Dentist - Readvertise (003).pdf

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1

1. REQUISITION NUMBER

I

PAG

OF

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30 I 8

2. CONTRACT NO.

I

3.AWARD/

4. ORDER NUMBER

5. SOLICITATION NUMBER

6. SOLICITATION

EFFECTIVE DATE 75H70622Q00004 ISSUE DATE

03/29/2022

7. FOR SOLICITATION

► INFORMATION CALL:

9. ISSUED BY

Belcourt PHS Indian 1300 Hospital Road P.O. Box 160 Belcourt ND 58316

•· NAME

PHYLLIS

Hospital

GOURNEAU

CODE 1163

11. DELIVERY FOR FOB DESTINA- 12. DISCOUNT TERMS

TION UNLESS BLOCK IS

MARKED

X- SEE SCHEDULE

15. DELIVER TO CODE I

17a. CONTRACTOR/ CODE I FACILITY I OFFEROR CODE

TELEPHONE NO.

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

19. 20.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES

The Quentin N Burdick Memorial Healthcare

I

b. TELEPHONE NUMBER (No co/leer calls)

8. OFFER DUE DATE/LOCAL TIME

701-477-8419 04/12/2022 1200 CT

10. THIS ACQUISITION IS LI UNRESTRICTED OR _)( SETASIDE: 100.00 % FOR:

,x; SMALL BUSINESS WOMEN-OWNED SMALL BUSINESS

'7 (WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

I HUBZONE SMALL !=.MAI I RI l�INFi=:� PR()�RAM

NAICS:5 613 2 0 BUSINESS EDWOSB

SERVICE-DISABLED 8(A)

VETERAN-OWNED

SMALL BUSINESS

La 13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

16. ADMINISTERED BY

Belcourt PHS Indian 1300 Hospital Road PO Box 160 Belcourt ND 58316

18a. PAYMENT WILL BE MADE BY

SIZE STANDARD:

13b. RATING

14. METHOD OF SOLICITATION

OCRFQ

Hospital

[ 1 1FB [ RFP

CODE 1163

CODE I

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

IS CHECKED SEE ADDENDUM

21. 22. 23. 24.

QUANTITY UNIT UNIT PRICE AMOUNT

$30.0

Facility (QNBMHF) in Belcourt, North Dakota is requesting responses to this Request for Quote (RFQ) to perform temporary staffing of 5 (five)

Dentist with one being for pediatrics. QNBMHF intends to award an Indefinite Delivery - Indefinite Quantity (IDIQ) contract. The RFQ is issued as a small business set aside, and the associated NAICS Code is 561320, temporary staffing. Size Standard $30.00

(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 FAR52.212- 1. 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA LX ARE [:l ARE NOT ATTACHED.

L ARE u ARE NOT ATTACHED.

127b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

X 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

30a. SIGNATURE OF OFFEROR/CONTRACTOR

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

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

I 30c. DATE SIGNED

29. AWARD OF CONTRACT: OFFER

DATED . YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

HEREIN. IS ACCEPTED AS TO ITEMS:

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

31b. NAME OF CONTRACTING OFFICER (Type or print)

I 31c. DATE SIGNED

CRAIG J. WELLS

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA • FAR (48 CFR) 53.212

19. 20. 21. 22.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT

This ID/IQ contract does not obligate any funds.

Funds will be obligate on an individual basis as

Task Orders and will be issued electronically sent via e-mail. For details please refer to the attached clauses FAR 52.216-18 Ordering, FAR

52.216-19 Order Limitations and FAR 52.216-22

Indefinite Quantity. The Unit Price is an all-inclusive cost. All inclusive cost is defined to include travel, lodging, per diem, fringe benefits, i.e., life insurance, social security, federal, state, and local taxes, plus all other costs pertinent to the performance of this IDIQ Contract.

SEE Attached Bid Schedule to submit pricing

Period of Performance will be Award date for one year and four one year options.

FAR 52.212-1 - Instructions to Offerors -

Commercial Items (NOV 2021) : Quotes shall be submitted on company letterhead stationary, signed and dated and it shall include:

1. Solicitation number 75H70622Q00004 -

Readvertise

2. Closing date of April 6' 2022 at 1200 (Noon)

CST.

Continued . . .

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED 0 INSPECTED 0 ACCEPTED AND CONFORMS TO THE CONTRACT EXCEPT AS NOTED·

23.

UNIT PRICE

24.

AMOUNT

32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE I

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED 36. PAYMENT 37. CHECK NUMBER

CORRECT FOR

COMPLETE PARTIAL FINAL

PARTIAL FINAL

38. SIR ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID B Y

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

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE 42b. RECEIVED AT (Location)

42c. DATE REC'D (YYIMMIDD) 142d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 2/2012) BACK

EFERENCE NO. OF DOCUMENT BEING CONTINUED

CONTINUATION SHEET 75H70622000004

NAME OF OFFEROR DR CONTRACTOR

ITEM NO.

