English language and shall communicate effectively with staff and residents.

9. CONTRACTING OFFICER AUTHORITY

9.1 In no event shall any understanding or agreement between the Contractor and any Government employee other than the Contracting Officer on any contract modifications, change orders, letter or verbal direction to the Contractor be effective or binding upon the Government. All such actions must be formalized by the proper contractual document executed by the appointed Contracting Officer.

9.2 Personnel visiting on site shall observe and comply with all rules and regulations prescribed by the installation authorities concerning fire, safety, sanitation, security, possession of firearms, or other lethal weapons. The Contracting Officer's Representative (COR) will provide copies of applicable local regulations or documents to the contractor upon request, if needed.

10. Conflict of Interest

10.1 The Contractor shall not employ off-duty COR or other Government employees if such employment would create a conflict of interest or be contrary to the policies contained in conflict-of-interest directives utilized by the AFRH and its entities.

11. HIPAA and Other Regulatory Compliance

11.1 Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the National Standards to Protect the Privacy and Security of Protected Health Information (PHI). As required by HIPAA, the Department of Health and Human Services (HHS) has promulgated rules governing the security, use, and disclosure of protected health information by covered entities. Contractor shall be required to be in compliance with all U.S. Laws and DoD regulations regarding sensitive information, patient confidentiality, and information security, as set forth in; Privacy Act of 1974, Computer Security Act of 1987, Clinger Cohen Act of 1996, OMB A-130 Appendix III and VA, VHA Directives 6210, and all other applicable regulations.

12. PERFORMANCE REQUIREMENT SUMMARY (PRS)

12.1 The Contractor service requirements are summarized into performance objectives that relate directly to the mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each service. These thresholds are critical to mission success.

Task # Required Service

Performance Standard

Monitoring Method

Provide survey & consultation services as outlined in the Performance Work Statement (PWS)

100% Perform services in accordance with current The Joint Commission standards.

Delivery of services according to timeline in PWS

12.2 Contractor Quality Control Plan (QCP)

The Contractor shall provide a Quality Control Plan as part of the technical proposal, to include the Offeror’s interpretation, approach to, and methodology of how quality is monitored and controlled to meet the requirements in the PWS. The QCP shall address the quality methodology to meet the Performance Requirements Summary (PR).