W91242-18-T-0001.pdf

SEE ADDENDUM

(No Collect Calls)

W91242-18-T-0001 07-Mar-2018

b. TELEPHONE NUMBER

919-664-6229

8. OFFER DUE DATE/LOCAL TIME

12:00 AM 09 Apr 2018

5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA – FAR (48 CFR) 53.212

(TYPE OR PRINT)

(SIGNATURE OF CONTRACTING OFFICER)

ADDENDA X ARE

26. TOTAL AWARD AMOUNT (For Gov t. Use Only )

23.

CODE 10. THIS ACQUISITION IS

SUCH ADDRESS IN OFFER

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT

BELOW IS CHECKED

TELEPHONE NO.

W912429. ISSUED BY

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a. UNLESS BLOCK

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

KYLE LAURICELLA

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NUMBER

(TYPE OR PRINT)

30b. NAME AND TITLE OF SIGNER 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a.UNITED STATES OF AMERICA

1 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1. 52.212-4. FAR 52.212-3. 52.212-5 ARE ATTACHED.X

25. ACCOUNTING AND APPROPRIATION DATA

1. REQUISITION NUMBER

20.

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

. YOUR OFFER ON SOLICITATION

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

% FOR:SET ASIDE:UNRESTRICTED OR X

SMALL BUSINESS

17a.CONTRACTOR/ CODE FACILITY

OFFEROR CODE

USPFO FOR NORTH CAROLINA (W91242)

ATTN KYLE LAURICELLA

PURCHASING & CONTRACTING

4201 REEDY CREEK RD

RALEIGH NC 27607-6412

18a. PAYMENT WILL BE MADE BY CODE

RATED ORDER UNDER

DPAS (15 CFR 700)

13a. THIS CONTRACT IS A

13b. RATING

CODE15. DELIVER TO CODE 16. ADMINISTERED BY

SEE SCHEDULE

12. DISCOUNT TERMS11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

14. METHOD OF SOLICITATION

RFQ IFB RFPX

919-664-6034FAX:

TEL: 919-664-6229 SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$20,500,000

NAICS:

621498

X

OFFER DATED

29. AWARD OF CONTRACT: REF.

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

EMAIL:

TEL:

31c. DATE SIGNED

SEE SCHEDULE

SCHEDULE OF SUPPLIES/ SERVICESITEM NO. QUANTITY UNIT UNIT PRICE AMOUNT

24.22.21.19.

X

WOMEN-OWNED SMALL BUSINESS (WOSB)

ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

(CONTINUED)

PAGE 2 OF66

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: ______________________________________________________

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f . TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

37. CHECK NUMBER

FINALPARTIALCOMPLETE

36. PAYMENT35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER

FINAL

33. SHIP NUMBER

PARTIAL

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42a. RECEIVED BY (Print)

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 2/2012) BACK

Prescribed by GSA – FAR (48 CFR) 53.212

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

SEE SCHEDULE

20.

SCHEDULE OF SUPPLIES/ SERVICES

21.

QUANTITY UNIT

22. 23.

UNIT PRICE

24.

AMOUNT

19.

ITEM NO.

Section B - Supplies or Services and Prices

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001 1 Job

Lenoir 14-15 Apr 18

FFP

220 PAX, 2-day event, 14-15 April 18, Address: 1535 Beecher Anderson Rd. , Lenoir NC 28645. IAW attached PWS. See Medical Event Request Form for details.

FOB: Destination FOB: Destination

NET AMT

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002 1 Job

Goldsboro 5-6 May 18

FFP

345 PAX, 2-day event, 5-6 May 18, Address: 700 US HIGHWAY 117 SOUTH BYPASS, Goldsboro NC 27530. IAW attached PWS. See Medical Event Request Form for details.

FOB: Destination FOB: Destination

NET AMT

0003 1 Job Winterville 21-22 Jun 18

FFP

175 PAX, 2-day event 21-22 Jun 18, Address: 3000 South Mill Street, Winterville NC 28590. IAW attached PWS. See Medical Event Request Form for details.

0004 1 Each

CMRA

FFP

eCMRA reporting requirement for FY18 ending September 30, 2018

Section C - Descriptions and Specifications

PERFROMANCE WORK STATEMENT

P

P

E

R

F oPerrmance Work Statement Periodic Health Assessment (PHA) and

Ancillary Laboratory, Audiology and Medical Support Services

PART 1 GENERAL

INFORMATION

1.1 Description of Services/Introduction: The contractor shall provide all personnel, equipment, tools, materials, supervision, and other items and non-personal services necessary to perform medical service support as defined in this Performance Work Statement except as Specified in section 3.

1.2 Background: Individual Medial Readiness (IMR) and Fully Medically Ready (FMR) are the basic principles of force-sustainment for North Carolina Army National Guard (NCARNG) forces. Medical readiness is vital for combined force health protection and failure to achieve a standard of level of medical health could preclude a soldier from deploying. Medical Readiness is a command responsibility.

