SPECIAL NOTICE
R -- REQUEST FOR INFORMATION | Veterans Health Administration | VISN 5 The Joint Commission Continuous Readiness Mock Surveys and Education Program
- Notice Date
- 10/18/2023 6:09:43 AM
- Notice Type
- Special Notice
- NAICS
- 541611
— Administrative Management and General Management Consulting Services
- Contracting Office
- 245-NETWORK CONTRACT OFFICE 5 (36C245) LINTHICUM MD 21090 USA
- ZIP Code
- 21090
- Solicitation Number
- 36C24524Q0058
- Response Due
- 10/24/2023 10:00:00 AM
- Archive Date
- 12/23/2023
- Point of Contact
- AMY.WALTER1@VA.GOV, CONTRACTING OFFICER, Phone: 410-691-7312
- E-Mail Address
-
Amy.Walter1@va.gov
(Amy.Walter1@va.gov)
- Awardee
- null
- Description
- REQUEST FOR INFORMATION 36C24524Q0058 Statement of Work For Joint Commission Continuous Readiness Mock Surveys and Education Program VISN 5 The following Statement of Work outlines contractor requirements regarding the provision of The Joint Commission (TJC) Continuous Readiness Assessment Services and Educational Programs to six of the VISN 5 facilities along with their respective sub-stations and Community Based Outpatient Clinics: VA Maryland Health Care System (STA 512), Maryland (Multi-Division Site) Beckley VAMC (STA 517), Beckley, West Virginia Louis A Johnson VAMC (STA 540), Clarksburg, WV Martinsburg VAMC (STA 613), Martinsburg, WV Washington DC VAMC (STA 688), Washington DC Huntington VAMC (STA 581), Huntington WV SCOPE The Contractor is to provide a Continuous Readiness Assessment JC Survey and/or Education for the purpose of performance improvement, improving system effectiveness, and achieving and maintaining compliance with JC standards for the selected VISN 5 facilities and its CBOC s. The assessment will be inclusive of the four TJC programs: Hospital, Home Care, Behavioral Health (including Opioid), and Nursing and Rehabilitation. DEFINITIONS AND TERMS: As used throughout this statement of work, the following terms shall have the meaning set forth below: Environment of Care (EC) The goal of this chapter is to promote a safe, functional, and supportive environment within the hospital so that quality and safety are preserved. The environment of care is made up of three basic elements: - The building or space, including how it is arranged and special features that protect patients, visitors, and staff - Equipment used to support patient care or to safely operate the building or space - People, including those who work within the hospital, patients, and anyone else who enters the environment, all of whom have a role in minimizing risks. Fire Safety Management Activities selected and implemented by the organization to assess and control the risks of fire, smoke, and other byproducts of combustion that could occur during the organization s provision of care, treatment, or services. Fire-Rated Material that has undergone a test and is fire protection rated or fire resistance rated. Two examples of the concept of fire-rated include the following: - fire resistance rating - The time, in minutes or hours, that materials or assemblies have withstood a fire exposure, as determined by tests, or methods based on tests, prescribed by the National Fire Protection Association (NFPA). - fire protection rating - A designation indicating the duration of fire test exposure to which a fire door assembly or fire window assembly was exposed and for which it met all the acceptance criteria, as determined in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, or NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies. Fire Watch The assignment of a person or persons to an area for the express purpose of protecting occupants from fire or similar emergencies. Examples of this protection include: - Notifying the fire department, the building occupants, or both of an emergency - Preventing a fire from occurring - Extinguishing small fires Hazardous Materials and Waste Materials whose handling, use, and storage are guided or defined by local, state, or federal regulation, such as the Occupational Safety and Health Administration s Regulations for Bloodborne Pathogens regarding the disposal of blood and blood-soaked items and the Nuclear Regulatory Commission s regulations for the handling and disposal of radioactive waste. This also includes hazardous vapors (for example, glutaraldehyde, ethylene oxide, nitrous oxide) and hazardous energy sources (for example, ionizing or nonionizing radiation, lasers, microwave, ultrasound). Although The Joint Commission (TJC) considers infectious waste as falling into this category of materials, federal regulations do not define infectious or medical waste as hazardous waste. Life Safety Code® A set of standards for the construction and operation of buildings intended to provide a reasonable degree of safety