rfq_12800_hospital_licensing.pdf

REQUEST FOR QUOTES (RFQ) 12800

DEPARTMENT OF HEALTH AND HUMAN SERVICES AGENCY

JOINT COMMISSION AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES

March 5, 2026

SMALL-LOCAL BUSINESS SET-ASIDE: In accordance with Board Policy A-87, the award of contracts resulting from this RFQ is reserved for Small-Local Businesses as defined in Board Policy B-53 Small-Local Business Policy (SLBP), which can be found at: B-53 Small-Local Business Policy (SLBP).

A. KEY INFORMATION

1. The County of San Diego is seeking quotes from firms interested in providing The Joint Commission and CMS survey readiness and compliance consulting services. (“Offerors”).

2. The County anticipates a contract term of an initial (base) period of one (1) year(s), with four (4) 1-year option periods.

3. The County has posted this solicitation on its official BuyNet website at https://sdbuynet.sandiegocounty.gov/ . To see all information related to this RFQ, to submit Questions, and to receive notifications of updates, Offerors must select “Participate in RFx” for this solicitation in BuyNet.

4. The Contracting Officer for this solicitation is Joshua Blandino, Procurement #Name, #Title, ( #email )

5. Schedule: This timeline is subject to change at any time, at the County’s sole discretion. The County will issue an addendum for changes to the Questions due date, or Quote due date.

Event Description Date and Time (San Diego Time) Questions due March 30, 2026, prior to 5:00 p.m.

Quotes due April 6, 2026, prior to 3:00 p.m.

6. Questions:

6.1. Offerors should submit all Questions, including requests for clarification related to definition or interpretation of this RFQ, in writing by the Date and Time specified in the Schedule. Offerors should submit Questions via BuyNet, by sending a message to the Contracting Officer through the “Discussions” functionality.

6.2. Non-Offerors should direct inquiries regarding this solicitation to the Contracting Officer.

7. Table of Contents:

A. Key Information B. RFQ Instructions and Rules C. Submittal Items D. Required Forms E. Statement of Work F. Payment Schedule

ALLEN R. HUNSBERGER

DIRECTOR

DEPARTMENT OF PURCHASING AND CONTRACTING

5560 OVERLAND AVENUE, SUITE 270, SAN DIEGO, CALIFORNIA 92123-1204

PHONE (858) 505-6367 FAX (858) 715-6452

BRENDA MILLER

ASSISTANT DIRECTOR

https://codelibrary.amlegal.com/codes/san_diego/latest/sandiego_board/b_53__small__local__business__policy_(_s_l_b_p) https://sdbuynet.sandiegocounty.gov/

COUNTY OF SAN DIEGO – REQUEST FOR QUOTATIONS (RFQ) 12800

DEPARTMENT HEALTH AND HUMAN SERVICES AGENCY

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 2 of 42 Services Template: rev 9/29/2025 v6.1

G. Draft Agreement

B. RFQ INSTRUCTIONS AND RULES

1. INSTRUCTIONS FOR SUBMITTING A QUOTE

1.1. It is Offeror’s responsibility to submit a quote based on the most current RFQ, addenda thereto, County’s responses to Questions, any other information posted on BuyNet, and any diligence material made available by the County. Offerors are advised to regularly check BuyNet for information. The County has no obligation to contact Offerors directly with any such RFQ-related information.

1.1.1. To see all information related to this RFQ, to submit Questions, and to receive notifications of updates, Offerors must select “Participate in RFx” for this solicitation in BuyNet.

1.1.2. If an Offeror is unable to download this document, an Offeror may request a hard copy from

Department of Purchasing and Contracting’s front desk or contact clerical support at (858) 505- 6367.

1.2. Forms required to be submitted with Offerors response to this RFQ are included in this RFQ or posted on the County’s web site at: https://www.sandiegocounty.gov/content/sdc/purchasing/purchasing-forms.html.

1.2.1. The County may update posted forms from time to time. Unless otherwise specified, Offerors may submit the version of a form in place as of the date of the posting of this RFQ or any later version thereof.

1.3. Offeror must submit a complete original quote in accordance with the format provided in this solicitation to the County of San Diego, Department of Purchasing and Contracting, through electronic upload to BuyNet before the Date and Time listed in Schedule.

1.3.1. If Offeror is unable to submit via BuyNet for any reason, Offeror may submit its quote via email to the Contracting Officer listed in this document or provide the Purchasing and Contracting front desk with either (i) electronic files on CD/DVD; or, (ii) a printed quote. Offeror must prominently mark such submissions with the RFQ number on the outside of the packaging. Please use this method only if unable to submit through BuyNet.

2. QUESTIONS

2.1. Offerors shall direct requests for explanation regarding the RFQ or related documents to the Contracting

Officer, in writing, as a question (“Question”). Offerors may submit Questions by sending a message to the Contracting Officer through the “Discussions” functionality in BuyNet.

2.2. The County may choose not to respond to Questions received after the date and time stated in the Schedule for Question submission. Offeror is responsible for ensuring that Questions are received by the County.

3. QUOTE FORMAT

3.1. Submit electronic quotes as files in .pdf format, except where specified otherwise. For pages other than signature pages, converted and searchable formats are preferred.

