F115-- Consulting Services to Assess and Review Safety Programs, Emergency Management and Engineering Programs

CStatement of Work and Attachment A

Assessment and Review of Safety, Emergency Management, and Engineering Programs

Joint Commission Readiness

Veterans Affairs Central California Health Care System

1.0 General Information: The VA Central California Health Care System (VACCHCS) has a requirement to procure consulting services for a comprehensive assessment and follow-up review of progress on previous written recommendations for Safety (OSHA), Life Safety, Emergency Management, Biomedical Engineering, Utilities Management, Hazardous Materials, Water Safety, Security Management programs and environment of care related to hazardous drug compounding in accordance with both USP 797 & USP 800 guidelines as they relate to the requirements of The Joint Commission.

1.1 The Contractor shall provide assessments and/or follow-up reviews identified on Attachment A.

1.2 Performance Period:

Base Period (includes 3-Days + Travel)

Option Year 1 (includes 3-Days + Travel)

Option Year 2 (includes 3-Days + Travel)

Option Year 3 (includes 3-Days + Travel)

Option Year 4 (includes 3-Days + Travel)

1.3 Hours of Performance: The Contractor shall work from at least 8:00AM-4:30PM, Monday through Friday, excluding the eleven national holidays observed by the Federal Government those holidays are: New Year s Day, Martin Luther King Jr Day, Presidents Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day, and Christmas Day.

1.4 Any other day specifically declared by the President of the United States to be a national holiday. If a holiday falls on Sunday, the following Monday will be observed as the legal holiday. If a holiday falls on Saturday, the preceding Friday is observed as a legal holiday by U.S. Agencies

2.0 Schedule of Facility Visits:

2.1 The Contractor shall conduct an on-site assessment and/or review along with training.

2.2 The on-site review and training shall be conducted during the facility visit. A facility visit shall be carried out over three days. A visit shall be scheduled before May 1, 2022. The second visit shall occur the month of September. After the initial year of period of performance, every extended option year will require the Contractor to be on site to perform their assessment no later than 3/15/XX and the second evaluation to be conducted by 09/15/XX.

2.3 The Contractor shall continue reviewing the reports as stated in Attachment A so that a determination of Joint Commission compliance with the Environment of Care, Life Safety, and Emergency Management standards can be assessed.

2.4 The Contractor shall meet with the COR to review the necessary information before conducting reviews.

2.5 Training. At the request of the facility the contractor will provide two training presentations; one training session for general staff that covers the basic Joint Commission process and an overview of the standards, including any changes to the standards for the year. The second training presentation shall be specific to the Environment of Care and Life Safety standards and include changes to those standards. These presentations are live educational presentations. A hard copy of the presentations shall also be provided in electronic form on Compact Disc (CD) or mutually agreed upon media determined by the COR and the Contractor.

3. Contractor s Qualifications: The vendor shall possess the following skills and experience:

3.1 The Contractor shall have extensive knowledge and experience with interpretation of the most recent Joint Commission standards, USP 797/ USP800 and applicable NFPA Regulations. The Contractor shall be trained in current Joint Commission Standards and National Fire Protection Association (NFPA) 101 Life Safety Code. The Contractor shall possess one of the following certifications (as a minimum): Professional Engineering license (PE), Healthcare Safety Professional (HSP), and Certified Clinical Engineer (CCE)

3.2 The Contractor shall possess at least 10 years of healthcare engineering and management experience.

4.0 Contractor Responsibilities:

4.1 Provide follow-up on previous facility visit recommendations, on-site review, and training of Safety (OSHA), Life Safety, Emergency Management, Biomedical Engineering, Security Management, Water Safety, USP 797/USP800 and Utilities Management programs at VACCHCS as defined under the Scope of Work.

4.2 The Contractor and their sub-Contractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract.

4.3 Deliverables:

4.3.1 The Contractor shall provide a detailed assessment report of compliance with the Environment of Care, Life Safety all related to the finding standards that clearly indicates areas that require action. Areas requiring action shall be assessed for risk and presented in a table format referencing the standard in violation, the level of impact, and the priority in accordance with the most recent scoring format by the Joint Commission.

4.3.2 The Contractor shall provide to the COR, the Associate Medical Center Director and the Chief of Safety all reports, copies of the training presentations and copies of appropriate reference documents. The Contractor shall also provide sample solutions to help resolve issues as appropriate. The Contractor shall also provide an electronic file as requested so that reports can be duplicated by the facility and distributed.

5.0 Security Considerations. The C&A requirements do not apply, and a Security Accreditation Package is not required. At no time shall the vendor be in contact or have access to VA sensitive information. VA sensitive information procedures will be followed per VA Handbook 6500.6.

6.0 Contractor s Quality Control Program:

6.1 The Contractor shall establish and maintain quality control to ensure all contract requirements are met. An original and one (1) copy of the QCP shall be forwarded to the COR along with the requested initial proposal. The COR will review the QCP and list any needed clarifications, and return to Contractor for response, if necessary.

6.2 The Contractor's QCP shall include the following or have incorporated into during performance of contract, at a minimum:

6.2.1 An inspection plan covering all services is required by this contract. The inspection plan shall specify the areas to be inspected on either a scheduled or unscheduled basis and how often inspections shall be accomplished and documented, and the title of the individual(s) who shall perform the inspections.

6.2.2 On-site records of all inspections conducted by the Contractor noting necessary corrective action taken. The Government reserves the right to request copies of any and/or each inspection.

6.2.3 The methods for identifying and preventing deficiencies in the quality of service performed, before the level of performance becomes unacceptable and organizational functions noting intermediate supervisory responsibilities and overall management responsibilities for ensuring total acceptable performance.

6.2.4 The Contractor shall maintain records identifying the certifications and ongoing training of each employee performing services under this contract. The Contractor shall make this record available for review by the VA. The Contractor shall provide a copy of the certification records and/or a photocopy of the employee s identification upon request by the COR.

7.0 Quality Assurance Monitoring.

7.1 The COR will evaluate the services required to ensure compliance with expectations based on participant written evaluation.

7.1 The COR will evaluate the services required to ensure compliance.

7.2 The Contractor shall perform all work in a satisfactory manner in accordance with the appropriate SOW tasks. The COR will not consider the task completed until all deficiencies have been corrected.

7.3 The COR will monitor the Contractor s performance to assure that the performance thresholds and standards of performance are met in accordance with the statement of work and the QASP. In accordance with FAR 52.212-4 (a) Inspection/Acceptance the Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The Government may require repair or replacement of nonconforming supplies or re-performance of nonconforming services at no increase in contract price.

7.4 QASP Plan

Factor #

Performance Criteria

Performance Standard

AQL Max allowable degree of deviation

Method -Type of Surveillance Reduction when AQL exceeded

1

Receipt of Detailed Assessment Report

Qualified staff to provide appropriate service

1 occurrence per year

Monitor by COR

2

Receipt of Reports, Copies of Training Presentations, Reference Documents

Qualified staff to provide appropriate service

1 occurrence per year

Monitor by COR

8.0 Invoicing

The vendor shall submit a copy of the invoice after completion of the training program to the COR prior to submitting it to DFAS Austin. The COR will verify the invoice and authenticate the invoice via Online Certification System (OLCS). This is the VA s process and procedure for submitting invoices for payment.

Attachment A of SOW

List of previous reports:

Environment of Care Committee (ECB) Minutes

Annual Reports provided to the ECB

Management Plans provided to the ECB

Statement of Conditions (SOC) binder from Engineering Service

SOC policy

Life Safety assessments

Interim Life Safety Measures (ILSM) forms resulting from Plan for Improvements (PFI)

Generator test logs and load test results

Fuel oil quality results

Battery light test logs

Uninterruptible Power Supply quarterly tests

Medical gas and vacuum system test results

Certification for new installations/renovations

Oxygen quality certificates

Fire test results

Supervisory devices

Tampers/waterflows

Fire/smoke detection

Extinguishing systems

Smoke/fire dampers

Horizontal/vertical fire doors

Life safety check of construction areas, buildings with inpatients and other high priority areas

Safety risk assessment

EOC Rounds documentation

Incident reports summaries

Safety training program

Security risk assessments

Identification policy

Security of sensitive areas

Hazardous materials inventory

Material Safety Data Sheets (MSDS) Management

Hazardous energy policy

Hazardous medication disposal procedure

Toxic vapor test results

Spill procedure policies

Decontamination procedure

Fire drill reports

Decoration policy

Open flame policy

ILSM procedures

Infection Control Risk Assessment (ICRA) evaluations

Rating of interior finishes

Medical Equipment

Inventory criteria

Inventory classification list

Testing policies, intervals

Product recall

Preventive maintenance completion rate data

Rentals, patient equipment

Vendor competency documents

Utility management inventory

Utility system as-built and valve charts

Utility failure procedures for clinical and maintenance staff

Airborne and waterborne pathogens policies

Emergency operations plan

Hazard vulnerabilities analysis

Incident command chart

Job action sheets for Integrated Campus Support (ICS)

96-hour timeline charts

Policies for critical areas

Disaster drill reports

Tabletop simulation procedure

GEMS Program

Water Quality Reports (Legionella & HPC i.e. Dental, Dialysis, SPS)