36C25520R0016-008.doc

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): [NAME, PHONE]

· Assigned Contract Specialist: [NAME, PHONE]

· 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): [NAME, PHONE]

c. Other Key Government Personnel - [As Assigned]

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

Nursing Home Care

Incentive

5. Incentives/RATING STANDARDS The Government will use past performance reports as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. Methods of QA Surveillance

Various methods exist to monitor performance. The CO and COR will use the surveillance methods listed below in the administration of this QASP. The CO and COR may receive input from other VA staff in all methods of surveillance. The CO, at any time during contract performance, may perform any of the observations, inspections or meetings identified herein in conjunction with, in absence of, or in lieu of the COR, or other CNH-related staff identified in this QASP.

a. DIRECT OBSERVATION - Surveillance will be accomplished through site visits; interviews with the veterans, the veteran families, and staff; medical records reviews, invoice and billing documentation, placement and medications documentation, and will be performed by COR and in conjunction with VA staff directly associated with CNH facility patient care.

b. PERIODIC INSPECTION - Inspections scheduled, monthly visits/inspections will be documented by the COR and in conjunction with VA staff directly associated with CNH facility patient care. Veterans may be interviewed, patient records and treatment goals may be reviewed, including provider visit documentation, continuity of care, safety, clinical nutrition, nursing, social work services, as well as any results of state surveys. Also includes invoice reviews and handling.

c. VALIDATED USER/CUSTOMER COMPLAINTS - Veteran or family complaints will be reviewed and addressed within seven (7) days of receipt. Contract discrepancies may be addressed using the Contract Discrepancy Report. This includes continuity of care, safety, clinical nutrition, nursing, social work services, as well as any results of state surveys. Also includes invoice reviews and handling. User and Customer complaints may be monitored by the COR, CNH Review Team or Contracting Officer.

d. RANDOM SAMPLING - Unscheduled inspections – The COR and CNH Review Team may conduct random inspections. Veterans may be interviewed, patient records and treatment goals may be reviewed, including provider visit documentation, continuity of care, safety, clinical nutrition, nursing, social work services, as well as any results of state surveys. Also includes invoice reviews and handling.

e. PROGRESS OR STATUS MEETINGS - Meetings may be requested by either the Contracting Officer, Contractor or the COR and will be used to update status and/or progress of health care of the veterans placed at the facility and overall contract performance and management.

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:

EXCEPTIONAL

Performance meets contractual requirements and exceeds many to the

Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

***Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.

VERY GOOD

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

***Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.

SATISFACTORY

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

***Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.

MARGINAL

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

***Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTORY

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

***Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental Deficiency Reports, or letters)

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.

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 must 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 communicate with the contractor as needed to assess performance and shall provide a written assessment to the Contracting Officer.

Signature – Contractor

Signature – Contracting Officer Representative � See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

Community Nursing Home SOP

Original Date: 05/02/2016