Page 4 of 16 THIS IS A SOURCES SOUGHT NOTICE (a) The Government does not intend to award a contract on the basis of this Sources Sought or to otherwise pay for the information solicited. (b) Although proposal, offeror, contractor, and offeror may be used in this sources sought notice, any response will be treated as information only. It shall not be used as a proposal. (c) Any information received from a contractor in response to this Sources Sought may be used in creating a solicitation. Any information received which is marked with a statement, such as proprietary or confidential, intended to restrict distribution will not be distributed outside of the Government, except as required by law. (d) This Sources Sought is issued for the purpose of collecting information about the availability of Offsite Gastroenterology Service from different sources for the desired service listed in the Performance Work Statement (PWS). (e) Contractors that feel they have an equal service are encouraged to provide a quote in response to this notice and/or email full information to Orville Landicho at Orville.
[email protected]. Contractors shall identify the NAICS code for the product being offered as well as their size status. Contractors shall identify whether they have a GSA contract or not as well as whether this requirement is on their GSA contract. Contractors shall furnish supporting documentation, which demonstrates that the proposed equal service meet or exceed the PWS. Contractor shall identify any concerns or questions regarding the PWS. Please respond no later than COB Monday 12/12/16. Performance Work Statement for Off Site Gastroenterology Services GENERAL: Services Provided: The Contractor shall provide an Offsite Gastroenterology Service and a Board Certified or Board Eligible Physicians in Gastroenterology as established by the American College of Gastroenterology. Performance of services shall be in accordance with the specifications contained herein to beneficiaries of the Department of Veterans Affairs (VA) and the Reno VAMC. Place of Performance TBD, or other physical locations designated by the Contractor as appropriate for the provision of care. Authority: Title 38 USC 8153, Health Care Resources (HCR) sharing Authority. Policy/Handbooks: - VA Directive 1663: Health Care Resources Contracting - Buying http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=347 VHA Directive 2006-041 Veterans Health Care Service Standards (expired but still in effect pending revision) https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1443 - VHA Handbook 1100.17: National Practitioner Data Bank Reports - http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2135 - VHA Handbook 1100.18 Reporting And Responding To State Licensing Boards - http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1364 - VHA Handbook 1100.19 Credentialing and Privileging - http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910 VHA Handbook 1907.01 Health Information Management and Health Records: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791 - Privacy Act of 1974 (5 U.S.C. 552a) as amended http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm Definitions/Acronyms- Terms used in this contract shall be interpreted as follows unless the context expressly requires a different construction and/or interpretation. In case of a conflict in language between the Definitions and other sections of this contract, the language in this section shall govern. ACG: American College of Gastroenterology (www.gi.org) ACGME: Accreditation Council for Graduate Medical Education ACLS: Advanced Cardiac Life Support AOD: Admitting Officer of the Day BLS: Basic Life Support CCNE:Commission on Collegiate Nursing Education: www.aacn.nche.edu/accreditation CDC: Centers for Disease Control and Prevention CDR: Contract Discrepancy Report CEU: Certified Education Unit CME: Continuing Medical Education CMS: Centers for Medicare and Medicaid Services Contracting Officer (CO) The person executing this contract on behalf of the Government with the authority to enter into and administer contracts and make related determinations and findings. Contracting Officer s Representative (COR) A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance with and adheres to the specifications contained in the contract and to protect the interest of the Government. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken. COS: Chief of Staff CPARS: Contractor Performance Assessment Reporting System CPRS: Computerized Patient Recordkeeping System- electronic health record system used by the VA. Credentialing: Credentialing is the systematic process of screening and evaluating qualification and other credentials, including licensure, required education, relevant training and experience and current competence and health status. DEA: Drug Enforcement Agency ED: Emergency Department FSMB: Federation of State Medical Boards Full Time Equivalent (FTE): VA s definition for full time- working the equivalent of 80 hours every two weeks, 2080 hours per year. In calculating FTE, any hours not worked on national holidays shall not be included. HHS: Department of Health and Human Services HIPAA: Health Insurance Portability and Accountability Act HR: Human Resources ISO: Information Security Officer Medical Emergency - a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in: Permanently placing a patient's health in jeopardy, causing other serious medical consequences, causing impairments to body functions, or causing serious or permanent dysfunction of any body-organ or part. MOD: Medical Officer of the Day National Provider Identifier (NPI): NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The Veterans Health Administration must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). NLNAC: National League for Nursing Accrediting Commission. www.nlnac.org Non-Contract Provider - any person, organization, agency, or entity that is not directly or indirectly employed by the Contractor or any of its subcontractors NP: Nurse Practitioner NPPES: National Plan and Provider Enumeration System PA: Physician Assistant PALS: Pediatric Advanced