PWS ambulatory accreditation.pdf

AIR FORCE MEDICAL OPERATIONS AGENCY

PERFORMANCE WORK STATEMENT

FOR

ACCREDITATION SURVEYS FOR AMBULATORY MEDICAL

TREATMENT FACILITIES

30 March 2010

TABLE OF CONTENTS

Page

1.0 DESCRIPTION OF SERVICES 3

1.1 Background 3

1.2 Scope 3

1.3 Acronyms 3

2.0 SUMMARY OF REQUIREMENTS 4

2.1 Description of Duties 4

2.2 General Contractor Personnel Requirements 7

2.3 Services Summary 9

2.4 Government Furnished Support 9

2.5 Travel 10

2.6 Security Requirements 10

2.7 Deliverables 13

2.8 Data Reporting Requirements 14

3.0 QUALITY CONTROL PLAN 15

4.0 NON PERSONAL SERVICES 15

5.0 CONTRACTOR IDENTIFICATION 15

6.0 HOURS OF OPERATION 15

7.0 APPENDICES 16

7.1 APPENDIX A: Health Insurance Portability & Accountability Act (HIPAA) of 1996 17

7.2 APPENDIX B: HQ USAF/SGR Organizational Conflict of Interest (OCI) 22

7.3 APPENDIX C: HQ USAF/SG Non-Disclosure Agreement 25

7.4 APPENDIX D: Customer Feedback Form 28

7.5 APPENDIX E: Proposed Tentative Inspection Schedule 2011-2015 29

7.6 APPENDIX F: Education With Industry (EWI) Position Description 30

1.0. DESCRIPTION OF SERVICES

1.1 Background: Department of Defense (DoD) Medical Treatment Facilities (MTFs) require an accreditation survey/inspection for the purpose of “Accreditation” by a nationally recognized Center for Medicare and Medicaid Deemed accrediting organization in accordance with DoD and contractor standards, policies and procedures. With the exception of the ambulatory MTF at Kunsan AB which receives an accreditation survey every two years until further notice, all other ambulatory MTFs receive an accreditation survey once every three years at the same time they are receiving a Health Services Inspection conducted by the Air Force Inspection Agency (AFIA). (Reference Appendix E Tentative Schedule).

1.2 Scope: The contractor shall furnish the necessary personnel, materials, facilities and other services as required to enter and survey the US Air Force medical treatment facilities (MTFs) for the purpose of Accreditation. These services shall include an on-site survey at each ambulatory MTF located in Continental United States (CONUS) and outside the Continental United States (OCONUS). All work performed shall comply with policies, procedures and appendices as defined in the accrediting organization’s accreditation manual.

The AFIA will provide a tentative five (5) year inspection / accreditation combined schedule, updated every twelve (12) months, and will finalize the schedule about six (6) months prior to survey with applicable MAJCOM, AFMOA and accrediting organization, taking into consideration wartime and Air Force Expeditionary Force (AEF) requirements.

USAF currently pays an annual fee, which may be called an application or subscription fee, only on the MTFs that are due for a survey during that year.

1.3 ACRONYMS

ACRONYMS

ACRONYM DEFINITIONS

ADP Automatic Data Processing AEF Air Force Expeditionary Forces AF Air Force AFIA Air Force Inspection Agency AFMS Air Force Medical Service AFMOA Air Force Medical Operations Agency AIS Automated Information System ASIMS Aeromedical Services Information Management System BAA Business Associate Agreement CDRL Contractor Data Requirements List CFR Code of Federal Regulations CO Contracting Officer COFC Court of Federal Claims CONUS Continental United States

CPAR Contractor Performance Assessment Report DoD Department of Defense DoDD Department of Defense Directive EWI Education With Industry FAR Federal Acquisition Regulation GAO Government Accounting Office GFI Government Furnished Information HSI Health Services Inspection HIPAA Health Insurance Portability and Accountability Act of 1996 HQ USAF/SG Headquarters United States Air Force Surgeon General IA Information Assurance IM/IT Information Management/Information Technology JTR Joint Travel Regulation MAJCOM Major Command MES Mission Essential Services MHS Military Health System MTF Military Treatment Facility NAC National Agency Check NDA Non-Disclosure Agreement OASD(HA) Office of Assistant Secretary of Defense for Health Affairs OCI Organizational Conflict of Interest OCONUS Outside Continental United States PA Privacy Act PM Program Manager POC Point of Contact POP Period of Performance PWS Performance Work Statement QAP Quality Assurance Person/Personnel QCP Quality Control Plan QSPAR Quality Systems Program Assessment Review SAF Secretary of the Air Force SG Surgeon General SI Sensitive Information SME Subject Matter Expert

2.0 SUMMARY OF REQUIREMENTS:

2.1 Description of Duties. The contractor shall:

2.1.1 Use a peer-based, consultative survey process utilizing surveyors that are currently practicing in healthcare.

2.1.2 Determine the type(s) of surveys required and coordinate with the Air Force Inspection Agency/Surgeon General (AFIA/SG), located at Kirtland AFB, NM, and the AFMOA/SGHQ QAP, located at Port San Antonio, TX.

2.1.3 Coordinate with the Health Services Inspection (HSI) office of the AFIA/SG, the annual scheduling of all surveys no later than six (6) months prior to the beginning of the first survey for that year.

