Attachment A - PWS Ambulatory Care Nursing Services REV 07.19.26.pdf

Attachment A – Performance Work Statement

PERFORMANCE WORK STATEMENT (PWS)

NON-PERSONAL SERVICE – Ambulatory Care Nursing Services

Table of Contents

Page

1.0 General 2

1.1 Background 2

2.0 Scope 2

3.0 Applicable Documents 3

4.0 Definitions 3-5

5.0 Government Furnished Information, Property & Services 5-6

6.0 Contractor Furnished Equipment 6

7.0 Performance-Work Statement (PWS) Requirements 6-9

7.1 Nursing Duties

7.2 Work Schedule

7.3 Leave Requests

7.4 Timesheets

7.5 Ethics & Conduct

7.6 Performance Evaluation

7.7 Identification of Contractor

7.8 Management of Medical Information

7.9 IHS Information Technology Systems

8.0 Contractor Qualification Requirements 9-10

8.1 Experience

8.2 License/Registration Certifications

8.3 Motor Vehicle Operator’s License

8.4 Certifications

8.5 Health Requirements/Conditions of Employment

8.6 Immunization

8.7 Language Requirement and Cultural Awareness

8.8 Information Technology Skills

8.9 Orientation

8.10 Background Checks

9.0 Technical Direction 10-11

10.0 List of Attachments and Exhibits 11

Performance Work Statement (PWS) Requirements Summary 23

1. General: This performance work statement describes the requirements for a Non-Personal Service Contract for Nursing Services in the Ambulatory Care department to support the mission of the Indian Health Service

(IHS).

1.1. Background: IHS is an agency within the U.S. Department of Health and Human Services and is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. The IHS is the principal federal health care provider and health advocate for the Indian people. The goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indians and Alaska Natives. The IHS currently provides health services to approximately

1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 34 states. There is a nationwide shortage of nurses, which is amplified by the remote and rural areas served by the Indian Health Service. This performance work statement covers requirements for the Navajo Area, Shiprock Service Unit, Four Corners Regional Health Center (FCRHC). The positions to be filled include Registered Nurse (RN) for Ambulatory and Urgent Care nursing services within Four Corners Regional Health Center.

2. Scope: The Contractor shall provide nursing services in accordance with this performance work statement.

2.1. Overview of deliverables may encompass outpatient nursing services and floating to other units as needed for nursing services to IHS patients.

2.1.1. Ambulatory Care

2.1.1.1. Develops patient care plans that involve patient assessment and evaluation, interviews patients and family members to evaluate needs, interprets vital findings for emergent care, provides treatments as directed, can instruct/teach patients, and records all observations and interventions in patient health records.

2.1.1.2. Care of patients with congestive heart failure or other heart conditions, hypertensive disorders, diabetes, infectious diseases, chronic conditions, autoimmune diseases, etc.

This includes pediatric and maternal patients being seen in the Outpatient clinic and Urgent Care.

2.1.2. Medical Surgical Care

2.1.2.1. Medical/Surgical Inpatient experience including admission and assessment of patients admitted for acute or chronic disease processes, surgical patients, and palliative care patients including procedures for various isolation requirements. Experience in basic nursing procedures such as starting IVs, doing lab draws, immunizations for both adults and pediatrics, assisting providers with lumbar punctures, paracentesis, and chaperoning for exams.

2.2. Place of Performance: Services are to be performed at Four Corners Regional Health Center, Red

Mesa, AZ.

2.3. Department: Ambulatory Care

2.4. Period of Performance: Shall be 1 Base Period + 4 Option Periods. Each contract period of performance shall contain a 6-month period of performance.

3. Applicable Documents: Please see the web link listed unless document is listed as an attachment.

3.1. The Joint Commission (TJC) http://www.jointcommission.org

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

3.3. Accreditation Association for Ambulatory Health Care(AAAHC) https://www.aaahc.org

3.4. Section 231 of Public Law 101-647, the Crime Control Act of 1990.

http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf

3.5. Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act http://www.icctc.org/IHS-BIA%20CPT%Handbook/PL%201101-630.pdf

3.6. Health Insurance Portability and Accountability Act (HIPAA) of 1996.

http://www.cms.gov/HIPAAGeninfo/

3.7. Privacy Act of 1974. http://www.justice.gov/opcl.privacyact1974.htm

3.8. Revised American Nurses Association Code of Ethics and Standards of Practice and Care (1996) http://www.nursingworld.org

3.9. State Nurse Practice Act for the Contractor's licensing state. http://www.medi-smart.com/

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. Computer Security Act of 1980 http://security.ihs.gov/index.cfm

3.12. Federal Code of Conduct: Contractor Code of Business Ethics and Conduct eCFR :: 48 CFR 52.203-13 -- Contractor Code of Business Ethics and Conduct. (FAR 52.203-13)

3.13. IHS General Directives http://www.ihs.gov/index.cfm?module=AtoZ&option=index

3.14. IHS Computer Security Directives: http://security.ihs.gov/index.cfm

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 46.5 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.

http://www.jointcommission.org/ http://www.jointcommission.org/ http://www.cms.hhs.gov/ http://www.cms.hhs.gov/ http://www.aaahc.org/ http://www.aaahc.org/ http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf http://www.icctc.org/IHS-BIA%20CPT%25Handbook/PL%201101-630.pdf http://www.icctc.org/IHS-BIA%20CPT%25Handbook/PL%201101-630.pdf http://www.cms.gov/HIPAAGeninfo/ http://www.cms.gov/HIPAAGeninfo/ http://www.justice.gov/opcl.privacyact1974.htm http://www.justice.gov/opcl.privacyact1974.htm http://www.nursingworld.org/ http://www.nursingworld.org/ http://www.medi-smart.com/ http://www.medi-smart.com/ http://security.ihs.gov/index.cfm http://security.ihs.gov/index.cfm https://www.ecfr.gov/current/title-48/chapter-1/subchapter-H/part-52/subpart-52.2/section-52.203-13 https://www.ecfr.gov/current/title-48/chapter-1/subchapter-H/part-52/subpart-52.2/section-52.203-13 http://www.ihs.gov/index.cfm?module=AtoZ&option=index http://www.ihs.gov/index.cfm?module=AtoZ&option=index http://security.ihs.gov/index.cfm http://security.ihs.gov/index.cfm http://security.ihs.gov/index.cfm

4.4. Code of Ethics: The Revised American Nurses Association Code of Ethics and Standards of Practice and Care, published in 1996 by the American Nurses Association, which makes explicit primary goals, values, and obligations of the nursing profession.

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 individual awarded a legally binding contract to provide supplies and 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., COR- Contracting Officer's Representative or GTR-Government Technical Representative).

4.8. Contractor Performance Assessment Report: A report that assesses a contractor's performance and provides a record, both positive and negative, on a given contract for a specific period of time.

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

Contractor's 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. 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.

4.15. Health Center: A facility physically separated from a hospital, with a full 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.

4.16. Health Insurance Portability and Accountability Act (HIPAA): A US law designed 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. Non-Personal Service Contracts: means 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.

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

4.19. 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 businesslike concern for the interest of the customer.

4.20. Patient Outcome: Result of nursing care.

4.21. Performance Work Statement Matrix: lists the services to be monitored and the standards to be applied.

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

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

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

4.25. Technical Direction: A directive to the Contractor that approves approaches, solutions, designs, or refinements; fills in details or otherwise completes the general description of work or documentation items; shifts emphasis among work areas or tasks; or furnishes similar instruction to the Contractor.

Technical direction includes requiring studies and pursuit of certain lines of inquiry regarding matters within the general tasks and requirements in Section 5 of this contract.

4.26. Tour of Duty: The time of day the nurse is scheduled to perform nursing care duties; also considered the shift of the day. Four Corners Regional Health Center’s outpatient clinic and urgent care tour of duty are 08000-1630. The time can vary according to the needs of the facility and/or clinic (most common is 8-hour Tour of Duty but can include 10-hour Tour of Duty and12-hour Tour of Duty). Does not include weekends or holidays.

