Description
STATEMENT OF WORK (SOW) FOR NON-EMERGENCY AMBULANCE TRANSPORTATION 1. Contract Title. Non-emergency ambulance transportation from the William C Talent Outpatient Clinic (WCTOPC), Knoxville, TN to the James H. Quillen VA Medical Center (JHQVAMC), Mountain Home, TN. 2. Background. JHQVAMC located in Mountain Home, TN (within Johnson City, TN) provides and operates the free standing WCTOPC in Knoxville, TN approximately ninety-five (95) miles apart. JHQVAMC does not currently provide urgent or observational medical transportation between WCTOPC and JHQVAMC. An ambulance service is required to transport patients whose medical condition warrants them to be seen at JHQVAMC or local hospital setting and warrants them to travel by ambulance not private vehicle or other means. JHQVAMC does not operate an ambulance service at either location. This contract provides non-emergent ambulance service between WCTOPC and JHQVAMC. 3. Scope. WCTOPC may require ambulance service to transport Veteran patients who are medically stable for transport to the JHQVAMC or nearest applicable non-VA medical center near the WCTOPC, Knoxville, TN. Further, JHQVAMC requires basic life support (BLS) for Veteran patient transport, and in some instances will also require advanced life support (ALS) for Veteran transportation from the WCTOPC to JHQVAMC and nearest appropriate non-VA medical center and from non-VA medical center to JHQVAMC. 4. Specific Tasks. Overview: a. Veterans who are assigned to the WCTOPC, Knoxville, TN area can receive primary care, optometry, mental health, radiology, laboratory, social work, dietetic consultation, prosthetics, nurse managed diabetes clinic, and clinical pharmacy consultative services. b. This contract includes requirements for a basic life support (BLS) vehicle staffed by an Emergency Medical Technician (EMT) and an advanced life support (ALS) vehicle staffed by Emergency Medical Technician Paramedic (EMTP). The contractor shall furnish on call non-emergent ambulance service for the WCTOPC on an as needed/on call basis. 5. Mileage Threshold/Chargeable Mileage: a. The mileage threshold is thirty (30) miles from the WCTOPC where no additional "mileage charge" shall be added to the base rate. For all one-way trips, the additional "mileage charge" shall apply only to those miles traveled beyond the 30 mile threshold. In the event fraction miles result, JHQVAMC shall pay the rounded off amount to the next higher even mile. The Bing, Dashboard Beneficiary Travel Mileage Calculator (BDBTMC) shall determine chargeable trip mileage from JHQVAMC or WCTOPC to the Veteran's home address. The BDBTMC shall be used to calculate all chargeable mileage. If the BDBTMC does not calculate the entire distance to the Veteran's address, JHQVAMC shall consider the actual mileage within a five to ten mile variance. b. All one-way trips ordered under the contract shall receive the base rate quoted ("Base Rate"). The Base Rate shall constitute full compensation for one-way trips, which do not exceed the mileage threshold as defined above. The contractor shall also receive the mileage rate quoted ("Mileage Rate") for any one-way trips in excess of the mileage threshold. The mileage rate is applicable only for mileage in excess of the mileage threshold and at no time shall the contractor receive reimbursement for mileage less than the mileage threshold. 6. Number of Patients: It is understood and agreed upon that only one patient shall be transported on a trip unless specifically requested by the contractor. Pursuant to the JHQVAMC authorization, when more than one patient is transported concurrently on a trip, reimbursement shall be made at the rates contained under the pricing schedule for transporting a single patient. Regardless of the number of patients transported concurrently on a single trip beyond the mileage threshold, the contractor shall be reimbursed at the mileage rate for one trip to the longest distance traveled with any one patient on that particular trip. The contractor must ensure that pick-ups and drop-offs are scheduled so that the distance traveled shall result in the most economical charge to the Government. 7. On-Site Transportation Services: a. The contractor shall provide a BLS unit for transportation of patients to and from WCTOPC property on an as-needed basis. b. If the contractor is unavailable due to unexpected mechanical reasons, the contractor shall provide service within 30 minutes of notification by the WCTOPC. 