2.1.4 Ensure that survey dates are mutually agreed upon by AFIA/SG and the contractor. Any repeat visits or surveys that may be required shall also be coordinated with AFIA/SG and the

QAP.

2.1.5 Combine all surveys (HSI and accrediting organization), unless there are extenuating circumstances. Extenuating circumstances must be approved by AFMOA/SGHQ.

2.1.6 Notify AFIA/SG and the QAP ten (10) calendar days prior to any visit or survey conducted by contractor that has not been previously coordinated on the annual schedule. Please reference Appendix E for a tentative list of MTFs due for a full accreditation survey in the next five (5) years.

2.1.7 Obtain a survey application from the MTF only during the required survey year, no sooner than twelve (12) months before the scheduled survey.

2.1.8 Notify the MTF and AFMOA/SGHQ Quality Assurance Person (QAP) in writing and electronically, no less than seven (7) business days prior to the date of any survey.

2.1.9 Notify the (QAP), in the event MTFs are not updating their application information in accordance with contractor application requirements.

2.1.10 Provide an on-site accreditation survey debrief, to include a verbal out-brief of the major findings at the end of any survey on the final day to the MTF executive staff, and any further staff as identified by the MTF commander (MTF/CC).

2.1.11 Deliver one (1) full final survey report to each of the following: the surveyed MTF/CC, the MAJCOM/SG for that MTF, AFIA/SG and the QAP at AFMOA/SGHQ within forty-five

(45) calendar days following the survey. (CDRL 0004)

2.1.12 Provide each MTF an opportunity to submit an appeal or reconsideration to the accreditation committee for any type of adverse finding within fifteen (15) calendar days from receipt of the written report. The MTF will follow the reconsideration or appeal process as determined by the contractor’s requirements.

2.1.13 Provide all copies of the required accreditation standard publications in a hardcopy plus an electronic format within thirty (30) calendar days of the publication of the accreditation product to the QAP, MTFs, MAJCOM and SG staff as outlined in 2.1.15.

2.1.14 Provide QAP, MTFs, MAJOCOM and SG staff any updates to the hardcopy and electronic product within thirty (30) calendar days of the publication of the change.

2.1.15 Mail hardcopy publications directly to the MTFs, MAJCOM and SG staff and shall coordinate with the QAP who will provide a list of mailing addresses for each MTF, MAJCOM and SG staff no later than January tenth (10th) of each year. This includes the following:

●Hardcopies - Includes one (1) hardcopy of the appropriate accreditation publication per MTF, MAJCOM and SG staff as determined by AFMOA/SGHQ. The contractor shall provide one (1) hardcopy of any published updates to the accreditation publication per MTF, MAJCOM and SG staff as determined by AFMOA/SGHQ.

●Electronic format (internet based) or its equivalent (CD) - Includes one (1) electronic version of the accreditation standards and scoring guidelines, plus if available, an unrestricted site license, any technical support as needed, and any published updates.

The electronic version(s) shall be based on the accreditation program(s) required for the MTF survey.

● Electronic Standards for Annual Self-Inspection- The contractor shall provide the current year’s standards to the QAP in an electronic word format compatible with Air Force computer technology within ten (10) calendar days of publication and/or revision.

These standards will be loaded into the Air Force’s MedFACTS system, a web-based, self-inspection system currently in use by all Air Force MTFs. The standards will be distributed for Air Force self-inspection use only. Ambulatory MTFs will use only the Air Force MedFACTS system for self-inspection.

*The contractor shall not charge AFMOA separately for postage and handling relative to the distribution of their products and publications but include in the cost for publications.

Express or overnight mail shall not be used unless approved by AFMOA, or accrediting organization chooses to send and to absorb the cost themselves.

2.1.16 Participate in daily discussions or “crosstalk” with the HSI team, for the purpose of collaboration, discussion of common standards, and incorporation of AFIA and contractor standards into the final report. This does not preclude the accrediting organization from independently assessing any standard in order to determine compliance from the accrediting organization’s perspective.

2.1.17 Provide the QAP a written and electronic report containing a summary of all Air Force findings for that year, including collated data on most frequent findings, number of facilities, etc.

This shall be provided by the tenth (10th) calendar day of January of the following year.

2.1.18 Provide the MTFs with one certificate of accreditation for each service, or applicable scope of survey and accreditation process within ten (10) calendar days of accreditation approval. Additional copies may be purchased directly by the MTF. The certificate and all copies remain the accrediting organization’s property. Accreditation Certificates must be returned if the MTF is issued a new certificate reflecting a name change, or if the MTF’s accreditation status is changed, withdrawn, or denied for any reason.

2.1.19 Set-up and attend an annual coordination meeting with representatives from AFMOA/SGHQ, and AFIA/SG, approximately one (1) day in length. The annual meeting shall take place at the contractor’s facility or contractor’s designated location (coordinated with AFMOA/SGHQ QAP and AFIA/SG). The annual meeting is to review changes to standards, any updates, and any other topic requiring coordination as determined by AFMOA/SGHQ, AFIA/SG and the contractor. The date of the annual meeting shall be mutually agreed upon between AFMOA/QAP, AFIA/SG and the contractor at least three (3) months in advance of the annual meeting.

2.1.20 Establish an Education with Industry (EWI) fellowship/position at the accrediting organization, for the purpose of bringing practical expertise and standards development to AFMS and to ensure the closest possible working relationship between AFMOA/SGHQ, AFIA/SG and the contractor. The position is no more than one (1) year in length; the start date is to be determined by the Air Force Institute of Technology (AFIT) located in Wright Patterson AFB, Ohio. The accrediting organization will provide a work area, orientation and learning experience to the AF Fellow. The AF Fellow will not be paid by the accrediting organization as the AF Fellow is paid by the AF, and accountable to AFIT to complete course paperwork as required by AFIT. The position description is outlined in Appendix F.

2.1.21 Provide at least one (1) annual educational program, in conjunction with the AFIA Health Services Inspection (HSI) program, and/or Quality Systems Program Assessment Review (QSPAR) conference with a focus toward representatives from MTFs, MAJCOMs, and SG staff.

The dates and locations shall be coordinated with the QAP and/or AFIA/HSI staff. Travel cost in accordance with JTR (see paragraph 2.5) and honorary will be provided to the educator/presenter.

2.2 GENERAL CONTRACTOR PERSONNEL REQUIREMENTS: The contractor shall provide personnel that meet the following standards:

2.2.1 ENGLISH LANGUAGE REQUIREMENT. On site contract personnel shall read, understand, speak, and write English fluently.

2.2.2 EMPLOYEES. The contractor shall not employ persons for work on this contract if such employee is identified to the contractor as a potential threat to the health, safety, security, general well being or operational mission of the installation and its population.

2.2.3 EDUCATION AND TRAINING REQUIREMENTS. Contractor personnel conducting on site surveys shall be able to demonstrate their expertise through a combination of education and experience. A minimum of a Bachelor’s degree in healthcare fields; Physician, Nurse, Hospital Healthcare Management/Administration is required. A minimum of 10 years experience in healthcare is required.

2.2.4 SOFTWARE PROFICIENCY. Contractor personnel shall be knowledgeable with standard AFMS software programs such as the Microsoft Office 2007 Professional Suite.

2.2.5 REQUIRED CERTIFICATIONS. None

2.2.6 SECURE INTERNET. Not required

2.2.7 The Contractor shall provide a Program Manager (PM) Point of Contact (POC) for this contract within three days after contract award. The PM shall be responsible for oversight of the performance of the work and manage the daily needs of the Air Force in answering all issues revolving around surveys and accreditation. At least one PM shall be available for telephone consultation and assistance during the application process, as well as, before and after the inspections, for MTFs, MAJCOMs, AFIA and AFMOA/SGHQ QAP. The PMs shall also be available via email; phone numbers. Email addresses shall be provided to the QAP. Any changes to these designated individual(s) and the contact information shall be provided to the QAP within 3 working days of occurrence.

2.2.8 CONDUCT OF CONTRACTOR PERSONNEL.

• Contractor personnel will be required to observe all base and facility parking, safety and traffic regulations that apply to all facility employees.

• Alcoholic beverages on the job are prohibited.

• There shall be no loud, profane or abusive language used on the job.

• Respect for and the welfare of visitors will be mandatory at all times.

• Contract personnel shall present a neat well-groomed appearance. Neat, clean, casual business attire clothing will be worn.

2.2.9 NON-DISCLOSURE AGREEMENT. Contractor shall provide signed Non-disclosure agreements to the QAP for each contract employee no later than five days after contract award (Appendix C).

2.2.10 Contractor shall provide signed Organizational Conflict of Interest (OCI) no later than five days after contract award (Appendix B).

2.2.11 EMPLOYEE IDENTIFICATION/BUILDING PASSES. Contractor personnel shall wear a Government provided identification badge (Visitor’s Pass) at all times while performing under this effort. When attending meetings and/or answering phones, the contractor employee will identify himself/herself as a contractor employee.

2.2.12 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE. The Contractor is advised that provisions of FAR subpart 52.237-7, Indemnification and Medical Liability Insurance, will be applied to the contract. The full text of the clause may be accessed electronically at this address: http://farsite.hill.af.mil/.

2.2.13 PRODUCTS. All products (software, coding, documentation, reports, or any other item developed under this contract) resulting from this contract shall be the property of the Government with unlimited rights, except as pursuant to 15 U.S.C. § 3710a©(7)(A) & (B), the Freedom of Information Act, 5 U.S.C. § 552, et seq.

2.2.14 GOVERNMENT’S LIABILITY. The Government shall not be liable for any injury to the Contractor's personnel or damage to the Contractor's property unless such injury or damage is due to negligence on the part of the Government and is recoverable under the Federal Torts Claims Act, or pursuant to other Federal statutory authority.

2. 3. SERVICES SUMMARY: Below is a matrix table listing a summary of performance objectives and performance thresholds required by the government in contractor performance.

