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[email protected] SUBSTANCE USE DISORDERS TREATMENT PROGRAM (SUDTP) CONTINUING CARE BEDS (CC) PERFORMANCE STATEMENT OF WORK PURPOSE. The Department of Veteran Affairs, Southern Arizona VA Health Care System (SAVAHCS) in Tucson, AZ ("VA") requires contractors to provide supervised housing and case management services as a residential component of its Substance Use Disorders Treatment Program (SUDTP) Continuing Care Services (CC). The goal of the CC is to provide a community-based, residential therapeutic community environment with sufficient supportive services to meet the needs of those Veterans receiving CC substance use treatment at the SAVAHCS. A. BACKGROUND. The Department of Veterans Affairs has established SUD treatment programs designed to provide comprehensive substance use treatment and rehabilitative services that improve the quality of life in a therapeutic community setting and prepare Veterans for independent living in the community of their choice. Such Veterans do not require hospital level care, but require a level of care that is provided in a community residential care facility. VA staff will provide clinical care, treatment and services at the SAVAHCS campus. The Contractor will provide an 18 bed freestanding facility or complex of facilities that provide a domicile environment, that promotes community integration, has a home-like feel and presentation, supportive residential staff, and personal and/or protective care for Veterans with substance use disorders. Contractor residential staff will be expected to communicate information pertinent to Veteran's treatment to the SUDTP clinical staff. The Contractor will provide case management, supervision and supportive services in collaboration with SUDTP staff. 1. Admission Criteria for Placement in Continuing Care Beds a. SUDTP housing coordinator or designated clinical staff will determine Veterans 's eligibility for admission to CC residential placement. b. CC patients are required to attend psychosocial interventions with therapeutic activities 3 or more hours per day, 3 days a week at a minimum at SAVAHCS campus. c. Veterans eligible for placement in Continuing Care Beds are limited to those who have successfully completed the Substance Abuse Rehabilitation Residential Treatment Program (SARRTP) or the Intensive Out Patient (IOP) Bed program. d. VA program staff will evaluate the Veteran's progress towards rehabilitation goals. e. All Veterans placed in housing should be capable of self-preservation. In an emergency situation, the Veteran should have sufficient: i. Capacity to recognize physical danger; ii. Judgment to recognize when such danger requires immediate exit from the group residence; iii. Capacity to follow a prescribed route of exit. iv. Physical mobility to accomplish such exit. f. Veterans cannot be a danger to self or others. g. Veterans need to be capable of independently performing all activities of daily living (i.e. bathing, dressing, feeding one's self, managing any incontinence issues, etc.) h. Veterans must be medically stable and medically cleared by a medical provider. i. Veterans must be able to manage and self-administer prescribed medications. j. Veterans must be on voluntary treatment agreement. k. Veterans cannot possess firearms or any other weapons on contract facility property. l. Veterans must also be willing to abide by the rules of the contract agency, including observing curfews, participating in drug testing; attending VA required mandatory group meetings, and refraining from drug and alcohol use. Such rules need to be approved by the Director of the VA Substance Use Disorder Treatment Program (SUDTP). m. Veterans must be willing to work toward resolving substance use issues and engaging in clinically appropriate substance use and mental health treatment. n. Veteran's placement shall be 3 to 6 weeks as clinically indicated and determined by SUDTP clinical Staff. B. SERVICES TO BE PROVIDED BASIC SERVICES: The contractor will provide and maintain a clean, safe, secure, aesthetically pleasing, and home-like environment. The contractor shall provide the following services: 1. Therapeutic and Rehabilitative Environment of Care: a. A freestanding facility or complex of facilities that provides a domicile environment capable of housing up to 18 Veterans. Facility must meet all applicable Federal, State, and local licensing and other requirements noted below for the operation of a facility in that/those location/s. Other facility requirements include but are not limited to compliance with the American Disabilities Act, referred to as architectural barriers act compliant. b. Facility/ies that comply with VA and accrediting bodies' environment of care standards (Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and Mathemateca) including but not limited to: i. Life Safety Codes (LSC) ii. space criteria iii. safety iv. security v. privacy vi. emergency planning preparedness c. Environment of care will be maintained in a clean and appropriately-furnished condition with timely repairs and regular maintenance. d. A milieu that will promote community interaction and a home-like environment. e. An environment designed to promote an individual sense of well-being, optimism, and social integration with the surrounding community (as opposed to a hospital or dormitory-like dwelling). NOTE: in the design and decoration of the space, a priority needs to be placed on promoting a sense of hope and belief in recovery. f. Appropriate space for Veterans to visit with significant others, family, and children at designated times. g. Separate and secure sleeping arrangements (unit or wing) for at least 2 female Veterans. h. Ensure that all facilities have locking bedrooms and bathrooms exclusively for female Veterans. i. Safe and secure exclusive bathroom arrangements for female Veterans. In mixed gender units, this includes but is not limited to, proximity to staff and door locks. j. Appropriate private space for women Veterans to visit with significant others and children at designated times. k. Controlled telephone access with ability to make local telephone