VETERANS HEALTH ADMINISTRATION (VHA) MEDICAL SHARING/AFFILIATE NATIONAL PROGRAM OFFICE (MSO) ONSITE GENERAL SURGERY PHYSICIAN SERVICES MASTER PACKAGE INCLUDES: SCHEDULE OF SERVICES (Page 1) PERFORMANCE WORK STATEMENT (PWS) (Page 6) QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) (Page 26) SCHEDULE OF SERVICES The Contractor shall furnish all key personnel to provide services necessary to perform onsite and on call Vascular Surgery Physician Services to eligible beneficiaries of the Department of Veterans Affairs (VA) Lebanon Medical Center. The Contractor s physician(s) care shall cover the range of Vascular Surgery 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 national standards as established by the American Board of Surgery (ABS): http://www.absurgery.org/default.jsp?cc_gs Place of Performance: Services shall be provided onsite, Lebanon VA Medical Center (LVAMC), 1700 South Lincoln Ave, Lebanon, PA 17042. The Contractor shall propose a minimum of 1 key personnel to be credentialed and be available for scheduling to meet the requirements of the contract. MEDICAL AND SURGICAL SPECIALTY CONSULTATIONS DURING OFF-TOUR HOURS Lebanon VA Medical Center Lebanon, PA 17042 Signatory Authority: Associate Chief of Staff (ACOS), Surgery & Medicine Responsible Owner: ACOS Surgery & Medicine/Specialty Care Staff SOP 175-09 Service Line(s): Surgery & Medicine Care Lines Effective Date: October 31, 2021 Recertification Date: October 31, 2026 Quality Assurance Surveillance Plan (QASP) PURPOSE AND AUTHORITY The purpose of this standard operating procedure (SOP) is to establish procedures to ensure our Veterans receive timely care for pre-operative risk assessments and post-operative consultations. This SOP ensures patients will be seen by an on-call specialist or transferred out of fee basis within 60 minutes for pre- operative risk assessments and post-operative consultations. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 2010-01. PROCEDURES The Surgery Care Line has a 24 hour a day for 7 days a week (24/7) on-call schedule for many of its specialties. The specialist providers will be available within 15 minutes by phone and 60 minutes in person (for specialty services, such as PFTs and cardiac catheterization provided by fee or contract, the patient may be seen either on-site or off-site): Cardiology b. If a specialist is unavailable within the time constraints above, 15 minutes by phone or 60 minutes in person, the Lebanon Veterans Affairs Medical Center (VAMC) will transfer the patient within 60 minutes on fee basis for the following specialties: Gastroenterology Hematology Infectious Disease Interventional Radiology Nephrology Neurology Orthopedic Surgery Pathology Pulmonary Urology ASSIGNMENT OF RESPONSIBILITIES The Associate Chief of Staff (ACOS), Surgery is responsible for maintaining appropriate staffing levels to provide on-call service and ensuring the SOP is followed. The Associate Chief of Staff (ACOS), Medicine is responsible for maintaining appropriate staffing levels to provide on-call service and ensuring the SOP is followed. The Specialty Care Staff are responsible for following this SOP. DEFINITIONS None REFERENCES Veterans Administration Central Office (VACO) Requirements per Complexity Level VHA Directive 2010-01 REVIEW This SOP must be reviewed at minimum at recertification. RECERTIFICATION This SOP is scheduled for recertification on or before the last working day of October 31, 2026. In the event of contradiction with national policy, the national policy supersedes and controls. Periods of Performance (POP): 9/28/2025 to 9/27/2030. Ordering Period 1: 9/28/2025 to 9/27/2026. LIN Description Qty. Unit Unit Cost Total Annual Cost 0001 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday. 4030 Hours 0002 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630 through Monday 0800 and all Federal Holidays. 2760 Hours 0003 Board Certified VASCULAR SURGERY Physician Services On-Call Vascular Services , Weekday In-house Coverage, up to 40 days per year. 960 Hours Ordering Period 2: 9/28/2026 to 9/27/2027 LIN Description Qty. Unit Unit Cost Total Annual Cost 0004 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday. 4030 Hours 0005 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services up to for all weekends, Friday 1630 through Monday 0800 and all Federal Holidays. 2760 Hours 0006 Board Certified VASCULAR SURGERY Physician Services On-Call Vascular Services , Weekday In-house Coverage, up to 40 days per year. 960 Hours Ordering Period 3: 9/28/2027 to 9/27/2028 LIN Description Qty. Unit Unit Cost Total Annual Cost 0007 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday. 4030 Hours 0008 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630 through Monday 0800 and all Federal Holidays. 2760 Hours 0009 Board Certified VASCULAR SURGERY Physician Services On-Call Vascular Services , Weekday In-house Coverage, up to 40 days per year. 960 Hours Ordering Period 4: 9/28/2028 to 9/27/2029 LIN Description Qty. Unit Unit Cost Total Annual Cost 0010 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday. 4030 Hours 0011 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630 through Monday 0800 and all Federal Holidays. 