PHA_Services_PWS.docx

Performance Work Statement Nevada Army National Guard (NVARNG) Medical and Dental Readiness In Support of Individual Medical Readiness (IMR) and Fully Medically Ready (FMR)

1. BACKGROUND:

Individual Medical Readiness (IMR) and Fully Medically Ready (FMR) are the basic principles of force-sustainment for Army National Guard (ARNG) forces. Medical and Dental health is vital for force health protection and failure to achieve a standard of level of medical and dental health could preclude a Soldier from deploying. Medical and Dental Readiness is a command responsibility. This Performance Work Statement (PWS) is to cover the various components of IMR/FMR to include but not limited to: Medical: Blood Pressure, height & weight, and questionnaire screening, Periodic Health Assessments (PHAs), Specialty Physical Exams such as Chapter 2 (schools), ‘Over-40,’ Flight, etc. in accordance with AR (Army Regulations) 40-501. Visual acuity and Optometry exams, DOEHRS compatible audiometry exams and SPRINT testing for H3 Soldier’s. MEDPROS data entry of all applicable and appropriate IMR/FMR functions with approval of the NVARNG DSS or Designee data entry not to exceed five (5) business days after the event. Dental: annual dental exams, digital bitewings radiographs, digital panoramic radiographs, DENCLASS data entry of all radiographs and dental records, identification and treatment (to 90+%) of all Class 3 Soldiers on alert orders and eligible Services are to be completed on site at various NVARNG Armories & Training Sites across the State. The PWS 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 a wholly owned and maintained OSHA, HIPPA, ADA, and Privacy Act Compliant Mobile, Self-Contained Health Practices depending on the individual site needs for the NVARNG.

Department of Defense (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 NVARNG shall receive an annual dental screening examination to determine their dental classification. As well as Soldiers alerted and on Mobilization Orders are eligible for Dental Treatment if they are Class 3 Status from examination. The results of that screening examination shall be entered into the DENCLASS database no later than five (5) days from the date of examination. The DENCLASS database updates the Army Medical Protection System, MEDPROS. Dental treatment that may be required is essential to be provided at the Government site to ensure the highest Dental Deployable Rate for the Mobilizing Soldiers. The NVARNG Deputy State Surgeon or Designee shall alert the Site Point of Contact (POC) in such cases.

2. OBJECTIVES AND SCOPE:

The objective of this PWS is to conduct and complete the requirements of IMR/FMR – Medical and Dental Readiness on all eligible (mobilizing or not) Service Members (SMs) utilizing an HIPPA, ADA and OSHA-Compliant mobile health facility(s). Medical and Dental services shall be performed by licensed professionals. Contractor shall be held liable and is responsible to ensure and verifying the appropriate level of Credentialing / Privileging (Licensure, Diploma, background checks, Common Access Card privileges etc.) for all contract providers in support of any service event.

MEDICAL

· Medical evaluations by a licensed provider (Physician, Physician’s Assistant (PA), or Nurse Practitioner (ARNP) IAW prescribed DODi 6200.06 for Periodic Health Assessments, Physical Exams (Over-40, flight, etc.).

· Mental Health Assessments by a Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) IAW prescribed DODi 6200.06 for Periodic Health Assessments

· Exams will be entered into the PHA module of MODS or an applicable substitute (ex…NGB Overprint) to be provided by the Office of the State Army Surgeon, NVARNG or approved designee.

· Results entry and input/entry of all medical related FMR/IMR functions into the MEDPROS module of MODS for Soldiers.

· Vision Screening

· Audiologist / SPRINT testing for all applicable Soldiers.

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

DENTAL

· Clinical evaluation by a licensed dentist of the oral cavity using a visual, clinical exam supported by bitewings taken by dental technicians.

· Each exam will 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, posted in the Soldiers Dental Record per AR 40-66, and entered into the DENCLASS module of the Medical Operational Data System (MODS).

· A legible photo print of each digital bitewing radiograph (Radiograph) and (if necessary) digital pantographic radiograph will be posted in the Soldiers Dental Record per AR 40-66, and entered into the DENCLASS module of the Medical Operational Data System (MODS). Thermal printers printing film radiographs are preferred as clarity of radiographs is superior.

· Dental Restorative Treatment with all necessary supplies, equipment, & instruments.

· Personnel performing the dental screening examination have a moral and ethical obligation to inform the Soldier if they observe or are apprised of any sign or symptom for which the Soldier should obtain further evaluation or care.

