10-30 PWS_RSU_CNM.docx

RFP: 75H70627R00005

PERFORMANCE WORK STATEMENT

Certified Nurse-Midwife (CNM) Services Outpatient Department Clinic and Emergency Department OB Call

1. BACKGROUND AND PURPOSE

The Indian Health Service (IHS), an agency within the U.S. Department of Health and Human Services, provides Federal healthcare services to American Indians and Alaska Natives (AI/AN). Rosebud IHS Hospital is a 35-bed comprehensive medical and surgical facility located on the Rosebud Sioux Indian Reservation in Rosebud, South Dakota, and serves members of the Rosebud Sioux Tribe (Sicangu Oyate) and surrounding communities.

This PWS establishes the requirements for two (2) full-time Certified Nurse-Midwives (CNMs) to provide outpatient obstetric and gynecological services and to respond to obstetric emergencies in the Emergency Department on an on-call basis. The requirement is intended to support continuity of maternal and women’s healthcare services for the Rosebud service population.

2. PERIOD OF PERFORMANCE

The total potential period of performance is twelve (12) months, consisting of the following:

Base Period: Three (3) months

Option Period 1: Three (3) months

Option Period 2: Three (3) months

Option Period 3: Three (3) months

The Government may exercise each option period by written notice to the Contractor in accordance with FAR 52.217-9. Exercise of an option is contingent upon continued Government need, satisfactory Contractor performance, availability of funds, and Contracting Officer approval.

3. SCOPE OF WORK

The Contractor shall provide professional Certified Nurse-Midwife services consistent with the American College of Nurse-Midwives (ACNM) Core Competencies, IHS clinical policies, applicable South Dakota licensure requirements, and Rosebud IHS Hospital medical staff bylaws and credentialing standards. This is a non-personal services contract. The Contractor shall independently manage and supervise its personnel, while the Government retains the right to evaluate the quality, timeliness, and completeness of services against the performance standards established in this PWS.

Services shall be provided in the following primary settings:

Outpatient Department (OPD) Clinic - scheduled clinic sessions for prenatal, postpartum, gynecologic, and women's primary care services.

Emergency Department (ED) - on-call coverage for OB emergencies outside of scheduled clinic hours.

The Contractor's CNM personnel shall adhere to the clinical protocols, credentialing requirements, and collaborative practice framework established by the Rosebud IHS Hospital medical staff bylaws and credentialing committee. Such adherence reflects the professional standard of care and facility access requirements, and does not constitute employer-employee supervision by the Government.

4. SPECIFIC TASKS AND DELIVERABLES

4.1 Outpatient Clinic Services

Each assigned CNM shall provide the following services during scheduled OPD clinic hours, generally Monday through Friday consistent with facility operating hours and as otherwise required by the PWS:

4.1.1 Prenatal Care

Conduct initial prenatal intake examinations, including comprehensive health history and physical assessment.

Develop individualized prenatal care plans in accordance with ACOG and ACNM evidence-based guidelines.

Perform all routine prenatal visits: assessment of fetal growth, fundal height, fetal heart tones, blood pressure monitoring, and symptom review.

Order and interpret prenatal laboratory studies, including but not limited to: complete blood count (CBC), blood type and Rh factor, rubella titer, hepatitis B surface antigen, HIV, syphilis (RPR/VDRL), gonorrhea/chlamydia culture, Group B Streptococcus (GBS) screening, and gestational diabetes screening (one-hour glucose challenge/three-hour GTT as indicated).

Perform or coordinate obstetric ultrasound as clinically indicated (dating, anatomy survey, growth, biophysical profile).

Assess and manage common pregnancy complications including hyperemesis gravidarum, anemia, gestational hypertension, and preterm labor risk, with timely physician consultation or referral for conditions exceeding CNM scope of practice.

Screen for intimate partner violence (IPV), substance use, and perinatal mood and anxiety disorders (PMADs) utilizing validated screening tools; initiate appropriate referrals to behavioral health and social services.

