ATTACHMENT B - D.2 QASP.docx

ATTACHMENT B

36C25226Q0180

QUALITY ASSURANCE SURVEILLANCE PLAN

for Contracted Residential Medical Respite Program

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate a contractor’s performance in the provision of Contracted Residential Services (CRS) to the Department of Veterans Affairs. This QASP provides systematic and effective methods to monitor and evaluate contractor performance, and explains the following:

· What shall be monitored.

· How monitoring shall take place.

· How often monitoring shall take place.

· Who shall conduct the monitoring.

· How monitoring efforts and results shall be documented.

This QASP does not detail how the Contractor accomplishes the work. Rather, the QASP is created with the premise that the Contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to ensure contract standards are achieved.

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)/Contract Specialist (CS) – The CO/CS 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/CS 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: Carrie DeSwarte Organization or Agency: VA NCO 12, Great Lakes Acquisition Center (GLAC), Milwaukee, WI

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: Li Drummond, LCSW VA Facility: Edward Hines Jr. Veterans Affairs Hospital

3. CONTRACTOR REPRESENTATIVES

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

Primary: __________________________________ Alternate: _________________________________ Organization or Agency:

4. PERFORMANCE STANDARDS

The contractor is responsible for the performance of, and compliance with, 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.

Performance standards define desired services. The Government performs surveillance to determine if the Contractor exceeds, meets or does not meet these standards. The Performance Standards are listed below in Section 8. 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. SURVEILLANCE: The government Quality Assurance (QA) person(s) and the COR shall use the surveillance methods listed below in the administration of this QASP.

a. Direct Observation/100% Review. Direct observation shall be performed periodically or through 100% review.

b. Periodic/Random Inspection. Evaluate outcomes on a periodic basis and/or random sampling.

c. Complaints. Complaints from agency personnel/veterans receiving services either presented to the Contractor or shared to the VA directly.

d. Reviewing Scorecard Data. VA will pull the data from the VA Homeless Hub Scorecard.

e. Contractor Reporting. Contractor provides information to the VA.

f. Site Visits/Facility Inspections. VA personnel come announced or unannounced to the contractor’s facility.

6. DOCUMENTING PERFORMANCE

a. The Government shall 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 for the CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality Level (AQL), the CO shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the CO determine formal written communication is required, the COR shall prepare a Contract Report (CR) and present it to CO. The CO will in turn review and present it to the contractor's program manager(s) for corrective action.

The contractor shall acknowledge receipt of the CR in writing. The CR 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 CR will also state how long after receipt the contractor has to present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. 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.

c. The COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment.

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

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

8. VISN 12 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Fiscal Year ______ Quarter ______

Very Good = 91% -94%

Satisfactory = 90%

Unsatisfactory = < 90%

Comments:

Very Good = 6% - 19%

Satisfactory = 20%

Unsatisfactory = >20%

· Review of Sign In and Out Logs or electronic tracking systems for utilization

· Documentation in medical record

Unsatisfactory = >3

Very Good = 91% - 97%

Satisfactory = 90%

Unsatisfactory = <90%

Veteran Treatment Plan/Plan of Care/Individual Service Plan developed within 72 hours after admission

Very Good = 95% - 97%

Satisfactory = 90% - 94%

Unsatisfactory = <90%

90%

Unsatisfactory <90%

Prior to discharge, an aftercare plan will be completed and provided to VA within 24 hours or the next business day after discharge along with discharge email.

90%

100% Review for aftercare plans and discharge emails for all VA discharges

Very Good = 91% - 97%

Satisfactory = 90%

Unsatisfactory = <90%

Nursing A Nurse should be assigned to the program designated to Recuperative Care in the Medical Respite program

Unsatisfactory = <35 hours per week

Unsatisfactory = >36 days

9. VA COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED: SIGNED:

5. DATES

a. CR PREPARED

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

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.)

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER