RFP ONLY - Attachment 02 - HSA-Clinical Lead-NM-CSM Function Guide.pdf

IHSC HSA / Discipline Specific Clinical Lead/ Nurse Manager/ Contract Service Manager Function Guide 2021

Purpose: The document is intended as a reference guide for navigating specific duties/responsibilities between different GTMs (HSAs and NMs), Clinical discipline leads, and the Contract Service Manager (CSM). All contractor relation questions, or clarification can be routed through the COR relevant Unit Chiefs.

Definitions:

Government Technical Monitors (GTM) - Primary GTM will be the Health Service Administrator (HSA) for all contract staff with exception of nursing. The GTM for Nursing contract staff is the Nurse Manager (NM). If HSA or NM are on leave, the HSA or NM will assume GTM duties for all CTRs.

Discipline Specific Clinical Lead - Clinical Director (CD), Lead Advanced Practice Provider (APP), Lead Pharmacist, Lead Dentist, Supervisory Behavioral Health Providers, etc. The Nurse Manager is also clinical lead for nursing.

Local Leadership Team (TRIAD) - Composed of HSA, CD, and NM

Local Governing Body - TRIAD plus other needed partners- AHSA, Lead APP, Supervisory Behavior Health Provider, FPHM, IPO, CSM, etc.

Regional Leadership Team - Regional HSA, Regional NM, Regional CD, Regional APP, Regional BH Consultant

Shift Requirements Document (SRD) - Monthly communication tool between vendor and the government documenting the governments staffing and shift requirements and vendors ability to fulfill those requirements.

Role HSA Responsibilities

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities Contract Service Manager Responsibilities

Workspace • Provide CSM with workspace as required, to include required workspace equipment (e.g., phone, computer scanner, desk, chair, etc.)

• No responsibility regarding workspace.

• No responsibility regarding workspace.

• Maintains workspace in a manner which aligns with local standards, including void of contraband and excessive personal items.

• Maintains personally identifiable information (PII) in accordance with IHSC and ICE standards/policy.

• Requests standard office supplies through written notification to local purchase card (PCARD) holder 30 days in advance of need or seeks to secure additional supplies through their employer.

Meetings • Establishes weekly meetings with CSM and GTMs (and CD if needed). This is separate from local weekly TRIAD meeting.

• Maintains agenda and minutes for weekly

CSM/GTM

meeting covering

• The CD or designated alternate can attend the weekly meetings scheduled with GTMs and CSM to ensure clear communication and collaboration with discipline leads as needed.

• NM-GTM attends weekly meetings with CSM to ensure clear communication and collaboration with discipline leads.

• Attends weekly meetings including GTMs and CD, covering at a minimum the following: staffing, scheduling, backfill, QI, orientation, training, tiers, and competency assessment.

• Does not attend fed only meetings (custody, ICE, TRIAD, etc.).

• Participates in all general staff meetings (monthly staff meeting, discipline at a minimum the following:

staffing, scheduling, backfill, quality Improvement (QI), onboarding and orientation, training, tiers, competency assessments.

• Permits CSM participation in all general staff meetings (monthly staff meeting, discipline specific meetings, and daily shift reports).

• Permits CSM attendance in local governing body meetings, QI and PHSP quarterly meetings.

specific meetings and daily shift reports).

• Attends local QI and PHSP quarterly meetings.

Scheduling • Communicates contract shift coverage priorities via the Shift Requirements

• Clinical Discipline Leads develop shift requirements for their discipline, schedule federal staff, and communicate staff needs to

• Nurse Manager develops shift requirements for nursing, schedules federal staff, and communicates contract needs to the HSA in accordance with SRD timeline.

• Fills all positions per the contract; will fill for all absences to include nursing backfills and extended absences (SOW 5.2.4)

Document according to established Shift Requirements Document (SRD) timeline.

• Works in collaboration with members of the Local Leadership TRIAD team to develop shift priorities and operational needs.

