A06 PWS FBSU Dentist Svc Draft.docx

Fort Belknap Service Unit (FBSU) Performance Work Statement (PWS) for Non-Personal Services

DENTIST Locums Services

Table of Contents

Section

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Performance Work Statement (PWS) Non-Personal Services

DENTIST Locums Services

1. PROJECT TITLE: FBSU General Dentist Locum Tenens Contract Services

1.1. BACKGROUND/PURPOSE: The primary purpose of this contract is to hire a contractor to assist the department/ program in meeting their daily work objectives in providing quality health care services. Currently this department does not have the necessary manpower and resources available to them in being able to complete both their short-term and long-term assigned duties. As a result, a work backlog has developed, which adversely affects the department’s level of service being provided to the Indian community.

Fort Belknap Hospital, Billings Area-Indian Health Service, Harlem, Montana provides support to the Fort Belknap Indian Reservation and includes a clinic at Hays, Montana.

2. SCOPE: The contractor shall provide DENTIST providers to provide dentist services at the Fort Belknap Service Unit, as outlined in section 7.0 (Performance-based requirements).

Duties and responsibilities consist of providing Dentist services to population of adults and children as well as performance of administrative duties, as assigned by the FBSU Supervisory Dentist.

2.1. PLACE OF PERFORMANCE: Services shall be performed at both facilities of the Fort Belknap Service Unit, on a rotating basis, as assigned by the supervisor:

Performance Period of this contract is 6 months from the start date. Start date is October 1, 2025 end date is March 31, 2026.

3. APPLICABLE DOCUMENTS: Please see the web link listed unless document is listed as an attachment:

3.1. The Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) http://www.jointcommission.org

3.2. Centers for Medicare and Medicaid Services (CMS) Standards http://www.cms.hhs.gov

3.3. Need for Background Checks: Section 231 of Public Law 101-647, The Crime Control Act of 1990. https://www.govinfo.gov/content/pkg/STATUTE-104/pdf/STATUTE-104-Pg4789.pdf

3.4. Need for supervision with Children: Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act.

https://www.govinfo.gov/content/pkg/CFR-2002-title42-vol1/xml/CFR-2002-title42-vol1-part136-subpartK.xml

3.5. Section 231 of Public Law 101-647, the Crime Control Act of 1990. http://www.policyalmanac.org/crime/archive/crs_federal_crime_policy.shtml

3.6. Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act. http://www.nicwa.org/policy/law/protection/index.asp

3.7. Health Insurance Portability and Accountability Act (HIPAA) of 1996. http://www.cms.hhs.gov/hipaa

3.8. Privacy Act of 1974. http://www.usdoj.gov/oip/privstat.htmhttp://www.usdoj.gov/oip/privstat.htm

3.9. American Medical Association Code of Medical Ethics (2001) https://code-medical-ethics.ama-assn.org/

3.10. IHS Service Unit and Health Center Policies, Procedures and Protocols. (See section 11.0 for a list of attachments and exhibits)

3.11. Federal Computer Security Act of 1987. https://www.congress.gov/100/statute/STATUTE-101/STATUTE-101-Pg1724.pdf

3.12. Information Systems Security Awareness (ISSA). https://www.ihs.gov/issa/

3.13. Federal Code of Conduct. http://www.ihs.govhttp://www.ihs.gov/

3.14. IHS General Directives. http://www.ihs.gov/adminmggrresouceshttp://www.ihs.gov/adminmggrresouces

3.15. IHS Computer Security Directives. http://www.ihs.gov/adminmggresources http://www.ihs.gov/adminmggresources

4. Definitions:

4. Definitions:

4.1. Acceptance: Constitutes acknowledgement that the supplies or services conform to the applicable contract quality and quantity requirements, except as provided in FAR subpart 46. D5 and subject to other terms and conditions of the contract.

4.2. Approval: Acknowledgment by the designated Government official that submittals, deliverables, or administrative documents (e.g., insurance certificates, installation schedules, planned utility interruptions, etc.) conform to the contractual requirements. Government approval does not relieve the Contractor from responsibility for compliance with contract requirements.

4.3. Area: A defined geographical region for Indian Health Service administrative purposes. Each Area Office may administer several Service Units.

4.4. Code of Ethics: The Revised National Association of Emergency Medical Technicians Code of Ethics for EMS Practitioners.

