LACKAWANNA/SPRINGVILLE COMMUNITY BASED OUTPATIENT CLINIC (CBOC) SERVICES IN ERIE COUNTY, NY   4

5. PROJECT NUMBER (if applicable) CODE 7. ADMINISTERED BY 2. AMENDMENT/MODIFICATION NUMBER CODE 6. ISSUED BY 8. NAME AND ADDRESS OF CONTRACTOR 4. REQUISITION/PURCHASE REQ. NUMBER 3. EFFECTIVE DATE 9A. AMENDMENT OF SOLICITATION NUMBER 9B. DATED PAGE OF PAGES 10A. MODIFICATION OF CONTRACT/ORDER NUMBER 10B. DATED BPA NO. 1. CONTRACT ID CODE FACILITY CODE CODE Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers E. IMPORTANT: is extended, (a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended. 12. ACCOUNTING AND APPROPRIATION DATA (REV. 11/2016) is required to sign this document and return ___________ copies to the issuing office. is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A. 15C. DATE SIGNED B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b). RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified. C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF: D. OTHER Contractor 16C. DATE SIGNED 14. DESCRIPTION OF AMENDMENT/MODIFICATION 16B. UNITED STATES OF AMERICA Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect. 15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER 15B. CONTRACTOR/OFFEROR STANDARD FORM 30 PREVIOUS EDITION NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.) (Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.) (If required) (SEE ITEM 11) (SEE ITEM 13) (X) CHECK ONE 13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS, IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14. 11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT (Signature of person authorized to sign) (Signature of Contracting Officer) 1 7 0002 12-20-2019 NONE Department of Veterans Affairs Network Contracting Office 400 Fort Hill Ave. Canandaigua NY 14424 Department of Veterans Affairs Network Contracting Office 400 Fort Hill Ave. Canandaigua NY 14424 To all Offerors/Bidders 36C24219R0014 11-29-2019 X X X 1 JANUARY 7, 2020 AT 12:00 PM ET This amendment to the above referenced solicitation hereby addresses the remaining vendor questions received through December 20, 2019 and also provides notification of two (2) revisions to the Performance Work Statement (PWS), as described within Attachment 1 to this amendment which begins on page 2. There are no outstanding questions at this time. The proposal submission deadline is revised to 12:00 PM ET on January 7, 2020. All other terms and conditions remain unchanged and in full force and effect. Allan M. Preston Contracting Officer Page 8 of 8 Attachment 1 Amendment 0002, RFP 36C24219R0014 Effective Date: December 20, 2019 This amendment to the above referenced solicitation hereby addresses remaining vendor questions received through December 20, 2019 as described below and also provides notification of two (2) revisions to the Performance Work Statement (PWS) as described below. PWS paragraph 4.7 SPACE REQUIREMENTS is revised and shall now read as: 4.7 SPACE REQUIREMENTS: PACT space standards are found in the PACT Space Module Design Guide at http://www.cfm.va.gov/til/dGuide/dgPACT.pdf. Accessibility design standards are defined in the VA Barrier Free Design Standard at: http://www.cfm.va.gov/til/etc/dsBarrFree.pdf. All doorways through which a patient may pass shall provide a minimum of 42 clear opening to allow for scooters, bariatric access, and mobile equipment. PWS paragraph 4.7.1.2 Primary Care is revised and shall now read as follows: 4.7.1.2 Primary Care: Minimum of three (3) rooms required per PACT Teamlet and each room must have an examination zone and consultation zone. Each room shall be a minimum of 125 square feet. Q40: 4.7.15.1.2: Setback distance from the face of the Building's exterior to the protected/defended perimeter (i.e., any potential point of explosion). This means the distance from the Building to the curb or other boundary protected by bollards, planters or other street furniture. Such potential points of explosion may be, but are not limited to, such areas that could be accessible by any motorized vehicle (i.e., street, alley, sidewalk, driveway, parking lot). What is the setback distance of the site to the bollards required for Physical security? Typically, it is 25 feet, but most clinics in shopping center etc. do not have spaces that conform to this requirement. For such cases, please advise. VA Response: If a pre-existing facility is being proposed, VA will not enforce the physical security requirements for the bollards since it is impractical to put bollards in these locations. Q41: Can the Government confirm that the minimum space requirements listed in sections 4.7.1.1 4.7.1.17 apply to each CBOC location? VA Response: Yes, the requirements apply to each location the main CBOC and the satellite outreach clinic. Q42: Paragraph 4.7.1.1 states, Each exam room contains a consultation zone and an examination zone , while paragraph 4.7.1.2 states, Minimum of two (2) exam rooms and one (1) combination exam/consultation room per PACT teamlet. This requirement is confusing because, per paragraph 4.7.1.1, all exam rooms are required to be combination exam/consultation rooms. Is it the Government s intention for there to be three (3) combination exam/consultation rooms per provider or two (2) exam rooms plus one (1) combination exam/consultation rooms per provider? VA Response: Yes, it is the Government s intention for there to be three (3) combination exam/consultation rooms per PACT Teamlet. PWS paragraph 4.7.1.2 has been revised and shall now read as follows. 