CRSU-17-046.pdf

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE 1 OF

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

2. CONTRACT NO. 3. AWARD/EFFECTIVE 4. ORDER NUMBER 5 . SOLICITATION NUMBER 6 . SOLICITATION ISSUE

DATE DATE

CRSU-17-046 07/18/2017

a. NAME b. TELEPHONE NUMBER (No collect 8. OFFER DUE DATE/

7. FOR SOLICITATION ~ calls) LOCAL TIME

INFORMATION CALL: Danielle Chasing Hawk, Supv Contract Speci 605-964-0605 08/18/2017

9 . ISSUED BY CODE 10. THIS ACQUISITON IS

OuNRESTRICTED OR lllsET ASIDE: % FOR:

Cheyenne River Health Center 0MALL BUSINESS D EMERGING SMALL 24276 166th Street, Airport Road BUSINESS

PO Box 1012 NAICS:

0 HUBZONE SMALL

BUSINESS

Eagle Butte , SO 57625 SIZE STANDARD: D SERVICE-DISABLED VETERAN- D 8(A)

OWNED SMALL BUSINESS

11 . DELIVERY FOR FOB DESTINA- 12. DISCOUNT TERMS 13b. RATING TION UNLESS BLOCK IS p 13a. THIS CONTRACT IS A

MARKED RATED ORDER UNDER 14. METHOD OF SOLICITATION

0 SEE SCHEDULE

DPAS ( 1 5 CFR 700)

IZIRFQ DIFB DRFP

1 5. DELIVER TO CODE 16. ADMINISTERED BY CODE I

Cheyenne River Health Center 24276 166th Street, Airport Road Pll Rrw 1n1?

1 7a. CONTRACTOR/

CODE I I FACILITY

1 8a. PAYMENT WILL BE MADE BY CODE I OFFEROR

CODE

Great Plains Area Indian Health Service Division of Financial Management Federal Building, Room 309 115 4th Ave SE

TELEPHONE NO .

Aberdeen, SO 57401

D 17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 1 8a UNLESS BLOCK

OFFER BELOW IS CHECKED D SEE ADDENDUM

19. 20. 21 . 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

Firm Fixed Price Non-Personal Healthcare Service contract under which the contractor that will result in a base year plus four (4) one ( 1) year options contract for a physician inpatient I outpatient services a the Cheyenne River Health Center in Eagle Butte, SO All work will be completed in accordance with the attached Statement of Work. TWO PHYSICIANS WILL

BE AWARDED FROM THIS SOLICIATION.

(Use Reverse and/or Attach Additional Sheets as Necessary)

25 . ACCOUNTING AND APPROPRIATION DATA 26 . TOTAL AWARD AMOUNT !For Govt. Use Only)

~ 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52 .212-1, 52.212-4. FAR 52.21 2-3 AND 52 .2 12-5 ARE ATTACHED . ADDENDA

27b . CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52 .212-4 . FAR 52 .212- 5 1S ATTACHED . ADDENDA

~ARE H ARE NOT ATTACHED

bdARE ARE NOT ATTACHED

~ 28 . CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _1 __ U 29. AWARD OF CONTRACT: REF. OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON AN Y (BLOCK 51 , INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

30a . SIGNATURE OF OFFEROR/CONTRACTOR 31a . UNITED STATES OF AMERICA (SIGNATURE OF CONTRA CTING OFFICER!

30b. NAME AND TITLE OF SIGNER (Type or print)

AUTHORQEDFORLOCALREPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER !Type or print) 31c. DATE SIGNED

STANDARD FORM 1449 !REV. 3/20051

Prescribed by GSA- FAR (48 CFR) 53 .2 12

19. 20. 21. 22 . 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

TWO PHYSICIANS WILL BE AWARDED FROM THIS

SOLICITATION.

PLEASE USE ATTACHED BID SHEET

32a. QUANTITY IN COLUMN 21 HAS BEEN

DRECEIVED DINSPECTED 0 ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c . DATE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33 . SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED

CORRECT FOR

39. S/R VOUCHER NUMBER 40. PAID BY

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

321. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

36. PAYMENT 37 . CHECK NUMBER

D COMPLETE D PARTIAL D FINAL

41 a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a . RECEIVED BY (Print)

41 b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41 c . DATE

42b. RECEIVED AT (Location)

42c . DATE REC'D (YY/MM/00) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 !REV. 3/20051 BACK