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

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: 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.

5.2.1. Government Vehicle: If required by the position, authorization shall be in accordance with IHS Manual, Chapter 9, Part 1 - Motor Vehicle Safety.

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 section 6. 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 $20.00 will be charged for lost or destroyed badges.

5.4. Training: Facility-specific 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 nursing services or includes mandates made by the service unit while the nurse 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 section 5 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments subject to the following:

6.1.1. Uniforms and Lab Coats: Uniforms and Lab Coats shall conform to the requirements of the

Indian Health Service Manual, Part 3, Chapter 6, and meet the approval of the SCN within the Shiprock Service Unit or Northern Navajo Medical Center.

6.1.2. Other personal medical instruments: "Other personal medical instruments" are defined as

Contractor-owned items that may include, but are not 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 Supervisory Clinical Nurse (SCN) before use by the Contractor. The Government reserves the right to prohibit the use of any materials, supplies, or equipment.

7. Performance Work Statement (PWS) Requirements.

7.1. Nursing Duties:

7.1.1. The Contractor shall perform nursing duties and manage patients' needs as described in this PWS and in accordance with technical direction provided by NNMC's Clinical Nursing Supervisor, otherwise known as the Supervisory Clinical Nurse (SCN) herein in this PWS.

7.1.2. The Contractor shall be flexible and be willing to allow nursing service rotations in other nursing departments as needed to support patient care needs (e.g., float as a sitter, go on transports, and/or float in another department)

7.1.3. The Contractor shall perform in accordance with the following competency standards:

7.1.3.1. Written Competency Standards

7.1.3.1.1. Confidentiality/HIPAA/Patient's Rights

7.1.3.1.2. EMTALA Compliance Exam, 2004

7.1.3.1.3. Age Specific Competency Verification

7.1.3.1.4. RN Medication Administration Competency Examination

7.1.3.1.5. RN Medication Administration Competency Verification

7.1.3.1.6. Intravenous Therapy Exam

7.1.3.1.7. Venipuncture Procedure Skills Competency Verification

7.1.3.1.8. Pain Management Competency Verification

7.1.3.1.9. Restraints

7.1.3.1.10. Soft Restraint Application Competency

7.1.3.2. Contract Nurse Orientation Check List I Health Stream

7.1.3.3. Contract Nurse Orientation Competency Verification Instructions

7.1.3.4. Contract Nurse Billing Information

7.1.3.5. Standard Emergency Codes

7.1.3.6. Confidentiality: Legal and Ethical Concerns in Healthcare

7.1.3.7. EMTALA- Emergency Medical Treatment and Labor Act

7.1.3.8. What are Age-Specific Competencies?

7.1.3.9. An Introduction to Navajo Culture

7.1.3.10. Verbal and Telephone Orders

7.1.3.11. Medication Administration

7.1.3.12. Pain Management

7.1.3.13. Latex Allergy

7.1.3.14. Charting

7.1.3.15. Patient Restraints

7.1.3.16. Charge Nurse Duties: Responsibility and Expectation

7.1.3.17. Nursing Standards

7.1.3.18. Standards of Nursing Practice

7.2. Work Schedule:

7.2.1. Hours are 800AM to 430PM Monday through Friday, 5 days a week. Clinics are closed on weekends and federal holidays unless specified by management.

7.2.2. The Supervisory Clinical Nurse (SCN) for each department will provide technical direction on the specific tour of duty the contract nurse will work.

7.3. Leave Requests

7.3.1. The Contractor is responsible for establishing and administering its own leave policies and procedures. The Contractor shall be solely responsible for managing leave, absences, and scheduling of its personnel. This includes establishing internal procedures for requesting, approving, and coordinating leave.

7.3.2. The Contractor shall coordinate leave in a manner that ensures continuity of services and always maintains adequate staffing levels. Contractor personnel availability shall be managed so that performance requirements are consistently met, and services are delivered without disruption.