4.5. Contracting Officer (CO): A Government employee with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

4.6. Contractor: The Company awarded a legal binding contract to provide supplies and/or services.

4.7. Contracting Officer’s Representative (COR): A federal employee who assists the ordering/issuing activity contracting officer in the administration of task orders issued under this contract. The COR is primarily responsible for the technical assistance and day-to-day program management of the ordering activity’s task orders. Ordering activities may have different designators for this employee (e.g. GTR – Government Technical Representative, COTR–Contracting Officer’s Technical Representative, or PO Project Officer). The Service Unit Director of Nursing (DON), designated Supervisory Dentist, or Technical Point of Contact (TPOC) providing assistance with management of facility Task Order(s), will be responsible for monitoring the technical progress including surveillance and assessment of performance for this order.

4.8. Technical Point of Contact: Eric C. Chenworth, D.O., Director of Clinical Services, FBSU, 406-353-3143.

4.9. Cooperative Attitude: Behavior that is positive and displays a willingness to perform assigned patient care tasks and to be a team player.

4.10. Cultural Awareness: Realization and respect for American Indian and Alaska Native practices.

4.11. Customer: Patients, staff and visitors of an IHS service unit and health center.

4.12. Customer Evaluation/Input: Written comments made to the Contracting Officer regarding the Contractors performance. This is one of the criteria used to evaluate the Contractor’s performance.

4.13. Dependability: Qualities of being trusted and being able to repeat the same task to yield the same result.

4.14. Federal Acquisition Regulation (FAR): The FAR is the primary regulation for use by all Federal Executive agencies in their acquisition of supplies and services with appropriated funds.

4.15. Government Vehicle: An IHS owned motor vehicle or a vehicle leased by IHS through agreements with the General Services Administration (GSA) or through commercial rental agreements.

4.16. Health Insurance Portability and Accountability Act (HIPPA): a US law designated to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

4.17. Health Station: A facility physically separated from a hospital, with a wide range of ambulatory services including at least primary care providers, nursing, laboratory, and x-ray which are available at least 40 hours a week for outpatient care.

4.18. Non-personal Services Contract: A contract under which the personnel rendering the services are not subject, either by the contract’s terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees, as defined in FAR 37.

4.19. Ordering Activity: An authorized user of IHS that may issue a task order to obtain required services under this contract.

4.20. Ordering Activity Contracting Officer: A Government employee of IHS authorized and warranted to issue task orders and to make subsequent task order modification(s) under this contract. The Ordering Activity CO has the authority to make initial determinations on all matters of dispute regarding task orders.

4.21. Orientation: An activity designed to provide basic familiarization of the facility and transition the Contract Dentist into the IHS Service Unit and/or Health Center and the nursing unit where the services will be provided.

4.22. Past Performance Information: Relevant information regarding a contractor’s actions under previously awarded contracts. This includes the contractor’s record of conformance to specifications and to standards of good workmanship; the contractor’s record of containing and forecasting costs on any previously performed cost reimbursable contracts; the contractor’s adherence to contract schedules, including the administrative aspects of performance; the contractor’s history for reasonable and cooperative behavior and commitment to customer satisfaction; and generally, the contractor’s business-like concern for the interest of the customer.

4.23. Patient Outcome: End result of medical (including Dental) care.

4.24. Performance based Matrix: Lists the services to be monitored and the standards to be applied.

4.25. Personal Protective Equipment (PPE): The equipment used to protect medical personnel from exposure to biological, chemical, and radioactive hazards.

4.26. Service Unit: The local administrative unit of IHS.

4.27. Standards of Practice and Standards of Care: Authoritative statements by which the medical profession describes the responsibilities for which its practitioners are accountable. The standards provide direction for medical practice and a framework for the evaluation of practice. The standards of medical practice may pertain to general or specialty practice.

4.28. Task Order: An order issued in accordance with the terms of the contract that details an ordering activity’s specific requirements. An ordering activity’s written order to obtain services, at a minimum will include the following where applicable: description of services, skill categories, hours, price, period of performance, contract number, and the ordering activity’s task order number.

4.29. Tour of Duty: The time of day the EMS Provider is scheduled to perform emergency medical services duties; to include thirty minutes to one hour lunch as scheduled for Internal Medicine or Family Practice.