8. Waiting Time: Time lost in waiting at either or both ends of a trip due to causes beyond the contractor's control, the contractor shall be reimbursed at the rate of one fourth the hourly rate quoted in the contractor's proposal for each quarter hour or fraction thereof in excess of one-half hour from the time he/she reports to the designated person at either WCTOPC or JHQVAMC. If the pickup is other than at WCTOPC or JHQVAMC, the contractor shall call the JHQVAMC Travel Clerk first, (423) 926-1171 extension 3306 or Travel Supervisor (423) 926-1171 extension 4438 during administrative hours (7:45a.m. through 4:30p.m., Monday through Friday) or the Medical Administrative Assistant (MAA) at (423) 926-1171 and ask for the MAA on duty during non-administrative hours (during evenings, nights, weekends, and holidays) as soon as it is anticipated that a delay may develop for which the Contractor expects to claim reimbursement. This call is only for the purpose of verifying the arrival time at the pick-up point and is not necessary if the Contractor anticipates no delay for which reimbursement will be claimed. The Contractor's failure to follow the above stated protocol when waiting beyond the grace period shall result in non-payment for waiting time. 9. Service Orders: a. Request for services will be made in writing or by telephone, and subsequently confirmed in writing by individual(s) designated by the Travel Supervisor (423) 926-1171 extension 4438 or 3306 7:45 a.m. to 4:30 p.m., Monday through Friday. After normal duty hours follow the protocol outlined in paragraph eight above. b. If the contractor fails to furnish ambulance service within 30 minutes after receiving a request for service, JHQVAMC reserves the right to obtain the service from another source and to charge the contractor excess cost/fees. The JHQVAMC shall be the sole judge in determining when to order service from another source. However, in no instance shall the contractor be required to furnish more than four ambulances for BLS service and two ambulances for ALS service at any one six hour time. When the total number of contracted vehicles is in use transporting WCTOPC patients, and the WCTOPC requires additional vehicles, the JHQVAMC shall first contact the contractor to provide additional vehicles at the contracted rate. If additional vehicles are not available from the contractor, the JHQVAMC shall contact another ambulance provider for transport at no cost to the contractor. c. The Travel Supervisor is designated by the Contracting Officer to serve as the Contracting Officer's Representative (COR). NOTE: The contractor shall immediately notify the Travel Supervisor as outlined in paragraph nine above of delays in transporting patients. 10. Toll Charges: It is agreed and understood that the prices quoted in the price schedule do not include any ferry, bridge, tunnel or road toll charges. Any such legitimate toll charges incurred shall be limited to one-way only and shall be listed separately on the contractor's invoices. The COR will verify these charges. 11. Vehicles: a. The ambulance (emergency medical care vehicle) under the term of this contract shall be licensed and meet the minimum vehicle requirements as established by the Board of Health, State of Tennessee, Emergency Medical Services Division. The specifications are mandatory, as minimal requirements for such vehicles, but chassis or compartment modification are permissible when they clearly exceed the minimal qualifications. b. Each ambulance shall have all required ambulance medical equipment items including but not limited to patient facilities, oxygen, suction and environmental climatic supplies as required by Federal Specification KKK-A-1822 Revision E for Ambulances. 12. Staff Qualifications: EMTs providing emergency services on ambulances serving WCTOPC must have the following qualifications: a. Completed training in accordance with the standards published by the Department of Health and Human Services (DHHS) with a minimum curriculum of eighty-one (81) hours or "equivalent" including an in-hospital training period. Such training programs must also be accepted under the regulating requirements for local emergency medical systems (EMS) supported by DHHS under PL 93-154.39 Federal Regulation 24304 (1974). b. Evidence of the "equivalent" training program successfully completed by the EMT shall be submitted with the offer to the Contracting Officer for inspection. c. The EMT shall be certified, licensed or otherwise officially recognized by the local, state or regional government or public entity where the emergency ambulance service is operated or by which it is governed. d. The EMT must be enrolled periodically in "refresher" continuing education or advanced training programs as required by local or state entity in which the service is rendered to Veterans, but in no instance shall this be more frequent than every two (2) years. Such "refresher" training shall be equivalent to that developed by the Department of Transportation, National Highway Safety Administration. Evidence of successful completion of refresher training must be submitted to the Contacting Officer for inspection. 13. Non-Emergency Attendant/Driver: Prices include non-emergency attendants and drivers as appropriate. Attendants and drivers must be capable to administer oxygen and have successfully completed the Standards and Advanced First Aid Courses of the American Red Cross or U.S. Bureau of Mines or equivalent. Proof in the form of a current certification that such first aid training has been successfully completed must be submitted with offer and available upon request for option years. 14. Escort: An authorized official of the contractor may in the interest of the patient, allow a relative to accompany him/her at no extra charge to the Government. 15. Cancellations: On trips within the mileage threshold, there shall be no charge to the Government for cancelled trips if the contractor is notified before the vehicle is dispatched. Outside the mileage threshold, there shall be no charge to the Government prior to the vehicle being dispatched. A "no show" is defined as a trip, which is cancelled upon the contractor's arrival at the pick-up point, and the contractor may request reimbursement for a one-way trip. 16. Patient Welfare and Abuse: a. The contractor shall be held responsible for patient welfare during transport. The contractor shall be held responsible for patient and/or Government property during transport. Any damage or lost wheelchairs, walkers, crutches or personal belongings shall be replaced at the contractor's expense. b. The Government requires the contractor to exercise extreme caution and care in the handling of patients. Any abuse of patients shall be grounds for default action or termination of the contract. c. The contractor will consider that he/she is transporting ill patients. Drivers of vehicles are required to observe speed limits, vehicles should be swept clean and exteriors washed periodically, and drivers will refrain from smoking. d. All of the contractor's employees shall be required to sign a JHQVAMC confidentiality statement and it is the responsibility of the contractor to assure these statements are kept current. This is inspectable by the COR upon request 17. Incident Report: When an incident/accident occurs, involving the welfare of a Veteran the contractor must submit, in writing, an incident/accident report within twelve (12) hours of the occurrence to the COR. 18. Reporting Procedures: a. During off duty tours, weekends and holidays, the crews shall report to the MAA at the JHQVAMC, who are located at the check-in desk of the JHQVAMC Emergency Room. b. Transport of baggage, medical records and other personal effects with Veterans, shall occasionally be required. c. Ambulance drivers shall deliver and pick-up patients at designated locations with-in the clinic or within JHQVAMC. The location will be designated when contact is made by authorized JHQVAMC Staff as outlined in paragraph nine above. d. Ambulance personnel shall report to the clinic check-in one, to announce his/her arrival to pick-up and transfer the patient and two, obtain report of pertinent information regarding the patient's condition from the primary care team nurse/physician. e. When delivering a patient, the ambulance personnel shall give report to appropriate nursing personnel and provide a copy of the run sheet, which shall be retained by the facility for the patient's medical record. f. In cases where the ambulance crew must divert to a local emergency room while performing authorized transport, the contractor is obligated to notify the JHQVAMC Travel Department or MAA of the patient's location and status as soon as this information becomes available but not later than 20 minutes after diverting to the closest emergency room. 19. Meals: When patients are traveling during mealtime in an ambulance, the contractor shall provide meals for the patient. The cost of the patient's meal shall be listed as a separate item on the contractor's invoice and shall be supported by a receipt for the patient's meal from the restaurant. No payment for meals shall be made unless the contractor furnishes a copy of the receipt to the COR. The maximum amount authorized for any one meal is $8.00. The contractor shall be notified at the time the call for transport is made if patients are authorized to receive meals. No meals shall be furnished unless authorized by the COR or MAA as outlined in paragraph nine above. 20. Equipment Specifications: a. Vehicles: Ambulance fleet, minimum of six (6), and its equipment and supplies must be of the quality, model and condition to assure the patient's complete safety, high quality medical transportation and emergency first aid, if needed; shall meet the minimum standards for maintenance, equipment and staffing for all ambulance vehicles operated. b. Each ambulance shall be of a model and make to insure safe and comfortable transportation of the patient. Vehicles must have sufficient headroom to accommodate the patient in Fowler's position and must be effectively heated and air-conditioned. Vehicles will be inspected and maintained daily to assure mechanical fitness and cleanliness. c. Ambulance Medical Equipment: Each ambulance shall be equipped at all times when transporting a patient in the performance of this contract with not less than required by Federal law, State law, County and City laws in which the ambulance is operated as well as the operational medical equipment described in Federal Specification KKK-A-1822 Revision E for Ambulances as: "(i) Shall have one ambulance cot and collapsible stretcher or two stretchers, one of which is collapsible. (ii) Shall have adequate straps to secure the patients safely to stretcher or ambulance cot, and adequate mens of securing the stretcher or ambulance cot within the vehicle. (iii) Shall have adequate supply of sanitary sheets, pillow cases and blankets. (iv) Shall have portable oxygen unit in good operating condition and with spare tank and with adequate supply of nasal cannulas or oxygen masks; oxygen masks must be of the disposable type or be thoroughly sterilized after each use and kept sterile. (v) Shall have standard first aid kit. (vi) Shall have portable O2 suction units available for emergency use in transfer of severely ill patients, to be operated by professional staff only. (vii) Shall have I.V. poles and stair chair. (viii) The contractor must have or have access to IV pumps and cardiac monitors, which are compatible to those used by the JHQVAMC. The contractor must also have access to a portable ventilator to be used when transporting JHQVAMC patients." 21. Enterprise Management Controls: a. Integration Management Control Planning: Provide the technical and functional activities at the required level for integration of all tasks specified within this SOW. Include productivity and management methods such as quality assurance, progress/status reporting and program reviews. Provide the centralized administrative, clerical, documentation and related functions. b. Contract Management: Prepare a contract management plan describing the technical approach, organizational resources and management controls to be employed to meet the cost, performance and schedule requirements throughout contract execution. Provide a monthly status report monitoring the quality assurance, progress/status reporting and program review applied to this contract. 22. Performance Monitoring: The COR will monitor contractor performance and certify the work was done in accordance with the contract. Routine inspections and product sampling by the COR as recorded in the Quality Assurance Plan is the method the COR will utilize to measure contractor performance. 23. Security Requirements: Contractor staff will have access to printed and verbal patient information and data but will not have access to JHQVAMC or WCTOPC computer systems. 24. Government-Furnished Equipment (GFE)/Government-Furnished Information (GFI): The Government including JHQVAMC and WCTOPC will not furnish any equipment under this contract. All government equipment, linens, etc., taken with patients must be returned. The Contractor shall furnish all linens, blankets, and supplies. JHQVAMC will not participate in a linen exchange program or any supply exchange program. The Contractor shall not be permitted to borrow medical equipment from the JHQVAMC or WCTOPC. The Contractor shall provide all medications required while in transport, sheets, and blankets and other equipment and supplies required for use while in transport, for direct patient care. Contractor shall at no time and under any circumstances exchange supplies, equipment, and/or medications with the JHQVAMC or WCTOPC. 25. Security Requirements for Unclassified Information Technology Resources: The contractor, their staff personnel and their subcontractors shall be subject to federal laws, regulations, standards, and Department of Veterans Affairs (VA) and the Veterans Health Administration (VHA) directives and handbooks regarding personal identifiable information and health information security as delineated in this contract an as outlined in the Health Insurance Portability and Accountability Act (HIPAA) . 26. Other Pertinent Information or Special Considerations: a. RECORDS: At the option of the Government, the Contractor may be required to transport records with patients from station to station. b. Packaging, Packing and Shipping Instructions: The contractor shall provide secure storage of any Veteran's belongings left on an ambulance and can be asked to ship personal belonging to the Veterans home address or bring it to the WCTOPC or JHQVAMC on the next trip. The contractor assumes complete responsibility for these belongings until turned over to the COR or the COR's designated point of contact. e. Inspection and Acceptance Criteria: The COR is responsible for certifying that the work done under the contract is performed to time, standard and quality established. The COR is also responsible to assure the inspection and acceptance of products provided incidental to services is acceptable. 27. Risk Control: Contractor is responsible for patient issues, infection control and risk management at the time of pick up until the time of drop off. 28. Period of Performance: The required start date for services is approximately June 2014 and the end date of the first period of service will be September 30, 2014. Option periods are defined as three subsequent years commencing September 2014, 2015, 2016. 