2.3.1 Measurable Terms

Performance Objectives PWS Paragraph

Performance Threshold/Standard

Scheduling of accreditation surveys of Air Force MTFs

2.1.3 100% No later than (6) six months prior to the beginning of the first survey for the year

Notice of any survey not previously coordinated with

AFIA/SG, QAP

2.1.6 100% notification with AFIA/SG and QAP no later than 10 calendar days prior to the survey

Survey application from the MTF only during the required survey year

2.1.7. 100% applications only during scheduled survey year

Notify the MTF and AFMOA/SGHQ Quality Assurance Person (QAP) in writing and electronically, prior to the date of the survey

2.1.8 100% notification with AFIA/SG and QAP prior to survey

Notify the (QAP), in the event MTFs are not updating their application information in accordance with contractor application requirements

2.1.9 100% notification to the QAP

Participate in daily discussion with AFIA HSI team and incorporate findings in final report

2.1.16 Provide evidence of crosstalk in the final

report 90% of the time

Contractor Program Manager to provide assistance to MTFs, MAJCOMs, AFIA, AFMOA/SGHQ before, during and after application

2.2.7. Respond to telephone calls and email

inquiries within 24 hours of receipt during normal contractor business hours process and inspections.

2.4 GOVERNMENT FURNISHED SUPPORT: The Government will provide all necessary space and support necessary for contractor to complete the survey process. The contractor will notify the MTF and QAP at least three (3) months before a survey of space and support needs.

2.5 TRAVEL: The contractor shall be required to perform periodic travel within the Continental United States (CONUS) and Outside of the Continental United States (OCONUS).

At a minimum, 60 calendar days prior to travel the contractor shall coordinate with and receive Government authorization from the office they support for all travel. The contractor shall be responsible for obtaining all passenger transportation, lodging, and subsistence. Reimbursement of travel costs will be in accordance with the Federal Travel Regulations per FAR 31.205-46, Travel Costs. The contractor shall travel using the lower cost mode transportation commensurate with the mission requirements. When necessary to use air travel, the contractor shall use the tourist class, economy class, or similar lodging accommodations to the extent they are available and commensurate with the mission requirements. Travel will be reimbursed on a cost reimbursable basis; no profit or fee will be paid.

Note: The Joint Travel Regulation (JTR) applies to OCONUS travel.

2.6 SECURITY REQUIREMENTS: The Contractor shall establish appropriate administrative, technical, and physical safeguards to protect any and all Government data accessed or generated by contractor during the performance of this contract. As a minimum, this shall include provisions for personnel security, electronic security and physical security.

2.6.1 Personnel Security. Documentation and costs required for security certification will be the responsibility of the contractor. Contract personnel must have a National Agency Check (NAC) investigation accomplished prior to beginning work. The contractor shall provide documentation received from the appropriate Government agency as to the verification of contract personnel’s NAC certification. In case the certification has been requested but not received, the contractor may provide documentation on any contractor employee where certification has been requested. In the instance, the contractor employee will be able to begin work in areas that would not conflict with Government security issues.

2.6.2 Work performed under the contract is unclassified. However, the technical and medical privacy data used within the scope of this contract requires adherence to security/privacy requirements imposed by the Government, DoD, AF and other applicable security clearance requirements as applicable to this contract. The contractor shall handle and protect all data as directed and implemented by the AFMSA enterprise and its implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (Appendix A)

2.6.3 Contractor personnel shall not release any personal or medical/patient information to include patient/person-level content with personal health information, during the course of this contract. Information shall be treated IAW the following:

2.6.3.1 The Privacy Act of 1974 (5 U.S.C. § 552a), which includes Public Law 100-503, Department of Defense Directive (DoDD) 5400.11, DoD Privacy Program and DoD 5400.11-R, DoD Privacy Program and must be treated as FOR OFFICIAL USE ONLY.

2.6.3.2 The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), which includes DoD 6025.18-R, DoD and is FOR OFFICIAL USE ONLY. (Appendix A)

2.6.3.2.1 Business Associate Agreement (BAA). Because the AFMS and its individual MTFs are covered entities under HIPAA, and the Contractor is a Business Associate of the covered entity, a BAA is required and is included as Appendix A of this PWS. Appendix A is a HIPAA compliant BAA that covers all AFMS MTFs surveyed by the Contractor. Therefore, each MTF shall not be required to enter any other individual BAA with the Contractor for this purpose.

2.6.3.3 Other Military Health Services, AFMOA, Federal and State laws may also be applicable.

2.6.3.4 Contractor shall provide patient information only to Government employees, Government Contractor, and subcontractors having a need-to-know such information in the performance of their duties for this project.

2.6.3.5 The QAP must be kept abreast of issues dealing with the security clearances and/or certifications. No foreign national candidates shall be utilized within the scope of this contract without prior approval of the Government (QAP will contact local Foreign Disclosure Officer for guidance).

2.6.3.6 Contractor personnel and their subcontractors must identify themselves as contractors or subcontractors during meetings, telephone conversations, correspondence, or in electronic messages related to this contract.

2.6.4 Contractor shall comply with DoD Directive 8570.1M, Information Assurance Workforce Improvement Program-25 Feb 2010, Change 2, DoD Instruction 8500.2, Information Assurance Implementation DoD Instruction 5400.11, DoD Privacy Program, and DoD Instruction 5200.2- R, Personnel Security Program Requirements.