4.30. Valid Patient Complaint: Justifiable accusation made by a patient and supported by investigation.

4.31. Verifiable Emergency: An unexpected/unplanned absence by the contractor requiring valid documentation to confirm the occurrence.

5. Government Furnished Information, Property and Services:

5.1. Information: Government unique information related to this requirement, which is necessary for Contractor performance, will be made available to the Contractor. The Contracting Officer or designee will be the point of contact for identification of any required information to be supplied by the Government.

5.2. Joint Use by the Government and the Contractor: Except for the property and service listed in 5.3 and 6.0, the Government will provide, for joint use by the Government and the Contractor, all necessary equipment, supplies, and clinic space to perform the services under this contract.

5.3. Contractor Exclusive Use:

5.3.1. Personal Protective Equipment (PPE): The Government will furnish the Contractor with appropriate PPE other than specified in paragraph 4 of the contract. The Government will be responsible for any repair, cleaning, and inventory required for the PPE. This does not include any type of uniform or laboratory coat.

5.3.2. The Government will provide facility specific contractor identification badges for each contractor. A minimum fee of $10.00 will be charged for lost or destroyed badges.

5.4. Training: Facility specific orientation/training necessary for the Contractor to perform the required duties, e.g., IHS information technology (IT) systems and operational procedures. Training will be provided ONLY if the subject matter is necessary to improve or enhance the quality of emergency medical services or includes mandates made by the IHS Service Units/Health Centers while the EMS provider is working under this contract. Training will not be provided for the purpose of continuing education, career development or individual development.

6. Contractor Furnished Property:

6.1. Except for the property specified in paragraph 3 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments subject to the following:

6.1.1. Uniforms shall conform to the requirements of the Indian Health Service Manual, Part 3, Chapter 4 and meet the approval of the Clinical Director at the IHS facility.

6.1.2. Other personal medical instruments: “Other personal medical instruments” are defined as Contractor owned items and may include but not is limited to stethoscope, scissors, as appropriate to the work unit. The Contractor shall not use unsafe equipment or supplies at any time during performance of this contract. All Contractor furnished equipment and supplies shall be subject to inspection by the Government and must be approved by the COR, Supervisor or TPOC prior to use by the Contractor. The Government reserves the right to prohibit the use of any materials, supplies, or equipment.

7. Performance-Based Requirements: The contractor shall provide Dentist providers for the delivery of patient care through performance of Dentist duties and management of patient’s needs as described in the Performance Work Statement and as identified by the Service Unit to the Billings Area Indian Health Service Hospitals, clinics, and health stations.

7.1. The contractor shall provide Contractor Dentists provider services in direct patient care.

7.1.1. When presenting candidate contractor dentist(s) to meet the solicited service on this contract, the following documents are required from the Contractor in order for the HIS to make a proper evaluation prior to selection of candidate(s):

7.1.1.1. Resume

7.1.1.2. College transcripts; conferred degrees and certified trainings in this field.

7.1.1.3. Letter of reference from current or recently previous employer(s).

7.1.1.4. Past Work Performance Statement, applicants must describe their present/previous work experience in this field.

7.1.1.5. Medical/Technical professionals, please include all credentialing documents and degrees conferred.

7.1.1.6. Medical/Technical professionals, if applicable, please include a copy of your current insurance certificate.

7.1.1.7. Medical/Technical professionals, please include a copy of all Licenses and Certificates.

7.1.1.8. Medical/Technical professionals, please include a current Health Status Statement.

7.2. The Contractor shall ensure 100% percent of all documentation meets established IHS Medical Facility, Joint Commission, and CMS standards to include, but are not limited to, timeliness, legibility, accuracy, content, date, time, signature and designated profession.

7.3. The Contractor Candidate shall perform in accordance with the competency standards listed in Section 24, Exhibits. Specific tasks include the following. The Contractor Candidate shall:

7.3.1. Provide full range of professional dental duties in connection with the treatment of greater-than-usual difficulty dental diseases or dental health problems requiring standard and advanced corrective, restorative, or preventive measures.

7.3.1.1. Incumbent must be able to independently treat patients having dental health concerns of greater than usual difficulty. Incumbent must be able to deal with dental health cases presenting concurrent with patient-behavior and communication challenges.