(Al

SUPPLIES/SERVICES

(B)

3. Name, address, telephone number of the offeror and email address of the contact person.

4. Technical description of the item/service being offered in sufficient detail to evaluate compliance with the requirements in the solicitation. This may include documents, if necessary;

.5. Remit to" address, if different than mailing address;

6. A completed copy of the representations and certifications at FAR 52.212-3 see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete ,electronically.

7. Acknowledgment of Solicitation Amendments (if .any issued) I

8. Resume stating ability to meet qualifications

1and the requirements of the statement of work for 'any and all candidate presented with the RFQ.

1 9. Past Performance information, when included as 'an evaluation factor, to include recent and 'relevant contracts for the same or similar items I , and other references (to include contract numbers, points of contact with telephone number and other pertinent information)

10. A statement specifying the extent of agreement with all terms, conditions and provisions included in the solicitations.

Offerors that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded In addition, Contractor shall provide the following in order to be considered technically acceptable.

1. Complete and sign Agreement of Child Care Position of Provisional Authoriza ion.

2. Complete and sign Declaration for Federal Employment Option Form 306

3. Complete and sign Addendum to Declaration for Federal Employment Option Form 306

4. Complete and sign Licensure Requirement Form.

5. Copy of Malpractice insurance coverage.

6. Shall meet the Professional Qualifications Criteria of the Statement of Work

7. Copy of Board Certifications

8. Copy of active, current full and unrestricted Continued ...

NSN 7540-01-152-8067

QUANTITY UNIT

(C) (D) I

UNIT PRICE

(E)

PAGE OF

3 8

AMOUNT

{F)

OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

REFERENCE NO. OF DOCUMENT BEING CONTINUED

CONTINUATION SHEET 75870622Q00004

NAME OF OFFEROR OR CONTRACTOR

ITEM NO.

(A)

SUPPLIES/SERVICES

(B) license to practice.

9. Copy of Diplomas/Specialty Certification

10. Copies of Continue Education

11. Current CV/resume

12. Name and phone number of three (3) current professional references

13. Copy of recent Health Examination

BASIS FOR AWARD

Quoters are advised that the Government will award a contract resulting from this solicitation to the lowest responsib e offeror whose offer conforming to the solicitation will me most advantageous to the Government, price and other factors considered. Award shall be made to the

Lowest Price Technically Acceptable Offer. The following factors shall be used to evaluate offers.

1. Ability to provide qualified candidates

2. Price

FAR 52.212-3 - Offeror Representations

Certifications - Commercial Items (Nov 2021)

- See attachment for full text and instruction for completion. An offeror shall complete only paragraph (b) of this provision if the offeror has completed the annual representations and certifications electronically via http://www.sam.gov. If an offeror has completed the annual representations and certifications electronically at the System for Award Management

(SAM) website, the offeror shall complete only paragraph (c) through (o) of this provision.

FAR 52.212-4 - Contract Terms and Conditions -

,commercial Items (NOV 2021) - See attachment; in by reference

FAR 52.212-5 - Contract Terms & Condition's

Required to Implement Statutes or Executive Orders - Commercial Items (JAN 2022) - See attachment for full text.

Attached are the Federal Acquisition Regulations (FAR) and the Health & Human Services Acquisition

Regulation (HHSAR) clauses that are applicable including the in the attachment

·Continued ...

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OPTIONAL FORM 336 (4-86)

REFERENCE NO. OF OOCUMENT BEING CONTINUED

CONTINUATION SHEET 75H70622Q00004

NAME OF OFFEROR OR CONTRACTOR

ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

Offers will be accepted electronically, Submit via e-mail to the following:

Quentin N Burdick Memorial Healthcare Facility -ndian Health Service

Phyllis Gourneau, Contract Specialist

PO Box 160

Belcourt, North Dakota 58316 e-mail: Phyllis.gourneau@ihs.gov

Phone: (701)477-8419

Contractor will need a DUNS number, TIN number and be registered with www.SAM.gov

Indian Health Service, requires Contractors to complete the Mandatory Annual Training, Protecting Children from Sexual Abuse by Health

Care Providers. Therefore, please forward this email to all health care contractors that are and will be working at any one of our IHS facilities.

Here's the Link for Contractors to access the site;

https://www.ihs.gov/sexualabuseprevention/training

I !When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and

Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

SECURITY CLEARANCE.

Performance of this contract wi_ require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.)

Before starting work requiring routine access to

I.H.S. facilities or systems each person must complete a FBI National Criminal History Check

(Fingerprint Check) adjudicated by an I.H.S.

employee using the Office of Personnel Management

Personnel Investigations Processing System.

Contractors shall allow five business days for

I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty

,business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of

I.H.S. sites with electronic fingerprint capability is available from the Contracting

Officer.