7.3.3. The Contractor is responsible for ensuring that leave or absences do not adversely impact the quality, timeliness, or effectiveness of services, including maintaining appropriate coverage to support patient care requirements.

7.3.4. The Contractor shall ensure that staffing levels remain sufficient to meet all contract requirements and performance standards, regardless of individual personnel availability. Any internal staffing adjustments necessary to maintain performance are the responsibility of the Contractor.

7.3.5. Leave must be contingent upon availability of adequate staffing.

7.3.6. The key personnel must notify their Supervisor, the Contractor and COR for any leave requests.

7.4. Timesheets: The contractor shall track timesheets and ensure accurate tracking of hours worked to allow for correct billing. The government shall provide a blank timesheet template for use to track hours for billing. The contractor shall use blank template or provide the nursing contractor a blank timesheet copies for accurate tracking.

7.4.1. Timesheets shall be verified by SCN or designee each week for correct billing purposes.

7.5. Ethics & Conduct: The Contractor shall meet standards as listed in the Federal Code of Conduct:

Contractor Code of Business Ethics and Conduct.

7.5.1. The Government reserves the right to examine and/or re-examine any Contractor who meets the criteria of unplanned absences and does not meet performance standards as listed herein in this

PWS.

7.6. Performance Evaluations:

7.6.1. The Contractor's performance will be evaluated in accordance with the standards set forth in the contract and Performance Work Statement Matrix on page 23.

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

7.7. Identification of Contractor:

7.7.1. The Contractor shall wear a government-issued contractor identification badge during performance of duty. The identification badge, any other assigned keys or badges that are given upon starting the contract, must be returned to the supervisor upon completion of the contract or service end date.

7.8. Management of Medical Information: The Contractor shall manage all patient information in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards, Privacy Act, and IHS Service Unit and/or Health Center specific policies and protocols.

7.8.1. The Contractor shall ensure adherence to DHHS IT system security policies and procedures.

The IT policies and procedures will be made available to the Contractor.

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

7.9. IHS Information Technology Systems:

7.9.1. In performance of this contract, the Contractor shall adapt to and successfully utilize IHS information technology systems that are deemed by the SCN as necessary for acceptable contractor performance.

7.9.2. The Contractor 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.

8. Contractor Qualification Requirements:

8.1. Experience: The Contractor shall have twenty-four (24) months of nursing experience, with a minimum of two (2) years in the Ambulatory or Medical Surgical Unit required by the contract, unless otherwise approved by the SCN.

8.2. License/Registration: All nurses shall possess a current, valid, unrestricted nursing 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.

8.3. Motor Vehicle Operator's License. If required by the position, the Contractor shall possess a valid state driver's license throughout the term of this contract.

8.4. Certifications:

8.4.1. Current Basic Life Support (BLS) is mandatory for all specialties.

8.4.2. Optional: Pediatric Advanced Life Support (PALS)

8.4.3. Optional: Newborn Life Support (NLS)

8.4.4. Optional: Advanced Trauma Care Nurse (ATCN) or Trauma Nurse Critical Care (TNCC).

8.4.5. Optional: Advanced Cardiac Life Support (ACLS).

8.4.6. The contractor shall ensure that the contract nurse's certifications remain valid throughout the term of this contract.

8.5. Health Requirements/Conditions of Employment:

8.5.1. Medical Evaluation. The Contractor 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.

8.6. Immunization. The Contractor shall also provide the following documentation before RN Candidate selection:

8.6.1. Immunity to Rubella, Mumps, and Rubeola (Measles);

8.6.2. Proof of Hep B vaccination x3 OR positive titer OR a signed declination of the Hep B vaccinations will also be accepted;

8.6.3. Documented history of chicken pox OR varicella vaccination x2 OR positive varicella titer;

8.6.4. History of Tdap vaccination, with subsequent Td vaccination if older than 10 years;

8.6.5. Documentation of Tuberculosis testing (TB skin test or IGRA) within the past 12 months with documentation of chest x-ray and follow-up for a positive history;

8.6.6. 12 months with documentation of follow-up for a positive test.