SOLICITATION CRSU-17-046

INPATIENT/ OUTPATIENT PHYSICIANS

DESCRIPTION QUANTITY UNIT UNIT PRICE AMOUNT

BASE YEAR/ 1248 HRS

REGULAR HOUR

BASE YEAR/ 624 HRS

WEEKNIGHT ON

CALL HOURS

BASE YEAR/ 300 HRS

CALL BACK

HOURS

OPT YR 1/ 1248 HRS

REGULAR

HOURS

OPTYR 1/ 624 HRS

WEEKNIGHT ON

CALL HOURS

OPT YR 1 / CALL 300 HRS

BACK HOURS

OPT YR 2/ 1248 HRS

REGULAR

HOURS

OPT YR 2/ 624 HRS

WEEKNIGHT ON

CALL HOURS

OPT YR 2 / CALL 300 HRS

BACK HOURS

OPTYR 3/ 1248 HRS

REGULAR

HOURS

OPTYR 3/ 624 HRS

WEEKNIGHT ON

CALL HOURS

OPT YR 3 / CALL 300 HRS

BACK HOURS

OPTYR4/ 1248 HRS

REGULAR

HOURS

OPT YR 4/ 624 HRS

WEEKNIGHT ON

CALL HOURS

OPT YR 4 / CALL 300 HRS

BACK HOURS

General

PERFORMANCE WORK STATEMENT

Cheyenne River Health Center (CRHC)

Inpatient/Outpatient Physician

This performance based work statement describes the requirements for non-personal services for Inpatient/Outpatient Physician to support the mission of the Indian Health Service (IHS)/Cheyenne River Health Center (CRHC).

The mission of the Cheyenne River Indian Health Service Hospital in Eagle Butte, South Dakota is to provide the best possible health care services to Cheyenne River Reservation in South Dakota.

Background

The Indian Health Service (IHS) an agency within the Department of Health & Human Services is responsible for providing federal health services to American Indians and Alaska Natives. The Indian Health Service provides a comprehensive health service delivery system for approximately 1.9 million American Indians and Alaska Natives who belong to 567 federally recognized tribes, in 35 states. The Indian Health Service Headquarters is located in Rockville, MD and then divided into twelve physical areas: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland and Tucson.

The Great Plains Area Office (GPAO) works in conjunction with its 191ndian Health Service Units and Tribal Managed Service Units to provide health care to approximately 122,000 Native American located in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office's service units include seven hospitals, eight health centers, and several smaller health stations and satellite clinics.

Our facility, the Cheyenne River Health Center (CRHC), falls under the GPAO. Cheyenne River Health Center (CRHC) provides medical care for approximately 9,000 tribal members living on the CRST Reservation. Serving a rural area, many of our patients travel100 miles' round trip to receive care. The CRHC was built in 2011 to provide an expanded level of health care services specifically designed to meet the needs of the CRHC population. Services include: Emergency Room Department, Pharmacy, Physical Therapy, Public Health Nursing, Radiology Services, Inpatient Care, Laboratory, MRI, Dental, Community Health, Contract Health Services, Dietitians, Audiology, Eye Care, Inpatient, Pain Management, and Specialist Clinics: OB/GYN, ENT, Podiatry & Neurosurgery. The Cheyenne River Sioux Tribe through a 638 contract with IHS, operates four satellite health stations which offer basic ambulatory services at Cherry Creek, Red Scaffold, Swiftbird, and Whitehorse communities.

Objective

To provide uninterrupted Inpatient/Outpatient Physician services, in the delivery of patient care, for the Inpatient and Outpatient Department, Cheyenne River Health Center.

Period of Performance

July 26, 2017 through July 25, 2022. Base year, to include 4 option years.

Base Year: September 1, 2017 through August 31,2018 Option Year One: September 1, 2018 through August 31,2019 Option Year Two: September 1, 2019 through August 31,2020 Option Year Three: September 1, 2020 through August 31, 2021 Option Year Four: September 1, 2021 through August 31,2022

Work Schedule

12 hour shifts , 2 Consecutive Days per Week, may be more than 2 days, occasionally, which may be weekly, for coverage of permanent physicians sick leave, annual leave, or any other unforeseen emergencies. Same Physician must provide services for contract to ensure continuity of care. Physician is allowed to switch or cover shifts for another contract physician, which will ensure continuity of care is maintained.

Outpatient Clinic- Physician will see scheduled patients and walk-in's.

Inpatient Department - Call from 7:45PM-7:45AM and Rounds in the morning if needed.

Place of Performance

Cheyenne River Health Center Inpatient and Outpatient Departments 24276 166th Street Airport Road Eagle Butte, South Dakota 57625

DESCRIPTION OF SERVICES: The contractor shall provide Inpatient/Outpatient Physician services required for the Cheyenne River Indian Health Service Hospital.

This contract is a non-personal health care services contract, as defined at Far Part 37.101 under which the Contractor is an independent contractor and which shall allow the Government to evaluate the quality of professional and administrative services provided, but retains no control over the medical, professional aspects of the services rendered, (e.g., professional judgements, diagnosis for specific medical treatment) . The Contractor shall indemnify the Government for any liability producing act or omission by the contractor, its employees and agents occurring during contract performance. The Contractor shall maintain medical liability insurance, in the coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned.