3.2. All quotes shall be signed with a handwritten signature by an authorized officer or employee of Offeror.

4. QUOTE ORGANIZATION

4.1. Your quote should be organized in accordance with the Submittal Items in this RFQ.

4.1.1. Offerors shall organize content to correspond to the applicable exhibit and question or item within each exhibit.

4.1.2. Offerors shall separate each exhibit into one or more files, clearly named as to the exhibit and order.

4.1.3. Pages shall be consecutively numbered within each exhibit at the bottom or top margin of each page.

4.1.4. Cost/Price information:

https://www.sandiegocounty.gov/content/sdc/purchasing/purchasing-forms.html https://www.sandiegocounty.gov/content/sdc/purchasing/purchasing-forms.html

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 3 of 42 Services Template: rev 9/29/2025 v6.1

4.1.4.1. Offerors must place all cost and pricing information within the Cost/Price exhibit. Price shall be inclusive of all proposed compensation.

4.2. Confidential/Proprietary information:

4.2.1. The County is a public agency subject to the California Public Records Act, Government Code §

7920.000, et seq. Some or all of the documents submitted in response to this RFQ may be subject to disclosure, and the County intends to publish any resulting contracts to its public website.

4.2.2. It is Offeror’s responsibility to identify and separate into a “CONFIDENTIAL/PROPRIETARY” exhibit and to provide a signed Nondisclosure Indemnification Agreement for:

4.2.2.1. All confidential information that Offeror represents, with legal basis, is exempt from disclosure pursuant to the California Public Records Act, including PI (Personal Information), PII (Personally Identifiable Information), or PHI (Protected Health Information);

4.2.2.2. Any proprietary or other information Offeror represents, with legal basis, is exempt from disclosure under the California Public Records Act and wishes to protect from disclosure.

4.2.3. The “CONFIDENTIAL/PROPRIETARY” exhibit must be clearly labeled with all pages marked as “CONFIDENTIAL/PROPRIETARY.”

4.2.4. Offeror should reference material in the “CONFIDENTIAL/PROPRIETARY” exhibit where it is needed to respond to a Submittal Item through citation to the “CONFIDENTIAL/PROPRIETARY” exhibit (for example “See response 1 contained within the ‘CONFIDENTIAL/PROPRIETARY’ exhibit for staff Social Security numbers”).

4.2.5. If the County determines that a submission improperly designates information as confidential or proprietary, the County may, at its sole discretion: (i) deem the information releasable; (ii) declare the submission non-conforming/non-responsive; (iii) remove such information, or (iv) take any other appropriate action. (Note: Pricing and Terms and Conditions are generally not confidential under the California Public Records Act).

5. QUOTE EVALUATION

5.1. Evaluations may consider factors such as technical merit, experience, capacity, history of Offeror compliance, availability, price, and more to determine the quote(s) that provide the best value to the County.

5.2. During evaluation, the County may appropriately consider the sustainability and social, human health, environmental, and economic impact of Offeror’s proposed products and/or approach to providing goods and/or services, in accordance with Board Policy B-67. Therefore, Offerors are encouraged to include relevant information in their quotes, to the degree related to the goods or services sought.

5.3. During evaluation, the County may appropriately evaluate the cultural competency of Offeror and Offeror’s proposed approach to providing goods and services. Therefore, Offerors are encouraged to include relevant information in their quotes, to the degree related to the goods or services sought.

5.4. When evaluating an Offeror’s cost or pricing, the County may also consider the effect of the quote on the overall total cost to the County.

6. COUNTY COMMITMENT

6.1. This RFQ does not commit the County to award a contract, nor does it commit the County to pay any of

Offeror’s costs incurred in the preparation or submission of the quote. Further, Offeror shall not incur any reimbursable cost in anticipation of a contract award.

6.2. Neither Offeror nor any of its representatives shall have any claims whatsoever against the County or any of its respective officials, agents, or employees arising out of or relating to this RFQ or these procedures (other than those arising under a definitive contract with Offeror in accordance with the terms thereof).

6.3. The County reserves the right to separately procure the same or similar goods or services.

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 4 of 42 Services Template: rev 9/29/2025 v6.1

6.4. The County may withhold all information regarding this procurement until after negotiations are complete, including, but not limited to: the number of quotes received; the identity of Offeror(s); the content of quotes; the County’s evaluation and results thereof. Information releasable after the conclusion of negotiations is subject to the disclosure requirements and withholding exemptions of the California Public Records Act.

6.5. Pursuant to County Charter §§ 703.10 and 916, award of a contract resulting from this RFQ may be subject to the County’s requirement to determine that the services can be provided more economically and efficiently by an independent contractor than by persons employed in the Classified Service.

6.6. In the event that an Offeror is involved in a merger, acquisition, or other change in control, the County reserves the right to award a contract to a resulting entity.

7. DILIGENCE AND DUTY TO INQUIRE

7.1. Should Offeror find discrepancies in or omissions from, or be in doubt as to the meaning of, the RFQ or related documents, Offeror shall have a duty to submit a Question to the County.

7.2. Offerors are expected to perform reasonable due diligence with regard to this RFQ and the work required, including, but not limited to, information that is publicly or otherwise reasonably available and, if applicable, information that can be obtained during a site visit (including verification of measurements, conditions, and other attributes). Neither the selected Offeror(s), nor any Offerors, shall be entitled to any price adjustment or other relief based upon information that was discovered or should have been discovered through due diligence.

