Attachment 03 - Quality Assurance Surveillance Plan.pdf

70CDCR23R00000006

ATTACHMENT 03 - QUALITY ASSURANCE SURVEILLANCE PLAN

1. INTRODUCTION

ICE’s Quality Assurance Surveillance Plan (QASP) is based on the premise that the Service Provider, and not the Government, is responsible for the day-to-day operation of the transportation and escort services and all the management and quality control actions required to meet the terms of the Agreement. The role of the Government in quality assurance is to ensure performance standards are achieved and maintained. The Service Provider shall develop a comprehensive program of inspections and monitoring actions and document its approach in a Quality Control Plan (QCP). The Service Provider’s QCP, upon approval by the Government, will be made a part of the resultant Agreement.

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

This QASP is based on the premise the Government will validate that the Service Provider is complying with ERO-mandated quality standards in transporting and escort unaccompanied minors. Performance standards address all facets of handling the children, including safety, health, legal rights, facility and records management, etc. Good management by the Service Provider and use of an approved QCP will ensure that the Services are operating within acceptable quality levels.

2. DEFINITIONS

Performance Requirements Summary (Exhibit A): The Performance Requirements Summary (PRS) communicates what the Government intends to qualitatively inspect. The PRS is based on the applicable American Correctional Association (ACA) Standards for Adult Local Detention Facilities (ALDF) and ICE Family Residential Standards (FRS). The PRS identifies performance standards grouped into seven (7) functional areas, and quality levels essential for successful performance of each requirement. The PRS is used by ICE when conducting quality assurance surveillance to guide them through the inspection and review processes.

Functional Area: A logical grouping of performance standards.

Contracting Officer’s Representative (COR): The COR interacts with the Service Provider to inspect and accept services/work performed in accordance with the technical standards prescribed in the Agreement. The Contracting Officer issues a written memorandum that appoints the COR. Other individuals may be designated to assist in the inspection and quality assurance surveillance activities.

Performance Standards: The performance standards are established in the ERO ICE FRS at http://www.ice.gov/detention-standards/family-residential/, as well as the ACA standards for ALDF that apply. Other standards may also be defined in the Agreement.

http://www.ice.gov/detention-standards/family-residential/

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 standards.

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

See Attachment A for information on the percentages of an invoice amount that may be withheld for each functional area. Funds withheld from payment are recoverable (See Sections 7 and 8) 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. The Service Provider will be notified immediately if such a situation arises. The Contracting Officer in consultation with the ERO will determine the amount of the deduction. Amounts deducted are not recoverable.

4. QUALITY CONTROL PLAN

The Service Provider shall develop, implement, and maintain a Quality Control Plan (QCP) that illustrates the methods it will use to review its performance to ensure it conforms to the performance requirements. (See Exhibit A for a summary list of performance requirements.)

Such reviews shall be performed by the Service Provider to validate its operations, and assure ICE that the services meet the performance standards.

The Service Provider’s QCP shall include monitoring methods that ensure and demonstrate its compliance with the performance standards. This includes inspection methods and schedules that are consistent with the regular reviews conducted by ERO. The reports and other results generated by the Service Provider’s QCP activities should be provided to the COR as requested.

The frequency and type of the Service Provider’s reviews should be consistent with what is necessary in order to ensure compliance with the performance standards, but no less frequent than what is described in the Government’s monitoring instrument/worksheets (See Exhibit B).

The Service Provider is encouraged not to limit its inspection to only the processes outlined in the FRS; however, certain key documents shall be produced by the Service Provider to ensure that the services meet the performance standards. Some of the documentation shall be generated and made available to the COR for inspection is listed below. The list is intended as illustrative and is not all-inclusive. The Service Provider shall develop and implement a program that addresses the specific requirement of each standard and the means it will use to document compliance.

• Written policies and procedures to implement and assess operational requirements of the standard

• Documentation and record keeping to ensure ongoing operational compliance with the standards (e.g.; inventories, logbooks, register of receipts, reports, etc.)

