Draft PWS - Licensed Practical Nurses.pdf

CUI

Department of Defense Defense Health Agency Medical Q-Coded Services (MQS)

Task Order Performance Work Statement

Service: (2) Licensed Practical Nurses

Location: Maxwell Air Force Base, AL

Date: 7/20/2026

PART 1

PERFORMANCE WORK STATEMENT

IN ADDITION TO THE BASIC CONTRACT ACQUISITION PWS, THE

FOLLOWING REQUIREMENTS ARE REQUIRED:

1.2. Description of Services: The service specifies are as follows:

Air Education Training University (AETC) has a requirement for two qualified 2 FTE Licensed Practical Nurses, to provide direct patient care services to officer trainees, cadets and staff members assigned to Officer Training School (OTS) and Reserve Officers’ Training Corps (ROTC). The Contractor shall provide qualified HCWs in accordance with the terms and conditions of the contract and task order issued under the contract.

The services required on this Task Order are in the following market segments:

☐ Physician Services ☐ Dental Services ☒ Ancillary Services ☒ Nursing Services

The services required on this Task Order are under the following special program:

N/A

1.5. General Information:

This Task Order is issued under the following arrangement:

☒Personal Services: The following labor categories are under a personal services arrangement on this TO: 2 FTE Licensed Practical Nurses

☐Non-Personal Services: The following labor categories are under a non-personal services arrangement on this TO:

1.5.4. Quality Assurance: The Government will evaluate the Contractor’s performance under this task order IAW a separate Quality Assurance Surveillance Plan (QASP). This Government-only plan is primarily focused on what the Government will do to ensure that the Contractor has performed IAW contract performance standards. The Task Order QASP provides a systematic method to evaluate performance to include how the performance standards will be applied, the frequency of surveillance, and the acceptable quality levels for each of the metrics identified in Exhibit 1, Performance Requirements Summary. The QASP is created with the premise that the Contractor is responsible for management and quality control actions to meet the terms of the TO while the Government is responsible for quality assurance actions.

1.5.5. Contracting Officer’s Representative (COR): The following individual is designated as the COR for this TO:

Name of COR: MSgt Carla Zuniga-Clark COR E-Mail Address: carla.zuniga_clark@us.af.mil COR Address: 501 Lemay Plaza North, Bldg 1487, Maxwell AFB, AL 36112 COR Telephone Number: 334-953-4017

1.5.6. Recognized Holidays: Contract HCWs ☒will ☐ will not be required to work on some federally recognized holidays. The contractor will be given a comp day in lieu of holidays worked.

The contractor will not provide services during any event on the below Federal Holidays:

New Year’s Day Thanksgiving Day Christmas Day

1.5.7.1. Hours of Performance:

Normal hours of operation are Monday through Friday, during the hours of 7:00 am and 4:00 pm and some weekends as needed, excluding identified federal holidays.

1.5.7.2. Scheduling: The schedule or scheduling process is as follows:

Contract employees will be scheduled by government supervisor/COR to work a shift between the hours of 7:00 am and 4:00 pm, Monday through Friday and occasional weekends with a one hour lunch period. Contractors will not exceed 8 hours per day unless patient care would be compromised/or contract permits. Hours worked beyond the normal duty day must be authorized by the Government Supervisor. Any changes in the schedule shall be coordinated between the HCW and the Government. Any planned absences of the HCW shall be communicated to the Government supervisor in advance of the absence in order to ensure that clinical operations are not adversely affected. The Government reserves the right to change shift hours with a five day notice to accommodate patient care needs and mission requirements.

1.5.7.3. Recording HCW Time: Changes to the recording of HCW time identified in the contract PWS are as follows:

1.5.7.4.3. Substitute HCWs: If the Contractor substitutes permanent HCWs for a temporary period of time, the substitute shall meet the same qualification standards and health requirements as stated in the contract and TO. Substitutions will be required when the permanent HCW is unavailable for more than 20 calendar days. Due to credentialing requirements, substitute should be identified at least 30 days in advance to allow proper time to credential prior to start date as well as obtain systems access required to perform HCW duties. Additional qualification and standards are as follows:

Locum tenens personnel will have all credentials accepted through the 42d Medical Group before any service is performed at Officer Training School (OTS).

1.5.7.5. Closures: During a planned closure of the facility due to training, holiday or unplanned closure due to unusual and compelling circumstances (e.g., natural disasters, military emergencies, severe weather), the Contractor will:

☐be compensated only for the actual hours the HCW provided services ☒ be compensated for the unplanned closure (personal services only)

1.5.8. Place of Performance: The work to be performed under this contract will be at Officer Training School, 501 LeMay Plaza, Bldg 1487A, Maxwell AFB, AL or Vigilant Warrior Expeditionary Skills Training Site, 245 Lakeland Road, Titus, AL 36080.

HCWs shall receive notification two weeks prior to the reassignment to another location with a 40-mile commuting radius of their assigned duty location.

1.5.9. Mission Essential: The following labor categories are designated as mission essential:

Medical support flight

1.5.17. Government Personnel: The Contractor ☐ shall ☒ shall not employ active duty military or government civilian employees to perform services under this contract unless approved by the TOKO on a case-by-case basis.

1.6.1. Quality Control Plan (QCP): The Contractor shall have a planned and systematic QCP that outlines the quality control process covering every aspect of the Contractor’s operation under this TO. The Contractor shall submit a Task Order QCP to the TOKO as outlined in Exhibit 2 of this TO. The TOKO will approve the QCP in writing. The Contractor shall submit changes to an approved QCP to the TOKO for approval throughout the life of the contract.