7.3. The County makes no representation or warranty, express or implied, as to the accuracy or completeness of any diligence material or other information provided by the County or any of its agents, representatives, contractors, or consultants. Such information may reflect good faith assumptions, estimates, or projections, which may or may not prove to be correct.

7.4. Offeror should not rely upon oral statements made or explanations given by the County, including any oral responses to Questions or other inquiries. No prior, current, or post award communication(s) with any officer, agent, or employee of the County shall affect or modify any terms or requirements of this RFQ, except as explicitly provided for in this RFQ.

8. OFFEROR COMMUNICATIONS

8.1. All communications from Offeror (including its employees, agents, and representatives) to the County or its officers and employees (including consultants working on or assisting with this procurement), related to this RFQ or Offeror’s quote, must be directed in writing exclusively to the Contracting Officer, unless otherwise authorized in writing by the Contracting Officer. Offerors shall not communicate with or attempt to contact any other County personnel about this solicitation, except as otherwise allowed for in this RFQ or by law. Any improper contact may, at the County’s sole discretion, cause Offeror to be removed from consideration for contract award.

8.2. If Offeror issues any public announcement or otherwise engages in communication that, in the County’s sole determination, compromises the integrity of this RFQ process or attempts to restrain competition, Offeror may be removed from consideration for award.

8.3. Audio and/or video recording of presentations, discussions, negotiations, or other communications with the County regarding this RFQ are prohibited, unless specifically authorized in writing by the Contracting Officer.

9. SOLICITING EMPLOYEES

9.1. Until contract award, Offerors shall not, directly or indirectly, solicit any employee of the County to leave the County’s employ in order to accept employment with Offeror, its affiliates, actual or prospective contractors, or any person acting in concert with Offeror without prior written approval of the County’s Contracting Officer. This paragraph does not prevent the employment by Offeror of a County employee who has initiated contact with Offeror.

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 5 of 42 Services Template: rev 9/29/2025 v6.1

10. PROHIBITED CONTRACTS AND SUBCONTRACTS

10.1. In accordance with Section 67 of the San Diego County Administrative Code, the County shall not contract with, and shall reject any quote submitted by, the person or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract:

10.1.1. Persons employed by the County or of public agencies for which the Board of Supervisors is the governing body;

10.1.2. Profit-making firms or businesses in which employees described in subsection 11.1.1 serve as officers, principals, partners, or major shareholders;

10.1.3. Persons who, within the immediately preceding twelve (12) months, came within the provisions of subsection 11.1.1 and who (i) were employed in positions of substantial responsibility in the area of service to be performed by the contract; or, (ii) participated in any way in developing the contract or its service specifications; and

10.1.4. Profit-making firms or businesses in which the former employees described in subsection 11.1.3 serve as officers, principals, partners, or major shareholders.

10.2. Per Board Policy A-79, a successful Offeror that is a non-profit corporation shall not subcontract any work under the agreement with a related for-profit subcontractor where an interlocking directorate, management, or ownership relationship exists, unless specifically authorized by the Board of Supervisors.

10.3. Offeror certifies that, if awarded a contract under this RFQ, such contract will be in compliance with Sections 11.1 and 11.2 above. Offeror shall promptly notify the County of any change in circumstance affecting these provisions.

11. CALIFORNIA REVENUE & TAXATION CODE § 18662

11.1. In compliance with California Revenue and Taxation Code § 18662, if Offeror is a non-resident of

California (out-of-state invoices) that receives California source income and has not completed Franchise Tax Board Form 590, there may be a backup withholding on all payments. Fifteen (15) business days prior to the first payment from the County, new suppliers or suppliers with expired forms or forms with incorrect information must submit new forms to the County (forms are available from the Franchise Tax Board website listed below).

11.2. Under certain circumstances, Offerors may be eligible for reduced or waived nonresident withholding. If Offeror has already received a waiver or a reduced withholding response from the State of California and the response remains valid, Offeror should submit the response to the County in lieu of the forms. Failure to submit the required forms will result in withholding of payments. Offerors should access the Franchise Tax Board websites, listed below, for tax forms and relevant information regarding non-resident withholding, including waivers or reductions. The County will not give Offerors any tax advice. It is recommended that Offerors speak with their tax advisers and/or the State of California for guidance.

Franchise Tax Board Websites:

https://www.ftb.ca.gov https://www.ftb.ca.gov/forms/search/

11.3. If selected for award, Offeror must submit applicable forms to the Auditor & Controller via fax, at (858) 694-2060, or mail originals to: County of San Diego, 5530 Overland Avenue, Suite 410, San Diego, CA 92123. The P.O. Number or Contract Number (if available) and “California Revenue and Taxation Code § 18662” must appear on fax cover sheet and/or the outside of the mailing envelope.

12. W-9 FORM

12.1. If selected for award, Offeror must complete and submit a W-9 form if a current form is not on file with the County.

C. SUBMITTAL ITEMS

Offeror’s response to these Submittal Items shall be no more than 5 pages.

https://www.ftb.ca.gov/ https://www.ftb.ca.gov/forms/search/

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 6 of 42 Services Template: rev 9/29/2025 v6.1

1. EXHIBIT 1 - REQUIRED FORMS

1.1 Submit a completed and signed Offeror’s Cover Page (PC600) form

• Required for all Offerors

• located at:

https://www.sandiegocounty.gov/content/dam/sdc/purchasing/docs/PC600_dpc_Offerors_Cover_Page.pdf

1.2 Submit a completed and signed Representations and Certifications form (PC601)

• Required for all Offerors

• located at:

https://www.sandiegocounty.gov/content/dam/sdc/purchasing/docs/PC601_dpc_Reps_and_Certs.pdf

Submit a completed and signed Nondisclosure Indemnification Agreement (PC620) (if applicable).

• Required if submitting Confidential/Proprietary Information (see RFQ Instructions and Rules section 4.2)

• located at:

https://www.sandiegocounty.gov/content/dam/sdc/purchasing/docs/PC620_dpc_Nondisclosure_Indemnity.pdf

2. EXHIBIT 2 - PROGRAM/TECHNICAL EXHIBIT

(RESERVED)

3. EXHIBIT 3 - COST/PRICE EXHIBIT

3.1 Submit a completed Payment Schedule

4. EXHIBIT 4 – ACCEPTANCE OF TERMS AND CONDITIONS

4.1 Confirm acceptance “YES/NO” of the County of San Diego’s Draft Agreement (including insurance requirements):

YES ☐ NO ☐

4.1.1 If “NO,” provide a detailed list of exceptions to the terms and conditions, the nature of its concern, and what terms the Offeror is willing to accept.

Note: The Offeror will be deemed to have accepted any terms and conditions of the Contract to which it does not take exception to. The County may, as part of its evaluation process, conclude that exceptions are so numerous and/or material as to make Offeror’s response to the solicitation unacceptable.

5. EXHIBIT 5 – CONFIDENTIAL PROPRIETARY

5.1 Include any Confidential/Proprietary Information in this exhibit, in accordance with RFQ Instructions and Rules section 4.2

D. REQUIRED FORMS

(RESERVED)

https://www.sandiegocounty.gov/content/dam/sdc/purchasing/docs/PC600_dpc_Offerors_Cover_Page.pdf https://www.sandiegocounty.gov/content/dam/sdc/purchasing/docs/PC601_dpc_Reps_and_Certs.pdf https://www.sandiegocounty.gov/content/dam/sdc/purchasing/docs/PC620_dpc_Nondisclosure_Indemnity.pdf

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 7 of 42 Services Template: rev 9/29/2025 v6.1

E. STATEMENT OF WORK

1. Scope of Work/Purpose Contractor shall provide survey readiness, consultation, training, mock surveys, and corrective action support to assist the County in maintaining current and ongoing compliance at the San Diego County Psychiatric Hospital (SDCPH) and Edgemoor Distinct Part Skilled Nursing Facility (Edgemoor DPSNF). Services shall address applicable and current The Joint Commission (TJC) Hospital Accreditation Standards; Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and Requirements of Participation (RoPs);

Department of Health Care Services (DHCS), California Department of Public Health (CDPH) licensing requirements; Title 22 of the California Code of Regulations (CCR); and any successor, amended, or newly applicable federal or state requirements, as applicable to each facility, program, and service line. Services shall also address applicable Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness requirements, including 42 CFR §482.15 (Hospitals) and 42 CFR §483.73 (Skilled Nursing Facilities), and any successor, amended, or replacement requirements, as applicable to each facility.

2. Background Information

2.1. The San Diego County Psychiatric Hospital (SDCPH) is a locked, free-standing, state-licensed acute psychiatric hospital with a crisis stabilization unit and an emergency department. SDCPH is accredited by The Joint Commission (TJC), certified by the Centers for Medicare & Medicaid Services (CMS), and designated under the Lanterman-Petris-Short (LPS) Act. The hospital provides 24/7 care for individuals aged 18 and older experiencing mental health crises, including acute psychiatric emergency services, patient stabilization, and transition to less restrictive levels of care, supported by dedicated medical, nursing, and ancillary staff.

SDCPH delivers approximately 14,000 inpatient bed days annually. SDCPH may expand its existing services to include additional long-term levels of care in the future.

2.2. Edgemoor is a County-operated distinct-part skilled nursing facility (DPSNF) serving adults aged 18 and older who require a higher level of care and increased staffing due to complex physical, cognitive, and/or behavioral health needs. Nearly all residents require long-term care. Edgemoor has a licensed capacity of 192 beds, primarily serves individuals covered by Medi-Cal, and is licensed by the California Department of Public Health (CDPH). The facility operates in conjunction with SDCPH under the County’s hospital license structure. Edgemoor also operates, and may expand, specialized programs including a 12-bed Acute Psychiatric Program (APH) and other inpatient psychiatric or specialty services.

2.3. Both SDCPH and Edgemoor are subject to evolving and overlapping federal, state, and local regulatory and accreditation requirements, including, but not limited to, CMS Conditions of Participation and Requirements of Participation; The Joint Commission standards, as applicable; California Health and Safety Code; Title 22 CCR; CDPH licensing requirements and guidance; LPS statutory and regulatory requirements; and other applicable or successor laws, regulations, or accreditation standards governing acute psychiatric hospitals, acute psychiatric programs, and skilled nursing facilities. Contractor services shall address current and future requirements, including circumstances in which federal and state standards overlap, diverge, or change over time. Such programs may require additional or modified licensure, certification, approvals, or oversight, and may necessitate expanded survey readiness, regulatory compliance support, and consulting services during the term of the contract

2.4. SDCPH utilizes The Joint Commission accreditation for deemed status purposes under CMS regulations.

Maintaining compliance with current and future CMS and TJC requirements, as well as applicable state licensing and oversight requirements, supports the hospital’s CMS certification, accreditation status, and the County’s quality, patient safety, and regulatory compliance programs.