1.3 Objectives: The objective of this PWS is to conduct and complete, either selective services or as a complete service, the requirements of NCARNG IMR/FMR - Medical Readiness on all eligible (mobilizing or not) Service Members (SMs) in the NCARNG utilizing a HIPPA, Privacy Act, and OSHA-Compliant portable health facility.

Medical evaluation by a licensed provider (Physician, Physicians Assistant (PA), or Nurse Practitioner (ARNP) IAW prescribed Army and NGB policy for Periodic Health Assessment, Physical Exams (Over-40, flight, and Specialty schools).

All routine and ordered phlebotomy services provided on location or shipped to the required processing center(CDD for HIV).

Electrocardiogram (EKG) service performed on all Soldiers over 40 years of age provided on location IAW CVSP guidelines.

All routine and theatre specific immunizations provided by contractor, administered and annotated on a DD Form 2766 - Adult Preventive and Chronic Care Flowsheet provided on location.

All baseline audiology (DD Form 2215 DD or DD Form 2216 Hearing Conservation Form), to include required follow-up for SPRINT Testing provided on location (if Audiologist is requested).

Height, weight and blood pressure taken, recorded and stored electronically provided on location.

Vision screening provided on location.

Eye exams provided on location for all Soldiers scoring worse than 20/40 on vision screening (if

Optometry is requested).

Routine urinalysis for pregnancy testing and >40 years of age services (and specialty schools) provided on location.

DNA and ABO-Rh testing/collection provided on location.

Exams will be entered into the PHA module of MODS on location and required documentation loaded into HRR as required.

Results entry and input/entry of all medical related FMR/IMR functions into the MEDPROS module of

MODS provided/entered on location.

Annotation and entry of services into the DD Form 2766 – Adult Preventive and Chronic Care Flow sheet or appropriate document.

1.4 General Information

1.4.1 Quality Control: The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s quality control program is the means by which he assures himself that his work complies with the requirement of the contract. As a minimum, the contractor shall develop quality control procedures that address the areas identified in Technical Exhibit 1, “Performance Requirements Summary”. After acceptance of the quality control plan the contractor shall receive the contracting officer’s acceptance in writing of any proposed change to his QC system.

1.4.2 Quality Assurance: The government shall evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan. This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.4.3 Government Remedies: The contracting officer shall follow FAR 52.212-4, “Contract Terms and Conditions- Commercial Items” or 52.246-4, “Inspection of Services-Fixed Price” for contractor’s failure to perform satisfactory services or failure to correct non-conforming services.

1.4.4 Recognized Holidays: The contractor is not required to perform services on these days Holidays or if the facilities are closed.

New Year’s Day Labor Day

Martin Luther King Jr.’s Birthday Columbus Day

President’s Day Veteran’s Day

Memorial Day Thanksgiving Day

Independence Day Christmas Day

1.4.5 Hours of Operation/Place of Performance: The contractor is responsible for conducting the tasks listed in section

5.0 during drill weekends and/or as requested. Soldier Readiness Processing for deployment and other training periods that would require physician support during normal hours of operations to be estimated at 10 hours a day. Usual hours are between 0700 and 1900 unless special arrangements are made. Services are to be completed on site at various NC-ARNG Armories & Training Sites across the State.

1.4.6 Travel Requirements: Contractor travel will be the sole responsibility of the contractor and should be included in the price schedule provided for services.

1.4.7 Qualifications: Providers holding a license to practice medicine. A provider is defined as: Advanced Registered Nurse Practitioner (ARNP), Physician’s Assistant (PA) or Physician (MD, DO). Medical services shall be performed by licensed medical professionals, who are board certified in their respective fields and have a license to practice medicine. Ancillary services (lab, vision, etc) will be provided by credentialed contractors but will work under the auspices of the licensed provider at [that] particular location. Contractor shall be held liable and is responsible for ensuring and verifying the appropriate level of Credentialing / Privileging (Licensure, Diploma, background checks, etc.) for all contact providers in support of any NCARNG event.

1.4.8 Special Requirements:

OSHA & HIPAA-Compliant Full PHA &/or Physical Exam Requirements Real-time Data Processing & Uploading capability.

Additional MODS Medical Resources required:

MEDPROS Wed Data Entry (MWDE) access/entry Electronic PHA Upload Entry of all work performed in the HRR module Entry of profiles into the e-Profile module

Contractor shall have network of local pharmacies for prescription medication services available for service members during contracted events.

1.4.9 Contracting Officer Representative (COR): The (COR) is identified below:

Primary: 2LT Jacquelyn Kahn, North Carolina Army National Guard HSS, G1-JFHQ, 919-664-6804 email Jacquelyn.a.kahn.mil@mail.mil

The COR monitors all technical aspects of the contract and assists in contract administration The COR is authorized to perform the following functions: assure that the Contractor performs the technical requirements of the contract: perform inspections necessary in connection with contract performance: maintain written and oral communications with the Contractor concerning technical aspects of the contract: issue written interpretations of technical requirements, including Government drawings, designs, specifications: monitor Contractor's performance and notifies both the Contracting Officer and Contractor of any deficiencies; coordinate availability of government furnished property, and provide site entry of Contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the Contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting order.