29. Delivery Schedule: Describe the items to be delivered throughout the period of performance and at completion of the contract, if applicable. The delivery schedule format is as follows: SOW Task# Deliverable Title Format Number Calendar Days After CO Start 1 Mileage Threshold/Chargeable Mileage Invoice/Statement - Design established by Contractor, Contracting Officer and COR * Standard Distribution Monthly 2 Number of Single Veteran Patient Transport Invoice/Statement - Design established by Contractor, Contracting Officer and COR * Standard Distribution Monthly 6 Toll & Bridge Charges Invoice/Statement - Design established by Contractor, Contracting Officer and COR * Standard Distribution Monthly 11 Cancelations Invoice/Statement - Design established by Contractor, Contracting Officer and COR * Standard Distribution Monthly 13 Incident/Accident Report Report Format to be Developed * Standard Distribution Within 12 hours of the incident or accident 15 Meals Invoice/Statement - Design established by Contractor, Contracting Officer and COR * Standard Distribution Monthly * Standard Distribution: 1 copy of the invoice/statement to the Contracting Officer and 1 copy to the COR both sent via email. 30. Performance Requirements Summary Matrix: Task ID Indicator Standard Acceptable Quality Level Method of Surveillance Incentive/ Disincentives Mileage Threshold/ Chargeable Mileage 1 Invoice/ Statement Design established by Contractor, Contracting Officer and COR Included in invoice of the month the patient transportation occurred. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO. Past performance 2 Number of Single Veteran Patient Transport Included in invoice of the month the patient transportation occurred. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO. Past performance 3 Toll & Bridge Charges Included as a separate line item in the invoice of the month the patient transportation occurred. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO. Past performance 4 Cancelations Included as a separate line item in the invoice of the month the patient transportation occurred. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO. Past performance 5 Incident/Accident Report Included as a separate line item in the invoice of the month the patient transportation occurred. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO. Past performance 6 Meals Included as a separate line item in the invoice of the month the patient transportation occurred. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO. Past performance Access (for all transportation services) 7 For all transportation services respond within 30 minutes of notification of service order Within 30 minutes of notification or sooner. 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance 7 ambulance maintains all required ambulance medical equipment items including but not limited to patient facilities, oxygen, suction and environmental climatic supplies as required by Federal Specification KKK-A-1822 Revision E for Ambulances. Required equipment stocked in all ambulances 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and random no notice visits 8 EMT Qualifications as detailed in paragraph 13 a., b., c.; d. of SOW Applicable to all EMTs providing emergency services on ambulances 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and random no notice visits 9 Non-Emergency Attendant/Driver Qualifications as detailed in paragraph 14 of SOW Applicable to all Drivers on ambulances 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and random no notice visits Patient Welfare and Abuse / Patient Safety 10 Responsible for patient welfare during transport Exercise extreme caution and care in the handling of patients 100% Observation and random inspection (auditing) patient complaints and patient evaluations Past performance and patient evaluations 11 Patient safety incidents must be investigated by the COR, confirmed and resolved. All incidents are investigated, confirmed and resolved. 100% Investigation report filed with the CO and Contractor Past performance and patient evaluations 12 Incident Report contractor must submit, in writing, an incident/accident report within twelve (12) hours of the occurrence to the COR 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and random no notice visits Government-Furnished Equipment (GFE)/Government-Furnished Information (GFI) 13 All government equipment, linens, etc., taken with patients must be returned At no time and under any circumstances exchange supplies, equipment, and/or medications with the JHQVAMC or WCTOPC 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and random no notice visits 14 Security Requirements for Unclassified Information Technology Resources contractor, their staff personnel and their subcontractors will be subject to federal laws, regulations, standards; Department of Veterans Affairs (VA); the Veterans Health Administration (VHA) directives and handbooks; Health Insurance Portability and Accountability Act (HIPAA) 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and reports from patients and staff 15 Risk Control Contractor is responsible for patient issues, infection control and risk management at the time of pick up until the time of drop off 100% Observation and random inspection (auditing) or any other method that the COR is approved to implement by the CO Past performance and reports from patients and staff