Contractor
CS119006
EXHIBIT A
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SCOPE OF WORK
1.
GENERAL SCOPE
Contractor agrees to provide pre-employment, annual, and first aid evaluations,
including lab testing and administration of required vaccinations, required for the
determination of whether or not the applicant or current employee is physically
qualified for a specific job.
2.
CONTRACT MANAGERS
The Contract Managers during the term of this Agreement will be:
Department of Developmental Services, (CS)
Canyon Springs
Ann Larsen
(760) 770-6248
Contractor:
3.
LICENSE REQUIREMENTS AND QUALIFICATIONS
Contractor, and/or Contractor’s employees who perform the physical
examinations required in this agreement must be:
a)
licensed as a Physician and Surgeon by the California Medical Board; or
b)
licensed as an Osteopathic Physician by the Osteopathic Medical Board of
California; or
c)
licensed by the California Medical Board, Physician Assistant Committee,
as a Physician Assistant; or
d)
licensed as a Nurse Practitioner by the California Board of Registered
Nursing.
Contractor must retain such licenses for the term of the contract.
Contractor and/or Contractor’s employees who perform the physical
examinations required in this agreement must not be considered an excluded
practitioner per the Medicare Office of Inspector General’s (OIG), List of
Excluded Individuals/Entities.
Contractor must provide prior to the implementation of this contract contact
information for three (3) references who can verify that within the past ten (10)
years Contractor performed services similar to those outlined in this Scope of
Work.
Contractor
CS119006
EXHIBIT A
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Contractor’s employees performing phlebotomy services under this agreement
must have and maintain a California Phlebotomy Certification.
Contractor’s employees must be trained and certified by the Federal Department
of Transportation (DOT) to collect blood for testing for candidates for employment
into designated “sensitive” positions at Canyon Springs (see #7c).
Contractor’s employees performing physical examinations under this agreement
must meet the license and qualification requirements noted above and the
provisions outlined in Exhibit D “Special Terms and Conditions.”
4.
CONTRACTOR’S FACILITIES
If the pre-employment physicals and/or annual physical examinations are done at
the Contractor’s facilities/office, Contractor’s facilities/office must be within a
fifteen (15) minute drive from Canyon Springs, and all required testing equipment
(radiology, phlebotomy/blood draws, other specimen collections, etc.) must be
available at the one location, to ensure Canyon Springs’ staff time away from the
Canyon Springs facility is minimized.
Contractor may use mobile facilities to complete the required pre-employment
and annual physical examinations at the Canyon Springs facility. However, such
mobile facilities must be self sufficient regarding water and electrical/power
sources, as Canyon Springs does not have the means to connect mobile facilities
to the Canyon Springs’ infrastructure.
5.
DUTY STATEMENTS AND STATE JOB SPECIFICATIONS
The CS Contract Manager will furnish the Duty Statement and State Job
Description applicable for the person being examined. Contractor shall
determine whether an applicant is physically qualified based on the Duty
Statement and/or State Job Specifications, and the Definition of Qualified
Applicant included in Exhibit A under item #10.
6.
SCHEDULING
The CS Contract Manager shall be responsible for scheduling examinations or
tests at a date and time mutually agreed upon. Contractor agrees to notify the
CS Contract Manager of no shows and cancellations. The CS Contract Manager
will inform Contractor at the time of request for testing which tests are to be
performed.
7.
PRE-EMPLOYMENT PHYSICAL EXAMINATIONS
Contractor
CS119006
EXHIBIT A
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Pre-employment physical examinations shall comply with California Code of
Regulations, Title 22, Chapter 8, Section 76539 “Employees’ Examinations and
Health Records.”
a)
b)
Employment candidates shall complete Pages 1 and 2 of the form STD.
