SOW-ENT.pdf

PERFORMANCE WORK STATEMENT

Cheyenne River Health Center (CRHC)

Ear, Nose, and Throat (ENT) Physician

General

This performance based work statement describes the requirements for non-personal services for ENT to support the mission of the Indian Health Service (lHS)/Cheyenne River Health Center (CRHC).

The mission of the Cheyenne River Indian Health Service Hospital in Eagle Butte, South Dakota is to provide the best possible health care services to Cheyenne River Reservation in South Dakota, Backqround

The Indian Health Service (lHS) an agency within the Department of Health & Human Services 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, i/D and then divided into twelve physical areas: Alaska, Albuquerque, Bemidji, Billings, Californja, Great

Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland and Tucson.

The Great Plains Area Office (GPAO) works in conjunction with its 19 Indian Health Service Units and Tribal

Managed Service Units to provide health care to approximately 122,000 Native American located in No(h Dakota, South Dakota, Nebraska, and lowa, The Area Office's service units include seven hospitals, eight health centers, and several smaller health stations and satellite clinics.

Our facility, the Cheyenne River Health Center (CRHC), falls under the River Health Center

ICnHC; proviOes medical care for approximately 9,000 tribal members Reservation. Serving a iurat area, many of our patients travel 100 miles' round trio to receive c as built in 2011 to provide an expanded level of health care services specifically designed to meet the needsofthe CRHC population Services incrude; Emersency Room Deparrment, Pharmacy, tt,'i:'rtff;T.t;

[:iJ|;Je3:i.tJil[iJ31l]Hljill:nw ics: OB/GYN, ENT, Audiology, and Podiatry. The

S, ooerates four satellite health stations which offer basic ird, and Whitehorse communities

Obiective

To provide ENT services 2 days per month as needed in support of the monthly ENT clinics during the term of the c0nract.

Period of Performance

Work Schedule provide 2 days of ENT consultation per month, scheduling of which will be determined by the clinical Director

Place of Performance

Cheyenne River Health Center ENT Deoartment

24276 166tn Street Airport Road

Eagle Butte, South Dakota 57625

DESCRIPTI0N OF SERVICES: The contractor shall provide ENT services required for the Cheyenne River Indian

Health Service Hospjtal.

This contract is a non-personal health care servrces contract, as deflned at Far Part 37,101 under which the

Contractor is an independent contractor and which shall 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 tor specific medical treatment). The Contractor shall indemnify the Governmenifor any liability producing act or omission by the contractor, its employees and agents occuning during contract performance. The Contractor shall maintain medical liability insurance, in the coverage amount acc.itable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned

Upon the receipt of an IHS purchase order, the Contractor shall locate, credential, and have available suffrcient ancillary staffing to provide ENT coverage for the ENT Depa(ment

The standards of medical practice and duties of the Contractor through its physicians shall be determined pursuant t0

Governing Body bylaws, medial staff bylaws provisioni of law including but not |imited to to licensure and regulation of physicians and h

Medicare and Medicaid Services) compliance The Contr quality improvement program, which is consistent with cur n 0I the quality and appropriateness of care

CONTRACTOR RESPONSIBILITY

Perform individual ENT examinations using the operating microscope nashopharyngeal and laryngeal mirr0rs, nasal soeculum' head mirror, fiber-optic flexible endoscope, curettes, al|rgator lorceps, suction'

Utilizes audiometric and tympanometric data performed by the contract ENT Physician

Provide Allergy Testing and follow up.

Provide examlnation, diagnosis, and follow-up and recommend treatment plans as part of the patient assessment

Perform routine clinical procedures as part of the clinical examination, such as the following listed below:

. Cautery and paper patch of small tympanic membrane perforationsl

. lvlicroscopic ear examinations o Removal of cerumen

. Removal of foreign bodies of ear and nose

. Microscopic cleaning of mastoid cavities o Flexiblenasophyngoscopylaryngoscopy lnstruct and counseI patients, parents, and/or fami|y members regarding the diagnosis, treatment, and surgica| management of ENT disorders

Provides ENT coverage in the event of any post-op complications'

TheprovisionofcomprehensivedirectpatientcareseNicesandservesasareferraIsourcenon-surgical management of patients with ENT disorders

The ENT Physician consultant provides phone consultation services to assure proper management of patients presenting at Cheyenne River Service Unit ENT with complications and emergencies.

lmprove the coordination of care between ENT and ENT patients, lmprove the quality of care for ENT patients.