during fires. These standards are prepared, published, and periodically revised by the National Fire Protection Association (NFPA) and adopted by TJC to evaluate health care organizations under its life safety management program. The VHA adopts and uses the current edition of each NFPA code Utility Systems Building systems that provide support to the environment of care, including electrical distribution and emergency power; vertical and horizontal transport; heating, ventilating, and air conditioning (HVAC); plumbing, boiler, and steam; piped gases; vacuum systems; and communication systems, including data exchange systems. Acronyms Applicable to this Statement of Work: COR - Contracting Officers Representative EC - Environment of Care LS - Life Safety NFPA National Fire Protection Association TJC The Joint Commission PERIOD OF PERFORMANCE This could result in a blanket purchase agreement (BPA) for a period of five years performance, one base year, plus four option years. Forecasted to start November 15, 2023. TASKS TO BE ACCOMPLISHED: A Continuous Readiness Assessment is important so that all areas of potential non-compliance are identified before TJC survey team arrives. As part of the Continuous Readiness Assessment, the Contractor will contact the Contracting Officer s Representative (COR) to have key documents sent to them for an off-site review at a minimum of four weeks prior to their visit. The on-site visit will follow the off-site review of the key documents. To accomplish the goal of TJC Continuous Survey Readiness, the Contractor shall perform the following activities: Survey Readiness Services: The contractor shall provide a limited range of survey readiness services (Mock TJC EOC/LS Survey) to include accreditation-related services that are offered and conducted on a scheduled basis in the areas of EC and LS. There are currently up to 6 VISN 5 facilities that will be reviewed. Elements to be reviewed will include but are not limited to the following; Environment of Care: I. Plan (EC.01.01.01) II. Implement A. Safety and Security (EC.02.01.01, EC.02.01.03) B. Hazardous Materials and Waste (EC.02.02.01) C. Fire Safety (EC.02.03.01, EC.02.03.03, EC.02.03.05) D. Medical Equipment (EC.02.04.01, EC.02.04.03) E. Utilities (EC.02.05.01, EC.02.05.03, EC.02.05.05, EC.02.05.07, EC.02.05.09) F. Other Physical Environment Requirements (EC.02.06.01, EC.02.06.05) III. Staff Demonstrate Competence (EC.03.01.01) IV. Monitor and Improve (EC.04.01.01, EC.04.01.03, EC.04.01.05) Life Safety: I. Administrative Activities A. Statement of Conditions (LS.01.01.01) B. Interim Life Safety Measures (LS.01.02.01) II. Health Care Occupancy A. All Health Care Occupancy Buildings 1. General Building Requirements (LS.02.01.10) 2. Means of Egress Requirements (LS.02.01.20) 3. Protection (LS.02.01.30) i. Fire Alarm (LS.02.01.34) ii. Extinguishment (LS.02.01.35) 4. Special Provisions (LS.02.01.40) 5. Building Services (LS.02.01.50) 6. Operating Features (LS.02.01.70) III. Ambulatory Health Care Occupancy A. All Ambulatory Health Care Occupancy Buildings 1. General Building Requirements (LS.03.01.10) 2. Means of Egress Requirements (LS.03.01.20) 3. Protection (LS.03.01.30) i. Fire Alarm (LS.03.01.34) ii. Extinguishment (LS.03.01.35) 4. Special Provisions (LS.03.01.40) 5. Building Services (LS.03.01.50) 6. Operating Features (LS.03.01.70 b. The Contractor shall provide: Provide a draft Continuous Readiness Assessment Agenda and/or Education Plan to the VISN and Medical Center Point of Contact (POC) three weeks prior to the visits. Assessment of patient-focused and organizational functions across all programs. Performance of patient care and patient system tracer activities utilizing tracer methodology. Evaluation of patient records and other information systems that support the delivery of quality patient care. Inpatient Mental Health Environmental Safety assessment. Examination of the organization s Performance Improvement Process including the mechanisms in place to address sentinel and other untoward events. Review of competency assessments, orientation, training, education, credentialing and privileging, leadership and governance, and planning processes. We will include an optional analysis of the condition of the physical plant, Environment of Care (EOC)/ Annual Workplace Evaluation (AWE), emergency management, Life Safety and, when applicable, the organization s Statement of Condition and/or open plans for improvement (PFI). This requirement is optional due to an existing contract between the Department of Veterans Affairs (10E2) and a vendor who should provide these services. We will only include this as an optional task. Beginning-of-the-day strategic sessions with leadership to discuss the key findings of the day and to provide time for