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QUALITY ASSURANCE SURVEILLANCE PLAN – NURSE REGISTRY

The contractor will be evaluated in accordance with the following:

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 through contract modification. 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 CO: Amanda J. Simmons Organization or Agency: NCO21

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: To Be Determined Organization or Agency: Sacramento VAMC

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternate:

Page 7 of 8 version 009 Dated 6/20/2017

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. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. 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. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. Surveillance by Charge Nurse and Nurse Manager as described in this PWS.

b. PERIODIC INSPECTION. Records will be randomly selected on a quarterly basis or more frequently as necessary should problems be discovered in accordance with the description in the PWS.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Patient complaints will be documented by Supervisor/Lead personnel.

d. RANDOM SAMPLING. Random sampling shall be done on a quarterly basis or more frequently as necessary if problems should be discovered. This varies based on the type of data sought. See PWS for details.

e. Verification and/or documentation provided by Contractor. The Contractor will provide evidence of licensing, registrations, and training as outlined in the PWS.

6.SAMPLE QASP PERFORMANCE REPORT DATE:__________________

Measures
PWS

Reference Performance Requirement

Standard
Acceptable Quality Level
Surveillance

Method

Incentive
Disincentive
On-Time Placement
11.8.1
Provide temporary Nursing Staff upon request within 24-hours
Qualified personnel must be at the facility by the date and time requested
85%
Periodic Inspection of timesheets and customer complaints
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Contractor Response Times
11.8.2
The Contractor shall respond to telephone calls form the COR
Response time is within 30 minutes 24 hours-per-day/seven days-per-week
90%
Customer Complaints
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation. Possible 5% reduction in payment.
Contractor Invoicing
11.8.3
The contractor will send the VA invoices monthly in arrears for provided services by the 20th of each month to cover the previous month’s services. Example: an invoice would be sent to the VA by the 20th of November for services performed 1 – 31 October. The main invoice will include the following information, as a minimum, in accordance with the Federal Acquisition Regulation (FAR):

A: Name and Address of Contractor B: Invoice No. & Inv. Date C: Contract No. & PO Number D: Contract Line Item Nos. (CLIN)s E: Names of Contract Personnel & Description of Service

F: QTY & UOM

G: Unit Price & Extended Price H: Shipping Terms (if app) I: Name, Title, & email of Contractor’s Rep. to whom pmt is sent J: Name, Title, & email of person to notify in the event of defective invoice

The Contractor will submit one invoice by the 20th of the month for services provided in the previous month.
85 %
Random Sampling
Favorable contactor performance evaluation.
Possible 5% reduction in payment for inaccurate invoices
Patient Safety
11.8.4
The Contractor personnel shall follow all established patient safety and infection control standards of care. The Contractor personnel shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breaches of patient safety shall be reported using the Electronic Patient Event reporting (ePER). Such events shall be reported immediately (prior to the end of the shift or within 24 hours of the incident) as required under VANCHCS Policy 00Q-20. At the time of submission of the ePER, the Contractor personnel shall forward a copy to the supervising VANCHCS Physician or Nurse. The Contractor’s personnel shall follow-up with VA as required or requested.
All patient safety incidents are reported using ePER prior to the end of the shift or within 24 hours of the incident. No acceptable deviations.
100 % of patient safety incidents are reported using ePER prior to the end of the shift or within 24 hours of the incident. No acceptable deviations.
Direct Observation
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation, suspension or termination of all physical and/or electronic access privileges and removal from contract, and possible termination
Contractor Quality Performance
11.8.5
All contract personnel shall perform the required services in accordance with clinical standards.
The Industry Standard for each respective labor category
98 %
Direct observation of contract personnel’s dress and professional mannerisms. Periodic sampling of records in accordance with the PWS.
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation. Possible 5% deduction from payment.
Qualifications of Key Personnel
11.8.6
All contract staff will hold the licensing/registrations/certifications required by the VA and the State of California.
All credentials are current within one year.
100 %
Periodic Sampling: contractor’s personnel qualification files are up to date and provided to the COR monthly.
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation, suspension or termination of all physical and/or electronic access privileges and removal from contract, and possible termination of contract.
Patient Access
11.8.7
All contract staff shall be available and on-time in the location of their assignment. Breaks are taken at designated times as determined by the Nurse Manager.
All Contractor’s personnel are on-time and available to provide services.
97%
Periodic Sampling of Time and Attendance sheets.
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation. Possible 5% deduction from payment.
Mandatory Training
11.8.8
All Contractor’s personnel shall complete all required training on time per VAMC policy.
All training is up to date for all contract staff.
100 %
Periodic Sampling of training records monthly.
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation. Possible 5% deduction from payment.
Privacy, Confidentiality and HIPAA
11.8.9
The Contractor and contract personnel are aware of the laws, regulations, policies and procedures relating to Privacy, Confidentiality, and HIPAA and complies with all standards. Zero breaches of privacy, confidentiality, or HIPAA.
All contract personnel comply with the laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA
100 %
Periodic Sampling: The Contractor shall provide evidence of the completed annual training required by VAMC. Reports any violations per VA Directive 6500.6.
Favorable contactor performance evaluation.

Depending on severity of offense, suspension or termination of all physical and/or electronic access privileges and removal from contract until such time as the training is complete.

7. CPAR RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/pdfs/CPARS-Guidance.pdf p. A2-1):

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 thecontractual 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 orEnvironmental Deficiency Reports, or letters).

8. 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 using CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, 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 will present to the contractor's program manager 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 must present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. 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.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR on the following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER
2. REPORT NUMBER FOR THIS DISCREPANCY
3. TO: (Contracting Officer)
4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY CONTRACTOR:
c. ACTION COMPLETE

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

7. SIGNATURE OF COR
Date:
8. SIGNATURE OF CONTRACTING OFFICER
Date:
9a. TO (Contracting Officer)
9a. FROM (Contractor)

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.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE
Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME
TITLE
SIGNATURE
DATE

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

Version 11/22/17 Nurse Registry Long Term

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