SOW_UPDATED_October2024_Registered Nurse Accreditation Readiness Specialist.pdf

Registered Nurse Accreditation Readiness Specialist

Statement of Work

Dated September 20, 2024

1. General

Indian Health Service (IHS) is a federal agency within the US Dept. of Health and Human Services and is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government to government relationship between the federal government and Indian tribes. The IHS is the principal federal health care provider and health advocate for the American Indian people. The goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Natives. The IHS currently provides health services to approximately 1.5 million American Indians and Alaskan Natives who belong to the 566 federally recognized tribes.

2. Statement of Objectives

IHS intends to award one purchase order for a period of performance of one year for one or more

Registered Nurses (RN) for continual Joint Commission Survey Readiness activities of Inter Cycle

Monitoring (ICM), Patient Tracers, and maintenance of the Quality Dashboard metrics. The contract RN is a nonpersonal services position located in the Quality Department of the Clinton Service Unit. Primary duty station shall be at the Clinton facility and includes day travel to the El Reno and Watonga locations periodically – up to weekly - providing continual survey readiness assessments, evaluations and corrective action plans. Additional activities shall include medical services for patients as needed during patient tracers including appropriate documentation in the Electronic Health Record (EHR) as stated by this

Statement of Work (SOW) and in accordance with the terms and conditions of this BPA. Occasionally, more than one registered nurse may be needed for assignments ranging from 6 months to one year. The care provided by the registered nurse shall be as comprehensive as the Indian Health Service supplied facilities; equipment and support services permit. The contractor shall provide a qualified registered nurse to provide services to provide clinical judgement for survey readiness and provide care to beneficiaries of the Indian Health Service.

2.1 KEY PERSONNEL

The Quality Director and COR are the main points of contact for all day-to-day operations under this purchase order.

Quality Director (Acting): Derek Lieser, Derek.Lieser@ihs.gov, 580-331-3300

Contract Specialist: Judy Eaves, Judy.eaves@ihs.gov, 405-951-3856

Contracting Officer’s Representative (COR): Jacob Brice, Jacob.brice@ihs.gov, 580-331-3300

2.2 PERIOD OF PERFORMANCE

November 22, 2024-November 21, 2025

PLACE OF PERFORMANCE

The Oklahoma City Area is comprised of the following facilities:

Claremore Indian Hospital, 101 South Moore Ave, Claremore, OK 74017

Lawton Indian Hospital, 1515 Northeast Lawrie Tatum Rd, Lawton, OK 73507

Anadarko Indian Health Center, 115 Northeast Old Town Drive, Anadarko, OK 73005 mailto:Derek.Lieser@ihs.gov mailto:Jacob.brice@ihs.gov

Carnegie Indian Health Center, 214 East 4th, Carnegie, OK 73015

Clinton Indian Health Center, 10321 N 2274 Road, Clinton, OK 73601 (Primary work site)

El Reno Indian Health Center, 1631 E Highway 66, El Reno, OK 73036

Haskell Health Center, 2415 Massachusetts Street, Lawrence, KS 66046

Pawnee Indian Health Center, 1201 Heritage Circle, Pawnee, OK 74058

Watonga Indian Health Center, 204 West Main Street, Watonga, OK 73772

Wewoka Indian Health Center, Highway 270 and 56, Wewoka, OK 74884

3. Key Deliverables

The contractor shall provide nonpersonal registered nurse services to include but not limited to the following:

• Assesses and evaluates organizational compliance with established accreditation standards as defined by The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and other regulatory bodies.

• Conducts tracer activities to affirm compliance with regulatory standards or identify opportunities for improvement.

• Serves as subject matter expert for regulatory standards and accreditation content for ambulatory services.

• In conjunction with clinical and non-clinical subject matter experts - develops corrective action plans and sustainability measures to address compliance deficiencies.

• Provides education to staff and leadership on accreditation topics and supports a state of continual survey readiness.

• Monitors and analyzes quality assessment and performance improvement (QAPI) dashboard and supports organizational engagement in QAPI activities.

• Assists human resources, department services and employees with the management and upkeep of employee HR files to main accreditation

• Oversees the abstraction and submission of quality reporting data supporting survey readiness

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

• Collaborates with Medical Staff leadership and the Medical Executive Committee to support the medical staff peer review process. Provides assistance to the CSU credentialing coordinator with the development peer review tools and processes that support compliance with accreditation standards and continual survey readiness.

