Site Consultant Statement of Work DRAFT.docx

DRAFT

San Francisco VA Medical Center 4150 Clement St.

San Francisco, CA 94121 Statement of Work Description

Background:

· The San Francisco VA Health care system supports 112 operating beds and a 120-bed Community Living Center, including 9 Community Base Outpatient Care (CBOC) facilities. Services include primary care, mental health, research, and specialty care. San Francisco VA (SFVA) Medical Center undergoes a variety of inspections to include Long Term Care Institute (LTCI) surveys, Annual Workplace Evaluation (AWE) inspections, and Joint Commission (TJC) surveys. Their inspections frequencies range from an annual basis out to every 36 months.

· The consultation request does not require a mock-survey type assessment. The consultant visit is intended to train, educate, and provided support to SFVA staff. Review and assist in developing engineering priority items associated with Life Safety, Environment of Care and Emergency Management concerns.

Period of Performance:

The period of performance for this requirement is from date of contract award to by 8 July 2024 and a second site visit is November 2024. Specific dates will be coordinated to include two sessions in 2024. Second will be required to review for improvement updated changes.

Project Scope

· Conduct training and support sessions to SFVA Medical Center staff on understanding The Joint Commission compliance program. The TJC training methodology should be in detail as to show how a hospital plan can be developed. Training will include information on understanding the Hospital Accreditation Manual, with emphasis on the Environment of Care, Life Safety, and Emergency Management sections.

· Demonstrate how Elements of performance may apply across multiple departments. Consultant will assist with Management Plan and Annual Evaluation development reviewing and aiding in establishing a standardize format that can be used across several departments. Review the departments existing program and provide a documentation structure that would create ways to improve during document reviews.

· Provide staff knowledge on how to interact with surveyors during building tours. Discuss the walk-thru process of how a survey team performs a hospital inspection flow from the first day onsite.

· Provide updates on recent and upcoming requirements to the standards. Discuss common trends, high-miss elements of performance that resulted in citations.

· Perform a facility tour to address any specific facility-related concern, identifying and discussing potential deficiencies, assisting staff with recommendations for correction.

· The consultant will, after site visit provide a report with observations and recommendations for improvement that would meet the CMS criteria within 14 business days after site visit. San Francisco VA is seeking specialized consultation visits periodically. The consultant will be paid upon receipt of the completion of the written report.

Specifications:

· The consultant should be very knowledgeable in Health Care Life Safety environment and should have minimum of eight years consultation experience. All recommendations for corrections shall meet/be in accordance with applicable SFVA Hospital Health Care and Life Safety standards, other federal, state, and local laws to meet Joint Commission requirements.

· Establish an onsite classroom type environment for training and educating staff members on the Hospital Accreditation Standards. Specifically, the areas of Life Safety, Environment of Care, and Emergency Management.

· Training information to be presented will include various formats such as Power Point, Word, Excel ect.

· Meet with EC Plan and/or EM Program Managers as appropriate to provide required updates to EC Management Plans and/or the EM Program based on mid-year changes to the applicable Standards effective since 1 July. Provide Model Management Plan and Sample, Annual Evaluation updates in a standardized format for EC and EM areas impacted by changes prior to the visit. This process will ensure that Plan/Program documents are up to date with respect to mid-year changes to the standards and will also help ensure that all Plan Managers understand the requirements, as well as, the documentation needed in support of the requirements.

· Provide an onsite Environment of Care/Emergency Management Seminar to EC/EM Plan/Program Managers and other personnel as appropriate to cover every applicable Standard/Element of Performance contained within the EC and EM Chapters of the CAMH, to include Safety, Security, Hazardous Materials and Waste, Life/Fire Safety, Medical Equipment, Utility Systems, and Emergency Management. The Seminar would also address the Unit Concept of Protection for Health Care Occupancies as essentially required by the Life Safety Code. This latter Concept will ensure that staff members understand the importance of ensuring that required LS features are not compromised. The Model Plan Concept would be utilized as a format for the training to reinforce the concept, as well as, to place increased emphasis on standardization within the Plans. The training location required audio-visual support, as well as copies of the Standards would be furnished by the organization.

· Conduct walk-throughs of specific areas of the facility at the request of the organization and as time permits to assist in clarification of Environment of Care or Life Safety concerns. This is not to be part of the required comprehensive building assessment as per the Life Safety chapter.

· Conduct a post summary brief with the Engineering Dept. prior to site departure.

Work Hours:

· On-site survey will be conducted between the hours of 7am to 4pm, Monday thru Friday except on Holidays.

· Consultant will coordinate with Engineering section representative upon arrival for scheduling. Site visits within to certain isolation the areas are subject to availability/occupancy. Pre-screening (rapid covid test) is required prior to entry into the assisted living facility.

· Consultant will require a temporary visitor ID/ pass and be escorted while on the premises.

Additional Government Representatives:

None