Provide patient education on nutrition, exercise, fetal movement monitoring, labor preparation, breastfeeding, and postpartum expectations.

Facilitate and document referrals to maternal-fetal medicine (MFM) specialists, genetic counseling, or other specialty services as clinically indicated.

4.1.2 Intrapartum Care (as applicable to facility capabilities) Provide labor support, assessment, and management within the scope of CNM practice and within facility capabilities.

Assess maternal and fetal status, including interpretation of electronic fetal monitoring (EFM) strips.

Manage normal labor progress, including amniotomy, oxytocin augmentation per protocol, and pain management options.

Attend and manage normal vaginal deliveries, including repair of first- and second-degree lacerations and episiotomies per facility policy.

Perform immediate newborn assessment and resuscitation (NRP-certified) pending pediatric provider response.

Recognize and respond to obstetric emergencies (e.g., shoulder dystocia, postpartum hemorrhage, cord prolapse) and initiate physician consultation/transfer protocols immediately.

4.1.3 Postpartum Care

Conduct postpartum visits at approximately 2 weeks and 6 weeks following delivery (or per facility protocol).

Assess uterine involution, wound healing, breastfeeding status, and emotional well-being.

Screen for postpartum depression and anxiety using the Edinburgh Postnatal Depression Scale (EPDS) or equivalent validated tool; initiate referral as indicated.

Counsel on contraception options and initiate family planning services during the postpartum period.

4.1.4 Gynecological and Women's Primary Care

Perform annual well-woman examinations including comprehensive physical assessment, clinical breast examination, and pelvic examination.

Collect cervical cytology specimens (Pap smears/liquid-based cytology) and manage results per current ASCCP guidelines.

Diagnose and treat common gynecological conditions including vaginitis, pelvic inflammatory disease (PID), sexually transmitted infections (STIs), dysmenorrhea, and abnormal uterine bleeding.

Provide full-scope family planning services including: oral contraceptive pills, injectable contraceptives (Depo-Provera), transdermal patch, vaginal ring, subdermal implant insertion/removal (Nexplanon), and intrauterine device (IUD) insertion/removal (hormonal and copper).

Perform preconception counseling, including folic acid supplementation, medication reconciliation, and management of chronic conditions prior to conception.

Provide health maintenance services including immunizations per ACIP guidelines, cancer screening coordination, and lifestyle counseling.

Manage menopause-related symptoms including hormone therapy counseling where clinically appropriate.

4.2 Emergency Department (ED) OB On-Call Services

Each assigned CNM shall participate in an on-call rotation to provide obstetric emergency coverage in the Rosebud IHS Hospital Emergency Department when the OPD clinic is not operational. On-call responsibilities shall be shared equitably between the two Contractor CNMs and any other credentialed CNM providers available at the facility.

While on call, the CNM shall:

Respond to the ED within a timeframe established by the facility, not to exceed 60 minutes from notification.

Evaluate and stabilize OB emergencies including but not limited to: antepartum hemorrhage, eclampsia/pre-eclampsia with severe features, preterm labor, premature rupture of membranes (PROM/PPROM), fetal distress, ectopic pregnancy, hyperemesis requiring IV management, and miscarriage (threatened, inevitable, incomplete, or complete).

Initiate emergency protocols, order laboratory and imaging studies, establish IV access, and administer medications within CNM scope of practice and applicable standing orders.

Immediately notify and collaborate with the on-call physician for any patient whose condition exceeds CNM scope of practice, requires operative intervention, or who meets criteria for emergent transfer.

Facilitate timely transfer to a higher level of care (e.g., Sioux Falls or Rapid City Monument Health Hospital) in accordance with EMTALA requirements and IHS transfer protocols.

Complete all required documentation in the electronic health record (EHR) in a timely manner.

4.3 Documentation and Health Records

Document all patient encounters, assessments, diagnoses, orders, and care plans in the Rosebud IHS Hospital electronic health record (EHR) system (Resource and Patient Management System [RPMS]/Electronic Health Record [EHR] module, or successor system) on the day of service.

Complete required IHS performance measure documentation, including Government Performance and Results Act (GPRA) clinical measures for maternal and child health.

Maintain accurate and legible medical records in compliance with IHS medical records standards, Joint Commission standards (if applicable), and applicable federal regulations.

Utilize CPT and ICD-10-CM coding accurately for all encounters to support billing and reporting requirements.

4.4 Coordination and Communication

Participate in scheduled multidisciplinary team meetings, case conferences, and departmental huddles.

Communicate effectively with supervising physicians, nursing staff, social workers, behavioral health providers, and other members of the patient care team.

Maintain collaborative practice relationships consistent with ACNM and ACOG joint practice guidelines.

Attend and complete all required IHS mandatory training (e.g., HIPAA, infection control, fire safety, workplace violence prevention) within established timelines.

4.5 Quality Improvement

Participate in facility quality improvement (QI) initiatives, peer review, and morbidity and mortality (M&M) review processes related to obstetric and gynecological care.

Contribute to development and review of clinical protocols and standing orders relevant to CNM practice areas.

Monitor and support achievement of IHS GPRA clinical performance metrics pertaining to prenatal care, postpartum visit rates, family planning, STI screening, and cervical cancer screening.

5. MINIMUM QUALIFICATIONS AND PERSONNEL REQUIREMENTS

All CNM personnel assigned to perform services under this contract shall satisfy the following minimum qualification requirements throughout the period of performance:

5.1 Education

Graduation from a graduate-level nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME).

Possession of a Master of Science in Nursing (MSN) with a nurse-midwifery specialty, Master of Midwifery (MM), Doctor of Nursing Practice (DNP), or equivalent graduate or higher-level degree from an accredited institution.

5.2 Certification

Current, valid national certification as a Certified Nurse-Midwife (CNM) issued by the American Midwifery Certification Board (AMCB). Certification must remain active and unencumbered throughout the period of performance.

5.3 Licensure

Current, valid, unrestricted licensure as a Registered Nurse (RN) and Advanced Practice Registered Nurse (APRN) in the State of South Dakota, or eligibility to obtain such licensure prior to commencement of services.

South Dakota APRN authorization to practice in the midwifery role.

Prescriptive authority consistent with South Dakota law; DEA registration (Schedule II-V) required.

5.4 Required Certifications and Competencies

Current Basic Life Support (BLS) certification - American Heart Association (AHA) or equivalent.

Current Neonatal Resuscitation Program (NRP) provider certification - American Academy of Pediatrics (AAP).

Current Advanced Cardiac Life Support (ACLS) certification - AHA (preferred; may be required by facility credentialing).

Completion of or willingness to complete training in: fetal heart rate monitoring interpretation (NICHD terminology), shoulder dystocia management, eclampsia management, postpartum hemorrhage (PPH) protocols, and maternal early warning systems (MEWS).

5.5 Experience

At least one (1) year of professional nurse-midwifery clinical experience demonstrating progressive responsibility in prenatal, intrapartum, and postpartum care.

At least one (1) year of professional nurse-midwifery clinical experience, including demonstrated competence in complex obstetric and gynecological case management, family planning procedures (IUD/implant insertion), and independent clinical decision-making.

Experience in federally qualified health centers (FQHCs), Indian Health Service facilities, or other rural or underserved community settings is strongly preferred.

Demonstrated familiarity with AI/AN health disparities, cultural competency in care delivery to Native American populations, and commitment to patient-centered, culturally respectful care.

5.6 IHS Credentialing and Privileging

All CNM Contractors shall complete and maintain IHS credentialing and privileging requirements prior to providing patient care, in accordance with IHS credentialing policy (IHS Manual Chapter 3-1.3).