In addition, no Contractor or subcontractor employee shal be permitted to perform work under

Continued ...

NSN 7540-01-152-8067

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OPTIONAL FORM 336 (4-86)

CONTINUATION SHEET ?SH70622Q00004

NAME OF OFFEROR OR CONTRACTOR

ITEM NO.

(A)

SUPPLIES/SERVICES

(B) this contract if listed on the HHS Office of

Inspector General List of Excluded

Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the

;performance of the work the Contractor shall

'provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the

Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access.

If this is a Fixed Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

'.Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with

IPAs or MOAs to tribal organizations please, click here IHS Sexual Abuse Prevention website.

When the contractors have completed and assed the training, please have them send a copy of the last page of the training with Name, Date, and

Time to their Supervisor, COR, and Kimmen LeBeau, e-mail:

I In the event the Contractor is unable to fulfill the task order requirements for whatever reason;

the government reserves the right to fulfill its need outside of this contract. A written

Continued ...

NSN 7540--01-152-8067

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OPTIONAL FORM 336 (4-86)

NAME OF OFFEROR OR CONTRACTOR

ITEM NO.

(A)

SUPPLIES/SERVICES

(B) confirmation from the contractor indicating the inability to fulfill the task order is immediately required. The quantity of hours ordered on the unfilled task order will be applied to the minimum quantity. The governments right to fulfill its need outside this :contract(s) does not waive its right to the issuance of a cure notice nor does it waive its right to terminate for default.

SEE BID SCHEDULE TO SUBMITT PRICING

INVOICE SUBMISSION AND PAYMENT

The Contractor shall submit a signed and approved invoice to request payment on at least a monthly basis.

l(a) The Contractor shall submit an original invoice to:

¼ttn: Accounts Payable Great Plains Area Indian Health Service Division of Financial Management 115 4th Avenue Southeast Room 309 Federal Building Aberdeen, South Dakota 57401

(b) The Contractor shall include the following information on each invoice in accordance with the Prompt Payment Act (5 CFR Part 1315.9(b)):

1. Contractor's name;

2. Invoice number and date;

3. Entire award number or other authorization number for delivery of goods or services;

4. Description (including dates of service), price, and quantity of goods and services rendered;

5. Shipping and payment terms;

6. DUNS number and Taxpayer Identifying Number I (TIN); and

7. Contact name (where practicable), title and telephone number.

Payment shall be made by the Great Plains Area Financial Management Branch, Room 309 Federal Building, Aberdeen, South Dakota 57401.

Continued

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OPTIONAL FORM 336 (4•86)

EFERENCE NO. OF DOCUMENT BEING CONTINUED

NAME OF OFFEROR OR CONTRACTOR

ITEM NO.

(A)

SUPPLIES/SERVICES

(Bl

The Government reserves the right to accept or reject services if the level or work is unsatisfactory.

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RFQ 7SH70622Q0004- Readvertise-Temporary Staffing -Dentist RFQ Quentin N

Burdick Memorial Healthcare Facility in Belcourt, North Dakota

Bid Schedule - QNBMHF In Belcourt, ND - Please Submit Pricing on this Bid Schedule iR's'servlce Unit Description Quantity Unit of Issue Unit Price

I 'l Belcourt !-.H:S Service Unit Te�porary Sta.ffing -. Dentist Base Yr.

Price per hour _____ X 8,800 hrs.

Temporary Staffing - Pediatric Dentist

Price per hour ____ X 2,200 hrs. _________ _

2. Belcourt I.H.S Service Unit Temporary Staffing - Dentist Option Yr. 1

Price per hour _____ X 8,800 hours·--------�-

Temporary Staffing - Pediatric Dentist

Price per hour _____ X 2,200 hrs. --------------

3. Belcourt !.H.S Service Unit Temporary Staffing Dentist Option Yr. 2

Price per hour _____ X 8,800 hrs.

Temporary Staffing - Pediatric Dentist

Price per hour _____ X 2,200 hrs.-------------

14. Belcourt I.H.S Service Unit Temporary Staffing Dentist Option Yr. 3

Price per hour ______ X 8,800 hrs. ------------- Temporary Staffing - Pediatric Dentist

Price per hour _____ X 2,200 hrs. --------------

S. Belcourt I.H.S Service Unit Temporary Staffing Dentist Option Yr. 4 Price per hour _____ X 8,800 hrs. ____ _

Temporary Staffing - Pediatric Dentist

Price per hour _____ X 2,200 hrs.-----

Total Cost £lase Plus Four Option Years •. =

Total Cost

PERFORMANCE WORK STATEMENT

Dentist Quentin N. Burdick Memorial Health Care Facility.

Part I

General Information

1. GENERAL: This is a non-personnel services contract to provide a Dentist for Dental services. The Government shall not exercise any supervision or control over the contract service providers performing the services herein. Such contract service providers shall be accountable solely to the Contractor who, in tum is responsible to the Government.