calls. l. Provide each individual Veteran a locked cabinet, drawer, locker, or other acceptable secured means accessible only to the Veteran and/or qualified contractor staff. Keys or codes must be unique to each Veteran's locked area. m. Provide food/meals/snacks 7 days a week, with kitchen facilities for the Veterans to prepare their own meals. Such food/meals shall be healthy and meet the nutritional needs of the Veterans to enhance their recovery. n. Sanitary procedures shall be established and maintained for washing dishes, cleaning equipment and work areas, and for proper waste disposal. o. Veterans shall be housed with no more than two per room. The contractor shall provide beds with mattresses (not bunk beds) for the Veteran's use; plus one nightstand/table in each room. Space shall be provided for Veteran to hang clothes either in fixed or portable closet areas in each room. p. Linens/bedding to be provided by contractor. q. On-site, adequate laundry facilities (including detergents) available for Veterans to do their own laundry, at no cost to the Veteran. r. Basic gender specific toiletries such as soap, shampoo, deodorant, shaving cream, razor, comb, toothbrush, toothpaste, toilet paper, menstrual pads, tampons, hair dryer, iron and ironing board. s. A television with basic cable or satellite TV service in each facility that houses Veterans. t. The contractor shall provide housing and supportive services in a manner that is free from religious discrimination. u. Other services provided by contractor include, but are not limited to: i. facility maintenance (including exterior maintenance) ii. Contractor will launder blankets and pillows for each bed after veteran is discharged from program. Cleaning supplies shall be provided by contractor. iii. refuse pickup iv. pest control (a) If any pest is found in the patient area by the Veterans, contract staff, or VA staff, within 24 hours of report, the contractor will provide licensed and certified professional pest control service. Upon completion of service certified professional pest control service will submit results to the VA. v. utilities vi. telephone/data connections vii. fire alarm/fire protection 2. Contractor/contract staff shall further: a. Provide staffing on a 24-hour, 7 days per week basis to supervise Veterans. (Please refer to Section C, Part 9, in this document for further staffing information.) b. Provide a safe and sober environment for all Veterans. c. Supervise Veterans to support a safe an alcohol/drug use-free lifestyle. d. Follow the principles of Veteran Centered Care including but not limited to: i. Enhance the quality of human interactions and therapeutic alliances by treating Veterans with respect and to promote veteran centered recovery plan. ii. Solicit and respect the Veteran's values, preferences, and needs. iii. Empower the Veteran through information and education. iv. Ensure emotional and spiritual support. v. Incorporate the nutritional, cultural, and nurturing aspects of food. e. Provide appropriate safety and security in all common areas, such as lounges, laundry rooms, shared kitchens, group rooms, entrances and exits, and hallways, through active monitoring. Monitoring may be done by frequent security staff observation. f. Communicate information pertinent to Veteran's wellbeing to SUDTP clinical staff. g. The SUDTP housing coordinator or designated staff should be notified immediately when a Veteran chooses to leave SUDTP CC, during after hours, a notification voicemail will suffice. h. Conduct at least one formal safety, security, and privacy self inspection each month documenting observations and corrective actions taken (including work orders submitted). Maintain records for monthly inspections and provide records to VA upon request i. Conduct daily and random health and welfare inspections of both public areas and resident rooms for any contraband and unsecured medications. Maintain records for daily inspections and provide records to VA upon request. All contraband and unsecured medications found shall be documented, immediately placed in secured storage, and reported to the SUDTP housing coordinator or designated clinical staff. Maintain records and provide records to VA upon request. j. Inspect a minimum of 25 percent of Veteran rooms, closets, lockers, and drawers each week to detect contraband. Maintain and provide records to VA upon request k. Conduct rounds to ensure the safety and security of Veterans, staff, and visitors. Staff shall conduct daily rounds of all public spaces, such as hallways, dayrooms, group rooms, stairwells, community bathrooms. Maintain and provide records to VA upon request. l. Check beds at approximately 10pm and 6am. Veterans will be expected to follow daily curfew of 8pm. These checks shall coincide with the daily procedures used to verify the physical presence of each Veteran. Additional bed checks or change of daily curfew may be requested by SUDTP housing coordinator or designated person. These checks may take place on any shift, including night time bedroom checks. m. Develop written procedures for intake and admission to contract facility including but not limited to orientation of facility, review of program rules/regulations, provide contact information of assigned case manager and/or designee available 24 hours, 7 days a week. n. Conduct health and welfare inspections of the Veteran's belongings at admission. o. Develop written procedures consistent with local.fedral and state laws for detecting contraband brought on the unit/residence. Procedures shall be approved by SUDTP housing coordinator. p. Develop written policies and procedures that address the following concerns and situations, procedures shall be approved by SUDTP housing coordinator or designee: i. Suspected or known drug or alcohol use or relapse by one or more Veterans ii. On-site contraband, weapons (including props or souvenirs that appear to be weapons), drug or alcohol related paraphernalia (i.e., found alcohol, drugs, drug "works", etc.) iii. Safe prescription medication storage and handling, including specific provisions for prescribed controlled substances iv. Safe prescription medication