1.6.3. Periodic Progress Meetings: Contractor ☒ will ☐ will not be required to attend periodic progress meetings at no additional cost to the Government. The terms at which the periodic meeting will be conducted include:

Progress meeting can be scheduled as needed and may be via telecon or in person.

1.6.4.1. Contractor Representative: The Contractor shall submit the Contractor representative contact information and any other key personnel, in writing, to the TOKO as identified in Exhibit 2 to this TO.

1.6.4.2. Representative Status Change: The Contractor shall notify the TOKO in writing of changes in the status (i.e., termination or replacement) of designated Contractor representative within 10 business days of the change.

1.6.6. Contractor Travel: Reimbursement ☐will ☒ will not be provided for travel within a 40-mile radius of the place of performance. HCW travel requirements are as follows:

N/A

Note: For travel outside of the 40-mile radius, the travel shall not be conducted prior to the appropriate funding being obligated.

1.6.7. Relocation Costs: The Government ☐will ☒will not pay the Contractor to relocate HCWs.

1.6.9 Orientation: Orientation will be ☒ paid at the billable rate or ☐ compensated separately.

1.6.9.2. Computer Skill Competency: Each HCW shall demonstrate competency as required in the contract and as follows:

Each HCW shall demonstrate competency as required in the contract and as follows:

Proficient in Microsoft Office software. Able to use various programs, such as Word, Excel, PowerPoint, and Project to generate a range of products (i.e., tables of contents, import graphs or databases, create glossaries, align multiple columns, print document, identify files or make other notations at the top or bottom of each page, and create form letters and automatically merging these with mailing lists). The contract personnel will also be required to independently operate EHRs (i.e. MHS Genesis) and any additional computer system as needed for the performance of their duties within 3 months of being trained

1.6.10. MTF Training: Additional training requirements are as follows:

A four-hour formal training program in the use of the MHS Genesis or other EHR with additional on-the-job training will be provided to the contract provider by the MTF. All contractor personnel shall participate in orientation to their work area and maintain a competency file (which is different from a credentials file) at the worksite (TJC standards). HCW must complete all mandated MTF training.

1.6.12. MTF Standards: Specific policies, procedures, and instructions/regulations for the place of performance are as follows:

The Contractor/HCW shall follow Maxwell Air Force Base security requirements IAW Appendix C of this PWS. AFI 44-119 Medical Quality Operations, AFI 44-102 Medical Care Management, AFI 41-123 Aerospace Medicine Medical Examinations and Standards. Air Force/Air Education Training Command policy letters.

1.6.20 HCW Health Requirements: The Contractor ☒ shall ☐ shall not provide documentation certifying health requirements such as immunizations, annual vaccinations, medical testing (i.e., tuberculosis, N95 particulate respirator duckbill mask fitting) and physical examination when required at the time of initial placement.

1.6.20.3. Occupational Health: The HCW ☒shall ☐shall not be required to obtain documentation of required physical testing or a report of a physical examination.

1.6.20.5. Tuberculosis Screening: The additional immunization/screening requirements for the risk of exposure to tuberculosis (TB) are as follows:

Maxwell Medical Group Medical Employee Health Program Requirements References Air Force Instruction 44-108, Infection Prevention and Control Program, 04 Jun 2019 Air Force Manual 41-210, Tricare Operations and Patient Administration Functions, 09 Sep 2019

MEHP Immunization I Screening Requirement

Presumptive evidence of immunity to measles, mumps and rubella includes any of the following

Measles, Mumps, Rubella (German Measles) NOTE: If a HCW with 2 documented doses of MMR vaccine is tested serologically and determined to have negative or equivocal measles titer results, it is not recommended that the person receive an additional dose of MMR vaccine. Such persons should be considered to have presumptive evidence of measles immunity.

1. Written documentation of vaccination with 2 doses of live measles, mumps, and rubella or MMR vaccine administered at least 28 days apart OR

2. Laboratory evidence of immunity (Positive "Convalescent" Measles, Mumps and Rubella immunoglobulin G (IgG) in the blood; equivocal results should be considered negative) OR

3. Laboratory confirmation in the HCWs record that the HCW had measles, mumps and rubella disease (Positive "Acute" Measles, Mumps, and Rubella immunoglobulin M (IgM) in the blood

OR

4. Birth before 1957 (The majority of persons born before 1957 are likely to have been infected naturally and may be presumed immune)

Tuberculosis (TB) Screening NOTE: HCWs with a baseline positive or newly positive test result from tuberculosis infection (i.e., TST or BAMT) or documentation of treatment for LTBI or TB disease should receive one chest radiograph result to exclude TB disease (or an interpretable copy within a reasonable time frame, such as 6 months).

1. Two-step tuberculin skin test {TST) for M. tuberculosis (BAMT)) that was performed within the previous 12 months

OR

2. An approved blood assays for M tuberculosis (BAMT)) that was performed within the previous 12 months

Varicella (Chicken Pox) All HCWs born after 1966 require proof of varicella immunity. Evidence of immunity includes

1. Written documentation of vaccination with 2 doses of varicella vaccine OR

2. Laboratory evidence of immunity or laboratory confirmation of disease OR

3. Diagnosis or verification of a history of varicella disease by a health-care provider

OR

4. Diagnosis or verification of a history of Herpes Zoster by a health-care provider

Tetanus, Diptheria and Pertussis (Tdap).