7.3.2. Makes clinical and radiographic examinations of the oral hard and soft tissues, and a diagnosis of pathological or irregular conditions that can be of greater than usual difficulty.

7.3.3. Reviews patient medical history and chart for evidence of disease or abnormalities which could adversely affected by dental treatment that can be of greater than usual difficulty.

7.3.4. Studies results of examination and determines types of services required and develops acceptable treatment plans that can be of greater than usual difficulty.

7.3.5. Performs endodontic, prosthodontic, periodontics, periodontic, operative, oral surgery and preventive orthodontic that can be of greater than usual difficulty.

7.3.6. Performs removal of un-erupted and impacted teeth, residual root tips, localized foreign bodies from the gingival tissues and alveolar sockets.

7.3.7. Performs prosthetic work involving complicating conditions such as lack of bone support for dentures, jaws which are irregularly formed, substantial changes in oral formation because of long years without teeth, and surgery on the bone and tissues in the supporting structure for the teeth.

7.3.8. Performs root canal therapy on the anterior teeth of both children and adults, and muco-gingival surgery. Treats rampant caries in children, acute cellulitis associated with dental pathology. and diseases of salivary glands and their ducts. Applies corrective treatment in cases of abnormal formation, where proper occlusion is difficult to attain.

7.3.9. Administers local anesthesia, often times on difficult patients.

7.3.10. Informs the patient about good dental health practices.

7.3.11. Provides dental care services to individuals eligible for services provided by the IHS in homes, schools, other community locations, and clinics in the Service Unit. Refers patients to appropriate contracted dental sources, such as other government facilities, or private practice.

7.3.12. Works with other health professionals on Patient Centered Medical Home (PCMH) objectives of the Fort Belknap Service Unit.

7.3.13. Meets all electronic health record completion time requirements.

7.3.14. Actively participates in quality management continuous performance improvement, staff development, risk management. infection control, GPRA measures. Health Promotion and Disease Prevention (HPDP), Meaningful Use, and safety activities.

7.3.15. Works closely with the Chief Dental Officer, Clinical Director, and Chief Executive Officer to meet any objectives they may develop as a team.

7.4. Contractor candidates shall promptly comply with IHS facility policies, procedures, protocols, and standards of care.

7.5. The Contractor Dentist shall be subject to peer review per Joint Commission standards and regulations.

7.6. The Contractor Dentist shall meet the safety management reporting requirements in accordance with the Service Unit Safety Measure Manual.

8. Conduct: The Contractor shall meet standards as listed in the HHS Residual Standards of Conduct, CFR Part 73 (revised 10/03/2024).

8.1. The Government reserves the right to remove from the facility any Contractor employee failing to abide with the HHS Residual Standards of Conduct.

8.2. A Contractor Provider demonstrating impaired judgment will not be allowed to continue working on the contract. The Government reserves the right to remove from the facility any Contractor Provider whom in the judgment of a licensed healthcare practitioner is impaired.

8.3. The Contractor will strictly adhere to and abide by Billings Area IHS Medical Staff Bylaws

9. Work Schedule: Full-time regular schedule of Monday – Friday 8:00am – 5:00pm (excluding Federal Holidays), to be scheduled at either the Little River Health Center Dental Clinic in Harlem, MT or the Eagle Child Health Station in Hays, MT per Supervisory Dentist or Clinical Director.

9.1. Travel will be required within 35min distance to satellite clinic in Hays MT. The Contract Dentist may be required to provide individual transportation between facilities if facility GSA vehicle transport is not available. The Contract Dentist is not eligible to drive federal GSA vehicles.

9.2. This contract does NOT include overtime or call-back hours to be performed by the Contractor Dentist.

9.3. The Contractor Dentist will be scheduled for lunch breaks of 30-60 minutes as assigned or rotated, depending upon department schedule.

9.4. All changes to the schedule are to be approved by the Supervisory Dentist or Clinical Director prior to being implemented.

9.5. The Contractor Dentist shall provide notice of unavailability to their employer (The Contractor) and the Supervisory Dentist or Clinical Director prior to any absence from work.

9.5.1. The Contractor Dentist shall provide notification at least 15 days in advance of a desired absence if the length of the absence exceeds eight (8) work hours.