· Hardcopy medical documentation file and organization in accordance with AR 40-66 in the Soldier Treatment Record (STR).

· Case Management services during dental events & post-event, if required

3. REFERENCES

· AR 40-501 Standards of Medical Fitness (https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/ARN3801_AR40-501_Web_FINAL.pdf)

· AR 40-35 Dental Readiness & Community Oral Health Prevention (https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/AR%2040-35_Final_Web_ARN641.pdf)

· DODi 6200.06 Periodic Health Assessment (https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/DODi/620006p.pdf)

· Army National Guard implementation Guidance on Selected Reserve (SELRES) Dental Readiness System (ASDRS) for providing Dental Treatment outside of Alert. (https://apps.dtic.mil/dtic/tr/fulltext/u2/a592706.pdf)

4. ACRONYMS

5. SERVICES TASKS - GENERAL

The contractor shall provide all management, labor, material, equipment, certifications and supplies necessary to provide all listed services in a mobile, HIPAA, Privacy Act, OSHA & ADA compliant, stand-alone environment. Events are currently scheduled to take place at armory locations within Nevada. Simultaneous requirements exist. The services shall provide mandated medical and dental requirements to meet readiness and deployability standards to ensure mission capability of the NVARNG.

a. MEDICAL TASKS

Periodic Health Assessments (PHA): The contractor shall conduct PHAs in accordance with the PHA guidance set forth by the Department of Defense Instruction 6200.06. The contractor must utilize either OSHA-Compliant Mobile Health Practices and/or sites determined by the ARNG. Compliance with OSHA, State & Federal Regulations is mandatory.

Physical Exams: The contractor shall conduct physical exams (Over-40, Chapter 2, Flight, etc.) in accordance with the AR 40-501. The contractor shall conduct physicals in a HIPAA, Privacy Act and OSHA Compliant designated area to include visual acuity, ANCI certified and DOEHRS compatible audiometry. All professionals shall be licensed and adhere to all requirements of OSHA, State & Federal Regulations is mandatory.

Visual Acuity Testing: The contractor shall conduct visual acuity testing in accordance with AR 40-501. TITMUS Visual Acuity Screening and Tonometry testing.

DOEHRS Compatible Audiometer Testing: The contractor shall conduct audiometry in accordance with AR 40-501. Audiometry must be DOEHRS compatible. Adherence to all requirements of OSHA, State & Federal Regulations is mandatory. Audiology Evaluations and Speech Recognition in Noise Test (SPRINT) testing will be performed IAW all applicable Federal, DOD, MEDCOM, NGB, and State guidelines. ISO-booths to be CAOCH certified.

b. DENTAL TASKS:

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. The contractor must use HIPAA, 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.

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. 8 exams per hour are necessary to ensure completion during time available.

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 1995 Special Supplement. This assessment will allow the ADCS to identify those at high risk for future disease.

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 both.

d. Oral cancer screening – Perform a thorough oral cancer screening on all Soldiers as part of 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 pantograph 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 pantographic radiographs. However, the pantographic 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 Pantograph on file in the DENCLASS system, regardless of when the hardcopy pantograph is dated or at the discretion of the State Dental Officer.

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. Electronic entry is required within 5 days of completion to include the upload of any radiographs taken during the event.

Dental Treatment: Based on National Guard Bureau’s national statistics, it is estimated that 30% of the Soldier exams will be Classification 3, Non-Deployable. Dental restorative treatment is necessary to get Class 3 Soldiers to a Class 2 Status, or deployable, before their Mobilization. The Contractor shall provide approved dental treatment only. See Appendix C- Authorized Dental Treatment.

Case Management services during event & post event:

· Contractor shall have capability to provide any general & specialty dental and Prescription services near event location

· Upon approval, contractor to arrange for local dental treatment and prescription medication for Soldier

· Government will provide Soldier transportation to local dental facility/pharmacy.

· Contractor shall pay local subcontracted provider

· Contractor to explain post-operatory instructions to Soldier and DSS or Designee.

· Case Manager to track all special dental treatment and medication expenses.

· Contractor to submit itemized invoice of special case costs to DSS for reimbursement.

