W912MM17T0059.pdf

PDF 667 KB Posted Sep 17, 2017

Attached to: SDARNG FY18 PHA Federal contract opportunity
Solicitation number: W912MM-17-T-0059
Issued by: Department of the Army South Dakota Army National Guard

About this file

From the source

SDARNG FY18 PHA Solicitation

View the file

On GovTribe

Work with this file on GovTribe

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

SEE ADDENDUM

(No Collect Calls)

W912MM-17-T-0059 17-Sep-2017

b. TELEPHONE NUMBER

(605) 737-6738

8. OFFER DUE DATE/LOCAL TIME

03:00 PM 06 Oct 2017

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 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.

W912MM9. ISSUED BY

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

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

MONTY C. EISENBRAUN

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

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

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

W90YD871560100

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 BUSINESSX

17a.CONTRACTOR/ CODE FACILITY

OFFEROR CODE

W912MM - USPFO FOR SOUTH DAKOTA

ATTN: CW4 MONTY EISENBRAUN

MONTY.C.EISENBRAUN.MIL@MAIL.MIL

2823 WEST MAIN STREET-BLDG 420

RAPID CITY SD 57702-8170

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

(605) 737-6752FAX:

TEL: (605) 737-6738

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$7,500,000

NAICS:

621399

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.

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 OF41

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 SF 1449 - CONTINUATION SHEET

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

General Information

FFP

This solicitation in no way obligates the Government to award a contract, nor does it commit the Government to pay any costs incurred in the preparation and submission of any offer/quote. Furthermore, the Government reserves the right to reject any and all offers, to award multiple contracts, to award contracts for any/all or none of the event service dates, if such action is considered to be in the best interest of the Government.

The contracting officer may determine an offer noncompliant with the terms and conditions of the solicitation if the contractor does not provide the information requested, specifically:

•Signed SF1449 (Page 1) with Cage Code, •Service Event (Location) Pricing, •References (2) Past Performance in the last two years that indicates a minimum level of satisfactory service for similar (Military) type requirements.

•Copy of General Liabiltiy Insurance Certificate

•Completed Provision 252.209-7999 REPRESENTATION BY CORPORATIONS

REGARDING AN UNPAID DELINQUENT TAX LIABILITY OR A FELONY

CONVICTION UNDER ANY FEDERAL LAW.

Send questions in writing to monty.c.eisenbraun.mil@mail.mil.

Deadline for questions is 27September17.

To comply with 10 U.S.C. sec. 2227, Department of Defense procedures require electronic submission of payment requests and the contractor’s ability to receive electronic funds transfer (EFT). In accordance with Defense Federal Acquisition

Regulation Supplement Clause at DFARS 252.232-7003 payment requests shall be submitted in one of several electronic formats. See clause 252.232-7006 for detailed invoicing information.

FOB: Destination

PURCHASE REQUEST NUMBER: W90YD871560100

NET AMT

0010 1 Each 3-5 November 17, Sioux Falls SD

FFP

SIOUX FALLS SOUTH DAKOTA, 3-5 November 2017 - Services Non-Personal

Operational - Friday 1700 - 2100, Saturday 0700-1700, Sunday 0700-1100

Services required – PHA, Immunization Administration (SDARNG to provide serum & DD2217), Vision Acuity Testing/Screening.

No Dental Exams, Hearing Tests or Bevavioural Health Screening Requested

Armory Space available***

Approximate number of soldiers 340

W90YD8-7156-0100

0020 1 Each 1-3 December 17, Watertown SD

FFP

WATERTOWN SOUTH DAKOTA, 1-3 December 2017 - Services Non-Personal

Operational - Friday 1700 - 2100, Saturday 0700-1700, Sunday 0700-1100

Services required –

DOEHRS Compatible Audiometer Testing/SPRINT Testing

No Armory Space available***

Approximate number of soldiers 330

0030 1 Each 7 January 18, Rapid City SD

FFP

RAPID CITY SOUTH DAKOTA, 7 January 2018 - Services Non-Personal

Operational - Sunday 0800-1200

Services required –

Audiologist – To conduct SPRINT Testing as needed, 0800-1200.

