ATL VAMC QASP.pdf

Attachment 2 – Quality Assurance Surveillance Plan

Nursing Home Care Services:

1. Purpose

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance of the stated Contract. This QASP explains the following:

• What will be monitored: Falls, Sentinel Events, Infections, Hospitalizations, Customer Satisfaction, Wounds, Medications Errors, Elopements, Parasuicidal Events, Annual Inspections, as also completed by the VA Community Nursing home Program Inspection Team and performance of the nursing home documented on the CNH Program National website.

• How monitoring will take place: Quarterly audits will be conducted with data obtained by the VA Community Nursing Home Program nurses pertaining to quality measures documented above.

The VA Community Nursing Home Oversite Committee Medical Director also conducts medical record audits of the CNH Program Staff’s clinical interventions for appropriate care and treatment planning.

• Who will conduct the monitoring: CNH Program Staff or other assigned Team Members?

• How monitoring efforts and results will be documented: A quarterly report is submitted to the

VAMC-Atlanta Quality Assurance Department for reviews by medical center administration.

Audits completed by the CHN Program Medical Director are documented in the CNH Program Oversite Committee Meeting minutes which are submitted to the VAMC-Atlanta Medical directors Office for review and maintained on file via SharePoint.

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 win 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 implementation surveillance activities.

2. Government Roles and Responsibilities

The following personnel shall oversee and coordinate surveillance activities.

• Contracting Officer (CO)- The CO ensures performance of all necessary actions for effective contracting, ensure compliance with agreement terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall assure that the contractor receives impartial, fair, and equitable treatment under this agreement. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

o Assigned Contracting Officer:

o Assigned Contract Specialist: TBD o Organization or Agency: U.S. Department of Veterans Affairs

• Contracting Officer’s Representative (COR) – The COR is responsible for the technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance though monitoring by the CNH team members. The COR shall keep a quality assurance file with input from the CNH team reviewed. The COR in not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

o Assigned CORs: Juanita D Jackson

• Other Key Government Personnel – [As Assigned]

3. Contractor Representatives

The following employees of the contractor serve as the contractor’s program manager for this agreement.

• Program Manager – As assigned by facility

• Other Contractor Personnel – As assigned by facility

4. Performance Standards

Performance standards define the minimum performance standards for 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

No. Paragraph in PWS

Indicator/Performance Standard

Standard Quality Level

Acceptable 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 performance 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 performance rating.

3 C (13) 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 performance rating.

4 C (15) Notice of all reportable events on VA contract veterans and all facility sentinel events within 24 hours or immediately the first business day after a weekend or holiday.

100% 100% Periodic Reviews and Spot checks

Positive past performance rating.

5 C (17) All medical records concerning the veteran’s care in the nursing home: a) will be readily accessible to VA b) are within acceptable standard and practice.

100% 100% Periodic Reviews and Spot checks

Positive past performance rating.

6 C (21) Invoices shall be timely and accurate for all items billed.

100% 95% Periodic Reviews and Spot checks

Positive past performance rating.

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

• Direct Observation

• Periodic Inspection

• User Survey

• Validated User/Customer Complaints

• Inspection

• Periodic Sampling

• Random Sampling

• Progress or Status Meetings

• Analysis of Contractor’s progress reports

7. Ratings

Metrics and methods are designed to determining 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:

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

8. Documenting Performance

• Acceptable Performance – The Government shall document positive or NEGATIVE performance.

Any report may become a part of the supporting documentation for any contractual action.

• Unacceptable Performance – When unacceptable performance occurs, the COR shall work with the Contracting Officer to 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 is the COR file. In order to assure that the contractor receive impartial, fair, and equitable treatment under this agreement, the COR will work with the contractor to increase performance to and 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 program manager.

The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contactor is requiring preparing a corrective action plan to document how the contractor shall correct the unacceptable performance and to 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 action deemed necessary by the CO.

9. Frequency of Measurement

• Frequency of Measurement – During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

• Frequency of Performance Assessment Meetings – The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Repesentative