9.5.2. Verifiable emergencies are the only exception to the advanced notification requirements.

9.6. The Contractor shall provide a qualified replacement Contractor Dentist for any absence of more than eight (8) work hours.

10. Deliverables:

10.1. Monthly Data Report: The contractor shall provide a monthly data report that identifies the task order, contract line-item number (CLIN), contractor dentist name, dates of service, quantity of hours worked, and hourly rate. The Contractor shall provide a summary of task order hours authorized, hours worked, and balance of hours remaining, estimated monthly invoice amount, and estimated balance of funds remaining.

10.2. The contractor shall notify the Contractor Officer and the COR via email when 75% of the authorized hours or 75% of obligated funding has been expended.

11. Contractor Qualification Requirements:

11.1. Experience. The Contractor dentist shall have thirty-six (36) months of experience, with a minimum of twelve (12) months in the specialty required by the contract, unless otherwise approved by the Contracting Officer and selecting Supervisor.

11.1.1. Experience shall equip the Contractor dentist with the particular knowledge, skills, and abilities to perform successfully the duties of the position, and that is typically in or related to the work of the Dentist services category to be filled.

11.2. License/Registration. The Contractor Dentist shall possess a current, valid, unrestricted medical license in a state, the District of Columbia, the Commonwealth of Puerto Rico, or a Territory of the United States, throughout the term of this contract.

11.3. Motor Vehicle Operator’s License. The Contractor Dentist shall possess a valid state driver’s license throughout the term of this contract.

11.4. Certifications. The Contractor Dentist shall possess current Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

11.4.1. The Contractor Dentist will utilize the American Heart Association, RQI 1 Stop Learning Platform available at the Service Unit to maintain RQI certification.

11.5. Degree or Diploma. The Contractor Dentist shall possess a degree or diploma from a professional dental program approved by the legally designated state accrediting agency at the time of the program was completed by the applicant.

11.6. Review of Qualifying Factors. The Supervisory Physician/Dentist at the onboarding IHS facility, or their designee, will review all required documentation, conduct candidate interview, and reference checks for each Contractor Dentist, to ensure verification and compliance prior to proceeding with background check/clearance process.

12. Background Checks / Security Clearance:

12.1. As directed by the Contracting Officer, the Contractor shall work with the IHS Personal Security Representative (PSR) Office and Contractor Dentist to ensure that the pre-employment screening process includes the appropriate investigation questionnaires and forms to be completed and that the Contract Dentist shall provide all requested information necessary to perform background checks.

12.2. The Contractor Dentist shall comply with the requirement to obtain security investigations by returning fully completed documents and information in a timely manner.

12.3. IHS will immediately remove a Contractor from the position if at any time the investigation receives unfavorable adjudication, or, if other unfavorable information that would affect the investigation becomes known.

12.4. Security Standards that are required for the position include: Privacy Act Compliance: Federal Employee Standards of Ethical Conduct Compliance: Indian Health Service Standards of Ethical Conduct: Child care National Agency Check and Investigation (CNACI) Compliance: Federal Security Identification Badge Request: It is the responsibility for the department to provide the necessary clearances to IHS computer systems as well as other security requirements needed for the contractor to perform their services.

13. Health Requirements / Conditions of employment.

13.1. Medical Evaluation: The Contractor Dentist shall provide a fitness for duty certificate issued by a licensed Physician to perform the proposed job without significant risk to personal health or the health and safety of others.

13.2. Immunization: The Contractor Dentist shall provide the documentation of the following:

13.2.1. Hepatitis A – 2 dose series at 0 and 6 months.

13.2.2. Hepatitis B – 3 dose series at 0, 1, and 6 months or documented immunity. A signed declination of Hepatitis B vaccination series will be accepted.

13.2.3. Measles, Mumps, Rubella (MMR) – 2 doses or titer documentation.

13.2.4. Varicella (chickenpox) – 2 doses, titer documentation or history of varicella/shingles.

13.2.5. Tetanus, diphtheria, pertussis (Tdap/Td) – 1 dose of Tdap, then tetanus (Td) booster every 10 years thereafter.

13.2.6. Meningococcal – Two vaccines (Men ACWY and MenB) recommended for microbiologists routinely exposed to N. meningitides.

