SOW - TLC Healthcare 2026 -final_signed.pdf

Department of Health and Human Services Indian Health Service

Clinton Indian Health Center

Statement of Work (SOW) RN Accreditation Specialist

1. PURPOSE OF THE PROJECT

The purpose of this contract is to provide contract RN Accreditation Specialist services for the Clinton Service Unit (CSU) that is comprised of the Clinton Indian Health Center (CIHC), El Reno Indian Health Center (EIHC) and Watonga Indian Health Center (WIHC). The Indian Health Services (IHS) requires RN Accreditation Specialist services without interruption during the term of this contract.

The Clinton Service Unit is a Joint Commission accredited federal facility. To meet the IHS mission, RN Accreditation Specialist services have been deemed necessary to augment the services within the facility and as such are necessary to support health care operations within the CSU healthcare facilities.

The Indian Health Service, an agency within the Department of Health and Human Services (HHS), is responsible for providing federal healthcare services to American Indians and Alaska Natives. The mission of the IHS is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level, assuring comprehensive, culturally appropriate personal and public health services are available and accessible to eligible members of federally recognized Tribes across the United States.

2. DETAILED DESCRIPTION OF THE TECHNICAL REQUIREMENTS

2.1 General Scope of Services

The Contractor shall provide full-time, non-personal Registered Nurse Accreditation Specialist services for the Clinton Service Unit (CSU). The primary duty station shall be the Clinton Indian Health Center; however, services may extend to other CSU, Indian Health Service (IHS), and Tribal facilities as required to support accreditation, regulatory compliance, and continuity of care.

The Contractor shall function as a Subject Matter Expert (SME) in an advisory capacity, for accreditation standards, regulatory compliance, and infection control and prevention for ambulatory healthcare services.

2.2 Accreditation and Regulatory Compliance

The Contractor shall:

• Assess, evaluate, and monitor CSU compliance with accreditation and regulatory standards, and provide findings and recommendations to the Government, including:

o The Joint Commission (TJC) o Centers for Medicare & Medicaid Services (CMS) o Indian Health Service (IHS) o Centers for Disease Control and Prevention (CDC) o Association for Professionals in Infection Control and Epidemiology (APIC) o Applicable federal, state, and local requirements

• Conduct tracer activities, including Joint Commission Resources (JCR) Tracers AMP, to validate compliance and identify performance gaps.

• Serve as the SME for accreditation and regulatory standards applicable to ambulatory services.

• Support continuous survey readiness and accreditation maintenance activities.

• Prepare, review, and maintain accreditation and regulatory documentation required for surveys and inspections.

• Initiate risk assessments and performance improvement activities related to accreditation compliance.

• Collaborate with clinical and non-clinical SMEs to develop, implement, and monitor corrective action plans and sustainability measures.

2.3 Infection Control and Prevention Program Oversight

The Contractor shall:

• Serve as the SME for the Infection Control and Prevention (ICP) Program at CSU.

• Develop, implement, maintain, and oversee a comprehensive, evidence-based Infection Control and Prevention Program, under Government direction and approval, in accordance with:

o IHS Indian Health Manual (IHM), Part 3, Chapter 33 o TJC, CMS, CDC, and APIC standards o Applicable federal, state, and local regulations

• Recommend, review, and update infection control policies and procedures to prevent, identify, and control infections and communicable diseases.

• Integrate infection control activities with quality improvement and patient safety initiatives.

2.4 Surveillance, Monitoring, and Reporting

The Contractor shall:

• Conduct ongoing infection surveillance to identify trends, risks, and potential outbreaks.

• Maintain accurate infection control and surveillance records in compliance with IHS and regulatory requirements.

• Analyze surveillance and quality data to support accreditation and infection prevention initiatives.

• Report findings to the CSU Quality Department, Executive Leadership, Governing Board, and appropriate regulatory authorities, as required.

• Lead outbreak investigations and coordinate response activities with public health authorities.

• Implement outbreak mitigation and control measures in accordance with IHS IHM and public health guidance.

2.5 Quality Assessment and Performance Improvement (QAPI)

The Contractor shall:

• Monitor, analyze, and support the CSU Quality Assessment and Performance Improvement (QAPI) dashboard.

• Support organizational engagement in QAPI activities related to accreditation, infection control, and survey readiness.

• Maintain abstraction and submission of quality reporting data required for accreditation and regulatory compliance.

• Assist the CSU credentialing coordinator with the development of peer review tools and processes supporting accreditation standards.

