PWS_16C0002_Hospital_Admin.docx

Performance-Based Work Statement (PWS) For Hospital Administration Service, Misawa Air Base, Japan

35 MDSS/SGSM

26 May 2015 Attachment 1, Performance-Based Work Statement (PWS) Contract No. FA5205-16-C-0002

TABLE OF CONTENTS

Para # Title Page #

1. DESCRIPTION OF SERVICES/GENERAL INFORMATION. This is a non-personal service. The contractor shall provide administrative services to ensure performance of daily functions associated with patient appointing, patient records management, consult tracking and any other administrative task assigned by the Medical Treatment Facility (MTF) officer/designee. The contractor shall not introduce services other than those included herein without prior recommendation to, and approval of, the Contracting Officer (CO).

1.1. ADMINISTRATIVE TASKS. The Contractor shall perform tasks listed in sections 1.1.1.-

1.1.12. Performance shall meet or exceed established standards that include, but are not limited to: timeliness, legibility, content, format, security and protection of patient identifying information. The contractor shall provide Administrative Services to any department or section to include: 1) Tricare Operations and Patient Administration, 2) Resource Management Office, 3) Front Desk Operations sections or patient check-in counters, 4) Urgent Care Clinic, 5) Appointment Line, 6) Commander’s Support, 7) Public Health, 8) Family Health Clinic, 9) Mental Health, 10) Pediatrics, 11) Flight Medicine, 12) Optometry, 13) Physical Therapy, 14) Orthopedics, 15) secretary sections, 16) Dental, or

17) Surgical Services. All departments or sections are limited to the following 35 MDG locations: Bldgs. 99 and 96, Misawa Air Base, Japan. The COR will coordinate with the Contractor on the location of contractor services. Tasks required at each (type of) department/section are as tabulated below:

Table 1 – Required Tasks at Departments/Sections

Section

General Clinic Windows: 1)Tricare Operations & Patient Admin, 3)Front Desk / Patient check-in Counters, 4)UCC, 7)Public Health, 8)Family Health Clinic, 9)Mental Health, 10)Pediatrics, 11)Flight Medicine, 12)Optometry, 13)Physical Therapy, 14)Orthopedics, 16)Dental, 17)Surgical Services

X

X

X

X

6)Commander’s Support

15)Secretary

1.1.1. General Information Management. The contractor is required to schedule and reschedule appointments within the Access to Care (ATC) categories per Air Force Instruction (AFI) 44-176, Access To Care Continuum. This and all other AFIs listed in this PWS can be found at www.e- publishing.af.mil. Administrative duties also include greeting patients and appropriately routing and screening phone calls. Verifies patients are registered in Composite Health Care Systems (CHCS) and Defense Eligibility and Enrollment Registration (DEERS). Assists with patient check in/out duties, performs end-of-day CHCS processing, completes clinic Ambulatory Data Management (ADM) functions, and coordinates patient related correspondence. Contractor is responsible to update demographic information. Orders, tracks, picks up, and delivers forms to customers.

1.1.2. Appointment Facilitation. The contractor is required to schedule appointments, locate medical records and ensure appropriate documents are available prior to all patient visits. Prints diagnostic reports and/or treatment profiles as necessary; participates with Primary Care Manager (PCM) teams to complete Preventive Health Assessment (PHA) tasking, i.e. routing charts for record reviews, initiating Department of Defense (DD) Forms 2766, Standard Form (SF) 507, AF1042, DD2766C, DD2766, DD2795, DD2796, DD2900, Pre Deployment Checklist, Post Deployment Checklist, Travel Med Checklist, AF 250, Exercise & C+20 Checklist. All forms listed in this PWS can be found at www.e- publishing.af.mil.

1.1.3. Referral Management. The contractor will receive medical provider referrals and ensure demographic information is accurate and complete; track referrals to include obtaining reports from network providers as needed. Attaches supplementary documentation (i.e. lab results) to referrals as requested. Coordinates all referral appointments. Manage clinical phone consult requests from patients. Disseminates referral instruction/handouts to beneficiaries with assistance of Government team members. Receives and routes evaluation/consultation reports to providers.

1.1.4. Medical Record Management. Medical record management and functions will be in strict accordance to higher headquarter guidance and or AFI 41-210, TRICARE Operations and Patient Administration. In the case of inconsistency Higher Headquarter guidance takes precedence. The contractor is must keep up general medical record by ensuring all forms are appropriately completed and filed, third party insurance information (DD Form 2569) and documentation is current and in the chart. This may include sensitive duty paperwork. Updates and validates CHCS/DEERS and other electronic healthcare databases. Retrieves, receives, and stores medical records. Processes requests for records and paperwork. Performs in and out-processing, audits, retirement actions, and copies medical records as required. Conducts research on loose documents, annotates and files accordingly. Researches records for appropriate MTF ownership and mails accordingly. All records, files, and documents provided by the government remain government property. The government section supervisor will provide guidance to the contract personnel who shall maintain and dispose of these records, files, and documents.

1.1.5. General Clinic Processing. The contractor will modify provider schedules and communicate schedule changes. Use current and department specific appointment booking protocols to schedule patient appointments. Coordinate with sensitive duty program monitor(s) as applicable. Perform Medical Expense and Performance Reporting System (MEPRS) monitor and Defense Medical Human Resource System-internet (DMHRSi) duties in accordance with AFI 41-102, Medical Expense and Performance Reporting System (MEPRS) for Fixed Military Medical and Dental Treatment Facilities. Retrieve, compile, and analyze data from a variety of sources. Assist in notification of patient duty absences (quarters/convalescent leave, etc.). Coordinates with the Medical Evaluation Board (MEB) clerk on MEB patients. Coordinates Aeromedical Evacuation as assigned. Assists with patient check in/out duties. Performs CHCS end-of-day processing and coordinates with PCMs until completion. Completes clinic Ambulatory Data Module (ADM) functions. Coordinates patient related correspondence. Validates coding of ADM encounters.

1.1.6. Documentation. Performs necessary paperwork such as general correspondence and committee minutes, and schedules and de-conflicts appointments. Schedules annual dental and physical exams for MDG active duty personnel. Tracks suspense. Proofreads/edits correspondence and documents for correct grammar, spelling, capitalization, punctuation, and format in accordance with Air Force Handbook 33-337, The Tongue and Quill. Returns incorrect material prepared by others with revisions marked.

1.1.7. Screen phone calls and visitors. Receives telephone calls, takes messages, greets visitors, and ascertains the nature of the call and visit.

1.1.8. Mail distribution. Sorts and distributes all 35 MDG incoming mail to appropriate departments. Delivers 35 MDG outgoing mail to the processing center and picks up incoming mail for 35 MDG. Processes accountable mail and secures until owner signs for receipt.

1.1.9. Drug control inventory. Sends out notifications to 35 MDG personnel detailed to conduct controlled drug inventory and tracks until completion. AFI 44-102, Medical Care Management, Section 8F Drug Inventory (8.9 Drug Inventory pg. 67/ 8.10 Controlled Drug Inventory Process pg. 69).

1.1.10. Record Management. Monitors the 35 MDG records management program, AFI 33-332, Record Management Program, pg. 11-14 # 7, 8, 9 ensuring compliance with Air Force directives. Serves as Records Custodian as assigned.

1.1.11. Personnel Record Management. Files paperwork in Personnel Information Files (PIFs). Updates and requests 35 MDG personnel information (i.e. decoration RIPS, duty titles change, reports, etc.). Distributes Weighted Airman Promotion System (WAPS) notifications. Review enlisted/officer performance reports and decorations. Sends out notifications regarding the Selective Reenlistment Program. Processes Temporary Duty (TDY), Environmental Morale Leave (EML), and Emergency Leave orders. Route and review with the management of all military and civilian evaluations and decorations within the group. Tracks and reports progress and ensures timely submission within the group, to the wing and Military Personnel Flight (MPF).

1.1.12. Customer Service. Performs routine customer service activities in a polite, professional and courteous manner. Greets patients and verifies patient identity and eligibility. Checks in patients for scheduled visits. Obtains/verifies third party insurance information. Identifies patients assigned to sensitive duty program. Verifies and updates patient demographics. Determines if visit is accident or injury-related and documents accordingly. Provides patient with required paperwork and clinic instructions and manages patient flow. Schedules follow-up appointments as required. Tracks, or assists with tracking, diagnostic results and route to appropriate health care provider. Requests and check in/out patient records. Generates provider rosters. Adds patients to wait list and modifies wait list requests.

1.2. QUALITY ASSURANCE. The Government will evaluate the contractor’s performance by appointing a Contracting Officer’s Representative (COR) to monitor performance and ensure services are received. The CORs will evaluate the contractor’s performance using a variety of means to include customer complaints, staff complaints and periodic inspection. Complaints will be evaluated by the COR for potential inclusion in the monthly surveillance. Complaints validated by the COR shall be reported in writing to the contract administrator and the contractor for action. Failure of the contractor to correct validated complaints raised by the Military Treatment Facility (MTF) staff or patients will be considered a deficiency.

1.2.1. Performance Evaluation Meetings. The CO shall require the contractor or representative to meet with the CO, contract administrator, COR and other government personnel. The contractor may request a meeting with the CO. Meetings will be documented in the contract file with written minutes signed by the CO. Should the Contractor not concur with the minutes, such non-concurrence shall be provided in writing to the CO within ten (10) calendar days of receipt of the minutes.

1.3. GOVERNMENT REMEDIES. If nonconforming services are identified, the COR shall promptly notify the contractor for correction. The contractor shall take corrective action in a timely manner at no additional cost to the government. If the contractor does not correct deficiencies within 5 duty days, the COR should report in writing to the CO. The contractor may refer to the CO for any disagreement with the COR observations. The CO shall follow the requirements of Federal Acquisition Regulation (FAR) 52.212-4, Contract Terms and Conditions for Commercial Items, for contractor’s failure to correct nonconforming services.

1.4. HOURS OF OPERATION. 35 MDG provides services 24 hours per day, seven (7) days per week. The allowable hours the contractor can perform are Monday - Friday, 0730-1630. Contractor is not required to perform on Saturday, Sunday, and the following U.S. federal holidays:

· New Year's Day 1st of January

· Martin Luther King's Birthday 3rd Monday of January

NOTE: Any of the above holidays falling on a Saturday will be observed on the preceding Friday; holidays falling on a Sunday will be observed on the following Monday. The Government may add additional family days in conjunction with these holidays which may result in MTF closures.

1.5. WORK SECTION COVERAGE In case of absences or illness, the contractor shall meet administration services with personnel of equal qualifications, appropriate CAC access, and healthcare- specific privacy training.

Unscheduled absences: For unscheduled absences projected to miss three (3) or fewer consecutive work days, replacement coverage is not required. For an unscheduled absence projected to exceed three (3) consecutive days, coverage shall be dispatched within one (1) duty day per section. Unscheduled absence is not to exceed three days per month per section. The COR and section supervisor must be notified of any lapse in contract coverage and the anticipated length as soon as possible.

Scheduled absences: For scheduled absences greater than three (3) days, coverage shall be dispatched immediately. The COR and section supervisor shall be notified within fourteen (14) days in advance of scheduled absence.

1.6. SECURITY REQUIREMENTS

1.6.1. Criminal Background Check. The Government will conduct a criminal history background check on the contractor personnel. Contractor personnel receiving unfavorable criminal background check status shall not perform the work under this contract.

1.6.2. National Agency Checks with Inquiries (NACI). The completion of a FBI fingerprint check with favorable results and submission of a National Agency Check with Inquiries to the Office of Personnel Management (OPM), or a DoD determined equivalent investigation is required for all contractor employees performing services under this contract and requiring access to Government computer systems. The government shall perform the security investigations on the contractor personnel in accordance with DoD 5200.2-R, Personal Security Program and AFI 33-119, Electronic Mail Management and Use. The contractor shall submit a request for NACI to the designated government

Attachment 1, Performance-Based Work Statement (PWS) Contract No. FA5205-16-C-0002 official (the Unit Security Manager) within five (5) working days from the contractor personnel’s first duty day. The contractor personnel receiving unfavorable NACI status shall not perform the work under this contract.

1.6.3. Installation Security Notice To Employees. The Government reserves the right to restrict employment under this contract of any contractor personnel, who are identified as a potential threat to the health, safety, security, general well-being, or operational mission of the installation and its population. The contractor shall inform all assigned workers that they may be subject to search, at the discretion of the installation commander, when entering or leaving the installation.

1.6.4. Random Antiterrorism Measures (RAMs). RAMS are conducted on Misawa Air Base at varying times during a 24-hour period and may consist of measures such as spot checks of identification credentials, random vehicle searches, and site security sweeps. The contractor is subject to participating and cooperating with RAMS as directed by competent authority. Anticipate increased RAMS during implementation of elevated Force Protection Conditions (FPCONs).

1.6.5. Reporting Suspicious Activity. It is the responsibility of all personnel working and residing on Misawa Air Base to be alert for detecting and reporting suspicious criminal or terrorist activity. The contractor shall immediately report any on-base observed suspicious activity to the 35 SFS/BDOC, Bldg. 646. All contractor-employed personnel shall be familiar with suspicious activity reporting numbers and procedures. The primary number for reporting suspicious activity on Misawa Air Base is 911from a base phone or 0176-53-1911 from a mobile phone or off-base.

1.6.6. Base Access. Prior to start of work, the contractor personnel shall submit 5 AF Form 99, Applications for Base Passes to 35th Contracting Squadron, Building 656, for employees requiring base access to perform the work. The contractor personnel shall submit 35 FW Form 54, Application for Vehicle and copies of vehicle inspection certificate, for all the vehicles requiring base access to perform the work. Upon completion of this contract, the contractor personnel shall return all passes to the Visitor Control Section, 35 SFS/SFAP, Bldg. 301, and obtain a certification of receipt. Final payment will be withheld until the contractor personnel have accomplished the required clearances.