6. CONTRACTOR PROVIDED EQUIPMENT AND PERSONNEL:

Contractor shall provide all necessary mobile units, licensed personnel and supply items to perform the Medical & Dental Readiness service requirements. Mobile units include, but are not limited to Audiology Trailers, Dental Exam/Treatment Trailers, and Panographic/Bitewing Trailers.

Medical & Dental mobile facilities shall meet all OSHA, HIPAA and Privacy Act standards to ensure a safe and productive workspace for services under the Individual Readiness Requirements. The Mobile facility must contain equipped & private medical/dental exam rooms, designated vitals area, visual acuity area, a lab with eye-wash stations, biohazard separated work areas, hearing booth with ISO-Booth for SPRINT testing, all emergency medical resources consistent with OSHA and a large reception area with full office capabilities. X-Ray-Radiograph Rooms shall contain lead-lined walls for radiation protection.

The Mobile Medical/Dental Unit shall have full treatment functionality consistent with traditional, fixed-site, private practice dental/medical offices. This includes non-portable and professional quality dental chairs, compressor systems, vacuum systems, and treatment instruments for fillings, extractions, root canals, and other authorized dental treatment.

Mobile Medical/Dental Facilities shall be fully functional offices whereby no additional space will be given inside military buildings during events as these events may be in remote areas.

Contractor must have the capability to conduct real-time, point of service E-PHA, HRR, DENCLASS and MEDPROS data upload. The Government will provide internet access, when required. The Contractor must have CAC enabled Event Managers & support staff. The workstations should have Bar-Code Scanning capability to ensure high quality standards of data entry. Contractor must be able to do Post-Operatory Panoramic X-rays upon completion of treatment whereby the forensics image will change materially. Also, Contractor must be able to upload images to the Active Duty Dental Repository (ADDRs) system for DENCOM requirements of deployability.

Due to nature of many drill weekends, Mobile Units must be able to be moved at short notice of a minimum of 1-hour notice to follow movement of patient base to be served.

Staffing Requirements:

a. Medical Physician/Dentist: minimum 1 year practice experience, minimum education: Possess MD or DO from accredited school, certification/license: active unrestricted state medical license, ACLS: preferred, and BCLS: preferred

b. Flight Provider: Must be board certified in Aviation Medicine or board certified in Family Medicine, Pediatrics, or Internal Medicine with certification in DOD sponsored Aviation Medicine Program. Must be Advanced Cardiac Life Support (ACLS) certified.

c. Physician's Assistant (PA): minimum 1 year experience, minimum education: master’s level degree and accredited PA program, certification/license: licensure required for state employment, BCLS: preferred

d. Nurse Practitioner (NP): minimum 1 year experience, minimum education: MSN or Advanced Certification, certification/license: required for state employment, ACLS: preferred, BCLS: required for state employment.

e. Registered Nurse: minimum 1 year experience, minimum education: master’s level degree, certification/license: licensure required for state employment, BCLS: preferred

f. Behavioral Health Specialist: minimum 1 year experience, minimum education: master’s level degree, certification/license: licensure required for state employment, BCLS: preferred

g. Audiologist: minimum 1 year practice experience, minimum education: possess MA or AuD from accredited school certification/license: active/unrestricted state licensure required, ACLS: preferred, and BCLS: preferred.

h. Audiology Technician: minimum 1 year experience, minimum education: Council for Accreditation in Occupational Hearing Conservation (CAOHC) certified: required

i. Optometrist: minimum 1 year practice experience, minimum education: Possess OD from accredited school, certification/license: active/unrestricted state licensure required, ACLS: preferred, and BCLS: preferred.

j. Optometry Technician: 2 years of experience in specialty: NA, minimum education: High School Diploma

k. Medical Assistant (Certified/Registered): years of experience in specialty: minimum 1 year experience, minimum education: state license and graduate of accredited MA program, certification/license: required

l. Case Managers

m. Medical Event Managers

n. MEDPROS & Electronic PHA Data Entry Specialists

o. Dental Assistant: Successful completion of (a) a 1-year dental assistant program or completion of 1 year of a dental hygiene program accredited by the American Dental Association's Commission on Accreditation that included a course in radiation physics; radiation biology; radiation health, safety, and protection; X-ray films and radiographic film quality, radiographic techniques; darkroom and processing techniques; and film mounting; or (b) practical nurse training approved by the appropriate State, territory, or District of Columbia accrediting body.