8.6.7. Proof of influenza vaccination from October -1 thru March 31, per IHS Mandatory Influenza

Vaccination Policy.

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

8.8. Information Technology Skills. The Contractor shall possess basic knowledge, skills, and abilities to use a computer.

8.9. Orientation. All nurses providing service under this contract shall attend mandatory orientations and training specified by the government.

8.10. Background Checks: As directed by the Contracting Officer, the Contractor shall provide all requested information necessary to perform background checks. The Contractor shall comply with the requirement to obtain security investigations. The Contractor shall work with the IHS to ensure that the pre-employment screening process includes the appropriate investigation questionnaires and forms to be completed. All completed forms will be reviewed by the Contractor and forwarded to the Government Personnel. The Contractor will be immediately removed from the position if at any time the investigation receives unfavorable adjudication, or if other unfavorable information that would affect the investigation becomes known.

9. Technical Direction:

9.1. Performance of work under this contract shall be carried out in accordance with the terms and conditions of the contract. The Government may provide clarifications, interpretations, or administrative guidance related to the contract requirements through the SCN.

9.2. The SCN is not authorized to alter the terms and conditions of the contract. Accordingly, any communication from the SCN shall not be construed as:

9.2.1. An assignment of work outside the Performance Work Statement;

9.2.2. A contract change as defined under the Changes clause;

9.2.3. Direction that would result in an increase or decrease in contract cost, fixed fee (if any), or performance schedule;

9.2.4. A modification of any contract terms, conditions, or specifications.

9.3. The Contractor remains solely responsible for determining the manner and means of performing the work required under this contract. If the Contractor believes that any communication from the SCN is inconsistent with the contract requirements, the Contractor shall notify the Contracting Officer in writing within five (5) working days and request clarification. The Contracting Officer will review the matter and, as appropriate, provide written clarification or issue a formal contract modification.

9.4. If the Contractor and Contracting Officer do not reach agreement regarding whether a matter constitutes a contract change or the appropriate course of action, the issue shall be resolved in accordance with the Disputes clause of the contract.

9.5. Only the Contracting Officer has authority to modify the terms of the contract. The Contractor shall not rely on any communication from individuals other than the Contracting Officer as authorization to change contract requirements.

10. List of Attachments:

A. Ambulatory and Urgent Care Department

1. Department-specific competencies

2. Blank timesheet template

B. Performance Work Statement (PWS) Requirements Summary

Four Corners Regional Health Center Ambulatory Care Department: Registered Nurse

(RN) Orientation Competency

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Employee Name/Title: ________________________________________ Date: _______________ Dept: PCC

Permanent: __________ Contract: __________

Please consult provided Competency Book or PDF File to view/review each competency listed.

SELF EVALUATION HOW COMPETENCY/SKILL IS VALIDATED EXPERIENCE LEVEL

1. Have not experienced before

2. Know principle, but have not performed

3. Have performed but not recently, need review

4. Feel comfortable and competent in activity/skill

Competency will be validated by:

Direct observation (D) Simulation (S) Return Demonstration (RD) Test (T) Class (C) Verbalize (V)

Use the appropriate letter in the column “How Validated.”

1. Acquired some experience (may require practice, assistance) = Fail

2. Competent and/or can perform independently = Pass

3. Competent, performs independently, and can teach and/or assess the competency of others = Pass

Use the appropriate number in the column “Experience Level”

Competency Self Eval Validation

Type Experience

Level Validating

Initials Date

Equipment Competencies

1. Vital Signs Machine (Datascope) RD

2. Infusion Pump (Alaris) RD

3. Bladder Scan RD

4. Doppler RD

5. Pap light and Pap light with cord RD

6. Body composition analyzer RD

7. Trophon EPR Ultrasound probe disinfection RD

8. EKG 12- Lead RD

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9. Fetal monitoring system RD