2.6.5 Contractor responsibilities for ensuring personnel security include, but are not limited to, meeting the following requirements:

• Initiate, maintain, and document minimum personnel security investigations appropriate to the individual’s responsibilities and access to DoD Sensitive Information (SI).

• Immediately report to the appropriate government representative if any contractor employee filling a sensitive position receives an unfavorable National Agency Check (NAC) adjudication, or if information that would result in an unfavorable NAC becomes available. Notify the Privacy Office within five working days if at any time a contractor employee has privileges revoked to a DoD data or system data because of security concerns.

• Immediately deny access to any automated information system (AIS), network, or MHS SI information to the contractor employee if, at any time, the individual receives an unfavorable NAC adjudication, or if directed to do so by the appropriate government representative for security reasons.

• Ensure that all contractor personnel receive information assurance (IA) training before being granted access to DoD AISs/networks, and/or MHS SI information.

• Ensure all contractor personnel are designated as ADP/IT-I, ADP/IT-II, or ADP/IT-III where their duties meet the criteria of the position sensitivity designations. The employee will be required to complete and submit the SF 85P, “Questionnaire for Public Trust Positions,” fingerprint forms, and such other documentation as may be required by the Office of Personnel Management (OPM) to open and complete investigations. The mailing address is: U.S. Office of Personnel Management, Investigations Services, P.O. Box 618, Boyers, PA 16018-0618.

2.6.6 PHYSICAL SECURITY: The Contractor shall be accountable for control of Government property IAW AFJI 31-102, Physical Security. The Contractor is also responsible for the protection of any contractor-owned equipment or supplies brought onto the installation IAW AFJI 31-102, Physical Security. Further, the Contractor shall not remove any Government property from the installation.

2.6.7 RELEASE OF MEDICAL INFORMATION. Contractor personnel are prohibited from releasing any personnel or medical/patient information to include patient/person-level content with personal health information during the course of this contract. Patient lists, no matter how developed, shall be treated as privileged information. Documentation of training shall be provided to the COR/QAE prior to the contract employee providing services. Information shall be treated IAW the following:

• The Privacy Act of 1974 (5 U.S.C. § 552a), which includes Public Law 100-503.

The Privacy Act of 1974 will cover all data associated with this requirement. All contractor personnel assigned will be required to take appropriate actions to prevent disclosure of this information.

• The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), which includes DoD 6025.18-R, DoD Health Information Privacy Regulation and is FOR OFFICIAL USE ONLY. Other Military Health Services, AFMSA, Federal and State laws may also be applicable.

2.6.8 INSTALLATION ENTRY: The Contractor will comply with established security procedures for entering the installation and its facilities to include any special security procedures that may be established for entry to Restricted Areas or mission essential or vulnerable areas. Temporary badges supplied by the Government shall be worn by contractor and subcontractor personnel and be visible at all times while in the MTF.

2.6.9 DENIAL OF ENTRY: Government reserves the right to terminate entry of any contractor employee upon disclosure of information that indicates the individual’s continued entry to the installation is not in the best interest of the national security. Additionally, violation of or deviation from established security procedures by contractor employees may result in confiscation of identification media and denial of future entry to the installation.

2.6.10 DISCLOSURE OF SENSITIVE DATA: The Contractor recognizes that, in the performance of the contracts, it may receive or have access to certain sensitive information.

Contractor agrees to use and examine this information exclusively in the performance of the contract and to take the necessary steps to prevent disclosure of such information to any party outside the Government. Work performed under the contract is unclassified. However, technical and medical privacy data used within the scope of this contract requires adherence to security/privacy requirements imposed by the Government, DoD, AF and other applicable security clearance requirements as applicable to this contract.

2.7 DELIVERABLES. Any papers, recommendations, etc. that the contractor submits are drafts, not final copies. The Government reserves the right to make changes on delivery dates.

2.7.1 DELIVERABLES

DELIVERABLE SOW

PARAGRAPH

DELIVERY DATE

Scheduling of accreditation surveys of Air Force MTFs

2.1.3 No later than (6) six months

prior to the beginning of the first survey for the year

Accreditation Survey Reports CDRL 0004 2.1.11 Within (45) forty-five calendar days following an accreditation survey

Publications 2.1.13 Within (30) thirty calendar days of publication of the accreditation product and / or updates

Electronic Standards 2.1.13 Within (30) ten calendar days of publication / revision of the standards

Summary of Findings 2.1.17 By the 10th calendar day of January of the following year

Certificate of accreditation 2.1.18 Within (10) ten calendar days of accreditation approval

Monthly Status/Financial Report CDRL

2.8.1 10th working day of the month following the end of the reporting period

Summary of Findings Report CDRL 0002 2.8.2.3 10th calendar day of January of the following year.

Quality Control Plan CDRL 0003 3.2 At time of proposal submission and any updates after contract award.

2.7.2 Criteria for Acceptance. All deliverables shall be submitted in a draft format mutually agreed upon by the contractor and the Government.

2.8 DATA REPORTING REQUIREMENTS

2.8.1. Monthly Status/Financial Report.

2.8.1.1 The contractor shall prepare and submit a monthly status/ financial report identifying all tasks performed, status, issues, and anticipated actions consistent with performance work statement (PWS). The report shall be submitted by the 10th day of the month following the end of the reporting period. (CDRL 0001)

2.8.1.2 One hard copy of this report shall be submitted to the Contracting Officer (CO) and an electronic copy to the QAP and program manager by the tenth working day of the month following the end of the reporting period.

