Loren Data's SAM Daily™

FBO DAILY ISSUE OF NOVEMBER 18, 2009 FBO #2916
MODIFICATION

Q -- RETINOPHATHY SCREENING

Notice Date

11/16/2009
 

Notice Type

Modification/Amendment
 

NAICS

621512 — Diagnostic Imaging Centers
 

Contracting Office

Department of Veterans Affairs;West Palm Beach VA Medical Center;7305 North Military Trail;Palm Beach Gardens FL 33410-6400
 

ZIP Code

33410-6400
 

Solicitation Number

VA-248-10-RP-0027
 

Response Due

11/30/2009
 

Archive Date

1/29/2010
 

Point of Contact

Adalberto Afanador
 

E-Mail Address

CONTRACT SPECIALIST
(adalberto.afanador@va.gov)
 

Small Business Set-Aside

Total Small Business
 

Description

Note: This amendment is a continuation to the description of the posted on the front page of the solicitation. SPECIAL CONTRACT REQUIREMENTS Under the authority of Public Law 104-262 and 38 USC 8153, the contractor agrees to provide Health Care Resources (Retinopathy tests/screenings) in accordance with the terms and conditions stated herein, to furnish to and at the Department of Veterans Affairs Medical Center, VA EYE CLINIC OR CBOC, the services and prices specified in the Section entitled Schedule of Supplies/Services of this contract. 1. SERVICES: a. The services specified in the Sections entitled Schedule of Supplies/Services and Special Contract Requirements may be changed by a bi-lateral modification to this contract. b. Other necessary personnel for the operation of the services contracted for at the VA will be provided by the VA at levels mutually agreed upon which are compatible with the safety of the patient and personnel and with quality medical care programming. c. The services to be performed by the contractor will be performed in accordance with VA policies and procedures and the regulations of the medical staff by laws of the VA facility. 2. TERMS OF CONTRACT: This contract is effective from date of award beginning January 1, 2010 and ending 30 September 2010. The contract is subject to the availability of funds. The contractor shall perform no services after September 30, 2010. 3. QUALIFICATIONS: Personnel assigned by the Contractor to perform the services covered by this contract shall be licensed in a State, Territory, or Commonwealth of the United States or the District of Columbia. All licenses held by the personnel working on this contract shall be full and unrestricted licenses. The qualifications of such personnel shall also be subject to review by the VA Chief of Staff and approval by the VA Facility Director. Each person assigned to work under this contract shall be licensed by (insert name of governing or cognizant licensing board) 4. PERSONNEL POLICY: The contractor shall be responsible for protecting the personnel furnishing services under this contract. To carry out this responsibility, the contractor shall provide the following for these personnel: - workers compensation; professional liability insurance; health examinations - income tax withholding, and social security payments. The parties agree that the contractor, its employees, agents and subcontractors shall not be considered VA employees for any purpose. 5. RECORD KEEPING: The VA Medical Center, VA EYE CLINIC OR CBOC shall establish and maintain a record keeping system that will record the hours worked by the contractor employee(s). Contractor's employee(s) shall report to Joanne Fiore Administrative Officer, or designee upon arrival at the VA EYE CLINIC OR CBOC. 6. CONTRACT PERFORMANCE MONITORING: (SEE ATTACHMENT 3-QASP) Monitoring of contractors time shall be demonstrated through sign-in/ sign-out sheets. The contractor shall be required to sign an attendance log upon reporting to work and departing from work. Joanne Fiore, COTR, 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. 7. KEY PERSONNEL AND TEMPORARY EMERGENCY SUBSTITUTIONS: The Contractor shall assign to this contract the following key personnel: a. During the first ninety (90) days of performance, the Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment. The Contractor shall notify the Contracting Officer, in writing, within 15 calendar days after the occurrence of any of these events and provide the information required by paragraph (c) below. After the initial 90-day period of the contract, the Contractor shall submit the information required by paragraph (c) to the Contracting Officer at least 15 days prior to making any permanent substitutions. b. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the Contracting Officer. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The Contracting Officer will notify the Contractor within 15 calendar days after receipt of all required information of the decision on the proposed substitutes. The contract will be modified to reflect any approved changes of key personnel. c. For temporary substitutions where the key person will not be reporting to work for three (3) consecutive work days or more, the Contractor will provide a qualified replacement for the key person. This substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above. 8. STATEMENT OF WORK SCOPE: The VA Medical Center, West Palm Beach, Florida, has a requirement for Diabetic retinopathy screening services. Contract period shall be January 1, 2010 - September 30, 2010. VAMC WPB estimates approximately 375 patients per month. The screening exams will be conducted at the WPB facility and at the Community Based Outpatient Clinics (including any new ancillary clinics which may open in our catchment area during the contract period) depending on geographic and patient demand. Contractor shall provide pricing on a per patient basis, to be all inclusive of photographer, equipment, Doctor, interpretation and written reports. The Contractor shall provide: 1)Equipment, Photography Technician, and Optometrist or board certified Ophthalmologist, or Reading Center under the direction of a Medical Director (board certified Ophthalmologist who is a retinal specialist), for image reading. Contractor shall provide imaging system that includes photography workstation with computer and digital