Contract physician care shall cover the range of medicine typically provided in a rural civilian practice of similar size.

The Contractor shall provide physicians to perform the necessary medical procedures for patients in Inpatient/Outpatient Departments. Primary Care, Outpatient Clinic experience within past 5 years and Hospitalist experience within the past 5 years.

Upon the receipt of an IHS purchase order, the Contractor shall locate, credential, and have available sufficient staffing to provide physician coverage for the Inpatient/Outpatient Departments.

The standards of medical practice and duties of the Contractor through it$ physicians shall be determined pursuant to Governing Body bylaws, medial staff bylaws, rules and regulations of the appropriated IHS hospital, applicable provisions of law including but not limited to rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals, and standards and recommendations of CMS (Centers for Medicare and Medicaid Services) compliance. The Contract Physician(s) shall be required to participate in a quality improvement program, which is consistent with current requirements for ongoing monitoring and evaluation of the quality and appropriateness of care.

CONTRACTOR RESPONSIBILITY

Staff Development/Education. Physician shall provide once quarterly for 20-30 minute medical lectures to provides at lunch break.

Medical Staff/Quality Assurance Participation. Active involvement in Quality Assurance Chart Reviews with Medical Staff.

Utilizes RPMS/EHR computer software/program for entering and signing of medical orders such as laboratory studies, and directly signing and dating radiological studies, etc.

EHR template development. Work with Medical Staff providers, Pharmacy, and CAC to develop EHR templates for Outpatient Clinic and Inpatient Unit.

Treatment Protocol development. Assist in development of treatment order sets and protocols that may be included in EHR in collaboration with CAC, Medical Staff, Pharmacy, and Nursing.

The Physicians actual clinical duties will be in accordance with his/her credentialed privileges.

Primary duty will be to provide care to Inpatient and Outpatient Department. Performs triage, assesses, and re assesses patients throughout the patient visits. Ensures documentation of medical assessments and observations are documented accurately in the patient's health care record . Documents consultations in the patient's health care record . Procedures for transfer of patients requiring transfer to facilities where a higher level of care must follow the "Emergency Medical Treatment and Labor Act" (EMTALA) guidelines. Obtains necessary information on patients seen in the Outpatient and Inpatient Departments, such as medical records, x-ray films and reports, and pathology slides and reports and documents pertinent normal and abnormal test results in the patient's medical record .

Implements, evaluates and is consulted on lnpatienUOutpatient procedures and instructions.

Establishes inter-personal and intra-departmental relationships to enhance optimal patient care.

Ensures a safe work environment and employee safe work habits.

Demonstrates competent and effective oral and written communication.

Computer efficiency required . Preferred 5 years of Electronic Health Record experience.

Maintain certification in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS).

REFERRALS AND CONSUSL TS. The provider shall follow IHS Purchased Referred Care regulations and policies when arranging for a referral or consult. The Physician shall be required to consult with other specialty practitioners for consultative opinions and continuation of care. The provider shall inform patients of the required referral or consult by indicating the specialty involved.

PRESCRIPTIONS. The provider shall use and follow the IHS formulary for prescriptions for all patients. The formulary list is approved and maintained by the Cheyenne River Health Center Pharmacy and Therapeutics Committee. Any drug not listed on the formulary must be approved by the Pharmacy and Therapeutics Committee.

CONTRACTOR TIMESHEETS. The Physician will be responsible for obtaining Medical Records (HIM) signature prior to CEO or representative signature for the completion of their timesheet. Invoices submitted without the signed timesheet including Medical Records (HIM) and CEO signatures will not be paid.

PROCEDURE GUIDANCE. Contractor providers shall perform procedures compatible with the medical facility's operating capacity and equipment.

PRIVACY OF INDIVIDUALLY IDENTIFABLE HEALTH INFORMATION. The Contract health care providers shall provide patients with the utmost care and attention. All patients shall be assured of their privacy and personal dignity. The Contractor shall ensure strict compliance to the release of Protected Health Information in accordance with the Code of Federal Regulation, Title 45, Public Welfare, Subtitle A, Department of Health and Human Services, Part 164, Security and Privacy (45 CFR 164) and AFI41-210, "Patient Administration Functions" paragraph 2.2.3, "Health Insurance Portability and Accountability Act (HIPAA)" and paragraph 2.3, "General Guidelines on Releasing Medical Information".

COMMUNICATIONS. The Contractor shall ensure contract providers maintain open and professional communication with members of the Medical Staff. Complaints validated by the Hospital Accreditation Specialist and CEO or shall be reported in writing to the Contracting Officer (CO) and the Contractor for action.

ENGLISH LANGUAGE REQUIREMENT. The Contractor provider(s) shall read, understand, speak and write English fluently.

