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SCHEDULE OF SERVICES The Contractor shall provide one 1.0 FTE Cardiac Sonographer to provide echocardiography services to eligible beneficiaries of the VA Palo Alto Health Care System (hereinafter ref... SCHEDULE OF SERVICES The Contractor shall provide one 1.0 FTE Cardiac Sonographer to provide echocardiography services to eligible beneficiaries of the VA Palo Alto Health Care System (hereinafter referred to as VAPAHCS). The contract provider s care shall cover the range of echocardiography services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding standards recognized by the American Registry for Diagnostic Medical Sonography (ARDMS) or by the Cardiovascular Credentialing International (CCI). Place of Performance: Services shall be provided on site primarily at the VAPAHCS Palo Alto VA, located at 3801 Miranda Avenue, Palo Alto, CA 94304. Services for other VAPAHCS Community Based Outpatient Clinics (CBOC) may be requested, depending on need. Period of Performance: BASE PERIOD: September 1, 2019 to August 31, 2020 CLIN No. SUB-CLIN Description Qty. Unit Unit Cost Total Annual Cost 0001 None Certified Cardiac Sonographer (1.0 FTE) Hours DO NOT PRICE DO NOT PRICE KEY PERSONNEL None 0001a Certified Cardiac Sonographer NAME:_________________________________ 2080 Hours $__________/hr $______________ TOTAL FOR BASE PERIOD $_____________________________ TOTAL FOR BASE PERIOD: $_____________________________ B.2 PERFORMANCE WORK STATEMENT GENERAL: Services Provided: The Contractor shall provide one 1.0 FTE Cardiac Sonographer to provide echocardiography services on site in accordance with specifications contained herein to beneficiaries of the Department of Veterans Affairs (VA) located at the VA Palo Alto Health Care System. Place of Performance - Contractor shall furnish services at the VAPAHCS Palo Alto VA, located at 3801 Miranda Avenue, Palo Alto, CA 94304, or at other VAPAHCS Community Based Outpatient Clinics, as needed. Authority: Title 38 USC 8153, Health Care Resources (HCR) sharing Authority. Policy/Handbooks the contractor shall be subject to the following policies, including any subsequent updates during the period of performance: VHA Directive 2006-041 Veterans Health Care Service Standards (expired but still in effect pending revision) https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1443 - VHA Handbook 1907.01 Health Information Management and Health Records: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791 - Privacy Act of 1974 (5 U.S.C. 552a) as amended http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm Definitions/Acronyms- Terms used in this contract shall be interpreted as follows unless the context expressly requires a different construction and/or interpretation. In case of a conflict in language between the Definitions and other sections of this contract, the language in this section shall govern. ARDMS: American Registry for Diagnostic Medical Sonography CCI: Cardiovascular Credentialing International CEU: Certified Education Unit CME: Continuing Medical Education CBOC: Community Based Outpatient Clinic Contracting Officer (CO) The person executing this contract on behalf of the Government with the authority to enter into and administer contracts and make related determinations and findings. Contracting Officer s Representative (COR) A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance with and adheres to the specifications contained in the contract and to protect the interest of the Government. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken. COS: Chief of Staff CPARS: Contractor Performance Assessment Reporting System CPRS: Computerized Patient Recordkeeping System- electronic health record system used by the VA. Credentialing: Credentialing is the systematic process of screening and evaluating qualification and other credentials, including licensure, required education, relevant training and experience and current competence and health status. HIPAA: Health Insurance Portability and Accountability Act ISO: Information Security Officer POP: Period of Performance PWS: Performance Work Statement Privileging (Clinical Privileging): Privileging is the process by which a practitioner, licensed for independent practice; e.g., without supervision, direction, required sponsor, preceptor, mandatory collaboration, etc.; is permitted by law and the facility to practice independently, to provide specific medical or other patient care services within the scope of the individual s license, based upon the individual s clinical competence as determined by peer references, professional experience, health status, education, training and licensure. Clinical privileges must be facility-specific and provider-specific. QA/QI: Quality Assurance/Quality Improvement QM/PI: Quality Management/Performance Improvement QASP: Quality Assurance Surveillance Plan RCS: Registered Cardiac Sonographer RCCS: Registered Congenital Cardiac Sonographer RDCS: Registered Diagnostic Cardiac Sonographer Veterans Health Administration (VHA): The central office for administration of the VA medical centers through throughout the United States. The VHA is located in Washington, D.C. Veterans Integrated Services Network (VISN): The regional oversight for the VA medical centers in California and Hawaii. VISTA (Veterans Integrated Systems Technology Architecture): A PC based system that will capture and store clinical imagery, scanned documents and other non-textual data files and integrates them into patient s medical record and with the hospital information system. VETPro: a federal web-based credentialing program for healthcare providers. VA Palo Alto Health Care System (VAPAHCS): Unless identified with the name of a different VA medical Center, for purposes of this contract, this term shall mean the VA Palo Alto Health Care System. QUALIFICATIONS: Staff/Facility Certification - All cardiac sonographers have completed an accredited training course in cardiac ultrasound and shall be certified as Registered Diagnostic Cardiac Sonographers (RDCS) by the American