Contractor shall cooperate fully with the Rosebud IHS Hospital credentials committee and provide all required documentation, including but not limited to: proof of education, AMCB certification, state licensure, malpractice insurance certificate, DEA registration, BLS/NRP/ACLS cards, and professional references.

5.7 Background Investigation

Each CNM Contractor shall undergo a suitability/background investigation as required for federal healthcare workers providing direct patient care in IHS facilities, consistent with 45 CFR Part 5 and IHS policy.

Contractor shall not begin patient care services until a favorable preliminary background determination has been received.

5.8 Health Requirements

1. MMR (Measles, Mumps, Rubella):

EITHER: 2 documented MMR vaccines OR: Positive antibody titers for each (Measles, Mumps, and Rubella) OR: 2 separate live vaccines for Measles and Mumps, plus 1 Rubella vaccine

2. Varicella (Chickenpox):

EITHER: 2 documented varicella vaccines OR: A positive varicella antibody titer OR: Physician-documented diagnosis of previous infection

3. Tetanus, Diphtheria, and Pertussis (Tdap):

Documentation of a Tdap vaccine at some point in the past AND a tetanus-containing vaccine (Td or Tdap) within the last 10 years

4. Hepatitis B:

EITHER: 3 documented Hepatitis B vaccinations OR: A positive Hepatitis B surface antibody titer OR: A signed declination form if you choose not to receive the vaccine

5. Tuberculosis (TB):

EITHER: 2 negative TB skin tests (done within the last 12 months) OR: 1 negative IGRA blood test (done within the last 12 months) If you have a history of a positive TB test or IGRA:

Provide a chest X-ray report dated within the last 5 years Include dates of TB treatment, if applicable

6. Influenza (Flu) Vaccine:

Required annually If your start date is before October 31, the vaccine will be administered on site If your start date is after October 31, provide written proof of vaccination

7. COVID-19 Vaccination:

Documentation of COVID-19 vaccination is required

6. PLACE AND HOURS OF PERFORMANCE

6.1 Clinic Hours

Services shall be performed at the Rosebud IHS Hospital Outpatient Department Clinic, located at 800 Hospital Drive , Rosebud, SD 57570. Standard clinic hours are Monday through Friday, 8:00 AM - 5:00 PM, excluding federal holidays. The CD or designee shall establish specific daily clinic schedules in coordination with the Outpatient Clinic Director. Schedules may be adjusted by mutual written agreement to meet operational needs.

6.2 On-Call Coverage

CNM Contractors shall share on-call responsibility for OB emergency coverage in the Emergency Department during non-clinic hours. An on-call rotation schedule shall be developed collaboratively between the two CNM Contractors and the supervising CD or designee prior to the commencement of services and updated at least monthly. The on-call schedule shall ensure:

24/7 CNM on-call availability for OB emergencies, shared equitably between the two Contractors.

At minimum, one CNM Contractor shall be designated as the primary on-call provider at all times.

On-call coverage, ED responses, and service interruptions shall be tracked and reported to the COR monthly for workload and performance-surveillance purposes. Such reporting shall not establish an hourly basis for payment.

6.3 Federal Holidays

CNM Contractors may be required to provide scheduled clinic services on federal holidays. On-call OB emergency coverage shall be maintained on all federal holidays as part of the on-call rotation.

7. GOVERNMENT-FURNISHED PROPERTY AND INFORMATION

The Government shall furnish the following property, information, and support at no additional cost to the Contractor:

Clinical workspace, examination rooms, and equipment within the OPD clinic adequate for CNM practice.

Access to the IHS electronic health record system (RPMS/EHR or successor) and related clinical information systems, including necessary training.

Laboratory services, diagnostic imaging, and pharmacy support consistent with Rosebud IHS Hospital capabilities.

Medical supplies, medications, and equipment available in the OPD clinic and ED for performance of patient care duties.