610 Health Questionnaire.
Contractor shall conduct a physical assessment and document findings for
the following items on Page 3 of the STD. Health Questionnaire form:
#1 Height & Weight
#2 Vision
#2a Color Vision if required as a Minimum Qualification for the specific
position
#3 Hearing (Audiometry is not required)
#4 Head
#5 Resting Pulse Rate and Blood Pressure
#6 Lungs
#7 Heart and Circulatory System
#8 Nervous System
#9 Abdomen & Hernia
#10 Genitourinary System Including Kidneys
#12 Spine
#13 Extremities
#14 Skin and Lymphatics, Significant Scarring
#15 Varicose Veins
#16 Urinalysis
#17 Specify Any Work Limitations
#18 Psychiatric Evaluation (Any mental disorder observed)
#19 Physician’s Signature and Date Signed
Note: #11 Rectal is specifically NOT required.
c)
Specific classifications designated “sensitive” require that the candidate
undergo a pre-employment drug screening test. Classifications
designated as sensitive are:
Health Services Specialist
Hospital Peace Officer I
Hospital Peace Officer II
Investigator
Licensed Vocational Nurse
Nurse Instructor
Nursing Coordinator
Painter I & II
Physician and Surgeon
Pre-Licensed Psychiatric Technician
Pre-Registered Nurse
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EXHIBIT A
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Program Director, DD & MD
Psychiatric Social Worker
Psychiatric Social Worker (HF)
Psychiatric Technician
Psychiatric Technician Apprentice
Psychiatric Technician Student
Psychiatric Technician Trainee
Psychiatric Technician Training
Candidate
Psychologist (Educational)
Psychologist (HF - Clinical)
Psychologist (HF - Counseling)
Psychologist (HF - Education)
Psychologist (HF - Experimental)
Psychologist (HF - Social)
Registered Nurse I & II
Rehabilitation Therapist/SH (Art)
Rehabilitation Therapist/SH (Dance)
Rehabilitation Therapist/SH (Music)
Rehabilitation Therapist/SH
(Occupational)
Rehabilitation Therapist/SH (Recreation)
Senior Psychiatric Technician
Senior Psychologist
Senior Psychologist (HF)
Senior Special Investigator
Social Work Associate
Special Investigator
Supervisor, Sheltered Workshop
Teacher
Unit Supervisor
Drug testing shall be done using a split sample collection method,
reserving one sample for retesting at applicant’s request, if original test
results are positive.
d)
Contractor shall offer the pre-employment candidate
vaccinations/immunizations required by California Code of Regulations,
Title 8, Section 5199, Aerosol Transmissible Diseases:
-
Influenza (One dose annually)
Measles (Two doses)
Mumps (One dose)
Rubella (One dose)
Contractor
CS119006
EXHIBIT A
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-
Tetanus, Diptheria, and Acellular Pertussis (Tdap) (One dose,
booster as recommended)
Varicella-zoster (VZV) (Two doses)
If the candidate declines the vaccination(s)/immunization(s), the
Contractor shall be responsible for ensuring that the candidate sign and
date a Vaccination Declination Statement(s) that complies with Title 8,
Section 5199.
e)
Contractor shall offer the pre-employment candidate the opportunity to be
tested for Hepatitis B and C (titer), and if needed, offered the Hepatitis B
vaccine series.
If the candidate declines the Hepatitis B vaccine series, the Contractor
shall be responsible for ensuring that the candidate sign and date a
Vaccination Declination Statement.
f)
Contractor will complete the following screenings:
a. CBC
b. UA dipstick
c. UA microscopic evaluation if indicated by the UA dipstick
d. Comprehensive Chemistry Panel 14
e. Hepatitis B titer
f. PPD (TB) skin test (if no earlier history of a positive reaction)
g. Chest X-ray for TB screening (if the candidate has a history of positive
PPD, the Contractor must determine if a chest x-ray is indicated; if not
indicated, the Contractor must document that determination in the
“comments” section of the questionnaire form).
h. Hepatitis C titer
i. Rubella Titer
j. Rubeola Titer
k. Mumps Titer
l. RPR Titer
Candidates for classifications requiring food handling (Food Manager, Cook
Specialist I & II, Food Service Technician I) are required to have an Ova and
Parasite Stool Culture.
8.