• Staff training records

• Contract Discrepancy Reports (CDRs)

• Investigative reports

• Medical records (if applicable)

• Records of investigative actions taken

• Equipment inspections

• System tests and evaluation

5. METHODS OF SURVEILLANCE

ICE will inspect the Service Provider’s operations using worksheets it developed for this purpose. All services will be subject to an annual full facility review. The Government’s annual full reviews will use the monitoring instruments embedded in the standards.

The on-site COR and/or designees will perform regular and more frequent inspections using the worksheet in Exhibit B attached. This worksheet, which distills some 600 review areas included in the standards, will help the COR or designee assess overall performance, by reviewing specific items within the seven (7) functional areas on a daily, weekly, monthly, and/or quarterly basis. Both annual and routine inspections will include a review of the Service Provider’s QCP activities including the reports and results generated by them.

The COR or designee will evaluate the Service Provider’s performance by (a) conducting site visits to assess the operational conditions, (b) reviewing documentation, and (c) interviewing the Service Provider’s personnel and/or children. NOTE: For day-to-day activities, the Government will conduct its surveillance using the worksheets created for this purpose, along with the Contract Discrepancy Reports (See Exhibit B and the “Compliance Monitoring Tool” set forth in Exhibit B . Where ICE/ERO/JFRMU standards are referenced for annual review purposes, the “Monitoring Instruments” and “Verification Sources” identified in the ERO standard will be used.

5.1 Site Visits: Site visits are used to observe actual performance and to conduct interviews to determine the extent of compliance with performance standards, and to ensure any noted defects are effectively addressed and corrected as quickly as possible. Routine reviews may involve direct observation of the Service Provider personnel performing tasks, interacting with children and other staff members, and/or reviewing documentation that demonstrates compliance with the ERO standards. On-site inspections may be performed by the COR or by other parties designated as representatives of ICE. Inspections may be planned (e.g., annual inspections and the regular inspections identified in Exhibit B ) or ad-hoc.

5.2 Ad-Hoc: These inspections are unscheduled and will be conducted as a result of special interests arising from routine monitoring of the Service Provider’s QCP, an unusual occurrence pertaining to the Agreement or other ICE concerns. These inspections may also be used as a follow-up to a previous inspection. Inspection findings will be provided to the Service Provider as appropriate.

When visiting a site, either the COR or a designated third party may conduct their own inspections of Service Provider performance activities, or accompany the Service Provider’s designated Quality Control Inspector (QCI) on scheduled inspections. The COR may also immediately inspect the same site as soon as the QCI has completed the quality control inspection to determine if any surveillance areas were overlooked. The COR may also inspect a site prior to the QCI and compare results. The COR will record all findings; certain deficiencies noted will be provided in writing and shall be corrected within a reasonable amount of time (See Exhibit B ).

5.3 Review of Documentation: The Service Provider shall develop and maintain all documentation as prescribed in the FRS (e.g., post logs, policies, and records of corrective actions). In addition to the documentation prescribed by the standards, the Service Provider shall also develop and maintain documentation that demonstrates the results of its own inspections as prescribed in its QCP. The COR will review both forms of documentation to affirm that the conditions, policies/procedures, and handling of children all conform to the performance standards stated herein. When reviewing the Service Provider’s documentation, the Government may review 100% of the documents, or a representative sample. Documentation may be reviewed during a site visit, or at periodic points throughout the period of performance.

5.4 Interviews and Other Feedback: The COR may interview key members of the Service Provider’s staff, children and other Government personnel to ascertain current practices and the extent of compliance with the performance standards.

6. FUNCTIONAL PERFORMANCE AREAS AND STANDARDS

To facilitate the performance review process, the required performance standards are organized into seven (7) functional areas. Each functional area represents a proportionate share (i.e., weight) of the monthly invoice amount payable to the Service Provider based on meeting the performance standards. Payment withholdings/deductions will be based on these percentages and weights applied to the overall monthly invoice.