2.8.1.3 Specific content of the report shall be coordinated with the QAP and delivered in an electronic format mutually agreed by the contractor and the Government. The report shall include the following items:

2.8.1.3.1 Highlights of the previous month’s activities.

2.8.1.3.2 Any issues or anticipated/current problems with each task.

2.8.1.3.3 Planned work for the next period; deliverable status information on all active tasks.

2.8.1.3.4 Status of QAP-generated action items, if any, from previous report and the resultant impact and schedule changes, if any.

2.8.1.3.4 Trend Analysis; summary of most frequent non-compliant and partial compliant findings found during the survey(s).

2.8.1.5 This report shall also keep the Government informed of all funds expended.

2.8.2 OTHER DATA REQUIREMENTS. In addition to the monthly status reports, the contractor shall provide the following data deliverables:

2.8.2.1 Activities log will be submitted monthly with the monthly status report.

2.8.2.2 Develop and maintain a complete Quality Control Plan (QCP). Initial QCP shall be provided during the proposal phase and any updates as they become final during the entire performance period.

2.8.2.3 Submit Summary of Findings reports as specified within the PWS. Any draft copies and final copies will be delivered both electronically and one hard copy to the Quality Assurance Person (QAP) in accordance with project milestones. (CDRL 0002)

3.0 QUALITY ASSURANCE PLAN: The Contractor is responsible for Contract Management and Quality Control, not The Government.

3.1 The Contractor shall be responsible for quality control (QC) for all work accomplished during the performance of this contract. All work shall be accomplished using the best commercial practices and be within the Government guidelines. Work and documentation produced by the contract personnel will be regularly reviewed by the Quality Assurance Personnel (QAP) Representative.

3.2 Quality Control (QC) Plan. The contractor shall provide to the government a Quality Control Plan at time of proposal and any updates after contract awarded. Any update to the QC Plan must be reviewed by the Government. (CDRL 0003)

3.3 Positive incentives as a result of performance that continually exceeds the performance objectives as outlined in the PWS may result in reduced surveillance and favorable Contractor Performance Assessment Reports (CPAR). Negative performance incentives include re-performance of the defective service in accordance with the Inspection of Services clause, reduction of fee/price, negative CPAR reporting and/or increased surveillance.

4.0 NON PERSONAL SERVICES: The Government will neither supervise contractor employees nor control the method by which the contractor performs the required tasks. Under no circumstances shall the Government assign tasks to, or prepare work schedules for, individual contractor employees. It shall be the responsibility of the contractor to manage its employees and to guard against any actions that are of the nature of personal services, or give the perception of personal services. If the contractor feels that any actions constitute, or are perceived to constitute personal services, it shall be the contractor’s responsibility to notify the CO immediately. These services shall not be used to perform work of a policy/decision making or management nature, i.e., inherently Governmental functions. All decisions relative to programs supported by the contractor shall be the sole responsibility of the Government.

5.0 CONTRACTOR IDENTIFICATION: All contractor/subcontractor personnel shall wear a Government identification badge at all times while performing under this effort. When attending meetings and/or answering phones or via electronic mail, the contractor/subcontractor personnel shall identify themselves as a contractor employee to avoid situations arising where sensitive topics might be better discussed solely between Government employees.

Contractors/subcontractors shall identify themselves on any attendance sheet or any coordination documents they may review. Electronic mail signature blocks shall identify their company affiliation. Where practicable, contractor/subcontractors occupying collocated space with their Government program customer should identify their work space area with their name and company affiliation or as a minimum “Contractor” after name.

6.0 HOURS OF OPERATION: Normal duty hours are 7:30 am to 4:30 pm (including a one hour lunch break), Monday through Friday (excluding Federal Holidays), unless mutually agreed upon by Government and contractor personnel. Due to mission need or due to unforeseen acts of nature or emergency, the Government and contractor may agree to different duty hour/work days. Overtime is not authorized.

6.1 Government agencies will not be available during scheduled holidays, inclement weather, weekends, after duty hours, or AF down days. All chargeable work will be directly attributable to the task being performed by the individual.

6.2 PLACE OF PERFORMANCE. The primary place of performance is the AF MTF site being surveyed (CONUS and OCONUS).

6.3 SCHEDULED HOLIDAYS. The following Government holidays are normally observed by Government personnel: New Years Day, Martin Luther King’s Birthday, Presidential Inauguration Day (metropolitan District of Columbia area only), President’s Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veteran’s Day, Thanksgiving Day, Christmas Day, and any other day designated by Federal Statute, Executive Order, and/or Presidential Proclamation.

7.0 APPENDICES

7.1 APPENDIX A. Health Insurance Portability and Accountability Act (HIPAA) of

1996.

