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

IHSC HSA / Discipline Specific Clinical Lead/ Nurse Manager/ Contract Services 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 Services Manager. All contractor relation questions, or clarification can be routed through the Contracting Officers Representative (COR).

Definitions:

Government Technical Monitors (GTM)- Primary GTM will be the Health Service Administrator (HSA). The primary delegated GTM for all contract staff that fall under Nursing is the Nurse Manager (NM). If HSA or NM are on leave, each will designate an acting GTM to cover the duties during their absence.

Discipline Specific Clinical Lead- Clinical Director (CD), Nurse Manager (NM), Lead Advanced Practice Provider (APP), Lead Pharmacist, Lead Dentist, and Supervisory Behavioral Health Providers (BHP).

Local Leadership Team (TRIAD)- Composed of HSA, CD, and NM. At the discretion of the Triad, it may also include the AHSA(s) and FHPM.

Local Governing Body- Led by the HSA and includes members of the TRIAD (CD & NM) plus other needed stakeholders- AHSA, Lead APP, Lead Dentist, Lead Pharmacist, Supervisory BHP, FPHM, IPO, and CSM.

Regional Leadership Team- Regional HSA (RHSA), Regional NM (RNM), Regional CD (RCD), and Regional APP (RAPP). Additional Regional leaders are included on an as needed basis.

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

Role HSA Responsibilities (Primary

GTM)

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services 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.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

• 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 (HSA & NM), and CD (and other supervisory SMEs as needed).

This is separate from the local weekly TRIAD meeting.

• Maintains agenda and minutes for weekly CSM/GTM meeting covering at a minimum the following: staffing, scheduling, backfill, quality Improvement (QI), onboarding and orientation, training, tiers, competency assessments.

• Permits Contract Services Manager participation in all general staff meetings

• 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 and HSA, and CD to ensure clear communication and collaboration.

• Attends weekly meetings with GTMs and CD (and other supervisory SMEs as needed), covering at a minimum the following:

staffing, scheduling, backfill, QI, orientation, training, tiers, and competency assessment.

• Only at GTMs request may attend federally based meetings (custody, ICE, TRIAD, etc.). Cannot represent

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

(monthly staff meeting, discipline specific meetings, and daily shift reports).

• Permits Contract Services Manager attendance in local governing body meetings, QI and PHSP quarterly meetings.

the government when attending.

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

• Attends local QI and PHSP quarterly meetings.

Scheduling • Communicates contract shift coverage priorities via the Shift Requirements 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

• Clinical Discipline Leads develop shift requirements for their discipline, schedule federal staff, and communicate staff needs to CD, CD gives to HSA GTM for approval.

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

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

• If discipline leads identify need

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

• Nurse Manager reviews schedule template provided by the Contract Services Manager and provides 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.

• Fills all positions at 2080 hours per year; will fill for all absences to include AL, SL, extended sick leave, FMLA and vacancies.

• Permitted to cover federal call outs/vacancies if requested and approved in writing by GTM.

• 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

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities timeline. The Scheduling Compliance Tool is forwarded when requested to the RHSA and CORs for awareness.

• Reviews in collaboration with Local Leadership Team, approves and posts the combined federal/CTR schedule in accordance with scheduling timeline. Posts and e-mails 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 “call outs”;

HSA must be kept in the loop as federal staff may need to cover if the CTR is unable to secure backfill.

• Utilizes the SharePoint reporting tool to document “call-outs” and accurately reflect coverage or lack of coverage.

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

for additional staff coverage they will communicate contract support needed to CD and CD will discuss with HSA.

HSA will communicate to CSM.

Any changes to the schedule should be routed through the CD to the primary GTM. Changes must be approved by the primary GTM.

• 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 nursing schedule should be communicated to primary

GTM.

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

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 in a 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

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities 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.

in 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.

Time and Attendance

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

• Clinical discipline leads communicate any identified

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

• Ensures all CTR staff use the government timekeeping system to

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

• 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 delegated GTM for Contract nursing staff.

• 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 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.

concerns about staff time and attendance to the HSA.

• 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.

officially document time in, meal breaks, and time out.

• Educates staff that only authorized hours worked 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 GTMs for review and approval.

• Identify individuals that are not meeting time and attendance requirements and takes appropriate actions to resolve; this may include tardiness, failure to report as scheduled or excessive unscheduled leave.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

• 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.

• May review daily assignments for staff (federal and contract) as applicable.

• 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.

• Avoids appearance of a personal services contract by

• 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.

• May review daily assignments developed by NM for staff (federal and contract) as applicable.

• 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.

• Nurse Manager or designee develops daily assignments for staff (federal and contract) at least 7 days in advance of shift and provides to HSA/CD for review as applicable.

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

• 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.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities 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.

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

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

• Ensures CTR staff carry out assigned taskings timely.

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

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 delivered in accordance with 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.

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

• 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

• 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.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities 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 vendor.

for nursing 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 vendor.

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 (except if Tier is for CSM).

• Forwards tiers for clinical staff to the CSM, CD, NM, Contract Deputy Program Manager (DPM) and Program Manager (PM) with a CSM to the CORs and RHSA/RCD (as needed for clinical disciplines)/RNM (for

• 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, the clinical discipline lead

• 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.

• Minor issues are expected to be addressed at the lowest possible level locally and do not require a Tier notification, however ongoing minor issues may escalate to a Tier if not addressed.

• An official response is required outlining the details of the event and the action, if any, that is being taken to prevent a similar incident from occurring in the future.

• Dialogue between the GTM and the Contract

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities nursing Tiers). Provides copy to the appropriate discipline clinical lead.

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

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

should be made aware through the CD/RCD.

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

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

Services Manager is expected to address the concerns of the GTM with the goal being resolution of the tier at the lowest possible level, as appropriate.

• The vendor will respond to all Tier III issues in writing via email within 24 hours.

• The vendor will respond to all Tier II issues in writing via email within 72 hours.

• The vendor will respond to all Tier I issues in writing via email within 5 business days.

• Administrative Tiers are for notification and documentation purposes, no response timeline required.

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

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

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

• Performs all aspects of interviewing, performing site-visits and determining appropriateness for site and position.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

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

waiver requests with CORs as needed.

waiver requests with CORs as needed.

• 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.

• Notifies local GTM of all new onboarding staff prior to start date.

Contractor Orientation/ Initial competency reviews

• Develops an orientation plan to include facility and IHSC/ICE policy, and accreditations, and ensures clinical specific components are completed in collaboration with local leadership team (TRIAD) Archive local copies of all staff completed orientation

• 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, providing

• 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,

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

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities 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.

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.

providing feedback to the individual/CSM.

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

Forwards a copy of all completed orientation documents to include scope of practice, 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 local copies of all completed staff annual competency reviews 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.

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

• 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 HSA or NM (for nurses) at the completion annually for review and final signature.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

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.

• Ensures staff participation and compliance with Peer Review process as per agency policy.

Contract Services 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).

• Provides training and orientation on government timekeeping system.

• The Lead CSM for vendor in collaboration with HSA 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

• No responsibility regarding Contract Services Manager 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.

• If the CSM is an RN selects and assigns preceptors to complete the IHSC RN training and competencies

• 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

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

• If CSM is an RN, will complete the RN training and orientation.

• The Lead CSM for vendor in collaboration with HSA will orient CSM on:

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

o Overview of Shift requirements

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities scheduling Compliance Reporting Tool.

o Expectations regarding staff call outs, backfill and overtime.

o Expectations regarding the CSM coverage and schedule.

orientation to CSM role.

• Provides finalized competencies to the HSA/CSM.

document and scheduling Compliance Reporting Tool.

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/ Resignation

• 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

• 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 to coordinate termination of staff with HSA/GTM.

• Responsible for escorting CTR staff off site upon termination.

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities required notifications, requests termination of eCW and computer access.

• Completes required exit document checklist.

• Notifies the CSM, in writing, of any identified back-fill requirements associated with the 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 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 or designee (i.e., Clinical Specialty lead).

• Ensures the tracking and return of government furnished equipment (PIV

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities card/phone/computer) until documentation is finalized.

• Ensures final timekeeping actions are completed.

Personnel, Health, Training, and Credentialing Files

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

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

• Provide any discipline specific orientation/training/Competen cies records that should be filed in permanent record to GTM upon completion.

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

• CSM is responsible to provide any required credentialing documents to ICPO as required.

• Maintains local 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 scope/competencies at all times. Staff not meeting this

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities 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 Preparedness 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.,

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

• Ensures contract staff participation in emergency preparedness activities

Clinical Discipline Leads (other than NM) Responsibilities

Nurse Manager Responsibilities (Nursing GTM)

Contract Services Manager Responsibilities

• Provides guidance to CSM on mission needs.

if more coverage needed above shift requirements document).

if more coverage needed above shift requirements document).

(recall roster drills, man down drills, fire drills and disaster drills).

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