2.5. Live Well San Diego Vision: The County of San Diego, Health and Human Services Agency (HHSA), supports the Live Well San Diego vision of Building Better Health, Living Safely, and Thriving. Live Well San Diego, developed by the County of San Diego, is a comprehensive, innovative regional vision that combines the efforts of partners inside and outside County government to help all residents be healthy, safe, FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 8 of 42 Services Template: rev 9/29/2025 v6.1 and thriving. All HHSA partners and contractors, to the extent feasible, are expected to advance this vision.

Building Better Health focuses on improving the health of residents and supporting healthy choices. Living Safely seeks to ensure residents are protected from crime and abuse, neighborhoods are safe, and communities are resilient to disasters and emergencies. Thriving focuses on promoting a region in which residents can enjoy the highest quality of life.

Information about Live Well San Diego can be found on its website dedicated to the vision:

http://www.LiveWellSD.org

2.6. A Trauma-Informed System: The County of San Diego Health and Human Services Agency (HHSA) is committed to becoming a Trauma-Informed System as part of its effort to build a better service delivery system. All programs operated and supported by HHSA shall be part of a Trauma-Informed System, which includes providing trauma-informed services and maintaining a trauma-informed workforce. It is an approach for engaging individuals – staff, clients, partners, and the community – and recognizing that trauma and chronic stress influence coping strategies and behavior. Trauma-informed systems and services minimize the risk of re-traumatizing individuals and/or families, and promote safety, self-care, and resiliency.

Trauma-Informed Principles include:

• Understanding trauma and its impact to individuals;

• Promoting safety;

• Awareness of cultural, historical, disability, and gender issues, and ensuring competence and responsiveness;

• Supporting consumer empowerment, control, choice, and independence;

• Sharing power and governance (e.g. including clients and staff at all levels in the development and review of policies and procedures);

• Demonstrating trustworthiness and transparency;

• Integrating services along the continuum of care;

• Believing that establishing safe, authentic, and positive relationships can be healing;

• Understanding that wellness is possible for everyone

3. Goals/Outcomes and Objectives

3.1. Goals: Consultant(s) shall conduct mock surveys at SDCPH to ensure continuous readiness for Joint Commission (TJC) accreditation and Centers for Medicare & Medicaid Services (CMS) certification. At Edgemoor, Consultant(s) shall provide targeted education, consultation, and licensing support services to prepare for the opening of the new inpatient unit and to strengthen survey readiness in identified areas; upon request, Consultant may conduct mock surveys at Edgemoor.

3.2. Outcomes:

3.2.1. Consultant(s) services shall result in:

3.2.1.1. Analyzed gaps in hospital policies, procedures, and practices against regulations.

3.2.1.2. Continued compliance with The Joint Commission Accreditation Participation

Requirements (APR), as applicable to SDCPH.

3.2.1.3. Strengthened compliance with TJC standards at SDCPH, including, but not limited to:

3.2.1.3.1. Physical Environment (PE) (including NFPA 101 Life Safety Code and related fire, life safety, and utility systems requirements)

3.2.1.3.2. Emergency Management (EM)

3.2.1.3.3. Human Resources (HR)

3.2.1.3.4. Infection Prevention and Control (IC)

http://www.livewellsd.org/

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 9 of 42 Services Template: rev 9/29/2025 v6.1

3.2.1.3.5. Information Management (IM)

3.2.1.3.6. Leadership (LD)

3.2.1.3.7. Medication Management (MM)

3.2.1.3.8. Medical Staff (MS)

3.2.1.3.9. National Performance Goals (NPG)

3.2.1.3.10. Nursing (NR)

3.2.1.3.11. Provision of Care, Treatment, and Services (PC)

3.2.1.3.12. Performance Improvement (PI)

3.2.1.3.13. Record of Care (RC)

3.2.1.3.14. Rights & Responsibilities (RI)

3.2.1.3.15. Transplant Safety (TS), as applicable

3.2.1.3.16. Waived Testing (WT), as applicable

3.2.1.3.17. PE readiness support across both facilities shall include focused ligature risk assessment support and Life Safety drawings review.

3.2.1.4. Strengthened compliance with CMS and CDPH standards at Edgemoor. Enhanced readiness at Edgemoor through licensing support, staff education, and targeted consultation services in anticipation of the new inpatient unit and current operations.

3.3. Objectives: SDCPH and Edgemoor are subject to different, but overlapping, accreditation, certification, and licensing oversight requirements. Consultant(s) shall assist in identifying compliance gaps and provide on-site services to SDCPH and Edgemoor, as applicable, including:

3.3.1. Identifying organizational and system-wide issues affecting safety, quality of care, treatment, and service delivery, including systemic risks, process interfaces, and recommended mitigation strategies.

3.3.2. Observing, assessing, and evaluating health care operations against organizational quality and patient safety goals, and providing a written summary of observations with improvement recommendations.

3.3.3. For SDCPH: Assessing compliance with the most current Joint Commission Hospital Accreditation

Standards, including applicable National Performance Goals (NPGs), and applicable Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) and other federal or state certification requirements applicable to psychiatric hospitals.

