FINAL QASP- Multi- Award CNH .pdf

CNH QASP

Effective Date: XXX

Revision: 034 Page 1 of 6

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 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): Melanie Hawley, melanie.hawley@va.gov

• Assigned Contract Specialist: Karen Battie, karen.battie@va.gov

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

b. The CNH Coordinator, Social Worker, or other authorized VA medical center personnel shall be responsible for technical monitoring of the contract and shall assure proper Government surveillance of the contractor’s performance. Authorized VA medical center personnel shall keep a quality assurance file. Authorized VA medical center personnel is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Authorized VA medical center personnel roles include CNH Coordinators, Social Workers, Nurse

Managers, names and contract information will be provided here but are subject to change and

Revision: 034 Page 2 of 6 other authorized VA medical center personnel may perform duties even if not named here:

Loretha Wright, Loretha.wright@va.gov

c. Other Key Government Personnel

Revision: 034 Page 3 of 6

QUALITY ASSURANCE SURVEILLANCE PLAN

Nursing Home Care

No. Paragrap h in PWS

Indicator/Performanc e Standard

Standar d for

Quality

Level

Acceptabl e Quality

Level

Method of

Surveillance

Incentive

1 (C)(9) Nursing Home shall provide VA with copies of all State / Federal licensures, certifications, and investigations reports when requested.

100% 100% Periodic

Reviews and spot checks

Positive past performanc e rating

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

Performance Work

Statement.

100% 100% Periodic

Reviews and spot checks

Positive past performanc e rating

3 (C)(11) 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 performanc e rating

4 (C)(12) Notice of all reportable events on VA contract veterans and all facility sentinel events within

24 hours or immediately upon the first business day after a weekend or holiday.

100% 100% Periodic reviews

Positive past performanc e rating

Revision: 034 Page 4 of 6

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.

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

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

5 (C)(14) 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% 100% Periodic

Reviews and spot checks

Positive past performanc e rating

6 (C)(19) Invoices shall be timely and accurate for all items billed.

100% 95% -100% Periodic

Reviews and spot checks

Positive past performanc e rating

Revision: 034 Page 5 of 6

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 Authorized VA medical center personnel shall work with the Contracting Officer (CO) who will inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, Authorized VA medical center personnel shall document the discussion and place it in the Authorized VA medical center personnel file’s. In order to assure that the contractor receives impartial, fair, and equitable

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

Revision: 034 Page 6 of 6 treatment under this contract, Authorized VA medical center personnel will work with the contractor to increase performance to an acceptable level.

When the CO determines formal written communication is required, the Authorized VA medical center personnel 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 Authorized VA medical center personnel. 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 and the CO will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

Authorized VA medical center personnel and CO shall meet with the contractor as needed to assess performance and provide a written assessment.

Signature – Contractor

Signature Authorized VA Medical Center Personnel

Signature – Contracting Officer