• Evaluates the quality of EHR documentation to ensure accreditation compliance, including but not limited to: assessments, care provided, orders, diagnosis, education and plan of care

• Ability to speak, understand, ready and write English fluently.

• Must maintain a registered nurse license

• May perform nursing care/intervention as determined by experience and licensure regulations.

• Serves as Subject Matter Expert (SME) for infection control and prevention program at the

Clinton Service Unit, including:

o Infection Control Program Oversight o Develop, implement, and maintain an effective infection control program within the IHS facility in accordance with IHS Manual Chapter 11, "Infection Control and Prevention."

o Recommend policies and procedures to IHS to prevent, identify, and control infections and communicable diseases among patients, staff, and visitors.

o Monitor the facility’s compliance with state, federal, and IHS infection control standards and ensure adherence to the Centers for Disease Control and Prevention (CDC) guidelines.

o Surveillance and Reporting o Conduct regular infection surveillance activities to identify potential infection risks and outbreaks within the facility.

o Maintain accurate records of infection control activities and report findings to the appropriate authorities in compliance with the IHS Manual and other applicable regulatory requirements.

o Implement JCR Tracers AMP to identified areas for improvement and in alignment with IHS Head Quarters requirements.

o Lead and coordinate the facility’s infection control committee meetings, providing expert advice and recommendations based on surveillance data and best practices.

o Education and Training o Develop and deliver ongoing infection control training programs for healthcare staff, ensuring that all personnel are informed of current infection control policies and procedures.

o Collaborate with other healthcare providers to promote a culture of infection prevention within the facility.

o Ensure that all new hires receive comprehensive infection control orientation as part of their onboarding process.

o Accreditation and Compliance o Assist the facility in maintaining accreditation by ensuring compliance with The Joint

Commission (TJC) standards related to infection control.

o Prepare and assist in the review of infection control documentation required for accreditation and regulatory inspections.

o Implement corrective actions in response to identified deficiencies in infection control practices, and monitor the effectiveness of these interventions.

o Policy Development and Review o Review, update, and develop infection control policies and procedures in alignment with IHS policies and evolving best practices in infection control and prevention.

o Provide recommendations for the integration of infection control activities with other patient safety initiatives within the facility.

o Outbreak Management o Lead the facility’s response to infectious disease outbreaks, coordinating with public health authorities as required.

o Develop and implement outbreak control measures in accordance with IHS Manual guidelines and public health directives.

The Contractor shall comply with the policies, procedures and by-laws of the on-site facility. The

Contractor shall also be required to perform this service in compliance with applicable standards of The

Joint Commission and Quality Improvement.

Contractor shall wear government issued contractor identification badge during performance of duty.

Contractor shall manage all patient information in accordance with HIPAA standards, Privacy Act, and

Oklahoma City Area Indian Health Service (OCAIHS) specific policies and protocols.

Contractor shall ensure that OCAIHS information technology system security policies and procedures are adhered to. The OCAIHS IT policies and procedures will be made available to the Contractor.

The Department Supervisor will provide technical direction on the specific tour of duty.

4. Professional Qualifications

Nurse specialist shall have a minimum of a Bachelor of Science in Nursing.

A minimum of twelve (12) months relevant experience within the last twenty-three (23) months is preferred; including Joint Commission survey and infection control and prevention.

Nurse specialist shall possess a current, valid, unrestricted nursing license within the Continental United States throughout the term of this contract.

Nurse Specialty Board Certification is preferred for each appropriate duty section at the time of employment and throughout the term of this contract.

Nurse specialist shall possess a valid state driver’s license throughout the duration of this contract.

Nurse specialist shall have the physical ability to perform assigned tasks, are able to lift fifty (50) pounds and are able to stand and walk for extended periods of time.

Nurse specialist shall also provide the following immunization documentation (vaccinations are to be complete prior to assignment and will not be administered by the Government):

• Immunity to Rubella, Mumps, Measles

• Influenza vaccine (Annually)

• Immunity to Hepatitis A and B (A signed delineation of the Hepatitis B vaccination series will be accepted)

• History of chicken pox disease or positive titer

• Tetanus Diphtheria (Td) within the last 5 years

• Documentation of receiving a TB skin test (PPD) within the past 12 months with documentation of follow-up for a positive test.

• COVID-19 vaccination is highly encouraged but not required. Should a contractor not be vaccinated, Covid testing shall be conducted weekly.

Accreditation Nurse Specialist Certifications/Requirements:

• Minimum one (1) years’ accreditation experience required and 5 years RN nursing experience full-time Med/Surg or Ambulatory Care/Clinic specific experience that has occurred within the past 23 months.