1.1 Description of Services/Introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform the duties of a Dentist as defined in this Performance Work Statement, except for those items specified as government furnished property and services. The contractor shall perform to the standards in this contract.

1.2 Background: The Mission of the Quentin Burdick Memorial Healthcare Facility Indian Health Service is to provide the best possible healthcare services to the patients of the Quentin Burdick Memorial Healthcare Facility Indian Health Hospital. To meet this mission, the Quentin Burdick Memorial Healthcare Facility Service Unit has identified a need for a Non-Personal Service Contract for providing Medical services for a Hospitalist.

1.3 Objectives: The contract Dentist agrees, to provide all necessary covered services within the Dental scope of practice, under the direction of the Clinical Director/Dental Director or designee.

• The Contracted Dentist shall provide a full scope of services to include adolescent, adult, and newborn patients at the Quentin Burdick Memorial Healthcare Facility Service Unit

1.4 Scope: Provide dental care services for Dentist/Dental services. Services include providing direct care to patients of all ages with a variety of dental/medical, surgical, pediatric, geriatric and health maintenance needs. The Indian Health Service requires a Dentist to provide Dental services as described above to continue without interruption during the term of this contract. The contractor shall accomplish Dental care provided by the Contracted a Dentist and shall be as comprehensive as the Indian Health Service supplied facilities, equipment, and support services permit.

The contract resulting from this solicitation shall:

a. Be a non-personal health care services contract under which the contractor is an independent contractor;

b. Require the contractor to promptly provide any and all requested information to allow for the proper credentialing and privileging of dental providers.

c. Allow the government to evaluate the quality of professional and administrative services provided, but retains no control over the dental, professional aspects of the services rendered, (e.g., professional judgments, diagnosis for specific dental treatment);

d. Require the contractor to indemnify the government for any liability producing act of omission by the contractor, its employees and agents occurring during contract performance;

e. Require the contractor to maintain dental liability insurance, in the coverage amount acceptable to the contracting officer, which is not less than the amount normally prevailing with the local community for the dental specialty concerned; and

f. Require the contractor to ensure its subcontracts for provisions of health care services, contain the requirements of the clause at FAR 52.237-7 (Indemnification and Dental Liability Insurance), including the maintenance of dental liability insurance and meet the Quentin Burdick Memorial

Healthcare Facility Indian Health Hospital's accreditation requirements with regard to professional credentials including any support staff.

g. Candidates with prior Dental Licensure actions are not eligible for temporary privileges. The process of granting of privileges by the facility Governing Body may take up to 3 months.

1.5 Period of Performance: The Period of Performance shall be listed on the Task Order as scheduled with the Clinical Director or designated representative. The Dentist shall provide health care services, for the entire Period of Performance at the Quentin Burdick Memorial Healthcare Facility. The usual work day will be a JO-hour work day from 7 AM to 5:30 PM Monday through Thursday the first week and Tuesday through Friday the second week.

1.6 General Information:

1.6.1 Quality Control: The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor's quality control program is the means by which he assures himself that his work complies with the requirement of the contract. The QCP is to be delivered within 30 days after contract award or with the contractors proposal ifit is an evaluation factor, three copies ofa comprehensive written QCP shall be submitted to the CO and COR within 5 working days when changes are made thereafter. After acceptance of the quality control plan the contractor shall receive the contracting officer's acceptance in writing of any proposed change to his QC system.

1.6.2 Quality Assurance: The government shall evaluate the contractor's performance under this contract in accordance with the Quality Assurance Surveillance Plan. This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.6.3 Recognized Holidays: The provider will be required to be on-call for Federal Government holidays, weeknights and weekends as depicted in schedules provided upon issuance of Task Order.

New Year's Day Martin Luther King Jr. 's Birthday President's Day Memorial Day Independence Day

Labor Day Columbus Day Veteran's Day Thanksgiving Day Christmas Day

1.6.4 Hours of Operation: The contractor is responsible for conducting business, between the hours of 7 AM - 5:30 PM Monday through Thursday the first week and Tuesday through Friday the second week except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. For other than firm fixed price contracts, the contractor will not be reimbursed when the government facility is closed for the above reasons. The Contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS when the Government facility is not closed for the above reasons. When hiring personnel, the Contractor shall keep in mind that the stability and continuity of the workforce are essential.

1.6.5 Place of Performance: The work to be performed under this contract will be perfonned at Quentin N.

Burdick Health care facility, Belcourt, ND which is an Indian Health Service government facility.