ICE may, consistent with the scope the Agreement, unilaterally change the functional areas and associated standards affiliated with a specific functional area. The Contracting Officer will notify the Service Provider at least thirty (30) calendar days in advance of implementation of the new standard(s). If the Service Provider is not provided with the notification, adjustment to the new standard shall be made within the thirty (30) calendar days after notification. If any change affects pricing, the Service Provider may submit a request for equitable price adjustment in accordance with the “Changes” clause. ICE reserves the right to develop and implement new inspection techniques and instructions at any time during performance without notice to the Service Provider, so long as the standards are not more stringent than those being replaced.

7. FAILURE TO MEET PERFORMANCE STANDARDS

Performance of services in conformance with the FRS standards is essential for the Service Provider to receive full payment as identified in the Agreement. The Contracting Officer may take deductions against the monthly invoices for unsatisfactory performance documented through surveillance of the Service Provider’s activities gained through site inspections, reviews of documentation (including monthly QCP reports), interviews and other feedback. As a result of its surveillance, the Service Provider 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

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

Using the above standards as a guide, the Contracting Officer will implement adjustments to the Service Provider’s monthly invoice as prescribed in Attachment A

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 Service Provider’s monthly invoice. This may happen when an event occurs, such as sexual abuse, when a particular deficiency is noted 3 or more times without correction, or when the Service Provider has failed to take timely action on a deficiency about which he/she 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 Service Provider has either corrected the deficiency, or made substantial progress in the correction. It is noted that the Contracting Officer, with consultation with JFRMU, may deduct a percentage less than the relative weight of the functional performance area.

Further, a deficiency found in one functional area may tie into another. If a child escaped, for example, a deficiency would be noted in “Security,” but may also relate to a deficiency in the area of “Administration and Management.”

8. NOTIFICATIONS

(a) Based on the inspection of the Service Provider’s performance, the COR will document instances of deficient or at-risk performance (e.g., noncompliance with the standard) using the CDR located at Exhibit B . To the extent practicable, issues should be resolved informally, with the COR and Service Provider 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 Service

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

(c) The COR, in addition to any other designated ICE official, shall be notified immediately in the event of all emergencies. Emergencies include, but are not limited to the following: activation of disturbance control team(s); disturbances (including gang activities, group demonstrations, food boycotts, work strikes, work-place violence, civil disturbances, or protests); staff use of force including use of lethal and less-lethal force (including children placed in restraints; assaults on staff or children resulting in injuries requiring medical attention (does not include routine medical evaluation after the incident); fights resulting in injuries requiring medical attention; fires; full or partial lock down of the location; escape; ;

suicide attempts; deaths; declared or non-declared hunger strikes; adverse incidents that attract unusual interest or significant publicity; adverse weather (e.g., hurricanes, floods, ice or snow storms, heat waves, tornadoes); vehicle damage; power outages; bomb threats;

significant environmental problems that impact the operations; transportation accidents resulting in injuries, death or property damage; and sexual assaults. Note that in an emergency situation, a CDR may not be issued until an investigation has been completed.

(d) If the COR concludes that the deficient or at-risk performance warrants a withholding or deduction, the COR will notify the Contracting Officer immediately upon completion of the form and include the CDR in its monthly report. The CDR will be accompanied by the COR’s investigation report and written recommendation for any withholding/deductions.

The Contracting Officer will consider the COR’s recommendation and forward the CDR along with any relevant supporting information to the Service Provider in order to confirm or further discuss the prospective cure, including the Government’s proposed course of action.

As described in section 7 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 Service Provider’s notification that the correction has been made, the COR may perform a re-inspection. Based upon the COR’s findings, he or she 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 Service Provider terminates the

Agreement, those funds will not be released. The Service Provider may only receive withheld payments upon successful correction of an instance of non-compliance. Further, the Service Provider 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 once 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.

