RFP-75H70622R00004 - RDMS.pdf

75H70622R00004

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

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C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) depository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

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M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

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SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

02/15/2022

Aberdeen Area Indian Health Servic Federal Building 115 Fourth Ave, SE Aberdeen SD 57401 until 1200 CS local time 02/28/2022

WENDA L WRIGHT 605

wenda.wright@ihs.gov

226-7724

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AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

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12. In compliance with the above, the undersigned agrees, if this offer is accepted within _____0_________ calendar days (60 calendar days unless a different period is inserted

A. This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in Federal Acquisition Regulation (FAR) Subpart 12.6, as supplemented with additional information included in this notice, FAR Part 12, Acquisition of Commercial Items (Title VIII of the Federal Acquisition Streamlining Act of 1994) (Public Law 103-355) & FAR 37.4, Non-Personal Health Care Services Contract (10 U.S.C. 2304 and 41 U.S.C 253). This announcement constitutes the only solicitation; proposals are being requested and a written solicitation will not be issued.

B. The Great Plains Area Indian Health Service (IHS) intends to award a Firm Fixed-Price, Non-Personal Healthcare Service, Commercial Item, Contract in response to Request for Proposal (RFP) 75H70622R00004.

C. This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2022-04/01-30-2022

D. This RFQ is a 100% Small Business solicitation and the associated NAICS Code is 621512, which has a small business standard of $16.5.

E. The quoted unit pricing must be “all inclusive” (to include but not be limited to travel, lodging, per diem, fringe benefits, federal, state and local taxes) plus all other costs pertinent to the performance of this contract. Utilize your most competitive and reasonable rates.

Complete the attached Price Schedule.

1. Base Year: May 1, 2022 thru April 30, 2023

One (1) RDMS or equivalent/Year $_______________.

Mobile Diagnostic Ultrasound Exam Unit to be placed on-site – 1080 Exams/Year Total Estimated Contract Price for the Base Year $_______________.

2. Option Year One (1): May 1, 2023 thru April 30, 2024 One (1) RDMS or equivalent/Year $_______________.

Mobile Diagnostic Ultrasound Exam Unit to be placed on-site – 1080 Exams/Year Total Estimated Contract Price for Option Year One (1) $_______________.

3. Option Year Two (2): May 1, 2024 thru April 30, 2025 One (1) RDMS or equivalent/Year $_______________.

Mobile Diagnostic Ultrasound Exam Unit to be placed on-site – 1080 Exams/Year Total Estimated Contract Price for Option Year Two (2) $_______________.

4. Option Year Three (3): May 1, 2025 thru April 30, 2026 One (1) RDMS or equivalent/Year $_______________.

Mobile Diagnostic Ultrasound Exam Unit to be placed on-site – 1080 Exams/Year Total Estimated Contract Price for Option Year Three (3) $_______________.

5. Option Year Four (4): May 1, 2026 thru April 30, 2027 One (1) RDMS or equivalent/Year $_______________.

Mobile Diagnostic Ultrasound Exam Unit to be placed on-site – 1080 Exams/Year Total Estimated Contract Price for Option Year Four (4) $_______________.

Total Estimated Contract Price for the Base + Four (4) Option Years $_______________.

G. Registered Diagnostic Medical Sonographer (RDMS)/On-site Medical Diagnostic Ultrasound Exam Unit Services

H. See attached Performance Work Statement. Services will be provided for the Woodrow Wilson Keeble Memorial Health Care Center, 100 Lake Traverse Drive, Sisseton, South Dakota. The period of performance will be May 1, 2022 through April 30, 2023 with Four (4) Option Years.

I. FAR 52.212-1 Instructions to Offerors-Commercial Items (November 2021).

Quotes shall be submitted on company letterhead stationery, signed, dated and it shall include:

1. Solicitation number RFP-75H70622R00004;

2. Closing Date: February 28, 2022 at 12:00 pm CST;

3. Name, address and telephone number of company and email address of contact person;

4. Technical description of the item/service being offered in sufficient detail to evaluate compliance with the requirements of the solicitation. This may include product literature, or other documents, if necessary;

5. Price and any discount;

6. “Remit to” address, if different than mailing address;

7. A completed copy of the representations and certifications at FAR 52.212-3 (see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete electronically);

8. Acknowledgment of Solicitation Amendments (if any issued);

9. Past performance information, when included as an evaluation factor, to include recent and relevant contracts for the same or similar items and other references (including contract numbers, points of contact with telephone numbers and other relevant information);

10. A statement specifying the extent of agreement with all terms, conditions, and provisions included in the solicitation. Offerors that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded from consideration.

In addition, Contractors shall provide the following:

Name and phone number of three (3) current professional references.

Complete and sign Child Care Position/Personnel Security Office form.