DOCUMENTATIONS. Contractor personnel shall prepare all documentation to meet or exceed established CMS standards and Cheyenne River IHS Medical Staff Bylaws.

AVAILABILITY:

HOURS OF OPERATION: Contractor coverage will be for the Inpatient/Outpatient Department (12 Hour shifts, 2 Consecutive Days Per Week, 7:45AM-7:45PM, to include week night on call (7:45PM-7:45AM), and call back. Same Physician must provide services for contract to ensure continuity of care). Occasionally additional hours may be required . The work schedule will consist of 2 consecutive days (Monday-Friday). Work hours will be scheduled by the CEO or to correspond to the needs of the facility and are subject to change. The Inpatient/Outpatient Physician shall arrive for each scheduled shift in a well-rested condition and shall have had at least six hours' rest from all other duties. Physicians will be expected to attend the Morning Purchased Referred Care Meeting.

CONTINUITY OF SERVICES/REPLACEMENT STAFF. The Contractor point of contact shall ensure qualified personnel are available to provide coverage at all times even during scheduled absences of contract providers.

The Inpatient/Outpatient Physician services are considered vital to the Government and must be continued with the minimal interruption. In order to minimize interrupted services, the incumbent contractor shall exercise its best efforts and cooperation to effect an orderly and efficient transition to a successor.

PERFORMANCE OF SERVICES DURING CRISIS DECLARED BY THE NATIONAL COMMAND AUTHORITY. On occasion, services may be required to support an activation or exercise of contingency plan outside the normal duty hours. Emergency situations (i.e. accident and rescue operations, civil disturbances, natural disasters) may necessitate the contractor provide increased or reduced with the contractor for the cost of these emergency requirements.

RECORDS. The contractor shall document all patient encounters legibly in the patient medical record . All documentation shall be timed and dated. Verbal orders are to be used as infrequently as possible. In the event of a major disaster or code all verbal orders are to be signed off immediately following the code or disaster. All Medical Records must be signed by the providers and charge ticket completed at the end of the visit. All Medical Records are to be completed within 24 hours of the provider's scheduled shift. All documentation shall meet the current CMS guidelines.

Final payment will be withheld until all medical records are completed by the contract physician.

PERSONNEL REQUIREMENTS

CONTINUING MEDICAL EDUCATION (CME) I CERTIFIED EDUCATION UNITS (CEU) REQUIREMENTS.

Maintain CME and review pertinent journals, books and publications. Health care providers registered or certified by the national/medical associations shall continue to meet the minimum standards for CME to remain current. CME hours shall be reported to the credentials office for tracking by the CEO.

LICENSURE/REGISTRATION. Contractor must maintain a current active and unrestricted license in at least one of the 50 United States or US territories.

CERTIFICATION. Board certified in field of specialty is favorable.

FORMAL EDUCATION. The Physician must have a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited college or university in the specialty area required to complete the FTE.

EXPERIENCE. The Physician must have a minimum of 3 years of experience within Family Practice to include fellow and residency time within the past 36 months prior to provider beginning performance at Cheyenne River Health Center.

PERFORMANCE-BASED SERVICE DELIVERY SUMMARY. The contractor's performance will be measured based on the following Performance Requirements. The Performance Requirements will be measured against Government Performance Standards and monitored in accordance with the following Methods of Government Surveillance or what is known as a Quality Assurance Surveillance Plan (QASP) to determine compliance. A 5% deduction will be assigned to each Performance Requirements not met. Deductions shall be assessed against individual invoices when services are not performed or do not meet contract requirements. Deductions will be done

· by the category that was deficient.

Performance Standards

Performance Indicator Standard/(AQL) Surveillance (QA) Incentive Task/Requirement Acceptable Quality Quality Assurance

Level

Completion of All patient 100% Random 5% deduction documentation of records must be observation and from weekly patient record documented HIM Report invoice.

accurately, Deductions will correctly, and increase by 1% in completely within subsequent 24 hours of months.

patient visit

Prompt and continuous Agency must 100% Provider Schedule For every shift not coverage provide a covered by competent Mid- Agency, the shift Level to ensure rate will be no gaps in deducted from coverage. next submitted invoice Credentialing Agency is 100% Credential Report 5% deduction allowed 3 from weekly business to invoice.

submit required Deductions will credentialing increase by 1% in documentation subsequent months.

Performance Evaluation. If the contractor fails to perform required services at the acceptable quality level, payment may be withheld until the contractor makes corrections. In the event that the contractor fails to perform any required services, the COR will provide written notice of such to the Contracting Specialist and CCO and the contractor. The Contracting Office will issue the contractor a Contract Discrepancy Report (CDR). The contractor shall have seven

(7) calendar days to provide the Contracting Office with their response to the CDR. Upon evaluation of the contractor's response to the CDR for tasks surveilled, the contractor's payment for the month in which the performance is question occurred will be calculated as outlined above.

