36C25220Q0404-003.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

The contractor service requirements are summarized into performance-based requirements that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. The thresholds are critical to mission success.

Quality Assurance Surveillance

Basic Cleaning Service: # 1 The contractor shall complete all standards within the performance threshold. (Reference 2.1)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

· EOC (daily Observations)

· Vendor Quality Control Plan Review

General Dusting/Disinfecting Surfaces: # 2 The contractor shall complete all standards within the performance threshold. (Reference 2.2)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Remove Trash and Recycling: # 3 The contractor shall complete all standards within the performance threshold. (Reference 2.3)

· Will be conducted daily.

· All trash & recycling containers shall be emptied daily. Liners will be replaced with a fresh unused liner before returning to initial location.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections

· All practices and standards shall be in compliance with Medical Center Memorandum EMS-133 Waste Management, Reduction, Recycling and Disposal when disposing of waste material.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Biohazard Containers & Needle Boxes: # 4 The contractor shall complete all standards within the performance threshold. (Reference 2.4-2.5)

· Will be emptied when contain in the container has reach the capacity of 2/3 full.

· Waste is stored in centralized biohazard waste containers.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· All practices and standards shall be in compliance with Medical Center Memorandum EMS-133 Waste Management, Reduction, Recycling, and Disposal when disposing of biohazard material and needle boxes.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Dirty Laundry bags: # 5 The contractor shall complete all standards within the performance threshold. (Reference 2.6)

· Will be emptied when contain in the bag has reach the capacity of 2/3 full.

· Will be emptied when requested.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-12 when Standard Precautions and Transmission Based Precautions are implemented.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

De-Scale sinks and traps: # 6 The contractor shall complete all standards within the performance threshold. (Reference 2.7)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Office Furniture: # 7 The contractor shall complete all standards within the performance threshold. (Reference 2.8)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Drinking Fountains: # 8 The contractor shall complete all standards within the performance threshold. (Reference 2.9)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

All Ventilation & Light Fixtures: # 9 The contractor shall complete all standards within the performance threshold. (Reference 2.10-2.11)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Equipment: # 10 The contractor shall complete all standards within the performance threshold. (Reference 2.12)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-12 when Standard Precautions and Transmission Based Precautions are implemented.

· All practices and standards shall be in compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-8 on Guidelines for Cleaning and Disinfecting of Non-Critical Reusable Medical Equipment (RME).

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Floor Maintenance, Tile Floors, Carpet Floors: # 11 The contractor shall complete all standards within the performance threshold. (Reference 2.13-2.15)

· Sweeping & wet mopping will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· Tile floor surfaces shall have the same uniform appearance across the entire surface.

· When waxing the floors, no hair fibers, or debris are to be left in finished deliverable work.

· Shall be scheduled within hours designated in the PWS.

· Floor waxing to standard

· Vacuuming will be conducted daily.

· Carpet floors including runner rugs shall be spot treated immediately as soon as a discoloration, spill, or other stain is noticed.

· When vacuuming all surface areas of the carpet shall be clean edge to edge.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-12 when Standard Precautions and Transmission Based Precautions are implemented.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Entrance & interior window cleaning: # 12 The contractor shall complete all standards within the performance threshold. (Reference 2.16)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Cleaning lunch room: # 13 The contractor shall complete all standards within the performance threshold. (Reference 2.17-2.19)

· Will be conducted daily.

· Moving of the equipment to clean surfaces behind and underneath shall be conducted monthly.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Restroom cleaning: # 14 The contractor shall complete all standards within the performance threshold. (Reference 2.20-2.21)

· Will be conducted daily.

· Will be conducted when requested.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines from Joint Commission and VA medical center infection control must be adhered to.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-12 when Standard Precautions and Transmission Based Precautions are implemented.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Examination Room /Laboratory/Pharmacy/ Radiology cleaning: # 15 The contractor shall complete all standards within the performance threshold. (Reference 2.22)

· Will be conducted daily.

· Will be conducted when requested.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· All patient care area will be cleaned and disinfected to the Standard Precaution guidelines found in Professional Services Memorandum No. VIII-12 Standard Precautions & Transmission Based Precautions.

· Transmission-Based Precautions guidelines will be performed when applicable. Guidelines can be found in Professional Services Memorandum No. VIII-12 Standard Precautions & Transmission Based Precautions.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Janitorial closet: # 16 The contractor shall complete all standards within the performance threshold. (Reference 2.23-2.23.9)

· Will be conducted daily.

· All surfaces will be free of dust, dirt, debris, lint, film, residue, grim, mildew, mold, sediment, scale, lime, smudges, marks, odor, other stains, discolorations, and other foreign matter.

· All guidelines from SDS and Safety must be adhered to.

· All guidelines and policies from Joint Commission and VA Medical Center Infection Control must be adhered to.

· Practices and Standards shall be in compliance with Medical Center Memorandum EMS-67 Comprehensive Environment of Care (CEOC) Inspections.

· All patient care area will be cleaned and disinfected to the Standard Precaution guidelines found in Professional Services Memorandum No. VIII-12 Standard Precautions & Transmission Based Precautions.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas.

· All practices and standards shall be in compliance with Medical Center Memorandum EMS-133 Waste Management, Reduction, Recycling, and Disposal when disposing of biohazard material and needle boxes.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Safety: # 17 The contractor shall complete all standards within the performance threshold. (Reference 3.0-3.7)

· Housekeeping carts shall not be left unattended or parked in walkway areas.

· When using a ladder 4 points of contact must be maintained.

· Carts shall be closed and locked at all times.

· Wet floor signs shall be posted and visually seen by all directions.

· A SDS binder shall be kept in each closet.

· All practices and standards shall be in compliance with Medical Center Memorandum 00S-0123 Hazard Communication Program.

· All practices and standards shall be in compliance with Medical Center Memorandum EMS-133 Waste Management, Reduction, Recycling and Disposal when disposing of waste material.

· All practices and standards shall be in compliance with Medical Center Memorandum 006S-028 Clement J Zablocki Medical Center Emergency Operations Plan.

· Business Continuity: Evacuation plan, Communications Disruption plan and Cyber-attacks.

· Naturally Occurring: Tornado and severe thunderstorms, winter storms, extreme temperatures.

· Internal Emergencies: Utility failures, fire, HAZMAT exposures, supply shortages.

· Human Related and External Emergencies: Active threat, hostage situation, mass casualty incident.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Infection Control: # 18 The contractor shall complete all standards within the performance threshold. (Reference 4.0-4.5)

· All practices and standards shall be in compliance with Medical Center Memorandum EMS-133 Waste Management, Reduction, Recycling, and Disposal when disposing of biohazard material and needle boxes.

· All practices and standards shall be in compliance with U.S. Department of Transportation Hazmat Training for Proper Packaging in Regulated Medical Waste in Accordance with 49 CFR, Part 172, Subpart H (172.704) when disposing of biohazard material.

· All practices and standards shall be in compliance with Medical Center Memorandum 00S-123 Hazard Communication Program when storage of products in all Janitorial closet areas.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-12 when Standard Precautions and Transmission Based Precautions are implemented.

· All practices and standards shall be in compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-8 on Guidelines for Cleaning and Disinfecting of Non-Critical Reusable Medical Equipment (RME); when properly cleaning and disinfecting of Non-Critical Reusable Medical Equipment is being conducted.

· All practices and standards shall be compliance with Medical Center Memorandum Professional Services Memorandum No. VIII-3 Infection Control Guidelines for Patient Care Areas when janitorial services are being rendered.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal

Information Security: # 19 The contractor shall complete all standards within the performance threshold. (Reference 5.0-5.1)

· All practices and standards shall be in compliance with Medical Center Memorandum ISO-200 Information Security (IS) Program when rendering services on patient Identifiable documents, shredding material, PIV Cards, and any sensitive data material.

· Form DA-5105

· Vendor Professional Cleaning Check List Informal