All HCWs, regardless of age, will receive a one-time dose of the Combined Tetanus, Diphtheria and Pertussis {Tdap) vaccine if not previously vaccinated.

HCWs will receive Td boosters every 10 years thereafter.

Influenza Immunization against seasonal influenza each year is required unless there is a documented medical contraindication.

Hepatitis B Virus (HBV) Vaccine and Immunity NOTE: All high-risk(1) and exposure-prone(2) HCWs who do not have a protective concentration of antiHBs (>10 miU/mL) after completion of the second vaccination series (i.e., after receiving a total of 6 doses) will be tested for Hepatitis B surface antigen (HBsAg) and Hepatitis B core antibody (anti-HBc) to determine infection status.

Completion of three doses of hepatitis B vaccine and serologic testing for Hepatitis B surface antibody (anti-HBs) within 30-60 days after completion of the three dose vaccination series is required for all HCWs with direct patient care duties.

(1) High-risk personnel: Personnel who have direct contact with patients or blood/body fluids, and are at ongoing risk for injuries with sharp instruments/needle sticks.

(2) Exposure-prone personnel: Medical and dental providers, nurses, and technicians who perform invasive procedures with sharp instruments in a poorly visualized or highly confined anatomic site, as defined by the most current CDC guidelines. All exposure-prone personnel are also high-risk.

1.6.25 Competency-Based HCW Interviews: Prior to HCW placement, the Government ☒will ☐ will not contact the HCW to determine if the HCW meets the requirements set in the contract and/or task order.

PART 2

GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

2. Government Furnished Items and Services:

2.1. General: The following additions are made to the Government furnished items and services for this TO:

OTS will provide computers, standard medical equipment required to perform duties, work area and administrative supplies.

PART 3

CONTRACTOR FURNISHED ITEMS AND SERVICES

3. Contractor Furnished Items and Responsibilities: 3

4.1. Rubber Stamp: The Contractor ☒ will ☐ will not be required to ensure privileged HCWs providing services on this contract have a rubber stamp.

3.2. General: The following Contractor furnished items and services are required for this

TO:

None

PART 4

PERFORMANCE REQUIREMENTS

Labor Category: Licensed Practical Nurse

HCW Qualifications (Contract PWS 5.2; 5.2.3; 5.2.4; 5.2.6.4.4):

• Degree/Education (5.2.4): See Exhibit 5

• Certifications in addition to Basic Life Support (5.2.3): In addition to Exhibit 5, the HCW must maintain current certification in Basic Life Support (BLS) for Healthcare Workers.

• Experience: In addition to Exhibit 5, the HCW shall have a least 24 months of experience as a Licensed Practical Nurse with the last 36 months in the following outpatient clinic settings: Family Medicine, Internal Medicine, or Urgent Care Emergency medicine.

• Board Certification (5.2.6.4.4): See Exhibit 5

• Licensure/Registration: See Exhibit 5

HCW Duties (5.1 Task 1): The duties for the HCW are as follows: In addition to Exhibit 5:

• Section flexibility. Contract personnel may be required to work in other duty sections.

Contract personnel shall be flexible in rotating temporary or permanently moving into other duty sections upon notification of the COR. If moved into a new duty section they will be required to undergo orientation to the new section.

• The contract provider shall assess medical care to assure its quality. All providers shall participate in a continual process of self-evaluation/peer reviews and strive for excellence in the clinic.

• The contract provider shall complete all administrative tasks associated with the clinical position in an accurate and timely manner.

• Provides trainee health support. Conducts medical record screenings and transcription of medical information into EHR. Assists with lab collections. Administers vaccines. Provides medical support for outdoor/field events.

5.1.1. Legal Authorization to Work in the United States: HCWs performing under this contract must be a U.S. Citizen or as defined by the Department of Homeland Security, U. S. Citizenship and Immigration Services, either a noncitizen national of the United State, lawful permanent resident of the United States, or alien authorized to work in the United States. Additional restrictions may be imposed at the Task Order Level.: Nothing

5.2.6. Qualifying/Credentialing Packages: The Contractor shall provide a complete package IAW Appendix A/B of this PWS and AFI 44-119.

The packages needed for this TO are as follows:

5.2.6.2. ☒Qualifying Package: The Contractor shall provide a complete, current, and accurate qualifying package for. 2 FTE Licensed Practical Nurses, within 15 days after TO award.

5.2.6.3. ☐Credentialing Package for Non-Privileged HCWs: The Contractor shall provide a complete, current, and accurate credentialing packages.

5.2.6.4. ☒Credentialing Package for Privileged HCWs: The Contractor shall provide a complete, current, and accurate credentialing package for 2 Licensed Practical Nurses within 30 days after TO award.

Completed packages will contain: (Please save each document separately as a PDF file, refer to the naming convention document for guidance in naming each document.) See Appendix A.

a . Digital Photo in PDF format

b. Verification of Employment- Verify employment from the time of degree earned. Gaps MUST be explained in memo

c. CV-

d. Copy of all Professional License(s), Primary Source Verified

e. Copy of BLS (based on AHA guidelines) or ACLS/PALS

f. Professional Education/Diploma, Primary Source Verified

g. Board Certifications, Primary Source Verified (if required)

h. Verification of all training programs (internship/residencies/fellowships, etc.)

i. CME's for past 3 years. Certificates or list to include title, location, dates, credit category and # of credits) must show that they are actively pursuing CEU's each for each calendar year.

j. Queries: DHHS Sanctions, TRICARE Sanction, FSMB (if MD/DO or PA & provider worked prior to `95) https://exclusions.oig.hhs.gov/ https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Program- Integrity/Sanctioned-Providers

k. Lab/Immunizations Record

5.2.6.4.1. Clinical Competency: Each HCW requesting clinical privileges shall ☒ shall not ☐ be required to demonstrate clinical competency within the past two years in the required clinical discipline as specified in this PWS.

5.2.9. Security Investigative Requirements: The Contractor shall ensure HCWs comply with the following security requirements not already identified in the contract PWS:

5.2.9.1. ☒ HCWs shall be subject to the following additional security investigative processes, to include appointments with Security Managers:

https://exclusions.oig.hhs.gov/ https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Program-Integrity/Sanctioned-Providers https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Program-Integrity/Sanctioned-Providers

OTS Security Manager SSgt Morgan Brett 334-953-9291 morgan.brett@us.af.mil

Security Investigation: As a minimum Contractor personnel shall have a favorably adjudicated Tier 1 background investigation (formerly a NACI), before operating Government-furnished workstations that have access to AF automated information systems. Requests for Contractor personnel hired at the beginning of the contract shall be submitted to the Government not later than 30 workdays from the contract start date.

Requests for Contractor personnel hired subsequent to contract start date shall be submitted to the Government not later than ten (10) workdays from the Contractor personnel’s first duty day. Contractor personnel receiving unfavorable Tier 1 shall not be employed. The Government will submit requests for investigations on AF IMT 2583, Request for Personnel Security Action, at no additional cost to the Contractor. The Contractor shall comply with the requirements of DoDM 5200.02, DAFMAN 16-1405, and AFI 17-130.

5.2.9.4. ☒ HCWs shall be subject to the following security processes for fingerprints:

The fingerprints are part of the Tier 1 security investigation process.

5.2.9.5. ☒The HCW shall complete either a ☒SF-85 or an ☐SF-86 Questionnaire for National Security Positions (or equivalent OPM investigative product)

5.3.1. Initial Placement: The Contractor shall provide the appropriate qualifying or credentialing package as required in the TO, the Contractor shall be given 30 calendar days from the CLIN start date to place non-credentialed HCWs and 60 calendar days from the CLIN start date to place privileged and non-privileged credentialed HCWs.

Unless otherwise established in the ensure HCWs begin performance as follows:

Once the documentation is received, the company will be provided reporting instructions and a contract employee start date. The company shall fill the positions as follows.

a.) Non-credentialed Contractor Personnel. The non-credentialed contractor personnel shall physically start work no later than 30 calendar days from the initial start date on the period of performance.

b.) Credentialed Contractor Personnel. The credentialed contractor personnel shall physically start work no later than 60 calendar days from the initial start date on the period of performance.

The contractor shall submit complete and accurate credentialing packages no later than 30 calendar days from the initial date on the period of performance.

5.4.3.2. Malpractice Insurance for Non-Personal Services: The Contractor and all subcontractors shall ☐shall not ☒ meet the requirements of FAR Clause 52.237‑7, Indemnification and Medical Liability Insurance, for its HCWs, in the following amounts for the entire performance period of the TO:

As further identified in Attachment B/C, Malpractice Insurance Certification Form in the proposal

5.4.4. Schedule Management: The TO will establish the work schedule and billable hours for each HCW. The Contractor shall maintain a process to monitor work and billable hours on the TO. When directed by the Government, the HCW shall remain on duty to complete patient treatment where lack of continuity of care would otherwise jeopardize patient health. This provision is not intended to apply to the time required to complete routine tasks (e.g., completion of paperwork or routine administrative tasks at the end of a shift) which are to be completed as part of the normal work schedule.

5.4.4.1. Schedule Management for Personal Services: The work schedule for each labor category is as follows:

Labor Category: Licensed Practical Nurse

Work Schedule: 7:00am to 4:00pm, Monday – Friday occasional Saturdays with a 1 hour lunch period. Contract employee's will not to exceed 8 hours per day unless directed by the Government Supervisor to complete patient treatment where lack of continuity of care would otherwise jeopardize patient health.

Duty Hours: 7:00am to 4:00pm

On-Call Hours: N/A

Overage Hours: N/A

5.4.4.1 Call-Back Hours: HCWs ☐ will ☒ will not be required to report in-person to the IDMT clinic during on-call hours if needed. The number if call-back hours and timeframe is as follows:

5.4.4.2. Schedule Management for Non-Personal Services: Hours of service and roster submission requirements are as follows:

N/A

5.4.4.4. On-Call Hours: On-call requirements for each labor category are as follows:

N/A

5.4.4.5. Overage Hours: Overage hours* for each labor category are as follows:

N/A

* Note, overage hours are often used by the Contractor to pay overtime pay to their employees.

5.5.3. Scope of Work: HCWs ☒will ☐will not be able to bill the Government for participation in administrative functions (i.e., orientation, quality improvement programs, clinical/administrative data collection, meetings, and training). Specific tasks associated with administrative duties beyond the tasks outlined in the contract PWS include:

Contract employees will be allowed to participate in outreach events and morale events with the approval of the Squadron Commander. Attendance at these events will not be considered billable hours, unless deemed an alternate duty location by the MTF Commander.

5.5.5. Billing for Services: The Contractor will only be paid for the actual hours the HCW provides services with the following exception for personal services HCWs:

When alternate duty location is directed by the Contracting Officer or Squadron Commander/ COR.

5.6.1. Task 6 – Reports. The minimum level of metrics maintained at the Task Order level include HCW overall fill rate, on-time fill percentage, turnover rate, and replenish rate. Acceptable Quality Levels (AQLs) on these metrics are set in Exhibit 1, PRS in this TO. The minimum values for AQLs on Task Order metrics are set as follows:

Overall Fill Rate: > 80% On-Time Fill Percentage: > 80% Turnover Rate: <100% Replenish Rate: > 80%

The minimum level of metrics will be calculated as follows:

5.6.1.1. Overall Fill Rate: The overall fill rate is the percentage of the total amount of required FTE-weighted days (i.e., purchased) filled in a reporting period. The overall fill rate is calculated by dividing the sum of FTE-weighted days HCWs fill a position in a reporting period by the total number of required FTE-weighted days in the same reporting period.

5.6.1.2. On-Time Fill Percentage: Percentage of FTEs filled by the required start date during the reporting period. The on-time fill percentage is calculated by dividing the number of initial and replacement FTEs assigned with a required start date in a reporting period filled on time by the total number of initial and replacement FTEs assigned with a required start date in the same reporting period.

5.6.1.3. Turnover Rate: The number of FTEs that turned over during a reporting period.

The turnover rate is calculated by dividing the number of assigned FTEs turned over in a reporting period (for any reason unless the TOKO informs the PMO not to count the turnover) by the total number of assigned FTEs in the same reporting period. Turnovers occurring less than 30 calendar days before the end of the TO will not be counted as a turnover for this metric.

5.6.1.4. Replenish Rate: The replenish rate is a measure of how well assigned positions remain filled in a reporting period. The replenish rate is calculated by dividing the sum of FTE-weighted assigned HCW days in a reporting period by the sum of FTE-weighted days available subsequent to initial HCW assignment start dates in the same reporting period.

5.6.1.5. Additional Metrics: Additional metrics, to include customer satisfaction, complaint resolution percentage or local metric, on this Task Order ☐ are ☒ are not identified in Exhibit 1, PRS.

PART 5

OTHER TERMS, CONDITIONS, AND PROVISIONS

5.4.4 Health Insurance Portability and Accountability Act (HIPAA): Additional or supplemental instructions unique to HIPAA for this TO are as follows:

Any and all HIPPA violations by an HCW will be reviewed by the MTF COR and the CO.

The violation and corrective actions can result in actions not limited to retraining of the individual that is responsible to on the spot removal from the MTF and MAFB.

PART 6

APPLICABLE PUBLICATIONS

6.1 Publications: In addition to the publications listed in the contract, the Contractor shall abide by the following applicable regulations, publications or manuals:

Local MTF regulations, publications and manuals apply

PART 7

ATTACHMENTS/EXHIBIT

EXHIBIT 1

PERFORMANCE REQUIREMENTS SUMMARY (PRS)

The following performance outcome acceptable quality levels (AQLs) for minimum quality levels of service are required on this TO:

Performance Objective Reference Performance Objective Method of

Surveillance AQL

Overall Fill Rate 5.1: Recruit HCWs

Percentage of days FTEs are assigned to a positon in a reporting period

Government Managed Oversight 80%

On-Time Fill Percentage

5.3: Place HCWs

Percentage of FTEs filled by the required start date in the TO during the reporting period

Government Managed Oversight 80%

Turnover Rate 5.3.2: Replace HCWs

The number of FTEs that turned over during a reporting period

Government Managed Oversight 100%

Replenish Rate 5.2: HCW Qualifications

The measure of how well assigned positions remain filled in a reporting period

Government Managed Oversight 80%

ADDITIONAL METRICS

Performance

Objective Reference Performance Objective Method of Surveillance AQL

Customer Satisfaction Rate

5.5.1: Manage HCWs

The aggregate rating on a 7-point scale as reported by CORs in a reporting period

Government management oversight;

95%

Complaint Resolution Percentage

5.5.6: Resolve Performance Issues

The percentage of discrepancy notices resolved on time in a reporting period

Government management oversight;

100%

EXHIBIT 2

DELIVERABLES SCHEDULE

Deliverable Frequency # of Copies Medium/Format Submit To

Key Personnel List NLT 10 business days of TO award

1 Electronic copy (MS Word) via email

TOKO/COR

Initial Placement of HCWs:

Qualifying Documentation (i.e., qualifying package;

credentialing package)

NLT 15/30 days after the TO award 1 PDF email

Maxwell MDG Credentialing Office/COR

Replacement of HCWs:

Qualifying documentation (i.e., qualifying package;

credentialing package)

NLT 20 days after vacancy occurs for non-credentialed HCWs; NLT 20 days after vacancy for credentialed HCWs

1 PDF email

Maxwell MDG Credentialing Office/COR

Quality Control Plan Within 30 days of TO award 1 PDF email TOKO/COR

Security Investigative Package

NLT 30 days before the required start date of the HCW

1 PDF email OTS Security Manager/COR

Appendix A

42D MEDICAL GROUP CREDENTIALING PROCEDURES

For Contracting Agencies

All required credentialing forms can be obtained from: MAXWELL MEDICAL GROUP

CREDENTIALS OFFICE / SGHC

300 S. Twining St. Bldg. 760

MAXWELL AFB, AL 36112

loretta.wood@us.af.mil

THE PROVIDER MAY NOT REPORT TO THE MTF UNTIL

ALL CLINICAL PRIVILEGES DOCUMENTS ARE RECEIVED

PLEASE CAREFULLY READ ALL INSTRUCTIONS ON ALL FORMS. IF ANY

PART OF THE APPLICATION PACKAGE IS INCOMPLETE OR MISSING,

THE ENTIRE PACKAGE WILL BE RETURNED FOR PROPER

COMPLETION.