3.3.4. For Edgemoor: Assessing compliance with applicable Centers for Medicare & Medicaid Services (CMS) skilled nursing facility Requirements of Participation (42 CFR Part 483), Title 22 of the California Code of Regulations (CCR), CDPH licensing requirements, and other federal or state licensing and certification requirements applicable to distinct-part skilled nursing facilities.

4. Specific Requirements for Service Delivery

4.1. Survey Readiness Activities

4.1.1. Mock Surveys:

4.1.1.1. Consultant(s) shall conduct a minimum of two (2) mock surveys per contract year at

SDCPH, simulating a TJC/CMS survey environment using tracer methodology, SAFER® Matrix scoring, direct observations, document reviews and staff interviews.

4.1.1.1.1. Mock surveys shall be conducted at approximately six (6) month intervals.

4.1.1.1.2. Upon request, Consultant may conduct mock surveys at Edgemoor to review for applicable licensing and certification readiness.

4.1.1.2. Consultant(s) shall be onsite a maximum of four (4) days per contract year, consisting of:

two (2) days for Behavioral Health/Clinical capacity, and two (2) days for Physical

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 10 of 42 Services Template: rev 9/29/2025 v6.1

Environment capacity. Consultant(s) shall assess the hospital’s organizational approach using tracer methodology in alignment with the most current TJC standards, including leadership, patient safety, clinical care, Physical Environment, ligature risk, workplace violence prevention, infection prevention and control, medication management, emergency management, data use and medical staff functions through interactive conferences, based on organization-specific agendas.

4.1.1.2.1. Review of workplace violence prevention shall be limited to survey-readiness evaluation of policies, training and implementation as required by applicable accreditation and regulatory standards, and shall not constitute a comprehensive Cal/OSHA compliance audit, unless expressly authorized by the COR.

4.1.1.3. Behavioral Health/Clinical Mock Survey (Annual):

4.1.1.3.1. Consultant(s) shall conduct one (1) clinical focused mock survey annually addressing:

• Physical Environment (PE)

• Emergency Management (EM)

• Human Resources (HR)

• Infection Prevention and Control (IC)

• Information Management (IM)

• Leadership (LD)

• Medication Management (MM)

• Medical Staff (MS)

• National Performance Goals (NPG)

• Nursing (NR)

• Provision of Care, Treatment, and Services (PC)

• Performance Improvement (PI)

• Record of Care (RC)

• Rights & Responsibilities (RI)

• Transplant Safety (TS)

• Waived Testing (WT)

4.1.1.4. Consultant(s) shall provide consultative guidance and education based on regulatory requirements and evidence-based, best practice in the community including:

4.1.1.4.1. Daily debrief summaries highlighting observations, staff feedback, and immediate corrective actions

4.1.1.4.2. Final out-brief upon completion of the mock survey

4.1.1.4.3. Written report due within ten (10) business days of completion

4.1.1.5. Physical Environment (PE) Mock Survey (Annually) addressing:

4.1.1.5.1. Consultant(s) shall conduct one (1) PE focused mock survey annually, including NFPA 101 Life Safety Code and related fire, life safety, and utility systems requirements, addressing:

4.1.1.5.2. Physical Environment (PE)

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 11 of 42 Services Template: rev 9/29/2025 v6.1

4.1.1.5.3. Emergency Management

4.1.1.5.3.1. Review shall include evaluation of emergency preparedness programs in alignment with CMS Emergency Preparedness requirements, TJC standards, and applicable hospital or SNF emergency operations plans, including exercises, after-action reporting and corrective action tracking.

4.1.1.5.4. Review of relevant policies, procedures and hospital plans

4.1.1.5.5. Physical plant/environment inspections

4.1.1.5.6. Review of Life Safety drawings

4.1.1.5.7. Utility and emergency management systems

4.1.1.5.8. Ligature risk assessments and mitigation strategies

4.1.1.6. Consultant(s) shall provide consultative guidance and education including:

4.1.1.6.1. Daily debrief summaries highlighting observations, staff feedback, and immediate corrective actions

4.1.1.6.2. Final out-brief upon completion of the mock survey

4.1.1.6.3. Written report due within ten (10) business days of completion

4.1.1.6.4. Offer coaching for Senior Leadership and department leaders

4.1.1.6.5. Advise on sustaining readiness beyond survey preparation

4.1.2. TJC Survey Support

4.1.2.1. Consultant(s) shall provide rapid response availability during actual TJC/CMS survey week as requested by the COR.

4.1.3. Post Survey Readiness Activities

4.1.3.1. Consultant(s) shall be available to assist in drafting and developing the Plans of Correction (PoC) and Evidence of Standards Compliance (ESC) following any survey, in coordination with the COR.