Optometric Exams 0800-1200- 30 PAX

Approximate number -See Above

0040 1 Each 19-21 January 18, Sioux Falls SD

FFP

SIOUX FALLS SOUTH DAKOTA, 19-21January 2018 - Services Non-Personal

Operational - Friday 1700 - 2100, Saturday 0700-1700, Sunday 0700-1100

Services required – PHA, Immunization Administration (SDARNG to provide serum & DD2217), Vision Acuity Testing/Screening, Behavioral Health Screening and Providers.

Dental Exams.

Audiologist – To conduct SPRINT Testing as needed on Saturday/Sunday

Approximate number of soldiers 350

0050 1 Each 9-11 March 2018 , Sioux Falls SD

FFP

SIOUX FALLS SOUTH DAKOTA, 9-11 March 2018 - Services Non-Personal

Operational - Friday 1700 - 2100, Saturday 0700-1700, Sunday 0700-1100

Services required – PHA, Immunization Administration (SDARNG to provide serum & DD2217), Vision Acuity Testing/Screening, Behavioral Health Screening and Providers, Approximate number of soldiers 350

0060 1 Each 7 April 18, Sioux Falls SD

FFP

SIOUX FALLS, SOUTH DAKOTA 7 April 2018 - Services Non-Personal

Operational - Saturday 0700-1700

Services required –

Restorative Dental Care for 40 Soldiers

Audiologist – To conduct SPRINT Testing as needed on Saturday

Approximate number of soldiers See Above

0070 1 Each 7-8 April 18, Rapid City SD

FFP

RAPID CITY, SOUTH DAKOTA 7-8 April 2018 - Services Non-Personal

Operational - Saturday 0700-1700, Sunday 0700-1100

Services required –

Restorative Dental Care for 40 Soldiers

Audiologist – To conduct SPRINT Testing as needed on Sunday

Approximate number of soldiers See Above

0080 1 Each 7-9 September 18, Rapid Ciity SD

FFP

RAPID CITY, SOUTH DAKOTA 7-9 September 2018 - Services Non-Personal

Operational - Friday 1700 - 2100, Saturday 0700-1700, Sunday 0700-1100

Services required – PHA, Immunization Administration (SDARNG to provide serum & DD2217), Vision Acuity Testing/Screening

Behavioral Health Screening and Providers.

Audiologist to conduct SPRINT Testing as needed on Saturday/Sunday

Approximate number of soldiers 250

0100 1 Each Contractor Manpower Reporting

FFP

Contractor Manpower Reporting - Services Non-Personal

The Office of the Assistant Secretary of the Army (Manpower & Reserve Affairs) operates and maintains a secure Army data collection site where the contractor will report ALL contractor manpower (including subcontractor manpower) required for performance of this contract. The contractor is required to completely fill in all the information in the format using the following web address:

https://armycmra.dmdc.osd.mil

The required information includes:

(1) Contracting office, Contracting Officer, Contracting Officer’s Technical

Representative;

(2) Contract number, including task and delivery order number;

(3) Beginning and ending dates covered by reporting period;

(4) Contractor name, address, phone number, email address, identity of contractor employee entering data;

(5) Estimated direct labor hours (including sub-contractors);

(6) Estimated direct labor dollars paid this reporting period (including sub-contractors);

(7) Total payments (including sub-contractors);

(8) Predominant Federal Service Code (FSC) reflecting services provided by contractor; FSC = Q403

(9) Estimated data collection cost;

(10) Organizational title associated with the Unit Identification Code (UIC) for the

Army Requiring Activity W8A7AA

(11) Locations where contractor and subcontractors perform the work (specified by zip code in the United States and nearest city, country, when in an overseas location, using standardized nomenclature provided on website);

(12) Presence of deployment or contingency contract language; and

(13) Number of contractor and subcontractor employees deployed in theater this reporting period (by country).