PLEASE SAVE EACH DOCUMENT SEPERATELY AS A PDF FILE, REFER TO

THE NAMING CONVENTION DOCUMENT FOR GUIDANCE IN NAMING EACH

DOCUEMENT.

PROVIDER:

1. Read, complete and return the following:

AF Form 1540 (typed or legible) Application for Clinical Privileges/Medical Staff Appointment

AF Form 1562, Credentials Evaluation of Health Care Practitioners (2 Forms are Required) These references are used to document CURRENT clinical competency and are completed by individuals who have knowledge of the applicant’s clinical performance within a year.

Bylaws (AFI44-119): Please ask provider to read at http://www.e-publishing.af.mil

2. JCCQAS Application for Clinical Privileges/Medical Staff Appointment. Complete Section I through XVI and sign. Please use MM/DD/YYYY format for all dates. In Section VII, please ensure that ALL facilities where you have EVER been granted privileges since qualifying degree are listed. In Section V, please ensure ALL licenses EVER HELD are listed.

3. Clinical Privilege Requested Section XII. Review and complete the privileges list for your specialty by placing a # 1, 2, or 4 in the requested column, according to the instructions at the top of the form. DO NOT use “x’s” check marks or initials!!! Also DO NOT use a code 3. Place your signature in the “Application Signature” space.

4. AF Form 1562. Sign and date the top section of each of the AF Forms 1562, (2 Forms are Required).

These will be sent to the individuals you list as references on your application Section IX.

5. Provide copies of the following documents if needed for your credentials folder (any training certificates, licenses, etc. listed on your application must be presented before privileges will be awarded):

Current BLS and, if required for your specialty, ACLS, PALS, ATLS, NRP certification.

DEA certificate, (Must comply with State license requirements) If applicable Photo ID CME's for the past 3 years or a list of CME’s.

NPI # (can print page from https://nppes.cms.hhs.gov website) Need to update to primary practice address. If applicable

THE CONTRACT COMPANY MUST EMAIL THE ITEMS ABOVE AND THE FOLLOWING

ITEMS:

*** All Verification documents MUST explain what is being verified and how verification was obtained Written, Telephone, Internet; Name of Agency contacted; Name and Title of the person providing verification; Phone #; Date & Time; If verified by internet the website address must be on the verification document.

mailto:loretta.wood@us.af.mil http://www.e-publishing.af.mil/ https://nppes.cms.hhs.gov/

Verification of Employment- Most recent 10 years to include Gaps. Gaps MUST be explained.

Verification of ALL facilities where the provider has EVER been granted privileges (since qualifying degree) A WRITTEN/FAXED verification is PREFERRED. ***See above for guidance.

A List of privileges from EACH facility where privileges are currently held. If no privileges are currently held, then list of privileges from most recent facility (during past year). A memo for record if NO privileges were held for each facility.

Verification of ALL licenses EVER held Verification of Board Certification(s) Verification of Professional Education Verification of all training programs (internship/residencies/fellowships, etc.)

Proof of malpractice insurance and claims history verification for the past 10 years.

AF Form 1562 – REFERENCES - Two are required - Completed by (Clinical Supervisor, Chief

Medical Staff or Peer) The two references will need to be listed on the JCCQAS Application for Clinical Privileges Section IX. Additionally, the two references must be credentialed providers (i.e. Physicians, Nurse Practitioner or Psychologist.) These references are used to document CURRENT clinical competency and are completed by individuals who have knowledge of the applicant’s clinical performance within a year.

Queries of: FSMB (if MD/DO or PA & provider worked prior to ‘95);

Inspection General Sanctions; Tricare Sanctions

19 April 2018

SECURITY REQUIREMENTS FOR UNCLASSIFIED SERVICES

CAC Required

1. Contractor Notification Responsibilities: The contractor shall notify the contracting office within 30 days before on-base performance of the service. The notification shall include:

a. Name, address, and telephone number of contractor representatives.

b. The contract number and contracting agency.

c. The location(s) of service performance and future performance, if known.

d. The date service performance begins.

e. Any change to information previously provided under this paragraph.

2. Antiterrorism: The contractor, all employees and any subcontractors are required to obey all orders from Security Forces personnel and are subject to spot checks/inspections while on the installation. The contractor, all employees and any subcontractors must adhere to all security measures implemented by the installation as a result of directed Force Protection Condition (FPCON) measures, currently Maxwell AFB and Gunter Annex are in FPCON Bravo.

The contractor, all employees and any subcontractors are expected to report any suspicious activities to the Security Forces Squadron (334-953-7222). Suspicious activities can be defined as suspicious packages or items observed, personnel conducting surveillance of the installation, unauthorized personnel requesting access to the installation, or personnel asking a lot of questions about the installation.

The contractor, all employees and any subcontractors should be aware of the Emergency Mass Warning (EMW) notification system. In the event of an incident on the installation the EMW system may be activated, and all personnel must follow all directions given via this system. To familiarize personnel with antiterrorism, the contractor, all employees and any subcontractors are required to complete Force Protection training annually and report their completion to their Unit Training Managers. This training can be found at the following link: https://usaf.percipio.com/linked-contents/e883913a-0321-40d6-980f-b9fdc207fd15/landing or https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf. If there are any questions or concerns regarding antiterrorism matters regarding Maxwell AFB or Gunter Annex contact the Installation Antiterrorism Program Manager at 334-953-9057.