4.2. Additional Consultation:

4.2.1. Consultant(s) may be asked to provide additional compliance related consultation. Upon COR approval, Consultant(s) may charge the hourly rate as specified on Exhibit C

5. Reports

5.1. Within ten (10) business days of each mock survey, Consultant(s) shall submit a written report to the COR and designated hospital leadership, including at minimum the following elements:

5.1.1. Findings related to areas of compliance and strength.

5.1.2. Findings related to areas of non-compliance, vulnerabilities, or risks.

5.1.3. Joint Commission accreditation standards compliance findings with risk rating and action recommendations.

5.1.4. NPG compliance findings with risk rating and action recommendations.

5.1.5. Assigned risk level for each finding (high, medium, low).

5.1.6. Responsible owner/department assigned to each finding.

5.1.7. Due dates and evidence required for corrective actions.

5.1.8. Recommendations for corrective actions and process improvement strategies.

5.1.9. Process improvement tools and methodologies to support survey preparation.

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 12 of 42 Services Template: rev 9/29/2025 v6.1

5.1.10. Any additional observations or information requested by the COR or hospital leadership.

5.2. Reports shall be submitted electronically in Word and/or PDF format as directed by the COR.

5.3. Reports and findings shall be suitable for use in Governing Body review, Quality Assessment and

Performance Improvement (QAPI) activities, regulatory response, and accreditation readiness tracking.

6. Consultant Requirements:

6.1. Qualifications Summary: Consultant(s) shall possess the education, experience, and professional expertise necessary to provide Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS) survey readiness services. At a minimum, Consultant(s) shall demonstrate relevant academic preparation, clinical and quality experience in hospital or behavioral health settings, specialized knowledge of TJC and CMS survey compliance, and the ability to apply tracer methodology, risk assessment, and safety practices in accordance with current standards and hospital requirements. Consultant(s) utilized at Edgemoor DPSNF shall have above qualification in addition to proficiency in California skilled nursing facility regulations.

6.2. Education:

6.2.1. Consultant(s) shall have a Bachelor’s degree in a relevant field (e.g., Healthcare Administration, Nursing, Public Health, or Business) is required. A Master’s degree is preferred.

6.3. Experience:

6.3.1. Consultant(s) shall have a minimum of three (3) years of clinical or quality experience in a hospital or behavioral health setting.

6.3.2. Consultant(s) shall have at least three (3) years of experience in TJC/CMS survey readiness and compliance, or experience as a TJC/CMS surveyor or consultant.

6.3.3. Experience with behavioral health specific risks (ligature, crisis interventions, etc.) is strongly preferred.

6.4. Tracer Methodology and Risk Review:

6.4.1. Consultant(s) shall utilize individual and system tracers to evaluate direct care processes across services and disciplines, including the physical environment. Information shall be collected through observations, staff interviews, and document reviews.

6.4.2. Consultant(s) shall apply tracer methodology to assess organizational processes and practices as they relate to TJC and CMS survey compliance.

6.4.3. Consultant(s) shall review processes, identify risk points, and recommend strategies to minimize risks.

6.5. Safety and Compliance

6.5.1. Consultant(s) shall follow the hospital’s current practices related to providing safe care and maintaining a safe environment and shall demonstrate ongoing knowledge of and remain continually updated on the most current editions of TJC and CMS standards, including all changes effective during the contract term.

7. Scheduling / Coordination:

7.1. Mock survey dates shall be scheduled in coordination with the COR at least fifteen (15) days in advance.

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 13 of 42 Services Template: rev 9/29/2025 v6.1

F. PAYMENT SCHEDULE

1. Pricing is firm fixed and unit price should be all inclusive, but less travel which will be reimbursed as explained in section 2 below.

2. Per Diem: Subject to COR approval, if travel is required and if approved, such travel will be paid as a firm fixed price, upon completion of the trip, at current GSA rates for meals and lodging, with other expenses itemized at actual costs (e.g., applicable airfare limited to coach class and applicable car rental limited to economy class). Not to Exceed $2,500 per Consultant per Contract Year. $5,000 maximum Contract Total of Per Diem per Contract Year.

INITIAL TERM

DESCRIPTION

Annual Estimated Quantity

Unit of Measure

Unit Price

Total Annual Estimated Costs

Biannual Mock Hospital Survey - Six Month Intervals

1. Two (2) days onsite with a Behavioral Health consultant, and written consultation report.

2 EACH $ $

2. Two (2) days onsite with an Environment of Care consultant, and written consultation report.

2 EACH $ $

Biannual Onsite Consultation - Six Month Intervals

3. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

4. Two (2) days onsite with an Environment of Care consultant, and written consultation report.

2 EACH $ $

Initial Contract Term Subtotal (Transfer to Pricing Summary) $

Per Diem Initial Contract Term Subtotal (Transfer to Pricing Summary) $

Initial Contract Term Grand Total $

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

Contract: ###### Page 14 of 42 Services Template: rev 9/29/2025 v6.1

COUNTY OPTION YEAR 1

Biannual Mock Hospital Survey - Six Month Intervals

5. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

6. Two (2) days onsite with an Environment of Care consultant, and written consultation report.

2 EACH $ $

Biannual Onsite Consultation - Six Month Intervals

7. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

8. Two (2) days onsite with an Environment of Care consultant, and written consultation report.

2 EACH $ $

County Option Year 1 Subtotal (Transfer to Pricing Summary) $

Per Diem County Option Year 1 Subtotal (Transfer to Pricing Summary) $

County Option Year 1 Grand Total $

COUNTY OPTION YEAR 2

9. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

10. Two (2) days onsite with an Environment of Care consultant, and written consultation report. 2 EACH $ $

Biannual Onsite Consultation - Six Month Intervals

11. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

12. Two (2) days onsite with an Environment of Care consultant, and written consultation report. 2 EACH $ $

County Option Year 2 Subtotal (Transfer to Pricing Summary) $

Per Diem County Option Year 2 Subtotal (Transfer to Pricing Summary) $

County Option Year 2 Grand Total $

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 15 of 42 Services Template: rev 9/29/2025 v6.1