Access to IHS clinical policies, standing orders, clinical protocols, and applicable Indian Health Manual (IHM) chapters.

Office space, telephone, and secure computer access necessary to perform administrative and documentation functions.

Required IHS mandatory training materials and computer-based training (CBT) modules.

8. CONTRACTOR RESPONSIBILITIES

Provide CNM services in accordance with applicable professional standards of nurse-midwifery practice and the requirements of this PWS.

Maintain all required licenses, certifications, and AMCB certification in good standing throughout the period of performance and notify the COR immediately of any change, lapse, investigation, restriction, or adverse action affecting licensure or certification.

Maintain professional malpractice liability insurance at levels consistent with IHS policy and South Dakota requirements; provide certificate of insurance to the COR prior to commencement of services and upon renewal.

Adhere to all IHS policies, Rosebud IHS Hospital medical staff bylaws, clinical protocols, patient safety standards, HIPAA privacy and security requirements, and applicable federal regulations.

Maintain patient confidentiality at all times and comply with 45 CFR Parts 160 and 164 (HIPAA).

Report all adverse patient events, near-misses, and sentinel events through the IHS ISTAR Reporting System in accordance with facility policy.

Comply with the Indian Child Protection and Family Violence Prevention Act (25 U.S.C. § 3201 et seq.) requirements, including mandatory reporting of child abuse and neglect.

Complete all required IHS mandatory training within timeframes specified by IHS.

9. CONTRACTOR MANAGEMENT AND NON-PERSONAL SERVICES

This is a non-personal services contract in accordance with FAR 37.101. The Contractor shall be solely responsible for managing, supervising, and directing its personnel. Government personnel shall not supervise or control Contractor personnel with respect to the manner of performance, work methods, or other employer-employee functions.

To preserve the non-personal nature of the services, the following requirements apply:

Government personnel shall communicate requirements and evaluate results through the Contracting Officer's Representative (COR), not through direct supervision of individual CNM personnel.

The Contractor shall designate a point of contact responsible for day-to-day coordination with the COR.

Scheduling of clinic sessions and on-call rotation shall be proposed by the Contractor and agreed upon in writing with the Clinical Director/Designee and COR in advance of each performance period.

Government employees shall not assign additional tasks to Contractor personnel outside the scope of this PWS.

Clinical consultation and collaboration with IHS physicians and other clinical staff, when required by clinical protocols, credentialing bylaws, or accepted standards of care, constitute professional practice requirements and do not create a personal-services relationship for purposes of FAR 37.104.

10. MONTH-OF-SERVICE AND INVOICING REQUIREMENTS

10.1 Month-of-Service Standard

One (1) Month of Service (MOS) consists of complete performance for the applicable contract month, including provision of two (2) qualified and credentialed CNMs; scheduled outpatient clinic services; required obstetric emergency on-call availability; ED response/callback services when required; clinical documentation; care coordination; and all other PWS requirements. The Contractor shall manage staffing and other resources necessary to satisfy these requirements for the firm-fixed monthly price. Clinic, on-call, and ED response activity may be tracked for scheduling, workload analysis, quality assurance, and performance surveillance, but shall not serve as the basis for invoice payment.

10.2 Invoicing Requirements

Invoices shall be submitted monthly and shall identify the contract number, applicable CLIN, month of service, and firm-fixed monthly MOS amount billed. Unless otherwise specified in the resulting contract, invoices shall be submitted no later than the 10th calendar day following the billing month. Invoices may be submitted only for services satisfactorily performed and accepted by the Government. The Contractor shall not invoice based on actual labor hours, on-call hours, or ED callback hours unless specifically authorized by a written contract modification signed by the Contracting Officer. Payment shall be made in accordance with the applicable payment clauses and the Prompt Payment Act.