1.4.10 Contract Manager: The contractor shall provide a contract manager who shall be responsible for the performance of the work. The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the contracting officer. The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract.

1.4.11 Identification of Contractor Employees: All contract personnel attending meetings, answering Government telephones, and working in other situations where their contractor status is not obvious to third parties are required to identify themselves as such to avoid creating an impression in the minds of members of the public that they are Government officials. They must also ensure that all documents or reports produced by contractors are suitably marked as contractor products or that contractor participation is appropriately disclosed.

1.5 Security Training Requirements:

1.5.1 Base security will require all employees and affiliated personnel of the contractor to carry a State recognized identification card or drivers license and all vehicles are subject to search without reason. The contractor shall comply with all installation security requirements.

1.5.2 AT Level 1 Training: All contractor employees, to include subcontractor employees, requiring access Army installations, facilities and controlled access areas shall complete AT Level I awareness training. The contractor shall obtain and have on file all certificates of completion for each affected contractor employee and subcontractor employee and must be able to provide copies whenever required to the COR or to the contracting officer. AT level I awareness training is available at the following website: https://atlevel1.dtic.mil/at.

1.5.3 Access and General Protection/Security Policy and Procedures. This standard language text is for contractor employees with an area of performance within an Army controlled installation, facility or area. Contractor and all associated sub-contractors employees shall comply with applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative). The contractor shall also provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services or Security Office.

Contractor workforce must comply with all personal identity verification requirements as directed by DOD, HQDA and/or local policy. In addition to the changes otherwise authorized by the changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the Government may require changes in contractor security matters or processes.

1.5.4 iWATCH Training. This standard language is for contractor employees with an area of performance within an Army controlled installation, facility or area. The contractor and all associated sub-contractors shall brief all employees on the local iWATCH program (training standards provided by the requiring activity ATO). This local developed training will be used to inform employees of the types of behavior to watch for and instruct employees to report suspicious activity to the COR.

1.5.5 Contractor Employees Who Require Access to Government Information Systems. All contractor employees with access to a government info system must be registered in the ATCTS (Army Training Certification Tracking System) at commencement of services, and must successfully complete the DOD Information Assurance Awareness prior to access to the IS and then annually thereafter.

1.5.6 For Contracts that Require OPSEC Training. Per AR 530-1, Operations Security, new contractor employees must complete Level I OPSEC training and must complete annual OPSEC awareness training.

1.5.7 For Information assurance (IA)/information technology (IT) training. All contractor employees and associated sub-contractor employees must complete the DoD IA awareness training before issuance of network access and annually thereafter. All contractor employees working IA/IT functions must comply with DoD and Army training requirements in DoDD 8570.01, DoD 8570.01-M and AR 25-2 within six months of employment.

1.5.8 For information assurance (IA)/information technology (IT) cortication. Per DoD 8570.01-M , DFARS

252.239.7001 and AR 25-2, the contractor employees supporting IA/IT functions shall be appropriately certified upon contract award. The baseline certification as stipulated in DoD 8570.01-M must be completed upon contract award.

PART 2

DEFINITIONS & ACRONYMS

AR Army Regulation

DA Department of the Army

DD (Defense) Department

FMR Fully Medically Ready

HIPAA Health Insurance Portability and Accountability Act

IMR Individual Medical Readiness

MEDCOM U.S. Army Medical Command

MEDPROS Medical Protection System

MMRB Medical MOS Retention Board

MODS Medical Operational Data System

NGB National Guard Bureau

OSArS Office of the State Army Surgeon

OSHA Occupational Safety and Health Administration

PEB Physical Evaluation Board

PHA Periodic Health Assessment

SRC Soldier Readiness Check

SRP Soldier Readiness Processing

STR Soldier Treatment Record

SOW Statement of Work

TMC Troop Medical Clinic

NCARNG North Carolina Army National Guard

PART 3

GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

No armory, TMC, or office space will be provided or utilized unless prior approval is obtained from the Office of the State Army Surgeon. The Deputy State Surgeon of the NCARNG has the option to provide any and all management, labor, material, equipment, and supplies necessary for the contract medical provider to function operationally. It is expected that any contracted assets will integrate and work seamlessly with the contracted work staff. The services that the Deputy State Surgeon shall provide for the contract provider will meet readiness and deployability standards to ensure mission capability of the NCARNG. A Common Access Card (CAC) sponsored by the G1/Deputy State Surgeon shall also be provided.

PART 4

CONTRACTOR FURNISHED ITEMS AND SERVICES

4.1 General: Except for those items specifically stated to be government furnished in Part 3, the contractor shall furnish everything required to perform this PWS.