access, including specific provisions for safe disposal of medications and syringes v. Assertive monitoring of controlled substances, including but not limited to: signing in medications after receipt from pharmacy with an observed pill count by contractor staff; staff observation and recording of taking of controlled substances and other medications by Veterans vi. Room inspections, daily curfew and daily bed checks of Veterans residing in the program, including methods and frequency vii. Grievance process to address Veteran complaints with time frames for responses from the contractor's program/facility management viii. Veteran abandonment of belongings in the facility, including time frames and procedures for disposal ix. Process to elicit Veteran satisfaction with the facility and onsite services, including information collection methods and frequency, and process for utilizing the information for continual performance improvement purposes. These policies and procedures must be communicated to Veterans both verbally and in writing in a manner that is understandable to them upon admission to the contractor facility. This communication must be documented in the contractor's Veteran client record. q. Develop a written case management and/or service plan based on Veteran's identified needs to achieve a more adaptive level of psychosocial functioning and promote community integration including utilization of community resources. r. Provide education and assistance to develop recovery based living patterns such as but not limited to: self-care skills, self-administration of medication(s), social skills, independent living skills, budgeting and finances, and linkages to outside resources and supportive services. s. Meet with Veterans weekly to follow up on Veteran's progress and identify any concerns/needs that need to be addressed. Maintain records of weekly meetings and provide records to the VA upon request. t. In the event a Veteran relapses on alcohol or drugs, Veteran's case will be staffed with SUDTP housing coordinator or designated clinical staff to determine Veteran's continued placement at the contractor facility. Determinations will be made on a case-by-case basis and based on Veteran's individual recovery needs. u. Notify SUDTP housing coordinator or designated clinical staff of any negative incident occurring with a Veteran within 24 hours of being informed or aware of the incident, if not sooner. Contractor will complete a written incident report within 48 hours of notification. Incidents include but are not limited to: death; fire; drug / police raid; suicide / suicide attempt; 911 call (police / fire dept. / paramedics / other); drug overdose; severe medical illness / emergency; severe psychiatric illness / emergency; sexual assault; act of violence by Veteran against other(s); abusive behavior by Veteran against staff; act of violence by other(s) against Veteran; abusive behavior by staff against Veteran; accident; medication problems or adverse drug reactions; or other untoward events. v. Sufficiently document all negative incidents including but not limited to: i. Staff name ii. Date iii. Time iv. Findings v. Outcome vi. Veteran name and social security number when indicated vii. VA staff notified when indicated Such documentation shall be maintained as required in Section C, Parts 3, 5, and 6-8; and be made available to VA inspection teams or staff when requested. C. ADDITIONAL CONTRACT REQUIREMENTS 1. Additional Guidelines: a. Unauthorized absences must be reported immediately to the SUDTP housing coordinator or designated clinical staff, during after hours, a notification voicemail will suffice. Unauthorized absences from the contract facility may result in Veteran's discharged by the SUDTP staff. b. Authorized absences from the contract facility must be approved by the SUDTP housing coordinator or designated clinical staff. c. Programming conflict: In the event of a conflict in VA program or facility guidelines, VA program will take precedence. d. All contractor staff who works with SUDTP CC Veterans shall be trained in basic First Aid and Cardiopulmonary Resuscitation (CPR) not less than once every two years. First Aid training shall meet or exceed basic First Aid Standards set by the American Red Cross. CPR training shall meet or exceed BLS/AED standards set by the American Heart Association. This training shall be paid for by the contractor. e. Contract staff shall be required to complete other VA mandated training as directed. VA shall be responsible to provide this additional training that will most often be offered at SAVAHCS. Contractor shall not be required to pay for this training BUT VA will not reimburse contractor for contractor employee time, travel, or food. Contractor shall be required to ensure all contract staff who work with SUDTP IOP Veterans receives this training as directed. f. Contract staff shall notify the SUDTP housing coordinator or designated clinical staff immediately when a medical emergency occurs, during after hours, a notification voicemail will suffice. When necessary the Veteran will be admitted to an appropriate VA facility. When such admission is not feasible because of the nature of the emergency, hospitalization in a non-Federal hospital may be accomplished provided VA authorization is obtained in advance. If hospitalization of a non-emergency nature is required that admission to the VA hospital will be accomplished promptly. g. In the event a beneficiary receiving care under this contract dies, the contract facility shall promptly notify the SAVAHCS and immediately assemble, inventory, and safeguard the patient's personal effects. The funds, deposits, and effects left by Veteran upon the premises of the contract facility shall be delivered by the facility to the person or persons entitled thereto under the laws currently governing the contract facility for making disposition of funds and effects left by Veterans, unless the beneficiary died without leaving a will, heirs, or next of kin capable of inheriting. When disposition has been made the itemized inventory, with a notation as to the disposition of the funds and effects, shall be immediately