Registry for Diagnostic Medical Sonography (ARDMS) or as Registered Cardiac Sonographer (RCS) or Registered Congenital Cardiac Sonographer (RCCS) by the Cardiovascular Credentialing International (CCI), and be currently certified in Basic Life Support (BLS), though Advanced Cardiac Life Support (ACLS) is preferred. All continuing education courses required for maintaining certification must be kept up to date at all times. The Contractor shall provide documentation verifying current certification to the VA COR upon request. Echocardiography Experience: All cardiac sonographers shall have a minimum of 2 years of echocardiography experience. Technical Proficiency - Contract personnel shall be technically proficient in the skills necessary to fulfill the government s requirements, including the ability to speak, understand, read and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed. Training (ACLS, BLS and VA MANDATORY): Contract personnel shall meet all VA educational requirements and mandatory course requirements defined herein; all trainings must be completed by the contract personnel as required by the VA. VA trainings include: Annual Government Ethics Training; Compliance and Business Integrity; Emergency Preparedness; GEMS; Infection Control; Hazardous Material; Medical Equipment Management; Prevention of Workplace Harassment/NO FEAR; Privacy and HIPAA Training; Safety; Security; Staff and Patient Boundaries; Utilities Management; VA Privacy and Information Security Awareness; and Visitation. Basic Life Support (BLS) is required and Advanced Cardiac Life Support is preferred. Citizenship related Requirements: The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals; While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all E-Verify requirements consistent with Executive Order 12989 and any related pertinent Amendments, as well as applicable Federal Acquisition Regulations. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001. The Contractor agrees to obtain a similar certification from its subcontractors. The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document. Annual Office of Inspector General (OIG) Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed contract personnel are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a Civil Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractors are and/or firm is not listed as of the date the offer/bid was signed. Clinical/Professional Direction: The qualifications of Contractor personnel are subject to review by VA Medical Center COS or his/her clinical designee and approval by the Medical Center Director as provided in VHA Handbook 1100.19. Clinical/Professional direction of all clinical personnel covered by this contract for quality purposes will be provided by the VAPAHCS COS and/or the Chief of the Service or his designee. A clinical COR may be appointed, however, only the CO is authorized to consider any contract modification request and/or make changes to the contract during the administration of the resultant contract. Non-Personal Healthcare Services: The parties agree that the Contractor and all contract personnel shall not be considered VA employees for any purpose. Inherent Government Functions: Contractor and Contract personnel shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees (outside a clinical context), selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy. No Employee status: The Contractor shall be responsible for protecting Contract personnel furnishing services. To carry out this responsibility, the Contractor shall provide or certify that the following is provided for all their staff providing services under the resultant contract: Workers compensation Professional liability insurance Health examinations Income tax withholding, and Social security payments. Tort Liability: The Federal Tort Claims Act does not cover Contractor or contract personnel. When a Contractor or contract personnel has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor s (or contract personnel) action or non-action shall be the responsibility of the Contractor and/or insurance carrier. Key Personnel: The VA Full Time Equivalency (FTE) for the echocardiography services required is one 1.0 VA FTE, to provide a total of 2080 hours of service coverage during the period of performance. The number of cardiac sonographers to provide service on a daily basis (be on site) is one as defined in paragraph Hours of Operation in this section. The Contractor shall be responsible for providing coverage to the VA during extended periods of vacancies of the Contractor s personnel due to sick leave and personal leave. For other requested time off, the contract personnel shall discuss with and obtain approval from the Palo Alto VA Echocardiography Lead Technician. Emergency Substitutions: During the first ninety (90) calendar days of performance, the Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment. The Contractor shall notify the CO, in writing, within 15 calendar days after the occurrence of any of these events and provide the information required below. After 90 days, the Contractor shall submit the information required below to the CO at least 15 calendar days prior to making any permanent substitutions. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO will notify the Contractor within 15 calendar days after receipt of all required information of the decision on the proposed substitutes. The contract will be modified to reflect any approved changes of key personnel. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct 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 patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. Should the VA COS or designee show documented clinical problems or continual unprofessional behavior/actions with any contract physician(s), s/he may request, without cause, immediate replacement of said contract physician(s). The CO and COR shall deal with issues raised concerning Contract personnel conduct. The final arbiter on questions of acceptability is the CO. Contingency Plan: Because continuity of care is an essential part of VAPAHCS s medical services, The Contractor shall have a contingency plan in place to be utilized if the contract personnel leaves Contractor s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract. HOURS OF OPERATION VA Business Hours: Monday Friday 8:00 AM 4:30 PM Contract personnel shall be available and present during normal VAPAHCS hours, which will be established, and may be revised, as deemed appropriate for patient care by the Chief of Staff or designee. Currently, normal hours are Monday Friday 8:00 AM 4:30 PM. Off-hours Coverage: Not Applicable. Off-hour onsite coverage is not required. Federal Holidays: The following holidays are observed by the Department of Veterans Affairs: New Year s Day President s Day Martin Luther King s Birthday Memorial Day Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Christmas Any day specifically declared by the President of the United States to be a national holiday. Cancellations: Unless a state of emergency has been declared by the VAPAHCS, the Contractor shall be responsible for providing services. CONTRACTOR RESPONSIBILITIES Clinical Personnel Required: The Contractor shall provide contract personnel who are competent, qualified per this performance work statement and adequately trained to perform assigned duties. Contract personnel shall be responsible for signing in and out when in attendance. Time sheets will be used by the COR to confirm hours/day and services provided against the contractor s invoices. The Contractor and/or contract personnel shall return required Background Investigation paperwork within 10 calendar days of receipt from the COR. Standards of Care: The contract personnel s care shall cover the range of echocardiography services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding current national standards recognized by the American Registry for Diagnostic Medical Sonography (ARDMS) or Cardiovascular Credentialing International (CCI). MEDICAL RECORDS: Authorities: Contract personnel providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the U.S.C.551a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts 160, 162, and 164 (HIPAA). HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to: a health care provider for treatment. Based on this exception, a BAA is not required for this contract. Treatment and administrative patient records generated by this contract or provided to the Contractors by the VA are covered by the VA system of records entitled Patient Medical Records-VA (24VA19). Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services are available for immediate transmission when requested by the VA. Records identified for review, audit, or evaluation by VA representatives and authorized federal and state officials, shall be accessed on-site during normal business hours or mailed by the Contractor at his expense. Contractor shall deliver all final patient records, correspondence, and notes to the VA within twenty-one (21) calendar days after the contract expiration date. Disclosure: Contract personnel may have access to patient medical records: however, Contractor shall obtain permission from the VA before disclosing any patient information. Subject to applicable federal confidentiality or privacy laws, the Contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over Contractor, may have access to VA s records, at VA s place of business on request during normal business hours, to inspect and review and make copies of such records. The VA will provide the Contractor with a copy of VHA Handbook 1907.1, Health Information management and Health Records and VHA Handbook 1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Handbook 1907.01 Health Information Management and Health Records: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791 and all guidelines provided by the VAPAHCS. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. In the case of the VA authorizing the Contractor to release patient information, the Contractor in compliance with VA regulations, and at his/her own expense, shall use VA Form 3288, Request for and Consent to Release of Information from Individual s Records, to process Release of Information Requests. In addition, the Contractor shall be responsible for locating and forwarding records not kept at their facility. The VA s Release of Information Section shall provide the Contractor with assistance in completing forms. Additionally, the Contractor shall use VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information, when releasing records protected by 38 U.S.C. 7332. Treatment and release records shall include the patient s consent form. Completed Release of Information requests will be forwarded to the VA Privacy Officer at the following address: Ana Marie Vitente, RN Privacy Officer Office of the Director VA Palo Alto Health Care System 3801 Miranda Avenue Palo Alto, CA 94304 Tel: 650-493-5000 ext. 64616 Fax: 650-849-0325 4.3.6 Direct Patient Care: 90% of the time involved in direct patient care. The contract personnel shall perform the following and remain within their scope of practice/privilege at all times: 4.3.6.1 Identify and record anomalies indicative of disease, injury, or other medically significant condition from ultrasound imaging and simultaneous records of the Doppler. Change and develop sounding techniques to accommodate such variables as limited patient mobility, variation in physical condition or dimensions of the patient, presence of prosthesis or foreign objects, and ultrasonic response to different body parts. Produce diagnostic quality images and Doppler frequency recordings using M-mode, two-dimensional, and continuous and pulse wave Doppler and color flow exam. Assist physicians in performing transesophageal echocardiograms. Assist Cardiology fellows in performing and interpreting echo exams and present information to the interpreting physicians. Perform stress echocardiograms with and without pharmaceuticals. Use problem-solving skills to optimize the evaluation and adjust the exams to ensure that they are comprehensive and accurate. Use independent judgment