S02 - 537-24-102_J-A_Executed.pdf

VHAPG Part 813.5 Simplified Acquisition Procedures for Certain Commercial Items Attachment 1: Request for Sole Source Justification Template >SAT-$7.5M under FAR13.5

Effective Date: 11/15/24 Page 1 of 6

REVISION: 01

Acquisition ID#: 36C252-25-AP-1969

DEPARTMENT OF VETERANS AFFAIRS

SOLE SOURCE JUSTIFICATION UNDER SIMPLIFIED PROCEDURES FOR CERTAIN COMMERCIAL ITEMS IN

ACCORDANCE WITH FAR 13.5

Acquisition Plan Action ID: 36C252-25-AP-1969

1. Contracting Activity: Department of Veterans Affairs, VISN 12, Jesse Brown VA Medical Center

2. Nature and/or Description of the Action Being Processed:

Correct patient safety deficiencies in the inpatient mental health department: including replacing the existing piano-hinged doors with anti-ligature sliding doors.

3. Description of Supplies/Services Required to Meet the Agency’s Needs:

Twenty-seven (27) Ligature Resistant, sliding door kits, made by Accurate Lock and Hardware (Accurate). Estimated value is $20,000 (Twenty Thousand Dollars) per door (material only, based on pricing for LR-SDS-9505 model) making the total estimated cost of goods $540,000 (Five Hundred and Forty Thousand Dollars).

Goods are estimated to be delivered by end of December of 2025, and installed by end of August of 2026.

4. Statutory Authority Permitting Restricted Competition:

FAR 13.5 Simplified Procedures for Certain Commercial Items. The statutory authority for applying the Simplified Procedures for Commercial Items of FAR 13.5 is 41 U.S.C. § 1901 and is implemented by FAR 13.106-1(b)(2) for restricting competition on this procurement. Competition is restricted on this procurement for the reason below:

(X) Only One Responsible Source and No Other Supplies or Services Will Satisfy Agency Requirements

( ) Unusual and Compelling Urgency ( ) Industrial Mobilization, Engineering, Developmental or Research Capability or Expert

Services ( ) International Agreement ( ) Authorized or Required by Statute ( ) National Security ( ) Public Interest

5. Demonstration that the Contractor’s Unique Qualifications or Nature of the Acquisition Requires the Use of the Authority Cited Above (applicability of authority):

Market research found only one (1) US manufacturer of ligature resistant sliding door systems:

Accurate Lock and Hardware.

Background: The existing Inpatient Mental Health room doors have what is called a “Piano/Continuous Hinge”. These hinges are known to be potential ligature points. This was brought

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Acquisition ID#: 36C252-25-AP-1969 up on multiple occasions during the national VHA Inpatient Community of Practice calls with local Mental Health staff.

The National Inpatient Community of Practice as well as the Station’s Mental Health Dept could not find an acceptable solution and recommend replacement with alternative door hardware.

Additionally, on 08/16/2020, a national safety alert memorandum was issued from the Acting Assistant Under Secretary for Health for Support concerning the protruding metal covers on top of the Inpatient rooms Door switches, being another ligature point (VIEWS# 3222375).

There are two types of door systems identified to replace the existing continuous hinge:

1. ligature resistant sliding doors

2. ligature resistant anti-barricade bi-swing doors. (aka wicket-style doors)

Of these two ligature resistant door systems, sliding doors have several of advantages over the wicket-style doors. (See 6 - 9 below)

The Product requested is the LR-SDS (Ligature Resistant Door System) made by Accurate Lock and Hardware.

The reasons this product is requested:

1. The only ENTIRELY MADE IN THE USA, Anti-Ligature sliding doors on the market.

2. It does not have identified ligature points, thus reducing the risk of veterans harming themselves through strangulation/ligature.

3. The Accurate Lock and Hardware Doors have an overhead latch, eliminating the bolt and strike ligature risk.

4. Thanks to the very precise hardware design, the door will not latch in the event where a patient tries to jam a curtain/sheet knot in between the door and the wall; the door will slide open, resulting the fabric knot to fall - thus defeating the attempt of inflicting self-harm.

5. Given the doors’ sliding nature, they are inherently anti-barricade and can’t be jammed shut.

6. The door’s sliding nature eliminates the risk of hiding behind/weaponizing it by swinging.

a. A significant advantage over the anti-barricade bi-swing doors

7. Staff must carry special keys/devices to unlock the bi-swing doors to swing outward in the event a patient attempts to barricade the door. These keys can be lost potentially increasing

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Acquisition ID#: 36C252-25-AP-1969 response time in an emergency situation. Sliding doors cannot be barricaded on the inside, so they do not require special keys.

8. Bi-swing doors would require additional work to modify inside the patient rooms to allow to doors to swing in. Increasing the duration and cost of construction.

9. Sliding doors do not require the installation of overdoor weight sensors and alarm systems which are required by VHA for swinging doors. Another significant advantage over bi-swing doors.

a. These sensors require routine maintenance and testing which is a burden on the facility’s resources

b. Also, the sensors are sensitive and prone to false alarms, which causes loud disruptions to staff and veterans and increases “alarm fatigue” whereby staff are more likely to ignore legitimate emergencies because of the prevalence of constant alarms.

This is an approved solution for the National Inpatient Community of Practice as well as the Station’s Mental Health Dept search for an alternative to the Continuous hinge as well as eliminating the ligature risk due to the Sensor Cover.