PART 5

SPECIFIC TASKS

5.1 Periodic Health Assessments (PHA): The contractor shall conduct PHAs in accordance with the PHA interim guidance set forth by the National Guard Bureau of the Surgeon General.

5.2 Periodic Health Assessments and Physical Exams: the contractor shall conduct Periodic Health Assessments (PHA) and other physical exams (Over-40, Chapter 2, Flight, etc.) in accordance with the AR 40-501 and the CVSP guidelines.

5.3 Visual Acuity Testing: The contractor shall conduct visual acuity testing in accordance with AR 40-501

5.4 Onsite at Post-Event Case Management of Temporary and Permanent Profiles:

• Licensed provider will identify and initiate the required Temporary and Permanent Profiles (T2 and T3, P2 and P3) to NCARNG soldiers via hardcopy record/spreadsheet, as well as, the MND module of MODS. A copy of the spreadsheet will be provided to the NCARNG case management staff at the event.

• The only permanent profiles to be written are for hearing (after SPRINT evaluation) or digital entry of a previously handwritten copy of a permanent profile.

• When required, contract manager will coordinate with Deputy State Surgeon and Health Services Section and arrange for fulfillment of required consultations and follow up.

• Follow-up conversations between Contractor and NCARNG treated soldier & Supervisor may be necessary depending on complexity of treatment and potential additional requirements.

5.5 Prescription Medication Services:

• Contractor shall set up network & account with local pharmacies near event location.

• Upon need of dentally treated soldiers & recommended by licensed dentist, Contractor to arrange for fulfillment of prescription medication for soldier.

• Contractor shall be invoiced by & submit payment to subcontracted local pharmacy utilized

• Follow-up conversations between Contractor and NCARNG treated soldier & Supervisor may be necessary depending on complexity of treatment and prescription medication, but will always engage Deputy State Surgeon.

• Contractor to collect & tally all expenses of prescription medication services & case management related

• Contractor shall submit costs to the COR.

5.6 Documentation:

The contractor shall ensure that all appropriate DA or DD forms (in accordance with references) are utilized for each service supplied. The forms will be made available through the North Carolina Army National Guard Medical Command office. The contractor shall provide all documentation concerning medical treatment to the NCARNG Deputy State Surgeon.

Reporting: The contractor shall provide a final report for all services provided to include a by name, unit, and social security number roster of all soldiers receiving services. The report shall be approved and verified by the NCARNG liaison with the office of the G1/Deputy State Surgeon of the NCARNG.

The following data elements will be reported at the end of an event:

Date Location List of contract employees Total number of patients scheduled Total number of patients examined Verification of entry into all necessary MODS modules (MEDPROS & e-PHA, HRR, etc).

A by name listing of all Soldiers examined and the dental classification of the Soldier (if dental services were requested) The provider shall document the results on the same day examinations are performed.

5.7 Electrocardiogram Testing:

The contractor shall conduct electrocardiogram testing on all Soldiers as required IAW prescribed Army and NGB policy and IAW AR 40-501for Periodic Health Assessment and Physical Exams (Over 40 years, flight, and Specialty Schools).

All electrocardiogram testing services shall be provided on location and loaded into HRR.

5.8 Phlebotomy Service:

The contractor shall perform all Phlebotomy services on location to any Service member requiring the services to include G6PD, PSA, full Lipid Panels, Cholesterol, Sickledex, Hematocrit, and HgB as required IAW prescribed Army and NGB policy and IAW AR 40-501 for Periodic Health Assessment and Physical Exams.

5.9 Eye Exam Testing:

Eye exams provided on location for all Soldiers scoring worse than 20/40 on vision screening by a certified Optometrist IAW AR 40-501 (if optometry services are requested).

5.10 DNA and ABO-Rh:

Testing provided on location as required by AR 40-501.

5.11 HIV

The contractor shall perform HIV tests to all Soldiers requiring as required IAW prescribed Army and NGB policy and IAW AR 40-501.

All phlebotomy service required for HIV testing must be provided on location and specimens shipped to the

CDD.

5.12 IMMUNIZATIONS

The contractor shall identify through MEDPROS immunizations required for each Soldier then administer necessary vaccines IAW AR 40-562, TB MED 114, Army and NGB policy.

The contractor shall utilize all MILVAX and AR 40-562 requirements for the transportation and storage of vaccines.

All immunization services must be provided on location.

5.13 HEARING

The contractor shall conduct hearing test IAW DA PAM 40-501 in a certified booth using DOEHRS approved equipment.

The booth and equipment will be provided by the contractor unless otherwise specified in the solicitation.

The current audiometric booth certification must be posted on the outside of the booth in an easily seen location or available for review.

5.14 Contractor Management Reporting (CMR): The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for ARMY collection site. The contractor is required to completely fill in all required data fields using the following web address:

http://www.ecmra.mil/. Reporting inputs will be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30.While inputs may be reported any time during the FY, all data shall be reported no later than October 31of each calendar year. Contractors may direct questions to the help desk at http://www.ecmra.mil.