4.7.1.2 Primary Care: Minimum of three (3) rooms required per PACT Teamlet and each room must have an examination zone and consultation zone. Each room shall be a minimum of 125 square feet. Q43: Is the requirement for a VA Multi-use office (paragraph 4.7.1.11) in addition to the Mental Health offices required by paragraph 4.7.1.4? Can the Government clarify the VA staff that would use this office? VA Response: Yes, the VA Multi-Use Office (paragraph 4.7.1.11) is in addition to the Mental Health offices required by paragraph 4.7.1.4. The purpose of this office is to accommodate VA personnel that may be onsite periodically at the clinics. Q44: Per paragraph 2.3.2, Contractor is responsible for ensuring that at all times there is at least one RN per site that has Hospital and Community Patient Review Instrument (H/C PRI) certification. If the RN Clinic Manager (required by paragraph 2.5.6) holds this certification, will that satisfy the requirement (applicable to times when the RN Clinic Manager is on-site)? VA Response: The Contractor is responsible for ensuring that at all times there is at least one RN per site that has H/C PRI certification. If the RN Clinic Manager holds this certification, it satisfies the requirement only when the RN Clinic Manager is on-site, meaning there must be at least one alternate RN with this certification at each site. Q45: Would the VA prefer for the contractor to provide a separate and dedicated office for the Medical Director? VA Response: If space allows for a separate and dedicated office, this is VA s preference, however, it is not a requirement and the Medical Director must still have a desk in the team work zone. Q46: Would the VA prefer for the contractor to provide a separate and dedicated office for the RN Clinic Manager? VA Response: If space allows for a separate and dedicated office, this is VA s preference, however, it is not a requirement and the RN Clinic Manager must still have a desk in the team work zone. Q47: Section 4.7.18 states, Contractor shall provide a CCTV system, 43 color monitor and DVR. Due to space considerations in the area where the monitor should be placed, would the Government allow monitors smaller than 43 inches to be used? VA Response: The Government s requirement is for a 43 monitor. Q48: Please confirm that phlebotomists are required to be LPNs per paragraph 2.5.3. VA Response: Yes, the phlebotomist must be an LPN in accordance with PWS paragraph 2.5.3. Q49: Please confirm that the Government is anticipating a declining patient population at both locations. VA Response: Yes; As stated in Amendment 0001, Question 3 The methodology used is a straight line projection conducted using a combination of observed historical enrollments at each site of care extrapolated against US Census Veteran prevalence data for each clinic region. Additionally, future care demands developed for VHA were consulted and mirrored the projections from VAWNYHS. Q50: Per paragraph 4.7.1.8, all patient corridors must be at least 6 feet wide. However, the PACT Space Module Design Guide, referenced in paragraph 4.7, recognizes that renovation of an existing medical facility may not allow for all Design Guide specifications to be followed (see section 4.5 Approach to Renovation ). Would the VA allow for patient corridors that are 5 feet wide (and in compliance with VA Barrier Free Standard) in an existing medical facility? VA Response: No, all patient corridors must be at least 6 feet wide. Q51: Paragraph 4.7.1.4 requires the provision of three (3) offices for mental health, and one of these offices can be used for telemental health. Paragraph 4.7.1.5 requires a telemental health room. Is this requirement in 4.7.1.5 in addition to the requirements of 4.7.1.4? VA Response: The requirement for the telemental health room in paragraph 4.7.1.5 may be met with one of the three (3) rooms required by paragraph 4.7.1.4 as long as it meets the stated requirements of this paragraph. Q52: Regarding the requirement for an RN Clinic Manager at each location (paragraph 2.5.6), would the VA consider allowing a Clinic Manager at the outreach clinic who is not an RN and who would be the administrative manager of the outreach clinic under the clinical direction of the RN Manager at the main clinic? VA Response: No, an RN Clinic Manager is required at each location. Q53: We are requesting clarification on the exact panel sizes that will be allowed for primary care providers at the Lackawanna and Springville locations. We present the full details of our questions below as it is crucial for all offerors to have the same understanding of allowable panel sizes, as these panel size quantities drive both staffing and facility space planning. Paragraph 2.1 of the Solicitation states Current standards are 1200 active patients per full time physician and 900 active patients per full time midlevel provider. Actual panel sizes can be determined by the VA in accordance with VHA Directive 1406, Patient Centered Management Module (PCMM) for Primary Care. We note that our experience has indicated that the VA-assigned panel sizes at VAWNYHS clinic locations are significantly lower than 1200 active patients per full time physician and 900 active patients per full time midlevel provider. Additionally, we note that VHA Directive 1406, Appendix E, provides various factors that affect panel sizes, including teamlet support staff ratio, number of exam rooms per provider, primary care intensity score, and women veteran population. Regarding support staff ratio, the Solicitation requirements of three support staff members per provider would equate to no adjustment to panel sizes, per Table 1 in Appendix E. Regarding exam rooms, the Solicitation requirements of three exam rooms per provider would equate to a +5% adjustment to panel sizes, per Table 2 in Appendix E. Regarding primary care intensity score, we are not sure what, if any, adjustment from Table 3 in Appendix E would apply, as the Solicitation does not indicate the primary care intensity scores for the clinics. Regarding women veteran population, assuming an even distribution of women veterans among the providers at a single location, we are not sure what, if any, adjustment from Table 4 in Appendix E would apply, as the Solicitation does not provide the number of women veterans for the clinics. In this context of the adjustments indicated by Appendix E and the assumptions that solicitation requirements for support staff and exam rooms will be followed and that women veterans will be divided evenly among all providers as a single location, we ask the following questions: Can the Government indicate the panel size that will be allowed for a full-time (non-medical director) physician at the Lackawanna CBOC location? VA Response: 1,200 with full-time support staff of 1 RN, 1 LPN and 1 MSA, however the designated WH Provider panel is 20% less of the total number of female veterans enrolled in the panel. Example: Of 1200 patients, 80 are Women Veterans, you would take 80 x .20 =16 (patients less) making the adjusted panel size 1,184. Can the Government indicate the panel size that will be allowed for a full-time mid-level provider at the Lackawanna CBOC location? VA Response: 900 with full-time support staff of 1 RN, 1 LPN and 1 MSA, however the designated WH Provider panel is 20% less of the total number of female veterans enrolled in the panel. Example: Of 900 patients, 80 are Women Veterans, you would take 80 x .20 = 16 (patients less) making the adjusted panel size 884. Can the Government indicate the panel size that will be allowed for a full-time (non-medical director) physician at the Springville CBOC location? VA Response: 1,200 with full-time support staff of 1 RN, 1 LPN and 1 MSA, however the designated WH Provider panel is 20% less of the total number of female veterans enrolled in the panel. Example: Of 1200 patients, 80 are Women Veterans, you would take 80 x .20 = 16 (patients less) making the adjusted panel size 1,184. Can the Government indicate the panel size that will be allowed for a full-time mid-level provider at the Springville CBOC location? VA Response: 900 with full-time support staff of 1 RN, 1 LPN and 1 MSA, however the designated WH Provider panel is 20% less of the total number of female veterans enrolled in the panel. Example: Of 900 patients, 80 are Women Veterans, you would take 80 x .20 = 16 (patients less) making the adjusted panel size 884. Q54: Can the government more specifically address the sharp decline in CLIN during the first two years of the contract? VETPOP 2016 demonstrates a significantly smaller, albeit still declining population projection, that is in line with year 3 CLIN and beyond in the RFP. VA Response: VAWNYHS utilized a straight line projection conducted using a combination of observed historical enrollments at each site of care extrapolated against US Census Veteran prevalence date for each clinic region opposed to Vet Pop 2016 projections. This modification from the normal planning purposes was due to unavailability of the Vet Pop 2016 data at the micro level necessary during development of the RFP and solicitation. Q55: Is there a new VA facility under construction that would compete with this facility for enrollment? VA Response: VAWNYHS is not planning for any additional or modification to current sites of care that would compete with this facility for enrollment. Q56: What are other specific reasons the government anticipate such a sharp, short-term decline? Please provide any relevant data. VA Response: VAWNYHS does not view the projections as sharp short term declines and they