As requested, meet with Family and/or Pediatric providers who provide medical care.

Regular and routine consultation with CRHC and Family Practitioner.

Review of care provided to ENT patients.

Establishes inter-personal and intra-departmental relationships to enhance optimal patient care

Ensures a safe work environment and employee safe work habtts.

Demonstrates competent and effective oral and written communication

Computer efficiency required. Prefened 5 years of Electronic Health Record experience

Maintain certification in Basic Life Support (BLS) or CPR

The Contractor shall provide adequate credentialed staff during the regular scheduled services dates and cover the salary for an ancillary staff brought to the service unit. Ancillary staff must have licensure/certillcation and competencies on file with the Contracting Offrcer.

The ENT consultant physician will be responsible for all travel and other personal expenses.

The ENT physician must abide by the Cheyenne River Health Center Bylaws, Rules, and Regulations and Clinical

Duties.

REFERRALS AND CONSUSLTS. The ENT Physician shall follow IHS Purchased Refened care regulations and polici al or consult. The ENT Physician shall be required to consult with other specialty pract ns and continuation ol care. The ENT Physician shall inform patients of the requi ating the specialty involved' coNTRACTOR Tt[/ESHEETS. The ENT Physician will be responsible for obtaining Medical Records (HlM) sijnature prior to Clinical Director or representative signature for the completion of their timesheet lnvoices iiilmrtteO'witnout ttre signed timesheei including Medical Records (HlM) and Clinical Director signatures will not be paid.

PROCEDURE GUIDANCE. Contractor ENT Physician shall perform procedures compatible with the medical facility's operating capacity and equrpment

PRIVACY OF INDIVIDUALLY IDENTIFABLE HEALTH INFORMATION. ThE CONITACI hEA|th CATE PTOV|dETS ShAII

Drovide oatients with the utmost care and attention All p dionitv. The Contractor shall ensure strict compliance to wiih tne Code of Federal Regulation, Title 45, Public Wel

Part 164, Security and Privacy (45 CFR 164) and AFI 41

"Health Insurance Portability and Accountability Act (HIP

Medical Information".

coMMUNICATIONS. The Contractor shall ensure contract ENT Physicians maintain open and professlonal communication wtth t.mO.rs ot me t'tel[uistuif Complaints validated by the Hospital Accreditation Speclalist and

Clinical Director or shatt be reporteJ in writing to the Coniracting Offlcer (CO) and the Contractor for action

ENGLISH LANGUAGE REQUIREIVENT, The Contract ENT Physician shall read, understand, speak and write

English fluently.

D0CUMENTATIONS. Contractor personnel shall prepare all documentation to meet or exceed established CMS standards and Cheyenne River IHS Medical Staff Bylaws.

AVAILABILITY:

HoURS 0F oPEMTIoN: 2 days per month ( Up to 8 hours per day).

CONTINUTTY OF SERVICES/REPLACEMENT STAFF, The Contractor point o{ contact shall ensure qualified personnel are available to provide covenge at all times.

PERFORMANCE OF SERVICES DURING CRISIS DECLARED BY THE NATIONAL COIVIVAND AUTHORITY, ON occasion, services may be required to support an activation or exercise of contingency plan outside the normal duty hours. Emergency situations (i.e, accident and rescue operations, civil disturbances, natural disasters) may necessitate the contractor provide increased or reduced with the contractor for the cost of these emergency requtrements, RECORDS. The contractor shall document all patient encounters legibly in the patient medical record All documentation shall be timed and dated, Verbal orde6 are to be used as infrequently as possible. In the event of a major disaster or code all verbal orders are to be signed off immediately following the code or disaster'. All Medical

Records must be signed by the ENT Physician and charge ticket completed at the end of the visit. All Medical

Records are to be completed within 24 hours of the ENT Physicians scheduled shift. All documentation shall meet the current C[/S guidelines.

Final payment will be withheld until all medical records are completed by the contract ENT Physician.

