Attachment_1_-_PWS_Ambulatory_Services_-_14_Aug_2014_(FINAL).pdf

AIR FORCE MEDICAL OPERATIONS AGENCY

PERFORMANCE WORK STATEMENT

FOR

ACCREDITATION SURVEYS FOR AMBULATORY MEDICAL

TREATMENT FACILITIES (MTFs)

14 Aug 2014

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 5

2.1 Description of Duties 5

2.2 General Contractor Personnel Requirements 8

2.3 Services Summary 12

2.4 Government Furnished Support 13

2.5 Travel 13

2.6 Security Requirements 13

2.7 Deliverables 13

2.8 Data Reporting Requirements 15

3.0 QUALITY CONTROL PLAN 16

4.0 NON PERSONAL SERVICES 16

5.0 CONTRACTOR IDENTIFICATION 16

6.0 HOURS OF OPERATION 16

7.0 APPENDICES 17

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

1996 18

7.2 APPENDIX B: HQ USAF/SGR Organizational Conflict of Interest (OCI) 23

7.3 APPENDIX C: HQ USAF/SG Non-Disclosure Agreement 26

7.4 APPENDIX D: Customer Complaint Record 29

7.5 APPENDIX E: Proposed Tentative Inspection Schedule 2015-2019 34

7.6 APPENDIX F: Education With Industry (EWI) Position Description 35

1.0. DESCRIPTION OF SERVICES

1.1 Background: Department of Defense (DoD) Medical Treatment Facilities (MTFs) require an accreditation survey for the purpose of “Accreditation” by an accreditation source approved by the Assistant Secretary of Defense for Health Affairs [ASD (HA)]. All outpatient MTFs will receive an accreditation survey every three (3) years. One exception is

Kunsan, which will be surveyed every two (2) years.

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 MTFs for the purpose of

Accreditation and Primary Care/Medical Home Certification. The period of performance shall include 96 on-site surveys at 62 ambulatory MTFs located throughout the 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 handbook or manual. The Contractor shall coordinate and finalize the survey schedule no later than six (6) months prior to each survey year with the Contracting Officer Representative (COR) located at AFMOA. USAF currently pays an annual fee, which may be called an application or subscription fee, only for 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

AFIS Air Force Inspection System

AFMS Air Force Medical Service

AFMOA Air Force Medical Operations Agency

AIS Automated Information System

ASC Ambulatory Surgical Center

ASIMS Aeromedical Services Information Management System

BAA Business Associate Agreement

CFR Code of Federal Regulations

CMRA Contractor Manpower Reporting Application (CMRA)

CMS Center for Medicare and Medicaid Services

CO Contracting Officer

COFC Court of Federal Claims

CONUS Continental United States

COR Contracting Officer Representative

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

HIPAA Health Insurance Portability and Accountability Act of 1996

HQ USAF/SG Headquarters United States Air Force Surgeon General

IA Information Assurance

IG Inspection General

IM/IT Information Management/Information Technology

JB Joint Base

JBSA Joint Base San Antonio

JTR Joint Travel Regulation

MAJCOM Major Command

MES Mission Essential Services

MHS Military Health System

MICT Management Internal Control Toolset

MTF Military Treatment Facility

NACI National Agency Check and Inquiries

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

PJM Project Manager

PM Program Manager

POC Point of Contact

POP Period of Performance

PWS Performance Work Statement

QCP Quality Control Plan

QM Quality Manager

QSPAR Quality Systems Program Assessment Review

SAF Secretary of the Air Force

SG Surgeon General

SI Sensitive Information

SME Subject Matter Expert

TDY Temporary Duty

UEI Unit Effectiveness Inspection

2.0 SUMMARY OF REQUIREMENTS:

2.1 DESCRIPTION OF DUTIES. The Contractor shall:

2.1.1 Use a peer-based, consultative accreditation process utilizing nationally recognized standards.

2.1.1.1 Utilize practicing health care professionals to perform the accreditation survey.

2.1.1.2 Maintain Medicare Deemed Status by the Centers for Medicare and Medicaid Services

(CMS).