10. Nurse Call-light System RD

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

11. Wall Suction set-up RD

12. Pediatric Table Height and Weight Scale RD

Skills & Procedures

13. Basic EHR training C, RD

14. Blood pressure monitoring (manual and automatic) RD

15. Orthostatic VS monitoring RD

16. Weight measurement RD

17. POCT (Accucheck Inform II Blood Glucose monitor, Urine dipstick, Pregnancy test, Rapid Strep A, HbA1c, BinaxNow, Rapid Flu A & B)

C, RD

18. COVID-19 swabbing for PCR Testing RD

19. Assisting with PAP smear D

20. Assisting with Pelvic exam D

21. Assisting with Colposcopy D

22. Assisting with Intrauterine device (IUD) insertion and removal D

23. DM foot exam C, RD, D

24. Liquid nitrogen set-up C, D

25. Six-minute walk test RD, D

26. Fecal Immunochemical Test (FIT) C, RD, D

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27. Ear irrigation C, RD, D

28. Vision screening C, RD, D

29. PICC line dressing change C, RD, D

30. Toenail Removal Set-up C, RD, D

31. Low-flow Oxygen Administration C, D

32. Paracentesis, Assisting and Set-up RD, D

Medication Administration

33. Medication Administration RD, D

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

34. Pyxis Medstation RD

35. Immunization administration D

36. Immunization documentation C, RD, D

IVs, Phlebotomy, Blood Administration

37. IV insertion and Venipuncture for Phlebotomy RD, D

38. Blood culture collection S, RD, D

39. Accessing an Implanted Port S, RD, D

40. PICC line blood sampling S, RD, D

41. Cortisol Test/ ACTH (Cosyntropin) Stimulation Test C, D

Infection Control

42. Hand Hygiene RD

43. Personal Protective Equipment (PPE) Transmission-based precautions RD

44. Point-of-use Cleaning of Reusable Medical Devices S, RD, D

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45. Disposable Instruments C, V

Communication & Safety

46. Overhead Paging with Plain Language V

47. Sitter training C

48. Patient Handoff - SBAR C, V

49. Chaperone for Sensitive Exams V, D

50. Critical Lab notification D, V

Others (Outpatient- specific)

51. BPRM- Moonwalk C, RD, D

52. EHR Documentation: Reminders (Red Clock) RD

53. EHR Documentation: Screening Documentation RD

54. EHR Documentation RD

55. ASIIS Training C

Validating Initials & Signatures:

Initials Signature Initials Signature

Acknowledgement:

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By signing this competency validation, I attest that I take responsibility for the contents therein. I have to the best of my knowledge and skills, verbalized and or demonstrated my competency for all topics and skills listed above. I will actively seek out resources for review of skills, as needed, in regular clinical practice.

Printed Name:___________________________________________ Signature: _________________________________________ Date: ___________

Clinical Coach Signature: _____________________________________ Date: _____________________

Supervisor Signature: (only required if multiple failed attempts) ______________________________________ Date: ___________________

Comments:

ADULTS

Date Immunizations given Injection site/age of pt. Comments of Preceptor

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PEDIATRICS

Date Immunizations given Injection site/age of pt. Comments of Preceptor

IV I NSERTION COMPETENCY

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Name of RN observing IV catheter size

Location site

Comments by Evaluator or Observing RN

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BLO OD DRAW COMPETENCY

Name of RN observing Type of Lab Drawn Comments by Observing Evaluator/Observing RN

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BY SIGNING BELOW, I ACKNOWLEDGE:

• I have received training to fill the role of a SITTER.

• I have had all of my questions answered.

• I understand that my role is very important related to patient safety and quality of care.

• I will report any changes to the patient’s condition to the nurse immediately.

• I will NOT use any type of electronic device while in the role of being a SITTER.

• I will accompany patient to the bathroom and keep them in view while they are toileting.

• I will be present with patient when they leave the unit for any procedures.

• I will ensure the patient is within “arms reach” at all time, including in the bathroom.

Printed Name: ______________________________________________

Signature: _________________________________________________ Date:______________

10 | P a g e

NNMC: Sitter Competency Test

Please circle correct answer.