Life Support POP: Period of Performance PPD: Purified Protein Derivative PWS: Performance Work Statement Privileging (Clinical Privileging): Privileging is the process by which a practitioner, licensed for 8independent practice; e.g., without supervision, direction, required sponsor, preceptor, mandatory collaboration, etc.; is permitted by law and the facility to practice independently, to provide specific medical or other patient care services within the scope of the individual s license, based upon the individual s clinical competence as determined by peer references, professional experience, health status, education, training and licensure. Clinical privileges must be facility-specific and provider-specific. QA/QI: Quality Assurance/Quality Improvement QM/PI: Quality Management/Performance Improvement QASP: Quality Assurance Surveillance Plan Veterans Health Administration (VHA): The central office for administration of the VA medical centers through throughout the United States. The VHA is located in Washington, D.C. Veterans Integrated Services Network (VISN): The regional oversight for the VA medical centers in Michigan and Indiana. VISTA (Veterans Integrated Systems Technology Architecture): A PC based system that will capture and store clinical imagery, scanned documents and other non-textual data files and integrates them into patient s medical record and with the hospital information system. VetPro: a federal web-based credentialing program for healthcare providers. Veterans Affairs Medical Center (VAMC): Unless identified with the name of a different VA medical Center, for purposes of this contract, this term shall mean the Reno VA Medical Center. QUALIFICATIONS: Staff/Facility License - Contractor s physician(s) assigned by the Contractor to perform the services covered by this contract shall have a current license to practice medicine in the state of Nevada, where services are being performed. All licenses held by the personnel working on this contract shall be full and unrestricted licenses. Contractor s physician(s) who have current, full and unrestricted licenses in one or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application will not be considered for the purposes of this contract. Board Certification - All Contractor s physician(s) shall be Board Certified /Board Eligible in Gastroenterology by the American College of Gastroenterology (ACG) and be currently certified in Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) or equivalency. All continuing education courses required for maintaining certification must be kept up to date at all times. Credentialing and Privileging Credentialing and privileging is to be done in accordance with the laws of the state of Nevada. The Contractor is responsible to ensure that proposed physician(s) possesses the requisite credentials enabling the granting of privileges. If a Contractor s physician(s) is not credentialed and privileged or has credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government. Technical Proficiency - Contractor s physician(s) shall be technically proficient in the skills necessary to fulfill the government s requirements, including the ability to speak, understand, read and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed. Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all Contractor physician(s). Standard Personnel Testing/Infection Control: Contractor shall provide statement that all required infection control testing is current and that the contractor is compliant with OSHA regulations concerning occupational exposure to blood borne pathogens. The Contractor shall also notify the VA of any significant communicable disease exposures and the VA will also notify the contractor of the same, as appropriate. Contractor shall adhere to current CDC/HICPAC Guideline for Infection Control in health care personnel ( as published in American Journal for Infection Control- AJIC 1998; 26:289-354 http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf) for disease control. Contractor shall provide follow up documentation of clearance to return to the workplace prior to their return. Tests shall be current within the past year. National Provider Identifier (NPI): NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The Veterans Health Administration must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). The Contractor shall have or obtain appropriate NPI and if pertinent the Taxonomy Code confirmation notice issued by the Centers for Medicare and Medicaid Services (CMS) National Plan and Provider Enumeration System (NPPES) be provided to the Contracting Officer with the proposal. DEA (as required) - Contractor shall provide copy of current DEA certificate in the state of Nevada, where services will be provided under this contract. Conflict of Interest: The Contractor and all Contractor s physician(s)are responsible for identifying and communicating to the CO and COR conflicts of interest at the time of proposal and during the entirety of contract performance. At the time of proposal, the Contractor shall provide a statement which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided. The Contractor shall also provide statements containing the same information for any identified consultants or subcontractors who shall provide services. The Contractor must also provide relevant facts that show how it s organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest. These statements shall be in response to the VAAR provision 852.209-70 Organizational Conflicts of Interest (Jan 2008) and fully outlined in response to the subject attachment in Section D of the solicitation document. Citizenship related Requirements: The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals; While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all E-Verify requirements consistent with Executive Order 12989 and any related pertinent Amendments, as well as applicable Federal Acquisition Regulations. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001. The Contractor agrees to obtain a similar certification from its subcontractors. The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document. Annual Office of Inspector General (OIG) Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed Contractor s physician(s)are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a Civil Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractors are and/or firm is not listed as of the date the offer/bid was signed. Facility: The Contractors facility shall meet all federal, state and local fire and life safety codes and must be accessible and convenient for wheelchair patients and other handicapped or disabled Veterans. Non Personal Healthcare Services: The parties agree that the Contractor and all Contractor s physician(s)shall not be considered VA employees for any purpose. Indemnification: The Contractor shall be liable for, and shall indemnify and hold harmless the Government against, all actions or claims for loss of or damage to property or the injury or death of persons, arising out of or resulting from the fault, negligence, or act or omission of the Contractor, its agents, or employees. Prohibition Against Self-Referral: Contractor s physicians are prohibited from referring VA patients to contractor s or their own practice(s). Inherent Government Functions: Contractor and Contractor s physician(s) shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees (outside a clinical context), selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy. No Employee status: The Contractor shall be responsible for protecting Contractor s physician(s) furnishing services. To carry out this responsibility, the Contractor shall provide or certify that the following is provided for all their staff providing services under the resultant contract: Workers compensation Professional liability insurance Health examinations Income tax withholding, and Social security payments. Tort Liability: The Federal Tort Claims Act does not cover Contractor or Contractor s physician(s). When a Contractor or Contractor s physician(s) has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor s (or Contractor s physician(s)) action or non-action shall be the responsibility of the Contractor and/or insurance carrier. Contingency Plan: Because continuity of care is an essential part of VAMC s medical services, the Contractor shall have a contingency plan in place to be utilized if the Contractor s physician(s) leaves Contractor s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract. HOURS OF OPERATION/SCHEDULING: Business Hours: Reno VAMC business hours, for administrative purposes, are generally Monday through Friday, from 8 AM to 4 PM. Patient Access/Timeliness of Scheduling: The Contractor shall schedule review of VA referrals within 24 hours of receipt, with the face-to-face consultation shall occur within seven (7) calendar days, or less. The Contractor shall submit the proposed treatment plan for approval within five (5) working days after the consultation, Written documentation associated with each visit shall be available to the VA within 24 hours of the each visit. When requested, such written documentation shall be provided to the VA within 24 hours. Off-hours Coverage: None. Cancellations: Contractor will advise VAMC daily of any patient cancellations, and provide rescheduling information/documentation. Unless a state of emergency has been declared, the Contractor shall be responsible for providing services. CONTRACTOR RESPONSIBILITIES The Contractor shall furnish all personnel to provide services necessary to perform gastroenterology services to eligible beneficiaries of the VAMC. All services shall be performed at the Contractor s facility. Contractor shall provide professional and technical services to include materials, supplies, equipment and qualified supervision s specified herein. Management and Supervision: The Contractor shall be responsible for supervising the daily services provided under this contract by the Contractor s staff. The Contractor shall have written policies and procedures regarding staff credentials and privileging. The VAMC will provide to the Contractor policies, procedures and processes necessary to allow cooperative functioning between the agency and VAMC. Updates and refreshers will be provided to the Contractor upon request and when policy procedures or process changes. The Contractor shall complete background investigations to insure that employees do not have a record of criminal offenses or substantiated incidents of patient abuse; and, if required to perform their duties, employees are properly licensed and insured to operate motor vehicles. Standards of Care: The contract physician (s) care shall cover the range of gastroenterology services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized TJC, VA and national standards as established by: Clinical guidelines as established by the American College of Gastroenterology (www.gi.org) VA Standards: VHA Directive 2006-041 Veterans Health Care Service Standards (expired but still in effect pending revision) https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1443 The professional standards of the Joint Commission (TJC) http://www.jointcommission.org/standards_information/standards.aspx The standards of the American Hospital Association (AHA) http://www.hpoe.org/resources?show=100&type=8 and; The requirements contained in this PWS. MEDICAL RECORDS Authorities: Contractor s physician(s)providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the U.S.C.551a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts 160, 162, and 164 (HIPAA). HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to: a health care provider for treatment. Based on this exception, a BAA is not required for this contract. Treatment and administrative patient records generated by this contract or provided to the Contractors by the VA are covered by the VA system of records entitled Patient Medical Records-VA (24VA19). Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services are available for immediate transmission when requested by the VA. Records identified for review, audit, or evaluation by VA representatives and authorized federal and state officials, shall be accessed on-site during normal business hours or mailed by the Contractor at his expense. Contractor shall deliver all final patient records, correspondence, and notes to the VA within twenty-one (21) calendar days after the contract expiration date. Disclosure: Contractor s physician(s) may have access to patient medical records: however, Contractor shall obtain permission from the VA before disclosing any patient information. Subject to applicable federal confidentiality or privacy laws, the Contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over Contractor, may have access to VA s records, at VA s place of business on request during normal business hours, to inspect and review and make copies of such records. The VA will provide the Contractor with a copy of VHA Handbook 1907.1, Health Information management and Health Records and VHA Handbook 1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Handbook 1907.01 Health Information Management and Health Records: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791 and all guidelines provided by the VAMC. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. In the case of the VA authorizing the Contractor to release patient information, the Contractor in compliance with VA regulations, and at his/her own expense, shall use VA Form 3288, Request for and Consent to Release of Information from Individual s Records, to process Release of Information Requests. In addition, the Contractor shall be responsible for locating and forwarding records not kept at their facility. The VA s Release of Information Section shall provide the Contractor with assistance in completing forms. Additionally, the Contractor shall use VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information, when releasing records protected by 38 U.S.C. 7332. Treatment and release records shall include the patient s consent form. Completed Release of Information requests will be forwarded to the VA Privacy Officer at the following address: Nigel Burns, Privacy/FOIA Officer, 775.328.1245, email:
[email protected] Direct Patient Care: As determined by Contractor. Per the qualification section of this PWS, the Contractor shall provide the following staff: Board Certified / Board Eligible Gastroenterology physicians Scope of Care: Contractor s physician(s) (as appropriate and within scope of practice/privileging) shall be responsible for providing a full range of gastroenterology treatment and services. Medications: Contractor physician(s) shall follow all established medication policies and procedures. No sample medications shall be provided to patients. Discharge education: Contractor physician(s) shall provide discharge education and follow up instructions that are coordinated with the next care setting for all gastroenterology clinical or surgical patients. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY IMPROVEMENT(QI) Quality Management/Quality Assurance Surveillance: Contractor performance will be monitored by the government using the standards as outlined in this Performance Work Statement (PWS) and methods of surveillance detailed in the Quality Assurance Surveillance Plan (QASP). The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. In the event that The Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall deal with issues raised concerning Contractor s conduct. The final arbiter on questions of acceptability is the CO. Performance Standards: Measure: Provider Quality Performance Performance Requirement: Contractor shall furnish provider specific quality data for gastroenterology services for each provider working under this contract, as requested. Data should include the following elements: A. Patient Care Performance B. Medical/Clinical knowledge C. Practiced Based Learning and Improvement D. Interpersonal and Communication Skills E. Professionalism F. System Based Practice Standard: Contractor provides documentation for all (100%) staff providing services under the contract. All staff (100%) meet Standards. Acceptable Quality Level: 100% meet Standards Surveillance Method: Document review Frequency: As requested, but not more than once per year. Incentive: Positive Past Performance Disincentive: Negative Past Performance Measure: Qualifications of Key Personnel Performance Requirement: All Contractor physician(s) shall be Board Certified /Board Eligible in gastroenterology in accordance with the American College of Gastroenterology Standards. Standard: All (100%) contract physicians are Board Certified /Board Eligible. Acceptable Quality Level: 100%. Surveillance Method: Random Inspection of qualification documents Frequency: As required Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Scope of Practice/Privileging Performance Requirement: Contractor s physician(s)perform within their individual scopes of practice/privileging. Standard: All (100%) Contractor s physician(s) perform within their scope of practice/privileges 100% of the time. Acceptable Quality Level: 100%. Contractor s physician(s) perform within their scope of practice/privileges 100%.of the time. Surveillance Method: Random Inspection of records. Frequency: As required. Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Patient Access Performance Requirement: The Contractor shall provide services in accordance with the access requirements outlined in this PWS. Standard: All (100%) Contractor s physician(s) are available to perform services. Acceptable Quality Level: Contractor s physician(s) are available to perform services 100% of the time Surveillance Method: Periodic Sampling of access and billing documents. Frequency: As required. Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Patient Safety Performance Requirement: Patient safety incidents shall be reported using Patient Safety Report. All incidents reported immediately (within 24 hours.) Standard: All (100%) of patient safety incidents are reported using Patient Safety Report within 24 hours of incident. Acceptable Quality Level: 100%.of patient safety incidents are reported using Patient Safety Report within 24 hours of incident. Surveillance Method: Sampling of documents submitted. Frequency: As required. Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Mandatory Training Performance Requirement: Contractor shall complete all required training on time per VAMC policy Standard: All (100%) of required training is complete on time by contract physician (s). Acceptable Quality Level: 95% Surveillance Method: Periodic Sampling Frequency: As required. Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Privacy, Confidentiality and HIPAA Performance Requirement: Standard: All (100%) contractor physician (s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA Acceptable Quality Level: 100%. Surveillance Method: Periodic Sampling; Contractor shall provide evidence of annual or other required training, reports violations per this agreement and applicable law. Frequency: As required. Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contactor performance evaluation. Registration with Contractor Performance Assessment Reporting System As prescribed in Federal Acquisition Regulation (FAR) Part 42.15, the Department of Veterans Affairs (VA) evaluates Contractor past performance on all contracts that exceed $150,000, and shares those evaluations with other Federal Government contract specialists and procurement officials. The FAR requires that the Contractor be provided an opportunity to comment on past performance evaluations prior to each report closing. To fulfill this requirement VA uses an online database, CPARS, which is maintained by the Naval Seal Logistics Center in Portsmouth, New Hampshire. CPARS has connectivity with the Past Performance Information Retrieval System (PPIRS) database, which is available to all Federal agencies. PPIRS is the system used to collect and retrieve performance assessment reports used in source selection determinations and completed CPARS report cards transferred to PPIRS. CPARS also includes access to the federal awardee performance and integrity information system (FAPIIS). FAPIIS is a web-enabled application accessed via CPARS for Contractor responsibility determination information. Each Contractor whose contract award is estimated to exceed $150,000 requires a CPARS evaluation.   A government Focal Point will register your contract within thirty days after contract award and, at that time, you will receive an email message with a User ID (to be used when reviewing evaluations).  Additional information regarding the evaluation process can be found at www.cpars.gov or if you have any questions, you may contact the Customer Support Desk @ DSN: 684-1690 or COMM: 207-438-1690. For contracts with a period of one year or less, the contracting officer will perform a single evaluation when the contract is complete. For contracts exceeding one year, the contracting officer will evaluate the Contractor s performance annually. Interim reports will be filed each year until the last year of the contract, when the final report will be completed. The report shall be assigned in CPARS to the Contractor s designated representative for comment. The Contractor representative will have sixty (60) days to submit any comments and re-assign the report to the CO. Failure for the Contractor s representative to respond to the evaluation within those sixty (60) days, will result in the Government s evaluation being placed on file in the database with a statement that the Contractor failed to respond; the Contractor s representative will be locked out of the evaluation and may no longer send comments. GOVERNMENT RESPONSIBILITIES VA Support Personnel, Services or Equipment: None contemplated. Contract Administration/Performance Monitoring: After award of contract, all inquiries and correspondence relative to the administration of the contract shall be addressed to: (enter contract administration if not already listed in another area- list the title (not name) and contact information for COR, Clinical point of contact, and any other relevant personnel involved). CO RESPONSIBILITIES: The Contracting Officer is the only person authorized to approve changes or modify any of the requirements of this contract. The Contractor shall communicate with the Contracting Officer on all matters pertaining to contract administration. Only the Contracting Officer is authorized to make commitments or issue any modification to include (but not limited to) terms affecting price, quantity or quality of performance of this contract. The Contracting Officer shall resolve complaints concerning Contractor relations with the Government employees or patients. The Contracting Officer is final authority on validating complaints. In the event the Contractor effects any such change at the direction of any person other than the Contracting Officer without authority, no adjustment shall be made in the contract price to cover an increase in costs incurred as a result thereof. In the event that contracted services do not meet quality and/or safety expectations, the best remedy will be implemented, to include but not limited to a targeted and time limited performance improvement plan; increased monitoring of the contracted services; consultation or training for Contractor personnel to be provided by the VA; replacement of the contract personnel and/or renegotiation of the contract terms or termination of the contract. COR Responsibilities: The COR shall be the VA official responsible for verifying contract compliance. After contract award, any incidents of Contractor noncompliance as evidenced by the monitoring procedures shall be forwarded immediately to the Contracting Officer. The COR will be responsible for monitoring the Contractor s performance to ensure all specifications and requirements are fulfilled. Quality Improvement data that will be collected for ongoing monitoring includes but is not limited to: enter data that may be collected. This contract is established with payment by 1358, therefor, COR will NOT review and certify monthly invoices for payment. All invoices will be submitted to the local fee office for review and certification for payment. All contract administration functions will be retained by the VA. SPECIAL CONTRACT REQUIREMENTS The Contractors facility shall meet all federal, state and local fire and