Complete and sign the Declaration for Federal Employment – Optional Form 306.

Complete and sign Addendum to Declaration for Federal Employment (OF306).

Complete and sign Licensure Requirement Form.

Copy of malpractice insurance coverage.

Shall meet the Qualifications and Knowledge Requirements in the Performance Work Statement and provide copies of the required documents (if needed).

Copy of current Board Certification Copy of active, current, full and unrestricted license to practice.

Copy of a recent Health Examination.

Copy of Diplomas/Specialty Certifications.

Copies of Continuing Education.

Current CV/resume.

J. FAR 52.212-2 Evaluation – Commercial Items (November 2021) – See attachment for full text.

K. FAR 52.212-3 Offer Representations and Certifications-Commercial Items (November 2021). See attachment for full text. The Offeror shall complete only paragraph (b) of this provision if the Offeror has completed the annual representations and certification electronically via the System for Award Management (SAM) website accessed through http://www.acquisition.gov. If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (p) of this provision.

L. FAR 52.212-4 Contract Terms and Conditions-Commercial Items (November 2021). Applied to this acquisition and it’s incorporated by reference.

M. FAR 52.212-5 Contract Terms and Conditions Required to Implement Statutes or Executive Orders- Commercial Items (January 2022). See attachment for full text.

N. Attached are the Federal Acquisition Regulations (FAR) & Health & Human Services Acquisition Regulation (HHSAR) clauses that are applicable including below.

O. Submit quote to:

Great Plains Area Indian Health Service Attn: Wenda Wright, Contract Specialist 115 4th Ave. SE, Room 309 Aberdeen, SD 57401 email wenda.wright@ihs.gov

Questions in regards to this solicitation shall be submitted in writing by email no later than February 22, 2022, 12:00pm CST.

SECURITY CLEARANCE

A security pre-clearance must be performed for any employees referred to IHS through this contract.

Fingerprints must be completed and adjudicated prior to services being performed under this contract.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List http://exclusions.oig.hhs.gov throughout the duration of the contract. It shall be the responsibility of the contractor to notify the acquisition official if there is a change in provider.

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.). Before starting work requiring routine access to I.H.S.

facilities or systems each person must complete a FBI National Criminal History Check (Fingerprint Check) adjudicated by an I.H.S. employee using the Office of Personnel Management Personnel Investigations Processing System.

Contractors shall allow five business days for I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of I.H.S. sites with electronic fingerprint capability is available from the Contracting Officer.

In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the performance of the work the Contractor shall provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access. If this is a Time and Materials, Labor-Hour or Cost Reimbursement contract, the contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. If this is a Fixed Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with IPA’s or MOA’s to tribal organizations please, click here IHS Sexual Abuse Prevention website. When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

ACCEPTANCE PERIOD: Your proposal must stipulate that it is predicated upon all the terms and conditions of this RFP. In addition, it must contain a statement to the effect that it is firm for a period of at least 90 days from the date of receipt by the Government.

No contract award shall be made to any vendor listed on the OIG Exclusions List at http://exclusions.org.hhs.gov throughout the duration of the contract.

Contractor must be registered with the System for Award Management (SAM) at www.sam.gov

“Certified Registered Nurse Anesthetist(s) (CRNA) will arrive on a Business Day ONLY to complete all Orientation and Background procedures. The Clinical Director or Designee will ensure all Orientation and Background procedures have been completed and an email will be sent to the Contracting department to state as such. The CRNA(s) will NOT see patients until Background/Fingerprints have been cleared.”

“The standards of medical practice and duties of the Contractor through its CRNA(s) shall be determined pursuant to the bylaws of the Service Unit. The regulations of the hospital, applicable provisions of law, other rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals must be followed.

Also the standards and recommendations of Centers for Medicare and Medicaid Services (CMS) or the Accreditation Organization must be adhered to. The Contract CRNA(s) shall be required to participate in a quality improvement program, which is consistent with current requirements for ongoing monitoring and evaluation of the quality and appropriateness of care.”

Invoice Processing Platform (IPP)

The Indian Health Service (IHS) is in the process of implementing an electronic invoicing system.

In compliance with the Office of Management and Budget (OMB) M-15-19 memorandum “Improving Government Efficiency and Saving Taxpayer Dollars Through Electronic Invoicing” directing Federal agencies to adopt electronic invoicing as the primary means to disburse payment to vendors. Invoices submitted under any award resulting from this solicitation will be required to utilize the Invoice Processing Platform (IPP) in accordance with HHSAR 352.232-71, Electronic Submission and Processing of Payment Requests”

IPP is a secure, web-based electronic invoicing system provided by the U.S. Department of the Treasury’s Bureau of the Fiscal Service, in partnership with the Federal Reserve Bank of St. Louis (FRSTL). Respondents to this solicitation are encouraged to register an account with IPP if they have not already done so. If your organization is already registered to use IPP, you will not be required to re-register- however, we encourage you make sure your organization and designated IPP user accounts are valid and up to date.