questions. Provide a comprehensive exit briefing to the facility and VISN leadership and/or designated audience at the end of the facility survey. Educate and consult with staff, one-on-one and small groups, throughout the Continuous Readiness Assessment to improve their understanding of TJC survey process, quality performance and standards. Conduct education sessions, not to exceed 2 hours per session, on topics as specified by the facility POC s. Provide focus reviews for problematic areas identified during the mock survey process to assess progress. Within two weeks of the completions of the Continuous Readiness Assessment, the contractor will provide a detailed report, which identifies areas of non-compliance to the VAMC Director and Director of Quality Management. Contractor will provide best practices and recommendations designed to bring VISN 5 Medical Centers and CBOC s into compliance with TJC standards. The report will include description of findings and a recommended action plan, when deficiencies have been identified. A written and electronic copy of the report will be provided to the VAMC Director and VISN Quality Management Officer. OPTIONAL PERIOD The contractor will provide a 2-day follow-up visit to review the highest priority open recommendations (as determined by the VAMC Director, Director of Quality Management, and VISN Quality Management Officer upon review of the initial report). DELIVERABLES Provide an optional on-site educational program for Environment of Care (EOC)/Life Safety including Annual Workplace Evaluation (AWE)/Emergency Management, Home Care, Behavioral Health and Nursing and Rehabilitation at the DC VAMC. Provide on-site educational programs for 2019 JC Standards and National Patient Safety Goals, Workplace Violence and Physical Security, H&P Requirements to Care Planning, Pain Management and Care Planning, Patient Education and Care Planning, Infection Control, Medication Management (optional, if agreed upon by both parties). Provide announced mock surveys inclusive of the four TJC programs: Hospital, Home Care, Behavioral Health (including Opioid), and Nursing and Rehabilitation. Provide announced mock surveys at the five identified VISN 5 Medical Center and potentially one CBOC to cover the four TJC programs: Hospital, Home Care, Behavioral Health (including Opioid), and Nursing and Rehabilitation. End-of-day strategic sessions with leadership to discuss the key findings of the day and to provide time for questions. Provide a comprehensive exit briefing to the facility and VISN leadership at the end of the facility announced/unannounced mock surveys, where applicable. Within two-weeks of the completions of the Readiness Assessment, contractor will provide a detailed report, which identifies areas of non-compliance. Contractor will provide best practices and recommendations designed to bring the VISN 5 facilities into compliance with the TJC standards. The report will include description of findings and a recommended action plan when deficiencies have been identified. A written and electronic copy of the report will be provided. Physician(s) with qualifications and experience required to perform a methodical in-depth quality assessment for total of fourteen (14) business days for no less than eight (8) hrs/day. Registered nurse(s) with qualifications and experience required to perform a methodical in-depth quality assessment for total of fourteen (14) business days for no less than eight (8) hrs./day. Environmental consultant(s) with expertise in Life Safety Codes with qualifications and experience required to perform a methodical in-depth quality assessment for a total of fourteen (14) business days for no less than eight (8) hrs/day. Both parties will have to agree on this prior to any follow up visit. Review specified Community Based Outpatient Clinic to be determined. Follow up Site Visit: 13. Environmental consultant(s) with expertise in Life Safety Codes with qualifications and experience required to perform a methodical in-depth quality assessment for a total of ten (10) business days for no less than eight (8) hrs/day. Both parties will have to agree on this prior to any follow up visit. 