Contractor Payment. If the contractor fails to perform required services at the acceptable quality level, payment may be withheld until contractor makes corrections.

Contracting Officer's Representative Designation

The Contracting Officer Representative (COR) designated for this Project is:

The COR is responsible for:

Jonni Pearman Assistant DON

Cheyenne River Health Center 24276 1661h Street, Airport Road

Eagle Butte, SD 57625 Office: 605-964-7724 Fax: 605-964-0522

a. Monitoring the Contractor's technical progress;

b. Interpreting the statement of work;

c. Technical evaluation as required;

d. Technical inspections and acceptance required by this contract; and,

e. Assisting the Contractor in the resolution of technical problems encountered during performance of this contract.

The contractor shall be paid a fixed flat rate of per hour. No differential pay for government holidays, compensation time, and night differential. Holidays and weekends shall be included as part of the work period and considered regular hours.

Quality Assurance Surveillance Plan (QASP). The purpose of the QASP is to provide a government developed system to assure the use of quality assurance methods in the administration of the performance based acquisition standards. The intent is to ensure that the Contractor performs services for the Cheyenne River Health Center that are provided in accordance with performance requirements set forth in the contract documents, that the government receives the quality of services called for in the contract and that the government only pays for the acceptable level of services received.

The plan provides the basis for the COR to evaluate the quality of the contractor's performance. The oversight provided for in the contract and in this plan will help ensure that service levels reach and maintain the required levels throughout the contract term. Further, this plan provides the COR with a proactive way to avoid unacceptable or deficient performance and provides verifiable input for the required past performance evaluations.

GOVERNMENT FURNISHED PROPERTY AND SERVICES.

EQUIPMENT. Contract providers shall have joint use of all available equipment for performing services required by this contract.

PERSONAL PROTECTIVE EQUIPMENT (PPE). The Government will furnish the contract provider(s) with appropriate PPE. 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.

IDENTIFICAITON CREDENTIALS. The Cheyenne River Health Center will provide each contract provider with the required identification card .

FORMS. The Cheyenne River Health Center will provide required Government forms used in the performance of services.

SUPPLIES. The Cheyenne River Health Center will provide medical and non-medical supplies commonly used in the facility for the care and management of patients and the performance of the requirements of this contract.

HOUSING. Contractor shall be responsible for all applicable Federal, State, and Local Taxes, Meals, Travel/Transportation, lodging, and per diem.

Government Housing: Lodging is available in government housing at prevailing rates, if available, and must be paid by the contractor. There are limited furnished units available for contract employees and prevailing rates range from Single -$34.72 daily, Shared $16.58 daily and Trailer Pads- $8.00 daily (Rates are subject to change) .

Local Hotel: Cheyenne River Motel (605) 964-8888.

SERVICES

ORIENTATION. The Contractor shall ensure that all new contract providers participate in the Cheyenne River Health Center Facility Orientation with an overlap of services to include one additional day. Providers must arrive on a Monday-Friday excluding holiday and participate in the orientation, which must be completed in the Monday· Friday timeframe, prior to providing services at the hospital.

Administrative Support. Cheyenne River Health Center will provide normal office administrative support services, to include telephone and utilities.

Patient Scheduling. Facility personnel will assist in patient scheduling. Complete administrative control of the patient shall remain with the facility.

Cheyenne River Health Center will provide all other ancillary personnel services required, including personnel to move patients or equipment.

CONTRACTOR FURNISHED ITEMS AND SERVICES

GENERAL. Except for those items or services specifically stated in Section Ill to be Government furnished , the Contractor shall furnish everything required to perform this contract in accordance with all of its terms.

CONTRACTOR OWNED EQUIPMENT. The provider will provide his/her own stethoscope.

INITIAL INSPECTION. Contractor owned equipment will be inspected and approved by the biomedical equipment maintenance section prior to use in the facil ity.

GENERAL INFORMATION

PERSONNEL.

POINT OF CONTACT. The Contractor shall provide a point of contact who shall be responsible for the performance of the work. The point of contact shall have full authority to act for the Contractor on all matters relating to the daily operation of this contract. The Contractor shall designate this individual, in writing, to the Contracting Officer before the contract start date. An alternate may be designated, but the Contract shall identify those times when the alternate shall be the primary point of contact.

CRIMINAL BACKGROUND INVESTIGATION. The Government will conduct at government expense, a state criminal history check on individuals providing direct, unsupervised child care services under this contract. As a minimum, the Contractor shall contact the Cheyenne River Health Center Contracting Officer for obtaining all necessary forms and directions for filing background check information in writing and electronically on personnel hired at the beginning of the contract. This action shall take place no later than five (5) working days from contract award date. Contractor shall submit completed personnel background check applications within Five (5) business days after award date to the Contracting Officers for processing . Contractor personnel will be required to be fingerprinted. Requests for personnel hired subsequent to the contact start date shall be submitted to the Government no later than five (5) working days from the employee's first duty day. Contractor shall provide a list of substitute contract personnel fulfilling contingency situations (i.e. absences of certificated contact personnel) . Names of substitutes and credentials shall be provided 15 calendar days in advance to accomplish background checks.

Contractor personnel receiving an unfavorable background check shall not be employed. Cheyenne River Health Center may employ an individual pending completion of successful background checks.

Background checks will be based on fingerprints of individual obtained by a Government law enforcement officer and inquiries conducted through the Federal Bureau of Investigation (FBI) and state criminal history repositories.

Individuals shall have the right to obtain a copy of any background check pertaining to themselves and to challenge the accuracy and completeness of the information contained in the report.

Individuals who have previously received a background check shall provide proof of the check to the CEO or obtain a new one.

CONFLICT OF INTEREST. The Contractor shall not employ any person who is an employee of the United States Government if the employment of that person would create a conflict of interest. The Contractor shall not employ any person who is an employee of HHS (Health and Human Services), unless such a person seeks and receives approval in accordance with the Department of HHS.

APPEARANCE. Employees are expected to comply with reasonable dress, grooming and hygiene standards based on comfort, productivity, health and type of position occupied. Employee attire will be in good repair, and should not be considered offensive, disruptive or unsafe.

Contract providers shall display their identification badge on their outer clothing.

PROTECTIVE CLOTHING. When required and supplied by the Government, the provider shall wear special protective clothing and shoe covers. When duties will be performed in specified areas, a disposable protective hood shall be worn to ensure infection control standards are met. The Government will provide this hood. These items shall remain the property of the Government and shall not be removed from the facility. After use, protective clothing shall be turned in or destroyed as directed by the Infection Control Policy.

PRIVILEGING REQUIREMENTS. The contract providers' credentials shall be reviewed by the Credentialing Specialist and the Credentialing Committee. The Contractor is responsible for ensuring that proposed providers possess the requisite credentials to enable granting of privileges by the Cheyenne River Health Center Medical Staff sufficient to allow for performance of al tasks identified. Medical Services cannot be performed by a contract Physician until professional staff membership and the Great Plains Indian Health Service Governing Body has granted clinical privileges in writing.

Initial applications for clinical privileges, to include credentials action history, malpractice history, and certified true copies of the documents listed below, shall be submitted to the Cheyenne River Health Center Credentialing Committee, through the Credentialing Specialist, no later than 3 calendar days after receipt of notice of contract award.

a. Copy of valid, current unrestricted state license and applicable Board Certification. (Submission of required with proposal).

b. Documentation of continuing education and training.

c. Current Basic Life Support (BLS) and Advances Cardiac Life Support (ACLS). (Submission required with proposal) .

d. A signed consent for release of information.

e. Current copy of Drug Enforcement Agency (DEA) Certificate.

f. A list of all states in which contract provider currently holds or has held a license to practice related services.

g. A current copy of the proposed contract providers professional resume.

h. Certification of current physical examination. The certification shall have a statement signed by the examining physician stating that the employee is free of any contagious diseases. The physical examination shall be current as of 12 months prior to application for privileges.

Applications for privileges will be screened through the National Practitioners Data Bank.

Re-appointment shall occur no less than every two years, in accordance with Cheyenne River Health Center Medical Bylaws.

DENIAUTERMINATION OF PRIVILEGES. Actions to limit, suspend, or revoke clinical privileges will be in accordance with the procedures outlined in the Medical Staff Bylaws. The CEO, will notify the Contracting Officer, and provide copies of pertinent documentation, as soon as possible when the necessity to exercise such authority becomes apparent. The Contracting Officer will notify the Contractor of the initiation of the revocation process if such action becomes apparent.

REVIEW OF CREDENTIALS PACKAGES. The Government reserves the right to limit the number of credentialing packages it will evaluate.

HEALTH REQUIREMENTS

The contract provider shall provide proof of current immunizations (Hep B, MMR, Varicella, Tdap, Flu) status and a current TST within the past year.

EMERGENCY HEALTH CARE. Cheyenne River Health Center will provide emergency health care for the contract providers for injuries incurred while on duty in the facility. These services will be billed to the Contractor at the current full reimbursement rate.

MEDICAL QUALITY IMPROVEMENT/RISK MANAGMENET (QI/RM).

The contract provider(s) shall participate in QI/RM activities to the extent required by Section 2C, AFI 44-119 and the individual Cheyenne River Health Center QI/RM plan or regulation.