• Must either hold or be finalizing completion (within 8 months of BPA award) of the AIPC

(Associate Infection Prevention and Control) certification.

o This certification is issued by the Certification Board of Infection Control and

Epidemiology (CBIC) through the Association for Professionals in Infection Control and

Epidemiology (APIC). The AIPC certification ensures foundational knowledge and competencies in infection prevention, in line with IHS standards.

o Contractor must be eligible to pursue further advanced certifications as required by IHS.

Eligibility for these certifications should be attained outside of contractual hours and within the stipulated timeframes to ensure ongoing compliance with IHS’s professional development requirements.

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

• Accreditation experience includes

▪ Oversee and implement infection control and prevention activities

▪ Evaluate standards compliance and address compliance deficiencies

▪ Perform tracer activities, create action plans for compliance, identify and implement improvement opportunities

▪ Provide staff education to both clinical and non-clinical staff

▪ Provide survey

▪ Appropriate documentation evaluation; develop, implement, evaluate and revise patient care plans to meet patient needs.

5. Security Clearance/Child Protection Act

The Contractor shall work with the Oklahoma City Area Indian Health Service (OCAIHS) to ensure that the pre-employment screening process includes the appropriate investigation questionnaires and forms to be completed. All contractors shall undergo a fingerprint check and background investigation and shall be cleared prior to hire. Contractor’s continued employment is contingent upon the outcome of a complete and favorable background investigation as determined by the sensitivity level of the position. If contractors are found not suitable, they will be removed.

This is a designated position covered by Public Law 101-647, 101-630, Crime Control Act of 1990, and the

Indian Child Protection and Family Violence Prevention Act, requiring contact or control over Indian children. Contractors shall be required to complete, sign, and submit the Addendum to OF-306, Child

Care & Indian Child Care Worker Position form. Due to this requirement, the agency shall ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes. Failure to comply with these statutes shall result in immediate removal.

In accordance with Public Law 101-647 and 101-630, all contractor staff assigned to this contract shall take the training that is available via IHS website, https://www.ihs.gov/sexualabuseprevention/training/, on protecting children from sexual abuse by health care providers, within 30 days from the contract award date, and yearly thereafter and regardless of the length of their assignment. Furthermore, all the new hires shall complete the training no later than 30 days after the assignment to the contract, throughout the contract period. This annual training covers the IHS Indian Health Manual Part 3 Chapter

20 policy that provides professional standards and guidance to protect against sexual abuse or exploitation of children by health care providers. The training covers what all IHS federal and contractor staff need to know about their critical role in preventing sexual abuse of children.

Anyone with knowledge or suspicion of child abuse has a responsibility to report the information to the contract contracting officer, local law enforcement; the IHS Headquarters Division of Personnel Security and Ethics; or the HHS Office of the Inspector General. IHS health care practitioners, administrators and other personnel including the contractor staff have a legal duty to report known or suspected abuse.

When reporting suspected child abuse case, the informer can be confident that The IHS Leadership will take the allegations seriously and without reprisal.

No later than 30 days after the award date, the contract company shall respond to the Contracting Officer via email with a completion status on behalf of all contractor staff assigned under the contract. This completion status shall be submitted to the Contracting Officer within 30 days of the start date for all nurses under this blanket purchase agreement. Additionally, compliance with this federal law requires all federal employees and contractors take annual policy training.

6. Government Furnished Facilities/Equipment/Supplies

The Government will provide the facilities, supplies, equipment and specialty and/or leadership support staff. Use of government furnished facility space, equipment, supplies, and personnel are for the provision of care and services set forth in this BPA only. This does not include any type of uniform or laboratory coat.

A written Orientation Manual of Policies and Procedures and application forms for appointment and privileging as associate staff members will also be provided by the Government. The Government will provide assistance, orientation and guidance in seeing patients as well as receiving supplies, utilizing and ordering laboratory, x-ray and pharmacy services.

7. Contractor Exclusive Use

The Government will provide facility specific contractor identification badges for each Contractor. A fee of up to $100.00 shall be charged for lost, destroyed and non-returned badges.

Facility specific orientation/training necessary for the Contractor to perform the required duties, e.g., OCAIHS information technology (IT) systems and operational procedures will be provided. Training will be provided ONLY if the subject matter is necessary to improve or enhance the quality of the nursing services or includes mandates made by Hospital, Oklahoma City Area Office, Indian Health Service and/or

Department of Health and Human Services while the nurse is working under this contract. Training may be provided for purposes of continuing education, career development or individual development should it benefit the organization and related to key deliverables.