forwarded to the SAVAHCS office. Should a deceased Veteran leave no will, heirs, or next of kin, their personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases the contract facility shall forward an inventory of any such property and funds in its possession to the appropriate VA office and shall hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from the SAVAHCS official concerning disposition. h. The SAVAHCS will process payments for services rendered in accordance with such authorization upon receipt of billings submitted by the contractor at the completion of each month's services. The SAVAHCS will pay per diem for the day of a patient's admission to the Contract Program or the day of the Veteran's discharge, but not both. If a beneficiary is admitted to and discharged from the housing center on the same calendar day, payment will be authorized for one day. i. Monthly invoices shall be submitted to the COR or other person designated at the address shown at the end of this contract. Invoices shall also be submitted monthly to VA's Financial Service Center, Region II, P.O. Box 149971, Austin, TX 78714-9971 or faxed to 512-460-5540. Invoices need to include at least a remit to address (or bank account number and bank routing number for direct deposit), invoice number, VA provided Purchase Order Number, and the amount invoiced. Other information may be required on the invoice including but not limited to: veteran names, social security number, and dates of service. The COR, VA finance, Director of SUDTP or other designee will provide further clarification after the contract is awarded. Contractor agrees to provide any and all requested information each invoice each month as requested for compensation. A requested change for information included on each monthly invoice is rare. 2. Records and Reports: The Contractor shall maintain an individual clinical record on each veteran outplaced under this contract. The contractor must comply with the requirements of the "Confidentiality of Certain Medical Records" (38 USC 4132), and the "Confidentiality of Alcohol and Drug Abuse Patients' Records" (42 CFR, Part 11) when appropriate, and shall be part of the contract. All case records will be maintained with such security and confidentiality as required, and will be made available on a need to know basis to appropriate VA staff members involved with the treatment program of the veterans concerned. The contractor is subject to annual security inspections by the VA Security department. In addition to reasons for referral, the clinical record maintained by the contract facilities will include: a. Relevant Releases of Information to communicate and coordinate Veterans' treatment with VA and other community based service providers. b. All essential identifying data relevant to the Veteran and the Veteran's family, in case of emergency, next of kin should be identified. c. Data relating to the Veteran's admission to SUDTPCC), including intake assessment(s) and anticipated length of stay provided by SUDTP housing coordinator or designated clinical staff. d. Copies of all medical prescriptions issued by any physician, including orders, if any, for medications to be taken and/or diets to be followed. e. Written case management plan and client progress notes. The Contractor shall be responsible for the following onsite records and reports: f. Daily sign-in sheets signed by program Veterans and/or contractor staff, to document and verify Veterans' presence at the facility during curfew and bed checks. Daily sign-in sheets must be completed clearly, accurately and thoroughly with full signatures and monitored so as to provide a full accounting of Veterans' stay. Maintain daily sign-in sheets and provide records to VA upon request. 3. Transportation: The Contractor shall provide Veterans with transportation to and from contract facility on day of admission and day of discharge, Monday-Friday. The Contractor shall provide transportation for Veterans in need of and urgent medical evaluation that does not require medical emergency services such as 911 call/paramedic services. The Contractor shall assist Veterans with accessing local transportation such as with provision of bus passes for local public transportation, including information and instructions necessary to enable Veterans to utilize public transportation. 4. Quality Improvement: a. The VA will conduct utilization review audits. b. Contractor will meet quality of patient care standards as specified by the VA. c. Contractor shall ensure confidentiality of patient record information as stipulated in Section C, Parts 3, 5, and 6-8; and provide complete and accurate financial invoices for contracted services. d. The comprehensive program monitoring and evaluation study mandated by law will draw part of its data from the contractor housing settings. e. The VA will conduct a resident Veteran satisfaction survey each month. The VA will use the Veteran satisfaction survey to evaluate contracto performance. f. The VA will conduct performance audits, see Attachment 1: Performance Requirements Summary 5. Governing Law: This contract shall be governed, construed and enforced in accordance with applicable Federal, State and Local Law. 6. Order of Precedence: The terms, conditions, and attachments referenced herein, including any formal written modifications thereto, constitute the complete agreement between the parties and take precedence over any other language, oral or written. 7. HIPAA Compliance: Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the National Standards to protect the privacy and Security of Protected Health Information (PHI). This contract and it's requirements meet the following exception and does not require a Business Associate Agreement (BAA) in order for Covered Entity to disclose protected Health Information to: An organization (Specialty Care Facility Provider) whose access to Protected Health Information would be incidental, if at all); Based on the exception, a Business Associate Agreement (BAA) is not required for this Contract. a. All contractor staff of the Contractor providing services under this contract shall complete the VA's HIPAA Training course or provide acceptable evidence that acceptable training has been provided. The VA training is located on the Web at ww.vhaprivactrainin.gov. The training certificate must be printed and presented annually to the COR, upon request. 