ANNUAL EMPLOYEE PHYSICAL EXAMINATIONS
Results of annual employee physicals will be documented on the “Annual Health
Questionnaire” form. Employees will complete the questionnaire, providing
information regarding changes in their health status over the past year.
The annual physical will consist of:
Contractor
CS119006
EXHIBIT A
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A.
B.
C.
D.
Recording of height, weight, pulse, and blood pressure.
PPD or chest x-ray (TB screening) as clinically indicated (if the employee
has a history of positive PPD, the Contractor must determine if a chest xray is indicated; if not indicated, the Contractor must document that
determination in the “comments” section of the questionnaire form).
Optional lab tests at employee’s request: UA dipstick and/or CBC.
Contractor shall review the employee’s immunization record, and offer the
employee recommended vaccinations/immunizations required by
California Code of Regulations, Title 8, Section 5199, Aerosol
Transmissible Diseases:
-
Influenza (One dose annually)
Measles (Two doses)
Mumps (One dose)
Rubella (One dose)
Tetanus, Diptheria, and Acellular Pertussis (Tdap) (One dose,
booster as recommended)
Varicella-zoster (VZV) (Two doses)
Hepatitis B titer and/or vaccination series
If the candidate declines the vaccination(s)/immunization(s), the
Contractor shall be responsible for ensuring that the candidate sign and
date a Vaccination Declination Statement(s) that complies with Title 8,
Section 5199.
Upon completion of the physical examination, Contractor shall document
pertinent findings, and a determination whether or not the employee can
physically perform the functions of his/her position at Canyon Springs.
9.
PRELIMINARY RESULTS
At the request of the CS Contract Manager, Contractor agrees to provide the
preliminary results of work performed to the CS Contract Manager as the results
become available. Contractor agrees to provide the CS Contract Manager with
written confirmation of verbal communications within 24 hours of said
communication.
10.
REPORT REQUIREMENTS FOR DISQUALIFIED APPLICANTS
Should an applicant be found unqualified for employment at Canyon Springs
because the medical history, physical examination, laboratory test(s) and/or x-ray
results discover a condition that would preclude execution of those duties
described in the State Job Specification and/or Duty Statement, Contractor will
furnish the CS Contract Manager a concise, concrete statement which sites the
reason(s) for disqualification.
Contractor
CS119006
EXHIBIT A
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11.
DEFINITION OF A QUALIFIED APPLICANT
a. An applicant for employment at Canyon Springs whose medical history and
physical examination determines no condition(s) that would preclude the
execution of those duties described in the State Job Specification and Duty
Statement provided to Contractor; and
b. Whose laboratory test and chest x-ray results have no abnormality that
remains unexplained and unclarified by the applicant’s personal physician;
and
c. Whose laboratory tests and chest x-ray have discovered no abnormality that
would preclude execution of these duties described in the State Job
Specifications and Duty Statement provided to Contractor; or
d. Whose laboratory tests and chest x-ray are normal*. (*Note: Presence or
absence of immunity to Hepatitis B, Hepatitis C, Varicella, Measles, mumps
and rubella of itself does not disqualify an applicant.)
12.
FOLLOW UP
In the event that during the physical examination it is discovered that the
applicant or employee is in need of immunizations/treatments beyond those
immunizations required per this contract, the applicant is to be referred to the
applicant’s private physician. Canyon Springs will not reimburse Contractor for
follow-up tests, treatments, or immunizations not specifically included in this
agreement.
13.
FIRST AID – EVALUATIONS
Contractor will provide first aid and evaluation of employees’ injuries to determine
if they are work related/Worker’s Compensation issues or to be referred to the
employee’s personal physician.
14.
TIMELY REPORTING
Contractor agrees to furnish a complete file of results of history, physical
examinations, laboratory tests, and x-ray readings, as well as a statement as to
applicant’s qualification or disqualification within fourteen (14) days of applicant’s
initial visit to Contractor’s Facilities. If Contractor is unable to meet the fourteen
(14) day deadline, Contractor agrees to notify the CS Contract Manager
immediately of the delay.