Additional Medical Resources:

· MEDPROS Wed Data Entry (MWDE) access/entry

· Electronic PHA Upload (requires Common Access Card privileges)

· DOEHRS Upload

· HRR Upload

· DENCLASS entry at event

· DENCLASS entry post event

7. GOVERNMENT-FURNISHED PROPERTY AND INFORMATION:

Only parking will be provided for Mobile Medical Practices Vehicles/Facilities. The contractor must provide generator power for utilities. Unless specified in the CLIN for the contractor to provide a mobile operational unit, office space or a work area will be provided for contractor use.

8. APPLICABLE DOCUMENTS

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 State Medical Commands office. The contractor shall provide all documentation concerning medical or dental treatment to the NVARNG Office of the Deputy State Surgeon or Designee.

9. PLACE OF PERFORMANCE

Services are required at multiple locations within Nevada.

10. PERIOD OF PERFORMANCE

As Specified in the Request for Quote.

11. OTHER CONDITIONS/ SECURITY

Safety: The Contractor shall establish a safety and health program in accordance with the standards of the Federal Occupational Safety and Health Standard (OSHA), Health Information Portability and Accountability Act (HIPPA), the Privacy Act and the American Dental Association (ADA).

Performance work statement is “UNCLASSIFIED” and under HIPAA guidelines. OSArS shall notify the Contractor if requirement exists for a secret classification and circumstances requiring secret classification for Readiness impact reporting.

Quality Control: The contractor shall create a quality assurance program that monitors all servicers being provided. The program must be approved by the NVARNG Deputy State Surgeon.

Hours of Operation: Soldiers will be made available to the contractor during regular drill weekends and training periods between the normal hours of operations to be estimated at 10 hours a day. Usual hours are between 0600 and 1800 unless special arrangements are made.

Security Requirements: The contractor shall comply with all applicable installation/facility access and local security policies and procedures, which may be obtained from the COR. The contractor and all associated subcontractor employees shall 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. The contractor shall ensure compliance with all personal identity verification requirements as directed by Department of Defense (DOD), Headquarters Department of Army (HQDA) and/or local policy. Should the Force Protection Condition (FPCON) change, the Government may require changes in contractor security matters or processes.

Common Access Card (CAC): The CAC is the DOD Federal Personal Identity Verification (PIV) credential. CAC issuance requirements are as follows:

In accordance with Department of Defense Manual (DODM) 1000.13-M-V1, DOD Identification (ID) Cards, January 23, 2014, initial issuance of a CAC requires, at a minimum, the completion of an Federal Bureau of Investigation (FBI) fingerprint check with favorable results and submission of a National Agency Check with Inquiries (NACI) (or investigation approved in Federal Investigative Standards) to the Under Secretary of Defense for Intelligence (USD(I)) approved investigative service provider. The issuance of a CAC will be based on four criteria:

(a) eligibility for a CAC;

(b) verification of DOD affiliation from an authoritative data source;

(c) completion of background vetting requirements according to the Federal Information Processing Standards Publication 201-2, Personal Identity Verification (PIV) of Federal Employees and Contractors, August 2013, and DOD Manual 5200.02, Procedures for the DOD Personnel Security Program (PSP), April 3, 2017

(d) verification of a claimed identity. Sponsorship and enrollment information about each applicant must be registered in the Defense Enrollment Eligibility Reporting System (DEERS) through either the Real-Time Automated Personnel ID System (RAPIDS) using the DD Form 1172-2, or the Trusted Associate Sponsorship System (TASS).

Reporting: 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 NVARNG liaison with the office of the Deputy State Surgeon.

See Appendix A:

Invoice: Contractor shall consolidate all medical services performed on an individual event basis and submit an invoice to the Contracting Officer Representative for certification and payment processing.

12. REQUIRED TRAINING:

a. Comply with the command's Acceptable Use Policy (AUP) for Government owned IS and sign an AUP prior to or upon account activation.

b. Complete initial and/or annual Information Assurance (IA) training as defined in the IA Best Business Practices (BBP) training https://atc.us.army.mil/iastar/docs/Training_BBP.pdf).

c. Complete HIPAA training at http://www.health.mil/Training-Center/Joint-Knowledge-Online-JKO (https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf).

