R420--CLC Mock Survey New Requirement For VHA VISN 1 Base 4 Single Award IDIQ

SOURCES SOUGHT SYNOPSIS The Department of Veterans Affairs, VISN 1, New England is issuing this synopsis as a means of conducting market research to identify parties having an interest in and the resources to support this requirement for CLC Mock Survey Services. Additional information regarding the requirement is available in the Appendix accompanying this notice. The result of this market research will contribute to determining the method of acquisition. The applicable North American Industry Classification System (NAICS) code assigned to this acquisition is 541611 Administrative Management and General Management Consulting Services. There is no solicitation at this time. This request for capability information does not constitute a request for proposals; submission of any information in response to this market survey is purely voluntary; the government assumes no financial responsibility for any costs incurred. If your organization has the potential capacity to perform these contract services, please provide the following information: organization name, address, email address, website address, telephone number, and size and type of ownership for the organization; and tailored capability statements addressing the particulars of this effort, with appropriate documentation supporting claims of organizational and staff capability. If significant subcontracting or teaming is anticipated to deliver technical capability, address the administrative and management structure of such arrangements. The government will evaluate market information to ascertain potential market capacity to: provide services consistent in scope and scale with those described in this notice and otherwise anticipated; secure and apply the full range of corporate financial, human capital, and technical resources required to successfully perform similar requirements; implement a successful project management plan that includes compliance with program schedules, cost containment, meeting/tracking performance, hiring/retention of key personnel, and risk mitigation; and provide services under a performance-based service acquisition contract. Based on the responses to this sources sought notice/market research, this requirement may be set aside for small businesses or procured through full and open competition, and multiple awards may be made. The government will not provide feedback or evaluations to companies regarding their submissions in response to this notice. Submission Instructions: Interested parties who consider themselves qualified to perform the above-listed services are invited to submit a response to this sources sought notice by March 11th, 2025 at 12:00pm EST. All responses under this notice must be emailed to David.Roy@va.gov. If you have any questions concerning this opportunity, please contact David Roy, Contract Specialist, at David.Roy@va.gov. APPENDIX 1: Preliminary Performance Work Statement (PWS) for Expected Requirement *A complete/proposed Performance Work Statement (PWS) will be furnished in the forthcoming, formal solicitation. PERFORMANCE WORK STATEMENT CMS SURVEY AND CONSULTING SERVICES 1. GENERAL: This is a firm fixed price indefinite delivery indefinite quantity contract for non-personal services to provide Centers for Medicare & Medicaid Services (CMS) Advisory Services to VA Medical Centers within Veterans Integrated Service Network (VISN) 1. The Government shall not exercise any supervision or control over the contract service providers performing the services herein. Such contract service providers shall be accountable solely to the Contractor who, in turn is responsible to the Government. 1.1 Description of Services/Introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform Advisory Services to help maintain compliance with CMS Conditions of Participation before during and after a CMS survey as defined in this Performance Work Statement. The contractor shall perform to the standards in this contract. 1.2 Background: VA Community Living Centers are surveyed annually by the Long-Term Care Institute (LTCI) to determine the level of compliance with CMS Conditions of Participation (CoPs). CMS requirements are complex and constantly changing and it s hard to understand the intent and interpretive guidelines of the regulations and what the CMS surveyors are looking for during a survey. Having a systemwide model for preparing for and responding to CMS with the goal of continuous readiness is essential. Accreditation Coordinators need assistance in assessing readiness of the organization. Conducting a Mock Survey within the year helps to identify areas of improvement and prepare staff for the real survey. The survey itself is very demanding on an organization which must provide all necessary interviews, documents and escorts during the 4-day survey. Developing an effective approach to establishing a command center is critical to effectively managing the demands of a survey. Throughout the 4-day survey the organization is made aware of deficiencies which can be mitigated in real-time with expert guidance in the command center. After the survey a Plan of Correction must be submitted to address all areas of deficiency. The plan will need to be monitored until fully compliant and incorporated into the annual cycle of learning and preparedness. 