The IPP website address is: https://www.ipp.gov

If you require assistance registering or IPP account access, please contact the IPP Helpdesk at (866) 973-3131 (M-F 8AM to 6PM ET), or IPPCustomerSupport@fiscal.treasury.gov

“Should the contractor feel that use of the IPP would be unduly burdensome, their response to this solicitation should include an explanation of this position for a determination by the contracting officer”.

A CONTINUING RESOLUTION, also known as a "CR" is legislation enacted by congress that continues funding for specific ongoing activities if the fiscal year appropriation has not been enacted by the beginning of the fiscal year.

"Due to the Continuing Resolution, funds are presently available through February 18, 2022 (P.L. 117-70). The Government's obligation for performance of this contract beyond that date is contingent upon the availability of appropriated funds. No legal liability on the part of the Government for any payment may arise for performance under this contract beyond February 18, 2022. If funds are made available to the Contracting Officer for performance beyond the above cited date, the Contractor will receive notification in writing by the Contracting Officer."

FAR 52.232-18 - Availability of Funds FAR 52.232-19 - Availability of Funds for the Next Fiscal Year

PRICE SCHEDULE

Woodrow Wilson Keeble Memorial Health Care Center (WWKMHCC), Sisseton, South Dakota Mobile Diagnostic Ultrasound Unit/Registered Diagnostic Medical Sonographer On-Site Services

BASE YEAR:

ITEM # DESCRIPTION ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1. Mobile Diagnostic Ultrasound Exam Unit to be placed on-site

1080 Exams Year $ ___________ $ ___________

2. One (1) Registered Diagnostic Medical

Sonographer (RDMS) or equivalent

Year $_________ $____________

GRAND TOTAL FOR BASE YEAR: $ ___________

OPTION YEAR ONE (1):

ITEM # DESCRIPTION ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1. Mobile Diagnostic Ultrasound Exam Unit to be placed on-site

1080 Exams Year $ ___________ $ ___________

2. One (1) Registered Diagnostic Medical

Sonographer (RDMS) or equivalent

Year $_________ $____________

GRAND TOTAL FOR OPTION YR ONE

(1):

OPTION YEAR TWO (2):

ITEM # DESCRIPTION ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1. Mobile Diagnostic Ultrasound Exam Unit to be placed on-site

1080 Exams Year $ ___________ $ ___________

2. One (1) Registered Diagnostic Medical

Sonographer (RDMS) or equivalent

Year $_________ $____________

GRAND TOTAL FOR OPTION YR

TWO (2):

OPTION YEAR THREE (3):

ITEM # DESCRIPTION ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1. Mobile Diagnostic Ultrasound Exam Unit to be placed on-site

1080 Exams Year $ ___________ $ ___________

2. One (1) Registered Diagnostic Medical

Year $_________ $____________

Sonographer (RDMS) or equivalent

GRAND TOTAL FOR OPTION YR

THREE (3):

OPTION YEAR FOUR (4):

ITEM # DESCRIPTION ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1. Mobile Diagnostic Ultrasound Exam Unit to be placed on-site

1080 Exams Year $ ___________ $ ___________

2. One (1) Registered Diagnostic Medical

Sonographer (RDMS) or equivalent

Year $_________ $____________

GRAND TOTAL FOR OPTION YR

FOUR (4):

GRAND TOTAL

FOR BASE + FOUR (4) OPTION YEARS: $ _______________________

Performance Work Statement: Diagnostic Ultrasound Services

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER

INDIAN HEALTH SERVICE

PERFORMANCE WORK STATEMENT

DIAGNOSTIC ULTRASOUND SERVICES

GENERAL

This work statement describes the requirements for a non-personal service contract to provide on-site diagnostic ultrasound exams to support the mission of the Sisseton Indian Health Service (IHS)/Woodrow Wilson Keeble Memorial Health Care Center (WWKMHCC).

BACKGROUND

The IHS is an agency within the Department of Health & Human Services and is responsible for providing federal health services to American Indians and Alaska Natives. The Indian Health Service provides a comprehensive health service delivery system for approximately 1.9 million American Indians and Alaska Natives who belong to 567 federally recognized tribes, in 35 states. The Indian Health Service Headquarters is located in Rockville, MD and then divided into (12) physical areas: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland, and Tucson.

The Great Plans Area Office (GPAO) works in conjunction with 19 Indian Health Service Units and Tribal Managed Service Units to provide health care to approximately 122,000 Native Americans located in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office’s service units include seven hospitals, eight health centers, and several smaller health stations and satellite clinics.

Our facility, the WWKMHCC, falls under the GPAO. WWKMHCC provides medical care for approximately 7,000 tribal members living on the Lake Traverse Reservation. Serving a rural area, many of our patients travel 100 miles round trip to receive care. The WWKMHCC was built in 2007 to provide an expanded level of outpatient health care services specifically designed to meet the needs of the WWKMHCC population. Services include: Pharmacy, Physical Therapy, Public Health Nursing, Radiology Services, Laboratory, Dental, Community Health, Purchased & Referred Care Services, Nutrition Services, and Optometry.

OBJECTIVE

To provide on-site various diagnostic ultrasound exams for the Indian Health Service. The services provided by the Contractor shall be as comprehensive as the Indian Health Service supplied facilities, equipment, and support services permit. The providers at the WWKMHCC will determine which of their patients require ultrasound exams based on urgency and the limited provision of services. The WWKMHCC requires this service to continue without interruption during the term of this contract.

PERIOD OF PERFORMANCE

Date of award for one year of service plus four option years as scheduled with the Radiology Supervisor or her designated representative. (May 1, 2022 – April 30, 2023 plus Four Option Years).

WORK SCHEDULE: Hours may range between 8:00am to 5:00pm Monday through Friday, depending on number of exams needed. Weekends, overtime, Federal Government holidays, and compensation time are excluded. The facility has the right to terminate services if a full-time employee is added to the department or for other situations where satisfactory department coverage is available through utilizing other department staff members. The facility will provide the Contractor with a 30-day notice if the above applies.

PLACE OF PERFORMANCE

Woodrow Wilson Keeble Memorial Health Care Center Indian Health Service 100 Lake Traverse Drive Sisseton, SD 57262

DESCRIPTION OF SERVICES

The mission of WWKMHCC is to provide the best possible healthcare services to the patients on the Lake Traverse Reservation in South Dakota. To meet this mission, the WWKMHCC is requesting a non-personal contract to provide on-site diagnostic ultrasound exams for IHS patients.

This contract resulting from this solicitation shall:

1. Be a non-personal health care services contract under which the Contractor is an independent contractor;

2. Allow the Government to evaluate the quality of professional and administrative services provided, but retains no control over the medical, professional aspects of the services rendered, (e.g. professional judgements, diagnosis for specific treatment);

3. Require the Contractor to indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring during contract performance;

4. Require the Contractor to maintain medical liability insurance, in the coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned; and

5. Require the Contractor to ensure its subcontracts for provisions of health care service, contain the requirements of the clause at FAR 52.237-7, including the maintenance of medical liability insurance.

CONTRACTOR RESPONSIBILITY

The Contractor shall:

1. Provide a Registered Diagnostic Medical Sonographer (RDMS or equivalent) to perform a variety of routine ultrasound examinations, including vascular, abdominal, OB/GYN, and echocardiography.

2. Provide an estimated total of 1,080 mobile diagnostic ultrasound exams per year on patients, as requested by providers at WWKMHCC for the term of this contract. Images obtained shall become the property of Indian Health Service, and submitted by WWKMHCC for diagnostic interpretation. Contract performance shall be according to the requirements contained in this Performance Work Statement.

3. Provide assurance that the ultrasound services provided, meet the rules and regulations outlined by JCAHO (Joint Commission on Accreditation of Healthcare Organizations), CMS (Centers for Medicare and Medicaid Services), HCFA (Health Care Financing Administration), and AAAHC (Accreditation Association for Ambulatory Health Care) standards set forth by the Indian Health Service.

4. Document compliance with personnel, orientation, obtaining and preserving records, equipment, safety, and quality assurance standards according to JCAHO, CMS, HCFA, AAAHC, American College of Radiology, the American Registry of Radiologic Technologists, and the American Registry of Diagnostic Medical Sonography.

5. Provide and maintain all ultrasound equipment. Maintenance shall be performed in accordance with the device manufacturer specifications. Contractor shall provide a copy of most recent calibration and maintenance records to IHS for any equipment brought into the facility, as well as copies of any service/calibration performed during the period of this contract.

6. Provide youth heart screenings and stroke screenings biannually on-site.

7. Shall meet and document all quality control and calibration requirements.

8. Shall work in conjunction with interpreting physicians and the radiology department and shall follow the facility procedures for corrective action when images obtained, are of poor quality.

9. Shall generate and maintain proper medical record information on beneficiaries to whom exams are provided in accordance with Indian Health Service regulations. The Contractor shall prepare all medical record documentation to meet or exceed the established standards of the IHS facility to include but not be limited to: timeliness, legibility, accuracy, content, and signature. All medical record information generated in the performance of this contract will remain the property of, and subject to, the exclusive control of the Indian Health Service. In-service on proper form completion will be given to the Contractor prior to providing services.