Unit Identification Code (UIC) for the Requiring Activity: W8BPAA Issuing Office DoDAAC: W91242

PART 6

APPLICABLE PUBLICATIONS

6.1 Publications applicable to this PWS are listed below.

AR 40-501 Standards of Medical Fitness NGB Memorandum Post Deployment Health Re-Assessment Screen (attached) NGB Memorandum Periodic Health Assessment Interim Guidance (attached)

All publications listed are available via the Internet at the specified web address. (http://www.usapa.army.mil/)

TECHNICAL EXHIBIT 1

Performance Requirements Summary

Specification Item Performance Objective

AQL Method of Surveillance

Sample Size

Frequency

Health Assessments (5.1, 5.2)

Exams are performed in accordance with all regulations

97% Inspection 100% 100%

Visual Acuity Testing (5.3)

Testing is performed in accordance with Army Regulation 40-501

97% Inspection 100% 100%

Management of Profiles (5.4)

Contractor will maintain files and follow-up on profiled soldiers

97% Inspection 100% 100%

Prescription Management (5.5)

Contractor provides prescription services and oversight

97% Customer Feedback

100% 100%

Administrative Functions (5.6)

All reports and documents are submitted and input appropriately as defined

100% Inspection 100% 100%

Electrocardiogram Testing (5.7)

Testing is performed in accordance with Army Regulation 40-501

97% Inspection 100% 100%

Phlebotomy Services (5.8)

Testing is performed in accordance with Army Regulation 40-501

97% Inspection 100% 100%

Eye Exam Testing (5.9)

Testing is performed in accordance with Army Regulation 40-501

97% Inspection 100% 100%

DNA and ABO-Rh Testing (5.10)

Testing is performed in accordance with Army Regulation 40-501

97% Inspection 100% 100%

HIV Testing Testing is 100% Inspection 100% 100% (5.11) performed in accordance with

Army Regulation

40-501

Immunizations Testing is 100% Inspection 100% 100% (5.12) performed in accordance with

Army Regulation

40-501

Hearing Testing is 100% Inspection 100% 100% (5.13) performed in accordance with

DA PAM 40-51

Performance Work Statement (PWS)

For

Dental Restorative Care

PART 1

GENERAL INFORMATION

1.1 Description of Services/Introduction: The contractor shall provide all personnel, equipment, tools, materials, supervision, and other items and non-personal services necessary to perform Dental Restorative Care as defined in this Performance Work Statement except as Specified in section C-3 as government furnished property and services within the state of North Carolina. The contractor shall perform to the standards in this contract.

1.2 Background: The North Carolina Army National Guard (NCARNG) recognizes the importance of Soldiers’ Dental Readiness. Individual Medical Readiness (IMR) and Fully Medically Ready (FMR) are the basic principles of force sustainment. Dental health is vital for force health protection and failure to achieve a standard level of oral health may preclude a Soldier from deployment status. The performance work statement includes the components of dental classifications for the Department of Defense (DOD) in order to identify varying degrees of dental health and readiness. This is to cover the various components of IMR/FMR to include; annual dental exams, digital bitewings radiographs, digital panoramic radiographs, DENCLASS data entry of all radiographs and dental records, identification and treatment (no less than 90+%) of all Class 3 soldiers eligible for treatment. Services are to be completed on site at NCARNG Armories & Training Sites across the State. The SOW identifies the purpose of the work to be performed by the contractor and provides a description of the work to be completed and any required outcomes. The contractor shall provide qualified personnel, material to perform the services, and /or OSHA, HIPPA, ADA, and Privacy Act Compliant Mobile, Self-Contained Dental Practices depending on the individual site needs for the NCARNG.

DoD established a uniform dental classification in HA Policy 02-11. DoD policy requires dental screening examinations and remediation to be accomplished and documented on 90%+ of service members. Members of the NCARNG shall receive an annual dental screening examination to determine their dental classification. The initial results of that screening examination shall be entered into the DENCLASS database on the date of examination.

Final data input by the contractor will be completed within 48 hours of state approval of the proposed treatment.

The DENCLASS database updates the Army Medical Protection System, MEDPROS. Dental treatment that may be required is essential to be provided at the SRP site to ensure the highest Dental Deployable Rate for the Mobilizing Soldiers.

1.3 Objectives:

Conduct and complete FULL Restorative Care for the requirements of the NCARNG mobilizing and non-mobilizing Soldiers Conform to the standards of HIPPA, Privacy Act, and OSHA-Complaint mobile dental facility Dental services to be performed by licensed dental professionals Input to Medical Protection System (MEDPROS) Input to DENCLASS Upon completion of each event, must submit a detailed list of services performed Submit a DENCLASS and MEDPROS input summary report

1.4 Scope:

The scope of this contract is to fulfill the requirements of NCARNG IMR/FMR - Dental Readiness on all eligible (mobilizing or not) Service Members (SMs) in the NCARNG utilizing an HIPPA, Privacy Act, and OSHA- Compliant mobile health facility. Dental services shall be performed by licensed professionals with oversight by the NCARNG Office of the State Army Surgeon. As well, the NCARNG Soldiers that are Class 3 Dental Status (non-deployable without approved dental treatment) require OSHA & ADA-Compliant dental treatment.