1.3 Objectives: To support continual readiness by conducting a mock survey that assesses readiness and identifies CMS CoP risk areas. To provide a post mock survey analysis delivered to VISN-1 leadership to address all areas of compliance, deficiency, and strategies for improvement with an implementation plan for CMS compliance. To provide onsite support during the LTCI Annual unannounced survey To provide remote support during the LTCI Annual unannounced survey To provide post CMS survey review of deficiencies, development of a Plan of Correction, provide an assessment of an implementation plan, provide guidance on submission of plan to CMS. To provide CMS survey preparation training and practical exercises to educate VISN-1 personnel on Medicare survey requirements and survey processes. Scope: Consultation services to assess and improve CMS readiness at VISN 1 Community Living Centers. Services include: On-site consultation for a full Medicare review of all 23 Conditions of Participation (CoPs); Offsite CMS consultation via phone calls or emails; CMS on-site emergent consultation within 24-48 hours of CMS survey announcement; and on-site leadership training. Period of Performance: The period of performance shall commence on the date of contract award and shall continue for one (1) Base Year of 12 months and four (4) 12-month option periods. The Period of Performance is as follows: Base Year (Date of Award through 365 calendar days) Option Year I (To be completed upon award) Option Year II (To be completed upon award) Option Year III (To be completed upon award) Option Year IV (To be completed upon award) 1.6 General Information 1.6.1 Quality Control: The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of identified deficiencies. The contractor s quality control program is the means by which he assures himself that his work complies with the requirement of the contract. The Quality Control Plan should be submitted with the contractor s proposal as an evaluation factor, three copies of a comprehensive written QCP shall be submitted to the CO and COR within 5 working days when changes are made thereafter. After acceptance of the quality control plan the contractor shall receive the contracting officer s acceptance in writing of any proposed change to his QC system. 1.6.2 Quality Assurance: The government shall evaluate the contractor s performance under this contract in accordance with a Quality Assurance Surveillance Plan. This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s). 1.6.3 Recognized Holidays New Year s Day Labor Day Martin Luther King Jr. s Birthday Columbus Day President s Day Veteran s Day Memorial Day Thanksgiving Day Independence Day Christmas Day When one of the holidays falls on Sunday, the following Monday shall be observed as a legal holiday by U.S. Government Agencies. When a holiday falls on a Saturday, the preceding Friday shall be observed as a legal holiday. Also included would be any other day specifically declared by the President of the United States to be a National holiday. 1.6.4 Hours of Operation: The contractor is responsible for conducting business, between the hours of 7:00am and 4:30pm EST Monday thru Friday except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The Contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS. 1.6.5 Place of Performance: The work to be performed under this contract will be performed at all VISN 1 Facilities CLC facilities in the following locations: Bedford, Leeds, and Brockton MA, West Haven CT, Augusta ME, and Manchester NH. (Facility Address list to be added before solicitation) 1.6.6 Security Requirements: All information must be safeguarded according to all federal, state, and local guidelines. A Business Associates Agreement (BAA) must be signed by the successful offeror and all VA Information and Information System Security Privacy safeguarding guidelines must be followed. VA Directive and Handbook, 6500 Managing Information Security Risk: VA Information Security Program; VA Directive 6515, Use of Web-Based Collaboration Technologies; and VA Directive 6102, Internet and Intranet Services, shall be in compliance prior to activating any web portal. Security language specific to VA Handbook 6500 attached to solicitation. 1.6.7 Special Qualifications: The contractor is responsible for ensuring all employees providing consultation possess at least 5 years of survey experience in the areas of acute care, long term care, and rehabilitation. All employees must have a minimum of a bachelor s degree and have expert knowledge of all the federal conditions of participation/condition of coverage and report out using the Principles of Documentation. The contractor must have the ability to travel within 24-hours to assist clients in Immediate Jeopardy situations. 1.6.8 Post Award Conference/Periodic Progress Meetings: The Contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. The contracting officer, Contracting Officers Representative (COR), and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance. At these meetings the contracting officer will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the government. 1.6.9 Contracting Officer Representative (COR): The (COR) will be identified by separate letter. The COR monitors all technical aspects of the contract and assists in contract administration The COR is authorized to perform the following functions: assure that the Contractor performs the technical requirements of the contract: perform inspections necessary in connection with contract performance: maintain written and oral communications with the Contractor concerning technical aspects of the contract: issue written interpretations of technical requirements, including Government drawings, designs, specifications: monitor Contractor's performance and notifies both the Contracting Officer and Contractor of any deficiencies; coordinate availability of government furnished property, and provide site entry of Contractor personnel. A letter of designation shall be issued to the COR, a copy of which is sent to the Contractor, it states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change the scope, price, or any of the terms and conditions of the resulting order. 1.6.10 Key Personnel: The follow personnel are considered key personnel by the government: Contract Manager, Alternate Contract Manager, Lead Consultant The contractor shall provide a contract manager who shall be responsible for the performance of the work. The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the contracting officer. The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to the daily operation of this contract. The contract manager or alternate shall be available between 7:00 a.m. to 4:30p.m., Monday thru Friday except Federal holidays or when the government facility is closed for administrative reasons. The Contractor shall have a contingency plan in place to be utilized if key contract personnel leaves the Contractor s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract. Qualifications for all key personnel are listed below: 5 years CMS inspection experience 1.6.11 Identification of Contractor Employees: Contractor and Contract personnel 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. Contractor personnel shall not create an impression that they are Government officials. They must also ensure that all documents or reports produced by the contractors are suitably marked as contractor products or that contractor participation is appropriately disclosed. Contractor Employees will be required to obtain and wear visitor badges in the performance of this service. 1.6.12 Contractor Travel: Contractor will be required to travel to VISN 1 Medical Centers and Community Based Outreach Centers (CBOCs) during the performance of this contract to attend meetings, conduct surveys and training. VISN 1 includes Maine, New Hampshire, Vermont, Massachusetts, Connecticut and Rhode Island. The contractor may be required to travel to off-site training locations and to ship training aids to these locations in support of this PWS. Travel expenses will not be reimbursed individually. Fixed prices proposed for each service identified in the schedule shall include travel expenses. OR Contractor will be authorized travel expenses consistent with the substantive provisions of the Federal Travel Regulation (FTR) and the limitation of funds specified in this contract. All travel requires Government approval/authorization and notification to the COR. One copy of your (and any proposed subcontractor's) written travel policy shall be included in the response to this solicitation . If you (or any proposed subcontractor) do not have a written travel policy, you shall so state. Locations and estimated time needed for surveys: Brocton MA 14 onsite days Bedford MA 14 onsite days Leeds MA 8 onsite days West Haven CT 8 onsite days Augusta ME 8 onsite days Manchester NH 8 onsite days Emergent CMS Services 8 onsite days 1.6.13 Organizational Conflict of Interest: Contractor and subcontractor personnel performing work under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent Organizational Conflict of Interests (OCI) as defined in FAR Subpart 9.5. The Contractor shall notify the Contracting Officer immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the Contracting Officer to avoid or mitigate any such OCI. The Contractor s mitigation plan will be determined to be acceptable solely at the discretion of the Contracting Officer and in the event the Contracting Officer unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the Contracting Officer may effect other remedies as he or she deems necessary, including prohibiting the Contractor from participation in subsequent contracted requirements which may be affected by the OCI. 1.6.14 Applicable Documents: Documents referenced or germane to this Performance Work Statement (PWS) are listed below. In the performance of the tasks associated with this PWS, the Contractor shall comply with the following: 44 U.S.C. § 3541, Federal Information Security Management Act (FISMA) of 2002 5 U.S.C. § 552a, as amended, The Privacy Act of 1974 Public Law 109-461, Veterans Benefits, Health Care, and Information Technology Act of 2006, title IX Information Security Matters 42 U.S.C. § 2000d Title VI of the Civil Rights Act of 1964 Department of Veterans Affairs (VA) Directive 6102 (Internet/Intranet Services) (http: www.va.gov/vai2) Department of Veterans Affairs (VA) Handbook 6102 (Internet/Intranet Services) (http: www.va.gov/vai2) Health Insurance Portability and Accountability Act (HIPAA); 45 CFR Part 160, 162, and 164; Health Insurance Reform: Security Standards; Final Rule dated February 20, 2003 VHA Security Handbook 1600.01, Business Associate Agreements (https://www.voa.va.gov/) 36 C.F.R. Part 1194 Electronic and Information Technology Accessibility Standards, July 1, 2003 Office of Management and Budget Circular A-130, Management of Federal Information Resources , November 28, 2000 An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, October 2008 Sections 504 and 508 of the Rehabilitation Act (29 U.S.C. Section § 794d), as amended by the Workforce Investment Act of 1998 (P.L. 105-220), August 7, 1998 Homeland Security Presidential Directive (12) (HSPD-12), August 27, 2004 VA Handbook 6500, Information Security Program, September 18, 2007. VA Handbook 6500.1, Electronic Media Sanitization, March 22, 2010. VA Handbook 6500.2, Management of Security and Privacy Incidents, June 17, 2008. VA Handbook 6500.3, Certification and Accreditation of VA Information Systems, November 24, 2008. 1.1.1.18. VA Handbook, 6500.5, Incorporating Security and Privacy in System Development Lifecycle. PART 2 SPECIFIC TASKS 2. Specific Tasks: 2.1. Basic Services. The contractor shall provide consultative services for Centers for Medicare & Medicaid Services (CMS) Compliance with Conditions of Participation. 2.2. Task Heading. Mock Survey that assesses readiness and identifies CMS CoP risk areas. Onsite consultation to support and guide organization before, during and after the survey. Onsite emergent consultation to support immediate jeopardy response and plan of correction. Offsite consultation to support and guide organization before during and after the survey Leadership education on Medicare requirements and survey process Performance Requirements Summary The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success. Performance Objective (The Service required usually a shall statement) Standard Performance Threshold (This is the maximum error rate. It could possibly be Zero deviation from standard ) Method of Surveillance PRS # 1. The contractor shall provide On-site CMS consultation for a full Medicare review of all 23 Conditions of Participation (CoPs). The contractor provided an on-site CMS survey and report based on the size of the Community Living Center: 100 Beds or Less: 3 days of 2 RNs and 2 days of 1 LS: total of 8 onsite days 100-300 Beds: 4 days of 3 RNs and 2 days of 1 LS: total of 14 onsite days Zero deviation from standard Accreditation Coordinator to provide 100% inspection of work. PRS # 2 The contractor shall provide on-site support during the LTCI Annual unannounced survey. The