8. Security Incident Investigation: a. The term "security incident" means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor shall immediately notify the COR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor has access. b. To the extent known by the contractor, the contractor's notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor considers relevant. c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement. d. In instances of theft or break-in or other criminal activity, the contractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA Office of Inspector General (OIG) and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident. 9. Liquidated Damages for Data Breach: a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information (SPI). If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract. b. The contractor shall provide notice to VA of a "security incident" as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination. c. Each risk analysis shall address all relevant information concerning the data breach, including the following: i. Nature of the event (loss, theft, unauthorized access); ii. Description of the event, including: date of occurrence; data elements involved, including any personal information, such as full name, social security number, date of birth, home address, account number, disability code; iii. Number of individuals affected or potentially affected; iv. Names of individuals or groups affected or potentially affected; v. Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text; vi. Amount of time the data has been out of VA control; vii. The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons); viii. Known misuses of data containing sensitive personal information, if any; ix. Assessment of the potential harm to the affected individuals; x. Complete data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents (see http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=406&FType=2); xi. Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised. d. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $(to be determined) per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following: i. Notification; ii. One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports; iii. Data breach analysis; iv. Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution; v. One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and vi. Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs. 10. VA Information Custodial Language: a. Information made available to the contractor by VA for the performance or administration of this contract or information developed by the contractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1). b. VA information should not be co-mingled with any other data on the contractor's information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA's information is returned to the VA or destroyed in accordance with VA's sanitization requirements. VA reserves the right to conduct on site inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements. c. Prior to termination or completion of this contract, the contractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract. d. The contractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if National Institute of Standards and Technology (NIST) issues or updates applicable Federal Information Processing Standards (FIPS) or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract. e. The contractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor electronic storage media for restoration in case any electronic equipment or data used by the contractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed. f. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12. g. If a VHA contract is terminated for cause, the associated Business Associate Agreements (BAA) must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01,. Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship. h. The contractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated. i. The contractor's firewall and Web services security controls, if applicable, shall meet or exceed VA's minimum requirements. VA Configuration Guidelines are available upon request. j. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor shall use and disclose VA information only in two other situations: i. in response to a qualifying order of a court of competent jurisdiction, ii. with VA's prior written approval. The contractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response. k. Notwithstanding the provision above, the contractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor is in receipt of a court order or other requests for the above mentioned information, that contractor shall immediately refer such court orders or other requests to the VA contracting officer for response. l. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require certification and accreditation (C&A) or an memorandum of understanding- interconnection security agreement (MOU-ISA) for system interconnection, the contractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COR. 11. Personnel: Sufficient staff must be provided in numbers and positions qualified to carry out the policies, responsibilities, and services of the program: a. The Contractor must have at a minimum, a full-time administrative staff member on duty on the premises and available for emergencies 24 hours a day, 7 days a week. b. A Director/Supervisor of the contract program and/or facility on call and available for emergencies 24 hours a day, 7 days a week. c. There must be staff present on site at all times Veterans are present. Veterans are generally NOT present at the contract facility during normal duty/business hours as Veterans will be participating in SUDTP programming during normal duty/business hours. There may be instances where a Veteran with a minor illness will need to remain at the facility for rest during