The Government will evaluate the provider's professional, as differentiated from administrative, performance under this contract using Quality Improvement standards specified in paragraphs 2.1 and 2.2. Nothing in this paragraph precludes the Government from also conducting inspections under the Inspection/Acceptance requirement of FAR clause 52.212-4.

PERFORMACE EVALUATION

The Cheyenne River Health Center will evaluate the contractors' performance under this contract. Evaluations will be provided to the contactor, in writing. These evaluations may be used by as a record of contract performance history for the purpose of evaluation in other competitive or non-competitive acquisitions.

FREEDOM OF INFORMATION ACT (FOIA) PROGRAM. All FOIA request shall be delivered immediately to the Medical Records Supervisor.

PHYSICAL ACCESS. The Contractor shall return identification badge to the IT Department and house keys to the Housing Officer, upon completion/termination of the contract.

Physical Security. The contractor shall safeguard all government property, including controlled forms provided for contractor use. At the close of each work period, government equipment, facilities, and other valuable materials shall be secured.

Weapons, Firearms, And Ammunition. Contractor employees are prohibited from possessing weapons, firearms, or ammunition, on themselves or within their contractor-owned vehicle or privately-owned vehicle while on the Cheyenne River IHS compound.

Reporting Requirements. Contractor personnel shall report to an appropriate authority any information or circumstances of which they are aware may pose a threat to the security of IHS personnel, contractor personnel or patients.

The contractor shall prohibit their use of keys, issued by the government, by any persons other than the contractor's employees and the opening of locked areas by contractor employees to permit entrance of person other than contractor employees engaged in performed of contract work requirement in those areas.

,/j# ... <YU~ li (- Indian Health Service i Office of Human Resources

Memorandum

To :

From:

Subject:

Date:

Supervisor of child care covered position incumbent Human Resources/Personnel Security Office Child Care Position Provisional Authorization

This is notice you will supervise a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act The Indian Health Service is required to compile a list of all authorized positions with duties and responsibil ities that involve regular contact with or control over Indian children and investigate the character of each individual who is employed or is being considered for employment in such a position. The requirement is that the individual is to be under the supervision and in sight (chaperoned) of a previously investigated staff person (favorably adjudicated).

The position and individual identified below has been designated as a covered position and has been granted provisional authorization :

Name:

Position title :

The following criteria must be met for the above mentioned individual:

):.> Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

):.> Continue with processing of background investigation - Tier 1 with child care (minimum).

):.> Provide requested documentation/information as requested from the Personnel Security/HR

Office.

Employee/Contractor/Affiliate must be 100% chaperoned at all times by a staff person and/or alternates who have at a minimum a favorably adjudicated Tier 1 with child care (Tier 1 C) or CNACI investigation .

The following individuals listed below agree and accept responsibil ity of the chaperone ro le.

Chaperone name: Case type favorably adjudicated Chaperone name: Case type favorably adjudicated Chaperone name: Case type favorably adjudicated

I have verified a favorable investigation is on file for identified chaperones :

Personnel Security/HR Office designee Date

Your signature indicates you are accepting responsibility , will comply with the above criteria, and will assure the above named individual will be chaperoned at times while on site .

Department Supervisor/Designee Date

This provisional authorization is in effect until the favorably adjudicated cert ification of investigation is in place. I am aware that fa ilure to comply with the above criteria cou ld result in removal and termination of the granted provis ional authorization .

Employee/Contractor/Affi liate Date

(PLEASE COMPLETE AND RETURN)

LICENSURE REQUIREMENT

PERSONAL AND NONPERSONAL SERVICE CONTRACfORS SHALL BE SUBJECT TO THE

SAME QUALITY ASSURANCE, CREDENTIALS, LICENSURE, AND OTHER QUALIFICATION

STANDARD AS THOSE REQUIRED OF IHS PERSONNEL. IN ADDITION, HEALTH CARE

PROVIDERS, OTHER THAN PROFESSIONALS, MUST BE LICENSED lN A STAtE, THE

DISTRICT OF COLUMBIA, PUERTO RICO, OR A TERRITORY OF THE UNITED STATES TO

. PERFORM tHE CONTRACT SERVICES WITHIN illS FACILITIES. THE CONTRACTING OFFICER WILL INSERT THE FOLLOWING CERTIFICATION STATEMENT IN AlL

PURCHASE ORDERS AND CONTRACTS FOR PROFESSIONAL MEDICAL SERVICES:

MY LICENSE TO PRACTICE 0 HAS 0 HAS NOT BEEN TERMINATED, SUSPENDED, OR

REVOKED IN ANY STATE, THE DISTRICT OF COLUMBIA, PUERTO RICO, OR A

TERRITORY OF THE U.S.