11. PERFORMANCE STANDARDS

12. CONTRACT VALUE AND UTILIZATION MONITORING

12.1 Monthly Contract Utilization Report

The Contractor shall submit a Monthly Contract Utilization Report to the Contracting Officer's Representative (COR) no later than the tenth (10th) calendar day following the close of each contract month. The report shall provide the Government with current information regarding contract utilization, invoicing status, remaining authorized contract value, and overall performance-period status.

Because this contract is structured as a Firm-Fixed-Price (FFP), Month-of-Service (MOS) acquisition, payment shall not be based on actual labor hours worked. Any clinic-hour, on-call, Emergency Department (ED) callback, or other labor-hour information maintained or reported by the Contractor shall be used solely for workload monitoring, performance surveillance, quality assurance, and contract administration and shall not serve as the basis for invoice payment.

The Monthly Contract Utilization Report shall include, at a minimum, the following information:

Contract number and applicable Contract Line Item Number (CLIN).

Applicable period of performance and Month of Service covered by the report.

Firm-fixed monthly price for the applicable CLIN.

Total authorized value for the applicable performance period.

Amount invoiced for the current month.

Cumulative amount invoiced for the applicable performance period.

Percentage of the authorized performance-period value invoiced to date.

Remaining authorized contract value for the applicable performance period.

Number of Months of Service completed and number of Months of Service remaining in the applicable performance period.

Status of any pending, unpaid, rejected, or unsubmitted invoices.

Any anticipated staffing, scheduling, credentialing, privileging, or performance issue that may affect continued performance.

Any known or anticipated circumstance that may require Contracting Officer action.

Submission of the Monthly Contract Utilization Report does not authorize the Contractor to exceed the scope, value, or period of performance established by the contract. Only the Contracting Officer has authority to modify the contract or authorize changes affecting contract price, scope, or period of performance.

12.2 Sixty Percent (60%) Contract Value Threshold Notification The Contractor shall provide written notification to the COR and Contracting Officer when cumulative invoiced amounts for the applicable performance period reach, or are reasonably projected to reach, sixty percent (60%) of the authorized value for that performance period. The notification shall be submitted within five (5) calendar days after the Contractor determines that the threshold has been reached or is projected to be reached.

The sixty percent (60%) threshold notification shall include, at a minimum:

Applicable contract number, CLIN, and performance period.

Total authorized value of the applicable performance period.

Cumulative amount invoiced and the percentage of authorized value invoiced.

Remaining authorized contract value.

Number of Months of Service completed and remaining.

Status of pending or unpaid invoices.

Any known circumstances that may affect completion of the remaining performance period.

Any anticipated need for Government or Contracting Officer action.

Receipt of a threshold notification does not authorize additional work, an increase in contract value, an extension of the period of performance, or performance beyond the terms of the contract. The Contractor shall not perform services outside the scope or period of performance of the contract without a duly executed contract modification signed by the Contracting Officer.

12.3 Additional Contract Value Threshold Notifications

In addition to the sixty percent (60%) notification required by Section 12.2, the Contractor shall provide written notification to the COR and Contracting Officer when cumulative invoiced amounts reach, or are reasonably projected to reach, eighty percent (80%) and ninety percent (90%) of the authorized value for the applicable performance period. Each notification shall contain the information required by Section 12.2.

These notifications are intended to provide the Government sufficient visibility into contract utilization and remaining authorized value to support timely contract administration. Threshold notifications do not constitute authorization to increase contract value, extend the period of performance, or alter any contract requirement.

12.4 Workload and Service Activity Reporting

The Contractor shall maintain sufficient records to demonstrate performance of the required services during each Month of Service. For contract administration and performance-surveillance purposes, the Government may require reporting of the following:

Scheduled outpatient clinic coverage provided during the month, including any missed or rescheduled clinic coverage.

CNM staffing and coverage provided during the month and the status of required credentials, privileges, licenses, and certifications.

On-call coverage schedules and any identified gaps in required coverage.

