Attachment 1- PWS Appendix 13_Quality Assurance Surveillance Plan.rtf

Attachment 1 – PWS Appendix 13_Quality Assurance Surveillance Plan (QASP)

Immigration and Customs Enforcement Enforcement and Removal Operations file_0.jpg file_1.wmf

Transportation Services Quality Assurance Surveillance Plan

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

DETENTION OFFICER (DO) SERVICES LOS ANGELES, SAN FRANCISCO, SAN DIEGO, PHOENIX, SALT LAKE CITY (AORs) IMMIGRATION AND CUSTOMS ENFORCEMENT (ICE) ENFORCEMENT AND REMOVAL OPERATIONS (ERO)

1. INTRODUCTION

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

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

This QASP is based on the principle that the Government will validate that the Contractor is complying with U.S. Immigration and Customs Enforcement, Enforcement and Removal Operations (ICE/ERO) - mandated quality standards in providing security and transportation. Performance standards address all facets of transportation related services. Efficient management by the contractor and use of an approved QCP ensures that the Contractor operates within acceptable quality levels.

2. DEFINITIONS

Performance Requirements Summary (Appendix A): The Performance Requirements Summary (PRS) depicts what the Government intends to qualitatively inspect. The PRS is based on:

• M-68 (A Guide to Proper Conduct and Relationships with Aliens and the General Public)

• All transportation requirements listed under SOW.

The PRS identifies performance standards grouped into five functional areas, and quality levels essential for successful performance of each requirement. The PRS is used by the Government reviewers (or their designated representative) when conducting quality assurance surveillance to guide them through the inspection and review processes for assessing compliance in meeting Government standards.

Performance Standards:

The performance standards are established in the ICE 2011 Performance Based National Detention Standards (PBNDS) at http://www.ice.gov/detention-standards/2011. Other standards may also be defined in the contract.

Withholding:

Amount of monthly invoice payment withheld pending correction of a deficiency. See Appendix A for information on percentage of invoice amount that may be withheld for each functional area. Funds withheld from payment are recoverable (see Sections 6 and 7) if the COR and Contracting Officer confirm resolution/correction, and should be included in the next month’s invoice.

Deduction:

Amount of monthly invoice payment deducted due to a deficiency. See Appendix A for information on percentage of invoice amount that may be deducted for each functional area. Funds deducted from payment are not recoverable (see Sections 6 and 7).

3. QUALITY CONTROL PLAN

As a part of its agreement with the Government, the Contractor is required to develop, implement, and maintain a Quality Control Plan (QCP) that describes the methods it will use to review its performance to ensure it conforms to the performance requirements. The Contractor shall perform such reviews in order to validate its operations, and assure the Government that the services meet the performance standards.

The Contractor’s QCP should 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 Contractor’s QCP activities shall be provided to the COR as requested.

The frequency and type of the Contractor’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 Appendix C).

The Contractor is encouraged not to limit its inspection to only the processes outlined in the

Government’s standard; however, certain key documents shall be produced by the Contractor to assure the Government that the services meet the performance standards. Some of the documentation that must be generated and made available to the COR for inspection are listed below. The list is intended as illustrative and is not all-inclusive. The Contractor shall develop and implement a program that addresses the specific requirement of each standard and the means it will use to document compliance.

4. METHODS OF SURVEILLANCE

The Government will inspect the services and operations provided by the Contractor using worksheets it developed for this purpose. Frequency of inspections will be determined by the COR. The COR or designee will evaluate the service provider’s performance by (a) reviewing documentation, and (b) interviewing the service provider’s personnel and/or detainees. NOTE: For day-to-day activities, the Government will conduct its surveillance using the worksheets created for this purpose, along with the Contract Deficiency Reports (CDRs: see Appendix B) and the “Contract Performance Monitoring Tool” set forth in Appendix C. Where ICE/ERO standards are referenced for annual review purposes, the “Monitoring Instruments” and “Verification Sources” identified in ICE/ERO standard will be used.

4.1 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 deficiencies are effectively addressed and corrected as quickly as possible. Routine reviews may involve direct observation of the Contractor personnel performing tasks, interacting with detainees and other staff members, and/or reviewing documentation that demonstrates compliance with ICE/ERO standards. On-site inspections may be performed by the ICE COR. Inspections may be planned (e.g., annual inspections and the regularly scheduled inspections identified in Appendix C) or ad-hoc.

4.2 Ad-Hoc:

These inspections are unscheduled and will be conducted as a result of special interests or unexpected conditions arising from routine monitoring of the Contractor’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 Contractor as appropriate.

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

4.3 Review of Documentation:

The Contractor shall develop and maintain all documentation as prescribed in the performance standards (e.g., post logs, policies, and records of corrective actions). In addition to the documentation prescribed by the standards, the Contractor 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 detainees all conform to the performance standards stated herein. When reviewing the Contractor’s documentation, the Government will review all the documents, or a representative sample. Documentation may be reviewed during a site visit, or at periodic points throughout the period of performance.

4.4 Interviews and Other Feedback:

The COR will interview key members of the Contractor’s staff, detainees, and other Government personnel to ascertain current practices and the extent of compliance with the performance standards.

5. FUNCTIONAL PERFORMANCE AREAS AND STANDARDS

To facilitate the performance review process, the required performance standards are organized into five (5) functional areas corresponding to the requirements in the Performance Requirements Summary (PRS). 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 will be based on these percentages and weights applied to the overall monthly invoice.