camera equipment. Included are all maintenance/PM (with parts & labor, etc.), calibrations, etc. necessary for operation. If the equipment is damaged, a field engineer will be dispatched from the Contractor's offices to service the equipment and return it to the original delivered configuration. The Contractor will be required to provide backup equipment if equipment is down for greater than 48 hours. Contractor will supervise the photography technician. Photography technician shall not be deemed or construed as a VA Employee. The Contractor is responsible for the quality of images performed by the photography technician. The Contractor will submit to VA Contracting Office, quality measures, review findings, and corrective measures taken of all work performed. Professional appearance of photography technician required at all times. Contractor shall provide backup for technician if he/she requests sick/annual/family leave, to ensure no interruptions of scheduled patients. 2)Interpretation of the images and written reports: a.Contractor shall provide medical supervision of the program and image evaluation services for the reading of the images. b.All interpretations of the images shall be done by a licensed Optometrist or board certified Ophthalmologist credentialed, privileged and appointed by VA, or by a qualified reading center operating under the direction of a Medical Director (board certified Ophthalmologist who is a retinal specialist) credentialed, privileged and appointed by WPB VAMC. c.Contractor shall provide an electronic report back to the referring physician through CPRS Electronic Medical Record. Report is required to be available in CPRS within 48 hours of photograph. d.Contractor shall provide direct physician-to-physician contact by telephone should a patient need immediate attention. All results will be entered into CPRS. e.Documentation to include, but not be limited to, presence or absence of diabetic retinopathy (preferably with ETDRS Final Retinopathy Severity Scale Level for each eye, macular edema stage for each eye), patient care recommendation according to the latest VHA/DoD Guidelines for Management of Patients with Diabetes Mellitus, and any other necessary information to meet clinical reminder requirements for retinal screening. f.Monthly report to the VA Medical Center Listing of the total number of Services performed and detailed information regarding each individual Services, specifically including: (1)date of service (2)Patient Unique Identifiers (3)Presence or absence of diabetic retinopathy (preferably with ETDRS Level and ETDRS Macular Edema Status) (4)Management Recommendations g.Provide VAMC with documentation of established quality assurance protocols and quarterly quality assurance reports. The reading center must be able to identify the quality assurance protocols used to monitor and validate its practices with regard to the process by which the images are read and provide WPB VAMC with documentation of same. The Contractor will also be expected to participate in onsite reviews and/or inspections as needed to ensure quality and continuous monitoring of the retinal screening program. WPB VAMC will also be conducting monthly and quarterly quality reviews related to timeliness and quality of examinations and completeness of documentation. Results of these reviews will be shared with the Contractor. The Contractor will respond with an action plan to correct any deficiencies within 14 days. h.Contractor shall obtain images from each eye, labeling and storing the images and associated medical record data, in a manner consistent with standards for electronic patient medical records, HIPPA and VAMC policies and procedures. i.Contractor will design, configure, provide for purchase by VA and install a retinal image storage solution as a FDA validated component of the Contractor's system for purposes of local hosting and access (behind the VA firewall) of all patient images acquired by Contractor. The storage solution will be preconfigured and validated by Contractor and implemented in a designated hosting facility within the local VA facility's network. j.Contractor will design, configure, provide for purchase by VA and install a retinal image viewing workstation which is a FDA validated component of the Contractor's overall system. The viewing system allows access to content on the storage solution. k.Ongoing administration and support of the storage and viewing devices will be provided by Contractor with repairs or upgrades provided on a materials-only basis. l.The contractor must perform the required work in accordance with Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards and/or any other regulatory standards i.e. OSHA, VHA, HIPAA. The contractor must comply with all annual updates as issued. The contractor shall also comply with the policies of the VA. 9. West Palm Beach VA Medical Center shall provide the following: (a)Adequate space for the Contractor-owned camera system or systems (b)Adequate hosting facilities for the VA purchased storage solution consistent with typical data center requirements (e.g. rack space, power, network connectivity, A/C, etc.) plus adequate space for VA-purchased viewing station. (c)Local Area Network access with network support for all connected components described herein. (d)Backup of the storage device will be the responsibility of the VA. Contractor will assist with any installation/configuration of backup software or agents as required. (e)Access to VA Computerized Patient Records System (CPRS) for review of medical information and entry of report. (f)Site-to-site remote (VPN) access (g)Disposable sunglasses for patient use following pupil dilation. (h)Primary Care referrals and list of patients eligible for the imaging service. 