d. Information Assurance (IA)/Information Technology (IT) Training: All contractor employees and associated subcontractor employees shall complete the DOD IA Awareness Training before issuance network access and annually thereafter. All contractor employees performing services involving IA/IT functions shall comply with DOD and Army workforce training requirements in DODd 8140.01, DOD 8570.01-M and AR 25-2 within six months of the start of contract performance. In accordance with DOD 8570.01-M, DFARS 252.239.7001 and AR 25-2, contractor employees performing Information Assurance Technical (IAT) functions shall be appropriately certified upon contract award. The baseline certification as stipulated in DOD 8570.01-M shall be completed upon contract award. All contractor employees with access to a government information system shall be registered in the Army Training Certification Tracking System (ATCTS) (https://atc.us.army.mil/iastar/index.php) at commencement of services, and shall successfully complete the DOD Information Assurance awareness training prior to access to the IS and then annually thereafter. (https://cs.signal.army.mil).

e. AT Level 1 Awareness Training (AT): Security Requirements. All contractor employees, to include subcontractor employees, requiring access to Army installations, facilities, and controlled access areas shall complete AT Level 1 Awareness training within 30 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 KO (if a COR has not been appointed) within 45 calendar days after completion of training by all employees and subcontractor personnel. AT Level 1 awareness training is available at the following website: https://jko.jten.mil/courses/atl1/launch.html

f. OPSEC: Security Requirements. Per AR 530-1, Operational Security, new contractor employees must complete Level 1 OPSEC training within 30 calendar days of reporting for duty. All contractor employees must complete annual OPSEC awareness training. OPSEC awareness training is available the following website: https://securityawareness.usalearning.gov/

g. Protection of Personally Identifiable Information (PII). The contractor shall protect all Personally Identifiable Information (PII) encountered in the performance of services in accordance with DFARS 224.103 and DoD 5400.11, Department of Defense Privacy Program, and DoD 5400.11-R. If a PII breach results from the contractor’s violation of the aforementioned policies, the contractor shall bear all notification costs, call-center support costs, and credit monitoring service costs for all individuals who’s PII has been compromised.

h. iWATCH Training. The contractor shall brief all personnel performing work under this contract on the local iWATCH program available on line at:

http://www.myarmyonesource.com/cmsresources/Army%20OneSource/Media/Videos/Family%20Programs%20and%20Services/iWatch_Program/iWATCH%2060_4streaming.wmv This training shall be completed within 30 calendar days of the contract award and within 30 days calendar days of new employees starting performance work under this contract, with the result reported to the Contracting Officer NLT 45 day after contract award or start date.

13. CONTRACT MANAGER (CM)

The contactor shall designate a contract manager who shall ensure performance under this contract. The name of this person, and an alternate who shall act for the contractor when the CM is absent, shall be designated in writing to the KO. The CM or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall work through the COR, to resolve issues, receive technical instructions, and ensure adequate performance of services. The CM shall ensure that contractor employees do not perform any services outside the scope of the contract without an official modification issued by the KO. The CM shall ensure contractor employees understand that services performed outside the scope of the contract are performed wholly at the expense of the contractor.

14. ACCEPTANCE PLAN:

All work performed, all materials and tasks data to be submitted under this task will be made available to be inspected for compliance with the PWS and accepted by the COR or authorized representative as specified herein.

15. APPENDICES:

A. Estimated Workload Data B. Dental Classification C. Authorized Dental Treatment

16. SKILLS. Personnel assigned to this contract shall possess the required technical skills and expertise to perform the functions with minimum guidance. The personnel will be experienced in all aspects and qualified in their respective functional areas.

17. FUNCTIONAL SKILLS. Contactor personnel must be capable of working, but shall not perform inherently governmental functions (i.e. representation of government, decision authority, etc.) Personnel shall have a working knowledge of group dynamics and organizational management.

18. COMPUTER HARDWARE AND SOFTWARE. Contractor personnel shall have a basic working knowledge of desktop computer operations and be proficient in Microsoft Word, Excel and PowerPoint.

19. TECHNICAL PERFORMANCE. Tasks performed by contractor personnel shall be accomplished in direct support of the COR. Satisfactory performance is contingent upon the contractor appropriately staffing this effort and performing in accordance with the terms and conditions of the referenced contract. However, the COR is not responsible for supervising Contractor employees as this is the responsibility of the Contractor management team.

20. RELEASE OF DATA. The contractor is prohibited from releasing any medical, personnel, financial or supporting data provided by the NVARNG to any other government agency, non-government agency, or individual unless specifically authorized, in writing, by the Contracting Officer. This includes any proprietary contractor information.