6. Description of Efforts Made to ensure that offers are solicited from as many potential sources as deemed practicable:

General Contractors and Installers of the doors will bid competitively on the project. However, thorough market research found no other approved anti-ligature door manufactured by a US based company while eliminating current doors flaws.

Accurate Lock & Hardware is the only manufacturer of a technically acceptable solution. There are 3rd party distributors of Accurate’ s ligature resistant sliding doors, such as DoorHardwareUSA, which would also meet the government’s need.

7. Determination by the CO that the Anticipated Cost to the Government will be Fair and Reasonable:

The Contracting Officer anticipates the cost to the Government will be fair and reasonable based on competition within the market. There are 16 distributors of the required LR-SDS (Ligature Resistant Door System), located within the Chicago, IL area alone, as identified on the Accurate Lock & Hardware website. There are many other vendors identified across the United States (based on the Accurate Lock & Hardware website) as well, where potential bidders could request quotes.

Description of the Market Research Conducted and the Results, or a Statement of the Reasons Market Research Was Not Conducted:

MHEOC Team and station engineering conducted thorough market research for brands of anti-ligature doors. Research included sending requests to perspective vendors for product information/specs. Consulting with other VA Medical Centers that utilize either sliding or wicket style ligature resistant doors. Consulting with the Office of Healthcare Engineering, and reviewing recommendations from ASHE, the Society of Healthcare Engineers related to construction of inpatient mental health units.

The research for “anti-ligature inpatient room doors” (specifically non-piano hinge door assemblies) returned 3 (three) possible contenders:

1. Kingsway Group:

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Acquisition ID#: 36C252-25-AP-1969

a. U.K. based company, but with U.S. manufacturing offers a bi-swing style door hinge that can swing in both directions to eliminate the risk of patients barricading themselves.

b. As stated above, sliding doors have significant advantages over the bi-swing door option. The existing floor plan only allows for doors to be swung outside of the rooms, to have the doors swing into the room would require renovations within the rooms. Similar to what we currently have, these doors will still create an obstruction hazard, when doors are open, staff cannot see down the hallways. Patients can hide behind doors and/or use the doors as weapons when swung into the hallway.

c. The doors from Kingsway Group are equipped with overdoor sensors. Such components require routine maintenance, testing, and are prone to fault (not trigger when necessary/trigger falsely)

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Acquisition ID#: 36C252-25-AP-1969

2. ABH Manufacturing:

a. They produce the bi-swing hinges and are American based.

b. They provide only the hardware (hinges and handles), so the full door system would require the general contractor to purchase a separate door and overhead alarm, and combine the different parts together which can create fit & quality issues, and complicate warranty claims due to multiple different material vendors.

c. Again sliding doors are preferable to bi-swing for the reasons listed above.

3. Accurate Lock & Hardware:

a. This manufacturer offers a sliding door that is surface-installed.

b. The Accurate Lock and Hardware Doors have an overhead latch, eliminating the bolt and strike ligature risk.

c. Given the doors’ sliding nature, they are inherently anti-barricade and can’t be jammed shut, and staff do not need to carry special keys.

d. The door’s sliding nature eliminates the risk of hiding behind/weaponizing it by swinging.

e. The doors also do not require the installation of overdoor weight sensors and alarm systems as opposed to traditional swing doors.

4. Non-U.S. companies: Several additional companies such as Safehinge Primera were identified in market research, but these other contenders are foreign companies without US based manufacturing. Because they do not comply with Buy American Act requirements they were not considered for this procurement.

8. Any Other Facts Supporting the Use of Other than Full and Open Competition:

N/A

9. Listing of Sources that Expressed, in Writing, an Interest in the Acquisition:

N/A: The requested Door and Hardware can be installed by a number of SDVOSB firms.

10. A Statement of the Actions, if any, the Agency May Take to Remove or Overcome any Barriers to Competition before Making subsequent acquisitions for the supplies or services required:

N/A

11. Requirements Certification: I certify that the requirement outlined in this justification is a Bona

Fide Need of the Department of Veterans Affairs and that the supporting data under my cognizance, which are included in the justification, are accurate and complete to the best of my knowledge and belief.

Gregory Cohen Date Healthcare Engineer Jesse Brown VAMC

Effective Date: 11/15/24 Page 6 of 6

Acquisition ID#: 36C252-25-AP-1969

12. Approvals in accordance with the VHAPM Part 806.3 OFOC SOP:

a. Contracting Officer or Designee’s Certification (required): I certify that the foregoing justification is accurate and complete to the best of my knowledge and belief.

Stacy Hoover Date Contracting Officer, NCO-12

b. One Level Above the Contracting Officer (Required over SAT but not exceeding $750K): I certify the justification meets requirements for other than full and open competition.

Ryan McMillin Date Branch Chief, NCO-12

c. VHA RPO HCA Review and Approval: I have reviewed the foregoing justification and find it to be complete and accurate to the best of my knowledge and belief and approve ($750K to $7.5 million (or $15.0 million for acquisitions described in FAR 13.500(c)) for other than full and open competition.

N/A – Not Required

Name Date VHA Head of Contracting Activity (HCA) https://dvagov.sharepoint.com/sites/VHAProcurement/VHAPM/VHAPM_Part_806.3.aspx