10. WORK SCHEDULE: The Contractor shall be required to furnish such services during normal VA business houses (8:00 a.m. - 4:30 p.m.), excluding (Federal) national holidays. National (Federal) holidays are: New Year's Day, Martin Luther King Jr.'s Birthday, President's Day, Memorial Day, 4th of July, Labor Day, Columbus Day, Veterans' Day, Thanksgiving Day, and Christmas Day. When one of the holidays falls on a Sunday, the following Monday will be observed as a legal holiday. When a holiday falls on a Saturday, the preceding Friday is observed as a national holiday by U.S. Government Agencies. Also included would be any day specifically declared by the President of the United States of America as a national holiday. 11. CONTRACTOR PERSONNEL SECURITY REQUIREMENTS: a. Contractor shall insure the confidentiality of all patient and employee information and shall be held liable in the event of breach of confidentiality. Any person, who knowingly or willingly discloses confidential information from the VA Medical Center, may be subject to fines of up to $20,000.00 as referenced in the VHA Handbook 1605.1, revised May 16, 2006, Privacy and Release of Information. b. All contractor employees who require access to the department of Veterans Affairs' computer system shall be the subject of a background investigation and must receive a favorable adjudication from the VA Office of Security and Law Enforcement prior to contract performance. This requirement is applicable to all subcontractor personnel requiring the same access. If the investigation is not completed prior to the start date of the contract, the contractor will be responsible for the actions of those individuals they provide to perform work for VA. Should a vendor other than OPM or the Defense Security Service (DSS) conduct the investigation, the investigating agency must possess OPM and DSS certification. Further, the investigative/clearance history must be maintained in the databases of OPM, the Defense Central Investigations Index (DCII), or the Defense Industrial Security Clearance Organization (DISCO). (1) Position Sensitivity - The position sensitivity has been designated as low risk. (2) Background Investigation - The level of background investigation commensurate with the required level of access is National Agency Check with Written Inquires. (3) Contractor Responsibilities (a) The contractor shall submit or have their employees submit the following required forms to the VA Contracting Officer within 30 days of employment: Standard Form 85P, Questionnaire for Public Trust Positions (i)Standard Form 85P-S, Supplemental Questionnaire for (ii)Selected Positions (iii)FD 258, U.S. Department of Justice Fingerprint Applicant (iv)Chart (v)VA Form 07-10, Authority for Release of Information Form (vi)Optional Form 306, Declaration for Federal Employment (vii)Optional Form 612, Optional Application for Federal (viii)Employment. c. The contractor shall bear the expense of obtaining background investigations. If the investigation is conducted by the Office of Personnel Management (OPM), the contractor shall reimburse VA within 30 days. d. The contractor shall prescreen all personnel requiring access to the computer systems to ensure they maintain a U.S. citizenship and are able to read, write, speak and understand the English language. e. The contractor, when notified of an unfavorable determination by the Government, shall withdraw the employee from working under the contract. f. Failure to comply with the contractor personnel security requirements may result in termination of the contract for default. g. Government Responsibilities (1) The VA Office of Security and Law Enforcement will provide the necessary forms to the contractor or to the contractor's employees after receiving a list of names and addresses. (2) Upon receipt, the VA Office of Security and Law Enforcement will review the completed forms for accuracy and forward the forms to OPM to conduct the background investigation. (3) The VA facility will pay for investigations conducted by the Office of Personnel Management (OPM) in advance. In these instances, the contractor will reimburse the VA facility within 30 days. (4) The VA Office of Security and Law Enforcement will notify the contracting officer and contractor after adjudicating the results of the background investigations received from OPM. (5) The contracting officer will ensure that the contractor provides evidence that investigations have been completed or are in the process of being requested. h. Contractor personnel who obtain access to hardware or media which may manipulate or store drug or alcohol abuse data, sickle cell anemia treatment records, records or tests or treatment for or infection with HIV, medical quality assurance records, or any other sensitive information protected under 38 U.S.C. 4132 or 3305, as defined by the Department of Veterans Affairs, shall not have access to the records unless absolutely necessary to perform their contractual duties. Any individual who has access to these data will disclose them to no one, including other employees of the Contractor not involved in the performance of the particular contractual duty for which access was obtained. Violation of these statutory provisions, as stated in department regulations by the Contractor's employees may involve imposition of criminal penalties. i. System of Records: The Veterans Administration system(s) of records to which the Contractor personnel will have access in order to maintain is "Patient Medical Records - VA (24VA136). j. Systems Security: The Contractor shall provide VHA with the full assurance that security measures have been implemented which are consistent with OMB Circular A-130 and VA Departmental Standards. k. Procedures for User Access: Access requirements to VA information systems by Contractors and Contractor personnel shall meet or exceed those requirements established for VHA employees as described in VHA Directives (and others) and in any subsequent VHA policy statements. A written and signed request for user access by VHA Management, or designee(s), constitutes management approval (sponsorship) to initiate a request for access to any sensitive automated information system. Access shall be granted to non-VA users only if the purpose for access meets criteria of the Privacy Act and VA Confidentiality regulations and transfer. Contractor will be required to sign and abide by the VA Computer Access Security Agreement and Confidentiality Agreement. All Contractor personnel will be required to complete VA Privacy Awareness and VA Information Security Awareness and Rules of Behavior training prior to being granted user access and then annually. 