ATTACH 1 QASP.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: CFA Food Service Improvement

Contract Number: N/A (TBD)

Contract Description: The VA Pacific Islands Health Care System (VA PIHCS) in Honolulu, Hawaii, requires meal service is for an estimated 65,700 meals annually. Additional meal trays are included in the annual estimate to serve as back-up for each meal service time. Providing meal service to patients within the CFA for meals three (3) times a day, seven (7) days a week, three hundred sixty-five (365) days per year for the following meal service times: breakfast:

7:30am to 8:30am, lunch: 12pm to 1pm and dinner: 5pm to 6pm.

Contractor’s Name: N/A (TBD)

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 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: Brandy Gastinell | Brandy.Gastinell@va.gov. Organization or Agency: Department of Veterans Affairs, Network Contracting Office V21

b. Contracting Officer’s Technical 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: Candi Medina

3. CONTRACTOR REPRESENTATIVES

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

• a. Program Manager(s) – N/A (TBD)

• b. Contract Assigned Personnel – N/A (TBD)

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. The Quality Assurance Specifications and Requirements, paragraph 13, in the contract, includes performance standards to be followed. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Quality Assurance Surveillance Plan (QASP)

Performance Standards Task

Indicator

Standard

Acceptable Quality Level

Score 90,95, 100%

Surveillance method

A.1.1. Performance All conditions must be met.

All conditions must be met.

100% Receipt of meals daily / 365 days per year

A.1.2. Timeliness Meals ready for pick up at the designated times by food courier.

Meals prepared are ready for pick up no more than 30 mins earlier than courier arrival.

90-100% Review of receiving and transport log.

A.1.3 Quality All meals must be prepared in a facility according to the Hawaii State Department of Health (DOH) green placard guidelines.

The contractors shall meet the Hawaii state green placard standards.

95%-100% Present local DOH clearance.

B.1 Locality All meals must be prepared in a facility according to Hawaii State DOH green placard guidelines.

The contractors shall meet the Hawaii DOH green placard standards.

95%-100% Present local DOH clearance.

E.1 Standards Refer to SOW E.1, Table A: Cycle Menu Requirements.

95% will have these minimum items provided. 100% provides more than the minimum.

95%-100% Periodic Cycle menu file inspection and/or random sampling

E.2 Coordination Meals will meet the diet order prescribed by the providers and agreed upon by the VA Dietitian or designee.

Meals must meet the dietary needs and preferences of the CFA veteran population as prescribed by the VA Dietitian or designee.

100% 4- Week Menu Cycle provided and reviewed each update/change or semi-annual – whichever happens first

F.1.1. HIPAA

Service

The contractor shall prepare and assemble patient meal trays for all CLC and PRRP patients. Refer to

SOW F.1.1.

The tray tickets shall only be viewed by staff on a need to know basis. Any unused tray ticket(s) will be returned to the VA with the meals delivered.

100% Periodic tray audit inspection and/or random sampling.

F.1.2. Service Prepared meals will be based on a 4-Week Cycle Menu in accordance with the prescribed therapeutic

Prepared meals shall meet the 4-Week menu cycle with minimal substitutions.

Anything less is 90%.

90%, 95%, 100%

Periodic tray audit inspection and/or random sampling..

and mechanically altered diet orders.

As required is 95% and more than required is 100%.

F.1.3. Service The contractor shall provide the VA Dietitian detailed recipes for all the approved menu items and meal item alternatives for CFA meal service (30 days) prior to service for approval.

The contractor will prepare meals from recipes approved by the VA Dietitian or Designee.

100% Periodic tray audit inspection and/or random sampling.

F.1.4. Quality Raw fruits and vegetables need to be chopped or finely diced. All foods will be chopped, diced or minced according to each patient’s needs and will be determined by the VA dietitian, speech therapist, and/or designee.

The contractor will prepare meals approved by the VA Dietitian, speech therapist, and/or designee.

100% Periodic tray audit inspection and/or random sampling

F.1.5. Quality The contractor will use a food processor to puree foods to maintain the appropriate texture and nutritive value.

Commercial thickeners may be used to achieve proper consistency as to the thickness of mashed potatoes rather than a gravy or watery texture.

In accordance to the dysphagia diet guidelines, pureed foods should be prepared so that they are attractive, appealing and served on a regular or divided plate instead of in individual bowls.

100% Periodic tray audit inspection and/or random sampling

G.1. Health and Sanitation

Contractor shall comply with all applicable health and sanitation laws and regulations of the State of Hawaii and meet or exceed standards of the Joint Commission (JC) and any other regulatory agencies.

Contractor shall meet laws and regulations obtained at the following web sites;

State of Hawaii:

www.hawaii.gov/doh, JC:

www.jointcommission .org, and Long-Term Care Institute (LTCI)

100% Provide documentation showing that all the above laws and regulations are met and all applicable licenses and insurance.

G.1.2.

I.1.

Food Safety

Quality

Food service manager, supervisor and others who may be described as “person in charge” per the most current NFAC-accepted FDA Food Code, must hold a Food Protection Manager certification.

Designee can taste test at any time

This certification must be from an accredited organization that issues food protection manager certifications:

https://anabpd.ansi.org /Accreditation/credent ialing/personnel-certification/food-protection-manager/ALLdirector yListing?menuID=8& prgID=8&statusID=4

Taste, consistency, and adherence to dietary order

90-100%

Provide proof of certification

Periodic test tray conducted once a week http://www.hawaii.gov/doh http://www.jointcommission.org/ http://www.jointcommission.org/ https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4 https://anabpd.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4

J.1.1.2

L.1.4.

L.1.5.

L.1.6.

L.1.6.1

Safety Standards

Food Safety

Contractors are subject to the latest VAPIHCS health policies

Vendor supervisor to meet as needed with VA Dietitian or designee to discuss and resolve dietary operational issues

VA has the right to schedule the Vendor’s kitchen, equipment, food, and services at any point in time designee will conduct quarterly audits using the VA’s Contract Food Service Evaluation Form

VA Dietitian will meet with Vendor Supervisor on a quarterly basis to discuss resident satisfaction surveys

Complies with latest VAPIHCS health policies to include COVID testing upon entering the CFA; as an example

Issues are resolved in an agreed upon timeframe between Vendor supervisor and designee

Random quarterly inspections conducted by VA Dietitian or designee

Quarterly audits scheduled on dates agreed upon by VA Dietitian or designee and Vendor supervisor

Quarterly meetings scheduled on dates agreed upon by VA Dietitian or designee and Vendor supervisor

Screening log where Contractors check in at designated CFA location.

Timeline tracker for issue resolution OR Quality Control Form

Green Health Placard approved by the State of Hawaii and/or Quality Control Form

Satisfactory or above ratings on VA Contract Food Service Evaluation Form

Satisfactory of above ratings on resident satisfaction surveys