2.1.2 Determine the type(s) of surveys required and coordinate with the COR located at

AFMOA/SGHQ in Port San Antonio, TX. Where “working days” or “calendar days” is not specified, calendar days shall take precedence.

2.1.3 Coordinate the annual scheduling of all surveys with the COR, no later than six (6) months prior to the beginning of the first survey for that year, excluding the base year which will be coordinated upon contract award and again 30 days before the actual survey. These MTFs will be notified of their survey dates prior to the survey to provide MTF necessary requirements for surveyors (Deliverable One (1))

2.1.4 Ensure that survey dates have been coordinated by the COR and the applicable Major

Command (MAJCOM) Gatekeeper. Any repeat visits or surveys that may be required shall also be coordinated with the COR, whom in turn, will coordinate with the applicable MAJCOM

Gatekeeper.

2.1.5 The number of surveyors and length of a survey are determined by the location, size, and scope of clinic services offered at the MTF.

2.1.6 Notify the COR 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 F for a proposed 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 12 months before the scheduled survey.

2.1.8 Notify the MTF Quality Manager and AFMOA/SGHQ (COR) in writing and electronically, 180 days prior to the date of the survey.

2.1.8.1 Notify the COR, in the event MTFs are not updating their application information in accordance with Contractor application requirements.

2.1.9 Provide an on-site accreditation survey debrief, to include a verbal out-brief of the major findings, at the end of any survey to the MTF Executive Staff and additional staff as identified by the MTF Commander (MTF/CC).

2.1.10 Deliver one (1) full final survey report to each of the following: the surveyed MTF/CC and the COR at AFMOA/SGHQ within forty-five (45) calendar days following the survey

(Deliverable Two (2)).

2.1.11 Provide each MTF the 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. The contractor will provide an explanation of the reconsideration or appeal process during the out-brief, as needed.

2.1.12 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 COR at AFMOA/SGHQ and MTF POCs as outlined in 2.1.14.

2.1.13 Provide the COR at AFMOA/SGHQ and MTF POCs hardcopy publication updates/changes within thirty (30) calendar days of the publication change (Deliverable Three

(3)).

2.1.14 Mail* hardcopy publications directly to the AFMOA/SGHQ COR and MTF POCs. The

COR will provide a list of mailing addresses for AFMOA and each MTF POCs no later than

January tenth (10th) of each year. This includes the following:

2.1.14.1 Include one (1) hardcopy of the appropriate accreditation publication per MTF as determined by AFMOA/SGHQ. The Contractor shall provide one (1) hardcopy of any published updates to the accreditation publication per MTF as determined by

AFMOA/SGHQ.

2.1.14.2 Include one (1) electronic version of the accreditation standards and scoring guidelines, and 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. Additionally, provide the COR a copy of the accreditation standards in Microsoft Word.

2.1.14.3 Electronic Standards for Annual Self-Assessment (SA). The contractor shall provide the current year’s standards to the COR in an electronic 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 Inspection System (AFIS), a web-based, SA system currently used by all Air Force MTFs (Deliverable Four (4)).

*Express or overnight mail may be required, without additional cost to the government.

2.1.15 If the contractor is present when the Inspection General (IG) team is on site, (to include the medical component of the Unit Effectiveness Inspection (UEI)), the contractor will participate in daily discussions or “crosstalk” with the team, at the request of the medical inspectors, for the purpose of collaboration and the discussion of common standards. This does not preclude the accrediting organization from independently assessing any standard in order to determine compliance from the accrediting organization’s perspective.

2.1.16 Provide the COR a written and electronic Summary of Survey Findings report by the tenth

(10th) calendar day of January of the following year. The Summary of Survey Findings report shall contain a summary of all Air Force findings for that year, including collated data on frequent findings, number of facilities and additional information as requested by the COR.

Compare the findings for each MTF with their previous survey findings. If the accrediting organization is unable to meet this requirement, they must contact the CO and COR (Deliverable

Five (5)).

2.1.17 Provide the MTFs with one certificate of Accreditation and one certificate for Patient

Centered Medical Home for primary care settings (i.e., Family Health, Pediatrics, Flight

Medicine, and Internal Medicine) 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 will 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 (Deliverable Six (6)).

2.1.18 Set-up and attend an annual coordination meeting with representatives from

AFMOA/SGHQ and others as required, up to one (1) day in length. The annual meeting shall take place at the contractor’s facility or contractor’s designated location (coordinated with the

COR). The annual meeting is to review changes to standards, provide updates and any other topic requiring coordination/discussion, as determined by the COR and contractor. The date of the annual meeting shall be mutually agreed upon between the COR and contractor at least three

(3) months in advance of the annual meeting. The agenda will be provided to the CO and COR seven (7) working days prior to the meeting.

2.1.19 Establish an Education with Industry (EWI) Fellowship at the accrediting organization for the purpose of bringing practical expertise and ambulatory standards development to the AFMS and ensure the closest possible working relationship between AFMOA/SGHQ and the contractor.

The position is no more than one (1) year in length, with the start date determined by the Air

Force Institute of Technology (AFIT), located at Wright Patterson AFB, Ohio. The accrediting organization will provide a work area, orientation, experiences related to all stages of survey preparation, MTF notification, and standards review for the AF Fellow. The AF Fellow is accountable to AFIT for completing all course paperwork/requirements. Provide the fellow’s contact information to the COR within seven (7) working days of starting. The AF position description is outlined in Appendix F.

2.1.20 Provide at least one (1) annual educational program, in conjunction with the Quality

Systems Program Assessment Review (QSPAR) conference as determined by the COR, with a focus toward representatives from AFMOA and the MTFs. The Presenter must be a Contractor's

Surveyor with AF MTF experience and/or the Contractor’s DoD Representative, or their designee. The dates and location(s) shall be coordinated with the COR. Travel cost shall be in accordance with JTR (see paragraph 2.5).

2.1.21 If QSPAR or other conference venues are cancelled; the contractor shall provide at least one (1) presenter for the educational program for years 2015 thru 2019 using the Defense

Connect Online (DCO) or other compatible audio/video web conferencing venue. The date(s) for the conference shall be coordinated with the COR. The contractor shall also electronically provide one (1) set of educational handouts or other related reading material to the COR to be shared with the MTF QMs and posted on the AFMOA/SGHQ Kx website. Presenter must be a

Contractor's Surveyor with AF MTF experience and/or the Contractor’s DoD Representative, or their designee.

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 Master’s degree in the healthcare field; Physician, Nurse, Hospital Healthcare Management/Administration is required. A minimum of ten (10) years’ experience in healthcare is required. Copies of resumes will be provided to the Contracting Officer and COR no later than ten (10) calendar days after the beginning of the period of performance and the notification of a vacancy.

2.2.3.1 Contractor personnel conducting on site surveys in MTF shall participate in formal training to include initial and ongoing training. The initial training shall include standards interpretation, the accreditation process, how to conduct surveys, how to evaluate compliance with the standards, and identification of military acronyms. The ongoing training shall include a minimum of one (1) annual refresher training session and the use of webinars and/or newsletters as determined by the

Contractor, to include changes to the standards and/or procedures for accreditation.

2.2.4 SOFTWARE PROFICIENCY. Contractor personnel shall be knowledgeable with software programs such as the Microsoft Office 2010 Professional Suite.

2.2.5 REQUIRED CERTIFICATIONS. None

2.2.6 SECURE INTERNET. Not Required

2.2.7 PERSONNEL SECURITY. The contractor shall be responsible for Personnel Security.

Documentation required for security certification will be the responsibility of the contractor and the client organization. Contract personnel must have a National Agency Check and Inquiries

(NACI) investigation accomplished prior to beginning work. The contractor shall provide documentation received from the appropriate Government agency to verify the contract personnel’s NACI certification. In case the certification has been requested and not received, the contractor may provide documentation on any contractor employee that certification has been requested. In the instance, the contractor employee will be able to begin work in areas that will not conflict with Government security issues.