12. MEDICAL RECORDS REQUIREMENTS: Contractor will provide health care to patients seeking care from or through VA. As such, Contractor is considered part of the Department health care activity for purposes of the following statues and the VA regulations implementing these statutes: the Privacy Act, 54 U.S.C. 552a, and 38 U.S.C. 5701, 5705 and 7332 and HIPAA. Contractor and its employees may have access to VA patient medical records to the extent necessary for the contractor to perform this contract. Notwithstanding any other provision of this contract, contractor and its employees may disclose patient treatment records generated by the contractor under this agreement only pursuant to explicit disclosure authority from VA. Contractor and its employees are subject to the penalties and liabilities provided in the statues and regulations mentioned in this paragraph for unauthorized disclosures of such records and their contents. 1. Records created by the contractor in the course of treating VA patients under this contract are and remain the property of the VA and shall not be accessed, released, transferred or destroyed except in accordance with applicable federal law and regulations. 2. The treatment and administrative patient records created by, or provided to, the contractor under this agreement are covered by the VA system of records entitled "Patient Medical Records-VA" (24VA136), 48 C.F.R. 52.239-1. 3. VA utilizes a fully automated electronic medical record (EMR). The EMR consists of two primary components. The first is the Veterans Health Information System and Technology Architecture (VISTA). The second component uses optical disk imaging technology to meet the remaining EMR information needs. 4. VA will provide the necessary training to contractor personnel on the proper use and operation of the computerized medical records system. Contractor personnel must sign access agreements to gain entrance to the system and are bound by confidentiality and release of information restrictions. 5. The VA has an unrestricted right of access to all medical records. All other requests and consents for release of information (third party) should be referred to the Release of Information Unit, Health Information Management Section (HIMS) of Medical Administration Service (MAS-136H). 6. Any record amendment requests or subpoena duces tecum with and without deposition should be forwarded to the Chief, Health Information Management Section/designee for appropriate processing. 13. SCHEDULE (attachment 4) (submit as a separate sheet) This contract shall be effective from 1/1/2010 -09/30/2010. PERIOD (1/1/2010 to 09/30/2010) Contract Line Item (CLIN) 1. Provide diabetic retinopathy Detection/screening in accordance With the attached Statement of Work, terms and conditions EST. QUANTITY 375/Month COST EACH $______ TOTAL COST $__________ 14. SOLICITATION PROVISIONS: FAR 52.212-1 Instructions to Offerors - Commercial Items (Jun 2008). SPECIAL NOTES (1)Any questions regarding this solicitation should be directed to Contract Specialist, Adalberto Afanador, by e-mail Adalberto.Afanador@va.gov no later than 10:00 A.M. November 28, 2009. Questions received after this date may not receive a response. (2)Contractor shall submit a Firm-Fixed Price proposal with F.O.B. Destination delivery terms. (3)All information requested must be filled out completely or your company's proposal may be considered non-responsive. (4)Offerors are hereby notified that award shall be made to an offeror who is registered in the Central Contractor Register (CCR). Registration can be accomplished through the following Internet Address: http://www.ccr.gov. (5)The Government intends to award a firm fixed price contract for the services. The period of performance is 1 January 2010 - 30 September 2010 (6)Priority for Contracting Preferences: Pursuant to 38 U.S.C. 8127(i), set-aside preferences for awarding contracts to small business concerns shall be applied in the following order of priority: (1) SDVOSB; (2) VOSB; (3) Contracts awarded pursuant to: (a) Section 8(a) of the Small Business Act (15 U.S.C. 637(a)); or (b) Section 31 of such Small Business Act (15 U.S.C. 657a) (HUBZone); and (4) Contracts awarded pursuant to any other small business contracting preference. 15. CHECKLIST One (1) page with the Pricing (only one line item) (see attachment 4) Suggestion: Complete the schedule with the pricing amounts for Contract line Item (CLIN) contained in the solicitation section titled Price Schedule 1.Provide three (3) copies of a technical proposal of the items being offered in sufficient detail to evaluate compliance with the requirements in the solicitation. (Note: Only one submission if submitted electronically.) See: 52.212-2 EVALUATION--COMMERCIAL ITEMS (JAN 1999) 2.The proposals require a cover page with at least the following information. a.)The solicitation number b.)The name, address, and telephone number of the offeror; e-mail c.)Duns & Bradstreet # and Tax ID Number d.)Electronic submissions are preferred and can be sent in either Microsoft Word (i.e.,.doc) or Adobe file (i.e., pdf) format. The E-mail subject line shall contain the Solicitation number and Offeror's name (i.e., company name) (Example: ABC Company VA-248-10-RP-0027. If an offeror is submitting a hard copy the following guidance shall be followed. 1.Follow the guidance provided above. 