9. CHILDREN OR MEMBER OF THE PUBLIC COMPLAINTS

The children and the public are the ultimate recipients of the services identified in this Agreement. Any complaints made known to the COR will be logged and forwarded to the Service Provider for remedy. Upon notification, the Service Provider shall be given a pre-specified number of hours after verbal notification from the COR to address the issue. The Service Provider shall submit documentation to the COR regarding the actions taken to remedy the situation. If the complaint is found to be invalid, the Service Provider shall document its findings and notify the COR.

10. ATTACHMENTS

A. Performance Requirements Summary

B. Sample Contract Discrepancy Report

Exhibit A. Performance Requirements Summary

IF

FUNCTIONAL

AREA/

WEIGHT

PERFORMANCE

STANDARD (NDS, ICE

POLICIES, PWS)

PERFORMANC

E

MEASURE

METHOD OF

SURVEILLA

NCE

ACCEP

TABLE

QUALIT

Y

LEVEL

WITHHOLDIN

G

CRITERIA

Safety Standards

(20%)

(Addresses a safe work environment for staff, and

UC/FAMU.)

FRS References: Part 1 -

SAFETY

1) Emergency Plans;

2) Environmental Health and Safety;

3) Transportation

(PWS, Part XI, Section J Emergencies. PWS, Part XI, Section E, 4 k Driving hours.)

Performance measures are reflected in the monitoring instrument that accompanies each standard or in the supplemental performance monitoring tool issued by the COTR

Annual review using Detention Management Control Program (DMCP) procedures and based upon the performance standard

Periodic reviews in accordance with the contract performance monitoring tool (see attached)

• Annual review using Detention Management Control Program

(DMCP)

procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool

• Monthly review of corrective action plan results

• Ad-hoc reviews as needed

• CDRs

Performan ce fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the

QASP)

A Contract Discrepancy Report that cites violations of cited FRS and PWS (contract) sections that provide a safe work environment for staff, volunteers, contractors and children, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section.

Security and Control (20%)

(Addresses protecting the community, contractor, and UC/FAMU from harm)

FRS References: Part 2 -

SECURITY

4) Contraband;

5) Funds and Personal Property;

6) Searches of UC/FAMU

7) Sexual Abuse and Assault Prevention and Intervention;

8) Staff-UC Communication;

9) Use of Physical Control Measures and Restraints.

(PWS, Part XI, Section B 4 Searches. PWS, Part XI Section H Transfer of Funds, Valuables and Personal Property. PWS, Part XI, Section M. Use of Restraints. PWS, Part VI.

ICE’s Commitment to the Best Interests of Children.

Sexual Assault 4-ALDF- 4D-22-8

Performance measures are reflected in the monitoring instrument that accompanies each standard or in the supplemental performance monitoring tool issued by the COR

Annual review using Detention Management Control Program (DMCP) procedures and based upon the performance standard

Periodic reviews in accordance with the contract performance

• Annual review using Detention Management Control Program

(DMCP)

procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool

• Monthly review of corrective action plan results

• Ad-hoc reviews as needed

• CDRs

Performan ce fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the

QASP)

A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that protect the community, staff, contractors, volunteers, and detainees from harm, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section.

IF

FUNCTIONAL

AREA/

WEIGHT

PERFORMANCE

STANDARD (NDS, ICE

POLICIES, PWS)

PERFORMANC

E

MEASURE

METHOD OF

SURVEILLA

NCE

ACCEP

TABLE

QUALIT

Y

LEVEL

WITHHOLDIN

G

CRITERIA

Permanent Logs 4-ALDF- 2A-11 monitoring tool (see attached)

Order (15%)

(Addresses contractor responsibility to maintain an orderly environment with clear expectations of behavior and systems of accountability)

FRS Reference: Part 3 -

ORDER

10) Disciplinary and Behavior Management (PWS Section L addresses Behavior Management plan.)

Performance measures are reflected in the monitoring instrument that accompanies each standard or in the supplemental performance monitoring tool issued by the COR

Annual review using Detention Management Control Program (DMCP) procedures and based upon the performance standard

Periodic reviews in accordance with the contract performance monitoring tool (see attached)

• Annual review using Detention Management Control Program

(DMCP)

procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool

• Monthly review of corrective action plan results

• Ad-hoc reviews as needed

• CDRs

Performan ce fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the

QASP)

A Contract Discrepancy Report that cites violations of FRS and PWS (contract) sections that maintain an orderly environment with clear expectations of behavior and systems of accountability permits the Contracting Officer to withhold or deduct up to 15% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section.