are consistent with observed workload at the sites of care and in line with analyst or project risk management variance. Q57: Would the VA be open to one CBOC operations director/nurse manager covering both sites? VA Response: See response to Question 52, above. Q58: Will the dietician and pharmacist be on-site? If so, how often? Or will they see patients via CVT? VA Response: No, the dietician and pharmacist would only be on-site if care for a specific patient required physical presence. Evaluation and treatment would most likely would be through tele-medicine Q59: Since the VA has agreed to a smaller Springville clinic at 5,000 to 8,000 square feet (Amendment 1, Question 20), what specific variations in the number of rooms (and size) will the VA accept for the Springville CBOC, given its lower enrollment and smaller staff? VA Response: The VA response within Amendment 0001, Question 20 stated Yes as long as all listed space requirements in PWS are met. The VA s expectation is that even though it is a smaller facility, it will still follow the PACT Space Module Design Guide and RFP requirements. For example, specifically, would the VA be open to the following, yes or no? Using one of the two Telehealth or one of the three Mental Health offices at the Springville CBOC for VA multi-use purposes instead of having a separate multi-use room? VA Response: No, VA requirements stand as written in the RFP regarding the VA Multi-Use Room. Reducing MH offices to two instead of three and Telehealth to one room instead of two? VA Response: No, VA requirements stand as written in the RFP regarding Mental Health and Telehealth. Can the CPS use one of the two Telehealth rooms or is a separate space required? VA Response: There is no requirement for a CPS office. If necessary, the CPS would use the VA Multi-Use Room. Can the Women s Health room be included as one of the PACT exam rooms? VA Response: Yes. Can one PACT exam room double as the consult room? VA Response: Yes, three (3) rooms per PACT Teamlet are required. These rooms shall be combination exam/consultation rooms. There is no requirement for a stand-alone consultation room. Q60: Typically, podiatry appointments are occurring every 15 minutes, would the VA podiatrist require two rooms to function out of for efficient patient flow? VA Response: Refer to PWS paragraph 2.5.1 which states: Services will be provided at VAWNYHS, via telehealth capabilities, or in the community, as appropriate. The VAWNYHS and contractor will work collectively to determine where the services will be provided (depending on the veteran s circumstances, i.e., travel within the community, telehealth capabilities, etc.) and will notify the veteran of where to obtain the services. Q61: We have received the questions and answers issued in Amendment 1 for RFP 36C24219R0014, and we respectfully submit a follow up question based on the answer to question 21, which does create an ambiguity that we hope can be addressed for all offerors. Question 21 (from Amendment 0001) states, 4.7.1.1 Door Openings: Does the VA strongly encourage sliding doors on both sides of the exam s rooms or on the patient side only? And the answer provided is, Patient-side. We note that while paragraph 4.7.1.1 is in the context of Patient Care Rooms (Exam/Consultation Rooms) , there are of course additional patient-side doorways throughout the clinic. Is it required for all doorways through which the patient may pass* inclusive of restroom doorways, waiting room doorways, group room doorways, mental health room doorways, and tele-health doorways to be a minimum of 3 6 as instructed in paragraph 4.7.1.1? [*Note: It is noted that an interpreted doorway width requirement of 3'6" for all doorways through which patients may pass as opposed to an interpreted doorway width requirement of 3'6" particularly specific to patient side doorways for PACT Exam/Consultation Rooms would be highly rare to find in the marketplace of existing outpatient medical space in the Buffalo/Lackawanna/Springville, NY area. As such, an interpretation of the 3'6" requirement as applicable to all doorways through which the patient may pass will render as functionally unsuitable the overall infrastructure of virtually all existing outpatient medical office facilities for this Solicitation. It is noted that such an interpretation/result would appear to be inconsistent with the intent of Section 4.5 Approach to Renovation of the VA PACT Design Guide.] VA Response: All doorways through which a patient may pass shall provide a minimum 42 clear opening. PWS paragraph 4.7 SPACE REQUIREMENTS is revised and shall now read as: SPACE REQUIREMENTS: PACT space standards are found in the PACT Space Module Design Guide at http://www.cfm.va.gov/til/dGuide/dgPACT.pdf. Accessibility design standards are defined in the VA Barrier Free Design Standard at: http://www.cfm.va.gov/til/etc/dsBarrFree.pdf. All doorways through which a patient may pass shall provide a minimum of 42 clear opening to allow for scooters, bariatric access, and mobile equipment.