SOW Rev.pdf

INDIAN HEALTH SERVICE

PHOENIX INDIAN MEDICAL CENTER

Rev 6/2016

Statement of Work

Background

The Phoenix Indian Medical Center (PIMC) is a 1.2M SF campus comprised of a hospital tower and numerous outpatient care and support buildings. The campus is located at 4212 North 16th Street, Phoenix, Arizona 85016. The PIMC hospital tower (Building 233) is a five-story, Joint Commission (TJC) accredited, 127-bed hospital employing 1,200 staff that primarily serves a patient population of 140,000

Native Americans in the Phoenix metropolitan area. The hospital tower was built in 1970 and is approximately 163,000 SF.

This is a federal facility on federal property and the authority having jurisdiction (AHJ) is not the City of

Phoenix. The AHJ is the Phoenix Area Indian Health Service Director of the Office of Environmental

Health and Engineering. To maintain TJC accreditation, PIMC must comply with Center for Medicare and

Medicaid Services (CMS) code requirements. At present, CMS has adopted the 2012 Life Safety Code

(NFPA 101). All NFPA codes referenced by NFPA 101, including but not limited to NFPA 25, NFPA 72, NFPA 80, NFPA 10, NFPA 105, NFPA 90A, NFPA 291, and NFPA 96 must be the most recent edition of

NFPA available in 2012 and cannot be newer than 2012.

Objective

The objective of this contract is to provide PIMC with subject matter expertise in all manors of compliance with the Life Safety and Environment of Care chapters of the Joint Commission

Comprehensive (TJC) Accreditation Manual otherwise known as the “Physical Environment”. Examples of areas of expertise in Physical Environment compliance include but are not limited to:

1) General Preparation for the physical environment portion of the TJC accreditation survey

2) Continuous compliance with TJC accreditation standards for the Physical Environment

3) Assistance in responding to TJC survey findings

4) Assistance in determining means and methods to correct TJC findings

5) Assistance in preparing and reviewing TJC required documentation

6) Assistance in performing Physical Environment assessments of Life Safety Code (NFPA 101 – 2012) and Health Care Facilities Code (NFPA 99 – 2012) including but not limited to:

a. Smoke and fire barrier penetration compliance

b. EXIT access door compliance

c. Access control compliance

d. Fire alarm and fire sprinkler system compliance

e. Life Safety Drawing Compliance

f. ASHRAE 170 air change and air pressure requirement compliance

g. Suite compliance

h. Fire drill compliance

7) Assistance in commissioning and decommissioning of life safety equipment

8) Assistance in writing and reviewing PIMC policies that involve the Physical Environment

Rev 6/2016

9) Assistance in training PIMC staff on various topics necessary for compliance, including but not limited to:

a. Repairing smoke and fire wall penetrations

b. Conducting smoke and fire wall penetration checks

c. Measuring air flow and air pressures

d. General survey process education for maintenance staff and hospital leadership

10) Assistance in writing various types of reports for Physical Environment topics

Additional Technical Requirements:

Resumes documenting multiple SMEs with 20 or more years of healthcare accreditation experience

Resumes documenting multiple SMEs that have held leadership positions in The Joint

Commission and/or CMS

SME resumes documenting number of years of experience performing:

o Smoke and fire barrier penetration compliance o EXIT access door compliance o Access control compliance o Fire alarm and fire sprinkler system compliance o Life Safety Drawing Compliance o ASHRAE 170 air change and air pressure requirement compliance o Suite compliance o Fire drill compliance o Physical Environment Healthcare Compliance Policy drafting o Providing assistance to hospitals in preparing for and responding to TJC surveys

Resumes/work history documenting SME experience training hospital medical staff, leadership, and maintenance staff on a variety of accreditation issues.

Resumes/work history documenting SME experience assisting facility in a variety of code interpretations such as:

o NFPA 99 o NFPA 101 o TJC Comprehensive Accreditation Manual o ASHRAE 170

Resumes/work history documenting SME experience reviewing LS/EC Survey Documentation and performing mock surveys

Contract Awardee Responsibilities & Tasks

1) Contractor shall have subject matter experts available for consultation in each area covered by the contract objective. Contractor must have multiple subject matter experts available with 20 or more years of healthcare compliance experience. Contractor shall also have subject matter experts available that have served in Physical Environment leadership positions with the Joint

Commission and/or CMS.

2) Contractor shall provide up to 100 hours of remote subject matter expertise consultation to

PIMC each option year.

INDIAN HEALTH SERVICE

PHOENIX INDIAN MEDICAL CENTER

Rev 6/2016

3) Contractor shall perform an in person mock survey tour of the Physical Environment once per option year. This mock survey shall include 1 individual walking the site with PIMC staff for 8 hours total to simulate the afternoon portion of Day 1 of a TJC survey and the morning portion of Day 2 of the TJC survey.

4) Contractor shall deliver a mock survey report to PIMC with overall assessment of the PIMC facility along with a summary of TJC deficiencies found along with corresponding SAFER Matrix risk levels and recommended corrective actions. This report is expected to take appx 8 hours of contractor time to produce.

5) Contractor shall conduct an annual assessment of PIMC’s documentation, listed as required in the current TJC Survey Activity Guide for LS and EC. This assessment is to be performed remotely with PIMC staff over a 4-hour period to simulate a TJC survey morning documentation review session.

6) Contractor shall deliver short report to PIMC with a general overall assessment of PIMC’s documentation along with recommendations for improvement. This report is expected to take appx 8 hours of contractor time to produce.

7) Contractor shall provide up to 80 hours of onsite subject matter expertise consultation to PICM each option year.

8) Contractor shall provide up to five (5) site visits to PIMC to support the contract objective per option year in addition to the site visit required for the annual mock survey for a total of six (6) site visits per option year. Each site visit includes lodging, airfare, and per diem per the Joint

Travel Regulations.

Contracting Officer Authority

Authority to negotiate changes in the terms, conditions, or amounts cited in this contract is reserved for the Contracting Officer.

Contracting Officer’s Representative (COR)

The person identified below is hereby designated as the Contracting Officer's Representative (COR) for this contract.

Contacts: Douglas Barber 602-263-1539 douglas.barber@ihs.gov mailto:douglas.barber@ihs.gov