1.6.6 Type of Contract: The government will award a firm-fixed price, non-personal service contract.

1.6.7 Security Requirements: The Contracted Dentist is subject to a background investigation and shall comply with Section 231 of the Crime Control Act of 1990, P.L. 101-647; and the Indian Child Protection and Family Violence Prevention Act, P.L. 101-630. In addition, the Dentist shall also comply with the

Privacy Act of 1974 and the HIPP A Act of 1996. Failure to comply with these statutes will result in immediate removal.

a. Contractor personnel performing work under this contract, which involve regular contact with, or control over, Indian children, are subject to a character investigation in accordance with the "Indian Child Protection and Family Violence Prevention Act" P.L.

IO 1-630. The Indian Health Service Personnel Office will conduct these investigations following award of a contract unless in the judgment of the Contracting Officer, in consultation with the Personnel Officer, investigation may be waived based on prior investigations on file. Until the character investigation has been completed and the Contracting Officer notified, such individual shall not have unsupervised contact with Indian children.

b. The Contracting Officer has the authority to temporarily waive the character investigation of a contractor. The "Agreement to a Temporary Waiver of Character Investigation" (See Attachment B) authorizes an agency to hire a contractor prior to the completion of a background check provided that at all times the contractor is within the sight and under the supervision of a government employee who has successfully completed the National Agency Check with written Inquiries (NACI).

c. This level of security is required, and must be maintained for the life of the contract.

1.6.7.1 PHYSICAL Security: The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor use. At the close of each work period, government facilities, equipment, and materials shall be secured. The contracted provider shall generate and maintain proper dental/medical record information on beneficiaries to whom treatment is provided, in accordance with Indian Health Service regulations. The contracted provider shall prepare all dental/medical records documentation to meet or exceed the established standards of the I.H.S. facility to include, but not be limited to: timeliness, legibility, accuracy, content, and signature. All dental/medical record information generated in the performance of the contract will be subject to the exclusive control of the Indian Health Service.

1.6.7.2 Key Control: The Contractor shall establish and implement methods of making sure all keys/key cards issued to the Contractor by the Government are not lost or misplaced and are not used by unauthorized persons. NOTE: All references to keys include key cards. No keys issued to the Contractor by the Government shall be duplicated. The Contractor shall develop procedures covering key control that shall be included in the Quality Control Plan. Such procedures shall include turn-in of any issued keys by personnel who no longer require access to locked areas. The Contractor shall immediately report any occurrences of lost or duplicate keys/key cards to the Contracting Officer.

1.6. 7 .2.1. In the event keys, other than master keys, are lost or duplicated, the Contractor shall, upon direction of the Contracting Officer, re-key or replace the affected lock or locks; however, the Government, at its option, may replace the affected lock or locks or perform re-keying. When the replacement of locks or re keying is performed by the Government, the total cost of re-keying or the replacement of the lock or locks shall be deducted from the monthly payment due the Contractor. In the event a master key is lost or duplicated, all locks and keys for that system shall be replaced by the Government and the total cost deducted from the monthly payment due the Contractor.

1.6. 7.2.2. The Contractor shall prohibit the use of Government issued keys/key cards by any persons other than the Contractor's employees. The Contractor shall prohibit the opening of locked areas by Contractor employees to permit entrance of persons other than Contractor employees engaged in the performance of assigned work in those areas, or personnel authorized entrance by the Contracting Officer.

1.6.8 Special Qualifications: It is a condition of this contract that all required certifications remain current during the life of this contract.

The contractor is responsible for ensuring the contracted Hospitalist shall possess a current, unrestricted state Dental license from any of the 50 United States or the Commonwealth of Puerto Rico, be registered with a Dental Board and registered with a Dental Licensure.

Possess current (BLS) Basic Life Support certification.

The contractor is responsible for ensuring the contracted Dentist shall

a. Not have any work or health restrictions, which interfere with the performance of general dental services.

b. Have skill and knowledge in providing dental care with full consideration of the mental, emotional, physical, and cultural factors involved, such that he/she can relate constructively to patients from the Native American community.

c. Ability to work with patients, the public, and hospital staff.

1.6. 9 Post Award Conference/Periodic Progress Meetings: The Contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. The contracting officer, Contracting Officers Representative (COR), and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance. At these meetings the contracting officer will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues.

These meetings shall be at no additional cost to the government.

1.6.10 Contracting Officer Representative (COR): The (COR) will be identified by separate letter. The COR monitors all technical aspects of the contract and assists in contract administration The COR is authorized to perform the following functions: assure that the Contractor performs the technical requirements of the contract: perform inspections necessary in connection with contract performance:

maintain written and oral communications with the Contractor concerning technical aspects of the contract:

issue written interpretations of technical requirements, including Government drawings, designs, specifications: monitor Contractor's performance and notifies both the Contracting Officer and Contractor of any deficiencies; coordinate availability of government furnished property, and provide site entry of Contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the Contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting order.

1.6.11 Key Personnel: The follow personnel are considered key personnel by the government:

Paula Bercier, MD/Clinical Director

Julius Theophilus, DDS/Dental Director

Jennilee Blue, Administrative Support Assistant/Cred. Tech.