PERSONNEL REQUIREMENTS

coNTtNUtNG [/EDICAL EDUCATION (CME)/ CERTIFIED EDUCATION UNITS (CEU) REQUIRE[/ENTS

Maintain CME and review pertinent joumals, books and publications. Health care providers registered or certified by the national/medical associations shall continue to meet the minimum standards for CME to remain current CME hourssha||bereportedtothecredentialsoffice{ortrackingbytheclinica|Director'

LICENSURE/REGISTMTION. Contractor must maintain a current active and unrestricted license in at least one of the 50 United States or US tenitories

CERTIFICATION. Board certilied in field of specialty is favorable'

FORIVAL EDUCATION, The ENT Physician must pssess an ASHA accredited graduate degree from an accredited

American College or UniversitY

EXPERIENCE, The ENT Physician must have a minimum of 5 years of experience within ENT to include fellow and

[rioencv ti.e "itnin the pasi36 months prior to ENT Physician beginning performance at Cheyenne River Health

Center.

pERFORMANCE.BASED SERVTCE DELIVERY SUMMARY. The contracto/s performance will be measured based on the following Performance Requirements. The Performance.Requirements will be measured agarnst

Govemment nce with the following t

Surveillance nce Plan (QASP)to d 5% deduction wil not met Deductions st individual inv not meet contract requirements Deductions will be done by the category that was delicient.

Performance Standards

Standardl(AQL) Acceptable Quality

Level

Complehon of documentation of patient record

All patient records must be documented accurately, correctly, and completely within

24 hours of

Random observation and Hl[/ Report

5% deduction from weekly invoice.

Deductions will increase by 1% in suDsequenl months.

Agency must provide a competent lvlid-

Level to ensure no gaps in c0verage, Provider Schedule For every shift not covered by Agency, the shift rate will be deducted from next submitted

Inv0tce

Agency is allowed 3 business to submit required credentialing documentatron

Credential Report 5% deduction from weekly

Involce.

Deductions will increase by 1% in subsequent months.

Credentialing

Prompt and continuous coverage

Pedormance Evaluation. lf the contractor fails to perform required services at the acceptable quality level, payment may be withheld until the contractor makes conections. In the event that the contractor fails to perform any required services, the COR will provide written notice of such to the Contracting Specialist and CCO and the contractor. The

Contracting Office will issue the contractor a Contract Discrepancy Report (CDR), The contractor shall have seven

(7) calendar days to provide the Contracting Office with their response to the CDR, Upon evaluation of the contractols response to the CDR for tasks surveilled, the contractor's payment for the month in which the performance is question occuned will be calculated as outlined above.

Contractor Payment. lfthe contractor fails to perform required services at the acceptable quality level, payment may be withheld until contractor makes corrections.

The Contracting Officer Representative (C0R) designated for this Project is:

Cheyenne River Health Center

COR: Robert Cadson, OD

24276 166h Street, Airport Road

Eagle Butte, SD 57625

Office: 605-964-7724

Fax: 605-964-0522

The COR is responsible for:

Monitoring the Contractor's technical progress;

Interpreting the statement of work;

Technical evaluation as required;

Technical inspections and acceptance required by thls contract; and, Assisting the bontractor in the resolution of technical problems encountered dunng performance of this contract.

b.

c.

d.

The contractor shall be paid a fixed flat rate of per hour. No differential pay for govemment holidays, compensation time, and night differential, Holidays and weekends shall be included as part ofthe woft period and considered regular hours.

Quality Assurance Surveillance Plan (QASP). The purpose ofthe QASP is to provide a government developed system to assure the use of quality assurance methods in the administration of the performance based acquisition standards. The intent is to ensure that the Contractor performs services for the Cheyenne River Health Center that are provided in accordance wth performance requirements set forth in the contract documents, that the government receives the quality of services called for in the contract and that the govemment only pays for the acceptable level of services received.

The plan provides the basis forthe C0R to evaluate the quality of the contractods performance, The oversight provided for in the contract and in this plan wili help ensure that service levels reach and maintain the required levels throughout the contract term. Further, this plan provides the COR with a proactive way to avoid unacceptable or deficient performance and provides verifiable input lor the required past performance evaluations.

GOVERNMENT FURNISHED PROPERTY AND SERVICES.

EQUIPMENT. Contract providers shall have joint use of all available equipment for performing services required by this contract.

PERSONAL PROTECTIVE EQUIPMENT (PPE). The Government will furnish the contract provide(s) with appropriate PPE. The Government will be responsible for any repair, cleaning and inventory required for the PPE.

This does not include any type of uniform or laboratory coat.

IDENTIFICAIToN CREDENTIALS. The Cheyenne River Health Center will provide each conhact provider with the required identification card.

F0RMS. The Cheyenne River Health Center will provide required Govemment forms used in the performance of services.