As part of its submission, the contractor will also provide the estimated total cost

(if any) incurred to comply with this reporting requirement. Reporting period will be the period of performance not to exceed 12 months ending September 30 of each government fiscal year and must be reported by 31 October of each calendar year. Contractors may use a direct XML data transfer to the database server or fill in the fields on the website. The XML direct transfer is a format for transferring files from a contractor’s systems to the secure web site without the need for separate data entries for each required data element at the web site. The specific formats for the XML direct transfer may be downloaded from the web site.

(End of Contractor Manpower Reporting)

PERFORMANCE WORK STATEMENT

Performance Work Statement for

Medical Readiness FY 2018

In Support of

Individual Medical Readiness (IMR) and

Fully Medically Ready (FMR)

South Dakota Army National Guard

(SDARNG)

April 11, 2017

1. BACKGROUND:

1.1 Individual Medial 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.

1.2 The objective of this Performance Work Statement (PWS) is to conduct and complete the various components of

IMR/FMR, Medical and Dental Readiness on all eligible Service Members (SM) of the SDARNG. Services are to be completed on location at various SDARNG Armories & Training Sites across the State. The contractor shall provide all personnel, equipment, tools, materials, supervision, and other items and non-personal Medical or Dental services for Soldiers in the South Dakota Army National Guard as defined in this Performance Work Statement

(PWS). The contract will utilize Government Space or provide OSHA, HIPPA, ADA, and Privacy Act

Compliant Mobile/Portable, Self-Contained Health Practices depending on the individual site needs for the

SDARNG. See event schedule for details.

1.3 Medical Services shall include but not limited to: Blood Pressure, height & weight, Periodic Health Assessments

(PHAs), IAW AR 40-501. Laboratory / phlebotomy work such as HIV, urine pregnancy, pelvic exams (pap-smears), DNA, G6PD, RPR, Immunizations required for IMR and theater specific compliance such as Hepatitis

A/B, TwinRex, Influenza and PPD. Visual acuity and Optometry exams, DOEHRS compatible audiometric exams and SPRINT testing for H3 Soldier’s. Behavioral Health screenings, including review of EPHA answers of SM.

Pre-event coordination with SDARNG team members shall be conducted to validate event requirements at Sixty

(60) and thirty (30) days prior to event.

1.4 MEDPROS data entry of all applicable and appropriate IMR/FMR functions with on location data entry or with approval of the SDARNG DSS or Designee data entry not to exceed 5 calendar days after the last day of services.

Preference is at the end of the event.

1.5 DoD established a uniform dental classification in HA Policy 02-11. DoD policy requires dental screening examinations and remediation to be accomplished as needed and documented on all service members. Members of the SDARNG shall receive an annual dental screening examination to determine their dental classification, including, digital bitewings radiographs and digital panoramic radiographs. Soldiers alerted and on Mobilization

Orders are eligible for Dental Treatment if they are Class 3 Status from examination. Identification and treatment of

ALL Class 3 soldiers on alert orders and eligible. Other Class 3 soldiers are to be treated if time allows. The results of that screening examination and radiographs and dental records shall be entered into the DENCLASS database through the Army Selected Reserve Dental Readiness System (ASDRS) Program. 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.

The SDARNG Deputy State Surgeon or Designee shall alert the Contract Event Manager in such cases.

2. MEDICAL SERVICES SCOPE:

The scope of contractor provided Medical Services is to conduct and complete the requirements of IMR/FMR

Medical Readiness on all eligible (mobilizing or not) Service Members (SMs). Medical services shall be performed by licensed professionals. Contractor shall be held liable and is responsible to ensure and verify 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.

A Medical POC must be a full time employee available 24hrs/7week for post event consult.