14. Registered nurse(s) with qualifications and experience required to perform a methodical in-depth quality assessment for total of ten (10) business days for no less than eight (8) hrs/day. Qualifications and Credentials The surveyor must possess the appropriate qualifications and credentials for conducting the surveys. The surveyor will be an expert on EC and LS matters, and have specific health care certifications, or equivalent. The surveyor must have at least five years experience in conducting mock TJC surveys on the whole range of Environment of Care, Life Safety, and Emergency Management-related issues. Experience on national committees or authoring articles on EC/LS related issues is preferred. Previous VA experience is preferred. If surveyor performance is less than satisfactory, the VA reserves the right to request a substitute surveyor at no additional cost to the VA. The surveyor will use the most current TJC Standards published in the Hospital Accreditation Standards Manual, Environment of Care Essentials for Health Care, and other related publications as enforced by the VHA. Travel Expenses All travel expenses associated with providing services under this contract are the responsibility of the contractor. The contractor must offer an all-inclusive price. A.6 PRICE/COST SCHEDULE ITEM INFORMATION ITEM NUMBER DESCRIPTION OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT 0001 0.00 NSP $0.00 Survey: Washington VAMC and 2 CBOCs Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0001AA 3.00 DY Physician Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0001AB 3.00 DY Nurse or CPHQ Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0001AC 3.00 DY EOC/LS Engineer Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0001AD 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): Nurse or CPHQ Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0001AE 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): EOC/LS Engineer Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0002 0.00 NSP $0.00 Survey: Martinsburg VAMC and 2 CBOCs Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0002AA 2.00 DY Physician Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0002AB 2.00 DY Nurse or CPHQ Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0002AC 2.00 DY EOC/LS Engineer Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0002AD 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): Nurse or CPHQ Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0002AE 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): EOC/LS Engineer Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0003 0.00 NSP $0.00 Survey: Maryland HCS includes Baltimore, Perry Point and 2 CBOCs Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0003AA 4.00 DY Physician Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0003AB 4.00 DY Nurse or CPHQ Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0003AC 4.00 DY EOC/LS Engineer Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0003AD 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): Nurse or CPHQ Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0003AE 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): EOC/LS Engineer Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0004 0.00 NSP $0.00 Survey: Louis A Johnson VA Medical Center, Clarksburg, WV includes Facility and 2 CBOCs Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0004AA 2.00 DY Physician Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0004AB 2.00 DY Nurse or CPHQ Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0004AC 2.00 DY EOC/LS Engineer Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0004AD 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): Nurse or CPHQ Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0004AE 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): EOC/LS Engineer Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0005 0.00 NSP $0.00 Survey: Hershel ""Woody"" Williams VA Medical Center, Huntington, WV. Facility and 2 CBOC's Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0005AA 2.00 DY Physician Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0005AB 2.00 DY Nurse or CPHQ Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0005AC 2.00 DY EOC/LS Engineer Surveyor Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0005AD 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): Nurse or CPHQ Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0005AE 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): EOC/LS Engineer Contract Period: Base POP Begin: 11-15-2023 POP End: 11-14-2024 0006 0.00 NSP $0.00 Survey: Beckley VA Medical Center, Beckley. Facility and 2 CBOC's Contract Period: Base POP Begin: 02-17-2020 POP End: 11-14-2024 0006AA 2.00 DY Physician Surveyor Contract Period: Base POP Begin: 02-17-2020 POP End: 11-14-2024 0006AB 2.00 DY Nurse or CPHQ Surveyor Contract Period: Base POP Begin: 02-17-2020 POP End: 11-14-2024 0006AC 2.00 DY EOC/LS Engineer Surveyor Contract Period: Base POP Begin: 02-17-2020 POP End: 11-14-2024 0006AD 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): Nurse or CPHQ Contract Period: Base POP Begin: 02-17-2020 POP End: 11-14-2024 0006AE 2.00 DY 2-Day Follow Up Site Visit (if Mutually agreed upon): EOC/LS Engineer Contract Period: Base POP Begin: 02-17-2020 POP End: 11-14-2024
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