21. CONTRACTOR MANPOWER REPORTING (CMR)

a. The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the Air Force collection site. The contractor is required to completely fill in all required data fields using the following web ad-dress: http://www.ecmra.mil/.

b. 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 31 of each calendar year. Contractors may direct questions to the help desk at http://www.ecmra.mil/.

PERFORMANCE WORK STATEMENT – MEDICAL and DENTAL READINESS – Oct 2009

APPENDIX A

ESTIMATED WORKLOAD DATA

MEDICAL

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 MEDPROS & Electronic PHA A by name listing of all Soldiers examined and the dental classification of the Soldier

DENTAL

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

Date Location List of contract employees (providers, dental technicians and administrative staff) Total number of patients scheduled Total number of patients examined Total number of Soldiers by dental classification: 1, 2, 3 Total number of bitewing radiographs (sets of 4 per patient) taken Total number of pantograph radiographs taken Verification of entry into DENCLASS A by name listing of all Soldiers examined and the dental classification of the Soldier

APPENDIX B

Department of Defense

Oral Health and Readiness Classification System

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1 (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, which require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prosthesis that can be maintained for a 12 month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodontium that:

(a) requires oral prophylaxis

(b) requires maintenance therapy

(c) requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis

(5) Unerupted partially erupted or malposed teeth that are without historical, clinical or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal.

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployment up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

c. Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

(1) Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prostheses that cannot be maintained for a 12 month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontontal abscess

(d) Progressive mucogingival condition

(e) Periodontal manifestations of systemic disease or hormonal disturbances

(f) Heavy subgingival calculus

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(5) Unerupted, partially erupted or malposed teeth with historical, clinical or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g., drain or suture removal0 until resolved.

(8) Acute Temporomandibular disorders requiring active treatment that may interfere with duties.

d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients normally are not considered to be worldwide deployable.

APPENDIX C

AUTHORIZED DENTAL TREATMENT

1. The following dental procedures are authorized:

(a) Diagnostic Services which are funded through NG6H 2065 Medical Readiness Funding:

D0120-Periodic Oral Evaluation D0150-Comprehensive Oral Evaluation D0330-Panoramic Film D0272-Bitewings-Two Films D0274-Bitewings-Four Films D0220/D0230- Periapical (limited)

(b) Restorative Services which are funded through the VFRE 2065 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D2140-Amalgam-One Surface D2150-Amalgam-Two Surfaces D2160-Amalgam-Three Surfaces D2161-Amalgam-Four or More Surfaces D2330-Composite-One Surface D2331-Composite-Two Surfaces D2332-Composite-Three Surfaces

Posterior composites will be authorized only when a posterior composite is necessary to provide a quality restoration and no other alternative is available.

D2335-Composite-Four or More Surfaces D2391-Composite-One Surface D2392-Composite-Two Surfaces D2393-Composite-Three Surfaces D2394-Composite-Four or More Surfaces D2799-Provisional Crown D2931-Prefabricated Stainless Steel Crown D2950-Core Buildup, including any pins D2954-Prefabricated Post and Core

(c) Endodontic Services which are funded through the VFRE 2065 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D3310-Anterior Root Canal Therapy D3320-Bicuspid Root Canal Therapy D3330-Molar Root Canal Therapy D3346-Anterior Root Canal Retreatment D3347-Bicuspid Root Canal Retreatment D3348-Molar Root Canal Retreatment

(d) Periodontal Services which are funded through the VFRE 2065 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D4355-Full Mouth Debridement D4342-Periodontal Scaling and Root Planning, 1 to 3 teeth per quadrant

Periodontal scaling and root planning is authorized only when a periodontal abscess is present)

(e) Prosthodontic Services which are funded through the VFRE 2065 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D5110-Complete Denture-Maxillary D5120-Complete Denture-Mandibular D5211-Maxillary Partial Denture-Resin Base D5212-Mandibular Partial Denture-Resin Base

(f) Oral Surgery Services which are funded through the VFRE 2065 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D7140-Extraction, Erupted Tooth or Exposed Root D7210-Surgical Removal of Erupted Tooth D7220-Romoval of Impacted Tooth, Soft Tissue D7230-Removal of Impacted Tooth, Partial Bony D7240-Removal of Impacted Tooth, Completely Bony

(g) Orthodontic Services which are funded through the VFRE 2065 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D8680-Orthodontic Retention

2. The following dental procedures are not authorized:

Bridges and/or implants Removal of Asymptomatic third molars Routine Prophylaxes (cleanings) Restorations for aesthetics only Restorations for small (non-class 3) caries Extensive Root plane/scaling Osseous Surgery Other diagnostic services

The above listings are guides to assist the State Dental Officer or his/her designee in the determining treatment to be authorized. The treatment provided by the NVARNG is to get the Soldier from a dental class 3 to a dental class 2 only. Comprehensive Treatment (to dental class I) is not authorized.