2760 Hours 0012 Board Certified VASCULAR SURGERY Physician Services On-Call Vascular Services , Weekday In-house Coverage, up to 40 days per year. 960 Hours Ordering Period 5: 9/28/2029 to 9/27/2030 LIN Description Qty. Unit Unit Cost Total Annual Cost 0013 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for after hour coverage 1630-0800, up to 5 days per week, Monday through Friday. 4030 Hours 0014 Board Certified VASCULAR SURGERY Physician Services On Call Vascular Services for up to all weekends, Friday 1630 through Monday 0800 and all Federal Holidays. 2760 Hours 0015 Board Certified VASCULAR SURGERY Physician Services On-Call Vascular Services , Weekday In-house Coverage, up to 40 days per year. 960 Hours Total price for all Ordering Periods: $ Performance Work Statement (PWS) for Onsite General Surgery Physician Services GENERAL: Services Provided: The Contractor shall provide Board Certified Vascular SURGERY Physician Services onsite in accordance with the specifications contained herein to beneficiaries of the VA and the Lebanon VAMC.The proposed action will allow the LVAMC to maintain its Level Ib Surgical Complexity Level. It will provide on-call coverage in the event of a surgical emergency of a vascular nature. Place of Performance: The Contractor shall provide services at the Lebanon VA Medical Center, 1700 South Lincoln Ave, Lebanon, PA 17042. Authority:Title 38 USC 8153, Health Care Resources (HCR) sharing Authority. Policy/Directives/Handbooks. The contractor shall be subject to the following policies, including any subsequent updates during the period of performance. The policies listed below can be accessed electronically at the following: VA Publications VHA Publications VA Directive 1663: Health Care Resources (HCR) Contracting Buying Title 38 U.S.C. 8153 1.4.2. VHA Directive 1003.04: VHA Patient Advocacy VHA Directive 1065: Productivity and Staffing Guidance for Specialty Provider Group Practice VHA Directive 1088(1): Communicating Test Results to Providers and Patients VHA Directive 1100.18: Reporting and Responding to State Licensing Boards VHA Directive 1100.20: Credentialing of Health Care Providers VHA Directive 1100.21: Privileging VHA Directive 1192.01: Seasonal Influenza Vaccination Program for VHA Health Care Personnel VHA Directive 1220(1): Facility Procedure Complexity Designation Requirements to Perform Invasive Procedures in Any Clinical Setting VHA Directive 1605.01: Privacy and Release of Information VHA Directive 1907.01: VHA Health Information Management and Health Records VHA Handbook 1100.17: National Practitioner Data Bank (NPDB) Reports Privacy Act of 1974 (5 U.S.C. 552a) as amended: http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm Acronyms/Definitions: 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. ABS: American Board of Surgery http://www.absurgery.org/ ACGME: Accreditation Council for Graduate Medical Education ACLS: Advanced Cardiac Life Support AJIC: American Journal for Infection Control AQL: Acceptable Quality Level BAA: Business Associate Agreement BBA: Balanced Budget Act BLS: Basic Life Support CDC: Centers for Disease Control and Prevention CDR: Contract Deficiency Report CEU: Certified Education Unit Clinical Privileging: Clinical Privileging is the process by which a practitioner, licensed for independent 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, and within available resources. CME: Continuing Medical Education CMP: Civil Monetary Penalty CMS: Centers for Medicare and Medicaid Services CO: Contracting Officer: 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. COI: Conflict of Interest COR: Contracting Officer s Representative: 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 Credentialing: Credentialing is the process of obtaining, verifying, and assessing the qualifications of a health care provider to provide care or services in or for the VA health care system. Credentials are documented evidence of licensure, education, training, experience or other qualifications. DEA: Drug Enforcement Agency EHR: Electronic Health Record - electronic health record system used by the VA EPA: Environmental Protection Agency FAPIIS: Federal Awardee Performance and Integrity Information System FAR: Federal Acquisition Regulation FOIA: Freedom of Information Act FPPE: Focused Provider Practice Evaluation FSMB: Federation of State Medical Boards FTE: Full Time Equivalent: VA s standard definition is for full time working the equivalent of 80 hours every two weeks, 2080 hours per year.  