COUNTY OPTION YEAR 3

13. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

14. Two (2) days onsite with an Environment of Care consultant, and written consultation report. 2 EACH $ $

Biannual Onsite Consultation - Six Month Intervals

15. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

16. Two (2) days onsite with an Environment of Care consultant, and written consultation report. 2 EACH $ $

County Option Year 3 Subtotal (Transfer to Pricing Summary) $

Per Diem County Option Year 3 Subtotal (Transfer to Pricing Summary) $

County Option Year 3 Grand Total $

COUNTY OPTION YEAR 4

17. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

18. Two (2) days onsite with an Environment of Care consultant, and written consultation report. 2 EACH $ $

Biannual Onsite Consultation - Six Month Intervals

19. Two (2) days onsite with a Behavioral Health consultant, and written consultation report. 2 EACH $ $

20. Two (2) days onsite with an Environment of Care consultant, and written consultation report. 2 EACH $ $

Hourly Consultation - As Needed

21. Hourly Rate for Survey Consultation Hourly EACH $

22. Hourly Rate for Medical Staff Support Consultation Hourly EACH $

County Option Year 4 Subtotal (Transfer to Pricing Summary) $

Per Diem County Option Year 4 Subtotal (Transfer to Pricing Summary) $

County Option Year 4 Grand Total $

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

Contract: ###### Page 16 of 42 Services Template: rev 9/29/2025 v6.1

PRICING SUMMARY

TERM Term Subtotal Per Diem Subtotal Annual Contract

Maximum (Not to Exceed)

Initial Contract Term: Date of Award – March 31, 2027 $ $ $ County Option Year 1: April 1, 2027 – March 31, 2028 $ $ $ County Option Year 2: April 1, 2028 – March 31, 2029 $ $ $ County Option Year 3: April 1, 2029 – March 31, 2030 $ $ $ County Option Year 4: April 1, 2030 – March 31, 2031 $ $ $

TOTAL CONTRACT MAXIMUM AMOUNT $

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 17 of 42 Services Template: rev 9/29/2025 v6.1

G. DRAFT AGREEMENT

The County’s contract with the successful Offeror(s) will be based upon the following Draft Agreement, structured as follows:

Draft Agreement

Exhibit A – Statement of Work Exhibit B – Insurance Requirements Exhibit C – Payment Schedule

Exhibits A (Statement of Work) and C (Payment Schedule) will be added during contract finalization. Offerors will be deemed to have accepted the Draft Agreement and Statement of Work, except where Offeror has taken clear exception in its quote in accordance with and when provided for in the Submittal Items.

FOR THE JOINT COMMISSION (TJC) AND CMS SURVEY READINESS AND COMPLIANCE CONSULTING SERVICES FOR THE SAN DIEGO PSYCHIATRIC HOSPITAL AND EDGEMOOR DISTINCT PART SKILLED

NURSING FACILITY SERVICES

Contract: ###### Page 18 of 42 Services Template: rev 9/29/2025 v6.1

RECITALS

A. Pursuant to the San Diego County Administrative Code section 401, the County’s Director of the Department of Purchasing and Contracting is authorized to award a contract for the joint commission (TJC) and CMS survey readiness and compliance consulting services for the San Diego Psychiatric Hospital and Edgemoor Distinct Part Skilled Nursing Facility.

B. Contractor is specially trained and possesses certain skills, experience, education, and competency to perform these services.

C. The Chief Administrative Officer made a determination that Contractor can perform the services more economically and efficiently than the County, pursuant to section 703.10 of the County Charter.

D. The Agreement shall consist of:

• This document,

• Exhibit A Statement of Work,

• Exhibit B Insurance Requirements, and

• Exhibit C Payment Schedule

E. In the event of a conflict between any provisions of this Agreement, the following order of precedence shall govern: First (1st) this document; Second (2nd) Exhibit B; Third (3rd) Exhibit A; and Fourth (4th) Exhibit C.

NOW THEREFORE, for valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:

ARTICLE 1

KEY PROVISIONS

1.1 CONTRACTOR: _____

1.2 SERVICES: _____

1.3 AGREEMENT TERM: The initial term of this Agreement shall begin on the date of the last signature on Signature Page and end on ____ __ 20__ (“Initial Term”).

1.4 OPTION TO EXTEND: The County shall have the option to extend the term of this Agreement for ____ increments of

___ year(s) (each an “Option Period”), for a total of ___ years beyond the expiration of the Initial Term, not to exceed ______ __, 20__. This option shall be automatically exercised unless County notifies Contractor in writing not less than thirty (30) days prior to an Option Period that the County does not intend to extend the Agreement.

1.4.1 Options to Extend for One to Six Additional Months at End of Agreement. County shall also have the option to extend the term of this Agreement, in one or more increments, for a total of no less than one (1) and no more than six (6) calendar months (“Incremental Options”). The County may exercise each Incremental Option by providing written notice to Contractor no fewer than fifteen (15) calendar days prior to expiration of this Agreement. The rates in effect at the time an Incremental Option is exercised shall apply during the term of the Incremental Option.

1.5 COMPENSATION: Pursuant to Exhibit C, Article 4, and other applicable provisions of this Agreement, County agrees to pay Contractor a sum not to exceed ($######) (“Maximum Agreement Amount”).