1.6.7. Vehicle Insurance: When contractor’s owned vehicles are being operated on Misawa Air Base,

1.6.7.1. The contractor shall procure and maintain during the entire period of his/her performance under this contract, the following minimum vehicle insurance: Property Damage - ¥2,000,000

1.6.7.2. Prior to the commencement of work hereunder, the contractor shall furnish to the Contracting Officer a certificate or written statement of the above required insurance. The contractor is required to notify the Contracting Officer immediately upon cancellation or of any material change in the policies adversely affecting the interests of the Government.

1.6.7.3. The contractor agrees to insert the substance of this clause including this paragraph 1.6.7.3., in all subcontracts hereunder.

1.6.8. CounterIntelligence Awareness and Reporting (CIAR). The contractor will comply with DoDD 5240.06, Counterintelligence Awareness and Reporting (CIAR) to include initial and annual CIAR training on the foreign intelligence entity (FIE) threat, methods, reportable information, and reporting procedures for all contract employees with access to the Air Force network and/or classified/sensitive information. The training requirement shall be satisfied through completion of the Force Protection training module from the Advanced Distributed Learning Service (ADLS) website at https://golearn.csd.disa.mil.

1.7. PERFORMANCE OF SERVICES DURING CRISIS DECLARED BY THE NATIONAL COMMAND AUTHORITY OR OVERSEAS COMBATANT COMMANDER. This service contract is not classified as “mission-essential” during a crisis as declared by the National Command Authority or Overseas Combatant Commander. In the event of such a crisis, the CO or the COR will direct the contractor personnel to discontinue the service due to base closure. Until such a notification, the contractor personnel are required to continue the performance.

1.8. SPECIAL REQUIREMENTS.

1.8.1. The Joint Commission (TJC). The contractor personnel shall meet all the applicable TJC standards during the contract performance. TJC standards can be referenced at the following website: http://www.jointcommission.org/Standards/FAQs/

1.8.2 Physical Security. The contractor personnel shall be responsible for safeguarding all medical information provided for contractor personnel use. At the close of each work period, all information shall be secured.

1.8.3 Key Control. The contractor shall establish and implement methods of ensuring that all keys and badges issued to the contractor by the government are not lost or misplaced and are not used by unauthorized persons. The contractor shall report lost keys and badges to the Government. The contractor shall not duplicate any keys.

1.8.4 Base Computer Network Access. Contractor personnel are required to have access to the government LAN. The government and the contractor personnel shall follow the requirements in AFFARS 5352.242-9001 - Common Access Cards for Contractor Personnel (Nov 2012), to obtain CAC(s) for contractor personnel.

1.9. CONTRACTOR PERSONNEL.

1.9.1. Conflict of Interest. The contractor personnel shall not be any person who is an employee of the Department of the Air Force, either military or civilian, unless such person seeks and receives approval in accordance with DOD Directive 5500.7-R, Joint Ethics Regulation. The contractor personnel shall not employ persons for the work of this contract if such employment would create a conflict of interest per AFI 64-106, Air Force Industrial Labor Relations Activities.

1.9.2. Contract Manager (CM). The contractor shall provide a CM who shall be responsible for the daily attendance of contractor personnel. The CM shall be available in person or via telephone Monday through Friday, 0730 until 1630 excluding federal holidays. An alternate may be designated, but the Contractor shall identify those times when the alternate shall be the primary point of contact. The Contractor shall designate this individual, in writing, to the Contracting Officer (CO) before the contract start date.

1.9.3. Appearance. The contractor personnel shall present a neat appearance, well groomed, clean image and be dressed in appropriate workplace attire (business casual). All tops (shirts and blouses) must cover the top of the shoulder and cover the torso with no holes or cut-outs. Jeans, t-shirts, low cut necklines, and footwear such as flip flops, sneakers, and sandals are not appropriate for business casual attire. The COR and the section supervisor retain the authority to ask the contractor to change if attire is distracting or offensive to staff or patients. The contractor personnel must be easily recognizable as a contractor personnel and not a government employee. Contractor work stations will be neat and have a professional appearance. There will be no use of personal electronic devices directly in the contractor’s work sections. All devices are only used in designated break rooms.

1.9.4. Identification. The contractor personnel shall be recognized as contractor personnel and shall wear an appropriate name tag or distinctive clothing. The name tag shall be provided by the 35th Medical Group and shall contain the company name, employee name, and read “contractor personnel.” In addition, email addresses for contractor personnel will identify them as a “contractor personnel.”