All services must be performed by organic staff (Exception for Special Case Services).

All data entry must be performed by organic staff.

Medical evaluation by a licensed provider (Physician, Physicians Assistant (PA), or Nurse Practitioner

(ARNP). RNs must have completed appropriate training IAW DoD service, USCG, and CDC guidelines and act within their scope of practice.

All routine and ordered phlebotomy services (lab work) provided on location.

All LAB/immunization technicians shall be MILVAX certified

All routine and theatre specific immunizations administered by contractor when requested in the services delivery schedule must be annotated on a DD Form 2766 - Adult Preventive and Chronic Care

Flow sheet. SDARNG will provide immunizations and DD Form 2766

Electrocardiogram (EKG) service performed on all Soldiers over 40 years of age.

Vision Screening, Optometric Evaluations as needed.

Eye exams and prescriptions (DD771s) provided on location for all Soldiers scoring worse than 20/40 on vision screening

Audiologist / SPRINT testing for all applicable Soldiers.

Audiology H2/H3/H4 and SPRINT testing on location in real time.

DOEHRS certified technicians must perform all audiology input to DOEHRS point of service data entry is preferred.

Maintain all records for events for a period of up to 6 months post event.

Special reporting to State Surgeon/ Deputy State Surgeon for special/unusual situations.

HRR data entry completed not to exceed 5 calendar days after the last day of services. Preference is at the end of the event.

Behavioral Health screening by a licensed behavioral health provider (Psychiatrist, Psychologist, Master of Social Work, etc) that has completed appropriate training IAW DoD service, and is acting within their scope of practice.

3. MEDICAL TASKS

3.1 Periodic Health Assessments (PHA): The contractor shall conduct PHAs in accordance with AR 40-501 and the

PHA guidance set forth by the National Guard Bureau of the Surgeon General. Compliance with OSHA, State &

Federal Regulations is mandatory.

Physical Exams: The contractor shall conduct PHA’s, on-site laboratory testing for lipids, glucose, cholesterol, urinalysis, HCG, and hemoglobin and EKG’s and Pulmonary services. All professionals shall be licensed and adhere to all requirements of OSHA, State & Federal Regulations is mandatory.

Special Lab/Phlebotomy: The contractor shall conduct/process all phlebotomy services such as HIV, G6PD, RPR blood draws, pregnancy testing, pap-smear testing, and lipid profiles in accordance with AR 40-501 as required.

SDARNG will provide bar codes, HIV tubes and paperwork required for HIV testing. SDARNG MRNCO will assist by providing a by name listing of requirements prior to each event so contractor can project for supplies and equipment needed.

DNA Collection: The contractor shall conduct DNA collection in accordance with the AR 40-501. The contractor shall utilize the SDARNG Medical Command for all DNA supplies, shipping supplies, and shipping guidance.

Adherence to all requirements of OSHA, State & Federal Regulations is mandatory.

Data input: Results entry of all medical related FMR/IMR functions into the MEDPROS module of MODS for soldiers not to exceed 5 calendar days after the last day of services. Preference is at the end of the event.

3.2 Behavioral Health Screening: The contractor shall conduct on-site screenings of behavioral health questions and scores within the EPHA. A list of all Soldiers needing further follow up and the reason for follow up needs to be reported to the SDARNG’s case manager at the end of the event. All professionals shall be licensed and adhere to all requirements of OSHA, State & Federal Regulations is mandatory.

3.3 Optometric Evaluations: The contractor shall conduct eye exams and provide prescriptions (DD771s) on location in accordance with AR 40-501 for identified Soldiers/events, see delivery schedule for details. SRTS data entry may be required.

Visual Acuity Testing: The contractor shall conduct visual acuity testing in accordance with AR 40-501. SRTS data entry may be required. See service delivery schedule for details.

3.4 DOEHRS Compatible Audiometer Testing: The contractor shall conduct audiometric exams in accordance with

AR 40-501. Audiometers 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.