2.2.7.1 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 applicable to this contract. The contractor shall handle and protect all data as directed and implemented by the AFMS enterprise and its implementation of the Health Insurance Portability and Accountability Act of 1996

(HIPAA). (Appendix A)

2.2.7.2 Contractor personnel shall not release any personnel or medical/patient information, to include content with personal health information during the course of this contract.

Information shall be treated IAW the following:

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

100-503, Department of Defense Directive (DoDD) 5400.11, and DoD 5400.11-R and must be treated as FOR OFFICIAL USE ONLY.

2.2.7.2.2 The Health Insurance Portability and Accountability Act of 1996 (Public

Law 104-191), which includes DoD 6025.18-R and is FOR OFFICIAL USE

ONLY. (Appendix A)

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

2.2.7.4 Contractor shall provide the CO within ten (10) days after contract award, a signed

Organizational Conflict of Interest (OCI) Avoidance or Mitigation Plan, addressing the activities of all contract employees. (Appendix B).

2.2.7.5 Contractor shall provide the CO within ten (10) days after contract award, signed

Non-Disclosure Agreements for each contract employee. (Appendix C).

2.2.7.6 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.

2.2.7.7 Contractor shall keep the COR 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.

2.2.8 Contractor shall comply with DoD Directive 8570.1M, Information Assurance Workforce

Improvement Program-May 15, 2008 Change 1, DoD Instruction 8500.2, Privacy Act Program

Requirements (DoD 5400.11), and Personnel Security Program Requirements (5200.2-R).

2.2.9 Contractor shall be responsible for ensuring personnel security to include, but 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 and Inquiries (NACI) adjudication or if information that would result in an unfavorable

NACI becomes available. Notify the COR, CO and Security Office within five (5) working days if, at any time, a contractor employee has privileges revoked to a DoD or systems data because of security concerns.

• Immediately deny access to any automated information system (AIS), network or MHS

SI to the contractor employee if, at any time, the individual receives an unfavorable

NACI 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 Sensitive Information (SI).

• Ensure all contractor personnel are designated as Automated Data Processing

(ADP)/Information Technology (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.

2.2.10 Physical Security: The Contractor shall be accountable for control of Government property IAW Air Force Joint Instruction (AFJI) 31-102. The Contractor is also responsible for the protection of any contractor-owned equipment or supplies brought onto the installation IAW

AFJI 31-102. The Contractor shall not remove any Government property from the installation.

2.2.11 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, mission essential or vulnerable areas.

2.2.12 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.

2.2.13 The Contractor shall provide a Project Manager (PJM) for this contract within three (3) days after contract award. The PJM 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. The PJM shall be available to the MTFs, MAJCOMs and

AFMOA/SGHQ COR for telephone consultation and assistance during the application process, as well as, before and after surveys. The PJM will provide their contact information to the COR three (3) days after contract award. Any changes to the designated individual and contact information, shall be provided to the COR within three (3) working days of occurrence.

2.2.14 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 is mandatory at all times.

Contract personnel shall present a well-groomed appearance. Neat, clean, business attire clothing will be worn throughout the survey.

2.2.15 EMPLOYEE IDENTIFICATION/BUILDING PASSES. Contractor personnel shall wear a Government-provided identification (Visitor’s Pass) and personal Contractor badge at all times while conducting the survey. When attending meetings and/or answering phones, the Contractor employee will identify himself/herself as a Contractor employee.

2.2.16 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE. The Contractor is advised that provisions of FAR 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/

2.2.17 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. § 3710ac) (7) (A) & (B), the

Freedom of Information Act, 5 U.S.C. § 552, et seq.

2.2.18 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.

2.2.19 Contractor Manpower Reporting Application (CMRA) Requirements:

2.2.19.1 The contractor shall report all contractor labor hours (including subcontractor labor hours) required for performance of services provided under this PWS via a secure data collection site. The contractor is required to completely fill in all required data fields at http://www.ecmra.mil.