10. Must have DICOM communication available for direct connection to PACS via the IHS network.

Contractor will be required to provide AE title and pro used by their Ultrasound unit and IHS will provide a static IP address for use when in the facility. IHS will perform safety inspections and enter the equipment into the IHS computerized management database and will provide an equipment control number that will remain with the equipment at all times. The contractor will purge or otherwise erase/delete all patient information and studies upon confirmation that the study has been stored in the PACS and prior to the equipment leaving the facility. Prior to equipment leaving the facility, purging/deletion of studies and patient information must be reviewed and confirmed by IHS staff.

11. In the event the ultrasound equipment is unable to send DICOM study information to our facilities PACS, the contractor shall provide a CD/DVD copy of all study information for department staff prior to leaving the facility.

12. Complete the IHS interconnectivity agreement within thirty (30) days of contract award date.

This agreement will allow Contractor’s imaging equipment to connect to the IHS Network.

Failure to complete this agreement may result in contract termination.

13. Shall perform all mobile, diagnostic ultrasound exams of IHS patients at the IHS facility except in certain instances when patients are referred to private facilities for performance of special diagnostic procedures or definitive care not offered in the IHS facility. All referrals to private facilities or providers for specialized diagnostic studies or definite care not offered at the IHS facility shall follow Indian Health Service regulations and policies on patient referrals.

14. Shall assess its services to assure its quality of care. The Contractor shall participate in a continual process of self-evaluation and strive for excellence in providing mobile, diagnostic ultrasound exam services.

15. Shall comply with all IHS facility infection control and safety procedures, practices, and standards.

16. Shall meet all applicable JCAHO, CMS, HCFA, and AAAHC standards during the performance of this contract.

17. Shall comply with Section 231 of the Crime Control Act of 1990, P.L. 101-647; the Indian Child Protection and Family Violent Prevention Act, P.L. 101-630; the Privacy Act of 1974; and the HIPAA Act of 1996. Failure to comply with these statutes will result in immediate removal. The Contractor shall be subject to a background investigation.

18. Shall respect and maintain the basic rights of patients, to include but not be limited to, personal dignity.

19. Shall coordinate a weekly schedule with the Project Officer/COTR (Contracting Officer’s Technical Representative) at the WWKMHCC.

20. Shall be responsible for all travel, lodging, meals, labor, fringe benefits, Life Insurance, Social Security, Federal, State, and Local taxes, plus any other costs pertinent to the performance of this contract.

21. Operator of the equipment must be in compliance with IHS Information Technology security training requirements (ISSA), HIPAA training, Privacy Act Training, ITAC, and have HSPD-12 clearance.

QUALIFICATIONS

1. The contract diagnostic medical sonographer shall meet the same privileging requirements as a permanent IHS radiology technologist before being allowed to provide services in an IHS facility.

2. The contract diagnostic medical sonographer shall be a Registered Diagnostic Medical Sonographer (RDMS or equivalent) to perform a variety of routine ultrasound examinations, including vascular, abdominal, OB/GYN, and echocardiography.

3. The contract diagnostic medical sonographer shall not have any work or health restrictions which interfere with the performance of services.

4. The contract diagnostic medical sonographer shall speak, understand, read, and write English fluently and communicate with sufficient clarity to be understood by WWKMHCC personnel and patients.

5. The contract diagnostic medical sonographer shall possess the skill, knowledge, and sufficient initiative, interpersonal relationship skills, and social sensitivity all with full consideration of the mental, emotional, physical, and cultural factors, such that he/she can relate constructively to patients from Native American communities.

6. The contract diagnostic medical sonographer shall maintain standards of personal hygiene and grooming such that his/her image is compatible with the expectations of the WWKMHCC clinical staff and the Indian community.

TECHNICAL REQUIREMENTS

The Contractor shall provide:

1. A Registered Diagnostic Medical Sonographer (RDMS or equivalent) to perform a variety of routine exams including echocardiography, and must be registered in abdomen, OB, and vascular ultrasound.

2. Reliable, scheduled services.

3. Ultrasound equipment and DICOM Image capture.

4. Images of high diagnostic quality, and follow established protocols for ultrasound exams.

GOVERNMENT FURNISHED PROPERTY, FACILITIES, AND SERVICES

The WWKMHCC shall:

1. Provide adequate space, electrical, and processing capability necessary to provide ultrasounds services at WWKMHCC.

2. Provide all administrative and professional support available to IHS personnel. This will include, but not limited to: copy machines, telefax machines, medical library, and telephone service. The same restrictions to use these items for official Indian Health Service business apply.

3. Provide an orientation to the WWKMHCC and the Indian community being serviced. The initial orientation and continuing orientation shall be provided by service unit personnel.