3.5 Immunizations: The contractor shall administer immunizations in accordance with AR40-501. Immunizations shall include, but not limited to, flu, varicella, MMR, yellow fever, typhoid, tetanus, hepatitis A, hepatitis B, and polio. Adherence to all requirements of the OSHA and all State & Federal Regulations is mandatory. In such cases, coordination with SDARNG Medical Command and the Office of the Deputy State Surgeon (DSS) to order and transport serum to sites will be made. Government will provide serum required for event.

Medical Service Delivery Schedule

The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service for each task.

Service Delivery Schedule: Medical Services in support of the South Dakota NG.

Deliverable Performance

Standard

Acceptable Quality Level (AQL) Method Used /

Frequency

Contractor coordinates with DSS and provides appropriate equipment to accomplish medical and dental services

Go/No Go Equipment is sterile and in good operating condition and adequate supplies are on hand.

Review

Spot Check or inspection

Customer

Complaint

Contractor coordinates with DSS and provides qualified and sufficient personnel during services

Go/No Go Vendor provides sufficient numbers of qualified required personnel to conduct medical services.

Contractor personnel to possess appropriate level of credentialing/licensing

Contractor provides Event

Manager to coordinate oversee execution of service event

Go/No Go EM is responsible for smooth execution of services

Contractor performs medical services at a rate to accomplish services on time.

Go/No Go Contractor completes testing at a rate of 6-8 soldiers per hour.

Contractor completes all required testing including:

Vision and hearing exams

Administers immunizations

Phlebotomy work

DNA, HIV Testing

Behavioral Health Screening

Completes

98% of all testing

Contractor completes all identified medical tests

– Blood pressure, Behavioral Health screening, PHA, EKG, specialty exams, schools, over 40 flight etc., IAW AR 40-501 as well as current published standards.

Contractor completes all required administration including:

Profile Management

Completes

100% of reports & documents

Contractor completes all reports/documents and submits as required.

Updates to personnel medical files must be error free and confidentiality maintained.

Contractor completes EPHA electronic entry of data contractor completes data entry by end of event or NLT 5 Days

5 days Contractor completes all data entry on site

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.

The COR referred to in this QASP is SFC Kelley Crane, kelley.c.crane.mil@mail.mil, Phone 605-737-6225.

Rating Description

Green Yes performance and technical specifications are being met at AQL.

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.

mailto:kelley.c.crane.mil@mail.mil

Signed_________________________________ Dated _________________________________________

RECEIVERS - MEDICAL QUALITY ASSURANCE PLAN WORKSHEET

Performance Rating

Deliverable/Service

Quality

Rating

Causative Factors Effect on Mission Action Required / Date

Contractor coordinates with

DSS and provides appropriate equipment to accomplish medical services

Green Comments Unnecessary for “Green” QA Rating.

Contractor coordinates with

DSS and provides qualified and sufficient personnel during services

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor provides Event

Manager to coordinate and oversee execution of service event

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor performs services at a rate of 6-8 soldiers per hour

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes all required testing Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes any required administrative paperwork and medical forms for profile management.

Red

Contractor completes EPHA electronic entry of data NLT 5 business days after event

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Other Green Comments Unnecessary for “Green” QA Rating.

4. DENTAL SERVICES SCOPE

Services include 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 DRC to include: annual dental exams, digital bitewing radiographs, digital panoramic radiographs, DENCLASS data entry of all radiographs and dental records, identification and treatment of all Class 3 soldiers on alert orders and/or eligible (except as

Specified in section C-3) through the Army Selected Reserve Dental Readiness System (ASDRS) Program to upgrade Class 3 or Class 4 Soldiers to a Class 2 or 1 status.

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

Individual case management, accountability and vendor oversight provided by a qualified and credentialed Dental Director (licensed DDS or DMD). This position shall be a staff position of the prime vendor.