• Forwards populated Shift Requirements Document (SRD) in accordance with SRD timeline.

• Receives from CSM the populated Schedule Template and the Scheduling Compliance Tool in accordance with SRD timeline. The Scheduling Compliance Tool

CD, CD gives to HSA GTM for approval.

• The discipline leads would notify HSA of any needs to make schedule adjustments to ensure proper/accurate time oversight and documentation.

• The discipline leads align appropriate federal staff on the schedule through communications with CD to best serve the mission.

• Nurse Manager reviews schedule template provided by the CSM and provided feedback to the HSA regarding adequacy of coverage provided.

• Nurse Manager in collaboration with the HSA identifies the need for callout backfill and develops contingency plans should coverage not be provided.

• Nurse Manager identifies need for additional nursing coverage and communicates contract support needed to HSA. HSA will communicate to CSM.

• Reviews requests for schedule changes/trades for adequacy of number and skill mix of clinician and provides feedback to the HSA.

• Any changes to the schedule should be routed through the GTMs. Changes must be approved by the GTMs.

• The nurse manager assigns appropriate federal nursing staff on the schedule to best serve the mission.

• Communicates contract shift coverage via the Shift Requirements Document according to established timeline.

Maximize use of 40-hours in one-week and 80 hours in two weeks scheduling permitted for all clinical staff.

The 40 or 80 flexible scheduling per pay period, incurs no IHSC billed overtime when scheduled 80 hours in 2-weeks.

Clinical staff are authorized to work no more than 16 hours per 24 hour period.

• Forwards populated Shift Requirement Document and the Scheduling Compliance Tool to HSA in accordance with timeline.

• Receives from HSA the approved Schedule in accordance with established timeline.

• Follows the communication plan with the HSA regarding back-fill and expectations associated with “call outs”;

communicate to the HSA in is forwarded to the RHSA and CORs.

• Reviews in collaboration with Local Leadership Team, approves and posts the combined federal/CTR schedule in accordance with scheduling timeline. Emails the schedule to the CSM and all staff.

• Archives a copy of the posted schedule and all subsequent revisions (fed/CTR) per IHSC guidance.

The schedule is a legal document.

• Develops a communication plan with the CSM regarding back-fill and expectations associated with writing any schedule changes as they occur.

• Notifies HSA, as early as possible, when back-fill options are determined.

• CTR and federal staff may be authorized to exchange shifts; this type of agreement is subject to final approval by the GTMs.

• Communicates personal schedule changes to the HSA as their GTM.

• CSM is available during core hours, with flexibility to alter schedule to observe and address staff and staff issues on off shifts. Contract staff schedule changes are communicated in writing to the HSA.

• The CSM position does not meet the requirements for regular scheduled AWP or

CWS.

“call outs”;

ensure you are in the loop as your federal staff may need to cover if the CTR plan fails.

• Utilizes the chief’s dashboard to document “call-outs” and accurately reflect coverage or lack of coverage.

• CTR and federal staff may be authorized to exchange shifts;

this type of agreement is done collaboratively with all staff and approval must be documented by the GTMs and

CSM.

• Communicates contract shift coverage priorities via the Shift requirements document according to established timeline.

• Serves as the GTM for the CSM and documents hours worked.

Time and Attendance

• Ensures an operational government time keeping system is in place.

• Ensures the CSM enforces the requirement for CTR staff to follow established procedure when punches are missed.

• Verifies hours worked via the e-timesheet as the GTM for all contract staff except contract nursing staff. The NM serves as primary GTM for Contract nursing staff.

• Ensures only authorized and

• Clinical discipline leads communicate any identified concerns about staff time and attendance to the HSA.

• Verifies hours worked by contract nurses via the e-timesheet.

• Assists the HSA to review and resolve any timecard/schedule discrepancies.