1.5 Period of Performance: 6 January 2018 – 27 March 2018

1.6 General Information

1.6.1 Quality Control: The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s quality control program is the means by which he assures himself that his work complies with the requirement of the contract. As a minimum, the contractor shall develop quality control procedures that address the areas identified in Technical Exhibit 1, “Performance Requirements Summary”. After acceptance of the quality control plan the contractor shall receive the contracting officer’s acceptance in writing of any proposed change to his QC system.

1.6.2 Quality Assurance: The government shall evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan. This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.6.3 Government Remedies: The contracting officer shall follow FAR 52.212-4, “Contract Terms and Conditions- Commercial Items” or 52.246-4, “Inspection of Services-Fixed Price” for contractor’s failure to perform satisfactory services or failure to correct non-conforming services.

1.6.4 Recognized Holidays: The contractor is required to perform services accordingly except on these Holidays:

New Year’s Day Labor Day

Martin Luther King Jr.’s Birthday Columbus Day

President’s Day Veteran’s Day

Memorial Day Thanksgiving Day

Independence Day Christmas Day

1.6.5 Hours of Operation/Place of Performance: The contractor is responsible for conducting restorative Care upon request between the hours of 0700-1900 on any required day of the week, except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The Contractor must at all times maintain an adequate work force for the uninterrupted performance of all tasks defined within this statement of work when the Government facility is not closed for the above reasons. When hiring personnel, the Contractor shall keep in mind that the stability and continuity of the work force are essential.

1.6.6 Type of Contract: The Government intends to award a Firm-Fixed Price contract. This Performance Work Statement will be incorporated into contract.

1.6.7 Travel Requirements: Contractor will be fully responsible for the travel and all expenses for their staff. Travel is only limited to all and any duty station within the state of North Carolina.

1.6.8 Qualifications: Contractors must have a full understanding of Individual Medical Readiness (IMR) and Fully Medically Ready (FMR) in order to provide services to the NCARNG Soldiers. They must know the requirements of Dental Readiness for the state of North Carolina and be proficient with DENCLASS and MEDPROS.

HIPAA certified Privacy Act OSHA & ADA compliant

1.6.9 Special Qualifications: The contractor is responsible for ensuring that all staff members are certified dental professionals. All dental assistants and staff shall be trained and professional with good morals and ethics.

1.6.10 Security Requirements: The contractor shall be responsible for safeguarding all government property provided for contractor use. At the close of each work period, government facilities, equipment, and materials shall be secured.

1.6.10.2 Key Control. (If Necessary) The Contractor shall establish and implement methods of making sure all keys/key cards issued to the Contractor by the Government are not lost or misplaced and are not used by unauthorized persons. NOTE: All references to keys include key cards. No keys issued to the Contractor by the Government shall be duplicated. The Contractor shall develop procedures covering key control that shall be included in the Quality Control Plan. Such procedures shall include turn-in of any issued keys by personnel who no longer require access to locked areas. The Contractor shall immediately report any occurrences of lost or duplicate keys/key cards to the Contracting Officer.

1.6.10.2.1. In the event keys, other than master keys, are lost or duplicated, the Contractor shall, upon direction of the Contracting Officer, re-key or replace the affected lock or locks; however, the Government, at its option, may replace the affected lock or locks or perform re-keying. When the replacement of locks or re-keying is performed by the Government, the total cost of re-keying or the replacement of the lock or locks shall be deducted from the monthly payment due the Contractor. In the event a master key is lost or duplicated, all locks and keys for that system shall be replaced by the Government and the total cost deducted from the monthly payment due the Contractor.

1.6.10.2.2. The Contractor shall prohibit the use of Government issued keys/key cards by any persons other than the Contractor’s employees. The Contractor shall prohibit the opening of locked areas by Contractor employees to permit entrance of persons other than Contractor employees engaged in the performance of assigned work in those areas, or personnel authorized entrance by the Contracting Officer.

1.6.10.3 Lock Combinations. (If necessary) The Contractor shall establish and implement methods of ensuring that all lock combinations are not revealed to unauthorized persons. The Contractor shall ensure that lock combinations are changed when personnel having access to the combinations no longer have a need to know such combinations.

These procedures shall be included in the Contractor’s Quality Control Plan.

1.6.10.4 Conservation of Utilities. The contractor shall instruct employees in utilities conservation practices. The contractor shall be responsible for operating under conditions that preclude the waste of utilities, which include turning off the water faucets or valves after using the required amount to accomplish cleaning vehicles and equipment.