However, providers may propose using their standard FTE definition. HHS: Department of Health and Human Services HICPAC: Hospital Infection Practices Advisory Committee HIPAA: Health Insurance Portability and Accountability Act IGRA: Interferon-gamma Release Assays ISO: Information Security Officer Key Personnel: The individuals specified in this contract who are essential to work performance. MRI: Magnetic Resonance Imaging MST: Military Sexual Trauma NPI: National Provider Identifier. NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The VHA must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). NPPES: National Plan and Provider Enumeration System NSO: National Surgery Office OGC: Office of General Counsel OIG: Office of Inspector General OPPE: Ongoing Provider Practice Evaluation OR: Operating Room POP: Period of Performance PPD: Purified Protein Derivative PPIRS: Past Performance Information Retrieval System PWS: Performance Work Statement QA/QI: Quality Assurance/Quality Improvement QM/PI: Quality Management/Performance Improvement QASP: Quality Assurance Surveillance Plan RFP: Request for Proposal SCS: Specialty Care Services SSAC: Sole Source Affiliate Contract TJC: the Joint Commission TST: Tuberculosis Skin Test USC: United States Code VA: Department of Veterans Affairs VA-FSC: VA Financial Services Center VAAR: VA Acquisition Regulation VETPro: is VHA s mandatory credentialing software platform to document the credentialing of VHA health care Providers. This system facilitates completion of a uniform, accurate and complete credentials file. VHA: Veterans Health Administration VistA: Veterans Integrated Systems Technology Architecture QUALIFICATIONS: Staff/Facility License: The 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 any State, Territory, or Commonwealth of the United States or the District of Columbia) when services are performed onsite on VA property. All licenses held by the key 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 by the ABS http://www.absurgery.org/, and be currently certified in BLS, ACLS or equivalency. All continuing education courses required for maintaining certification must be kept up to date at all times. Documentation verifying current certification shall be provided by the Contractor to the VA COR on an annual basis for each year of contract performance. Credentialing and Privileging: Credentialing and privileging is to be done in accordance with the provisions of VHA Directive 1100.20 and VHA Directive 1100.21 referenced above. The Contractor is responsible to ensure that proposed physician(s) possesses the requisite credentials enabling the granting of privileges. No services shall be provided by any Contractor s physician(s) prior to obtaining approval by the Facility Medical Executive Board and Medical Center Director. If a Contractor s physician(s) and/or other contract provider(s) are 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 s physician(s) and Contractor s physician(s) shall be responsible for abiding by the Facility's Medical Staff By-Laws, rules, and regulations (referenced herein) that govern medical staff behavior. Continuing Medical Education (CME)/ Certified Education Unit (CEU) Requirements: Contractor shall provide the COR copies of current CMEs as required or requested by the facility. Contractor s physician(s) registered or certified by national/medical associations shall continue to meet the minimum standards for CME to remain current. Contractor shall report CME hours to the credentials office for tracking. These documents are required for both privileging and re-privileging. Failure to provide shall result in loss of privileges for Contractor s physician(s). Training (ACLS, BLS, EHR and VA MANDATORY): Contractor shall meet all VA educational requirements and mandatory course requirements defined herein; all training must be completed by the contractor s physician(s) as required by the VA. Other training may become required. VA will communicate any changes to the training requirement to the contractor. Training Frequency Annual Hours ACLS/BLS Yearly 1 hour Active Threat Training N/A Blood Administration: Complications N/A EHR N/A Government Ethics N/A Hospice and Palliative Care for VA Clinicians N/A Military Sexual Trauma (MST) for Medical Providers N/A Moderate Sedation In-Service Training N/A PACT Act 2022 Toxic Exposure Screening (TES) N/A Patient Abuse N/A Patient Rights N/A Patient Safety N/A Prevention/Management of Disruptive Behavior/Violence Prevention Level I N/A Prevention of Workplace Harassment/No Fear Act N/A Suicide Prevention: Suicide Risk Management Training for Clinicians N/A SUX Infection Control and Blood Borne Pathogens N/A VA Core Values Training (ICARE Recommitment) N/A VA Privacy and Information Security Awareness and Rules of Behavior Yearly 1 hour VHA MRI Safety Training Level 1 Training (all who enter MRI suites) N/A VHA Privacy and HIPAA Focused Training Yearly 1 hour VistA Imaging N/A STANDARD INFECTION CONTROL MEASURES (PPD, IMMUNIZATIONS, ETC.): Contractor shall provide proof of the following for physicians within five (5) calendar days after contract award and prior to the first duty shift to the COR and CO. Tests shall be current within the past year. TUBERCULOSIS TESTING: Contractor shall provide proof of a negative Tuberculosis Skin Test (TST) or interferon-gamma release assays (IGRA) for all Contractor s physician(s) upon hire in accordance with CDC guidance. (This