1.9.5. Professional Environment. The contractor will promote an environment that is in compliance with DOD and Air Force directives prohibiting unlawful discrimination and sexual harassment. This environment will be free from personal, social, or institutional barriers based on race, color, religion, sex, or national origin. The contractor will report any suspected problems to the Chief Medical Administrator (SGA) or the Medical Support Squadron's chain of command for review and investigation. The contractor shall refrain from the use of profanity, sexual or racial jokes, or other behavior that would normally be considered unprofessional in a medical setting.

1.10. QUALIFICATIONS.

1.10.1. ENGLISH LANGUAGE REQUIREMENT. Personnel shall read, understand, speak, and write English to at least a STEP (Eiken) 2nd grade, TOEIC score 519 or TOEFL score 456 level or higher. If personnel’s primary language is English, no certification is required.

1.10.2. HIGH SCHOOL DIPLOMA OR GENERAL EDUCATIONAL DEVELOPMENT (GED) EQUIVALENCY.

1.10.3. EXPERTISE. The personnel performing this duty will be knowledgeable in general medical ethics, health records administration, telephone etiquette, office management methods, excellent communications and customer service skills, strong organizational background and computer operations to include Windows Operating Systems, spreadsheet, database, and word processing applications. Personnel shall also be knowledgeable in computer operations to include Windows Operating Systems and Microsoft Office applications. Personnel must understand the importance of deadlines.

1.11. MEDICAL SERVICES. The following vaccinations are mandatory IAW AFI 44-108, Infection Prevention and Control Program. The government will offer them at no cost to the contractor upon contract award:

· Hepatitis B Vaccination Series

· Tuberculosis Skin Test (TST) or documentation of appropriate TB test within 12 months

· Human Immunodeficiency Virus (HIV) Test, every 2 years

· Measles, Mumps, Rubella/Rubeola (MMR) Vaccination or proof of immunity by titer screening

· Varicella Vaccination or proof of immunity by titer screening

· Tetanus/Diphtheria/Pertussis (Tdap) and booster Td booster every 10 years

· Influenza, annual and IAW DoD policy and annual AF/SG seasonal influenza memorandum.

2. SERVICES SUMMARY.

The contract service requirements are summarized in performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimally acceptable levels of service required for each requirement. These thresholds are critical to mission success. Procedures as set forth in the FAR 52.212-4(a), Contract Terms and Conditions – Commercial Items, Inspection/Acceptance, will be used to remedy all deficiencies.

Para.

Contractor performance meets or exceeds established standards with administrative services.

1.1.1. - 1.1.12.

No more than 2 deficiencies or COR- validated customer complaints per month in any one of Administrative Tasks category (para. 1.1.1.

thru 1.1.12).

Contractor appearance shall be neat and clean and professional behavior must be used at all times.

1.9.2. - 1.9.5.

Contractor provides continuous and reliable work as scheduled.

1.4.- 1.5.

Contractor performance Meets all Joint Commission and HIPAA Security Compliance.

1.8.1. & Appen- dix A

3. GOVERNMENT PROVIDED PROPERTY AND SERVICES.

3.1. EQUIPMENT. The government will provide hospital identification badges to access areas of operation and to other parts of the MTF as required for the performance of services. A desk, chair, workspace, computer and computer equipment, necessary software, required network access and connectivity, telephone, fax, reproduction services, office supplies, and parking on a shared basis. The contractor shall be responsible for any damage to the Government Furnished Materials (GFM) or equipment when “caused by contractor.”

3.1.1. Contractor-Owned/Contractor Operated Equipment. Except for items or services specifically stated here to be Government provided, the contractor shall furnish everything else required to perform this contract in accordance with this PWS.

3.1.1.1. Initial Inspection. All contractor-owned equipment shall be inspected and approved by the biomedical equipment maintenance section prior to use in the facility to ensure the equipment is safe for use and that it meets facility electrical standards. This includes but is not limited to personal items such as coffee makers and radios.

3.1.1.2. Replacement Of Contractor-Owned/Operated Equipment. If, based on diagnostic testing and established industry standards, any contractor-owned/operated equipment is deemed unsafe by biomedical equipment maintenance section personnel, it shall be tagged as unserviceable and removed from use. Replacement of any equipment such removed shall be at contractor expense.

3.2. COMPUTER SYSTEMS. The government will provide the contractor personnel access to the computer programs required to perform the tasks to include AHLTA, CHCS, TRICARE Online, ADS, Secure Messaging, Referral Management and electronic healthcare record software/applications, and general desktop settings. IAW AFFARS 5352.242-9001, Common Access Cards (CACs) For Contractor Personnel (Nov 2012), CAC will be issued to the contractor personnel.