7.2 APPENDIX B. HQ USAF/SGR Organizational Conflict of Interest (OCI)

7.3 APPENDIX C. HQ USAF/SG Non-Disclosure Agreement

7.4 APPENDIX D. Customer Feedback Form

7.5 APPENDIX E. Proposed Tentative Inspection Schedule 2011-2015

7.6 APPENDIX F. Education With Industry (EWI) Fellow Job Description

Appendix A.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF

HIPAA is comprised of several different sections, each to be implemented by the Dept. of Health and Human Services. The AFMS and its components are specifically listed as covered entities (CE) under HIPAA. Currently, HIPAA Privacy and Security Rules, as set forth in the Code of Federal Regulations, are in effect for all AFMS CEs. The specific implementation of HIPAA Privacy for DOD medical facilities is set forth in DOD 6025.18-R, and for HIPAA Security, the requirements for the AFMS are contained in DOD 8580.02-R and AFI 41-217, which also contains additional Information Assurance requirements. DOD 6025.18-R, DOD 8580.02-R and AFI 41-217 are incorporated herein by reference. AFMS organizations are responsible to insure overall compliance with HIPAA requirements, which includes incorporation of certain requirements in contracts entered into or amended after the respective implementation dates.

IAW these regulations, the Contractor and its employees meet the definition of Business Associate. Therefore, a Business Associate Agreement is required by law to comply with both the HIPAA Privacy and Security regulations. This clause serves as that agreement for this contract, whereby the Contractor and its employees agree to abide by all HIPAA Privacy and Security requirements regarding health information as defined in this clause, DOD 6025.18- R, DOD 8580.02-R, and AFI 41-217. Additional HIPAA requirements will be addressed when implemented.

Introduction

(a) Definitions. As used in this clause generally refer to the Code of Federal Regulations (CFR) definition unless a more specific provision exists in DOD 6025.18-R, DOD 8580.02-R or AFI 41-217.

Individual has the same meaning as the term “individual” in 45 CFR 164.50 1 and 164.103 and shall include a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g).

Privacy Rule means the Standards for Privacy of Individually Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and E.

Protected Health Information has the same meaning as the term “protected health information” in 45 CFR 164.501, limited to the information created or received by The Contractor from or on behalf of the Government.

Electronic Protected Health Information has the same meaning as the term “electronic protected health information” in 45 CFR 160.103.

Required by Law has the same meaning as the term “required by law” in 45 CFR 164.501 and 164.103.

Secretary means the Secretary of the Department of Health and Human Services or his/her designee.

Security Rule means the Health Insurance Reform: Security Standards at 45 CFR part 160,162 and part 164, subpart C.

Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in 45 CFR 160.103, 160.502, 164.103, 164.304 and 164.501.

(b) The Contractor agrees to not use or further disclose Protected Health Information other than as permitted or required by the Contract or as Required by Law.

c) The Contractor agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Contract.

(d) The Contractor agrees to use administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits in the execution of this Contract.

(e) The Contractor agrees to mitigate, to the extent practicable, any harmful effect that is known to the Contractor of a use or disclosure of Protected Health Information by the Contractor in violation of the requirements of this Contract.

(f) The Contractor agrees to report to the Government any security incident involving protected health information of which it becomes aware.

(g) The Contractor agrees to report to the Government any use or disclosure of the Protected Health Information not provided for by this Contract of which the Contractor becomes aware of.

(h) The Contractor agrees to ensure that any agent, including a subcontractor, to whom it provides Protected Health Information received from, or created or received by the Contractor on behalf of the Government agrees to the same restrictions and conditions that apply through this Contract to the Contractor with respect to such information.

(i) The Contractor agrees to ensure that any agent, including a subcontractor, to whom it provides electronic Protected Health Information, agrees to implement reasonable and appropriate safeguards to protect it.

(j) The Contractor agrees to provide access, at the request of the Government, and in the time and manner designated by the Government to Protected Health Information in a Designated Record Set, to the Government or, as directed by the Government, to an Individual in order to meet the requirements under 45 CFR 164.524.

(k) The Contractor agrees to make any amendment(s) to Protected Health Information in a Designated Record Set that the Government directs or agrees to pursuant to 45 CFR 164.526 at the request of the Government or an Individual, and in the time and manner designated by the Government.

(1) The Contractor agrees to make internal practices, books, and records relating to the use and disclosure of Protected Health Information received from, or created or received by the Contractor on behalf of, the Government, available to the Government, or at the request of the Government to the Secretary, in a time and manner designated by the 'Government or the Secretary, for purposes of the Secretary determining the Government's compliance with the Privacy Rule.

(m) The Contractor agrees to document such disclosures of Protected Health Information and information related to such disclosures as would be required for the Government to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528.

(n) The Contractor agrees to provide to the Government or an Individual, in time and manner designated by the Government, information collected in accordance with this Clause of the Contract, to permit the Government to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528.

General Use and Disclosure Provisions

Except as otherwise limited in this Agreement, the Contractor may use or disclose Protected Health Information on behalf of, or to provide services to, the Government for treatment, payment, or healthcare operations purposes, in accordance with the specific use and disclosure provisions below, if such use or disclosure of Protected Health Information would not violate the HIPAA Privacy Rule, DOD 6025.18-R, the HIPAA Security Rule, or DOD 8580.02-R if done by the Government.

Specific Use and Disclosure Provisions

(a) Except as otherwise limited in this Agreement, the Contractor may use Protected Health Information for the proper management and administration of the Contractor or to carry out the legal responsibilities of the Contractor.

