36C25019Q0843-006.pdf

Quality Assurance Surveillance Plan (QASP)

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 Contracting Officer (CO): Lisa D. Bailey

• Assigned Contract Specialist: Michelle C. Ford

• 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): Stacy Hassett, 269-966-5600 x31164

c. Other Key Government Personnel - Fred Reynolds, 269-966-5600 x35682

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – As assigned by facility

b. Other Contractor Personnel - As assigned by facility

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

No. Paragraph in PWS

Indicator/Performance Standard Standard for

Quality Level

Acceptable Quality Level

Method of Surveillance0F

Frequency

1 (A)(7) (A)(8)

Accreditation/Licensing: Contractor shall possess Accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) or Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Contractor shall be licensed to provide substance abuse services by the State of Michigan Office of Recovery Oriented Systems of Care (OROSC). Contractor shall be licensed to provide Methadone and Buprenorphine in the State of Michigan.

100% 100% Inspection of records.

VA team Inspection.

Yearly and Randomly.

2 (A)(14.1) Training and Certification of Staff: Staff shall have appropriate level of education as documented in the PWS.

100% 100% of randomly inspected files.

Inspection of records.

VA team Inspection.

Yearly and Randomly.

3 (A)(21) Billing: Authorizations and payments will match corresponding dates of service and services performed.

100% 95% Inspection of records.

Periodically

4 (A)(13)

Documentation: Veteran files at Contractor location will be kept separate from other files at Contractor location. All information contained in Veteran files will be kept confidential except if Veteran provides authorized release.

Veteran files at Contractor location shall contain the following documentation:

1. BCVAMC authorization form from COTR that includes services to be covered.

2. Release of Information allowing BCVAMC to communicate with Contractor staff regarding Veteran’s treatment and progress.

3. Consent to treatment form that

100% 95% Periodic sampling

Yearly and Randomly.

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

outlines Veteran’s expectations.

4. All essential identifying data relevant to the Veteran and his/her family, will be found on the demographic face sheet contained in the Veteran's chart.

5. Assessment tool determining the appropriate level of care (e.g.

ASAM).

6. Brief Addiction Monitor (BAM) completed.

7. Advance Directive was completed or declined.

8. Documentation that Veteran was provided with information regarding their patient rights and grievance process.

9. Documentation that Veteran was provided with sexual harassment training as part of orientation.

10. Documentation that a suicide risk assessment was completed at admission, discharge and yearly or as clinically indicated. Veterans who are deemed to be at risk for suicide will complete a suicide safety plan.

11. Documentation that the Veteran was screened for Military Sexual Trauma and referral was made if positive.

12. Treatment Plan is developed around goals express by the Veteran (Veteran Centered Care). Treatment Plans to be updated based on timeframes included in the plan.

13. Psychosocial Assessment includes SNAP (Strengths, Needs Abilities and Preferences).

14. If a Veteran misses an appointment, a no-show note will be entered and the Veteran will be contacted 3 times within 24 hours.

15. If/when a Veteran discharges from Contractor’s care, a Discharge Summary to be completed documenting any beneficial changes noted during the treatment period, reason for leaving the program and future plans.

Documentation that a Veteran is contacted thirty days after completing the program.

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

7. RATINGS

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 contract, 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.

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

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

Various methods exist to monitor performance.