3.3. FACILITIES. The Government will provide use of all available MTF facilities and support services, materials, publications and forms and equipment required for contract performance (except as designated in the contract). Contract personnel shall keep government furnished supplies, equipment, and work areas in safe, orderly and clean condition. Contract personnel shall notify the Government whenever maintenance of equipment is required.

3.4. WORK AREA/SPACE. Any space used by contract personnel in performance of this contract may be used for other purposes during their absence. Items of clothing, personal effects, or equipment may not be able to be secured. The government will not incur any liability for theft, damage, or loss of such personal items.

3.5. TELEPHONE. The Government will provide defense switching network (DSN) lines limited to matters related to performance of this contract. Personal long distance calls are not authorized and the cost of all personal calls made will be deducted from the Contractor’s invoice.

3.6. UTILITIES. Electricity, water, sewage, and heat shall be furnished by the Government, at no cost to the contractor for their use in the performance of this contract.

3.7. SECURITY FORCES AND FIRE PROTECTION. The Government shall provide these services.

· Security Forces phone number: 911

· Fire Department’s phone number: 911

3.8. MISAWA AIR BASE FIRE PREVENTION. The contractor shall be responsible for fire prevention in all contracted area, and be free from any potential fire hazards. The contractor shall comply with the following fire prevention guidance

3.8.1. Fire Reporting: 1) The primary emergency reporting number on Misawa Air Base is 911 or 0176-53-1911 from off base. Fire Department operations take place out of Bldg. 947 and 3003 for main base, and Bldg. 1940 for the north housing area. 2) On-base telephones if any, in the on-base warehouse(s) shall have “911” stickers. 3) All contractor-employed personnel shall be familiar with fire reporting numbers and procedures, and shall to put the number “0176-53-1911” into his/or her mobile- phone.

3.8.2. Vehicles: 1) Access for fire fighting vehicles must be maintained at all working sites. 2) Contractor’s vehicles shall not be parked within 15 feet of any fire hydrant of Fire Department connection. 3) Contractor’s vehicles shall give the right-of-way to responding fire/emergency vehicles.

3.8.3. Electrical Hazards: 1) All the contractor’s electrical tools and equipment shall be in good (original) working condition and its maintenance shall be done properly in compliance with manufacturer’s maintenance instructions. 2) All extension cords used shall be equipped with circuit breakers and plugged directly in the outlets (not other extension cords). 3) Building utility panels shall not be blocked by contractor tools/supplies.

3.8.4. Storage: 1) Flammable liquids shall not to be stored inside the warehouses, next to the buildings, or near exit ways. 2) Fire protection system shall not be obstructed at any time. Carpet storage shall be neat in a manner which does not present fire/safety hazards and not to block the access to where fire-extinguishers are mounted.”

3.9. TRAININGS. The contractor shall comply with and attend local 35 MDG Government- provided training which will include, but is not limited to, topics such as Compliance, Patient Safety, Newcomers Orientation, Force Protection, Performance Improvement, Risk Management, Infection Control, Fire Protection, Security, Patient Sensitivity, Automation Processing, and local in-service briefings. The classes may be scheduled individually throughout the year or scheduled at one time. This local training will count toward the 40 hour per week requirement. .

4. APPLICABLE PUBLICATIONS AND FORMS. Publications and forms applicable to the performance work statement (PWS) are listed below. The contractor is obligated to follow those publications. Publications are available in the MTF and are maintained by the 35 MDG. Supplements or amendments to the below listed publications may be issued during the life of the contract. The contractor shall immediately implement those changes in publications which result in no change in the price of the contract and notify the CO in writing as such. Should the government determine a decrease in contract price results from such a change, the CO shall require a proposal for reduction in the contract price. For any changes that the contractor determines should result in an increase to the price of the contract, the contractor shall notify the CO and submit a price proposal justifying the increase. This new price proposal shall be submitted to the CO within 30 days of receipt of the changes by the contractor. Failure of the contractor to submit a price proposal to the CO within 30 days from receipt of any changes shall entitle the Government to performance in accordance with such changes at no increase in contract price.

4.1. DEPARTMENT OF DEFENSE (DOD) REGULATIONS/MANUALS INSTRUCTIONS/ DIRECTIVES

4.2. AIR FORCE INSTRUCTIONS

4.3. OTHER REFERENCES

APPENDIX A

HIPAA Compliance. Introduction

In accordance with 45 CFR 164.502(e)(2) and 164.504(e) and paragraph C.3.4.1.3 of DoD 6025.18-R, “DoD Health Information Privacy Regulation,” January 24, 2003, this document serves as a business associate agreement (BAA) between the signatory parties for purposes of the Health Insurance Portability and Accountability Act (HIPAA) and the “HITECH Act” amendments thereof, as implemented by the HIPAA Rules and DoD HIPAA Issuances (both defined below). The parties are a DoD Military Health System (MHS) component, acting as a HIPAA covered entity, and a DoD contractor, acting as a HIPAA business associate. The HIPAA Rules require BAAs between covered entities and business associates. Implementing this BAA requirement, the applicable DoD HIPAA Issuance (DoD 6025.18-R, paragraph C3.4.1.3) provides that requirements applicable to business associates must be incorporated (or incorporated by reference) into the contract or agreement between the parties.