2.2.19.2 Reporting Period: Reporting inputs will be for the labor executed during the period of performance for each Government fiscal year (FY), which runs 01 October through 30 September. While inputs may be reported any time during the FY, all data shall be reported no later than 31 October of each calendar year. Contractors may direct questions to the CMRA help desk.

2.2.19.3 Uses and Safeguarding of Information: Information from the secure web site is considered to be proprietary in nature when the contract number and contractor identity are associated with the direct labor hours and direct labor dollars. At no time will any data be released to the public with the contractor name and contract number associated with the data.

2.2.19.4 User Manuals: Data for Air Force service requirements must be input at the Air

Force CMRA link. However, user manuals for Government personnel and contractors are available at the Army CMRA link at http://www.ecmra.mil.

2.3. SERVICES SUMMARY: Below is a matrix table listing a summary of performance objectives and thresholds required by the Government in Contractor performance. The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success.

2.3.1 Initial Contract Performance Review: The initial evaluation of contractor performance is a joint determination by the multi-functional team that the contractor has successfully started performance, completed transition, is fully operational, and is within the estimated cost, schedule and performance parameters of the contract. The initial evaluation will be conducted by the Government within thirty (30) calendar days after the contractor assumes full performance responsibilities.

2.3.2 Measurable Terms

Performance

Objectives

PWS

Paragraph

Performance Threshold/Standard Surveillance

Method

1. Scheduling of accreditation surveys of

Air Force MTFs

2.1.3 100% of the time/No later than six (6) months prior to the beginning of the first survey for the year, excluding the base year that will be coordinated upon contract award and again 30 days before the actual survey

100%

Inspection

2. Notice of any survey not previously

2.1.6 100% of the time/Notification to COR no later than ten (10) calendar days prior to any visit 100%

Inspection http://www.ecmra.mil/ coordinated with COR or survey

3. Obtain Survey application from the

MTF only during the required survey year

2.1.7 100% of the time/Obtain survey applications from MTFs only during required survey year, no sooner than 12 months before the scheduled survey

Periodic

Inspection

Quarterly

4. Notify the MTF and

AFMOA/SGHQ COR in writing and electronically prior to the date of the survey

2.1.8 100% of the time/ Notification to the COR

180 days prior to the date of survey

100%

Inspection

5. Notify the COR, in the event MTFs are not updating their application information in accordance with

Contractor application requirements

2.1.8.1 100% of the time/Notification to the COR 100%

Inspection

6. Contractor PJM is available to MTFs, MAJCOMs and

AFMOA/SGHQ COR

for telephone consultation and assistance during the application process, as well as, before and after surveys

2.2.13 Respond to telephone calls and email inquiries

within twenty-four(24) hours of receipt during normal Contractor business hours

Customer

Complaint

Record

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 at least three (3) months before the survey start date of space, document and support requirements.

2.5 TRAVEL: The contractor shall be required to perform 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 COR 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 mode of transportation commensurate with the mission requirements and the lowest fare. When necessary to use air travel, the Contractor shall use the tourist class, economy class 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. Travel receipts for all expenses related to the travel shall be submitted to the COR with invoices.

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

2.6 SECURITY REQUIREMENTS: N/A

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 or submitted documents/information.

2.7.1 DELIVERABLES:

DELIVERABLE SOW

PARAGRAPH

DELIVERY DATE

1. Scheduling of accreditation surveys of AF

MTFs

2.1.3 No later than six (6) months

prior to the beginning of the first survey for the year, excluding the base year which will be coordinated upon contract award and again thirty (30) days before the actual survey

2. Accreditation Survey Reports 2.1.10 Within forty-five (45) calendar days following an accreditation survey

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

4. Electronic Standards 2.1.14.3 Within ten (10) calendar days of publication or revision of standards

5. Summary of Survey Findings 2.1.16 By the 10th calendar day of

January of the following year

6. Certificates of accreditation (facility and

Medical Home)

2.1.17 Within ten (10) calendar days

of accreditation approval

7. Monthly Status/Financial Report 2.8.1.1 10th working day of the month following the end of the reporting period

8. Quality Control Plan 3.2 At time of proposal submission and any update(s) after contract award

2.7.2 Criteria for Acceptance. All deliverables shall be submitted in draft format mutually agreed upon by the contractor and the Government. If unable to meet above delivery dates, contact the AFMOA/SGHQ COR and Contracting Officer with an explanation and remedy.