Julie Laducer, RN/COR II

The contractor shall provide a contract manager who shall be responsible for the performance of the work.

The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the contracting officer. The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The contract manager or alternate shall be available between 6:00 a.m. to 6:30p.m., Monday thru Friday except Federal holidays or when the government facility is closed for administrative reasons.

1.6.12 Identification of Contractor Employees: All contract personnel attending meetings, answering Government telephones, and working in other situations where their contractor status is not obvious to third parties are required to identify themselves as such to avoid creating an impression in the minds of members of the public that they are Government officials. They must also ensure that all documents or reports produced by contractors are suitably marked as contractor products or that contractor participation is appropriately disclosed. The contractor personnel will be required to obtain and wear badges in the performance of this service.

1.6.13 Contractor Travel: The Contractor shall be responsible for arranging travel and all associated costs related to the performance of this contract.

1.6.14 Other Direct Costs The Contractor shall be responsible for arranging travel, lodging, per diem, labor, fringe benefits, and any applicable Federal, State, and Local taxes, plus any other costs pertinent to the performance of this contract.

1.6.15 Data Rights: The Government has unlimited rights to all documents/material produced under this contract. All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the Contracting Officer. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

1.6.16 Organizational Conflict oflnterest: Contractor and subcontractor personnel performing work under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent Organizational Conflict oflnterests (OCI) as defined in FAR Subpart 9.5. The Contractor shall notify the Contracting Officer immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the Contracting Officer to avoid or mitigate any such OCI. The Contractor's mitigation plan will be determined to be acceptable solely at the discretion of the Contracting Officer and in the event the Contracting Officer unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the Contracting Officer may affect other remedies as he or she deems necessary, including prohibiting the Contractor from participation in subsequent contracted requirements which may be affected by the OCI.

PART2

DEFINITIONS & ACRONYMS

2. DEFINITIONS AND ACRONYMS:

2.1. DEFINITIONS:

2.1.1. CONTRACTOR. A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

2.1.2. CONTRACTING OFFICER(CO). A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

2.1.3. CONTRACTING OFFICER'S REPRESENTATIVE (COR). An employee of the U.S. Government appointed by the contracting officer to administer the contract. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

2.1 .4. DEFECTIVE SERVICE. A service output that does not meet the standard of performance associated with the Performance Work Statement.

2.1.5. DELIVERABLE. Anything that can be physically delivered, but may include non-manufactured things such as meeting minutes or reports.

2.1.6. KEY PERSONNEL. Contractor personnel that are evaluated in a source selection process and that may be required to be used in the performance of a contract by the Key Personnel listed in the PWS. When key personnel are used as an evaluation factor in best value procurement, an offer can be rejected if it does not have a firm commitment from the persons that are listed in the proposal.

2.1.7. PHYSICAL SECURITY. Actions that prevent the loss or damage of Government property.

2.1.8. QUALITY ASSURANCE. The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

2.1.9. QUALITY ASSURANCE Surveillance Plan (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.1.10. QUALITY CONTROL. All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

2.1.11. SUBCONTRACTOR. One that enters into a contract with a prime contractor. The Government does not have privity of contract with the subcontractor.

2.1.12. WORK DAY. The number of hours per day the Contractor provides services in accordance with the contract.

2.1.12. WORK WEEK. As specified otherwise.

2.2. ACRONYMS:

ACOR

AFARS

FP

Alternate Contracting Officer's Representative Army Federal Acquisition Regulation Supplement Family Practice

IM

CCE

CFR

CONUS

COR

COTR

COTS

IHS

DD250

DD254

DFARS

DMDC

DOD

FAR

HIPAA

KO

OCI

OCONUS

ODC

PIPO

POC

PRS

PWS

QA

QAP

QASP

QC

QCP

TE

Internal Medicine Contracting Center of Excellence Code of Federal Regulations Continental United States (excludes Alaska and Hawaii) Contracting Officer Representative Contracting Officer's Technical Representative Commercial-Off-the-Shelf Indian Health Service Department of Defense Form 250 (Receiving Report) Department of Defense Contract Security Requirement List Defense Federal Acquisition Regulation Supplement Defense Manpower Data Center Department of Defense Federal Acquisition Regulation Health Insurance Portability and Accountability Act of 1996 Contracting Officer Organizational Conflict of Interest Outside Continental United States (includes Alaska and Hawaii) Other Direct Costs Phase In/Phase Out Point of Contact Performance Requirements Summary Performance Work Statement Quality Assurance Quality Assurance Program Quality Assurance Surveillance Plan Quality Control Quality Control Program Technical Exhibit

PART3

GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SER VICES

This section identifies those items such as property, information and/or services that will be provided for the contractor's use (without cost to the contractor) to allow them to provide the required Physician services, such as materials, facilities, training, etc. Examples provided below.