is applicable to all health care workers). A negative chest radiographic report for active tuberculosis shall be provided in cases of positive TST or IGRA results. MEASLES, MUMPS, & RUBELLA TESTING: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}. VARICELLA: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}. ACELLULAR PERTUSSIS: Contractors shall provide proof of 1 dose of Tdap vaccination for all Contractor physicians {This is applicable to all health care workers}. INFLUENZA: Contractors shall provide proof that all Contractor physicians have received the annual Influenza vaccine unless it is contraindicated. If the Contractor physician has a medical contraindication to the vaccine they shall be required to wear a mask during the Influenza season. {This is applicable to all health care workers}. COVID-19: Vaccination required or request an exemption. OSHA REGULATION CONCERNING OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS: Contractor shall provide evidence of completing and passing generic self-study blood-borne pathogen training for all Contractor s physician(s) {This is applicable to all health care workers}; provide their own Hepatitis B vaccination series and hepatitis B surface antigen test results following the hepatitis B vaccination series; maintain an exposure determination and control plan; maintain required records; and ensure that proper follow-up evaluation is provided following an exposure incident. The facility shall notify the Contractor of any significant communicable disease exposures 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. NPI: NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The VHA 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 CMS NPPES be provided to the CO with the proposal. DEA: Contractor shall provide copy of current DEA certificate. Conflict of Interest (COI): 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 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 VA patient referrals. While performing services for the VA, 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 FAR. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the VA 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 VA patient referrals; or other place where the Contractor provides services to veterans who have been referred by the VA; 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 OIG Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the HHS 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. Clinical/Professional Performance: The qualifications of Contractor personnel are subject to review by facility COS or his/her clinical designee and approval by the Medical Center Director as provided in VHA Directive 1100.20 and VHA Directive 1100.21. Clinical/Professional performance monitoring and review of all clinical personnel covered by this contract for quality purposes will be provided by the facility COS and/or the Chief of the Service or his designee. A clinical COR may be appointed, however, only the CO is authorized to consider any contract modification request and/or make changes to the contract during the administration of the resultant contract. 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. Key Personnel: The VA Full Time Equivalent (FTE) for the services required is 2. (enter the number of VA FTE that the resultant contract will provide hours of service coverage for example 2080 hours = 1.0 VA FTE). The minimum number of Board Certified Vascular SURGERY physicians required to be onsite daily is 1 to be onsite as defined in paragraph Hours of Operation in this section. The Contractor shall be responsible for providing coverage to the VA during periods of vacancies of the Contractor s personnel due to sick leave, personal leave, vacations and additional coverage as required. In the event a scheduled physician is unable to complete an assigned shift, the Contractor shall provide replacement physician coverage within 2 hours and notify the COR immediately of the schedule change. Personnel Substitutions: During the first ninety (90) calendar 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 CO, in writing, within 15 calendar day(s) after the occurrence of any of these events and provide the information required below. After 90 days, the Contractor shall submit the information required below to the CO at least 15 calendar days prior to making any permanent substitutions. 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 CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO 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. For temporary substitutions where the key person shall not be reporting to work for 3 consecutive workdays or more, the Contractor shall provide a qualified replacement for the key person. The substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above. 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 or interferes with the regular and ordinary operation of the facility. 