contractor provided on-site consultation services within 24-48 hours. To include daily telephone consultation, command center operations and plan of correction. Zero deviation from standard Accreditation Coordinator to provide 100% inspection of work. PRS # 3 The contractor shall provide on-site emergent consultation to support immediate jeopardy response The contractor provided on-site emergency consultation services within 24-48 hours. To include immediate telephone consultation and mitigation of Immediate Jeopardy. Zero deviation from standard Accreditation Coordinator to provide 100% inspection of work. PRS # 4 The contractor shall provide offsite consultation to support and guide organization before during and after the survey The contractor provided offsite consultation via telephone and email Zero deviation from standard Accreditation Coordinator to provide 100% inspection of work. PRS # 5 Leadership education on Medicare requirements and survey process The contractor provided onsite leadership education. Zero deviation from standard Accreditation Coordinator to provide 100% inspection of work. DELIVERABLES SCHEDULE Deliverable Frequency # of Copies Medium/Format Submit To Mock Survey Reports Daily verbal reports of findings and Full written report following each Mock Survey conducted. One full report within 10 business days of survey. Electronic Associate Director Quality Management and Accreditation Coordinator Plan of Corrections Within 15 days following CMS survey. One full report of plan of correction for all deficiencies. Electronic Associate Director Quality Management and Accreditation Coordinator 3. Records Management and Security 3.1. Applicability This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists. 3.2. Definitions Federal record as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them. The term Federal record: 1. includes VHA records. 2. does not include personal materials. 3. applies to records created, received, or maintained by Contractors pursuant to their VHA contract. 4. may include deliverables and documentation associated with deliverables. 3.3. Requirements Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation. In accordance with 36 CFR 1222.32, the Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data. VHA and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of VHA or destroyed except in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage, or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, the Contractor must report to VHA. The agency must report promptly to NARA in accordance with 36 CFR 1230. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records, or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract vehicle]. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records, and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records, and/or equipment is no longer required, it shall be returned to VHA control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand-carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the [contract vehicle]. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4). The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material, and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and VHA guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with VHA policy. The Contractor shall not create or maintain any records containing any non-public VHA information that is not specifically tied to or authorized by the contract. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act. The VHA owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which VHA shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20. Training. - All Contractor employees assigned to this contract who create, work with or otherwise handle records are required to take VHA-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training. ** VHA training for contractors is available in Talent Management System (TMS): Records Management for Records Officers and Liaisons, Item #3873736 3.4. Flow down of requirements to subcontractors 1.The Contractor shall incorporate the substance of this clause, its terms, and requirements including this paragraph, in all subcontracts under this [contract vehicle], and require written subcontractor acknowledgment of same. 2.Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor. 3.5. The A&A requirements do not apply, and the Security Accreditation Package is not required. 3.6. VA ACQUISITION REGULATION SOLICITATION PROVISION AND CONTRACT CLAUSE NOTE: This clause will undergo official rule making by the Office of Acquisitions and Logistics. The below language will be submitted for public review through the Federal Register. The final wording of the clause may be changed from what is outlined below based on public review and comment. Once approved, the final language in the clause can be obtained from the Office of Acquisitions and Logistics Programs and Policy. 1. SUBPART 839.2 INFORMATION AND INFORMATION TECHNOLOGY SECURITY REQUIREMENTS 839.201 Contract clause for Information and Information Technology Security: a. Due to the threat of data breach, compromise or loss of information that resides on either VA-owned or contractor-owned systems, and to comply with Federal laws and regulations, VA has developed an Information and Information Technology Security clause to be used when VA sensitive information is accessed, used, stored, generated, transmitted, or exchanged by and between VA and a contractor, subcontractor or a third party in any format (e.g., paper, microfiche, electronic or magnetic portable media). b. In solicitations and contracts where VA Sensitive Information or Information Technology will be accessed or utilized, the CO shall insert the clause found at 852.273-75, Security Requirements for Unclassified Information Technology Resources. 2. 852.273-75 - SECURITY REQUIREMENTS FOR UNCLASSIFIED INFORMATION TECHNOLOGY RESOURCES (INTERIM- OCTOBER 2008) As prescribed in 839.201, insert the following clause: The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract. 3.7. VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE FOR INCLUSION INTO CONTRACTS, AS APPROPRIATE 1. GENERAL Contractors, contractor personne...