1) True or False The sitter is free to leave the patient once family members have arrived to visit the patient.

2) True or False direct observation within “arms reach” of patient must be maintained at all times (including while toileting patient).

3) True or False Any room can be used as a suicide observation room; however, removal of items from the room is needed to decrease the risk of patient suicide attempt.

4) List examples of items found in the patient care area that could be used as an :

i. Anchor point: ___________________________ ii.

For self-harm: ___________________________ iii.

As a weapon: ____________________________

5) True or False: The sitter is important in ensuring the patient remains safe while receiving care at this healthcare facility. 6) True or False: Sitters may sleep on duty

7) Select all correct precautions the sitter should take to maintain a safe environment:

(a) Wear dangling earrings and keep sharp objects in the room

(b) You may leave the patient alone while you take a restroom break

(c) Monitor utensils from food tray

(d) Keep the patient actively monitored at all times

(e) Refer any object brought in by visitors to the Nurse

8) Select all the correct examples of situations a sitter may be required:

(a) Confused patient.

(b) Drug or alcohol intoxicated with stable vital signs and CIWA protocol.

(c) Unstable patient with Suicidal ideation.

(d) Patients with severe Alzheimer’s, or other diagnosis encompassing themselves from all a fall.

WEEKLY NURSING TIMESHEET

WEEK OF:

COMPANY NAME

FACILITY NAME: Four Corners Regional Health Center

EMPLOYEE NAME: CONTACT INFO:

PO NUMBER: PCN #:

DEPARTMENT: SUPERVISOR:

REGULAR HOURS

DATE DAY

START

TIME

LUNCH

(mins)

END

TIME

TOTAL

HOURS NOTES

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

WEEKLY

TOTALS

Use increments of .25

Use increments of .25

BILL TO LINE:

EMPLOYEE: I CERTIFY THAT THE HOURS SHOWN ABOVE REPRESENT MY TOTAL HOURS WORKED

AND THAT THEY ARE PROPERLY VERIFIED.

EMPLOYEE SIGNATURE: DATE:

SUPERVISOR SIGNATURE: DATE:

PERFORMANCE WORK STATEMENT (PWS) REQUIREMENTS SUMMARY

2 IDENTIFICATIONS OF REQUIRED PERFORMANCE STANDARD/QUALITY LEVELS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets, or does not meet these standards.

The Government shall use these standards to determine contractor performance.

TASK ID INDICATOR STANDARD ACCEPTABLE QUALITY

LEVEL

METHOD OF

SURVEILLANCE

INCENTIVE

Contractor shall provide Nursing services for the delivery of patient care in accordance with this PWS in the Ambulatory Care department at Four Corners Regional Health Center, in Red Mesa, Arizona.

A

Patient Care Contractor services are fully successful or deemed excellent patient care as rated under Element 1 & Element 3 of the Peer Review NAO

Provider Exit Profile (refer to Section 10.1 of the PWS). No reports of breached safety or other procedures that may have adversely affect patient outcomes.

A rating or “Fully Successfully or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract price for satisfactory service.

Favorable CPAR report

B

Compliance No reprimands or disciplinary actions or violations of published Policies; Procedures; Standards of Care or Hospital Protocols

No reprimands or disciplinary actions

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of contract price for satisfactory service.

Favorable CPAR report

C Culturally Sensitivity

Contractors were compassionate culturally sensitive

A rating or “Fully Successful” or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract price for satisfactory service.

Favorable CPAR report

D Documentation Contractors completed require documentation in clear and legible form in a timely manner. (Element 6)

A rating or “Fully Successful” or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of contract price for satisfactory service.

Favorable CPAR report

E Professionalism Contractors presented in professional appearance demonstrated exceptional ethical conduct with effective communication, and exhibited exemplary attitude by being flexible and being adaptable.

(Element 4, Element 5 & Element 8)

A rating or “Fully Successful” or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract price for satisfactory service.

Favorable CPAR report