4. Provide all medical and non-medical equipment and supplies used in the IHS facility for the care and management of patients.

5. Provide all required blank Government forms applicable to the IHS. An appropriate orientation to the necessity of such forms will be provided by service unit personnel.

6. Accompany minor children and assure that proper consent has been signed by a parent or legal guardian.

7. Preserve and maintain images, and the diagnostic interpretation thereof.

8. Provide an ongoing method of monitoring and evaluation of the quality and appropriateness of patient care and of identifying deficiencies in the quality of services performed before the level of performance becomes unacceptable.

9. Bill for ultrasound exams and interpretation.

10. Generally, the WWKMHCC will not provide patient transcription services. Legible handwritten documentation of medical records is acceptable in place of recorded dictation.

CONTRACTOR FURNISHED EQUIPMENT, FACILITIES, AND SERVICES

The Contractor shall:

1. Provide DICOM compliant diagnostic ultrasound equipment and transducers that are maintained and calibrated in accordance with device manufacturer specifications and calibrated at least annually.

2. Supply all patient consumable items required for ultrasounds including transmission gel and specific cold sterilization products if required by the manufacturer of the contractor’s equipment.

3. Provide a Registered Diagnostic Medical Sonographer (RDMS or equivalent) to perform a variety of routine exams.

RECORD OF SERVICES PROVIDED

Radiology Supervisor shall submit quarterly spreadsheet of placement dates to the COR to monitor the placement requirement of seamless coverage. A record must be maintained in order to follow the budget of the contract. This is a Firm Fixed-Price, Indefinite Delivery/Indefinite Quantity contract. Records will be maintained for the life of the contract as per FAR regulations for contract close-out processes and will be subject for review and/or audit by the Radiology Supervisor, Contracting Officer, or Contract Officer Representative at any time during business hours.

Designated Project Officer The Designated Project Officer/COR for this contract is:

Ella Greybuffalo Administrative Support Assistant Woodrow Wilson Keeble Memorial Health Care Center 100 Lake Traverse Drive Sisseton, SD 57262 Phone: (605) 742-3862 Ella.Greybuffalo@ihs.gov

PAYMENT PROCESS

The contractor shall submit a monthly, original invoice to:

Great Plains Area Indian Health Service ATTN: Finance Department

Room 309 Federal Building 115 4th Avenue S.E.

Aberdeen, SD 57401

The following information must be included on the invoice to process payment:

1. Contractor Name

2. Mailing Address

3. Telephone Number

4. Tax ID Number

5. Purchase Order Number (in Block #3 of the OF-347 form)

6. Invoice Number and Date

7. Description of Services Provided, Quantity, Unit of Issue, and Total Amount Due

8. DUNS Number (Data Universal Number)

Please send copy of the invoice to:

Woodrow Wilson Keeble Memorial Health Care Center ATTN: Property and Supply

100 Lake Traverse Drive Sisseton, SD 57262

PERFORMANCE SURVEILLANCE PLAN. Performance surveillance monitors will be established to comply with regulatory guidelines and to monitor contract performance. The performance surveillance plan has been developed to outline the Indian Health Service’s general plan in providing effective and systematic surveillance and reporting of all aspects of contract performance. This plan recognizes the responsibility of the contractor to carry out its own quality control obligations in the performance of this contract.

Surveillance will be accomplished through review of the contractor’s performance against requirements listed in the work statement and performance standards listed in this plan. Performance-based incentives are consistent with the intent and purpose of the contract.

Upon completion of the contract, the Government will complete and keep on record the Contractor’s performance evaluation form based on the following objectives.

OBJECTIVE/

TASK

PERFORMANCE

STANDARD

ACCEPTABL

E QUALITY

LEVEL (AQL)

SURVEILLANCE

METHOD/

MEASURES

CONTRACTOR

INCENTIVE

Disincentive/ Deduct

PERFORMANCE

OBJECTIVE 1

The contractor shall establish a technical approach and management plan for the placement of a Registered Diagnostic Medical Sonographer (RDMS) into temporary assignments five days a week at

WWKMHCC

providing seamless coverage

Contractor shall provide a Registered Diagnostic Medical Sonographer (RDMS or equivalent) to complete all paperwork within established time frames

Complete IHS background investigation information and return to WWKMHCC within 7 days.

Placement of staff 100% of the time

Radiology Supervisor shall submit quarterly spreadsheet of placement dates to the COR to monitor the placement requirement of seamless coverage

Favorable contractor performance evaluation

Unfavorable contractor performance evaluation

PERFORMANCE

OBJECTIVE 2

Contractor shall provide optimal sonography images to the Radiologist for interpretation

The Contractor will provide acceptable and optimal images to the Radiologist at all times.