SUPPLIES. The Cheyenne River Health Center will provide medical and non-medical supplies commonly used in the facility for the care and management of patients and the performance of the requirements of this contract, H0USING. Contractor shall be responsible for all applicable Federal, State, and Local Taxes, l\,leals, Travel/Transportation, lodging, and perdiem, Government Housinq: Lodging is available in govemment housing at prevailing rates, if available, and must be paid by the contractor, There are limited furnished units available for contract employees and prevailing rates range from Single -$34.72 daily, Shared $16.58 daily and Trailer Pads - $8.00 daily (Rates are subject to change), Local Hotel: Cheyenne River Motel (605) 964-8888.

SERVICES

ORIENTATION. The Contractor shall ensure that all new contract providers participate in the Cheyenne River Health

Center Facility Orientation with an overlap of services to include one additional day. Providers.must arrive on a

Monday-Friday excluding holiday and participate in the orientation, which must be completed in the Monday'

Friday timeframe, prior to providing services at the hospital.

Administrative Support, Cheyenne River Health Center will provide normal ofiice administrative support servlces, t0 include telephone, fax, computer, and utilities.

patient Scheduling. Facility personnelwtll assist in patient scheduling, Complete administrative control of the patient shall remain with the facility, CONTRACTOR FURNISHED ITEMS AND SERVICES

GENERAL. Except for those items or services specifically stated in Section lll to be Government fumished, the Contractor shall furnish everything required to perform this contract in accordance with all of its terms. The Contractor shall provide adequate credentialed staff during the regular scheduled services dates and cover the salary for an ancillary staff brought to the service unit, Ancillary staff must have licensure/certification and competencies on file with the Contracting Officer.

CONTRACTOR OWNED EQUIPMENT. The provider will provide his/her own stethoscope, penlights, etc., and white physician coat.

lNlTlAL INSPECTION. Contractor owned equipment will be inspected and approved by the biomedical equipment maintenance section prior to use in the facility.

GENERAL INFORMATION

PERSONNEL,

PoINT 0F CoNTACT. The Contractor shall provide a point of contact who shall be responsible for the performance of the work. The point of contact shall have full authority to act for the Contractor on all matters relating to the daily operation of this contract. The Contractor shall designate this individual, in writing, to the Contracting Officer before the contract start date. An altemate may be designated, but the Contract shall identify those times when the alternate shall be the primary point of contact.

CRIIVINAL BACKGR0UND INVESTIGATION, The Government will conduct at government expense, a state criminal history check on individuals providing direct, unsupervised child care services under this contract. Asa minimum, the Contractor shall contact the Cheyenne River Health Center Contracting Officer for obtaining all necessary forms and directions for filing background check information in writing and electronically on personnel hired at the beginning of the contract. This action shall take place no later than five (5) working days from contract award date, Contractor shall submit completed personnel background check applications within Five (5) business days after award date to the Contracting Officers for processing. Contractor personnel will be required to be fingerprinted. REuests for personnel hired subsequent to the contact start date shall be submitted to the

Government no later than five (5) working days from the employee's flrst duty day, Contractor shall provide a list ol substitute contract personnel fulfilling contingency situations (i.e. absences of certificated contact personnel). Names of substitutes and credentials shall be provided 15 calendar days in advance to accomplish background checks.

Contractor personnel receiving an unfavorable background check shall not be employed. Cheyenne River Health

Center may employ an individual pending completion of successful background checks.

Background checks will be based on fingerprints of individual obtained by a Govemment law enforcement officer and inquiries conducted through the Federal Bureau of Investigation (FBl) and state criminal history repositories, Individuals shall have the right to obtain a copy of any background check pertaining to themselves and to challenge the accuracy and completeness of the information contained in the report.

CONFLICT OF INTEREST, The Contractor shall not employ any person who is an employee ofthe United States

Government if the employment of that person would create a conflict of interest. The Contractor shall not employ any person who is an employee of HHS (Health and Human Services), unless such a person seeks and receives approval in accordance with the Department of HHS.

APPEARANCE, Employees are expected to comply with reasonable dress, grooming and hygiene standards based on comfort, productivity, health and type of position occupied. Employee attire will be in good repair, and should not be considered offensive, disruptive or unsafe, Contract providers shall display their identification badge on their outer clothing pROTECTIVE CLOTHING. When required and supplied by the Govemment, the provider shall wear special protective clothing and shoe covers. When duties will be performed rn specified areas, a disposable protective hood shall be worn to ensure infection control standards are met, The Govemment will provide this hood. These items shall remain the property ofthe Government and shall not be removed from the facility, After use, protective clothing shall be turned in or destroyed as directed by the Infection Control Policy.