13.2.7. Documentation of annual TB test – may include Mantoux TB skin test (PPD). All medical providers (Contract Dentists) require the 2 step TST. Acceptable lab testing: Quantiferon Gold or T-Spot test. For positive TB test results, please submit a copy of recent chest x-ray results.

13.2.8. Influenza – MANDATORY annual vaccination.

13.2.9. Consider COVID vaccination.

14. Transportation and Lodging: The Contractor shall be responsible for all applicable Federal, State, and Local Taxes, Meals, Travel/Transportation. Lodging may be available at IHS Quarters, but must be paid for by the Contractor or Contractor Dentist, based on the set federal rental rate for the particular quarters unit. The contractor Dentist must work with the FBSU Quarters Manager to apply for housing, check in and sign a rental agreement, set up arrangements for scheduled rental payments, must abide by the rental agreement, and must also sign out upon end of rental agreement. The Contractor shall be responsible and liable for the proper care of government owned or leased property furnished in occupied quarters.

15. Performance Evaluation:

15.1. The Contractor’s performance will be evaluated in accordance with the standards set forth in the contract and Performance-based Matrix of section 24.0.

15.2. Substantiated reports written by any customer dealing with patient safety, infection control, or other procedure that adversely affects patient outcome constitutes a breach of contract.

16. Identification of Contractor: The Contractor Dentist shall wear a government issued contractor identification badge during performance of duty.

17. Management of Medical/Dental Information: The Contractor Dentist shall manage all patient information in accordance with HIPAA standards, Privacy Act, and IHS Service Unit and/or Health Center specific policies and protocols.

17.1. The Contractor Dentist shall ensure adherence to Department of Health and Human Services (DHHS) IT system security policies and procedures. The IT policies and procedures will made available to the Contractor Contract Dentist upon request.

17.2. The Contractor Dentist shall immediately report to the Contracting Officer or COR any information or circumstances that may violate any statute, policy, or procedure.

18. IHS Information Technology Systems: The Contractor Dentist shall possess basic knowledge, skills, and abilities to use a computer.

18.1. The Contractor Dentist shall adapt to and successfully utilize IHS information technology systems that are deemed by the Supervisory Dentist as necessary for acceptable contractor performance.

18.2. The Contractor Dentist shall ensure that IHS information technology system security policies and procedures are adhered to. The IT policies and procedures will be made available to the Contractor at each IHS facility.

19. Orientation: The Contractor Dentist providing service under this contract shall attend mandatory orientations and training specified by the IHS, the Service Unit Administration, Clinical Director, and the Supervisory Dentist.

20. Language Requirements and Cultural Awareness: The Contractor Dentist shall read, understand, speak, and write English to effectively communicate with patients and other health care workers, and shall be respectful of the local culture of American Indian and Alaska Native community members.

21. Challenges to Conflicts: The Contractor Dentist shall maintain an appropriate professional demeanor in the presence of patients and with each other. Harmony and good communication between the staff are necessary to maintain the best patient care environment and all staff members are expected to contribute to a positive milieu. Violent language, profanity, and any threatening behaviors are specifically prohibited. Professionalism is to be maintained at all times.

22. Technical Point of Contact: Dr. Eric C. Chenworth, (406) 353-3143.

23. PRIVACY ACT: Based on the Privacy Act (Apr 1984), the Contractor agrees to:

23.1. Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies

23.1.1. The systems of records; and

23.1.2. The design, development, or operation work that the contractor is to perform;

23.2. Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the redesign, development, or operation of a system of records on individuals that is subject to the Act; and

23.3. Include this clause, including this paragraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a system of records.

23.4. In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a system of records on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a system of records on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a system of records on individuals to accomplish an agency function, the Contractor is considered to be an employee of the agency.

23.5. “Operation of a system of records,” as used in this clause, means performance of any of the activities associated with maintaining the system of records, including the collection, use, and dissemination of records.

23.6. “Record,” as used in this clause, means any item, collection, or grouping of information about an individual that is maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and that contains the person’s name, or the identifying number, symbol, or other identifying particular assigned to the individual, such as a fingerprint or voiceprint or a photograph.

23.7. “System of records on individuals,” as used in this clause, means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual.

23.8. Whenever the Contractor is uncertain with regard to the confidentiality of or a property interest in information under this contract, the Contractor should consult with the Contracting Officer prior to any release, disclosure, dissemination, or publication.