• Ensures only authorized and verified hours worked are recorded on the e-Timesheet as verified by punch cards.

• Ensures approved deviation from scheduled hours worked are documented in writing and communicated to the HSA/CSM.

• Ensures hours worked dashboard is completed for contract nursing staff monthly as per the instruction of the CORs.

• Ensures all CTR staff use the government timekeeping system to officially document time in, meal breaks, and time out.

• Educates staff that only verified and authorized time are to be documented on the e-Timesheet.

• Educates staff on the process for documenting missed punches.

• Educates staff on documenting the “7-minute rule” on e-timesheets.

• Reconciles the CTRs punch cards with the e-timesheet to ensure all entries are accurate prior to submitting to the HSA for review and approval.

• Identify individuals that are not meeting time and attendance requirements and takes appropriate actions to resolve; this may verified hours worked are recorded on the e-Timesheet as verified by punch cards.

• Ensures approved deviation from scheduled hours worked are documented in writing and communicated to the CSM.

• Maintains copies of all approved e- Timesheets and corresponding punch cards (if applicable) for seven years after the end of the contract on which they were worked.

• • Ensures Hours Worked Dashboard is completed for all contract staff monthly as per the instruction of the COR.

include tardiness, failure to report as scheduled or excessive unscheduled leave.

• CSM submits their approved leave to HSA in advance of posting of the schedule.

• CSM to work during core operational hours, M-F, to ensure availability on shifts staffed by the federal administrators; variances due to operational needs will be coordinated with the HSA.

Staff Assignments

• Ensures post assignments are designated for all staff via the 24- Hour Shift Report, or via national/local process established in collaboration with TRIAD.

• Local Leadership TRIAD Team develops daily assignments for staff (federal and contract) at least 7 days in advance of shift.

• Ensures assignments align with duties and responsibilities in the staff's position description (PD) and scope of practice.

• Modifies assignments during the day as mission priorities change.

• Clinical Discipline Leads make recommendations to the CD for communication to TRIAD in development of daily assignments for staff (federal and contract) at least 5 days in advance of shift.

• Daily assignments can be adjusted as needed based on changing mission, but this must be communicated to GTMs.

• Ensures post assignments are designated for all staff via the 24- Hour Shift Report, or via national/local process established in collaboration with TRIAD. Daily shift assignments are discussed at each shift report.

• Local Leadership TRIAD Team develops daily assignments for staff (federal and contract) at least 7 days in advance of shift.

• Daily assignments can be adjusted as needed based on changing mission, but this must be communicated to GTMs.

• NM in collaboration with HSA ensures that all finalized 24-hour Shift Report Forms are archived for a minimum of 6 years.

• Ensures post assignments are communicated to contract staff in coordination with local leadership (TRIAD) team.

• Ensures assignments align with duties and responsibilities in the staff's PD and scope of practice.

• Ensure contract staff compliance with mission assignment priorities changes as communicated by GTMs.

• Avoids appearance of a personal services contract by adhering to employer employee relationship boundaries.

• Ensures CTR staff carry out assigned taskings timely.

• Avoids appearance of a personal services contract by adhering to employer employee relationship boundaries.

• In collaboration with nurse manager ensures that all finalized 24-hour Shift Report Forms are archived for a minimum of 6 years.

Staff Clinical Supervision / Oversight

• HSA has Government Technical Monitor (GTM) responsibilities in relationship to contract staff and collaborates with clinical supervisors to ensure care is care is delivered in accordance to position descriptions and scope of practice.

• Responsible as clinical discipline leads to supervise clinical care and practices to identify concerns with standards of practice, performance issues, to investigate reported incidents or errors, reports, etc.

Responsible to provide written feedback to the CD to provide to TRIAD for the development of process improvement recommendations.

• Responsible as GTM/clinical discipline lead for nursing to supervise clinical care and practices to identify concerns with standards of practice, performance issues, to investigate reported incidents or errors, reports, etc. Responsible to provide written feedback to the CSM and TRIAD for the development of process improvement recommendations.

• Supervises the clinical onboarding, orientation, and ongoing competency training for nursing

• Performs all oversight for contract staff in collaboration with clinical discipline leads to include completion of assigned workload and documentation according to position description and scope of practice.

• Supervises the clinical onboarding, orientation, and ongoing competency training for the discipline.

Collaborates locally with the triad/CSM on education/competency training to ensure knowledge of required clinical processes are established.

• Provides feedback to the

CD/HSA to CORs when best practices or exceptional performance is noted for coordination of recognitions approved by STGi.

staff. Collaborates locally with the CSM on education/competency training to ensure knowledge of required clinical processes are established

• Provides feedback through HSA or

NSU Leadership to the CORs when best practices or exceptional performance is noted for coordination of recognitions approved by STGi.

Tier Reporting

• Collaborates with Local Leadership Team (TRIAD) and reports timely, in writing to the CSM, performance or behavioral issues of contract staff.

• Follows IHSC Tier Memorandum and includes the CSM on Tier communication regarding contract staff.

• Responsible as clinical discipline leads to supervise clinical care and practices to identify concerns with standards of practice, performance issues, to investigate reported incidents or errors, reports, etc.

Responsible to provide written feedback to the CD to provide to HSA for the development of process improvement recommendations or contract tiers when necessary.

• If tiers are written for other than clinical specific reasons,

• Responsible as nurse manager to supervise nursing clinical care and practices to identify concerns with standards of practice, performance issues, to investigate reported incidents or errors, reports, etc.

• Collaborates with Local Leadership

Team (TRIAD) and reports timely, in writing to the CSM, of performance or behavioral issues of contract staff.

• Follows IHSC Tier Memorandum and includes the CSM on Tier communication regarding contract staff.

• Responds to all Tiers within established timeframes, in writing, to all parties originally copied on the Tier.

• Ensures that all Tiers are recorded on the Site Status Report.

• Forwards tiers for clinical staff to the CSM, CD, NM, DPM and PM with a CSM to the CORs and RHSA. Provides copy to the appropriate discipline clinical lead.

• Forwards tiers involving the CSM to the DPM and PM to the CORs and RHSA.

• Immediately elevates to Regional discipline lead if tier issues cannot be agreed upon locally

• Documents in real time, performance concerns using the Tier Reporting system.

the clinical discipline lead should be made aware through the CD and/or the triad.

• Forwards tiers for clinical staff to the CSM, CD, HSA, DPM and PM with a CSM to the CORs and RHSA.

• Documents in real time, performance concerns using the Tier Reporting system.

• Immediately elevates to Regional discipline lead if tier issues cannot be agreed upon locally

Performance Appraisals

• The government has no role in contractor

• The government has no role in contractor performance appraisals.

• The government has no role in contractor performance appraisals.

• Ensures regular performance evaluations are completed per company policy.

performance appraisals.

Hiring • For site visits-forwards all security clearance requirements received from CSM to local ICE authority for approval.

• Plays no role in the hiring process for contract staff.

• Discipline specific HQ leads assists credentialing department in reviewing professional requirements/licensure issues as needed and reviews hiring waiver requests with CORs as needed.

• Discipline specific HQ leads assists credentialing department in reviewing professional requirements/licensure issues as needed and reviews hiring waiver requests with CORs as needed.

• Performs all aspects of contractor staff interviewing, performing site-visits and determining appropriateness for site and position in accordance with company policies.

• Ensures newly onboarded CTR staff have eCW and computer access, that signature blocks follow IHSC guidelines, credential/personnel records have been established and are compliant with IHSC policy.

• Secures appropriate documentation for a local security clearance for site-visits; provides all required documents to the HSA for processing.