100% Radiology Supervisor will document any complaints from Radiologist on provided sonography imaging.

Favorable contractor performance evaluation

Unfavorable contractor performance evaluation, Contractor to provide an acceptable Registered Diagnostic Medical Sonographer to provide sonography services

PERFORMANCE Providers shall be respectful, courteous, and

No more than two (2) valid

The contractor shall respond to the COR in

Favorable contractor

The invoice for the provider will be put

OBJECTIVE 3

Contract Provider(s) are capable and knowledgeable of effective communication culturally sensitive to IHS patients and staff complaints per provider writing whenever they receive notice of more than two complaints against a provider with an explanation of what was done to address the matter performance evaluation on hold until the complaint is investigated and resolved in 7 working days, removal from contract until such time the contract provider(s) meet qualification standards

PERFORMANCE

OBJECTIVE 4

Completion of medical record documentation

Completes medical record documentation by deadlines as required in scope of work

Completes check-out with Health Information Department (HIM) on last scheduled day to confirm completion of records

Documentatio n completed by deadline at least 95% of the time

Clinical Director reviews weekly documentation report from HIM, the contractor shall respond to the COR in writing whenever documentation does not meet the deadlines

Favorable contractor performance evaluation

The invoice for the Contract Provider in question will be put on hold until proper documentation of the chart(s) is completed

PERFORMANCE

OBJECTIVE 5

Contract Provider(s) shall complete all required trainings on time

All required training is completed on time

95% completion, no deviations

Periodic sampling Favorable contractor performance evaluation

Unfavorable contract performance evaluation, suspension or termination of all physical and/or electronic access privileges and removal from contract until training is completed

PERFORMANCE

OBJECTIVE 6

Contract Provider(s) is aware of all laws, regulations and policies related to Privacy, Confidentiality and HIPAA, and complies with all standards of privacy

All Contract Provider(s) comply with all laws, regulations and policies relating to Privacy, Confidentiality and HIPAA

100% compliance, no deviation

Contract Provider shall provide copies of all required trainings to Clinical Director, HIM will report any violation to the Clinical Director for review

Favorable contractor performance evaluation

Immediate removal of Contract Provider(s) from contract

1./7#

.... "f� (

Indian Health Service Office of Human Resources

Memorandum

To:

From:

Subject:

Date:

Supervisor of child care covered position incumbent Human Resources/Personnel Security Office Child Care Position Provisional Authorization

This is notice you will supervise a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act. The Indian Health Service is required to compile a list of all authorized positions with duties and responsibilities that Involve regular contact with or control over Indian children and investigate the character of each individual who is employed or is being considered for employment in such a position. The requirement is that the individual is to be under the supervision and in sight (chaperoned) of a previously investigated staff person (favorably adjudicated).

The position and individual identified below has been designated as a covered position and has been granted provisional authorization:

Name:

Position title:

The following criteria must be met for the above mentioned individual:

► Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

► Continue with processing of background investigation - Tier 1 with child care (minimum).

► Provide requested documentation/information as requested from the Personnel Security/HR

Office.

Employee/Contractor/Affiliate must be 100¾ chaperoned at all times by a staff person and/or alternates who have at a minimum a favorably adjudicated Tier 1 with child care (Tier 1 C) or CNACI investigation.

The following individuals listed below agree and accept responsibility of the chaperone role.

Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated

I have verified a favorable investigation is on file for identified chaperones:

Personnel Security/HR Office designee Date

Your signature indicates you are accepting responsibility, will comply with the above criteria, and will assure the above named individual will be chaperoned at times while on site.

Department Supervisor/Designee Date

This provisional authorization is in effect until the favorably adjudicated certification of investigation is in place. I am aware that failure to comply with the above criteria could result in removal and termination of the granted provisional authorization.

Employee/Contractor/Affiliate Date

Declaration for Federal Employment"'

('Thia form may also be used to eases& fltneu ror federal contract employment) form Al)prove<l:

0MB No 3206-01$2

Instructions-------------------------------

The Information collected on lhls form Is used to determine your acceptablllty for Federal and Federal contract employment end your enrollment status In lhe Government's Life Insurance program. You may be asked to complete this form et any lime during the hiring process. Follow Instructions lhel the agency provides. If you ere selected, before you are appointed you wlll be asked to Update your responses on this form end on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this dec laratlon or attached fom,s or sheets may be grounds for not hiring you, or for flrlng you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, tltle 18, section 1001).