normal duty hours. When an illness stay is approved, contract staff member/s will need to stay at the facility with the Veteran during normal business hours. d. The Contract facility provides services to Veterans to include providing a safe, secure, confidential and structured environment that addresses the needs of the Veteran. e. VA inspection teams will evaluate the ability of the Contract facility to consistently assure the presence of staff capable of providing the services required under the terms of the contract. f. The records of contractor personnel shall be subject to review by the VA Chief of Staff or designated representative. g. The Contractor must identify each person functioning as "Key Personnel" under this contract, and provide to the VA a description of the services to be provided by such person/s, together with a resume summarizing that person's relevant skills and experience. h. The Contractor shall assign to this contract personnel that by education and training (and, when required, certification or licensure) are qualified to provide the Basic Services and Additional Contract Requirements required by this Statement of Work. i. During the first thirty (30) calendar days of contract performance, the Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment. Within 14 days after substitutions necessitated by situations described above, the Contractor shall provide resumes for the substitute key personnel. For substitutions proposed by the Contractor after the initial 30 calendar day period, the Contractor shall provide resumes for the substitute personnel, together with any other additional information requested by the Contracting Officer, at least 15 days before the substitution is to occur. The Contracting Officer shall notify the Contractor within fifteen (15) calendar days after receipt of all required information if the VA refuses to accept the substitute key personnel. The VA reserves the right to refuse or revoke acceptance of key personnel if personal or professional conduct, or lack of required skills or experience, jeopardizes patient care or interferes with the regular and ordinary operation of the facility. j. Temporary substitutions of key personnel shall be permitted in accordance with the Contractor's contingency plan. The Contractor's contingency plan to be utilized if personnel leave Contractor's employment or are unable to continue performance in accordance with the terms and conditions of the resulting contract must be submitted as part of the Contractor's offer. k. All Contractor staff providing services to Veterans under this contract must undergo the appropriate background investigation as required by the VA. Before receiving an initial referral of Veterans under the contract, the Contractor shall submit a listing of all Contractor personnel proposed to provide services to Veterans under the contract. The VA will provide the necessary background information forms to the Contractor or to the Contractor's employees after receiving a list of names and addresses. l. Upon receipt, the VA Contracting Officer will review the completed forms for accuracy and forward the forms to proper federal authorities to conduct background investigations. m. The VA facility shall pay for investigations conducted by the Office of Personnel Management (OPM) in advance. However, the Contractor is required to reimburse the VA for the cost of the investigations. The estimated cost for a Low Risk Level Background Investigation is $250 per employee. The VA shall recover the cost of the investigations from the Contractor through offsets against amounts invoiced or against the guaranteed minimum payment, as appropriate. n. The VA Contracting Officer shall forward the completed background investigations to the Office of Security and Law Enforcement for adjudication. The Office of Security and Law Enforcement shall notify the Contracting Officer and Contractor after adjudicating the results of the background investigations received from the investigating office. o. If the VA staff suspects a contractor staff may be impaired due to the influence of drugs or alcohol that staff member will be required to leave the Veteran care area immediately. Within 2 hours of suspicion, suspected staff accompanied by the Contractor designee must report for breathalyzer and urinalysis toxicology test to a certified 24/7 laboratory of contractor's choice. Contractor must provide results to the VA Medical Center. Positive results will result in immediate dismal and removal from the facility. p. The Contractor staff will not engage in inappropriate relationships with the Veterans. Any violation will result in immediate dismissal and removal from the facility. q. The COR shall be responsible for verifying that investigations have been completed or are in the process of being requested before Veterans are referred to the Contractor's facilities. 12. Absences and Cancellation a. Absence of the Veteran from the Contract facility will not be reimbursable except with the prior approval of the VA Medical Center Chief, Behavior Health Service or his/her designee. b. Veterans receiving care under this contract, who begin to require more than the level of care authorized by VA, will be readmitted to an appropriate VA facility, as determined and authorized by VA. When such admission is not feasible because of the nature of the emergency, it is agreed that VA authorization must be obtained within 72 hours of admission of the patient to a non-Federal facility. If hospitalization of a non-emergency nature is required, it is agreed that readmission to a VA Medical Center will be accomplished as soon as the patient's condition is sufficiently stabilized to permit admission to VA. 13. Contractor Staff Conduct/Complaints Handling: a. The contractor shall notify the authorizing VA facility immediately of any incidents involving Veterans residing in the SUDTP IOP program. The contractor shall notify the SUDTP housing coordinator or designated person. b. Contractor personnel shall be expected to treat referred Veterans and VA staff with dignity and respect, and abide by standards of conduct mirroring those prescribed by current federal personnel regulations. The Contractor shall comply with the VA Patient's Bill of Rights and Veterans Healthcare Service Standards as set forth in VHA Directive 2006-041 (See http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1443 for more information). c. The VA reserves the right to exclude Contractor staff members from providing services to Veterans under this contract based on breaches of conduct, including conduct that 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 Veterans or other staff members to designated Government representatives. The Contractor and Contracting Officer's Representative shall deal with issues raised concerning contractor personnel conduct. The Contracting Officer shall be the final arbiter on questions of acceptability and in validating complaints. 