(b) Except as otherwise limited in this Agreement, the Contractor may disclose Protected Health Information for the proper management and administration of the Contractor, provided that disclosures are required by law, or the Contractor obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the Contractor of any instances of which it is aware in which the confidentiality of the information has been breached.

(c) Except as otherwise limited in this Agreement, the Contractor may use Protected Health Information to provide Data Aggregation services to the Government as permitted by 45 CFR 164.504(e)(2)(i)(B).

(d) Contractor may use Protected Health Information to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR 164.502(j)(1).

Obligations of the Government

Provisions for the Government to Inform the Contractor of Privacy Practices and Restrictions

(a) Upon request the Government shall provide the Contractor with the notice of privacy practices that the Government produces in accordance with 45 CFR 164.520, as well as any changes to such notice.

(b) The Government shall provide the Contractor with any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, if such changes affect the Contractor's permitted or required uses and disclosures.

(c) The Government shall notify the Contractor of any restriction to the use or disclosure of Protected Health Information that the Government has agreed to in accordance with 45 CFR 164.522.

Permissible Requests by the Government

The Government shall not request the Contractor to use or disclose Protected Health Information in any manner that would not be permissible under the HIPAA Privacy Rule, DOD 6025.18-R, the HIPAA Security Rule, or DOD 8580.02-R, if done by the Government, except for providing Data Aggregation services to the Government and for management and administrative activities of the Contractor as otherwise permitted by this clause.

Termination

(a) Termination. A breach by the Contractor of this clause, may subject the Contractor to termination under any applicable default or termination provision of this Contract.

(b) Effect of Termination.

(1) If this contract has records management requirements, the records subject to the Clause should be handled in accordance with the records management requirements. If this contract does not have records management requirements, the records should be handled in accordance with paragraphs (2) and (3) below.

(2) If this contract does not have records management requirements, except as provided in paragraph (3) of this section, upon termination of this Contract, for any reason, the Contractor shall return or destroy all Protected Health Information received from the Government, or created or received by the Contractor on behalf of the Government. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of the Contractor. The Contractor shall retain no copies of the Protected Health Information.

(3) If this contract does not have records management provisions and the Contractor determines that returning or destroying the Protected Health Information is infeasible, the Contractor shall provide to the Government notification of the conditions that make return or destruction infeasible. Upon mutual agreement of the Government and the Contractor that return or destruction of Protected Health Information is infeasible, the Contractor shall extend the protections of this Contract to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as the Contractor maintains such Protected Health Information.

Miscellaneous

(a) Regulatory References. A reference in this Clause to a section in DOD 6025.18-R, HIPAA Privacy Regulation or DOD 8580.02-R, HIPAA Security Regulation or any CFR or AFI provisions means the section as currently in effect or as amended, and for which compliance is required.

(b) Survival. The respective rights and obligations of Business Associate under the "Effect of Termination" provision of this Clause shall survive the termination of this Contract.

(c) Interpretation. Any ambiguity in this Clause shall be resolved in favor of a meaning that permits the Government to comply with DOD 6025.18-R, the CFR HIPAA Privacy Rule, DOD 8580.02-R, the CFR HIPAA Security Rule and AFI 41-217.

APPENDIX B

HQ USAF/SG ORGANIZATIONAL CONFLICT OF INTEREST

ORGANIZATIONAL CONFLICT OF INTEREST

Revised: 30 Aug 2007

The purpose of this clause is to accomplish the following three objectives: (1) to inform prospective offerors that AFMOA presumes that award of this contract or task order may give rise to real or apparent OCIs with respect to other requirements or contracts within AFMOA or the AFMS; (2) to assist current contractors and prospective Offerors in developing their own business strategies regarding participation in AFMOA or AFMS requirements and in identifying and, where possible, avoiding or mitigating against OCIs; and (3) to ensure that all current contractors and prospective Offerors are afforded the maximum practicable opportunity to compete for all AFMOA and AFMS requirements consistent with the restrictions required under FAR Subpart 9.5, Government Accountability Office (GAO) or Court of Federal Claims (COFC) decisions, and sound business practices.

The Contractor and all of its agents (including officers, managers, employees, consultants, and subcontractors) will fully comply with the Special Terms and Conditions Organizational Conflict of interest (OCI) required for efforts in support of AFMOA activities. Contractor will ensure that all confidential and sensitive information will be fully protected. Such information will include, but not be limited to, all source selection sensitive information, government plans or strategies, and all proprietary information of other companies during contract performance. The disclosure of information shall not constitute a grant of any species of right, title, interest, or property in or to said information.

The Contractor understands and appreciates the absolute need to prevent conflicting roles that could or may bias its support to the AFMOA office and its AF-wide responsibilities. To ensure that any support provided by the Contractor, its personnel, or its agents, is free of any bias in judgment or objectivity and to preclude the Contractor, its personnel, or its agents, from any unfair competitive advantage in current or future acquisitions, the Contractor will implement the following:

• Organizational Isolation

• Company Wide Policy Implementation

• Non-Disclosure Agreements

Contractor participation in a requirement or contract with AFMOA programs may give rise to an unfair competitive advantage in other AFMOA procurement actions because of access to advance acquisition planning, source selection sensitive or proprietary information.