Either type your responses on this form or print clearly In dark Ink. If you need addition el space, attach letter-size sheets (B.6" X 11"), Include your name, Social Security Number, and Item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management Is authOrlzed to request this Information under sections 1302, 3301, 3304, 3328, and 8716 or title 6, U.S. Code. Sectlon 1104 of tllle 5 allows the Office ot Personnel Management 10 delegate personnel management functions to other Federal agencies. If necessary, and usually In conjunction with another form or forms, this form may be used In conducting an Investigation to determine your sultablllty or your ability to hold a security clearance, and II may be disclosed to authorized offlclels making similar, subsequent determinations.

Your Social Security Number (SSN) Is needed to keep our records accurate, because other people may have the same name and birth dale. Public Law 104-134 (Apr/I 26, 1996) asks Federal agencies to use this number to help Identify Individuals In agency records. Giving us your SSN or any other Information Is voluntary. However, If you do not give us your SSN or any other Information requested, we cannot process your appllcellon. Incomplete addresses end ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure or this record or Information In this record Is In accordance with routine uses found In System Netice OPM/GOVT-1, General Personnel Record�. This system allows disclosure of Information to: training faollllles; organizations deciding claims for retirement. Insurance. unemployment, or health benefits; officials In lillgatlon or administrative proceedings where the Government Is a party; law enforcement agencies concerning e vlolntlon or law or regulallon; Federal agencies for stallslical reports and studies: oHicials of labor organizations recognized by law In connection with representation of employees; Federal agencies or olher sources requesting Information for Federal agencies In connecllon with t'llrlng or ratalnlng, security clearance.

securlly or sullablilty lnvostiga!ions, classifying Jobs, contructing, or Issuing licenses. grants, or olher banellls; public and private organizations, Including news media, which grant or publicize employee recognitions and awards; the Maril Systems Protection Ooard, the Office of Special Counsel, the Equal EfTlployment Opportunity Commission. the Federal Labor Rolellons Authority, Iha National Archives and Records Adtninlstretlon, end Congressional offices In connection with their officla.l functions; prospective non-Federal employers concerning tenure of employment, clvU service status, length of service, end lhe date ond noture of action for separation as shown on the sr- 50 (or authorized exception) of a specifically Identified Individual: requesting organizations or Individuals concerning the home address and other relevant information on those w110 mlgM have contracted en Illness or been exposed to a health hazord; authorized Federal and non-Federi:il agencies for use In computer matching: spouses or dependent children asking whether the employee has changed from a sell-and•famlly to a sell-only hea!th benents enrollment; lndlvldueh;

working on a contract, service, grant, cooperative agreemenl. or job for the Federal government; non-agency members of en agency's performance or other panel; and agency-appointed representaHves or employees concerning Information Issued to the en1ployees about fitness-for-duty or agency-flied dlsablllty rellroment procedures.

Publlc Burden Statement ----------------------------•

Public burden reporting for this collecllon of Information Is estimated lo vary rrom 5 to 30 minutes with an average of 15 minutes per response, Including time for reviewing 1nstn1c1lons, searching existing data sources. gathering the data needed, and complellng and reviewing the collectlon of information. Send comments regarding the burden esllmete or any olher aspect of the collection of Information, Including suggestions for reducing lhls burden, to lhe U.S. Office of Personnel Management, Reports and Forms Manager (3206-0102), Washington, DC 20415-7900. The 0MB nurnber, 3206-0102, Is valid. OPM may (101 coltec;t this Information, and you are not required lo respond, unless this number Is displayed, U.S. Office of Personnel Management 6 U 9 C 1302, 3301, 3�, 3328 & 8718

�form"°6 R•vl>ed Ociober 2011

Provk>u■ edllk>n1 0010/ole and unuub/o

Declaration for Federal Employment* ("This form may also be used to 11&eeu mne88 for federal contraot employment)

GENERAL INFORMATION

fom, /.pproved:

0MB No. �206--0182

1. FULL NAME (Provide your full name. If you h11ve only Initials in your name, provide them and Indicate "Initial only". If you do not have I middle name Indicate "No Middle Name", If you ara a "Jr.," "Sr.," etc. enter this under Suffi>1, First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3b, ARE YOU A U.S. CITIZEN?

3a. PLACE OF BIRTH (Include city and state or country)

J YES I. NO (lf"NO", provide country of citizenship) ♦

4, DATE OF BIRTH (MM/0D/YYYY)

6, OTHER NAMES EYER USEC (For example, maiden name, nickname, elo) 6, PHONE NUMBERS (Include area codes)

Selective Service Registration

Doy ♦

Night ♦

If you are a male born after December 31, 1959, and are at least 1 B years or age, civil service employment law (5 U,S,C, 3326) requires that you must register with the Selective Service System, unless you meet certain exemptions, 7a. Are you a male born after December 31, 1959? ,:; YES r/ NO (If "NO", proceed to 8.)

7b. Have you registered With the Selective Service System? 1: YES (lf"YES", proceed to 8.) r: NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) In Item 16.

MIiitary…