14. Facility: a. It is the responsibility of the Contractor to properly maintain its facilities and the VA shall have no responsibility for paying or reimbursing the Contractor for such expenses. The contract facility must: i. have a current occupancy permit issued by the local and state governments in the jurisdiction where the facility is located, or a statement from the appropriate city or state office, stating there is not a need for an occupancy permit. ii. be in compliance with existing standards of State safety codes and local, and/or State health and sanitation codes. iii. where applicable, be licensed under State or local authority. iv. where applicable, be accredited by the State. v. be equipped with operational air conditioning /heating systems vi. be kept clean and free of dirt, grime, mold, or other hazardous substances and damaged item/s that noticeably detract from the overall milieu and appearance. vii. be equipped with first aid equipment and an evacuation plan in case of emergency. viii. have windows and doors that can be opened and closed in accordance with manufacturer standards. b. The contractor facility must meet fire safety requirements, as follows: i. The building must meet the requirements of the applicable residential occupancy chapters of the current version of NFPA 101, National Fire Protection Association's Life Safety Code. Any equivalencies or variances must be approved by the appropriate Veterans Health Administration Veterans Integrated Service Network (VISN) Director. ii. All residents in the facility must be mentally and physically capable of leaving the building, unaided, in the event of an emergency iii. The Contract Facility warrants that all applicable fire laws (City, State, Federal) are being complied with and there are no unresolved recommendations that have been made by fire officials that have not been resolved. Fire drills will be conducted monthly to include an evening Fire Drill every quarter. New Veterans will be oriented to Fire and Safety Policies and Procedures within 5 days of taking residence in the facility. Veterans must be instructed in evacuation procedures when the primary and/or secondary exits are blocked. iv. Contracted staff will have fire and safety training every two months. Contract facility will maintain documentation of fire drills, new patient orientation and contract staff training for a minimum of 2 years. v. A written fire plan for evacuation in the event of fire shall be developed and reviewed annually. The plan shall outline the duties, responsibilities and actions to be taken by the staff and residents in the event of a fire emergency. This plan shall be implemented during fire exit drills. vi. A written policy regarding tobacco smoking in the facility shall be established and enforced. vii. Portable fire extinguishers shall be installed at the facility. Use NFPA 10, Portable Fire Extinguishers, as guidance in selection and location requirements of extinguishers. viii. Requirements for fire protection equipment and systems shall be in accordance with NFPA 101. All fire protection systems and equipment, such as the fire alarm system, smoke detectors, and portable extinguishers, shall be inspected, tested and maintained in accordance with the applicable NFPA fire codes and the results documented. c. The annual inspection by a VA team required by Part C. Section 15 Inspection of Facility and Program shall include a fire and safety inspection conducted at the facility unless a review of past Department of Veterans Affairs inspections or inspections made by the local authorities indicates that a fire and safety inspection would not be necessary, in which case the fire and safety inspection may be waived by the VA. 15. Inspection of Facility and Program a. The Contract Facility is subject to inspection by a VA Inspection Team prior to contract award and not more than 45 days prior to the annual contract renewal date, to insure compliance with all contract requirements. The multi-disciplinary VA team will consist of the VA Medical Center Contracting Officer's Representative (COR), a social worker, dietitian, registered nurse, a representative of the VA Police, and a Facilities Management Safety Officer, and other subject matter experts as determined necessary by the medical center director or SUDTP housing coordinator shall conduct a survey of the Contractor's facilities to be used to provide Veterans food, shelter, and therapeutic services to assure the facility provides quality care in a safe environment. Inspections may also be carried out at such other times as deemed necessary by the Department of Veterans Affairs. b. Surveys of the housing setting shall be made quarterly by the VA team and COR or a designated representative. c. Prior to making each inspection of a facility, the team will: i. Review the report of most recent inspection, if any, and discuss with team members any problems or irregularities which they may have encountered earlier in dealing with the facility. ii. The safety officer will be prepared to inspect the setting for conformity to the current Life Safety Code (National Fire Protection Association (NFPA #101) iii. Review terms of any existing contract housing agreements. d. The clinical members of the team will focus on an assessment of the quality of care provided by the facility and the quality of life within the