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. Should the VA COS or designee show documented clinical problems or continual unprofessional behavior/actions with any Contractor s physician(s), s/he may request, without cause, immediate replacement of said Contractor s physician(s). The CO and COR shall deal with issues raised concerning Contractor s physician(s) conduct. The final arbiter on questions of acceptability is the CO. Contingency Plan: Because continuity of care is an essential part of Facility 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. VA HOURS OF OPERATION/SCHEDULING: VA Business Hours: On Call Vascular Services: after hour coverage 1630-0800, up to 5 days per week, Monday through Friday, all weekends, Friday 1630 through Monday 0800 and all Federal Holidays and Weekday In-house Coverage, up to 40 days per year. OR Schedule: On Call services only as outlined in 3.1. If an emergency Vascular event arises as identified by a staff physician; phone contact will be made within 15 minutes to the contract Vascular Surgeon/s on-call. It is required that the contract provider be on site within 60 minutes of receipt of the phone call. Upon stabilization of the patient and assessment of further needed intervention, the contract provider may decide to transfer the patient to a Non-VA facility for provision of an advanced level of patient care.. Contractor s physician(s) shall be available and present in clinic during normal Lebanon VAMC clinic hours if needed, which will be established, and may be revised, as deemed appropriate for patient care by the ACOS. Currently, normal clinic hours are Monday through Friday 8:00 am to 4:30 pm. Off-hours Coverage: On Call Vascular Services: after hour coverage 1630-0800, up to 5 days per week, Monday through Friday, all weekends, Friday 1630 through Monday 0800 and all Federal Holidays and Weekday In-house Coverage, up to 40 days per year. On-call Contractor s physician(s) must be available at all times for phone consultations with VA residents and physicians. On-call providers must be available within 15 minutes by phone and onsite within 60 minutes. 3.3 Federal Holidays: The following holidays are observed by the VA: New Year s Day Martin Luther King s Birthday Presidents Day Memorial Day Juneteenth Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Christmas Any day specifically declared to be a national holiday. Cancellations: If a clinic cancellation is needed, Contractor will provide a contingency plan to see clinic patients withing 5 busines days. CONTRACTOR RESPONSIBILITIES: Clinical Personnel Required: The Contractor shall provide Contractor s physician(s) who are competent, qualified per this performance work statement and adequately trained to perform assigned duties. Contractor s physician(s) shall be responsible for signing in and out when in attendance. Time sheets will be used by the COR to confirm hours/day and services provided against the contractor s invoices. Standards of Care: The Contractor s physician(s) care shall cover the range of Vascular Surgery 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 the Joint Commission (TJC), VA and national standards as established by: The ABS http://www.absurgery.org/ The professional standards of 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 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 5 U.S.C.552a (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 of VA patients. Based on this exception, a BAA is not required for this contract. Health records generated by this contract or provided to the Contractors by the VA are covered by the VA Privacy Act system of records entitled Patient Medical Records-VA (24VA10A7). 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 provided to VA patients are captured in the VA electronic health record system as required by VA policy as discussed in 4.4.4. Disclosure: Contractor s physician(s) may have access to patient medical records for the purpose of providing medical care and services to VA patients and performing services under the contract; however, Contractor shall obtain permission from the VA before disclosing any patient information outside VA. VA authorizes the Contractor to discuss patient health information for coordination of care within community health care providers in compliance with VA regulations, HIPAA and VHA Directive 1605.1, Privacy and Release of Information. The VA will provide the Contractor with a copy of VHA Directive 1907.01, Health Information Management and Health Records and VHA Directive1605.1, 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 Directive 1907.01 Health Information Management and Health Records: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 and all guidelines provided by the facility. Release of Information: The VA shall maintain control of releasing any copies of patient health information or health records and will follow policies and standards as defined, but not limited to Privacy Act requirements. The Contractor will not release or disclose copies of records and will refer all such requests to the Release of Information Department at the VA facility where assigned. Management for Medical