S02 - Attachment 1 - 2024 HCHV CERS QSAP.pdf

Quality Assurance Surveillance Plan (QASP) HCHV CERS Transitional Housing for Homeless Veterans

The contractor will be evaluated in accordance with the following:

1. Purpose

This Quality Assurance Surveillance Plan is a government-developed document used to determine if the contractor’s performance meets the performance standards contained in the contract. The QASP establishes procedures on how this assessment/inspection process will be conducted. It provides the detailed process for a continuous oversight process:

• What will be monitored

• How monitoring will take place

• Who will conduct the monitoring

• How monitoring efforts and results will be documented

The contractor is responsible for implementing and delivering performance that meets contract standards using its Quality Control Plan. The QASP provides the structure for the government’s surveillance of the contractor’s performance and their Quality Assurance/Quality Control (QA/QC) actions to assure they meet contract standards. It is the government’s responsibility to be objective, fair and consistent in evaluating contractor performance.

The QASP is not part of the contract nor is it intended to duplicate the contractor’s quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

2. Roles and Responsibilities

The following personnel shall oversee and coordinate surveillance activities.

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 ensure that the contractor receives impartial, fair, and equitable treatment under this contract. Determine the final assessment of the contractor’s performance.

Assigned CO:

Organization or Agency:

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 to authorize any contractual changes on the Government’s behalf.

Assigned COR: Adam Cothran Organization or Agency: Eastern Oklahoma VA Healthcare System

Other Key Government Personnel: This may include performance monitors, inspectors, technical experts, or others who provide information that helps the COR monitor contractor performance. Other key personnel for this contract:

Christina Perez-Lanik GPD Liaison subject matter expert . Organization or Agency: Eastern Oklahoma VA Healthcare System.

Contractor Representatives

Adam Cothran, COR Christina Perez-Lanik, GPD Liaison, subject matter expert

3. Performance Requirements and Method of Surveillance

3.1. Contract Surveillance

The goal of the QASP is to ensure that contractor performance is effectively monitored and documented. The COR’s contribution is their professional, non-adversarial relationships with the CO, PM and the contractor, which enables positive, open and timely communications. The foundation of this relationship is built upon objective, fair, and consistent COR evaluations of contractor performance against contract requirements. The COR uses the methods contained in this QASP to ensure the contractor is in compliance with contract requirements. The COR function is responsible for a wide range of surveillance requirements that effectively measure and evaluate the contractor’s performance.

Additionally, this QASP is based on the premise that the contractor, not the government, is responsible for management and QC/QA actions to successfully meet the terms of the contract.

3.2. Performance Rating Definitions

The performance ratings below reflect definitions at FAR 42.1503 Table 42-1.

The COR will use these rating to evaluate the quality of contractor’s performance. [If your organization requires that you use a different rating mechanism, insert it here.]

Performance Rating

Definition

Exceptional Performance meets contractual requirements and exceeds many to the government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

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

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.

Marginal Performance does not meet some contractual requirements.

The contractual performance of the element or sub-element being evaluated 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.

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 contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Note 1: Plus or minus signs may be used to indicate an improving (+) or worsening (-) trend insufficient to change the evaluation status.

Note 2: N/A (not applicable) should be used if the ratings are not going to be applied to a particular area for evaluation.

4. Performance Standards

The Contractor is responsible for performance of 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.

The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined.

The Government shall use the performance ratings with the performance standards listed below to determine contractor performance. 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. Incentives/deducts

The Government shall use favorable contractor performance evaluation and exercise option period as an incentive. Incentives shall be based on meeting or not meeting performance standards.

6. Methods of QA surveillance

Direct observation: COR and VA staff will directly monitor performance of contractor.

Customer complaints: Patient complaints regarding quality of care reported to the COR and VA staff. COR will meet with contractor for a resolution.

Inspection: Annual inspections will be completed with inspection team of nurse, clinician, VA police, dietician, and VA facility safety.

7. Documenting performance

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 using CONTRACTOR PERFORMANCE

ASSESSMENT REPORT (CPAR)

If contractor does not meet the acceptable quality level, the CO shall inform the contractor. The CO will document the discussion and place it in the contract file. If the COR and CO determine formal written communication is required, the COR shall prepare a contract discrepancy report (CDR) and present it to the CO. The CO will review and will present it to the contractor’s program manager for corrective action.

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 will correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to prevent the corrective action plan to the CO. The Government shall review the contractors corrective action plan to determine acceptability. The CO shall also ensure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractors performance and the acceptability of the contractors corrective action plan.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

COR and contractor acknowledgement of the QASP

Signed:

Cor Name/title DATE

Signed:

Contractor name/title DATE

Inspection Metrologies:

M1: Inspection of Reports.

Statements Standards/AQLs Inspections Ratings Food services meet applicable standards of state and federal law.

Food service COR monitoring and VA staff monitoring, dietician inspection

All patient complaints are reported in accordance with the contract.

Patient complaints regarding quality of care are reported to the COR and VA staff.

VA staff meeting with Veterans, COR and VA staff meeting with contractors on a scheduled basis

Contractor meets all SOW and contract requirements.

Work complies and meets SOW standards.

COR monitoring and VA staff monitoring

Contract meets all fire, safety, and sanitation standards

Assessment of whether the facility meets applicable fire, safety, and sanitation standards

COR monitoring, VA staff monitoring, and annual inspection.

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY MAJOR MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

ACCEPTED REJECTED

12. CLOSE DATE

CUSTOMER COMPLAINT RECORD

DATE/TIME OF COMPLAINT

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING NUMBER

INDIVIDUAL

PHONE NUMBER

NATURE OF COMPLAINT

CONTRACT REFERENCE

VALIDATION

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR

RECEIVED/VALIDATED BY

PERFORMANCE ASSESSMENT REPORT (PAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACT/TASK ORDER NUMBER 2. CONTRACTOR 3. TYPE OF SERVICES

4. QUALITY ASSURANCE PERSONNEL (COR) SIGNATURE AND DATE

5. COR PHONE 6. SUSPENSE DATE

I. PERFORMANCE

7. DEFICIENCY (CHECK ALL BOXES THAT APPLY)

NEW

REPEAT

NO DEFICIENCY NOTED

8. SERVICES SUMMARY or PWS PARAGRAPH ITEM REVIEWED

9. BRIEF DESCRIPTION OF DEFICIENCY (IF DEFICIENCY BOX WAS

CHECKED)

10. DETAILED PERFORMANCE ASSESSMENT

II. CONTRACTOR VALIDATION

11. CONTRACTOR REPRESENTATIVE CONCUR NON-CONCUR

12. CORRECTIVE ACTION ESTIMATED COMPLETION DATE

13. CONTRACTOR REPRESENTATIVE CORRECTIVE ACTION AND PREVENTION OF RECURRENCE OR REASON FOR NON-

CONCURRENCE OF COR CITED DEFICIENCY

III. ACTION CORRECTED

14. CONCUR NON-CONCUR COR SIGNATURE AND DATE

15. COR REMARKS (REQUIRED)

6. CONTRACTOR REPRESENTATIVE REMARKS