• Collaborate with Medical Staff Leadership and the Medical Executive Committee to support the medical staff peer review process.

• Evaluate electronic health record (EHR) documentation for accreditation compliance, including assessments, level of care, orders, diagnoses, education, and plans of care.

2.6 Education, Training, and Competency

The Contractor shall:

• Develop and deliver ongoing accreditation- and infection control–related education for staff and leadership.

• Conduct infection control training with competency validation using standardized policies and procedures.

• Ensure infection control orientation is completed for all new employees during onboarding.

• Promote a culture of infection prevention, patient safety, and continual survey readiness.

• Complete all CSU-required internal training by assigned due dates.

2.7 Committees, Leadership, and Administrative Support

The Contractor shall:

• Lead and coordinate Infection Control Committee meetings as directed by the Government.

• Serve as CSU lead and staff trainer for JCR Tracers AMP software and Illuminate analytics.

• Provide expert recommendations based on surveillance data, accreditation requirements, and best practices.

• Assist with preparation of formal reports for the CSU Quality Department, Executive Leadership, and Governing Board.

• Assist Human Resources by supporting the organization, review, and maintenance of employee files required for accreditation compliance.

2.8 Clinical Responsibilities (As Applicable)

• Perform nursing care and interventions as permitted by licensure, experience, and facility needs.

• Maintain a current, valid Registered Nurse license throughout the contract period.

2.9 Policy Compliance and Professional Conduct

The Contractor shall:

• Follow all CSU policies and procedures in a safe and effective manner.

• Protect patients, staff, and self from injury and exposure.

• Acknowledge CSU’s authority to assign additional responsibilities as necessary, provided such responsibilities remain within the overall scope and intent of this Statement of Work.

3. PERIOD OF PERFORMANCE

Base plus an additional two (2) 6-month option periods.

Base period: 05/21/2026 - 11/20/2026 Option period 1: 11/21/2026 – 05/20/2027 Option period 2: 05/21/2027 – 11/20/2027

4. LEVEL OF EFFORT

4.1 Work Hours and Schedule

• The Contractor shall provide forty (40) hours per week of services, as mutually agreed upon with the Clinton Service Unit.

• Standard duty hours are Monday through Friday, 8:00 a.m. to 5:00 p.m., with flexibility to adjust based on CSU operational needs.

• The Government reserves the right to negotiate changes to workdays, hours, duty location, or service distribution as mutually agreed.

• No additional compensation shall be provided for federal holidays, sick leave, or annual leave.

4.2 Accreditation and Infection Control Support

• Provide full-time accreditation, regulatory compliance, and infection control support to CSU facilities.

• Conduct routine tracers, surveillance, audits, education, committee participation, and outbreak response activities to maintain continual survey readiness.

4.3 Education and Professional Development

• The Contractor must be eligible to pursue advanced certifications as required by IHS.

• Certification eligibility and preparation shall be completed outside contractual hours and within required timeframes to maintain compliance with IHS professional development requirements.

4.4 Quality Assurance Participation

• Participate in quality assurance and performance improvement activities to support high-quality patient care and efficient utilization of CSU resources.

5. SPECIAL REQUIREMENTS

5.1. The supervising official will determine if the contractor will be subject to PIV credentialing requirements for physical and logical access, in line with the below requirements.

5.1.1. Long-term contractors are defined as working in excess of four months (or 120 days, consecutively) for the purpose of background investigations. All long-term contractors must have, at minimum, a favorably adjudicated Tier 1 background investigation. Some positions may require a higher-tiered investigation, in accordance with the OMB M- 05-24 Sections, 7.F “Applying guidance to temporary employees and contractors.”

5.1.2. Short-term contractors are defined as working for less than six months or 1040 hours in a one-year period of service for the purpose of HSPD-12, in accordance with 5 CFR Part 316. Short-term contractors are not issued a PIV card, except when required for routine facility or network access. Short-term contractors are subject to an investigation conducted in accordance with the risk/sensitivity of the position.

5.1.3. Temporary hires and volunteers are defined as working for 120 days or less. The supervising official will determine whether a temporary hire working 121 days or more will be subject to PIV credentialing requirements based on the need for network and facility access. Temporary hires are subject to all personnel security requirements.

5.1.4. If onsite service employee does not require 5.1.1 through 5.1.3, then a visitor’s pass must be requested upon arrival with either the front desk or facilities and worn at all times while on the premises.

5.2. The US PHS Clinton Indian Health Center is a tobacco/smoke free environment (buildings and grounds). No tobacco/smoking use will be tolerated during service.

5.3. Security Requirements: Contractor personnel will be required to contact the government designated point of contact upon arrival when reporting for service calls or delivery supplies. The contractor shall be responsible for the security of all organizational information. Current rules and regulations applicable to the premises, where the work shall be performed shall apply to the contractor and its employees while working on the premises. These regulations include but are not limited to, escort by CSU official, presenting valid identification, smoking restriction and any safety procedures.

5.4. The contractor shall not disclose or cause to disseminate any information concerning operations of CSU. Such action(s) could result in violation of the contract and possible legal actions.

5.4.1. All inquiries, comments, or complaints arising from any matter observed, experienced or learned of as a result of or in connection with the performance of the contract, the resolution of which may require the dissemination of official information, shall be directed to the government’s designated representative.

6. PERSONNEL QUALIFICATIONS, CREDENTIAL VERIFICATION, AND INSURANCE

6.1. Applicability: This section applies to all Contractor and subcontractor personnel performing work under this contract.

6.2. Personnel Qualifications:

6.2.1. Education/Training/Experience:

6.2.1.1. Minimum one (1) year accreditation experience required.

6.2.1.2. Minimum 5 years of RN nursing experience, full-time Med/Surg, or Ambulatory Care/Clinic specific experience that has occurred within the past 23 months.

6.2.1.3. Minimum of two (2) years Infection Prevention experience within the last three (3) years.

6.2.2. Licensure/Certification:

6.2.2.1. A current, valid, and unrestricted [Registered Nurse] issued by the State/Commonwealth of [Oklahoma] (or another U.S. jurisdiction acceptable to the Government).

6.2.2.2. Associate Infection Prevention and Control (AIPC) certification (APIC or CIC) issued by the Certification Board of Infection Control and Epidemiology (CBIC) through the Association for Professionals in Infection Control and Epidemiology (APIC). Any required professional certification(s) must be current and in good standing.

6.2.2.3. Current Basic Life Support (BLS) or Advanced Life Support (ACLS) is required. Pediatric Advanced Life Support (PALS) Basic Dysrhythmia is an alternative option.

6.2.3. Additional Requirements: Personnel shall meet any other qualifications required by applicable law, regulation, or policy, including agency security, training, and health/safety requirements.

6.3. Non-Personal Services: It is expressly agreed and understood that this is a non-personal services contract as described in the Federal Acquisition Regulation. The Government may evaluate the quality of professional and administrative services provided but does not supervise or control the Contractor’s professional methods, judgment, diagnosis, or treatment decisions. The Contractor is solely responsible for the professional aspects of performance and for the acts or omissions of its employees and agents. The Contractor shall indemnify the Government for liability producing acts or omissions of the Contractor, its employees, or agents.

6.4. Contractor Responsibility for Credential Verification: The Contractor is responsible for primary source verification of the current status and validity of all required licensure, education, certification(s), and, if applicable, registration or credentialing, prior to the commencement of services and throughout performance. Primary source verification means confirmation directly with the issuing authority or through a verification service that queries the issuing authority.

6.4.1. Cooperation: The Contractor shall fully cooperate and provide information or documentation reasonably requested by the Clinton Service Unit to facilitate confirmation of licensure, certification, or credentialing status.

6.4.2. Recordkeeping: The Contractor shall maintain a credential file for each individual, including copies of required credentials and dated proof of primary source verification. Upon request, the Contractor shall provide the requested documentation to the Government within two (2) business days.

6.5. Notification of License/Certification Issues: The Contractor shall notify the Clinton Service Unit in writing within one (1) business day after becoming aware of any lapse, expiration, restriction, suspension, revocation, investigation, or other action affecting any personnel’s licensure, certification(s), education, registration, or credentialing status.

6.6. Removal and Replacement of Unqualified Personnel: If any individual lacks the required and valid licensure, education, or certification(s), or if any such credential becomes expired, suspended, restricted, or otherwise invalid, the Government may direct the Contractor to remove that individual from the assignment immediately. The Contractor shall promptly provide a qualified replacement who meets all requirements of this section at no additional cost to the Government.

6.7. Government Review: The Government may review rosters, sample credential files, and verification evidence at any time, on reasonable notice. Government review, acceptance, or failure to object does not waive or diminish the Contractor’s responsibilities under this section.

7. DELIVERABLES AND REPORTING REQUIREMENTS

7.1. Onboarding of Contractor personnel: The contractor will coordinate the onboarding date with the designated government contact(s).

