36C24819R0032-009.pdf

ATTACHMENT SEVEN (7) – QUALITY ASSURANCE SURVEILLANCE PLAN

Quality Assurance Surveillance Plan

The contractor will be evaluated in accordance with the following:

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

What will be monitored.

How monitoring will take place.

Who will conduct the monitoring.

How monitoring efforts and results will be documented.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government will coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions will be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel will oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO will ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and will safeguard the interests of the United States in the contractual relationship. The CO will also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned CO: Network Contracting Office 8 (NCO8)

Organization or Agency: Veterans Health Administration

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and will assure proper Government surveillance of the contractor’s performance. The COR will keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Driven by the Veterans Affairs Medical Center – Delegation will be provided to the Contractor upon award.

Organization or Agency: Veterans Health Administration

Quality Assurance Surveillance Plan

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

Alternate:

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract.

CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP will be used to determine the level of contractor performance in the elements defined.

Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section six (6). The Government will use these standards to determine contractor performance and will compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR will use the surveillance methods listed below in the administration of this QASP.

a. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per the COR delegation or as needed. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

b. Verification and/or documentation provided by Contractor. For example, discharge/relapse plan information, reports of periodic re-evaluation, state agency reports, on-site inspection reports by VA Staff and QA management reports.

Measures PWS Refere nce

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met

AQL/DID

NOT

MEET

AQL-

CPAR

RATING/

ADD

COMMEN

TS

1 – Joint Commission Requirements

2.1.2. Accreditation

by the TJC or equivalent is required.

CARF is evidence of internal quality assurance mechanisms and is required.

Where applicable, the residential treatment setting must have a current occupancy permit issued by the authority having jurisdiction.

TJC and

CARF

Requirem ents.

All (100%) must meet or exceed TJC or equivalent and CARF standards

Quarterly review of contractor records.

2 - Discharge Plan

6. VHA requires a targeted discharge plan as a Best Practice.

Discharge planning begins at the time of the admission assessment.

Standard

CTS.06.0

5.03 of the Joint Commissi on 2016 Guidelines

All (100%) of patients shall have a discharge plan at the time of discharge.

No acceptable deviation.

Quarterly review of discharge plan timeliness for each patient referred to the contractor facility

3 – Medical and Psychiatric Stabilization

4.12.2. Vital signs and

laboratory data consistent with facility standards for discharge of acute and/or residential patients

Standard

CTS.04.0

1.01 of the Joint Commissi on 2016 Guidelines

All (100%) of patient safety incidents are reported using a Patient Safety Report as soon as practicable (but within

Quarterly review of medical record for patient safety incidents for each VA patient referred to the Contractor facility twenty-four (24)) hours.

No acceptable deviation

4 – Privacy, Confidentiality and HIPAA

1.3.5.

1.3.11.

4.6.1.

4.7.1.

4.7.3.

Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards.

Zero (0) breaches of privacy or confidentiality

All (100%) Contractor ’s Personnel comply with all laws, regulation s, policies and procedure s relating to Privacy, Confidenti ality and

HIPAA

100% compliance;

no deviations

Contractor shall provide a description documenting the report of any violations per VA Directive 6500.6

5- Clinical Outcome Measures

8. This contract requires establishment and documentation of treatment goals specific to the patient’s condition and designed to specifically address each problem identified in the evaluation;

design of a plan of care addressing the patient’s disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment;

continued assessment and analysis during implementation of the services at regular

All (100%) In the weekly report on progress required, the facility shall report on progress, on meeting goals establishe d in the treatment plan including any measurem ent-based outcome measures and patient will show progress toward meeting the goals.

All (100%) Although status is reported weekly, progress must be shown over the preceding two (2)-week period toward meeting the goals as determined by measureme nt-based outcomes used by the facility. If a patient has not shown progress toward goals in the preceding two (2)-week period, the treatment plan should be reviewed with input from the VA

Surveillance will usually occur via weekly oral progress reports. At VA discretion, VA may also request that the facility provide copies of the treatment plan and reviews and have ready access to the medical records if requested.

intervals.

Assessment and analysis include but is not limited to measurement-based outcomes using standardized assessments at regular intervals.

referring provider.

Lack of progress toward goals over a four

(4) -week period may be grounds to discontinue Contractor services for that Veteran at the discretion of the VA.

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings will be used:

OUTSTANDING: Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

VERY GOOD: Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

SATISFACTORY: Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

MARGINAL: Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

UNSATISFACTORY: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

8. DOCUMENTING PERFORMANCE

a. The Government will document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, the CO will inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO will document the discussion and place it in the contract file.

When the COR and the CO determines formal written communication is required, the COR will prepare a Contract Discrepancy Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to present this corrective action plan to the CO. The Government will review the contractor's corrective action plan to determine acceptability. The CO will also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CDR below.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting. The COR will communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER