Draft Performance Work Statement - Nurse Practitioner.pdf

Performance Work Statement (PWS)

Service: Nurse Practitioner

Location: Maxwell Air Force Base, AL

Date: 4/2/2025

PART 1

PERFORMANCE WORK STATEMENT

1.0. Description of Services: The services needs are as follows:

Officer Training School (OTS) has a requirement for a qualified 1 Full-Time Nurse Practitioner, 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 Health Care Workers (HWC) in accordance with the terms and conditions of the contract.

The services required are in the following market segments:

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

1.1. General Information:

This Contract is issued under the following arrangement:

☒Personal Services: The following labor categories are under a personal services arrangement: 1 Full Time Employee (FTE) Nurse Practitioner

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

1.2. Quality Assurance: The Government shall evaluate the Contractor’s performance under this contract in accordance with (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 in accordance with (IAW) contract performance standards. The QASP provides a systematic method to evaluate performance to include how the performance standards shall 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 shall be responsible for management and quality control actions to meet the terms of the contract and PWS while the Government is responsible for quality assurance actions.

1.3. Contracting Officer (KO): The following individual is designated as the KO for this Contract:

Name of KO: William Stallings KO E-Mail Address: william.stallings.1@us.af.mil KO Address: 50 S. Lemay Plaza South, Maxwell AFB, AL 36112 KO Telephone Number: 334-953-3266

1.4. Contracting Officer’s Representative (COR): The following individual is designated as the COR:

Name of COR: TBD COR E-Mail Address:

COR Address: Click here to enter email address of the COR COR Telephone

1.5. 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

1.6. Hours of Performance:

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

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

Contract employees shall be scheduled by government supervisor/COR to work a shift between the hours of 7:00 am and 4:00 pm, Monday through Friday with a one-hour lunch period. Contractors shall 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 14 calendar days 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.

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

1.6.3. 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. Substitutions shall 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: None

1.6.4. 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 shall:

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

1.7. Place of Performance: The work to be performed under this contract shall 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.

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

None

1.9. 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 CO on a case-by-case basis.

2.0. 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. The Contractor shall submit a QCP to the COR as outlined in Exhibit 2 of this PWS. The COR will approve the QCP in writing. The Contractor shall submit changes to an approved QCP to the COR for approval throughout the life of the contract.

2.1. 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:

Telecon or in person.

2.2. Contractor Representative: The Contractor shall submit the Contractor representative contact information and any other key personnel, in writing, to the CO and COR as identified in Exhibit 2 to this PWS.

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

2.3. 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.

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

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

2.4. Computer Skill Competency: Each HCW shall demonstrate competency as required 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 Electronic Health Records (EHR) (i.e. Military Health System Genesis (MHS Gensis), Aeromedical Services Information Management System (ASIMS) and any additional computer system as needed for the performance of their duties within 3 months of being trained

2.5. Military Treatment Facility (MTF) Training: Additional training requirements are as follows:

An eight-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 (The Joint Commission (TJC) standards). HCW must complete all mandated MTF training.

2.5.1. 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, DAFMAN 48-123 Medical Examinations and Standards. Air Force/Air Education Training Command policy letters.

2.5.2 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.

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

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

42d Medical Group Medical Employee Health Program Requirements References Air Force Instruction 44-108, Infection Prevention and Control Program, 05 Jun 2019 DAFMAN 41-210, Tricare Operations and Patient Administration Functions, 30 Jan

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.

PART 3

GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

3. Government Furnished Items and Services:

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

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

PART 4

CONTRACTOR FURNISHED ITEMS AND SERVICES

4. 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. Rubber stamp shall display name and National Provider Identifier (NPI) number.

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

None

PART 5

PERFORMANCE REQUIREMENTS

5.1 Labor Category: Nurse Practitioner

5.1.1 HCW Qualifications:

5.1.1.1 Degree/Education: See Appendix A

5.1.1.2 Certifications in addition to Basic Life Support: In addition to Appendix A, the HCW must maintain current certification in Basic Life Support (BLS) for Healthcare Workers.

5.1.1.3 Experience: In addition to Appendix A, the HCW shall have a least 24 months of experience as a Nurse Practitioner with the last 36 months in the following outpatient clinic settings: Family Medicine, Internal Medicine, or Urgent Care Emergency medicine.

5.1.1.4 Board Certification: See Appendix A

5.1.1.5 Licensure/Registration: See Appendix A

5.1.2 HCW Duties: The duties for the HCW are as follows:

• 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 shall 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. Develops policies and procedures and prepares directives governing communicable disease, illness and injuries, preventive medicine, and occupational medicine. Serves as liaison with federal, state, and local agencies in matters related to preventive medicine and occupational medicine. Determines recommendations on waivers of medical standards. Develops programs for medical support of contingency operations.

• Advises medical staff. Provides medical advice and guidance to bioenvironmental engineering, military public health, physiological training, and others.

5.1.2.1 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 Contract Level.: Nothing

5.1.2.2. Qualifying/Credentialing Packages: The Contractor shall provide a complete package IAW Appendix A of this PWS and AFI 44-119 Clinical Performance Improvement Chapter 3 – Licensure, Certification, and/or Registration of Healthcare Personnel.

The packages needed for this contract are as follows:

5.2. ☒Qualifying Package: The Contractor shall provide a complete, current, and accurate qualifying package for 1 FTE Nurse Practitioner, within 15 days after contract award.

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

5.2.2. ☒Credentialing Package for Privileged HCWs: The Contractor shall provide a complete, current, and accurate credentialing package for Nurse Practitioner 30 days after contract award.

Completed packages shall 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.

5.2.3. AF Form 1540 and Joint Centralized Credentials Quality Assurance System (JCCQAS) Application for Clinical Privileges and Medial Staff Appointment. (Included on application) 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. DO NOT use a code 3. Code 3 is for facility use only. Place your signature in the “Provider Signature” space.

5.2.4. Two AF Form 1562's. Credentials Evaluation of health Care Practitioners (from two references must be credentialed providers, i.e. Physicians, Nurse Practitioner or Psychologist).

References must be current within 1 year and must be reference on the AF Form 1540/JCCQAS Application for Clinical Privileges and Medial Staff Appointment. Or a form/letter with comparable information will be accepted.

5.2.5. Digital Photo in PDF format

5.2.6. Current Drug Enforcement Agency (DEA) certificate, if applicable. Verification of DEA

5.2.7. National Provider Identifier (NPI) number (can print page from https://nppes.cms.hhs.gov website.)

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

5.2.9. Curriculum Vitae (CV)

5.2.10. Provide privileges held from each facility. A memo for record if NO privileges were held for each facility.

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

5.2.12. Copy of National Certification(s), Primary Source Verified

5.2.13. Copy of Basic Life Support (BLS) (based on AHA guidelines) or ACLS/PALS 5.2.l4. Professional Education/Diploma, Primary Source Verified

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

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

5.2.17. Continued Medical Education (CME) 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.

5.2.18. Certificates of insurance for at least past 10 years or a list of insurance companies/addresses

5.2.19. Queries: Department of Health and Human Services (DHHS) Sanctions, TRICARE Sanction, Federation of State Medical Boards (FSMB) (if Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO) or Physician’s Assistant (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

5.2.20. Lab/Immunizations Record

5.2.21. Verification of malpractice insurance and claims history for the past 10 years.

5.3. 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.

5.4. Drug Enforcement Agency (DEA) Registration: Requirements for DEA registration numbers must meet their state’s license requirements. Click here to enter the labor categories or type N/A if not applicable

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

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

OTS Security Manager TBD

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.

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

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

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

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

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

5.7. 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 contract:

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

5.8. Schedule Management: The COR shall establish the work schedule and billable hours for each HCW. The Contractor shall maintain a process to monitor work and billable hours on the COR. 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.

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

Labor Category: Nurse Practitioner

Work Schedule: 7:00am to 4:00pm, Monday – Friday with a 1-hour lunch period.

Contract employee's shall 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

5.8.2 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:

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

N/A

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

N/A

5.8.5. 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.

5.9. 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 shall 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.

5.10. Billing for Services: The Contractor shall 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.

5.11. 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, Performance Requirement Summary (PRS) in this contract. 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 shall be calculated as follows:

5.12. 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.

5.13. 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.

5.14. 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 COR 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 contract will not be counted as a turnover for this metric.

5.15. 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.

5.16. 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 6

OTHER TERMS, CONDITIONS, AND PROVISIONS

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

Any and all HIPPA violations by an HCW shall 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 7

APPLICABLE PUBLICATIONS

7. 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 8

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 contract:

Performance Objective Reference Performance Objective Method of

Surveillance AQL

Overall Fill Rate 5.12: Recruit HCWs

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

Government Managed Oversight 80%

On-Time Fill Percentage

5.13: Place HCWs

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

Government Managed Oversight 80%

Turnover Rate 5.14: 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%

EXHIBIT 2

DELIVERABLES SCHEDULE

Deliverable Frequency # of Copies Medium/Format Submit To

Key Personnel List NLT 10 business days of award

1 Electronic copy (MS Word) via email

CO/COR

Initial Placement of HCWs:

Qualifying Documentation (i.e., qualifying package;

credentialing package)

NLT 15/30 days after the award 1 PDF email

42 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

42 MDG

Credentialing Office/COR

Quality Control Plan Within 30 days of award 1 PDF email CO/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: TBD

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) 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.

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.