24.0 Performance – Based Matrix

This Standard describes “What Success Looks Like.”

Contractor shall provide Dental services in the delivery of patient care to the Fort Belknap Service Unit.

Competency

Compliance

Quality

Patient Outcomes

Professionalism

Documentation

Maintain 100% of the required competencies (refer to Section 25.0)

100% compliance with IHS Service Units and/or Health Centers published Policies; Procedures; Standards of Care; and hospital and nursing Protocols.

Perform 100% of the required tasks (refer to Section 7.0) during scheduled tour of duty (refer to Section 9.0)

No reports of breached patient safety, infection control, and other procedures that might adversely affect patient outcome.

Performance characterized by continual cultural awareness and focus on customer service at 100% adherence to the Nursing Code of Ethics and Federal Code of Conduct.

100% percent of all documentation meets established IHS Medical Facility, Joint Commission, and Centers for Medicare and Medicaid Services (CMS) standards to include, but are not limited to, timeliness, legibility, accuracy, content, date, time, signature and designated profession.

See QASP. Surveillance systems will include direct observation, periodic inspections, validated customer complaints, random sampling, and verification of documentation provided by the contractor.

Payment of contract price for satisfactory service.

Contractor performance will be evaluated using the Contractors Performance Assessment Report (CPAR). The evaluation will be considered when future IHS Contract selections are made.

25.0 Quality Assurance Monitoring Form

26. List of Exhibits and Attachments. To be provided by the Contracting Officer upon request.

1. Exhibits

1. Quality Assurance Surveillance Plan (QASP)

2. Contract Data Requirements List (CDRL) DD Form 1423

3. Quality Assurance Form (Monthly Contractor Monitoring)

2. Attachments

1. Witten Competency Assessments

2. Contract Dentist Orientation Check List

3. Contract Dentist Orientation Competency Verification Instructions

4. Contract Dentist Billing Information

5. Standard Emergency Codes

6. Confidentiality: Legal and Ethical Concerns in Healthcare

7. EMTALA – Emergency Medical Treatment and Labor Act

8. What are Age‐Specific Competencies?

9. An Introduction to the Native American Culture

10. Verbal and Telephone Orders

11. Medication Administration

12. Pain Management

13. Latex Allergy

14. Focus Charting

15. Patient Restraints

16. Charge Contract Dentist Duties: Responsibility and Expectation

17. Medical Standards

18. Standards of Medical Practice

19. Immunization documentation

20. Required certification documentation

21. Billings Area Bylaws of Medical Staff

27. PRIVACY

Privacy or Security Safeguards (Aug 1996)

(a) The Contractor shall not publish or disclose in any manner, without the Contracting Officer’s written consent, the details of any safeguards either designed or developed by the Contractor under this contract or otherwise provided by the Government.

(b) To the extent required to carry out a program of inspection to safeguard against threats and hazards to the security, integrity, and confidentiality of Government data, the Contractor shall afford the Government access to the Contractor’s facilities, installations, technical capabilities, operations, documentation, records, and databases.

(c) If new or unanticipated threats or hazards are discovered by either the Government or the Contractor, or if existing safeguards have ceased to function, the discoverer shall immediately bring the situation to the attention of the other party.

Privacy Act (December 18, 2015)

This contract requires the Contractor to perform one or more of the following: (a) design; (b) develop; or (c) operate a federal agency system of records to accomplish an agency function in accordance with the Privacy Act of 1974 (Act) (5 U.S.C. 552a(m)(1)) and applicable agency regulations.

The term system of records means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual. Violations of the Act by the Contractor and/or its employees may result in the imposition of criminal penalties (5 U.S.C. 552a(i)).

The Contractor shall ensure that each of its employees knows the prescribed rules of conduct in 45 CFR part 5b and that each employee is aware that he/she is subject to criminal penalties for violation of the Act to the same extent as Department of Health and Human Services employees. These provisions also apply to all subcontracts the Contractor awards under this contract which require the design, development or operation of the designated system(s) of records (5 U.S.C. 552a(m)(1)). The contract work statement:

(a) Identifies the system(s) of records and the design, development, or operation work the Contractor is to perform; and

(b) Specifies the disposition to be made of such records upon completion of contract performance.

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