in applying knowledge of clinical cardiology and ultrasound, and Doppler principles. Independently set, calibrate, and operate all echocardiography machinery/equipment. Have intimate knowledge of thoracic anatomy and physiology as related to cardiovascular function. Receive patients and explain procedures to patient and family members. ADMINISTRATIVE: 10% of time not involved in direct patient care Quality Improvement Meetings: If applicable, the contract personnel shall participate in continuous quality improvement activities and meetings with committee participation as required by the VAPAHCS Chief of Service, Chief of Staff, or designee. Meetings will be on an as-needed basis and will occur during regular working hours. Staff Meetings/Rounds: The contract personnel shall attend staff meetings as required by the VAPAHCS Chief of Service, Chief of Staff, or designee. Contractor to communicate with COR on this requirement and report any conflicts that may interfere with compliance with this requirement. QA/QI documentation: The contract personnel shall complete the appropriate QM/PI documentation pertaining to all procedures, complications and outcome of examinations as needed. Patient Safety Compliance and Reporting: The contract personnel shall follow all established patient safety and infection control standards of care. Contract personnel shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breeches of patient safety shall be reported to the COR VA Safety Policy. As soon as practicable (but within 24 hours) Contractors shall notify COR of incident and submit to the COR the Patient Safety Report, following up with COR as required or requested. Medical Records: The contract personnel shall complete all required clinical and medical record documentation for echocardiography services within the required timeframe. The contract personnel shall utilize VA s electronic medical record system for all patient care documentation, where applicable, including the Computerized Patient Record System (CPRS). Invoicing/Billing: In order to adequately document services provided under this contract, a record keeping system of Contractor work hours shall be established and implemented by the COR. Payment for services will not be made until all required documentation related to the services has been submitted. Contractor shall submit monthly invoices within 30 days. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY IMPROVEMENT (QI) Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance: Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE). Contractor performance will be monitored by the government using the standards as outlined in this Performance Work Statement (PWS) and methods of surveillance detailed in the Quality Assurance Surveillance Plan (QASP). The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. In the event that The Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse. The Government reserves the right to refuse acceptance of any contract personnel at any time after performance begins, if personal or professional conduct 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 patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall deal with issues raised concerning Contractor s conduct. The final arbiter on questions of acceptability is the CO. Performance Standards: Measure: Provider Quality Performance Performance Requirement: All contract personnel shall perform in accordance with clinical standards of care. Standard: All services performed within clinical standards of care. Acceptable Quality Level: 100% No deviations accepted. Surveillance Method: Random Inspection Frequency: Annually or as needed Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Qualifications of Key Personnel Performance Requirement: All contract personnel shall be certified in accordance with ARDMS or CCI Standards. Standard: All contract personnel are certified. Acceptable Quality Level: 100% No deviations accepted. Surveillance Method: Direct Observation of qualification documents Frequency: Annually or as needed Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Removal from contract until such time the contract personnel meet qualification standard. Measure: Scope of Practice Performance Requirement: All contract personnel shall provide services within their scope of practice. Standard: All contract personnel perform within their scope of practice/privileges 100% of the time. Acceptable Quality Level: All contract personnel perform within their scope of practice/privileges 100% of the time. No deviations accepted. Surveillance Method: Random Inspection of records. Frequency: Annually or as needed Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Measure: Patient Access Performance Requirement: The Contractor shall provide contract personnel in accordance with the operating hours and VA clinical schedule outlined in this PWS. Standard: All contract personnel are on time and available to perform services. Acceptable Quality Level: Contract personnel is on time and available to perform and provide services 90% of the time Surveillance Method: Periodic Sampling of Time and Attendance Sheets Frequency: Monthly or when itemized invoices are submitted Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation. Deduction: No monetary incentive for work not performed. Contractor will be paid for actual hours worked. Measure: Patient Safety Performance Requirement: Patient safety incidents shall be reported using Patient Safety Report. All incidents reported immediately (within 24 hours.) Standard: All patient safety incidents are reported using Patient Safety Report within 24 hours of incident. Acceptable Quality Level: All patient safety incidents are reported using Patient Safety Report within 24 hours of incident. No acceptable deviation. Surveillance Method: Direct Observation, Validated Patient Complaints Frequency: Annual, per incident, or as needed. Incentive: Favorable contactor performance evaluation. Disincentive: Unfavorable contractor performance evaluation Measure: Maintains licensing, registration, and certification Performa...