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.

http://www.e-publishing.af.mil/ https://nppes.cms.hhs.gov/

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. Obtaining and Retrieving Identification Media: As prescribed by the DAFFAR

5352.242-9000, Contractor access to Air Force installations, DAFFAR 5352.242-9001, Common Access Cards (CAC) for Contractor Personnel, 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 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 for 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 to obtain a vehicle pass. Government ID card holders may not use their credentials to sponsor an individual on to the base to perform work that’s been contracted to an official contractor.

c. Common Access Cards (CACs). For contractors who require a CAC, 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 Trusted Associate Sponsorship Systems (TASS) 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, the contractor shall be responsible for obtaining required identification for newly assigned personnel and for prompt return of credentials for any employee who no longer requires access to the work site.

e. When work under this contract requires unescorted entry to controlled or restricted areas, the contractor shall comply with DoDM 5200.08v3_DAFMAN 31-101v3, Installation Perimeter Access Control, and DoD 5200.02_AFMAN 16-1405, Air Force Personnel Security Program.

f. Upon completion or termination of the contract or expiration of the identification passes, the prime contractor shall ensure that all base identification passes issued to employees and subcontractor employees are returned to the issuing office.

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.

http://static.e-publishing.af.mil/production/1/af_a4_7/publication/afi31-101/releasibility_for_afi31-101.pdf http://static.e-publishing.af.mil/production/1/af_a4_7/publication/afi31-501/afi31-501.pdf

3. Computer and Network Access Requirements: Contractor personnel that required access to unclassified government computers and operations systems Information Technology (IT) Systems will be designated as Nonsensitive 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. Contractor personnel will complete the current DoD IAA CyberAwareness Challenge course.

4. 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/.

5. Controlled Unclassified Information (CUI): The contractor shall comply with DoDI

5200.48_DAFI 16-1403, Controlled Unclassified Information, DoDM 5200.01v1_AFMAN 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.

6. Reporting Requirements: The contractor shall comply with DAFI 71-101, Volume-1, Criminal Investigations, and Volume-2, Protective Service Matters, requirements.

Contractor personnel shall report to 42 Air Base Wing Information Protection Office, any information or circumstances of which they are aware may pose a threat to the security of DoD personnel, contractor personnel, resources, and classified or unclassified defense information. Contractor employees shall be briefed by their immediate supervisor upon initial on-base assignment and as required thereafter.

7. Physical Security: Areas controlled by contractor employees shall comply with base operations plans/instructions for FPCON procedures, Random Antiterrorism Measures (RAMS) and local search/identification requirements. The contractor shall safeguard all government property, including controlled forms, provided for https://www.my.af.mil/gcss-af61a/afrims/afrims/ https://www.my.af.mil/gcss-af61a/afrims/afrims/ contractor use. At the close of each work period, government training equipment, ground aerospace vehicles, facilities, support equipment, and other valuable materials shall be secured.

8. Internal Operating Instructions: The contractor will adhere to the Air Force activity operating instructions (OI) for internal circulation control, protection of resources, and to regulate entry into Air Force controlled areas during normal, simulated, and actual emergency operations.

9. Traffic Laws: The contractor and their employees shall comply with base traffic regulations set forth in DAFI 31-218, Motor Vehicle Traffic Supervision and DoDM 5200.08v3_AFMAN 31-101v3, Installation Perimeter Access Control.

Personnel in violation may be issued a Central Violations Bureau Form 1805 traffic ticket.

10. Random Installation Entry/Exit Checks: Entry/exit vehicle checks are conducted by order of the 42 ABW Commander. These checks are conducted for the purpose of safeguarding the base and protecting government property by discovering and seizing stolen property, classified information and contraband. Refusal to submit to an installation (entry/exit) vehicle check may result in the loss of base driving privileges, revocation of base registration, or debarment action.

11. Cellular Phone Operation Policy: The use of cellular phones while operating a motorized vehicle is prohibited on Maxwell-Gunter. Although discouraged, drivers are authorized to use devices, i.e. ear bud or ear boom, which allows their cellular phone to be operated hands-free. The device must not cover both ears.

This policy applies to everyone driving on Maxwell-Gunter AFB. Personnel in violation may be issued a Central Violations Bureau Form 1805 traffic ticket.

12. Security Education and Training: The contractor will be required to participate in the government’s in-house and web-based security training program under the terms of the contract.

13. Operation Security (OPSEC): The contractor will comply with installation and organizational OPSEC requirements in accordance with AFI 10-701 and applicable supplements. They will also receive a local threat briefing.

14. Wireless Electronic Devices: The contractor will not establish their own Information

Technology (IT) systems or networks (Local Area Networks [LAN], Wide Area Network [WAN], Cellular phone/USB Modem as WAN, Wi-Fi as WAN, etc.), or camera system without the direct permission of the Program Manager and governing communications and responsible information systems office (42 CS).

15. Firearms and Ammunition: Transporting weapons or ammunition, concealed or otherwise, IS NOT permitted by any non-law enforcement personnel on Maxwell

AFB/Gunter Annex at any time regardless of state issued concealed weapons permits. Violations may result in criminal prosecution under the applicable federal laws.

16. Illegal Weapons. The below weapons are considered illegal, unless specifically authorized by competent authority, and are prohibited on Maxwell

AFB/Gunter Annex. Violations may result in criminal prosecution under the applicable federal laws.

a. Switchblade knives or knives with any type of automatic blade release.

b. An incendiary/explosive weapon (e.g., grenades, flash bangs).

c. Fireworks

d. Homemade mortars, aka "tennis ball launchers" or similar devices.