Contractor Orientation/ Initial competency reviews

• Develops an orientation plan to include facility and IHSC/ICE policy, accreditation and ensures clinical specific components are completed in

• Oversees orientation schedule using established discipline specific orientation requirements for clinical orientation in coordination with CD, HSA, and CSM.

Selects and assigns preceptors. Review’s care and learning throughout process,

• Oversees orientation schedule using established discipline specific orientation requirements for clinical orientation in coordination with CSM. Selects and assigns preceptors. Review’s care and learning throughout process, providing feedback to the individual/CSM.

• Implements orientation schedule as agreed upon, monitors staff’s progress, meets with new hires weekly to ensure timely completion of orientation.

• Forwards a copy of all completed orientation documents to include scope of practice, collaboration local leadership team (TRIAD)

• Archive copies of all staff completed orientation documentation to include scope of practice, competency checklist required by non-LIP's and ensure privileges have been granted by IHSC and secured in local personnel files.

providing feedback to the individual, HSA, CD, and CSM.

• Reviews and finalizes completed discipline specific orientation, competencies, and training documents final documents to the CSM to be shared with HSA for local personnel files.

• Reviews and finalizes completed discipline specific orientation, competencies, and training documents for local personnel files.

competency checklist for non-LIP's and privileging documents granted by IHSC for LIPs to the appropriate GTMs at the completion of orientation for review and final signature.

Annual Competency Review

• Ensures all annual training and competencies reviews are completed as required.

• Archives copies of all completed staff annual competency reviews to include scope of practice, competency

• Oversees annual training and/or competency review schedule in coordination with HSA, CD, and CSM.

• Selects and assigns preceptors.

• Monitors clinical care provided throughout the onboarding process, providing feedback to the individual staff member/CD/HSA and CSM.

• Reviews and finalizes completed annual discipline specific training documents,

• Oversees annual training and competency review schedule in coordination with CSM. Selects and assigns preceptors Review’s care and learning throughout process, providing feedback to the individual/HSA/CSM.

• Reviews and finalizes completed annual discipline specific competencies and training documents for local personnel files.

• Implements annual training and competency review schedule in collaboration with GTMs and discipline specific leads, monitors staff’s progress

• Forwards a copy of all completed annual documents to include scope of practice, competency checklist for non-LIP's and privileging documents granted by IHSC for LIP's are forwarded to the GTMs at the checklist required by non-LIP's and ensure privileges have been granted by IHSC and secured in local personnel files.

credentialing and privileging documents and provides final documents to the HSA through the CD.

completion annually for review and final signature.

Annual Peer Review

• Ensures annual peer review process is completed in accordance with policy.

• The CD or clinical discipline leads organizes initial and annual peer review, in collaboration with the CD/HSA and CSM as appropriate and oversees the peer review process.

• The NM leads and organizes initial and annual peer review for nursing staff, in collaboration with the CSM as appropriate, and oversees the peer review process.

• Collaborates with clinical discipline leads in annual peer review process.

Contract Service Manager Orientation

• Develops and implements orientation plan to include facility and IHSC/ICE policy, accreditation, and Facility Orientation Checklist.

• Reviews the Pena document for understanding of what and when to report an incident to the Joint Intake Center (JIC).

• No responsibility regarding CSM orientation unless instructed by CD.

• Develops and oversees orientation schedule using established discipline specific orientation requirements for clinical orientation in coordination with vendor supervisor during first six to eight weeks.

• Selects and assigns preceptors.

• Review’s care and learning throughout process, providing feedback to the individual/HSA/vendor lead CSM.

o Reviews and finalizes completed discipline specific competencies and scopes with CSM and HSA.

o CSM will be oriented to discipline specific role prior to completing orientation to CSM role.

• Completes orientation as provided by HSA/designee and communicates any issues that need clarification to same.

• The Lead CSM for vendor will orient CSM on:

o An overview and orientation of IHSC Schedule and scheduling process and scheduling timeline and 2080 requirement.

o Overview of Shift requirements document and scheduling Compliance Reporting Tool.