1.6.11 Contracting Officer Representative (COR): The (COR) is identified below:

Primary: 2LT Jacquelyn Kahn, North Carolina Army National Guard HSS G1- JFHQ, 919-664-6804 email Jacquelyn.a.kahn.mil@mail.mil

The COR monitors all technical aspects of the contract and assists in contract administration The COR is authorized to perform the following functions: assure that the Contractor performs the technical requirements of the contract:

perform inspections necessary in connection with contract performance: maintain written and oral communications with the Contractor concerning technical aspects of the contract: issue written interpretations of technical requirements, including Government drawings, designs, specifications: monitor Contractor's performance and notifies both the Contracting Officer and Contractor of any deficiencies; coordinate availability of government furnished property, and provide site entry of Contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the Contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting order.

1.6.12 Contract Manager: The contractor shall provide a contract manager who shall be responsible for the performance of the work. The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the contracting officer. The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract.

1.6.13 Identification of Contractor Employees: All contract personnel attending meetings, answering Government telephones, and working in other situations where their contractor status is not obvious to third parties are required to identify themselves as such to avoid creating an impression in the minds of members of the public that they are Government officials. They must also ensure that all documents or reports produced by contractors are suitably marked as contractor products or that contractor participation is appropriately disclosed.

1.7 Security Training Requirements:

1.7.1 Base security will require all employees and affiliated personnel of the contractor to carry a State recognized identification card or drivers license and all vehicles are subject to search without reason. The contractor shall comply with all installation security requirements.

1.7.2 AT Level 1 Training: All contractor employees, to include subcontractor employees, requiring access to Army installations, facilities and controlled access areas shall complete AT Level I awareness training within 15 calendar days after contract start date or effective date of incorporation of this requirement into the contract, whichever is applicable. The contractor shall submit certificates of completion for each affected contractor employee and subcontractor employee, to the COR or to the contracting officer, if a COR is not assigned, within 15 calendar days after completion of training by all employees and subcontractor personnel. AT Level I awareness training is available at the following website: https://atlevel1.dtic.mil/at.

1.7.3 Access and General Protection/Security Policy and Procedures. This standard language text is for contractor employees with an area of performance within an Army controlled installation, facility or area. Contractor and all associated sub-contractors employees shall comply with applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative). The contractor shall also provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services or Security Office.

Contractor workforce must comply with all personal identity verification requirements as directed by DOD, HQDA and/or local policy. In addition to the changes otherwise authorized by the changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the Government may require changes in contractor security matters or processes.

1.7.4 iWATCH Training. This standard language is for contractor employees with an area of performance within an Army controlled installation, facility or area. The contractor and all associated sub-contractors shall brief all employees on the local iWATCH program (training standards provided by the requiring activity ATO). This local developed training will be used to inform employees of the types of behavior to watch for and instruct employees to report suspicious activity to the COR.

1.7.5 Contractor Employees Who Require Access to Government Information Systems. All contractor employees with access to a government info system must be registered in the ATCTS (Army Training Certification Tracking System) at commencement of services, and must successfully complete the DOD Information Assurance Awareness prior to access to the IS and then annually thereafter.

1.7.6 For Contracts that Require OPSEC Training. Per AR 530-1, Operations Security, new contractor employees must complete Level I OPSEC training and must complete annual OPSEC awareness training.

1.7.7 For Information assurance (IA)/information technology (IT) training. All contractor employees and associated sub-contractor employees must complete the DoD IA awareness training before issuance of network access and annually thereafter. All contractor employees working IA/IT functions must comply with DoD and Army training requirements in DoDD 8570.01, DoD 8570.01-M and AR 25-2 .

1.7.8 For information assurance (IA)/information technology (IT) certification. Per DoD 8570.01-M , DFARS

252.239.7001 and AR 25-2, the contractor employees supporting IA/IT functions shall be appropriately certified upon contract award. The baseline certification as stipulated in DoD 8570.01-M must be completed upon contract award.

PART 2

DEFINITIONS & ACRONYMS

ADA American Dental Association

AR Army Regulation

DA Department of the Army

DD DoD (Defense) Department

FMR Fully Medically Ready

HIPAA Health Insurance Portability and Accountability Act

IMR Individual Medical Readiness

MODS Medical Operational Data System

NGB National Guard Bureau

OSArS Office of the State Army Surgeon

OSHA Occupational Safety and Health Administration

RDA Registered Dental Assistant

SRC Soldier Readiness Check

SRP Soldier Readiness Processing

STR Soldier Treatment Record

SOW Statement of Work

TMC Troop Medical Clinic

NCARNG North Carolina Army National Guard

PWS – Performance Work Statement

Contracting Officer’s Representative (COR): A representative from the requiring activity assigned by the Contracting Officer to perform surveillance and to act as liaison to the contractor

CCE– Contracting Center of Excellence

Defective Service. A service output that does not meet the standard of performance associated with it in the Performance Work Statement.