3. GOVERNMENT FURNISHED ITEMS AND SERVICES:

3. 1. Services: The Government will provide personnel to assist with orientation and guidance to the Indian Health Service and its requirements.

3.2 Facilities: The Government will provide the necessary workspace for the contractor staff to provide the support outlined in the PWS to include desk space, telephones, computers, and other items necessary to maintain an office environment for the nursing inpatient services.

3.3 Utilities: The Government will provide all utilities in the facility will be available for the contractor's use in performance of tasks outlined in this PWS. If utilities are furnished, the following is required: The Contractor shall instruct employees in utilities conservation practices. The contractor shall be responsible for operating under conditions that preclude the waste of utilities, which include turning off the water faucets or valves after using the required amount to accomplish cleaning vehicles and equipment.

3.4 Equipment: The Government will provide equipment and/or what the contractor will have access to, i.e., computer, phone, scanners, fax machines, printers, shipping crates, lighting and sound, etc.

3.5 Materials: The Government will provide materials, i.e., Standard Operating Procedures and Policies.

PART4

CONTRACTOR FURNISHED ITEMS AND SERVICES

4. CONTRACTOR FUR ISHED ITEMS AND RESPONSIB ILITIES:

4.1 General: The Contractor shall furnish all supplies, equipment, facilities and services required to perform work under this contract that are not listed under Section 3 of this PWS.

4.2 Verification of Licensure

To ensure that Dentist providing services under this contract are properly licensed and that the I.H.S. is made aware of all disciplinary actions taken against such Dentist, the contractor will:

a. Verify through the National Dental Boards database all active, inactive, and lapsed licenses that are held, or have been held, by Dentist who would provide services in I.H.S. hospitals and clinics under this contract.

b. Inform I.H.S. of the status of all licenses for each Dentist who would provide services under this contract in I.H.S. hospitals and clinics, including all reasons for each inactive or lapsed license.

c. Obtain at least three letters of reference from health care providers whom have knowledge of the applicant's clinical practice skills within the past six months. One letter must be from the previous supervisor, at the Institution where the Dentist holds or last provided Dental care.

d. Provide all information regarding performance and disciplinary actions that is collected on a provider who would be placed under this contract to the receiving I.H.S. facility linical Director.

This includes all information that is collected and compiled on such providers at the time of initial hire by the Contractor, and/or information that is reported during periods that the Contractor is an agent of such Dentist for placement under this contract.

e. Certify that all information obtained on Dentist whom they would assign to I.H.S. hospitals and clinics has been reviewed and verified by the Contractor. This certification must include a statement that the Contractor has found no reason to reject the Dentist application. The names of the contacts, their titles, telephone numbers, and dates of representative collecting and reviewing such information must be recorded in writing and made available to the I.H.S. by the Contractor.

The Contractor must provide all of the information required above to the Clinical Director of the receiving I.H.S. facility no less than ten to fourteen days before the physicians actual report date. When the requirements or the I.H.S. do not allow for hard copies of information to be received at least ten days before a nurses placement, the Contractor may provide such assurances to the I.H.S. facility Clinical Director within five days after physician's placement. Such instances shall be kept to a minimum and the reasons for each instance must be documented and well justified by the Clinical Director at the receiving I.H.S. facility. (Per amend. #2-9/28/95)

4.3 Dental liability Insurance:

The Contractor will be solely liable for and expressly agrees to indemnify the Government with respect to any professional liability producing acts or omissions by it or its employees or agents. The Contractor will maintain during the term of this contract liability insurance issued by a responsible insurance carrier of not less than One (I) Million Dollars per occurrence and $3,000,000.00 aggregate.

An apparently successful offers or upon request by the contracting officer, will furnish prior to contract award evidence of its insurability concerning the medical liability insurance required by this contract.

Liability insurance may be on either an occurrence basis or on claims made basis. If the policy is on claims made basis, an extended reporting endorsement (tai 1) for a period of not less than three (3) years after the end of the contract term must also be provided.

A CERTIFICATE OF INSURANCE EVIDENCING THE REQUIRED COVERAGE WILL BE

PROVIDED TO THE CONTRACTING OFFICER PRIOR TO THE COMMENCEMENT OF SERVICES

UNDER THIS CONTRACT. If the insurance is on a claims made basis and evidence of an extended reporting endorsement (tail) is not provided prior to the commencement of services, evidence of such endorsement will be provided to the Contracting Officer prior to the expiration of this contract. Final payment under this contract will be withheld until evidence of the extended reporting endorsement (tail) is provided to the Contracting Officer.

The policies evidencing required insurance will also contain an endorsement to the effect that any cancellation or material change adversely affecting the Government's interest will not be effective until 30 days after the insurer or the Contractor gives written notice to the Contracting Officer. If during the performance period of the contract the Contractor changes insurance providers, the Contractor will provide evidence that the Government will be indemnified to the limits specified in this Statement of Work. This will be for the entire period of the contract, either under the new policy, or a combination of old and new policies.

