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Joint Commision Mock Survey - Attachment

General Information

Document Type:FILE
Posted Date:Nov 30, 2017
Category: Special Studies and Analyses - Not R&D
Set Aside:N/A

Contracting Office Address

Department of Veterans Affairs;Network Contracting Office 2;James J. Peters VA Medical Center;130 West Kingsbridge Road;Bronx NY 10468-3904


The Joint Commission Environment of Care, Emergency Management, and Life Safety Programs Evaluation Scope of Work Conduct an on-site review of the existing Environment of Care, Emergency Management, and Life Safety programs at the VA Hudson Valley Health Care System in Montrose and Castle Point, New York. This includes on-site review of documentation and review of the physical environment for the health care facilities, preparing and submitting written report resulting from this on-site review, written report to provide specific recommendations to help staff meet current Joint Commission standards, written report to include additional information to improve the effectiveness of existing programs and strategies to ensure continuous compliance with Joint Commission standards and expectations. A minimum of three days to conduct this evaluation which includes a physical inspection, policies, procedures, and plans review, and interviews at both medical facilities at Montrose and Castle Point, New York.. The medical facilities are 45 minutes north and south of each other. The surveyor will provide an agenda of the simulated survey to help plan for the on-site simulation. The evaluation includes: Performance Period: February 13, 2018 through February 15, 2018 Type of Contract: The government agrees to contractor s price based on firm fixed price. CHANGES TO STATEMENT OF WORK: Any changes to this SOW shall be authorized and approved only through written correspondence from the Contracting Officer. A copy of each change will be kept in a COR folder along with all other required documents. Costs incurred by the vendor through the actions of parties other than the Contracting Officer shall be borne by the vendor. Environment of Care evaluation: Safety and security. This evaluation addresses risks in the physical environment, access to security- sensitive areas, product recalls, and smoking. Hazardous materials and waste. This evaluation addresses risks associated with hazardous chemicals, radioactive materials, hazardous energy sources, hazardous medications, and hazardous gases and vapors. Fire safety. This evaluation addresses risks from fire, smoke, and other products of combustion; fire response plans; fire drills; management of fire detection, alarm, and suppression equipment and systems; and measures to implement during construction or when the Life Safety Code cannot be met. Medical equipment. This evaluation addresses selection, testing, and maintenance of medical equipment and contingencies when equipment fails. Utilities. This evaluation addresses inspection and testing of operating components, control of airborne contaminants, and management of disruptions. Emergency Management: The internal, external, regional and national disaster plans using the incident command system will be reviewed. Emergency Plan designed to respond to the effects of potential emergencies that fall on a continuum from disruptive to disastrous. Tested through staged emergency response exercises in order to evaluate its effectiveness. Adjustments made to the Emergency Management plans. Documentation for hazard vulnerability analysis, identification of potential hazards, threats, and adverse events, and assess their impact on the care, treatment, and services they provide for their patients. The four phases of emergency management (mitigation, preparedness, response and recovery), terrorist response, drill implementation (including community-wide drills) and staff knowledge will be reviewed. Total facility evacuation plans will also be evaluated. Adequacy of communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities, and processes for the following maintaining continuity of information, responding to outbreaks of infectious disease, and identifying and mitigating impediments to patient flow. Life Safety: Evaluate the adequacy of fire protection program (creating safe areas (smoke compartments); moving people to safe areas within the building; and/or moving people out of a building. Evaluate facility features designed to prevent, detect, and suppress fires, measures taken to protect occupants from the dangers of fire. Identification of fire risks, conducting fire drills, maintaining fire protection equipment, etc. Evaluation of conformance to current building codes. Evaluation of passive fire protection systems (such as doors and walls). Evaluation of active fire protection systems such as fire alarms and automatic sprinkler systems. Evaluate both existing and new health care occupancies, including buildings with final plans for new construction, additions, renovations, or changes in occupancy. Evaluate conformance to The Joint Commission pertaining to the NFPA s Life Safety Code. Evaluate life safety design and building construction, means of egress, including design of space, travel distances, egress illumination, and signage, protection provided by door features, fire windows, stairs, and other vertical openings; corridors; smoke barriers; and interior finishes, fire alarm notification, including audible and coded alarms, suppression of fires, including sprinkler systems, building services, including elevators and chutes, decorations, furnishings, and portable heaters At the conclusion of the review, a verbal summary will be provided to selected staff so that high priority recommendations may be addressed immediately. Data Analysis and Report Presentation Information obtained from the on-site simulation will be analyzed as it pertains to the current Joint Commission Environment of Care, Emergency Management, and Life Safety standards. A written report will be issued that will include the following information: Projected grades or level of compliance for each TJC element of performance that were reviewed during the on-site survey. These scores will be based upon currently available information and will indicate the degree of compliance with the standards if an actual TJC survey had been conducted. Action recommendations for each element of performance that result in a grade of less than full compliance, and advisory comments for issues that could be improved, will be provided. A summary of Environment of Care, Emergency Management, and Life Safety standards deficiencies resulting from the facility tours. An analysis of staff knowledge resulting from the Tracer interviews that will be conducted. An action tracking sheet that includes the recommended priorities that will permit the highest grade to be achieved with the financial and time-dependent resources that are available. Appendix documents that will serve as examples for required policies and procedures. If the deficiencies are the result of incomplete or missing policies and procedures, sample documentation will be provided in the appendix of the report. Additional written information will also be provided concerning survey strategies, interpretations and preparation. An electric file will also be included with the written report that contains each of the files in Microsoft WORD and PDF format as well as a self-assessment checklist to permit internal electronic distribution of the report and assessment documents. Credentials: The on-site consultant who will performing the survey simulation and facility review will have over 10 years of experience in the health care field in the areas of the Join Commission accreditation and audits, healthcare facilities management and engineering. He/she will have experience in the regulatory compliance area with healthcare institutions throughout the United States in both the public and private sectors. The consultant will have conducted on-site consultations and Life Safety TJC Surveys. Provide references Place of Performance / Delivery: ATTN: Larry Johnson Safety Manager VA Hudson Valley HCS FDR Montrose & Castle Point Campuses Engineering Safety Section (138S) P.O. Box 100Montrose, NY 10548 FDR Montrose: 2094 Albany Post Road, Engineering (Safety Section) Bldg. 16 Montrose, NY10548 Castle Point: 41 Castle Point Road Engineering (Safety Section) Bldg. 9 Wappinger Falls, NY 12590

Original Point of Contact

POC Natalie Acevedo

Place of Performance

VA HUDSON VALLEY HEALTH CARE SYSTEM.;Montrose campus and Castle Point Campus;20940 Albany Post Rd.;Montrose, NY
Link: FBO.gov Permalink
Link: FBO.gov Permalink
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