Attachment 1 - Quality Assurance Surveillance Plan.pdf

Attachment 1: Quality Assurance Surveillance Plan

1.0 Introduction

This Quality Assurance Surveillance Plan (QASP) is based on the premise that the contractor is responsible for complying with all the requirements listed in the Statement of Work (SOW) entitled “Religious Services Program” as well as its subsequent attachments.

The role of the Government in quality assurance is to ensure performance standards are achieved and maintained. This

QASP sets forth the procedures and guidelines ICE Enforcement and Removal Operations (ERO) will use in evaluating the technical performance of the service contractor.

1.1 Purpose

This QASP is designed to provide an effective surveillance method to monitor the contractor’s performance relative to the requirements listed in the SOW/Attachments. The QASP illustrates the systematic method the Government (or its designated representative) will use to evaluate the services the contractor is required to furnish.

The purpose of this QASP is to describe the systematic methods used to measure performance and to identify the reports required and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting performance standards as identified in the SOW and its attachments. This QASP is designed to define roles and responsibilities, identify the performance objectives, define methodologies used to monitor and evaluate the contractor’s performance, describe quality assurance reporting, and describing the analysis of quality assurance monitoring results.

1.2 Performance Management Strategy

1.2.1 The contractor shall develop a Quality Control Plan (QCP) which will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, and other performance requirements in the SOW and its attachments. The contractor must develop and implement a performance management system with processes to assess and report their performance to the COR.

1.2.2 The COR will monitor performance and determine how the contractor is performing against the performance objectives stated in Section 4.9 – Monthly Deliverables and Meetings, of the SOW. The Government will make decisions based on performance data and notify the contractor of those decisions. If it is determined that the contractor is not completing services and it is deemed negligent/fraudulent, there will be a 2% deduction on total monthly billing for the month in which discrepancies were found. The contractor will be responsible for making required changes in the processes and practices to ensure performance is effectively managed.

2.0 Government Roles and Responsibilities

The following personnel must oversee and coordinate surveillance activities.

2.1 Contracting Officer (CO)

The CO must ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and must safeguard the interests of the United States in the contractual relationship. The CO must 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.

2.2 Contracting Officer’s Representative (COR)

The COR is responsible for technical administration of the contract and must assure proper Government surveillance of the contractor’s performance. The COR must 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.

3.0 Definitions

Measures: The method for evaluating compliance with the standards.

Acceptable Quality Level: The minimum level of quality that will be accepted by ICE to meet the performance standard.

Withholding: Amount of total monthly invoice payment withheld pending correction of a deficiency. See Performance

Requirements Summary for information on the percentages of an invoice amount that may be withheld for each functional area.

Funds withheld from payment are recoverable if the COR and Contracting Officer confirm resolution or correction and should be included in the next month’s invoice.

Deduction: Funds may be deducted from a monthly invoice for an egregious act or event, or if the same deficiency continues to occur in accordance with the percentages listed in the Performance Requirements Summary. The contractor will be notified immediately if such a situation arises. The Contracting Officer in consultation with ERO will determine the amount of the deduction.

Amounts deducted or withheld are calculated on the total monthly invoice and deducted amounts are not recoverable.

4.0 Failure to Meet Performance Standards

The Contracting Officer may take withholdings or deductions against the monthly invoices for unsatisfactory performance documented through surveillance of the contractor’s activities gained through site inspections, reviews of documentation, interviews and other feedback. As a result of its surveillance, the contractor will be assigned the following rating relative to each performance standard:

Rating Description

Acceptable Based on the measures, the performance standard is demonstrated.

Deficient Based on the measures, compliance with most of the attributes of the performance standard is demonstrated or observed with some area(s) needing improvement. There are no critical areas of unacceptable performance

Using the above standards as a guide, the Contracting Officer will implement adjustments to the contractor’s monthly invoice as prescribed in the Performance Requirements Summary (PRS). See attachment 1A below.

Rather than withholding funds until a deficiency is corrected, there may be times when an event or a deficiency is so egregious that the Government deducts (vs. “withholds”) amounts from the contractor’s monthly invoice. This may happen when a significant event occurs, when a particular deficiency is noted multiple times without correction, or when the contractor has failed to take timely action on a deficiency about which the Contractor was properly and timely notified.