THE CONTRACTOR SHALL INSERT THE SUBSTANCE OF THIS CLAUSE, INCLUDING THIS

PARAGRAPH, IN ALL SUBCONTRACTS UNDER THIS CONTRACT FOR HEAL TH CARE

SERVICES AND WILL REQUIRE SUCH SUBCONTRACTORS TO PROVIDE EVIDENCE OF AND

MAINTAIN INSURANCE IN ACCORDANCE WITH THIS CLAUSE.

AT LEAST 5 DAYS BEFORE THE COMMENCEMENT OF WORK BY ANY SUBCONTRACTOR,

THE CONTRACTOR WILL FURNISH TO THE CONTRACTING OFFICER EVIDENCE OF SUCH

INSURANCE.

4.3 Payment for services

The Government reserves the right to accept or reject services if the level of work is unsatisfactory.

A task order will be used to pay for the services rendered. The payment shall be mutually agreed between the Contractor and the Contracting Officer or designated representative. The Contractor shall submit an original timesheet for review and verification to Dental Services. The Contractor shall submit an original invoice to purchase order instructions.

4.3.1 Invoice information requirements:

1. Contractor/Vendor Name

2. Mailing Address

3. Telephone Number

4. TIN (Tax Identification Number)

5. Bank Routing Number (9 digits)

6. Checking or Savings Account Number

7. Purchase Order Number (in Block #3 of the OF-347 form)

8. Invoice Date and Number

9. Description of Services Provided, Quantity, Unit Issue, Unit Price, and Total Amount Due I 0. DUNS Number (Data Universal Number)

Please provide a copy of the invoice to:

Quentin N. Burdick Memorial Healthcare Facility, Indian Health Service ATTN: Property & Supply P.O. 160 Belcourt, ND 58316

Email: Julie.Laducer@ihs.gov COR II Email: Mary.Mckay@ihs.gov Receiving

4.4 Employee Health Requirements:

Quentin N. Burdick Health Care Facility (QNBMHCF) requires contract provider on boarding health information for all job applicants to whom conditional offers of employment have been made in order to evaluate the applicant's health, to protect patients and staff from exposure to communicable diseases. If the job applicant refuses to provide health information, proof of immunizations as recommended by the Centers for Disease Control (CDC) concerning health-care workers in the United States, the refusal is deemed sufficient grounds for Quentin N. Burdick Health Care Service Unit to deny employment.

Information obtained regarding the medical condition or history of the applicant will be collected and maintained on separate forms and in separate medical files in accordance with federal law and will be treated as a confidential medical record.

GUIDELINES

Contract provider onboarding health information must include the following:

Previous immunization history is reviewed by the Employee Health Nurse. QNBMHCF requires all potential caregivers to provide proof of the following immunization records. If the caregiver cannot provide proof appropriate laboratory testing will be ordered.

Hepatitis B (Vaccination-declination required) All QNBMHCF contract providers who perform tasks that may involve exposure to blood or body fluids should receive a 3-dose series of hepatitis B vaccine according to manufacturer recommendations. Test for hepatitis B surface antibody (HBSAB) to document immunity 1-2 months after dose #3. lfHBSAB is positive, the caregiver is immune. No further testing or vaccination is recommended.

For new hires providing proof of previous vaccination: HBSAB testing will be performed. If HBSAB results are > I 0mIU/mL the caregiver is immune and no additional vaccination is required. If the HBSAB is < I 0mIU/mL the care giver should be revaccinated with 3-dose series on an appropriate schedule and serologic testing repeated in 1-2 months. If HBSAB is negative following 6 doses of vaccine, the caregiver is a non-responder.

For non-responder blood exposure: Consult the QNBMHCF Infection Control Plan.

Measles, Mumps, Rubella (MMR)

All QNBMHCF contract providers must be immune to Measles (Rubeola), Mumps and Rubella. For HCP without serologic evidence of immunity to each component of the vaccine or proof of 2 vaccinations, recommend additional doses needed per CDC guidelines.

Varicella All QNBMHCF contract providers must be immune to varicella. Evidence of immunity for the Caregiver includes documentation of2 doses ofvaricella vaccine give per manufacturer recommendation, history of varicella or herpes zoster, laboratory evidence of immunity or laboratory confirmation of disease. Proof of varicella history will be obtained through laboratory testing if no serologic testing is provided at the time of screening.

All QNBMHCF Caregivers between 19-64 years of age ( or per manufacturer recommendation) must receive a I -time dose ofT-dap, with priority given to those having contact with infants younger than age 12 months.

Influenza (Required Vaccination unless approved declination for medical or religious reasons) COVID-19 testing is required

Tuberculosis All potential QNBMHCF contract providers must have a two-step (boosted) TBST or are sent to the Laboratory for QuantiFERON TB-Gold blood assay testing if they…