Pre-event scrub of records through DENCLASS, ADDRs or CDR

Staff a dedicated and organic emergency 1-800 # (manned 24/7) call line for Soldiers to call, should dental emergencies emerge upon completion of dental work.

Oral surgery on location and Endodontic treatment on location at same time as the event

“Chair-side” dental classification, entered “real-time” (5 business days from the event if no connectivity) 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.

All services and data entry must be performed by organic staff

All access to MODS modules (www.mods.army.mil) will be performed by awarded vendor.

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

Provide “real-time” pharmacy prescriptions for each restorative event (and qualified staff to obtain medications) for any Soldier requiring medications post-event.

Provide a qualified bio-medical machine technician for each examination and restorative event, in case of equipment failure.

Provide dental screening examination to identify deficiencies (but does NOT include the dental treatment required to restore those deficiencies unless Class 3 status, or in need of full mouth debridement).

Review of post event Soldier complications to include but not limited to: abscess, dry socket defective filling ETC. within 24hrs of notification by DSS, review shall include a recommended course of action.

Maintain treatment records for 180 days post event.

http://www.mods.army.mil/

5. DENTAL TASKS:

5.1 The contractor shall provide customized comprehensive dental readiness services to include annual dental examinations and clinically indicated radiologic studies (bite-wing x-rays) when requested, and specified treatment outlined in the patient’s treatment plan and IAW AR 40-501 and AR40-35. Upon completion of services, medical information will be documented in accordance with Department of the Army Policy. Reports will be provided to the

SDARNG Deputy State Surgeon’s Office. The contractor shall also ensure the requirements of Occupational Safety and Health Administration (OSHA) and applicable federal regulations are met.

5.2. Exam - A periodic oral evaluation shall assess the current state of oral health and 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:

5.3. Caries Risk Assessment – Classify Soldiers as low, moderate, or high risk for caries as described by the

American Dental Association’s 1995 Special Supplement. This assessment will allow the ADCS to identify those at high risk for future disease and appropriately manage their care.

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

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

5.5. Tobacco Risk Assessment – Classify Soldiers as a smoker, user of smokeless tobacco, both or neither.

5.6. Oral Cancer Screening – Perform a thorough oral cancer screening as part of all examinations

5.7. 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 the 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.

The contractor shall have experience in and capability to upload all exam and digital radiographs into the

DENCLASS system. If upon QA of work performed at event by contractor the SDO or designee finds radiographs that are of not diagnostic quality within 30 calendar days post event, arrangements to obtain repeat radiographs will be made at no expense to the Govt. or SDARNG.

5.8 Treatment. Only treatments that have been identified in the patient’s treatment plan will be accomplished. These treatments are designed to improve the dental classification status of the Soldier from Class 3 to Class 2.

5.9. Documentation. Documentation of exam and treatments shall be returned to the South Dakota Army National

Guard Medical Representative (Deputy State Surgeon) from the Office of the State Surgeon. The Contractor will return all functional files maintained by the Contractor to the government upon completion of the required services.

5.10. SF 603/603A, Record of Dental Exam and treatment shall be completed.

5.11. Supporting Radiographs (pantograph/four bitewings) if necessary.

5.12 A diagnostic quality copy of all radiographs must be placed in the dental record as required.

5.13 Treatment Locations. The contractor shall be able to provide services throughout the state of South Dakota (or needs of the SDARNG) as requested by the Government within notification of 15 business days from the requested event date.

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: SDARNG intent is for the contractor to resolve any dental issue that develops from treatment post event. History indicates 1 case in every 3 events.

• 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 shall pay for repeat radiographs.

• 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 within 10 business days post event.

6. APPLICABLE PUBLICATIONS

Publications applicable to this PWS are listed below. The publications must be coded as mandatory or advisory, the date of the publication, and what chapters or pages are applicable to the requirement. All publications listed are available via the Internet at the specified e-mail address:

https://apps.mods.army.mil/MEDPROS/Secured/ https://apps.mods.army.mil/denclass/ https://apps.mods.army.mil/MEDPROS/Secured/ https://apps.mods.army.mil/denclass/

Dental Service Delivery Schedule

Service Delivery Schedule: Dental Services in support of the South Dakota NG.

Deliverable Performance

Standard

Acceptable Quality Level (AQL) Method Used /

Frequency

Contractor provides adequate and appropriate equipment to accomplish required Dental

Services

Go/No Go Vendor coordinates with the Deputy State

Surgeon prior to conducting services

Review

Spot Check or

Inspection

Customer

Complaint

Contractor provides qualified and sufficient personnel to conduct all required Dental

Services

Go/No Go Vendor coordinates with the Deputy State

Surgeon prior to conducting services to determine the personnel required to conduct dental services for in the period identified.

Contractor personnel to possess appropriate level of credentialing

Contractor provides Case

Manager (CM) Go/No Go Case Manager oversees services and is responsible for smooth execution of services

Contractor performs Dental

Exams at a rate of 8 per hour Go/No Go Contractor completes exams at a rate that will complete services within the identified period

Contractor completes Dental

Exams Completes

100% of exams

Contractor completes oral exams IAW AR

40-501 & AR 40-35 & completes -

Caries risk assessment

Periodontal assessment

Oral cancer screening

Panoramic Radiographs as needed to represent soldiers current condition (filed & DENCLASS)

Contractor completes dental treatment Completes

97% of

Class 3’s

Contractor performs authorized dental procedures on class 3 soldiers to bring the soldiers to class 2

CM coordinates and tracks any special dental requirements 100% CM arranges & tracks any special event or post event special dental services & prescriptions

Contractor completes required paperwork & final reporting Completes

100% of needed paperwork

Contractor completes any required paperwork for dental files – ie SF 603 & SF 5570.

Contract completes and submits final data to

Deputy State Surgeon & tracks special cases

Contractor completes electronic entry of data in DENCLASS 100% Contractor completes real time and chair side data entry of all results into DENCLASS

Quality Assurance Surveillance Plan:

The Contracting Officer Representative (COR) will monitor contractor performance and complete the Quality

Contracting Officer.

The COR referred to in this QASP is SFC Kelley Crane, kelley.c.crane.mil@mail.mil, Phone 605-737-6225.

Rating Description

Green Yes performance and technical specifications are being met at AQL.

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.

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 - DENTAL QUALITY ASSURANCE PLAN WORKSHEET

Performance Rating

Deliverable/Service

Quality

Rating

Causative Factors Effect on Mission Action Required / Date

Contractor provides adequate and appropriate equipment to accomplish required Dental

Services

Contractor provides qualified and sufficient personnel to conduct all required Dental

Services

Contractor provides Case

Manager (CM) Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor performs services 8 soldiers per hr Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes Dental

Exams Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes dental treatment Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor coordinates and tracks any special dental requirements

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes required paperwork & final reporting.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes electronic entry of data in DENCLASS Green Comments Unnecessary for “Green” QA Rating.

Signed ____________________________________________ Dated ______________________________

7. SERVICES TASKS - GENERAL

7.1 The contractor shall provide all management, labor, material, equipment, tools, supplies and certifications necessary to provide all listed Medical and Dental services in this PWS.

7.2 The Medical Dental Event Schedule identifies services required and the approximate number of personnel requiring services and the availability of event space. Simultaneous may requirements exist. The services shall provide mandated medical and dental requirements to meet and deploy ability standards.

8. CONTRACTOR PROVIDED EQUIPMENT AND PERSONNEL:

8.1 The contractor shall provide all material, equipment, and supplies necessary to provide all listed service requirements listed in the event schedule in either mobile/portable space or inside Government facilities.

8.2 Contractors shall provide all necessary mobile/potable events space (see event schedule). Medical & Dental mobile/portable facilities shall meet all OSHA, HIPAA and Privacy Act standards to ensure a safe and productive workspace for services under the Individual Readiness Requirements. Mobile and or portable exam/treatment areas must ensure that privacy is observed for all medical/dental exam rooms. There shall be a designated vitals area, visual acuity area, a lab with eye-wash stations, biohazard separated work areas, hearing booth(s) 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 be compliant with all radiation safety standards.

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

8.4 Due to nature of many drill weekends, Mobile/Portable Medical/Dental 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.

8.5 Contractor must have the capability to conduct real-time, point of service E-PHA, HRR, DENCLASS and

MEDPROS data upload on location or with the approval of the SDARNG DSS or designee. Data entry shall not to exceed 5 calendar days after event. The contractor shall provide their own mobile internet access for all service events.

8.6 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. All Personally Identifiable Information (PII) will be safeguarded, see

DoD Directives 5400.11 and 5400.11-R.

9. GOVERNMENT-FURNISHED PROPERTY AND INFORMATION:

9.1 The Government will provide an administrative space for soldier check-in and out and vision run/space for vision tests for all events.

9.2 For Armory Space Events, coordination with the Office of the Deputy State Surgeon prior to the setup for each event is required.

9.3 Only parking will be provided in events identified as mobile/portable.

10. 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 SDARNG Office of the Deputy State

Surgeon or Designee.

11. PLACE OF PERFORMANCE

Specific services are required at various locations in South Dakota (See Event Schedule).

12. PERIOD OF PERFORMANCE

The performance period is specific to each event location. (See Event Schedule).

13. OTHER CONDITIONS/ SECURITY

13.1 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).

13.2 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.

13.3 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.

13.4 Contraction Officer Representative (COR). The COR is identified below, no changes to event will be made without prior consent of:

COR is SFC Kelley Crane, kelley.c.crane.mil@mail.mil, Phone 605-737-6225.

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, 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.

13.5 Hours of Operation: Operation hours are specific to each event, see event schedule.

13.6 Security Requirements: All contractor employees and affiliated personnel of the contractor are to possess identification that identifies them as such. All vehicles are subject to search without reason. The contractor shall comply with any and all installation security requirements.

13.7 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

SDARNG liaison with the office of the Deputy State Surgeon.

13.8 Event Manager: The contractor shall provide a Event 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.

13.9 All care givers (data entry/admin technicians, Physicians, Dentists, phlebotomists, Nurses, etc) at each and every location for this contract must be direct employees of the prime contractor.

13.10 Invoice: Contractor shall consolidate all medical services performed on an individual event basis and submit an invoice through Wide Area Work Flow within 10 business days post event

14. ACCEPTANCE PLAN:

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

15. REFERENCES

DoD Directive 5400.11 DoD Privacy Program http://dpclo.defense.gov/privacy/

DoD Directive 5400.11-R DoD Defense Privacy Program http://dpclo.defense.gov/privacy/

AR 40-501 Standards of Medical Fitness http://www.apd.army.mil/

AR 40-35 Dental Readiness & Community Oral Health Prevention http://www.apd.army.mil/

Army National Guard implementation Guidance on Selected Reserve (SELRES) Dental Readiness

System (ASDRS) for providing Dental Treatment outside of Alert. (attached)

Vision Readiness Screening and Classification (VRSC) Tracking in MEDPROS (attached)

Vision Readiness Screening Guide (MEDPROS)

OTSG/MEDCOM Policy Memo 11-054 Women’s Readiness (available upon request)

16. APPENDICES:

A. Estimated Workload Data

B. Dental Classification

C. Authorized Dental Treatment

D. ALARACT Vision Readiness

W912MM-17-T-0059

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 (providers, nurses, and administrative staff)

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 medical classification of the Soldier

A by name listing of all Soldiers requiring Behavioral Health follow up and main concern

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 panograph 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.

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Nov 14, 2017.