(a) Catchall Definition. Except as provided otherwise in this BAA, the following terms used in this BAA shall have the same meaning as those terms in the DoD HIPAA Rules: Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices (NoPP), Protected Health Information (PHI), Required By Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use.

Breach means actual or possible loss of control, unauthorized disclosure of or unauthorized access to PHI or other PII (which may include, but is not limited to PHI), where persons other than authorized users gain access or potential access to such information for any purpose other than authorized purposes, where one or more individuals will be adversely affected. The foregoing definition is based on the definition of breach in DoD Privacy Act Issuances as defined herein.

Business Associate shall generally have the same meaning as the term “business associate” in the DoD HIPAA Issuances, and in reference to this BAA, shall mean Hospital Administration Service Contractor.

Agreement means this BAA together with the documents and/or other arrangements under which the Business Associate signatory performs services involving access to PHI on behalf of the MHS component signatory to this BAA.

Covered Entity shall generally have the same meaning as the term “covered entity” in the DoD HIPAA Issuances, and in reference to this BAA, shall mean 35th Medical Group.

DHA Privacy Office means the DHA Privacy and Civil Liberties Office. The DHA Privacy Office Director is the HIPAA Privacy and Security Officer for DHA, including the National Capital Region Medical Directorate (NCRMD).

DoD HIPAA Issuances means the DoD issuances implementing the HIPAA Rules in the DoD Military Health System (MHS). These issuances are DoD 6025.18-R (2003), DoDI 6025.18 (2009), and DoD 8580.02-R (2007).

DoD Privacy Act Issuances means the DoD issuances implementing the Privacy Act, which are DoDD 5400.11 (2007) and DoD 5400.11-R (2007).

HHS Breach means a breach that satisfies the HIPAA Breach Rule definition of breach in 45 CFR 164.402.

HIPAA Rules means, collectively, the HIPAA Privacy, Security, Breach and Enforcement Rules, issued by the U.S. Department of Health and Human Services (HHS) and codified at 45 CFR Part 160 and Part 164, Subpart E (Privacy), Subpart C (Security), Subpart D (Breach) and Part 160, Subparts C-D (Enforcement), as amended by the 2013 modifications to those Rules, implementing the “HITECH Act” provisions of Pub. L. 111-5. See 78 FR 5566-5702 (Jan. 25, 2013) (with corrections at 78 FR 32464 (June 7, 2013)). Additional HIPAA rules regarding electronic transactions and code sets (45 CFR Part 162) are not addressed in this BAA and are not included in the term HIPAA Rules.

Service-Level Privacy Office means one or more offices within the military services (Army, Navy, or Air Force) with oversight authority over Privacy Act and/or HIPAA privacy compliance.

I. Obligations and Activities of Business Associate

(a) The Business Associate shall not use or disclose PHI other than as permitted or required by this Agreement or as required by law.

(b) The Business Associate shall use appropriate safeguards, and comply with the DoD HIPAA Rules with respect to electronic PHI, to prevent use or disclosure of PHI other than as provided for by this Agreement.

(c) The Business Associate shall report to Covered Entity any Breach of which it becomes aware, and shall proceed with breach response steps as required by Part V of this BAA. With respect to electronic PHI, the Business Associate shall also respond to any security incident of which it becomes aware in accordance with any Information Assurance provisions of this Agreement. If at any point the Business Associate becomes aware that a security incident involves a Breach, the Business Associate shall immediately initiate breach response as required by part V of this BAA.

(d) In accordance with 45 CFR 164.502(e)(1)(ii)) and 164.308(b)(2), respectively, and corresponding DoD HIPAA Issuances, as applicable, the Business Associate shall ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to the Business Associate with respect to such PHI.

(e) The Business Associate shall make available PHI in a Designated Record Set, to the Covered Entity or, as directed by the Covered Entity, to an Individual, as necessary to satisfy the Covered Entity obligations under 45 CFR 164.524 and corresponding DoD HIPAA Issuances.

(f) The Business Associate shall make any amendment(s) to PHI in a Designated Record Set as directed or agreed to by the Covered Entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy Covered Entity’s obligations under 45 CFR 164.526, and corresponding DoD HIPAA Issuances.