7.2. Clinton Service Unit facility locations:

7.2.2. Clinton Indian Health Center: 10321 N. 2274 Rd, Clinton, OK 73601

7.2.3. El Reno Indian Health Center: 1801 Parkview Dr, El Reno, OK 73036

7.2.4. Watonga Indian Health Center: 1305 S. Clarence Nash Blvd, Watonga, OK 73772

7.3. Contractor Point of Contact: The contractor shall furnish one designated point of contact (POC) to the government’s designated representative for coordination of supplies, delivery, and/or maintenance. The POC will be empowered to make daily decisions to ensure that the contract implementation and day-to-day maintenance meets the terms and conditions of this contract.

7.4. Contractor’s Phone Numbers: The contractor shall provide a toll-free telephone number for service calls, which must be answered during at least eight working hours, between 8:00 am and 4:30 pm, Monday through Friday

8. GOVERNMENT FURNISHED PROPERTY, FACILITIES AND SERVICES

8.1. The Government shall supply the facilities, supplies, materials, and equipment necessary for the performance of this contract.

Use of government furnished facility space, equipment, supplies, and personnel are for the provision of care and services set forth in this SOW only.

8.2. An orientation manual of policies and procedures will also be made available by the Government. The Government will provide assistance, orientation, guidance, and training.

8.3. The contractor's primary duty station is the Clinton Indian Health Center; however, periodically, at the direction of the supervisor, the contractor may be required to travel to other IHS facilities within the Clinton Service Unit to provide support services.

8.4. If necessary, upon completion of Government Vehicle training, the contractor may have use of a government vehicle for authorized travel within the Oklahoma Area and will be compensated for travel time and expenses in accordance with federal travel regulations.

9. CONTRACTOR FURNISHED PROPERTY, FACILITIES AND SERVICES

9.1. The contractor shall furnish personnel qualified to meet the requirements as defined within the SOW.

10. CHANGES TO THE STATEMENT OF WORK (SOW)

Any changes to this SOW shall be authorized and approved only through written correspondence from the Contracting Officer. Costs incurred by the contractor through the actions of parties other than the Contracting Officer shall be borne by the contractor.

11. DELIVERABLES/PERFORMANCE MATRIX – ELEMENTS MUST BE RELEVANT TO YOUR CONTRACT!

Measureables to be evaluated at the conclusion of awarded contract:

1. Contract Compliance and Timely Deliverables: Contractor fulfills responsibilities outlined in the SOW and submits required reports and deliverables in a timely manner.

1) ≥ 90% of required reports and deliverables submitted by agreed-upon deadlines.

2) Deliverables are substantially complete and accurate, requiring no more than two revisions requested by the Government Monitoring Method: Review tracers and submission timelines.

☐YES ☐NO ☐N/A

2. Accreditation and Regulatory Compliance Support: Contractor provides effective support toward maintaining compliance with accreditation and regulatory standards.

1) ≥ 90% of assigned tracer activities, audits, and compliance reviews completed as scheduled.

2) ≥ 85% of identified findings include documented recommendations or corrective action support provided within 15 business days

Monitoring Method: Review of tracer documentation and corrective action records

3. Quality Control and Quality Assurance Support: Contractor provides quality control support and participates in quality assurance activities when required.

1) ≥ 90% participation in scheduled quality control and quality assurance activities

2) Data submissions demonstrate an accuracy rate of ≥ 90% (validated)

Monitoring Method: Review tracers and report data

4. Quality Improvement: Contractor provides quality improvement information to support CSU QAPI activities

1) At least one (1) documented quality improvement observation, data trend, or recommendation submitted semiannually.

2) Participation in scheduled QAPI meetings and activities Monitoring Method: Review of QAPI documentation and meeting attendance

5. Customer Service: Contractor provides professional customer service aligned with the CSU vision of “Exceed the Need.”

1) Has positive feedback from CSU leadership, Quality staff, or departments

2) Responds quickly to internal needs.

Monitoring Method: feedback, stakeholder input

Additional Measureables to be evaluated for awarded contract providing temporary employees (excluding medical staff)

License / BLS / Certification were maintained, current at all times and provided to CSU Human Resources prior to expiration

Evidence of staff competency provided when requested & required prior to expiration (Q3 years). ☐YES ☐NO ☐N/A

Staff competency conducted by contractor is acceptable and submitted prior to expiration (Q3 years).

Comments:

Department Supervisor Signature: _______________________________

Administrative Officer Signature: _______________________________