The Contractor shall use reasonable care to avoid damaging existing buildings, equipment, and vegetation on the Government installation. If the Contractor’s failure to use reasonable care causes damage to any of this property, the Contractor shall replace or repair the damage at no expense to the Government as the Contracting Officer directs. If the Contractor fails or refuses to make such repair or replacement, the

Contractor shall be liable for the cost, which may be deducted from the contract price.

8. Contractor Furnished Property

Except for the property specified in Section 6 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments such as: Professional clothing, Uniforms, Lab Coat and stethoscope.

Uniforms and personal instrument shall conform to the requirements of the Indian Health Service

Manual, Part 3 Chapter 4 and meet the approval of the Quality Director. The Contractor shall not use unsafe equipment or supplies at any time during performance of this contract. The Government reserves the right to prohibit the use of any materials, supplies, or equipment.

It is expressly agreed and understood that this is a non-personal services contract, as defined in Federal

Acquisition Regulation (FAR) 37.101, under which the professional services rendered by the Contractor are rendered in its capacity as an independent contractor. The Contractor shall be solely liable for and expressly agrees to indemnify the Government with respect to any liability producing acts or omissions by it or by its employees or agents. The Contractor shall maintain during the term of this contract liability insurance issued by a responsible insurance carrier of not less than $1,000,000 per specialty per occurrence, $3,000,000 aggregate.

9. Work Schedule/Rates

Purchase order shall be for a period of performance of one year.

The Director of Quality will provide the contractor a document to log hours worked. The contractor will log: contractor name, date, hour of arrival, hour of departure, total daily hours worked and total weekly hours worked.

The supervisor will sign the log as verification of services rendered and to certify payments.

The contractor shall provide services 8 hours per day, Monday – Friday and occasional Saturday clinic (if applicable); for a total of 40 hours per week. Daily hours may range from 7:30 AM – 5:00 PM and will be adjusted to ensure compliance with 40 hours per week.

Overtime is allowed with pre-approval by the supervisor. No additional compensation is allowed including paid holidays, sick leave or annual leave.

The contractor’s primary duty station is the Clinton Indian Health Center; however, periodically, at the direction of the supervisor, the contractor may work remote and/or travel to other IHS facilities within the Oklahoma City Area to provide survey readiness services or as part to the quality team.

The contractor may be contracted to travel to other Oklahoma City Area IHS facilities if Clinton Service

Unit Director of Quality agrees and services rendered are within the scope of this contract.

Upon completion of Government Vehicle training, the contractor will 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.

Any changes to the preceding shall require mutual agreement of the Contractor, Director of Quality and

Contract Specialist.

The Contractor shall provide written documentation from a qualified health care provider for absences of three (3) or more consecutive days, due to illness, stating:

• The cause of the current illness/incapacitation

• Indicating the contractor as contagious or non-contagious

• Anticipated return date

10. Invoicing Procedures

Invoicing shall be submitted monthly. In order to be paid in a timely manner, all invoices shall contain information as defined in Federal Acquisition Regulation 32.905, Payment Documentation and Process.

11. Government Contract Quality Assurance

The Contractor shall meet standards as listed in the Federal Code of Conduct. The Government reserves the right to examine and or re-examine any Contractor who fails to meets the criteria.

Substantiated reports written by any staff or patient dealing with accreditation standards, patient safety, infection control, or other procedure that adversely affects patient outcome constitutes a breach of contract.

Contractors demonstrating impaired judgment shall not be permitted to work at the Indian Health

Service. The Government reserves the right to remove from the facility any Contractor who in the judgment of a licensed physician is impaired by drugs or alcohol.

Quality and technical oversight of professional and administrative services provided will be evaluated.

Should the Government be made aware of a critical or major nonconformance matter the contractor will be given the opportunity to remedy.

The Contractor shall immediately report to the Contracting Officer Representative (COR) any information or circumstances that may violate any statute, policy, or procedure.

Although a nonpersonal services requirement, the Government will evaluate the quality of professional and administrative services provided and record in the Contractor Performance Assessment Reporting

System (CPARS).

Quality assurance methods will include both written and verbal feedback from the Clinical Directors, staff and patients. Should the Government be made aware of a critical, major or minor non-conformance matter the locum company will be notified in writing in the form of a Non-Conformance report (Appendix

A) and given the opportunity to remedy. All Non-Conformance Reports will be made a record of the locum company’s past performance.