The amount deducted will be consistent with the relative weight of the functional performance area where the deficiency was noted.

The deduction may be a one-time event or may continue until the contractor has either corrected the deficiency or made substantial progress in the correction.

Further, a deficiency found in one functional area may tie into another. In no event will the withhold or deduction exceed 100% of the invoice amount.

5.0 Notifications

(a) Based on the inspection of the contractor’s performance, the COR will document instances of deficient or at-risk performance

(e.g., noncompliance with the standard) using the Contract Discrepancy Report (CDR) (see Attachment 1B below). To the extent

Based on the performance measures, the majority of a performance standard’s attributes are not met.

At-Risk practicable, issues should be resolved informally, with the COR and contractor working together. When documentation of an issue or deficiency is required, the procedures set forth in this section will be followed.

(b) When a CDR is required to document performance issues, it will be submitted to the contractor with a date when a response is due.

Upon receipt of a CDR, the contractor shall immediately assess the situation and either correct the deficiency as quickly as possible or prepare a corrective action plan. In either event, the contractor shall return the CDR with the action planned or taken noted. After the COR reviews the contractor’s response to the CDR including its planned remedy or corrective action taken, the

COR will either accept the plan or correction or reject the correction or plan for revision and provide an explanation. This process should take no more than one week. The CDR shall not be used as a substitute for quality control by the contractor.

(c) The COR, in addition to any other designated ICE official, shall be notified immediately in the event of all emergencies.

(d) If the COR concludes that the deficient or at-risk performance warrants a withholding or deduction, the COR will include the CDR in its report, with a copy to the Contracting Officer. The CDR will be accompanied by the COR’s investigation report and written recommendation for any withholding. The Contracting Officer will consider the COR’s recommendation and forward the CDR along with any relevant supporting information to the contractor in order to confirm or further discuss the prospective cure, including the Government’s proposed course of action. As described in the section above, portions of the monthly invoice amount may be withheld until such time as the corrective action is completed, or a deduction may be taken.

(e) Following receipt of the contractor’s notification that the correction has been made, the COR may re- inspect. Based upon the

COR’s findings, the COR will recommend that the Contracting Officer continue to withhold a proportionate share of the payment until the correction is made or accept the correction as final and release the full amount withheld for that issue.

(f) If funds have been withheld and either the Government or the contractor terminates the contract, those funds will not be released.

The contractor may only receive withheld payments upon successful correction of an instance of non-compliance. Further, the contractor is not relieved of full performance of the required services hereunder; the Agreement may be terminated upon adequate notice from the Government based upon any one instance, or failure to remedy deficient performance, even if a deduction was previously taken for any inadequate performance.

(g) The COR will maintain a record of all open and resolved CDRs.

Attachment 1A: Performance Requirement Summary

Functional

Area/Weight

Performance

Standard (ICE

Policies, SOW, etc.)*

Performance

Measure

Method of

Surveillance

Acceptable

Quality Level

Withholding/Deduction

Criteria

Administration &

Management (5%)

(Addresses general administration, organization and management requirements)

SOW Section 4.2 –

Administration, Organization and

Program

Management

Performance measures are reflected in the monitoring instruments that accompany each standard or in the supplemental performance monitoring tool issued by the COR.

• Periodic reviews in accordance with the contract performance monitoring tool

• Monthly Status

Reports

• Monthly review of corrective action plan results

• Ad‐hoc reviews as needed.

• Review of contractor’s quality control program monitoring reports

• CDR’s

Performance fully complies with all elements of standard at a level no less than acceptable (See

SOW Section 8.0 –

Quality Assurance

Surveillance Plan).

A rating of Deficient on the standard will result in up to a 5% deduction in the monthly invoice until compliance with the standard is established.

A rating of At-Risk on any of the standards will result in up to a 5% withholding in the monthly invoice until compliance with the standard is established.