ED obstetric responses or callbacks and whether applicable response-time standards were met.

Service interruptions, staffing shortages, replacement-provider actions, or other matters affecting continuity of services.

Status of required clinical documentation, mandatory training, and other applicable performance standards.

Corrective actions, unresolved deficiencies, or other information reasonably necessary for the Government to verify satisfactory monthly performance.

Workload and service-activity information shall be used for performance monitoring and contract administration only and shall not establish an hourly labor arrangement or create a basis for payment based on actual hours worked. The Contractor remains responsible for providing all services required by this PWS for the firm-fixed monthly price established in the applicable CLIN.

12.5 Government Acceptance of Month of Service

The Government will accept the applicable Month of Service upon verification that the Contractor furnished the required CNM staffing and coverage; maintained required credentials and privileges; provided required outpatient clinic and obstetric emergency on-call services; completed required documentation; complied with applicable privacy, security, patient-safety, and professional standards; and otherwise satisfied the requirements of this PWS for the applicable month.

If a material portion of the required monthly services is not provided or does not conform to contract requirements, the Government may exercise the rights and remedies available under the resulting contract.

12.6 Service Interruptions and Corrective Action

The Contractor shall promptly notify the COR of any anticipated or actual service interruption that may affect outpatient clinic coverage, required on-call availability, or continuity of patient care. The Contractor remains responsible for furnishing qualified replacement personnel and maintaining required service coverage throughout the period of performance.

When requested by the Government, the Contractor shall submit a corrective-action response identifying the issue; corrective action taken or planned; responsible personnel; completion timeline; and measures intended to prevent recurrence.

Monthly reporting, utilization monitoring, threshold notifications, performance surveillance, and corrective-action requirements do not alter the Firm-Fixed-Price Month-of-Service pricing structure and do not create an hourly labor arrangement.

13. APPLICABLE REGULATIONS AND REFERENCES

Indian Health Service - Indian Health Manual (IHM), Part 3, Chapter 3-1.3 (Credentialing and Privileging) OPM Professional Work in the Medical and Healthcare Group, 0600 (September 2017) ACNM Core Competencies for Basic Midwifery Practice (current edition) ACOG/ACNM Joint Statement of Practice Relations Between Ob-Gyns and CNMs/CMs (current edition) South Dakota Codified Law Title 36, Chapter 36-9A (Nurse Practitioner and Nurse Midwife Practice Act) 45 CFR Parts 160 and 164 (HIPAA Privacy and Security Rules) 25 U.S.C. § 3201 et seq. (Indian Child Protection and Family Violence Prevention Act) 42 U.S.C. § 1395dd (EMTALA - Emergency Medical Treatment and Labor Act) FAR Part 37.101 and 37.103 (Non-Personal Services Contracts - Service Contracts Generally) IHS Great Plains Area - applicable area office policies and clinical standards

14. APPROVAL AND CERTIFICATION

This Performance Work Statement has been reviewed and approved by the undersigned.

SOW ADDENDUM

1. Authority

1.1 No person other than the Contracting Officer has authority to bind the Government with respect to this contract;

1.2 No action or omission of any government employee or representative other than the Contracting Officer shall increase or decrease the scope of this contract or shall otherwise modify the terms and conditions of this contract;

1.3 In no event shall any of the following be effective or binding on the Government or imputed to the Contracting Officer with respect to this contract;

1.3.1 An understanding or agreement between the Contractor and anyone other than the Contracting Officer;

1.3.2 A purported modification or change order issued by anyone other than the Contracting Officer;

1.3.3 A promise by anyone other than the Contracting Officer to provide additional funding or make payments or;

1.3.4 An order, direction, consent, or permission from anyone other than the Contracting Officer to;

1.3.4.1 Incur costs in excess of a specified estimated cost, allotment of funds, or other ceiling or;

1.3.4.2 Expend hours in excess of a specified level of effort.

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