facilities, giving particular attention to the following critical indicators: i. Patient records maintained in a manner compliant with Part D, Sections 5 and 7 of this contract. ii. Making a spot check of Veterans' records to ensure accuracy with respect to Veterans' length of stay and services provided to the Veterans. iii. Documentation that basic services are provided to Veterans on an ongoing basis. iv. General observation of Veterans indicating they maintain an acceptable level of personal hygiene and grooming. v. Evidence of facility-community interaction. This may be demonstrated by the nature of scheduled activities or by involvement of other than facility staff with the Veterans. vi. Observation of staff behavior and interaction with Veterans to determine if they convey an attitude of genuine concern and caring. vii. Evidence that the contract facility shall provide documentation that staff is available for emergencies 24/7. viii. There is documented evidence of the facility's commitment to the implementation of the Patient's Bill of Rights. e. Other items to be included in the inspection: i. Assessment of whether the facility meets applicable fire, safety and sanitation standards. ii. Inspecting the types of meals and other nutrition provided to Veterans (approval will be gained by the Nutritionist on the inspection team). f. The contractor will be advised of the findings of the inspection team. If deficiencies are noted during any inspection, the contractor will be given a reasonable time to take corrective action and to notify the Contracting Officer that the corrections have been made. A contract will not be awarded until noted deficiencies have been eliminated. Failure by the Contractor to take corrective action within a reasonable time will be reported to the VA Contracting Officer. If corrections are not made to the satisfaction of the VA, the Contracting Officer will consult with the appropriate officials so that suitable arrangements can be made to discontinue plans to award a contract, or to discharge or transfer patients and to terminate the existing contract, as appropriate. g. A formal report of each inspection will be prepared and forwarded to the Medical Center Contracting Officer. In accordance with normal contract administrative practices, the following actions shall ensue: i. The Facility will be advised of the findings of the inspection team. ii. In the event deficiencies have been noted, the Facility will be given a reasonable time to take corrective action and to notify the Contracting Officer that the corrections have been made. iii. Any unsatisfactory conditions noted during a follow-up visit to a contract facility will be reported in writing to the Contracting Officer through the Medical Center Director. In already existing contracts, satisfactory corrections must be made within a negotiated time frame with the Contract Liaison and SUDTP housing coordinator. When this is not done, the Contracting Officer will consult with the concerned officials so that suitable arrangements can be made to discharge or transfer patients and terminate the contract. h. If, during the course of inspection, an unresolved discrimination complaint arises or maintenance of segregated facilities has been observed, a report will be forwarded to the VA Medical Center Director. The report will contain pertinent facts and observations with a description of action taken to correct the situation. A copy of the report will be given to the Contracting Officer and Contract Facility i. The original copy of the inspection report and pertinent correspondence will be kept in the contract file. The Contract Facility (contractor) shall make documented information available to VA, as deemed necessary, to conduct utilization review audits, to verify quality of care to Veterans, to assure confidentiality of Veterans record information, and to determine the completeness and accuracy of financial records. The comprehensive programs monitoring the evaluating study mandated by 38 U.S.C 1720(f) will draw part of its data from the contract facilities. j. The government shall, at its discretion, choose at any time, announced or unannounced to have VA personnel inspect the contractor's facility. \ k. All Department of Veterans Affairs reports of inspection of residential facilities furnishing treatment and rehabilitation services to eligible Veterans shall, to the extent possible, be made available to all government agencies charged with the responsibility of licensing or otherwise regulating or inspecting such institutions. 16. Contract Changes/ Technical Directions: a. The Contracting Officer is the only person authorized to approve changes or modify any of the requirements of this contract. The Contractor shall communicate with the Contracting Officer on all matters pertaining to contract administration. Only the Contracting Officer is authorized to make commitments or issue changes that shall affect price, quantity or quality of performance of this contract. b. IN THE EVENT THE CONTRACTOR AFFECTS ANY SUCH CHANGE AT THE DIRECTION OF ANY PERSON OTHER THAN THE CONTRACTING OFFICER WITHOUT AUTHORITY, NO ADJUSTMENT SHALL BE MADE IN THE CONTRACT PRICE TO COVER AN INCREASE IN COSTS INCURRED AS A RESULT THEREOF. c. The COR will be responsible for the overall technical administration of this contract as outlined in the COR Delegation of Authority, including monitoring of the Contractor's performance. 17. Contracting Officer's Representative (COR): a. After contract award, a Department of Veterans Affairs employee(s) may be designated as the Contracting Officer's Representatives (CORs), for the purpose of administering the technical aspects of this procurement. The COR is authorized to clarify technical (clinical) requirements and to review and approve work which is clearly within the scope of the contract. He/she is NOT authorized to change the contract scope of work or agree to any contract price revision. The following position will be designated as the COR and such designation shall be provided separately in writing. 1. Appointed COR 2. SAVAHCS 3. 3601 S. 6th AVE 4-116b 4. Tucson, AZ 85723 5. Telephone (520) 792-1450 x 5047