1. If a Soldier needs all of his/her remaining teeth in an arch extracted and a denture placed, the Soldier will not be available for deployment for at least 6 months and shall be disqualified from immediate deployment. However, if the Soldier is otherwise deployable (passes all medical, personnel and training requirements) and, after extraction and placement of prosthesis, would be deployable, the dental treatment could be provided and the Soldier could be considered as a replacement at a later date.

2. If a Soldier will have a number of teeth extracted to the extent mastication and speech are adversely affected, then an acrylic removable partial denture will be authorized if there is sufficient time for healing and construction of the partial denture prior to departure to Mobilization Station.

3. Soldiers requiring extensive periodontal treatment will be disqualified from deployment and educated on the TRICARE Dental Program. If he/she obtains the required therapy (from his/her private dental provider) and reaches a maintenance level, then he/she would become deployable.

4. The State Dental Officer (or designated representative) will review any dental treatment plan for dental care which exceeds $800.00 to insure that the above clinical guidelines are met. Exceptions can be made, but they must be coordinated with the Deputy State Surgeon, State Dental Officer or Designee.

Service Delivery Summary Worksheet Dental Services.

Deliverable

Performance Standard

Acceptable Quality Level (AQL)

Method Used / Frequency

Spot Check or Inspection

Customer Complaint

1. Contractor personnel to possess appropriate level of credentialing

1. Caries risk assessment

1. Periodontal assessment

1. Oral cancer screening

1. Panoramic Radiographs as needed to represent Soldiers current condition (filed & DENCLASS)

1. Contract completes and submits final data to Deputy State Surgeon & tracks special cases

Quality Assurance Surveillance Plan:

The Contracting Officer Representative (COR) will monitor contractor performance and complete the Quality Assurance Surveillance Plan Worksheet provided below for each event location completed. The following information will be provided to the Contracting Officer to ensure services and/or deliverables support the PWS objectives. If the performance rating for any task in this order is “Red” during any time in the performance period, the COR will provide the Contracting Officer the details regarding the deficiency. The quality rating may change from “Green” to “Red” without notice. We anticipate the COR utilizing the “Yellow” quality rating to alert the contracting office of quality issues that have the potential for a “Red” quality rating if corrective action is not taken.

The Quality Assurance Surveillance Plan Worksheet will be submitted to the Contracting Officer following each service event. The COR by signing the form below documents services and/or deliverables with a “Green” quality of performance rating unless otherwise annotated.

At the end of the service period of performance, the COR will be asked to complete a Quality Performance Review to document the quality performance rating during the performance period. This will be submitted to the Contracting Officer.

If Contractor response to an identified quality deficiency is unsatisfactory, the Contracting Officer will contact the appropriate Contractor representative to implement a plan of action to remedy the identified deficiency.

Yellow Yes, performance and technical specifications are currently being met at the minimum AQL, but the following service / deliverable needs contractor attention.

The Customer must identify what component of the deliverable and/or service requires attention.

Red No, performance and technical specifications are not being met at AQL and the following service / deliverable needs immediate contractor resolution.

The Customer must identify what component of the deliverable and/or service is below the minimum AQL.

RECEIVERS - MEDICAL QUALITY ASSURANCE PLAN WORKSHEET

Performance Rating

Deliverable/Service

Contractor provides adequate mobile examination units and all appropriate equipment to accomplish medical services

Yellow

Red

Contractor provides qualified and sufficient personnel during services

Yellow

Red

Contractor provides Case Manager (CM)

Yellow

Red

Contractor performs services 6-8 Soldiers per hour

Yellow

Red

Contractor completes all required testing

Yellow

Red

Contractor completes all required paperwork

Yellow

Red

Contractor coordinates any special medical service requirements

Yellow

Red

Contractor completes EPHA electronic entry of data NLT 10 business days after event

Yellow

Red