Quality Assurance Surveillance Plan (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

Quality Control. Those actions taken by a contractor to control the performance of services so that they meet the requirements of the PWS.

Quality Assurance. Those actions taken by the government to assure services meet the requirements of the Performance Work Statement.

PART 3

GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

3.1 GENERAL: Only parking will be provided for HIPAA, Privacy Act, OSHA & ADA-Compliant, Self Contained Mobile Medical/Dental Practices. No inside armory, TMC, or office space will be provided or utilized without prior approval from the Office of the Deputy State Surgeon.

PART 4

CONTRACTOR FURNISHED ITEMS AND SERVICES

4.1 General: Except for those items specifically stated to be government furnished in Part 3, the contractor shall furnish everything required to perform this PWS.

PART 5

SPECIFIC TASKS

5.1 Digital Bitewings, Digital Panoramic Radiographs & Dental Exams: The contractor shall perform required dental examinations to include digital bitewings and digital panoramic radiographs if clinically indicated in support of the annual dental screenings in accordance with the AR 40-501 and AR 40-35 in an undetermined number of Armories and training sites in North Carolina to be determined in each delivery order. The contractor must use HIPAA, Privacy Act, OSHA & ADA-Compliant Mobile Dental Practice or Portable Dental equipment. The contractor shall have experience in and capability to upload all exam and digital radiographs into the DENCLASS system. The contractor shall ensure all soldiers have a current Panoramic Radiograph on file and if missing, the contractor shall perform new radiographs. Adherence to all OSHA requirements, State and Federal Regulations are mandatory. Film or ‘digitized’ radiographs will not be accepted (see Technical Exhibit 1).

Exam. A periodic oral evaluation shall assess the current state of oral health, risk for future dental disease as well as assessing general health factors that relate to the treatment of the patient. The following measures are required for each periodic oral evaluation:

a. Caries risk assessment – Classify Soldiers as low, moderate or high risk for caries as outlined by the American

Dental Association’s 2009 Special Supplement. This assessment will allow the ADCS to identify those at high risk for future disease and appropriately manage their care.

b. Periodontal assessment – Periodontal Screening and Recording (PSR), a screening procedure endorsed by the

American Dental Association and the American Academy of Periodontology, should be utilized to determine the need for periodontal treatment.

c. Tobacco risk assessment – Classify Soldiers as a smoker, user of smokeless tobacco or as both.

d. Oral cancer screening – Perform a thorough oral cancer screening on all beneficiaries as part of all annual examinations.

e. Digital radiographs should be taken only for clinical reasons according to FDA guidelines as determined by the patient’s dentist. Radiographs should be of diagnostic quality, properly identified and dated. A panograph is required to be present in dental record and that it is of adequate quality for diagnostic/identification purposes. There is no time requirement on updating panographic radiographs. However, the panographic radiograph will adequately represent the current oral condition of the Soldier. Digital radiographs shall be performed on all service members who do not have a Panograph on file in the DENCLASS system, regardless of when the hardcopy panograph is dated.

Each exam shall be entered into the DENCLASS reporting system and annotated on the SF 603 (Health Record – Dental) and the SF 5570 (Health Questionnaire for Dental Treatment) of the Soldier’s dental records.

Setup of contractor’s dental equipment is to be completed the day prior to event commencement.

Setup of contractor’s dental equipment is the sole responsibility of the contractor.

Breakdown of the contractor’s dental equipment is the sole responsibility of the contractor.

As required provide timely feedback and work progress/ status of number of Dental examinations completed to the Office of the State Army Surgeon’s POC (or designated representative) as to timelines or factors that may negatively impact processing 8 Soldier exams per hour.

Provide completion status to Office of the State Army Surgeon’s POC (or designated representative) as to time requirements to complete jobs to insure processing 8 Soldier exams per hour.

Contractor must notify the Office of the State Army Surgeon’s POC (or designated representative) at the end of the event.

Electronic entry of data into the DENCLASS database is required by the close of business on the day of the exam.

All follow-up DENCLASS database entries will be entered within 48 hours of the States initial approval of treatment plans.

Contractor will have an in house quality assurance program to ensure accuracy of dental classifications. All exams where the Soldier is identified as a DRC 3 will be verified by second Dentist at the event for accuracy. Any Soldier identified with x5 Class 2 lesions or Class 2 Full Mouth Debridement (FMD) will have a second dentist validate the exam to ensure they do not need to be upgraded to a Class 3 and have restorative treatment completed. 10% of all Class 2 and 100% of Class 3 exams completed will be reviewed to ensure accuracy of dental classification and to help ensure that all dentists are performing exams within the standards. This will be completed before the Soldier leaves the event.

Example: Contract dentist identifies a Class 2 FMD. There is radiographic evidence of calculus that should be classified as a Class 3. The second dentist will review the treatment plan and upgrade the Soldier to a Class 3 and the treatment will be performed.

If the State Dental Officer finds that there is missed treatment during his review, the contractor is responsible for contacting the Soldier and coordinating and paying to have a…