2.Hard copies shall be provided on loose leaf paper in a folder or paper clipped. The proposals shall not be stapled and or inserted into any type of binder. The above is requested because the hard copies are scanned and added to an electronic contract file. 3.Past Performance Documents shall be submitted in accordance with guidance provided in this Solicitation. (see attachment 2) 4. Point of contact is Adalberto Afanador, Contract Specialist e-mail Adalberto.Afanador@va.gov Disclaimer The purpose of the checklist is to provide assistance to offerors as it pertains to submission requirements. It is not intended to alter and or replace the requirements set forth in the solicitation. The offeror is responsible to read and conform to the solicitation in its entirety. ATTACHMENT 1 ADDENDUM 52.212-2 EVALUATION--COMMERCIAL ITEMS (JAN 1999) 1. PROCESS "Proposals will be evaluated in accordance with the requirements of Federal Acquisition Regulation (FAR) Part 12.6. When all proposal evaluations (Technical, Past Performance and Price) are completed, the Contracting Officer will make the judgments required, all factors considered, in selection of the offeror whom he/she considers having the ability to perform overall the contract in a manner most advantageous to the Government. "The Government may award a contract on the basis of initial offers received, without discussions. Therefore, each initial offer should contain the offeror's best terms from a cost/price and technical standpoint. "The Government may make a single or multiple awards contingent upon best value and the offeror's ability to meet all requirements. The Government intends to make an award based on the best value to the Government by performing a price/technical tradeoff analysis. "Understanding the factors and the associated criteria indicate the excellence of the work offered and the ability of the offeror to actually accomplish what is offered. Proposals will be evaluated based upon factors and criteria set-forth herein. " The relative importance of each Sub-factor is shown in descending order of preference. "Offerors shall submit in detail adequate information for evaluation purposes on the evaluation criteria. Each area shall be specifically labeled and identifiably separate from other areas. The award will be on a firm-fixed price. Price shall be submitted under separate cover from the other evaluation criteria. The offeror with the lowest capitation rate alone will not necessarily be awarded the contract. 2.EVALUATION FACTORS A.Technical Evaluation Factor 1 - Experience and Staffing: Subfactor 1: Provide a list of the names of the qualified physicians and other staff intended to be utilized in the performance of this contract and/or describe the mechanism used to provide qualified physicians and staff to perform the contract work. Provide copies of the following information on any physician to be assigned to this contract. Include physicians providing coverage relief: (i) Board certification in Ophthalmology with special training in retinal screening (ii) Active, current, unrestricted license. (iii) Curriculum Vitae. (iv) Completed application process information including application Form 10-2850 and three (3) narrative letters of reference. Subfactor 2: Describe the mechanism to schedule qualified staff to cover the required clinic schedule. Describe contingency plan for covering assign patients' appointments due to schedule or unscheduled leave. Subfactor 3: List the number of administrative support staff and describe the level of training and experience that will be utilized to meet the administrative support functions of this contract, including such functions as patient scheduling, medical record documentation, record processing and reporting, and quality assurance and performance improvement. Subfactor 4: Describe average personnel turnover rate and how it might affect contract performance. Describe the capability to recruit adequate staffing to meet the needs of this contract. Subfactor 5: Describe your organization structure and management practices relative to the requirements contained in the contract. B. Technical Evaluation Factor 2 - Coordination and Continuity of Care: Subfactor 1: Describe the ability to provide the full range of services covered under this contract. Subfactor 2: Describe the performance measurement process that will be implemented to monitor quality, appropriateness of care and patient satisfaction. Subfactor 3 - Describe the computer hardware and software and other equipment available to be utilized under this contract. Describe your contingency plan for equipment downtime. C. Evaluation Factor 3 - Past Performance Past performance information is one indicator of an offeror's ability to perform the contract successfully. Current and relevant information, source of information, context of data, and general trends in contractor's performance will be considered as it pertains to the performance of work described in this solicitation. Provide a minimum of three (3) past performance surveys*, (including Federal, State and local Government and private), including names, telephone and fax numbers of responsible individuals who would have firsthand knowledge of performance relative to the same type of service. Offerors with no relevant performance history will not be evaluated favorably or unfavorably on past performance. Offerors may provide information on problems encountered on identified contracts and the offeror's corrective action. The Government shall consider this information as well as information obtained from any other sources, when evaluating the offeror's past performance. The VA shall determine the relevance of similar past performance information. *past performance survey see attachment 2 D. Evaluation Factor 4 - Price: The cost stated in the Schedule of Services is to be inclusive of all services and must be stated as a cost per completed screening examination. *Note: When combined technical evaluations and past performance are more important than price. ATTACHMENT 2 PAST PERFORMANCE SURVEY (Due to West Palm Beach Contracting Office no later than 12/2/2009) REFERENCE INSTRUCTIONS: VA Medical Center, West Palm Beach Fl is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm's past performance. The intent of this form is to evaluate Diabetic Retinopathy Services. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror's past performance. Survey should be completed by evaluator and returned no later than the above date, or by Facsimile to: 561-422-6507 Information of company to be evaluated: Company name: ________________________________________ Address: _______________________________________________ ________________________________________________ ________________________________________________ Information of company's evaluating: Evaluator's name: __________________________________ Title: _________________________________________ Company name: __________________________________ Address: __________________________________________ Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, please provide additional information in the appropriate block or in the remarks section of this form. "O" =Outstanding =Performance greatly exceeded the contract requirements. "A" =Above Average =Performance exceeded the contract requirements "S" =Satisfactory =Performance met the contract requirements "M" =Marginal =Performance met the minimum contract requirements but some material aspects of the contractor's performance were less than satisfactory "U" =Unacceptable =Performance was poor and/or did not satisfy contract requirements Please rate and provide information/comments for the following:Circle one Q1. To what extent did the contractor comply with contract requirements? O A S M U Q2. If reports were required, were they accurate in meeting contract requirements? O A S M U Q3. To what extent did the contractor use appropriate personnel for contract requirements? O A S M U Q4. To what extent did the contractor display technical expertise? O A S M U Q5. Quality control: O A S M U Please rate and provide information/comments for the following:Circle one T1. To what extent was contractor able to meet the performance schedule: O A S M U T2. What extent was contractor flexible in responding to changing needs? O A S M U T3. To what extent was the contractor reliable? O A S M U T4. To what extent was the contractor responsive to technical directions? O A S M U T5. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain. Yes No C1. Would you award another contract to the party being evaluated? If no, please explain: Yes No C2. Was the customer satisfied with the end product? If no, please explain: Yes No C3. To what extent did contractor notify you of problems or potential problems? O A S M U 15. Additional Remarks: Signature of Evaluator Date ATTACHMENT 3 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) For: Health Care Resources (Retinopathy tests/screenings) Contract Number: ____________________________ Contract Description: Under the authority of Public Law 104-262 and 38 USC 8153, the contractor agrees to provide Health Care Resources (Retinopathy tests/screenings) in accordance with the terms and conditions stated herein, to furnish to and at the Department of Veterans Affairs Medical Center, VA EYE CLINIC OR CBOC, the services and prices specified in the Section entitled Schedule of Supplies/Services of this contract. SERVICES a. The services specified in the Sections entitled Schedule of Supplies/Services and Special Contract Requirements may be changed by a bi-lateral modification to this contract. b. Other necessary personnel for the operation of the services contracted for at the VA will be provided by the VA at levels mutually agreed upon which are compatible with the safety of the patient and personnel and with quality medical care programming. c. The services to be performed by the contractor will be performed in accordance with VA policies and procedures and the regulations of the medical staff by laws of the VA facility. Contractor's name: ___________________________________ A.PURPOSE This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following: "What will be monitored. "How monitoring will take place. "Who will conduct the monitoring. "How monitoring efforts and results will be documented. This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government's responsibility to be objective, fair, and consistent in evaluating performance. This QASP is a "living document" and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities. B. GOVERNMENT ROLES AND RESPONSIBLITIES The following personnel shall oversee and coordinate surveillance activities. (1)Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor's performance. The VA will provide the following: "Adequate space for the Contractor-owned camera system or systems "Adequate hosting facilities for the VA purchased storage solution consistent with typical data center requirements (e.g. rack space, power, network connectivity, A/C, etc.) plus adequate space for VA-purchased viewing station. "Local Area Network access with network support for all connected components described herein. "Backup of the storage device will be the responsibility of the VA. Contractor will assist with any installation/configuration of backup software or agents as required. "Access to VA Computerized Patient Records System (CPRS) for review of medical information and entry of report. "Site-to-site remote (VPN) access "Disposable sunglasses for patient use following pupil dilation. "Primary Care referrals and list of patients eligible for the imaging service. Assigned CO: ______________________ Assigned Administrative Contracting Officer: Adalberto Afanador Organization or Agency: Department of Veterans Affairs, Procurement Business Division (2). Contracting Officer's Technical Representative (COTR) - The COTR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor's performance. The COTR shall keep a quality assurance file. The COTR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government's behalf. Assigned COTR: Joanne Fiore, Health Systems Specialist (3). Other Key Government Personnel C. CONTRACTOR REPRESENTATIVES The following employees of the contractor serve as the contractor's program manager for this contract. a.Program Manager - ________________________________ (Contractor Personnel) b.Other Contractor Personnel - (if applicable) D. PERFORMANCE STANDARDS Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards. The Performance Requirements are listed below in Section 5. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL). Compare contractor performance to the Acceptable Quality Level (AQL). E. METHODS OF QA SURVEILLANCE Various methods exist to monitor performance. The COTR shall use the surveillance methods listed below in the administration of this QASP. TaskIDIndicatorStandardAcceptable Quality LevelMethod of Surveillance Basic Services1The services to be performed by the contractor will be performed in accordance with VA policies and procedures and the regulations of the medical staff by laws of the VA facility. The contractor will perform all duties in accordance with the SOW and local VA policies100%Direct Observation, periodic and random inspection (auditing) 2Staffing and equipmentEquipment, Photography Technician, and Optometrist or board certified Ophthalmologist, or Reading Center under the direction of a Medical Director (board certified Ophthalmologist who is a retinal specialist), for image reading. Contractor shall provide imaging system that includes photography workstation with computer and digital camera equipment. Included are all maintenance/PM (with parts & labor, etc.), calibrations, etc. necessary for operation. If the equipment is damaged, a field engineer will be dispatched from the Contractor's offices to service the equipment and return it to the original delivered configuration. The Contractor will be required to provide backup equipment if equipment is down for greater than 48 hours. Contractor will supervise the photography technician. Photography technician shall not be deemed or construed as a VA Employee.100%Direct Observation, periodic and random inspection (auditing) 3Quality Of imagesThe Contractor is responsible for the quality of images performed by the photography technician. The Contractor will submit to VA Contracting Office, quality measures, review findings, and corrective measures taken of all work performed.100%Direct Observation monthly and random inspection (auditing) Basic Service4Interpretation of imagesAll interpretations of the images shall be done by a licensed Optometrist or board certified Ophthalmologist credentialed, privileged and appointed by VA, or by a qualified reading center operating under the direction of a Medical Director (board certified Ophthalmologist who is a retinal specialist) credentialed, privileged and appointed by WPB VAMC.100%Direct Observation monthly and random inspection (auditing) Employee files 5Electronic report to referring physicianContractor shall provide an electronic report back to the referring physician through CPRS Electronic Medical Record. Report is required to be available in CPRS within 48 hours of photograph. Contractor shall provide direct physician-to-physician contact by telephone should a patient need immediate attention. All results will be entered into CPRS.100%Direct Observation monthly and random inspection (auditing) 6Clinical DocumentationDocumentation to include, but not be limited to, presence or absence of diabetic retinopathy (preferably with ETDRS Final Retinopathy Severity Scale Level for each eye, macular edema stage for each eye), patient care recommendation according to the latest VHA/DoD Guidelines for Management of Patients with Diabetes Mellitus, and any other necessary information to meet clinical reminder requirements for retinal screening100%Direct Observation monthly and random inspection (auditing) Quality Care: Reports Licensing Handling of Medical Records 7Monthly ReportsMonthly report to the VA Medical Center Listing of the total number of Services performed and detailed information regarding each individual Services, specifically including: (a)date of service (b)Patient Unique Identifiers (c)Presence or absence of diabetic retinopathy (preferably with EDTRS LEVEL AND ETDRS Macular Edema Status) (d)Recommendation100%Direct Observation quarterly and random inspection (auditing) 8LicensingAll providers must carry sufficient license to carry out duties as prescribed in section statement of work100%Direct Observation quarterly and random inspection (auditing) 9Medical RecordsContractor shall obtain images from each eye, labeling and storing the images and associated medical record data, in a manner consistent with standards for electronic patient medical records, HIPPA and VAMC policies and procedures100%Direct Observation quarterly and random inspection (auditing) Equipment operation, Professional standards; And security requirements10Retinal Image storage Viewing workstation admin and SupportOperate, maintain, repair and upgrade Retinal image equipment98% Day to day operation. 11Joint Commission Standards The contractor must perform the required work in accordance with Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards and/or any other regulatory standards i.e. OSHA, VHA, HIPAA. The contractor must comply with all annual updates as issued. The contractor shall also comply with the policies of the VA100%Direct Observation quarterly and random inspection (auditing) 12CONTRACTOR PERSONNEL SECURITY REQUIREMENTS:Contractor shall insure the confidentiality of all patient and employee information and shall be held liable in the event of breach of confidentiality. Any person, who knowingly or willingly discloses confidential information from the VA Medical Center, may be subject to fines of up to $20,000.00 as referenced in the VHA Handbook 1605.1, revised May 16, 2006, Privacy and Release of Information..)100%Observation and random inspection (auditing) F. RATINGS The contractor is expected to meet the acceptable quality level at all time and will receive full annual inspections of facilities and services at the 100% level. The contractor will be rated on a scale of as follows: "Outstanding - Exceptional Quality "Satisfactory-Meets Standard - There may be recommendations for process improvement recommended. Areas needing f/u or improvement will be provided by Contracting Officer Technical Representative. "Marginal-Needs Improvement - Areas requiring f/u and improvement