3. REAL ID Act: All Maxwell Air Force Base and Gunter Annex visitors must present a REAL ID-compliant credential to be issued a pass.

REAL ID-compliant cards have a star marking ⭐on the upper portion of the card. If the card does not have a star marking, it is not REAL ID-compliant and won’t be accepted as https://usaf.percipio.com/linked-contents/e883913a-0321-40d6-980f-b9fdc207fd15/landing https://usaf.percipio.com/linked-contents/e883913a-0321-40d6-980f-b9fdc207fd15/landing https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf proof of identity to board commercial aircraft or access military installations like Maxwell or Gunter.

Those without a REAL ID-compliant driver’s license may also use a U.S. passport or passport card, a Transportation Worker Identification Card (TWIC), a Veteran Health Identification Card (VHIC), or a combination of the following documents to be issued a pass:

• An original or certified true copy of a birth certificate with a raised seal

• A social security card

• A driver’s license issued by a state, territory, or the District of Columbia that is not REAL ID-compliant.

All three documents must reflect the same name (or a documented former name through legal name change documents such as a court order, marriage certificate, or divorce decree).

More information about accessing Maxwell can be found here: https://www.maxwell.af.mil/About-Us/Fact-Sheets/Display/Article/4024201/base-access-information/

4. Obtaining and Retrieving Identification Media: As prescribed by FAR 52.204-9, Personal Identity Verification of Contractor Personnel, DoDI 5200.46, DoD Investigative and Adjudicative Guidance for Issuing the Common Access Card and DoDM 1000.13, DoD Identification (ID) Cards, ID Card Life-Cycle, the contractor must comply with the requirements set forth in these guidance.

a. The contractor shall obtain base identification, and vehicle passes, if required, for all contractor personnel who make frequent visits to or perform work on the Department of the Air Force installation(s) cited in the contract. Contractor personnel are required to wear or prominently display installation identification badges or contractor-furnished contractor identification badges while visiting or performing work on the installation.

b. The contractor shall submit a written request on company letterhead to the contracting officer listing the following: contract number, location of work site, start and stop dates, and names of employees and subcontractor employees needing access to the base. The letter will also specify the individual(s) authorized to sign a request for base identification credentials or vehicle passes. The contracting officer will endorse the request and forward it to the issuing base pass and registration office or Security Forces for processing. When reporting to the registration office, the authorized contractor individual(s) should provide a valid driver’s license, current vehicle registration, valid vehicle insurance certificate, and obtain a vehicle pass.

c. Common Access Cards (CACs). Contractors shall provide a listing of personnel who require a CAC to the contracting officer. The government will provide the contractor instruction on how to complete the Mission Partner Identity, Credential, and Access Management (MP ICAM) application and then notify the contractor when approved.

Contractor personnel shall obtain a CAC from the nearest Real Time Automated Personnel Identification Documentation System (RAPIDS) Issuing Facility (typically the local Military Personnel Flight (MPF)). While visiting or performing work on installation(s)/ location(s), contractor personnel shall wear or prominently display the CAC as required by the governing local policy. In order to be issued a CAC, the contractor must meet the requirements:

• A favorably adjudicated National Agency Check with Inquiries (NACI) (now a Tier 1 or T1 background investigation) or equivalent in accordance with revised Federal Investigative Standards is the minimum background investigation required for a final credentialing determination for a CAC.

• A CAC may be issued on an interim basis based on a favorable National Agency Check or a Federal Bureau of Investigation (FBI) National Criminal History Check (fingerprint check) adjudicated by appropriate approved automated procedures or by a trained Security or Human Resources (HR) specialist, and successful submission to the investigative service provider (ISP) of a NACI or a personnel security investigation (PSI) equal or greater in scope.

If the contractor does not meet the minimal criteria for CAC issuance, the COR will work with the unit security assistant and 42 ABW/IP office to initiate the process on behalf of the contractor.

d. During performance of the service, within seven (7) working days of any changes to the listing of the contract personnel authorized a CAC, provide an updated listing to the contracting officer who will provide the updated listing to the authorizing government official. Return CACs in accordance with local policy/directives within seven (7) working days of a change in status for contractor personnel who no longer require logical or physical access.

e. When work under this contract requires unescorted entry to controlled or restricted areas, the contractor shall comply with DAFI 31-101, Integrated Defense, and DoD 5200.02_DAFMAN 16-1405, Air Force Personnel Security Program.

f. Upon completion of the contract, termination of the contract, or expiration of the identification passes/CAC, the prime contractor shall ensure that all base identification passes/CACs issued to employees and subcontractor employees are returned to the contracting official representative or the issuing office within seven (7) working days.

Contractor shall report any lost or stolen CACs.

http://static.e-publishing.af.mil/production/1/af_a4_7/publication/afi31-501/afi31-501.pdf http://static.e-publishing.af.mil/production/1/af_a4_7/publication/afi31-501/afi31-501.pdf

g. All commercial vehicles will be directed to Gate 3 (Kelly St) or Gate 4 (Congressman Dickenson for Gunter) for processing through the Commercial Vehicle Inspection (CVI) Area, when operational. During non-duty hours and holidays, commercial vehicle inspections will be conducted at Gate 1 (Maxwell Blvd) or Gate 4 only. Inspection members will conduct thorough inspections of the interior and exterior of the vehicle for items prohibited from the installation such as explosive devices, weapons and ammunition, drugs, and open or closed alcohol containers.

h. Failure to comply with these requirements may result in withholding of final payment.

5. Visit Request: Ensure an initial and annual Visit Request (VAR) has been submitted for all contractors performing unclassified duties as part of this contract via company letterhead to 42 ABW/IP Office (42ABW.IP.Workflow@us.af.mil). If the company doesn’t have the ability to encrypt this information, they can contact 42 ABW/IP Office who will provide them with a secure method to transmit via DoD SAFE. The VAR shall include the contract number, dates, work location, each contractor employee's full name, date of birth, social security number, and be signed by company Key Management Personnel (KMP). The VAR will also indicate for each contractor if they require a common access card (CAC) or a DBIDS identification card. This information will be used to assist in the vetting and monitoring process for contractors who require a CAC.

The VAR shall be updated any time there is a personnel change (added/removed) from the contract.

6. Computer and Network Access Requirements: Contractor personnel that require access to unclassified government computers and operations systems Information Technology (IT) Systems will be designated as Non-sensitive Positions. Contractor personnel must have a Tier 1 and the Tier 1 be favorability adjudicated before operating government furnished computer workstations or systems that have access to Air Force e-mail systems. These investigations shall be submitted by the government at no additional cost to the contractor. NOTE: Since the background investigation process can take up to 18 months, contractor personnel may be issued a CAC before the process is completed after a favorable fingerprint return (3-5 working days) and investigation package submitted to the investigative service provider and the investigation is scheduled.

The servicing Information Protection Office (IPO) is responsible for submitting Tier 3 and Tier 5 investigations for contractor personnel in positions designated as “national security positions” but without a requirement for access to classified information. The servicing IPO will submit these investigation requests based on contract requirements, which will be validated through the Office of Personnel Management’s Position Designation Tool (PDT). These investigations shall be submitted by the Government at no additional cost to the Contractor. The Contractor shall comply with DoDM 5200.02_DAFMAN 16-1405, Air Force Personnel Security Program; and AFI 10-701, Operations Security (OPSEC) instructions, OUSD(I) Memorandum, Clarification of Clearance Requirements for Access to Investigative and Adjudicative Relevant Data, 27 mailto:42ABW.IP.Workflow@us.af.mil

Jun 2019, and DoDI 5200.46, DoD Investigative and Adjudicative Guidance for Issuing the Common Access Card, and Homeland Security Presidential Directive-12 (HSPD-12) requirements.

Contractor personnel that require access to the Air Force network will complete the current DoD IAA CyberAwareness Challenge course located in the Department of the Air Force (DAF) e-Learning or https://public.cyber.mil/training/cyber-awareness-challenge/.

7. Freedom of Information Act Program (FOIA): The contractor shall comply with DODM 5400.07_AFMAN 33-302, DoD Freedom of Information Act (FOIA) Program, requirements. The regulation sets policy and procedures for the disclosure of records to the public. The contractor shall comply with AFI 33-332, Air Force Privacy and Civil Liberties Program, when collecting and maintaining information protected by the Privacy Act of 1974 authorized by Title 10, United States Code, section 8013. The contractor shall maintain records in AFI 33-322, Records Management and Information Governance Program; and disposed of in accordance with Air Force Records Information Management System (AFRIMS) Records Disposition Schedule (RDS) located at https://www.my.af.mil/gcss-af61a/afrims/afrims/.

8. Controlled Unclassified Information (CUI): The contractor shall comply with DoDI 5200.48_DAFI 16-1403, Controlled Unclassified Information, DoDM 5200.01v1_DAFMAN 16-1404v1, Information Security Program, and Freedom of Information Act Program. The contractor shall monitor CUI aggregation and compilation based on the potential to generate classified information pursuant to security classification guidance addressing the accumulation of unclassified data or information.

All CUI associated with this contract must be safeguarded to prevent unauthorized public disclosure. CUI such as PII, Security Classification Guides (SCG), and other technical information with Distribution Statements B, C, D, E or F are not authorized for public release and cannot be placed on a publicly accessible web site or web server. All emails containing such information or attachments must be appropriately marked, and digitally signed and encrypted if being transmitted. All transmissions to personal email accounts (AOL, Yahoo, Hotmail, Comcast, etc.) and posting on social media websites (Facebook, Instagram, Twitter, LinkedIn, etc.) are prohibited. Destroy all CUI associated with this contract by any of the following approved methods: A cross-cut shredder (that produce 1mm x 5mm or 0.04in x 0.2in particles or smaller); a certified commercial destruction vendor; a central destruction facility; incineration; chemical decomposition; pulverizing, disintegration (pulverize or disintegrate with a 3/32in or 2.4mm security screen); or methods approved for classified destruction.

General: There are types of information that are not classified but require application of access and distribution controls and protective measures developed for DoD Controlled Unclassified Information for a variety of reasons. The types of CUI identified for the program are identified in DODI 5200.48 and have replaced legacy formats such as For Official Use Only (FOUO), Law Enforcement Sensitive (LES), as well as some of those https://public.cyber.mil/training/cyber-awareness-challenge/ https://public.cyber.mil/training/cyber-awareness-challenge/ https://www.my.af.mil/gcss-af61a/afrims/afrims/ developed by other Executive Branch agencies of the U.S. Government and technical data described below as well as protective measures for CUI material.

Formats such as FOUO, LES, et al. are legacy formats no longer in use but are protected as if they have CUI markings. Protections and restrictions can be found in DoDI 5200.48, CUI 06 March 2020.

Technical Data Description: Any recorded information related to experimental, developmental, or engineering works that can be used to define an engineering or manufacturing process, or can be used to design, procure, produce, support, maintain, operate, repair, or overhaul program material.