Attach. 6 FY24 RMW QASP 12222023.pdf

REGULATED MEDICAL WASTE SERVICE

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

For:(10) locations:

a. Alvin C. York Campus 3400 Lebanon Pike Murfreesboro, TN 37129

b. Nashville Campus 1310 24th Avenue South Nashville, TN 37212

c. Chattanooga VA Outpatient Clinic 6098 Debra Rd Suite 5200, Bldg 6200 Chattanooga, Tennessee 37411

d. Charlotte Avenue Clinic 1919 Charlotte Avenue Nashville, TN 37203

e. Women Veterans Healthcare Center 1919 Charlotte Avenue Suite 300 Nashville, TN 37203

f. Albion Street Outpatient Clinic 1818 Albion Street Nashville, TN 37208

g. Tullahoma Outpatient Clinic 225 Von Karman Road Arnold Air Force Base, TN 37389

h. Clarksville Dental Clinic 2291 Dalton Drive Suite F Clarksville, TN 37043 i.

International Plaza VA Clinic 2 International Plaza Suite 300 Nashville, TN 37217

j. Clarksville VA Medical Clinic 782 Weatherly Drive Clarksville, TN 37043

Contract Number: Provided Upon Award

Contract Description: Regulated medical Waste Services

Contractor’s name: Provided Upon Award

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 shall coordinate changes with the contractor.

Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall 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: Lori Ellis Organization or Agency: Department of Veterans Affairs, NCO9

b. Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall 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. Additionally, an Alternate COR (ACOR) may be appointed.

a. Assigned COR: Jennifer R Boyd, Administrative Officer, EMS

b. Assigned ACOR: Tina Taylor-Jackson., Chief, EMS

c. Other Key Government Personnel - Upon award, Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who may act on behalf of the COR to monitor performance.

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager: Completed upon award

b. Other Contractor Personnel: Completed upon award

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

Required Service

Performance Standard

Method of Surveillance

Incentive

Contractor provides sufficient amount of collection containers and dollies

No more than two (2) instances where sites run out of containers or dollies

Observation and random inspection (auditing).

Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

Contractor transports waste in a safe manner

Zero violations of local, state, county or federal laws pertaining to

OSHA, EPA

and DOT regulations

Observation, random inspection (auditing), and user/customer complaints.

Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

Contractor provides all applicable materials for packaging waste

No more than two (2) instances where sites run out of materials to include red bags, cardboard boxes, generator

Observation and random inspection (auditing).

Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

Observation and random inspection (auditing).

labels and tape

Contractor provides the destination manifest back to the facility within 30 days after removal of materials

No more than two (2) instances where the destination manifest (proof of disposal) is returned to the facility more than 30 days after removal of materials

Observation and random inspection (auditing).

Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

Contractor provides annual on-site training to include topics as defined in the SOW, to participating facility employees

Zero instances where annual training is not provided and certificate of completion returned to COR more than 30 days after training

Direct Observation Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

Contractor ensures all waste is sent for a “greener” disposition in accordance with their submittal based on the PWS

Zero instances where this standard is not met

Observation and random inspection (auditing)

Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

Contractor provides all monthly waste data to COR by

No more than two (2) instances where waste data provided

Direct Observation Deficiencies noted in quarterly performance evaluations, and notes made in

CPARS.

the 15th day of the following month later than the 15th day of the following month

5. INCENTIVES

Incentives shall be based on exceeding, meeting, or not meeting performance standards. If applicable, the Government shall use “Potential Future Ordering Period” as an incentive.

6. METHODS OF QA SURVEILLANCE

The Government facilities may at any time inspect and verify that the accuracy of the work compares to that indicated on the invoice. Any deviation will be deducted from the invoice price

The COR shall use the surveillance methods listed below in the administration of this

QASP.

a. DIRECT OBSERVATION: 100% surveillance/Inspection

b. PERIODIC INSPECTION: Inspections will be scheduled Daily, Weekly, Monthly, Quarterly, annually and unscheduled, as needed.

c. USER SURVEY: Customer complaints and random sampling. Random survey is conducted to solicit user satisfaction.

d. VALIDATED USER/CUSTOMER COMPLAINTS: Complaints are investigated and validated.

e. PROGESS/STATUS MEETINGS: Quarterly

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE:

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE:

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the Contracting Officer (CO) determines formal written communication is required, a Contract Discrepancy Report (CDR) shall be prepared and presented to the contractor's program manager.

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 Contracting Officer. The Contracting Officer shall review the contractor's corrective action plan to determine acceptability.

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

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement:

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings:

The COR shall meet with the contractor quarterly to assess performance and shall provide a written assessment. The written assessment will be placed in the COR file and a copy provided to the Contracting Officer.

Signature – Contractor Program Manager (contractor)

Signature – Contracting Officer’s Representative (COR)