Records: National Archives and Records Administration record disposition requirements are found in RCS 10-1 Chapter 6, 6000 series. Direct Patient Care: Estimated % of the time involved in direct patient care. Contractor shall be responsible for Scope of Care: Contractor s physician(s) shall be responsible for providing VASCULAR SURGERY Physician care, including, but not limited to: Clinic Responsibilities: Contractor physician(s) shall be present on time for any scheduled clinics/surgeries start times as documented by physical presence in the clinic or OR at the scheduled start time. Communication of Test Results: Mechanisms must be in-place to provide notification of test results for patients receiving care in accordance with VHA Directive 1088, Communicating Test Results to Providers and Patients. Medications: Contractor s physician(s) shall follow all established medication policies and procedures. No sample medications shall be provided to patients. Discharge education: Provide discharge education and follow up instructions that are coordinated with the next care setting for all GENERAL SURGERY clinical or surgical patients. ADMINISTRATIVE: Estimated 0% of time not involved in direct patient care Quality Improvement Meetings: The Contractor s physician(s) shall participate in continuous quality improvement activities and meetings with committee participation as required by the facility Chief of Service, COS, or designee. List all meetings, associated time and frequency. Meeting Frequency (once a year, etc.) Annual Hours Case Conference Monthly, as needed, to present case. 1 Staff Meetings: The Contractor s physician(s) shall attend staff meetings as required by the facility Chief of Service, COS, or designee. Contractor to communicate with COR on this requirement and report any conflicts that may interfere with compliance with this requirement. QA/QI documentation: The Contractor s physician(s) shall complete the appropriate QM/PI documentation pertaining to all procedures, complications and outcome of examinations. Patient Safety Compliance and Reporting: Contractor s physician(s) shall follow all established patient safety and infection control standards of care. Contractor s physician(s) shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breeches of patient safety shall be documented in the medical record of those impacted and disclosed to the patient or surrogate. As soon as practicable (but within 24 hours) Contractors shall notify COR of incident and submit an entry in the VA Patient Safety Reporting System, following up with COR as required or requested. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY IMPROVEMENT(QI): Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance: Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE). Contractor performance will be monitored by the government using the standards as outlined in this PWS and methods of surveillance detailed in the 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. If 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 or interferes with the regular and ordinary operation of the facility. 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: All Contractor s physician(s) shall perform in accordance with clinical standards Standard: OPPE documentation for all (100%) staff providing services under the contract. All staff (100%) meet Standards AQL: 100% meet Standards Surveillance Method: OPPE data pertinent to care performed for each provider working under this contract. OPPE data will review the following elements: Patient Care Performance Medical/Clinical knowledge Practiced Based Learning and Improvement Interpersonal and Communication Skills Professionalism System Based Practice Frequency: _Every 12 months__________ Measure: Qualifications of Key Personnel Performance Requirement: All Contractor s physician(s) shall be Board Certified in accordance with ABS Standards for General Surgery Standard: All (100%) Contractor s physician(s) are Board Certified. AQL: 100% Surveillance Method: Periodic Inspection or Random Sampling of qualification documents Frequency: Every 12 months 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 AQL: 100% Contractor s physician(s) perform within their scope of practice/privileges 100% of the time Surveillance Method: Random Sampling of records Frequency: Every 12 months Measure: Patient Access Performance Requirement: The Contractor shall provide Contractor s physician(s) in accordance with the operating hours and VA clinical schedule outlined in this PWS Standard: All (100%) Contractor s physician(s) are on time and available to perform services AQL: Contractor s physician(s) is on-time and available to perform services 100% of the time Surveillance Method: Periodic Inspection of Time and Attendance Sheets Frequency: Monthly Measure: Patient Safety Performance Requirement: Patient safety incidents shall be reported using VA Patient Safety Reporting System. All incidents reported immediately (within 24 hours.) Standard: All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident AQL: 100% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident Periodic Inspection or Random Sampling Frequency: Quarterly Measure: Maintains licensing, registration, and certification Performance Requirement: Updated licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current Standard: All (100%) licensing, registration(s) and certification(s) for Contractor s physician(s) shall be provided as they are renewed. Licensing and registration information kept current AQL: 100% licensing, registration(s) and certification(s) for Contractor s physician(s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation. Surveillance Method: Periodic Inspection or Random Sampling Frequency: Every 12 months Measure: Mandatory Training Performance Requirement: Contractor shall complete all required training on time per facility policy Standard: All (100%) of required training is complete on time by Contractor s physician(s) AQL: 100% completions Surveillance Method: Periodic Inspection or Random Sampling Frequency: Every Quarter Measure: Privacy, Confidentiality and HIPAA Performance Requirement: Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality Standard: All (100%) Contractor s physician(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA AQL: 100% compliance Surveillance Method: Periodic Inspection; Contractor shall provide evidence of annual training required by the facility, reports violations per VA Handbook 6500.6 Frequency: Every 12 Months Registration with Contractor Performance Assessment Reporting System As prescribed in FAR Part 42.15, the VA evaluates Contractor past performance on all contracts that exceed the Simplified Acquisition Threshold 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 Sea 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 the Simplified Acquisition Threshold 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 CO will perform a single evaluation when the contract is complete. For contracts exceeding one year, the CO 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: Laptop if needed to maintain remote access. 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 CO is the only person authorized to approve changes or modify any of the requirements of this contract. The Contractor shall communicate with the CO on all matters pertaining to contract administration. Only the CO 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 CO shall resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. In the event the Contractor effects any such change at the direction of any person other than the CO 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 for this contract is: Beverly Miller, Admin Program Specialist, Surgery Careline, [email protected], 717-272-6621 ext. 4120 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 CO. 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. The COR will maintain a record-keeping system of services by email correspondence. The COR will review this data monthly when invoices are received and certify all invoices for payment by comparing the hours documented on the VA record-keeping system and those on the invoices. Any evidence of the Contractor's non-compliance as evidenced by the monitoring procedures shall be forwarded immediately to the CO. The COR will review and certify monthly invoices for payment. If in the event the Contractor fails to provide the services in this contract, payments will be adjusted to compensate the Government for the difference. All contract administration functions will be retained by the VA. SPECIAL CONTRACT REQUIREMENTS: 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. The following are brief descriptions of required documents that must be submitted by Contractor: upon award; weekly; monthly; quarterly ; annually, etc. identified throughout the PWS and is provided here as a guide for Contractor convenience. If an item is within the PWS and not listed here, the Contractor remains responsible for the delivery of the item. What Submit as noted Submit To Quality Control Plan: Description and reporting reflecting the contractor s plan for meeting of contract requirements and performance standards Upon proposal and as frequently as indicated in the performance standards CO Other than Cost and Price Information Supporting Proposed Physician Rate (required for Affiliate onsite hourly- remove if it does not apply) Upon proposal, to submit EPA request, upon change in key personnel CO Copy of Subcontracting Plan is required for all large businesses. Copy of Contractor Certification Statement if no subcontracting possibilities exist Upon proposal and as updated CO Copies of any and all licenses, board certifications, NPI, to include primary source verification of all licensed and certified staff Upon proposal and upon renewal of licenses and upon renewal of option periods or change of key personnel CO with proposal; renewal submitted to VETPRO system Certification that staff list has been compared to OIG list Upon proposal and upon new hires CO Proof of Indemnification and Medical Liability Insurance Upon proposal and upon renewals CO Certificates of Completion for Cyber Security and Patient Privacy Training Courses Before receiving an account on VA Network and annual training and new hires. CO ACLS/BLS Certification Upon award and every two years after award COR Contingency plan for replacing key personnel to maintain services as required under the terms of the contract Upon proposal and as updated COR Billing: Invoice requirements and supporting documentation: Supporting documentation and invoice must be submitted no later than the last workday of the month. Subsequent changes or corrections shall be submitted by separate invoice. In addition to information required for submission of a proper invoice in accordance with FAR 52.212-4 (g), all invoices must include: Name and Address of Contractor Invoice Date and Invoice Number Contract Number and Purchase/Task Order Number Date of Service Contractor s physician(s) Hourly Rate Quantity of hours worked Total price Vendor Electronic Invoice Submission Methods: Invoices will be electronically submitted to the Tungsten website at https://www.tungstenautomation.com/. Tungsten Automation direct vendor support number is 877-489-6135 for VA contracts. The VA-FSC pays all associated transaction fees for VA orders. During Implementation (technical set-up) Tungsten Automation will confirm your Taxpayer ID Number with the VA-FSC. This process can take up to 5 business days to complete to ensure your invoice is automatically routed to your Certifying Official for approval and payment. To successfully submit an invoice to VA-FSC please review How to Create an Invoice within the how to guides. All invoices submitted through Tungsten Automation to the VA-FSC should mirror the current submission of Invoice. Clarification of additional requirements should be confirmed with your Certifying Official (your CO or buyer). Payment will only be made for actual services rendered. Payments shall be made monthly in arrears. The VA-FSC requires specific information in compliance with the Prompt Pay Act and Business Requirements. The contractor shall be reimbursed upon receipt of a proper invoice. For additional information, please contact: Tungsten Support Phone: 1-877-489-6135 Website: https://www.tungstenautomation.com/ Department of Veterans Affairs Financial Service Center https://www.fsc.va.gov/einvoice.asp   Reduction in Services: This is a fixed quantity contract for a specified number of hours. If, at the end of the POP, the government has not utilized the total number of hours required under this contract because of a change in its requirements, the parties agree that they will attempt to negotiate in good faith a contract modification reducing the scope of the contract with a corresponding adjustment in the total contract price. In no event will the VA pay for hours that exceed the total number of hours specified in the contract for the POP. 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 (VA Handbook 6500.6). The contractor will be evaluated in accordance with the following: 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 will monitoring will take place? Who will conduct the monitoring? How will monitoring efforts and results 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 through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities. GOVERNMENT ROLES AND RESPONSIBILITIES The following personnel shall oversee and coordinate surveillance activities. 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. Assigned CO: Organization or Agency: Lebanon VA Medical Center Contracting Officer s Representative (COR) The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government s behalf. Assigned COR: Beverly Miller Organization or Agency: Lebanon VA Medical Center CONTRACTOR REPRESENTATIVES The following employee(s) of the contractor serve as the contractor s program manager(s) for this contract. Primary Program Manager: Dr. Carl Reese, ACOS Surgery Careline Alternate Program Manager: Dr. Richard LaTour, Deputy ACOS Surgery Careline PERFORMANCE STANDARDS The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards. The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract. METHODS OF QA SURVEILLANCE Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP. DIRECT OBSERVATION. 100% surveillance: Surveillance will be conducted by peers. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Ten (10) randomly selected patient files will be reviewed per year. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.) VALIDATED USER/CUSTOMER COMPLAINTS. No more than one patient complaint per quarter. Random inspection and auditing is performed on a quarterly basis All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.) VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. All medical documentation is completed per Medical Staff By-Laws. Encounters and progress notes are completed within 7 days of patient visit and outpatient documents are signed within 7 days of visit. End of Performance Work Statement (PWS)

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