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 the PWS. The report shall be submitted by the 10 th working day of the month following the end of the reporting period

(Deliverable Seven (7)).

2.8.1.2 One hard copy of this report shall be submitted to the Contracting Officer (CO) and an electronic copy to the COR and Government PM by the 10th working day of the month following the end of the reporting period.

2.8.1.3 Specific content of the survey report shall be coordinated with the COR 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, to include deliverable status information on all active tasks.

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

2.8.1.3.5 Trend Analysis, to include a summary of the frequent, non-compliant and partial compliant findings found during the survey(s).

2.8.1.3.5 Provide the COR and Government a report 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 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 COR in accordance with project milestones. The COR will review the data prior to finalizing the summary.

3.0 QUALITY CONTROL 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 COR or designated representative.

3.2 Quality Control Plan (QCP). The Contractor shall provide to the Government a QCP at time of proposal and any updates after contract awarded. Any update to the QCP must be reviewed by the Government (Deliverable Eight (8)).

3.3 Positive incentives as a result of performance that continually exceeds the performance objectives as outlined in the PWS shall result in reduced surveillance and favorable Contractor

Performance Assessment Reporting (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 report 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 personal in nature 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 the

Government personnel should identify their workspace area with their name and company affiliation, or as a minimum, “Contractor” after their 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), family days or other days designated by the MTF. Due to mission operations or to unforeseen acts of nature or emergency, the Government and contractor may agree to different duty hours/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/family 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 Year’s 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 Complaint Record

7.5 APPENDIX E. Proposed Tentative Inspection Schedule 2015-2019

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

7.1 APPENDIX A

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

(HIPAA) OF 1996

HIPAA is comprised of several different sections, each to be implemented by the Dept. of

Health and Human Services. The medical facilities of the military services and the DOD health plans are specifically listed as covered by HIPAA. Currently, HIPAA Privacy and

Security Rules, as set forth in the Code of Federal Regulations, are in effect for all MTFs.

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 AF MTFs are contained in DOD

8580.02-R and AFI 41-217, which also contains additional Information Assurance requirements for all AF MTFs. DOD 6025.18-R, DOD 8580.02-R and AFI 41-217 are incorporated herein by reference. MTFs are responsible to insure overall compliance with

HIPAA requirements, which includes incorporation of certain requirements in contracts entered or amended after the respective implementation dates.

IAW these regulations, the Contractor and its employees meet the definition of Business

Associates. 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 each

MTF, 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 8520.02-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 8520.02-R or

AFI 41-217.

HITECH Act shall mean the Health Information Technology for Economic and Clinical Health

Act included in the American Recovery and Reinvestment Act of 2009.

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 Incident shall have the same meaning as the term “security incident” in 45 CFR

164.304, limited to the information created or received by Contractor from or on behalf of the

Covered Entity.

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 maintain the privacy of the Protested

Health Information and to prevent use or disclosure of the Protected Health Information other than as provided for by this Contract.

(d) The HIPAA Security administrative, physical, and technical safeguards in 45 CFR 164.308,

164. 310, and 164.312, and the requirements for policies, procedures and documentation in 45

CFR 164.316 shall apply to the Contractor. The additional requirements of Title XIII of the

HITECH Act that relate to security and that are made applicable with respect to covered entities shall also be applicable to the Contractor. 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. The additional requirements of Title XIII of the HITECH Act that relate to privacy and that are made applicable with respect to covered entities shall also be applicable to the Contractor.

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 6025.18R, 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 provision 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

8520.02-R, the CFR HIPAA Security Rule and AFI 41-217.

7.2 APPENDIX B

HQ USAF/SG ORGANIZATIONAL CONFLICT OF INTEREST

ORGANIZATIONAL CONFLICT OF INTEREST

Revised: 30 Aug 2007

The purpose of this clause is…