PRIVILEGING REQUIREMENTS. The contract providen' credentials shall be reviewed by the Credentialing Specialist and the Credentialing Committee, The Contractor is responsible for ensuring that proposed providers possess the requisite credentials to enable granting of privileges by the Cheyenne River Health Center Medical Staff sufficient to allow for performance of al tasks identified, Medical Services cannot be performed by a contract ENT Physician until professional staff membership and the Great Plains Indian Health Service Governing Body has granted clinical privileges in writing.

Initial applications for clinical privileges, to include credentials action history, malpractice history, and certified true copies of the documents listed below, shall be submitted to the Cheyenne River Health Center Credentialing

Committee, through the Credentialing Specialist, no later than 3 calendar days after receipt of notice of contract awar0, a, Copyofvalid, current unrestricted state license and applicable Board Certification. (Submission of required with proposal).

b, Possess a ASHA accredited graduate degree from an accredited American College or University,

c. Documentation of continuing education and training.

d, Cunent Basic Life Support (BLS) or CPR. (Submission required with proposal).

e. A signed consent for release of information.

f. A list of all states in which contract ENT Physician cunently holds or has held a license to practice related services.

g. A current copy of the proposed contract ENT Physician professional resume.

h. Certification ol current physical examination, The certification shall have a statement signed by the examining physician stating that the employee is free of any contagious diseases. The physical examination shall be cunent as of '12 months prior to application for privileges.

Applications for pnvileges will be screened through the National Practitioners Data Bank.

Re-appointment shall occur no less than every two years, in accordance with Cheyenne River Health Center Medical

Bylaws.

DENIALfIERMINATION 0F PRIVILEGES, Actions to limit, suspend, or revoke clinical privileges will be in accordance with the procedures outlined in the Medical Staff Bylaws. The Clinical Director, will notify the Contracting

Officer, and provide copies of pertinent documentation, as soon as possible when the necessity to exercise such authority becomes apparent. The Contracting officer will notify the Contractor of the initiation of the revocation process if such aclion becomes apparent.

REVIEW OF CREDENTIALS PACKAGES. The Government reserves the right to limit the number of credentialing packages it will evaluate, HEALTH REQUIREMENTS

The contract ENT Physician shall provide proof of cunent immunizations (Hep B, MMR, Varicella, Tdap, Flu) status and a cunent TST within the past year, The Contractor shall comply with all IHS infection control/employee health and safety procedures, practices, and standards.

EMERGENCY HEALTH CARE. Cheyenne River Health Center will provide emergency health care for the contract

ENT physician for injuries incuned while on duty in the facility. These services will be billed to the Contractor at the cunent full reimbursement rate.

MEDICAL QUALITY IMPROVEMENTIRISK MANAGMENET (OURM).

The contract ENT Physician (s) shall participate in QI/RM activities to the extent required by Section 2C, AFI44-119 and the individual Cheyenne River Health Center QURM plan or regulation.

The Government will evaluate the ENT Physician's professional, as differentiated irom adminrstrative, performance under this contract using Quality lmprovement standards specified in paragraphs 2.1 and 2.2. Nothing in this paragraph precludes the Government from also conducting inspections under the Inspection/Acceptance requirement of FAR clause 52.212-4, PERFORMACE EVALUATION

The Cheyenne River Health Center will evaluate the contractors' performance under this contract. Evaluations will be provided to the contactor, in writing. These evaluations may be used by as a record of contract performance history for the purpose of evaluation in other competitive or non-competitive acquisitions.

FREEDOM OF INFORMATION ACT (FOIA) PRoGRAM. All FOIA request shall be delivered immediately to the

Medical Records Supervisor, PHYSICAL ACCESS, The Contractor shall return identification badge to the lT Department and house keys to the

Housing Officer, upon completionitermination of the contract.

Physical Security, The contractor shall safeguard all government property, including controlled lorms provided for contractor use. At the close of each work period, government equipment, facilities, and other valuable materials shall be secured.

Weapons, Firearms, And Ammunition, Conhactor employees are prohibited from possessing weapons, firearms, or ammunition, on themselves or within their contractor-owned vehicle or privately-owned vehicle while on the

Cheyenne River IHS compound.

Reporting Requirements. Contractor personnel shall report to an appopriate authority any information or circumstances of which they are aware may pose a threat to the security of IHS personnel, contractor personnel or oatients.

The contractor shall prohibit their use of keys, issued by the government, by any persons other than the contractor's employees and the opening of locked areas by contractor employees to permit entrance of person other than contractor employees engaged in performed of contract work requirement in those areas.