I CURRENTLY HOLD AN ACTIVE MEDICAL LICENSE lN THE FOLLOWiNG STATE(S):

STATE LINCESURE NO. ISSUE DATE

1 HAVE AN INACTIVE MEDICAL LICENSE IN THE FOLLOWING STATE(S):

LICENSURE NO. ISSUE DATE

I HEREBY CERTIFY THAT THE PURPOSES OF APPLICATION OF THE FALSE

STATEMENTS PROVISIONS OF THE PROGRAM FRAUD CIVIL REMEDIES ACT OF 1986 (45

CFR 79), THAT TO THE BEST OF MY KNOWLEDGE, EACH OF THE ABOVE STATEMENTS

IS TRUE, ACClJMTE, AND DOES NOT OMIT ANY MATERIAL FACT THAT WOULD

RENDER THE STATEMENT FALSE, FICTITIOUS, FRAUDULENT AS A RESULT OF THE

OMISSION.

SIGNATURE OF PRACTITIONER DATE

PO Number-------

AGREEMENT TO A TEMPORARY PROVISIONAL OF CHARACTER INVESTIGATION (FOR

GOVERNMENT CONTRACTORS ONLY)

Per your request, the Senior Contracting Officer, Aberdeen Area Indian Health Service has agreed to a temporary waiver of the character investigation for ·

(Name of Contractor)

This temporary waiver has been agreed to with the understanding that you will continue the process of accomplishing the character investigation in accordance with Public Law 101-630, Indian Child Protection and Family Violence Prevention Act and Public Law 101-647, Crime Control Act. Upon completion of the character investigation, you shall notify the Contracting Officer.

Your signature indicates you are taking the responsibility to assure the Senior Contracting Officer that the above named individual will not have unmonitored

. contact with Indian children. This agreement is in effect until the Senior Contracting officer is notified that the above named contractor has successfully completed the background investigation.

I understand that in accordance with Section 231 of the Crime Control Act of 1990 (P;L. 101- 647 and P .L. 101-630), that failure to comply with these statues will result in my immediate removal.

CONTRACTOR DATE .

I hereby assure that such continuous monitoring will occur when said individual is in contact with Indian Children under the age of 18 years. I am aware, and will assure, that those providing DIRECT SIGHT MONITORING shall as a minimum, have had a successfully completed NACI. I certify that the permanent federal employees assigned to provide DIRECT SITE MONITORING has met the requirements of Section 231 of the Crime Control Act of 1990 (P.L. 101-630)

SIGNATURE OF INDIVIDUAL RESPONSIBLE

FOR DIRECT SIGHT MONITORING

SERVICE UNIT DIRECTOR

December 2005

DATE

DATE

Declaration for Federal Employment

Instructions

Form Approved OMB No. 3206·0182

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program . You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete . A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets ( 8.5" X 11"). Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement ----------------------------- The Office of Personnel Management is authorized to request this information under sections 1302, 3301 , 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees;

Federal agencies or other sources requesting information for Federal agencies In connection with hiring or retain ing, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media , which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions;

prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual: requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment;

individuals working on a contract, service. grant, cooperative agreement, or job for the Federal government: non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement

Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information . Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington , DC 20415-7900. The OMB number, 3206-0182, is valid . OPM may not collect this information , and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management 5 u.s.c. 1302. 3301. 3304, 3328 & 8716

NS N 7540-01·366-7775

Optional Form 306 Revised January 2001

Previous editions obsoleto and unusable

Declaration for Federal Employment

GENERAL INFORMA T/ON

Fotm Approved OMB No. 3206-0182

1. FULL NAME (First, middle, last)

2. SOCIAL SECURITY NUMBER

3. PLACE OF BIRTH (Include city and state or country)

4. DATE OF BIRTH (MM/00/YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc) 6. PHONE NUMBERS (Include area codes)

• Day +

Night +

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

?a. Are you a male born after December 31, 1959? D YES

7b. Have you registered with the Selective Service System? 0 YES B NO If "NO" skip lb and lc. If "YES" go to lb.

NO If "NO" go to lc.

?c. If "NO," describe your reason(s) in item #16.

Military Service

8. Have you ever served in the United States military? 0 YES Provide information below

If you answered "YES," list the branch, dates, and type of discharge for all active duly.

If your only active duty was training in the Reserves or National Guard, answer "NO."

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,1 0, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law.

9.

10.

11 .

12.

13.

During the last 10 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies , firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the dale, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

Have you been convicted by a military court-martial in the past 10 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

Are you now under charges for any violation of law? If "YES,'' use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S . Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES,'' use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

DD

YES NO

DO

YES NO

DD

YES NO

DO

YES NO

DO

U.S. Office of Personnel Management 5 u.s.c. 1302. 3301, 3304, 3328 & 8716

NSN 7540-01-368-7775

Oplional Form 306

Revised January 2001 Previous editions obsolete and unus~ble

Declaration for Federal Employment Form Approved:

OMS No.