Attachment 03a - QASP_PRS_PBNDS_2026AUG.pdf

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QUALITY ASSURANCE SURVEILLANCE PLAN

AND PERFORMANCE REQUIREMENTS SUMMARY

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 facility 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 operating and maintaining detention facilities. Performance standards address all facets of detained aliens handling, 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 performance is within acceptable quality levels.

2. DEFINITIONS

Performance Requirements Summary (PRS): The PRS communicates what the Government intends to qualitatively inspect. The PRS is based on the American Correctional Association (ACA) Standards for Adult Local Detention Facilities (ALDF) or Core Jail Standards, and ICE 2011 Performance Based National Detention Standards (PBNDS) with 2016 revisions. The PRS identifies performance standards grouped into nine 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 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 (CO) 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 2011 PBNDS with 2016 revisions at http://www.ice.gov/detention-standards/2011 as well as the ACA standards for ALDF.

http://www.ice.gov/detention-standards/2011

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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.

Deduction: Funds may be deducted from a monthly invoice for a failure to perform required services, 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 CO in consultation with the ERO and legal will determine the amount of the withholding/deduction. Amounts deducted are not recoverable.

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

See below PRS 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 CO confirm resolution or correction and should be included in the next month’s invoice.

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 below 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 will 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.

The service provider is encouraged not to limit its inspection to only the processes outlined in the 2011 PBNDS with 2016 revisions; however, certain key documents shall be produced by the service provider to ensure that the services meet the performance standards. Some of the documentation that 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 ensuring ongoing operational compliance with the standards (e.g.; inventories, logbooks, register of receipts, reports, etc.)

• Staff training records

• Contract discrepancy reports (CDRs)

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• Investigative reports

• Medical records

• Records of investigative actions taken

• Equipment inspections

• System tests and evaluation

5. METHODS OF SURVEILLANCE

ICE will monitor the service provider’s compliance with the Performance Standards using a variety of methods. All facilities will be subject to a full annual inspection, which will include a review of the service provider’s QCP activities. In addition, ICE may conduct additional routine, follow-up, or unscheduled ad hoc inspections as necessary (for instance, as a result of unusual incidents or data reflected in routine monitoring). ICE may also maintain an on-site presence in some facilities in order to conduct more regular or frequent monitoring. Inspections and monitoring may involve direct observation of facility conditions and operations, review of documentation (including QCP reports), and/or interviews of facility personnel and aliens.

5.1 Documentation Requirements: The service provider shall develop and maintain all documentation as prescribed in the PBNDS (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 Government may review 100% of the documents, or a representative sample, at any point during the period of performance.

6. FUNCTIONAL PERFORMANCE AREAS AND STANDARDS

To facilitate the performance review process, the required performance standards are organized into nine 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 and deductions will be based on these percentages and weights applied to the overall monthly invoice.

ICE may, consistent with the scope of the agreement, unilaterally change the functional areas and associated standards affiliated with a specific functional area. The CO will notify the service provider at least 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 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 PRS standards as well as delivery of all requirements outlined in the IGSA and performance work statement (PWS) are essential for the service provider to receive full payment as identified in the agreement. The CO may take withholdings or deductions against the monthly invoices for unsatisfactory performance

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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.

At-Risk 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

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

Using the above standards as a guide, the CO will implement adjustments to the service provider’s monthly invoice as prescribed 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 service provider’s monthly invoice. This may happen when a significant event occurs, when a particular deficiency is noted multiple times without correction, or when the service provider has failed to take timely action on a deficiency about which he 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.

Further, a deficiency found in one functional area may tie into another. In the case of an escape, for example, a deficiency would be noted in “Security,” but may also relate to a deficiency in the area of “Administration and Management.” In no event will the withholding or deduction exceed 100% of the invoice amount.

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 Attachment 3A. 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

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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 service provider.

(c) 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 recommend a deduction to the CO. The CDR will be accompanied by the COR’s investigation report and written recommendation for any withholding or deduction. The CO 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, a facility may be re-inspected. Based upon the COR’s findings, he or she will recommend that the CO 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. If a deduction was made for the infraction, the funds are not recoverable.

(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 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.

9. ATTACHMENTS

A. Contract Discrepancy Report Template

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10. PERFORMANCE REQUIREMENT SUMMARY

FUNCTIONAL AREA/

WEIGHT

ACCEPTABLE QUALITY LEVEL and/or

PERFORMANCE STANDARD (PBNDS

2011)

WITHHOLDING/DEDUCTION

CRITERIA

Safety (20%) Addresses a safe work environment for staff, volunteers, contractors and alien

PBNDS References Part 1 - SAFETY

1.1 Emergency Plans

1.2 Environmental Health and Safety

1.3 Transportation by Land

IGSA/PWS sections that describe provide a safe work environment for staff, volunteers, contractors and aliens.

A Contract Discrepancy Report (CDR) that cites violations or failure to meet the AQLs/Performance Standards in this functional category permits the Contracting Officer (CO) to withhold or deduct up to 20% of a month invoice until the CO determines there is full compliance with the standard or section.

Security (20%) Addresses protection of the community, staff, contractors, volunteers, and aliens from harm

PBNDS References: Part 2 -SECURITY

2.1 Admission and Release

2.2 Classification System

2.3 Contraband

2.4 Facility Security and Control

2.5 Funds and Personal Property

2.6 Hold Rooms in Detention Facilities

2.7 Key and Lock Control

2.8 Population Counts

2.9 Post Orders;

2.10 Searches of Detainees

2.11 Sexual Abuse and Assault Prevention

and Intervention

2.12 Special Management Units

2.13 Staff-Detainee Communication

2.14 Tool Control

2.15 Use of Force

PREA Regulations

IGSA/PWS sections that protect the community, staff, contractors, volunteers, and aliens from harm

A CDR that cites violations or failure to meet the AQLs/Performance Standards in this functional category permits the CO to withhold or deduct up to 20% of a monthly invoice until the CO determines there is full compliance with the standard or section.

Order (10%) Addresses service provider responsibility to maintain an orderly environment with clear expectations of behavior and systems of accountability

PBNDS Reference: Part 3 - ORDER

3.1 Disciplinary System

IGSA/PWS sections that maintain an orderly environment with clear expectations of behavior and system of accountability

A CDR that cites violations or failure to meet the AQLs/Performance Standards in this functional category permits the CO to withhold or deduct up to 10% of a monthly invoice until the CO determines there is full compliance with the standard of section.

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Care (20%) Addresses service provider responsibility to provide for the basic needs and personal care of aliens

PBNDS References: Part 4 - CARE

4.1 Food Service

4.2 Hunger Strikes

4.3 Medical Care

4.4 Personal Hygiene;

4.5 Suicide Prevention and Intervention

4.6 Terminal Illness, Advanced Directives, and Death

4.7 Electronic Quality Medical Care

(QMC), Reporting

IGSA/PWS sections that provide for the basic needs and personal care of aliens and related attachments (if applicable)

A CDR that cites violations or failures to meet the AQLs/Performance Standards in this functional category permits the CO to withhold or deduct up to 20% of a monthly invoice until the CO determines there is full compliance with the standard or section.

Activities (10%) Addresses service provider responsibilities to reduce the negative effects of confinement

PBNDS References: Part 5 -

ACTIVITIES

5.1 Correspondence and Other Mail

5.2 Escorted Trips for Non-Medical

Emergencies

5.3 Marriage Requests

Recreation

5.4 Recreation

5.5 Religious Practices

5.6 Telephone Access

5.7 Visitation

5.8 Voluntary Work Program

IGSA/PWS sections that reduce the negative effects of confinement

Virtual Attorney Access (if applicable) Language Service Requirements

A CDR that cites violations or failures to meet the AQLs/Performance Standards in this functional category permits the CO to withhold or deduct up to 10% of a monthly invoice until the CO determines there is full compliance with the standard or section.

Justice (10%) Addresses service provider responsibilities to treat aliens fairly and respect their legal rights and the adequacy of policies and procedures to prevent discrimination against aliens based on their sex, race, religion, national origin, or disability.

PBNDS References: Part 6 - JUSTICE

6.1 Detainee Handbook

6.2 Grievance System

6.3 Law Libraries and Legal Materials

6.4 Legal Rights Group Presentations

IGSA/PWS sections that treat aliens fairly and respect their legal rights or cites violations of the ALDF standards associated with Alien Discrimination

Discrimination Prevention

A CDR that cites violations or failures to meet the AQLs/Performance Standards in this functional category permits the Contracting Officer to withhold up to 10% of a monthly invoice until the CO determines there is full compliance with the standard or section.

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Administration and Management (10%)

Addresses service provider responsibilities to administer and manage the facility in a professional and responsible manner consistent with legal requirements.

PBNDS References: Part 7 -

ADMINISTRATION AND

MANAGEMENT

7.1 Detention Files

7.2 News Media Interviews and Tours

7.3 Staff Training

7.4. Transfer of Detainees

7.5 Pre-Transition and Transition

IGSA/PWS sections that require the service provider’s administration and management of the facility in a professional and responsible manner consistent with the legal requirements.

Inspection Compliance DHS or ICE Inspections DHS PREA Regulations

Accommodations for the Disabled, 4-

ALDF-6B-04, 4-ALDF-6B-07

A CDR that cites violations o or failures to meet the AQLs/Performance Standards in this functional category permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the CO determines there is full compliance with the standard or section.

Findings identified through DHS, ICE, medical, or PREA inspections, reviews, or audits must be resolved within the applicable timeframe and may result in invoice deductions or withholdings as outlined in the bullets below.

Workforce Integrity (20%) Addresses meeting the staffing plan, adequacy of the detention/correctional officer hiring process, staff training and licensing/certification and adequacy of systems

IGSA/PWS sections that are associated with Workforce requirements

Staff Background and Reference Checks

Staff Misconduct

Staffing Pattern in compliance with the required staffing percentages stated in the

IGSA.

Staff Training, Licensing, and Credentialing

A CDR that cites violations or failures to meet the AQLs/Performance Standards in this functional category permits the CO to withhold or deduct up to 20% of a monthly invoice until the CO determines there is full compliance with the standard or section.

Administration and Management details:

• DHS or ICE Inspection Findings: Any finding from a DHS or ICE inspection must be resolved as required by the PWS, but no later than the next inspection. Any such finding that remains unresolved by the next inspection may result in a 10% withholding/deduction of the monthly invoice until compliance with the finding is established.

• Medical Inspection or Medical Site Review Findings: Any finding requiring a Uniform Corrective Action Plan (UCAP) must be resolved within the timeframe specified in the UCAP. UCAP findings will be categorized by risk level, as determined by IHSC, based on the severity of the finding, recurrence, and potential impact on health, safety, or required services. IHSC will determine whether the corrective action implemented by the service provider sufficiently resolves the finding.

o Moderate- or High-Risk UCAP Findings: Failure to resolve a moderate- or high-risk UCAP finding within the specified timeframe may result in a 10%

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withholding/deduction of the monthly invoice until compliance with the finding is established.

o Low-Risk UCAP Findings: Low-risk findings will not ordinarily result in a deduction unless IHSC determines the finding is recurrent, systemic, or otherwise remains unresolved after the service provider has been provided notice and an opportunity to cure.

• DHS PREA Audit Findings: A rating of “Doesn’t Meet Standard” for any facility-related DHS PREA standard on an audit report may result in a withholding or deduction of up to 10% of the monthly invoice until compliance with the deficient PREA standard(s) is established.