• Provides finalized competencies to the HSA/CSM.

o Expectations regarding staff call outs, backfill and overtime.

o Expectations regarding the CSM coverage and schedule.

• Provide overview of appropriate contract boundaries as it relates meetings and representation.

• Provide overview of the Tier reporting process.

• The Lead CSM for the vendor will ensure that competencies for the CSM are submitted to the GTM.

Termination • Ensures government equipment, keys, facility ID card, and PIV card are received/secured and disposed of, if indicated, per IHSC policy

• Reviews and completes required documents, makes required notifications, requests termination of

• Notifies the CD of any identified back-fill requirements associated with contract termination.

• Assists HSA in termination activities as needed.

• Notifies the HSA/CSM, in writing, of any identified back-fill requirements associated with the termination.

• Responsible coordinate termination of staff with

HSA/GTM.

• Responsible for escorting CTR staff off site upon termination. Security staff assistance may be requested.

• Secures government equipment and IDs (PIV and facility ID card).

• Ensures exit document checklist is completed in collaboration with HSA.

• Forwards all items to the GTM for processing (exit eCW and computer access.

• Completes required exit document checklist.

• Notifies the CSM, in writing, of any identified back-fill requirements associated with the termination.

documents, facility ID card, PIV card and equipment).

• Reviews eCW and ensures all provider notes are locked and closed.

• Reassigns all pending appointments to other CTR staff as appropriate; if unable to reassign to other CTRs due to workload constraints coordinate reassignment requirements with the HSA.

• Ensures the tracking and return of government furnished equipment (PIV card/phone/computer) until documentation is finalized.

Personnel, Health, Training, and Credentialin g Files

• Ensures the maintenance of personnel, training, credential, and health records for all staff.

• Performs a review of contractor personnel records (paper or electronic equivalent) bi-annually or more

• Provide any discipline specific orientation/training/

Competencies records that should be filed in permanent record to GTM upon completion.

• Provide any discipline specific orientation/training/Competencie s records that should be filed in permanent record to HSA. Assist HSA in ensuring compliance with personnel records, etc.

• Maintains personnel, health, training, and credential files.

• Provides GTM a copy/access to the tracking mechanism on a quarterly basis. If there are known deficiencies, identifies failures and corrective action plan to accompany tracking document.

• Ensures CTR staff performing care have current BLS, licensure, privileges, and frequently if compliance issues are identified.

• Submits Tiers for identified deficiencies in maintenance of personnel, training, credential, and health records.

• Submits Tiers for any significant failure to maintain training records (staff meetings, PALMS and site-specific training).

scope/competencies at all times. Staff not meeting this requirement are removed from performing work on the contract until compliance is met.

• Ensures that collaborative practice agreements for APPs, if indicated, are active and maintained per state board regulations.

• Ensures all mandatory training directed by ICE or local leadership is completed by suspense date to include POOL staff.

• Ensures CTR staff review staff meeting minutes are reviewed and an understanding of acknowledgement is signed within 14 days of the scheduled meeting.

• Maintains staff CEUs in training folders;

encourages collecting CEUs at time of renewed licensure receipt.

Emergency Preparednes s and Response

• Responsible to communicate emergency status to CSM with action request and copy CORs.

• Assesses, coordinates, and communicates to the HSA clinical staffing needs related to emergency operations (e.g., if more coverage

• Assesses, coordinates, and communicates to the HSA clinical staffing needs related to emergency operations (e.g., if more coverage needed above shift requirements document).

• Ensures contract staff participation in emergency preparedness activities (recall roster drills, man down drills, fire drills and disaster drills).

• Provides guidance to CSM on mission needs.

needed above shift requirements document).

• In the event of an actual disaster the CSM will contact the HSA/GTM and seek guidance and direction. They CSM may be recalled to the facility to assist in emergency response activities.