36C25018Q0375-002.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

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 agreement 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 agreement. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

• Assigned Contracting Officer (CO):

• Organization or Agency: U.S. Department of Veterans Affairs

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.

Assigned COR(S):

c. Other Key Government Personnel -

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – As designated by contractor upon award

b. Other Contractor Personnel - As designated by contractor 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.

QUALITY ASSURANCE SURVEILLANCE PLAN

Nursing Home Care

Task

Description

No.

Paragraph in

PWS

Indicator/Performance

Standard

Standard for Quality

Level

Acceptable

Quality

Level

Method of

Surveillance1

Incentive

1 (B)(9) Nursing Home shall maintain a current and unrestricted state license to operate as a skilled nursing facility. Federal licensures, certifications, and investigations reports when requested.

100% 95% Periodic

Reviews and spot checks

Positive past performance rating

2 (B)(10) The Contractor shall cooperate in developing plans of corrective action according to outlined criteria in the

Performance Work

Statement

100% 95% Periodic

Reviews and spot checks

Positive past performance rating

3 (B)(7)(13) Notice of veteran being hospitalized within 72 hours and notice of any veteran death within 24 hours or immediately the first business day after a weekend or holiday.

100% 95% Periodic

Reviews and spot checks

Positive past performance rating

4 (B)(15) Notice of all reportable events on VA contract veterans and all facility sentinel events within 24 hours or immediately the first business day after a weekend or holiday.

100% 95% Periodic reviews

Positive past performance rating

5 (B)(17) All medical records concerning the veteran's care in the nursing home a) will be readily accessible to VA, and b) within acceptable standards and practice.

100% 95% Periodic

Reviews and spot checks

Positive past performance rating

1 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

6 (B)(21) Invoices shall be timely and accurate for all items billed.

100% 95% Periodic

Reviews and spot checks

Positive past performance rating

7 (B)(24) Medicare/Medicaid

Standards. VA Contracted

Nursing Homes must Pass

4 out of 7 Criteria listed on the Medicare.gov/nursing home compare website

100% 95% Periodic

Reviews and spot checks

Positive Past

Performance rating

5. INCENTIVES/RATING STANDARDS

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance.

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION

c. USER SURVEY

d. VALIDATED USER/CUSTOMER COMPLAINTS

e. INSPECTION

f. PERIODIC SAMPLING

g. RANDOM SAMPLING

h. PROGRESS OR STATUS MEETINGS

i. ANALYSIS OF CONTRACTOR’S PROGRESS REPORTS

k. VA Contracted Nursing Homes must Pass 4 out of 7 Criteria listed on the https://www.medicare.gov/nursinghomecompare website to be eligible for continued VA Contract Nursing Home program. These criteria are as listed:

1. Deficiencies: (Facility fails if there are 3 levels G or worse deficiencies in the current survey

2. Health Requirements Deficiencies: (The total number of health requirements deficiencies cannot be more than twice the State Average in the current survey)

3. Staff Treatment of Residents and Facility Licensure: (Fail with Rating E-L or higher. OSCAR Level E-L equals

Nursing Home Compare of 2 or higher)

4. RN Hours: Fail if less than the State Average

5. Total Nursing Hours: Fail if less than State Average

6. Nursing Deficiencies: (Includes Nursing (F353), Nursing Aid Training (F494), Nursing Aid Competency(F495), Nursing Aid Registry Verification (F496), Regular In-service Training (F497), Proficiency of Nursing Aids (F498), Staff

Qualifications (F499)

7. Quality Measures: A facility fails when 6 or more of the CMS Quality Measures listed in Nursing Home Compare fall above the state Average.

*All Immediate Jeopardy tags (IJ tags) will be reported to the COR/CNH Coordinator within 24 hours of receipt from the State.

7. RATINGS

https://www.medicare.gov/nursinghomecompare

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive OR NEGATIVE 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 work with the Contracting Officer (CO) 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. In order to assure that the contractor receives impartial, fair, and equitable treatment under this agreement, the COR will work with the contractor to increase performance to an acceptable level.

When the COR and CO determines formal written communication is required, the COR and CO shall prepare a Contract

Discrepancy Report (CDR) and present it 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 COR. The Government 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.

9 . 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 as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Representative

See above Acceptable Quality Level & Method of Surveillance located in QASP