UC Care (25%)

(Addresses contractor responsibility to provide for the basic needs and personal care of detainees)

FRS References: Part 4

- CARE

11) Food Service;

12) Hunger Strikes;

13) Medical Care;

14) Personal Hygiene;

15) Suicide Prevention and Intervention;

16) Terminal Illness, Advanced Directives, and Death.

(PWS Part XI, Section B 2c – UC/FAMU Preparation. PWS, Part XI Section F Snacks and Meals.

Communicable Disease

4-ALDF-4C-14

reflected in the monitoring instrument that accompanies each standard or in the supplemental performance monitoring tool issued by the COR

Annual review using Detention Management Control Program (DMCP) procedures and based upon the performance standard

Periodic reviews in accordance with the contract performance

• Annual review using Detention Management Control Program

(DMCP)

procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool

• Monthly review of corrective action plan results

• Ad-hoc reviews as needed

• CDRs

Performan ce fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the

QASP)

A Contract Discrepancy Report that cites violations of FRS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contracting Officer to withhold or deduct up to 25% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section.

IF

FUNCTIONAL

AREA/

WEIGHT

PERFORMANCE

STANDARD (NDS, ICE

POLICIES, PWS)

PERFORMANC

E

MEASURE

METHOD OF

SURVEILLA

NCE

ACCEP

TABLE

QUALIT

Y

LEVEL

WITHHOLDIN

G

CRITERIA

monitoring tool (see attached)

Justice (5%) responsibilities to treat detainees fairly and respect their legal rights-At this Contract Detention

Facility, performance of the applicable PBNDS are the responsibility of ICE and are not the responsibility of the Contractor)

FRS References: Part 6

- JUSTICE

18) Grievance System;

(PWS, Part XI, Section Q, 1d) reflected in the monitoring instrument that accompanies each standard or in the supplemental performance monitoring tool issued by the COR

• Annual review using Detention Management Control Program

(DMCP)

procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool

• Monthly review of corrective action plan results

• Ad-hoc reviews as needed

• CDRs

Performan ce fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the

QASP)

A Contract Discrepancy Report that cites violations of FRS and PWS sections that treat children fairly and respect their legal rights, permits the Contracting Officer to withhold or deduct up to 5% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section.

Administration and

Management (15%) responsibilities to administer and manage the facility in a professional and responsible manner consistent with legal requirements)

PBNDS References:

Part 7 - -ADMIN &

MANAGEMENT

19) Admissions Documentation/Files;

20) News Media Interviews and Tours;

21) Staff Hiring and Training;

(PWS, Part XI, Section D Transport Documents.

Part XI, Section L Training. Part XI, Section P Media Inquiries Policy Development and Monitoring 4-

ALDF-7D-06

Contractor Quality Control/ Assurance Program (Contract) 4-

ALDF-7D-02

reflected in the monitoring instrument that accompanies each standard or in the supplemental performance monitoring tool issued by the COR

• Annual review using Detention Management Control Program

(DMCP)

procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool

• Monthly review of corrective action plan results

• Ad-hoc reviews as needed

• CDRs

Performan ce fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the

QASP)

A Contract Discrepancy Report that cites violations of FRS and PWS sections that require the Contractor’s administration and management of the facility in a professional and responsible manner consistent with legal requirements, permits the Contracting Officer to withhold or deduct up to 15% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section.

Exhibit B- Contract Discrepancy Report

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER

Report Number: Date:

2. TO: (Contractor and Manager Name)

3. FROM: (Name of COTR)

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 TECHNICAL REPRESENTATIVE (COTR)

6. TO: (COTR)

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

NAME AND TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COTR

CONTRACTING

OFFICER