(g) The Business Associate shall maintain and make available the information required to provide an accounting of disclosures to the Covered Entity or an individual as necessary to satisfy the Covered Entity’s obligations under 45 CFR 164.528 and corresponding DoD HIPAA Issuances.

(h) To the extent the Business Associate is to carry out one or more of Covered Entity's obligation(s) under the HIPAA Privacy Rule, the Business Associate shall comply with the requirements of the HIPAA Privacy Rule that apply to the Covered Entity in the performance of such obligation(s); and

(i) The Business Associate shall make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules.

II. Permitted Uses and Disclosures by Business Associate

(a) The Business Associate may only use or disclose PHI as necessary to perform the services set forth in this Agreement or as required by law. The Business Associate is not permitted to de-identify PHI under DoD HIPAA issuances or the corresponding 45 CFR 164.514(a)-(c), nor is it permitted to use or disclose de-identified PHI, except as provided by this Agreement or directed by the Covered Entity.

(b) The Business Associate agrees to use, disclose and request PHI only in accordance with the HIPAA Privacy Rule “minimum necessary” standard and corresponding DHA policies and procedures as stated in the DoD HIPAA Issuances.

(c) The Business Associate shall not use or disclose PHI in a manner that would violate the DoD HIPAA Issuances or HIPAA Privacy Rules if done by the Covered Entity, except uses and disclosures for the Business Associate’s own management and administration and legal responsibilities or for data aggregation services as set forth in the following three paragraphs.

(d) Except as otherwise limited in this Agreement, the Business Associate may use PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate. The foregoing authority to use PHI does not apply to disclosure of PHI, which is covered in the next paragraph.

(e) Except as otherwise limited in this Agreement, the Business Associate may disclose PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate, provided that disclosures are required by law, or the Business Associate obtains reasonable assurances from the person to whom the PHI is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

(f) Except as otherwise limited in this Agreement, the Business Associate may use PHI to provide Data Aggregation services relating to the Covered Entity’s health care operations.

III. Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions

(a) The Covered Entity shall notify the Business Associate of any limitation(s) in the notice of privacy practices of the Covered Entity under 45 CFR 164.520 and the corresponding provision of the DoD HIPAA Issuances, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI.

(b) The Covered Entity shall notify the Business Associate of any changes in, or revocation of, the permission by an Individual to use or disclose his or her PHI, to the extent that such changes affect the Business Associate’s use or disclosure of PHI.

(c) The Covered Entity shall notify the Business Associate of any restriction on the use or disclosure of PHI that the Covered Entity has agreed to or is required to abide by under 45 CFR 164.522 and the corresponding DoD HIPAA Issuances, to the extent that such changes may affect the Business Associate’s use or disclosure of PHI.

IV. Permissible Requests by Covered Entity

The Covered Entity shall not request the Business Associate to use or disclose PHI in any manner that would not be permissible under the HIPAA Privacy Rule or any applicable Government regulations (including without limitation, DoD HIPAA Issuances) if done by the Covered Entity, except for providing Data Aggregation services to the Covered Entity and for management and administrative activities of the Business Associate as otherwise permitted by this BAA.

V. Breach Response

(a) In general.

(1) In the event of a breach of PII/PHI held by the Business Associate, the Business Associate shall report the breach to the Covered Entity in accordance with Section VII, assess the breach incident, take mitigation actions as applicable, and notify affected individuals, as directed by the Covered Entity.

(2) The Business Associate shall coordinate all investigation actions with the Covered Entity, and at a minimum, follow the breach response requirements set forth in this Part V, which is designed to satisfy both the Privacy Act and HIPAA as applicable. If a breach involves PII without PHI, then the Business Associate shall comply with DoD Privacy Act Issuance breach response requirements only; if a breach involves PHI (a subset of PII), then the Business Associate shall comply with both Privacy Act and HIPAA breach response requirements. A breach involving PHI may or may not constitute an HHS Breach. If a breach is not an HHS Breach, then the Business Associate has no HIPAA breach response obligations. In such cases, the Business Associate must still comply with breach response requirements under the DoD Privacy Act Issuances.

(3) The Business Associate shall, at no cost to the government, bear any costs associated with a breach of PII/PHI that the Business Associate has caused or is otherwise responsible for addressing.

(b) Government Reporting Provisions

(1) If the Covered Entity determines that a breach is an HHS Breach, then the Business Associate shall comply with both the HIPAA Breach Rule and DoD Privacy Act Issuances, as directed by the Covered Entity, regardless of where the breach occurs.. If the Covered Entity determines that the breach does not constitute an HHS Breach, then the Business Associate shall comply with DoD Privacy Act Issuances, as directed by the applicable Service-Level Privacy Office.

(2) This Part V is designed to satisfy the DoD Privacy Act…