Personnel (10%)

(Addresses contractor responsibility in areas of hiring and retention, SOW Section 4.2 –

Administration, Organization and

Program

Management

SOW Section 4.3 –

Performance measures are reflected in the monitoring instruments that accompany each standard

• Periodic reviews in accordance with the contract performance monitoring tool

• Ad-hoc reviews

Performance fully complies with all elements of standard at a level no less than acceptable (See

SOW Section 8.0 –

A rating of Deficient on any two of the standards will result in up to a

10% deduction in the monthly invoice until compliance with the competency, promptness, appearance, behavior, and integrity)

Personnel

SOW Section 4.4 –

Personnel

Requirements

SOW Section 4.5 –

Standards of

Conduct

SOW Section 4.6 –

Removal from Duty

PBNDS 2011

W/2016

REVISIONS

Section 5.5 Part C

(Religious Practices

– Chaplains or

Other Religious

Services

Coordinators or in the supplemental performance monitoring tool issued by the

COR.

as needed.

• Attendance logs

• Hiring and attrition rates

• CDR’s

Quality Assurance

Surveillance Plan).

A rating of At‐Risk on result in up to a 10% withholding in the monthly invoice until compliance with the standard is established.

Background and

Clearance

Procedures (5%) background investigations, security requirements, suitability determinations, background investigations, employment, and

SOW Section 4.2 -

Administration, Organization and

SOW Section 4.7 –

Security Clearance, Drug Testing and

Credentials

Performance measures are reflected in the monitoring instruments that accompany each standard or in the supplemental performance monitoring tool issued by the

COR.

• Periodic reviews in accordance with the contract performance monitoring tool

• Monthly review of corrective action plan results

• CDR’s

Performance fully complies with all elements of standard at a level no less than acceptable (See

SOW Section 8.0 –

Quality Assurance

Surveillance Plan).

A rating of Deficient on any two of the standards will result in up to a 5% deduction in the monthly invoice until compliance with the standard is result in up to a 5% withholding in the monthly invoice until continued eligibility and security management) compliance with the

Deliverables (5%) required reports and documentation required from the contractor)

SOW Section 4.2 -

Administration, Organization and

SOW Section 4.9 –

Monthly

Deliverables and

Meetings

Performance measures are reflected in the monitoring instruments that accompany each standard or in the supplemental performance monitoring tool issued by the

COR.

• Monthly review of corrective action plan results

• CDR’s

• Ad-hoc reviews as needed

• Review of contractor’s quality control program monitoring reports

Performance fully complies with all elements of standard at a level no less than acceptable (See

SOW Section 8.0 –

Quality Assurance

Surveillance Plan).

A rating of Deficient on any two of the standards will result in up to a 5% deduction in the monthly invoice until compliance with the standard is result in up to a 5% withholding in the monthly invoice until compliance with the standard is established.

Performance of

Religious

Services/Classes

(40%)

(The contractor shall coordinate a group of volunteers to organize religious services, instructional classes, and the contractor shall provide personal counseling to detainees)

SOW Section 4.2 -

Administration, Organization and

SOW Section 5.0 –

Measures

REVISIONS

Section 5.5 Part F

(Religious Services

– Pastoral Visits) measures are reflected in the monitoring instruments that accompany each standard or in the supplemental performance monitoring tool issued by the

COR.

• Monthly review of corrective action plan results

• CDR’s

• Ad-hoc reviews as needed

• Review of contractor’s quality control program monitoring reports

Performance fully complies with all elements of standard at a level no less than acceptable (See

SOW Section 8.0 –

Quality Assurance

Surveillance Plan).

A rating of Deficient on any two of the standards will result in up to a

40% deduction in the monthly invoice until result in up to a 40% withholding in the monthly invoice until

REVISIONS

Section 5.5 Part G

(Religious Services

– Detainees in

Special

Management

(SMU) and

Hospital Units)

REVISIONS

Section 5.5 Part H

(Religious Services

‐ Introduction of

New or Unfamiliar

Religious

Components)

REVISIONS

Section 5.5 Part I

(Religious Services

– Religious Holy

Days)

REVISIONS

Section 5.5 Part J

(Religious Services

– Religious

Property and

Personal Care)

REVISIONS

Section 5.5 Part N

(Religious Services

– Religious Use of

Wine)

Religious Dietary

Needs (20%)

(Approve requests for religious dietary needs)

SOW Section 4.2 -

Administration, Organization and

REVISIONS

Section 5.5 Part K

(Religious Services

– Dietary

Requirements)

REVISIONS

Section 5.5 Part L

(Religious Services

– Religious Fasts)

Performance measures are reflected in the monitoring instruments that accompany each standard or in the supplemental performance monitoring tool issued by the

COR.

• Monthly review of corrective action plan results

• CDR’s

• Ad-hoc reviews as needed

• Review of contractor’s quality control program monitoring reports

Performance fully complies with all elements of standard at a level no less than acceptable (See

SOW Section 8.0 –

Quality Assurance

Surveillance Plan).

A rating of Deficient on any two of the standards will result in up to a

20% deduction in the monthly invoice until result in up to a 20% withholding in the monthly invoice until compliance with the standard is established.

Facilitate Access to

Religious Items for

Worship (15%)

SOW Section 4.2 -

Administration, Organization and

Program

Performance measures are reflected in the monitoring

• Monthly review of corrective action plan

Performance fully complies with all elements of standard at a level

A rating of Deficient on any two of the standards will result in up to a

15% deduction in the

(Procure items requested by detainees for religious worship)

REVISIONS

Section 5.5

Appendix 5.5A

(Religious Services

– Appendix A –

Religious

Headwear, Garments, and

Other Religious

Property) instruments that accompany each standard or in the supplemental performance monitoring tool issued by the

COR.

results

• CDR’s

• Ad-hoc reviews as needed

• Review of contractor’s quality control program monitoring reports no less than acceptable (See

SOW Section 8.0 –

Quality Assurance

Surveillance Plan).

monthly invoice until result in up to a 15% withholding in the monthly invoice until compliance with the standard is established.

*Revisions made in December 2016 will ensure that PBNDS 2011 remains consistent with federal legal and regulatory requirements as well as prior ICE and ICE Enforcement and Removal Operations (ERO) policies and policy statements.

The following is a breakdown of the percentage amounts that will be withheld or deducted for each functional area for 1st offense through 4th offense in deficient and at‐risk. As stated in the withholding and deduction criteria, no more than the total weight for each functional area (for example 5% for Administration and Management) will be withheld or deducted on a monthly invoiced per diem day rate. The offenses will be recorded on a 12 month basis.

Deficient 1st

Offense

2nd

Offense

3rd

Offense

4th

Offense

Administration & Management

1.25% 2.50% 3.75% 5.00%

Personnel 2.50% 5.00% 7.50% 10.00%

Background and

Clearance

Procedures

1.25% 2.50% 3.75% 5.00%

Deliverables 1.25% 2.50% 3.75% 5.00%

Performance of

Religious Services

/ Classes

10.00% 20.00% 30.00% 40.00%

Religious Dietary Needs 5.00% 10.00% 15.00% 20.00%

Facilitate Access to Religious

Items for Worship

3.75% 7.50% 11.25% 15.00%

At‐Risk 1st Offense

2nd Offense

3rd Offense

4th Offense

Administration & Management

1.25% 2.50% 3.75% 5.00%

Personnel 2.50% 5.00% 7.50% 10.00%

Background and

Clearance

Procedures

1.25% 2.50% 3.75% 5.00%

Deliverables 1.25% 2.50% 3.75% 5.00%

Performance of Religious Services / Classes

10.00% 20.00% 30.00% 40.00%

Religious Dietary Needs 5.00% 10.00

15.00% 20.00%

Facilitate Access to

Religious Items for

Worship

3.75% 7.50% 11.25% 15.00%

Attachment 1B: Contract Discrepancy Report

CONTRACT DISCREPANCY

REPORT

1. CONTRACT

NUMBER

Report Number:

Date:

2. TO: (Contractor and Manager Name) 3. FROM: (Name of COR)

DATES

CONTRACTOR

NOTIFICATION

CONTRACTOR

RESPONSE DUE BY

RETURNED BY

CONTRACTOR

ACTION COMPLETE

4. DISCREPANCY OR PROBLEM (Describe in Detail: Include reference in PWS / Directive:

Attach continuation sheet if necessary.)

5. SIGNATURE OF CONTRACTING OFFICER’S REPRESENTATIVE (COR)

6. TO: (COR) 7. FROM: (Contractor)

8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND

ACTIONS TO PREVENT RECURRENCE. ATTACH CONTINUATION SHEET IF

NECESSARY. (Cite applicable Q.A. program procedures or new A.W. procedures.)

9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 10. DATE

11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN:

(Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet if necessary)

12. GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.)

CLOSE OUT

CONTRACTOR

NOTIFIED

NAME AND TITLE

SIGNATURE

DATE

COR

CONTRACTING

OFFICER