life safety codes and must be accessible and convenient for wheelchair patients and other handicapped or disabled Veterans. Reports/Deliverables: The Contractor shall be responsible for complying with all reporting requirements established by the Contract. Contractor shall be responsible for assuring the accuracy and completeness of all reports and other documents as well as the timely submission of each. Contractor shall comply with contract requirements regarding the appropriate reporting formats, instructions, submission timetables, and technical assistance as required. Billing: Invoice requirements and supporting documentation: Payment to the Contractor shall be made monthly, in arrears, upon receipt of a properly prepared invoice. Payment for services will be at the rates agreed to in the PWS. The Contractor shall submit invoices using CMS Uniform Billing (UB-04) forms covering the services performed under this contract. The invoices shall contain the following information: Contract Number and Purchase Order Number (if applicable) Name of Beneficiary and last four digits of the Social Security Number Itemized statement of services rendered by CPT Code and Rates Total Price Payment Adjustments/Performance Related Payment Deductions: The contractor shall be paid only for actual work performed. Performance Deductions: None contemplated. Payments in full/no billing VA beneficiaries: The Contractor shall accept payment for services rendered under this contract as payment in full. VA beneficiaries shall not under any circumstances be charged nor their insurance companies charged for services rendered by the Contractor, even if VA does not pay for those services. This provision shall survive the termination or ending of the contract. To the extent that the Veteran desires services which are not a VA benefit or covered under the terms of this contract, the Contractor must notify the Veteran that there will be a charge for such service and that the VA will not be responsible for payment. The Contractor shall not bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against, any person or entity other than VA for services provided pursuant to this contract. It shall be considered fraudulent for the Contractor to bill other third party insurance sources (including Medicare) for services rendered to Veteran enrollees under this contract. Contractor Security Requirements (Handbook 6500.6) Contractor Security Requirements (Handbook 6500.6): Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures. Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness. Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor. The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination. VA INFORMATION CUSTODIAL LANGUAGE Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1). VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA s information is returned to the VA or destroyed in accordance with VA s sanitization requirements. VA reserves the right to conduct onsite inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements. Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract. The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract. The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12. If a VHA contract is terminated for cause, the associated BAA must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship. The contractor/subcontractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated. The contractor/subcontractor s firewall and Web services security controls, if applicable, shall meet or exceed VA s minimum requirements. VA Configuration Guidelines are available upon request. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA s prior written approval. The contractor/subcontractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response. Notwithstanding the provision above, the contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor is in receipt of a court order or other requests for the above mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COR. SECURITY INCIDENT INVESTIGATION The term security incident means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access. To the extent known by the contractor/subcontractor, the contractor/subcontractor s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.  LIQUIDATED DAMAGES FOR DATA BREACH Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract. The contractor/subcontractor shall provide notice to VA of a security incident as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination. Each risk analysis shall address all relevant information concerning the data breach, including the following: Nature of the event (loss, theft, unauthorized access); Description of the event, including: Date of occurrence; Data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code; (3) Number of individuals affected or potentially affected; Names of individuals or groups affected or potentially affected; Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text; Amount of time the data has been out of VA control; The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons); Known misuses of data containing sensitive personal information, if any; Assessment of the potential harm to the affected individuals; Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $37.50 per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following: Notification; One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports; Data breach analysis; Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution; One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs. TRAINING All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems: Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems; Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training; Successfully complete the appropriate VA privacy training and annually complete required privacy training; and Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document e.g., any role-based information security training required in accordance with NIST Special Publication 800-16, Information Technology Security Training Requirements.] The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.