will be provided by the Contracting Officer Technical Representative. "Unsatisfactory-Unacceptable - Results in formal investigation and written plan of improvement. " If the agency is unable to comply with acceptable standards, the following will occur: "The contractor will receive written notice of a fact-finding investigation of all breaches of patient safety, and will be given 72 hours to respond to written safety recommendations. Refusal will result in termination of the contract. "The contractor will receive written documentation of any investigation with regarding patient satisfaction, basic services, and quality care and will comply with recommendations for performance improvement within 7 days. "The contractor will provide evidence of improvement processes within 7 days. G. DOCUMENTING PERFORMANCE (1). ACCEPTABLE PERFORMANCE The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action. (2). UNACCEPTABLE PERFORMANCE When unacceptable performance occurs, the COTR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COTR shall document the discussion and place it in the COTR file. When the COTR determines formal written communication is required, the COTR shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor's program manager. The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to present this corrective action plan to the COTR. The Government shall review the contractor's corrective action plan to determine acceptability. Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. H. FREQUENCY OF MEASUREMENT (1). Frequency of Measurement. During contract performance, the COTR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. (2). Frequency of Performance Assessment Meetings. The COTR shall meet with the contractor QUARTERLY to assess performance and shall provide a written assessment and forward report to contracting officer. _____________________________ Signature - Contractor Program Manager _____________________________ Signature - Contracting Officer's Technical Representative ATTACHMENT 4 (schedule of prices) This contract shall be effective from 1/1/2010 -09/30/2010. PERIOD (1/1/2010 to 09/30/2010) Contract Line Item (CLIN) 1. Provide diabetic retinopathy Detection/screening in accordance With the attached Statement of Work, terms and conditions EST. QUANTITY 375/Month COST EACH $______ TOTAL COST $__________ CONTRACT CLAUSES: FAR 52.202- 1 Definitions. As prescribed in 2.201, insert the following clause: Definitions (July 2004) FAR 52.203-5 Covenant Against Contingent Fees. As prescribed in 3.404, insert the following clause: (Apr 1984) FAR 52.203-6 Restrictions on Subcontractor Sales to the Government. As prescribed in 3.503-2, insert the following clause: (Sept 2006) FAR 52.203-7 Anti-Kickback Procedures. As prescribed in 3.502-3, insert the following clause: (Jul 1995) FAR 52.204-7 Central Contractor Registration (Apr 2008) FAR 52.204-9 Personal Identity Verification of Contractor Personnel (Sep 2007) FAR 52.212-4 Contract Terms and Conditions -- Commercial Items (Mar 2009). FAR 52.212-5 Contract Terms and Conditions Required To Implement Statutes Or Executive Orders -- Commercial Items (Aug 2009) For the purpose of this clause, items (b) 6, 10, 19, 21, 22, 23, 24, 27, and 40 are considered checked and apply. FAR 52.216-18 Ordering (Oct 1995) for the purpose of this clause insert: (October 1, 2009 through September 30, 2010) FAR 52-216-19 Order Limitations (Oct 1995) For the purpose of this clause, the blanks are filled in as: (a) $100.00 (b) (1) $100,000.00 (b)(2) $100,000.00 (b)(3) 30 days, (d) two days. FAR 52.216-22 Indefinite Quantity (Oct 1995) for the purposes of this clause insert (September 30, 2010) FAR 52.217-8 Option to Extend Services (Nov 1999) (Insert 30 days) FAR 52.217-9 Option to Extend the Term of the Contract (Mar 2000) (Insert 30 days and 60 days) FAR 52.224-1 Privacy Act Notification (Apr 1984) FAR 52.224-2 Privacy Act (Apr 1984) FAR 52.225-13 RESTRICTIONS ON CERTAIN FOREIGN PURCHASES (Mar 2005). FAR 52.232-1 Payments. (Apr 1984) FAR 52.233-1 Disputes (July 2002) FAR 52.233-2 Service of Protest. (Sept 2006) FAR 52.233-3 Protest after Award. (Aug 1996) FAR 52.233-4 Applicable Law for Breach Of Contract Claim (Oct 2004) FAR 52.236-5 -- Material and Workmanship. (Apr 1984) FAR 52.237-2 Protection of Government Building, Equipment, and Vegetation (Apr 1984) FAR 52.237-3 Continuity of Services (Jan 1991) FAR 52.244-6 Subcontracts for Commercial Items. (Aug 2009) FAR 52.252-2 Clauses Incorporated By Reference (Feb 1998) for the purposes of this clause, the blanks are filled in as http://www.acquisition.gov/far/index.html and http://www.va.gov/oamm/oa/ars/policyreg/vaar/index.cfm respectively. VAAR 852.203-70 Commercial Advertising (Jan 2008) VAAR 852.203-71 Display of Department of Veterans Affairs Hotline Poster (Dec 1992) VAAR 852.216-70 Estimated Quantities (Apr 1984) VAAR 852.237-7 Indemnification and Medical Liability Insurance (Jan 2008) For the purpose of this clause, insert $1,000,000.00. VAAR 852.237-70 Contractor Responsibilities (Apr 1984) VAAR 852.271-70 Nondiscrimination in Services Provided to Beneficiaries (Jan 2008) VAAR 852.273-75 Security Requirements for Unclassified Information Technology Resources (Interim - Oct 2008) VAAR 852.273-76 Electronic Invoice Submission (Interim - Oct 2008) FAR 52.212-3 Offeror Representations and Certifications -- Commercial Items (Aug 2009): Offerors must include a completed copy of the provision with its offer. FAR 52.216-1 Type of Contract (Apr 1984) For the purpose of this clause, the blank is filled in as Firm Fixed Price, Indefinite Quantity. FAR 52.252-1 Solicitation Provisions Incorporated by Reference (Feb 1998) For the purpose of this provision, the blanks are filled in as http://www.acquisition.gov/far/index.html and http://www.va.gov/oamm/oa/ars/policyreg/vaar/index.cfm respectively. VAAR 852.270-1 Representatives of Contracting Officers (Jan 2008) VAAR 852.273-70 Late Offers (Jan 2003) VAAR 852.273-74 Award Without Exchanges (Jan 2003)
 

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