ICE may, consistent with the scope of the contract, unilaterally change the functional areas and associated standards affiliated with a specific functional area. The Contracting Officer will notify the Contractor at least 30 calendar days in advance of implementation of the new standard(s). If the Contractor is not provided with the notification, adjustment to the new standard must be made within 30 calendar days after notification. If any change affects pricing, the Contractor may submit a request for equitable price adjustment in accordance with the FAR Clause 52.243-1 Changes – Fixed Price. ICE reserves the right to develop and implement new inspection techniques and instructions at any time during performance without advance notice to the Contractor, so long as the standards are not more stringent than those being replaced, unless agreed upon by the parties. The Contractor shall provide asafe and secure environment for staff and detainees through effective and continuously monitored program management.

6. FAILURE TO MEET PERFORMANCE STANDARDS

Performance of services in conformance with the PRS standards is essential for the Contractor to receive full payment as identified in the contract. The Contracting Officer may withhold or take deductions against the monthly invoices for unsatisfactory performance documented through surveillance of the Contractor’s activities gained through site inspections, reviews of documentation (including monthly QCP reports), 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 / 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 Contractor’s monthly invoice as prescribed in Appendix 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 Contractor’s monthly invoice. This may happen when an event occurs, such as an escape, traffic accident due to the Contractor negligence, or sexual abuse, when a particular deficiency is noted three or more times without correction, or when the Contractor 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 Contractor has either corrected the deficiency, or made substantial progress in the correction. Amounts deducted are not recoverable.

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

7. 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 CDR form located at Appendix B. To the extent 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 corrects 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 plan/remedy, the COR will either accept the plan or correction or reject the correction/plan for revision and provide an explanation. This process should take no more than one week. The Contractor shall not use the CDR as a substitute for quality control.

(c) The COR and CO, 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: staff use of force including use of lethal and less-lethal force (includes detainees in restraints more than eight hours); assaults on staff/detainees resulting in injuries requiring medical attention (does not include routine medical evaluation after the incident); fights resulting in injuries requiring medical attention; fires; escape; weapons discharge; suicide attempts; deaths; adverse incidents that attract unusual interest or significant publicity; adverse weather (e.g., hurricanes, floods, ice/snow storms, heat waves, tornadoes); 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 must include the complete CDR (with official response from Contractor/service provider) in its monthly report to ICE/ERO Headquarters, with a copy to the Contracting Officer. The CDR must be accompanied by the COR’s investigation report and written recommendation for any withholding. If contractual action including a withholding or deduction is appropriate, ICE/ERO headquarters will forward the CDR and supporting information to the Contracting Officer for action. 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 Section 6 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, he/she may 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 agreement, 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 shall not be 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.

8. DETAINEE/MEMBER OF PUBLIC COMPLAINTS

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

9. APPENDIXES

A. Performance Requirements Summary B. Contract Discrepancy Report C. Performance Monitoring Tool

Appendix A - Performance Requirements Summary

FUNCTIONAL

AREA/ WEIGHT

2011 PERFORMANCE BASED

NATIONAL DETENTION STANDARDS (NDS, ICE POLICIES, SOW)

PERFORMANCE

MEASURE

METHOD OF

SURVEILLANCE

ACCEPTABLE

QUALITY LEVEL

WITHHOLDING

CRITERIA

Safety (40%)

(Addresses a safe work environment for staff, volunteers, contractors and detainees) PBNDS References: Part 1 - SAFETY

1) Emergency Plans;

2) Environmental Health and Safety;

3) Transportation (by Land).

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 Performance 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 PBNDS and SOW (contract) sections that provide a safe work environment for staff, volunteers, contractors and detainees, permits the Contract Officer to withhold or deduct up to 40% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

Security (30%)

(Addresses protecting the community, staff, contractors, volunteers, and detainees from harm) PBNDS References: Part 2 - SECURITY

13) Searches of Detainees

14) Sexual Abuse and Assault Prevention and Intervention;

16) Staff-Detainee Communication;

18) Use of Force and Restraints.

Weapons Control 4-Adult Local Detention Facilities (ALDF)-2B-04, 4-ALDF-

2B-08, 4-ALDF-7B-14

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

Permanent Logs 4-ALDF-2A-11

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 Performance 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 SOW (contract) sections that protect the community, staff, contractors, volunteers, and detainees from harm, permits the Contract Officer to withhold or deduct up to 30% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

Order (10%)

(Addresses contractor responsibility to maintain an orderly environment with clear expectations of behavior and systems of accountability) PBNDS Reference: Part 3 - ORDER

19) Disciplinary System.

Diversity Training 4-ALDF-6A-08, 4- ALDF-7B-10 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 Performance 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 SOW (contract) sections that maintain an orderly environment with clear expectations of behavior and systems of accountability permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

Workforce Integrity (10%)

(Addresses the adequacy of the detention/correctional officer hiring process, staff training and licensing/ certification and adequacy of systems to report and address staff misconduct) Staff Background and Reference Checks (Contract) 4-ALDF-7B-03

Staff Misconduct 4-ALDF-7B-01

Staffing Pattern Compliance within 10% of required (Contract) 4-ALDF-2A-14

Staff Training, Licensing, and Credentialing (Contract) 4-ALDF-4D-05, 4-ALDF-7B-05, 4- ALDF-7B-08 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 (DCMP) procedures and based upon the performance standard

• Periodic reviews in accordance with the attached contract performance monitoring tool

• Monthly review of corrective action plan results.

• Ad-hoc reviews as needed

• CDRs Performance fully complies with all elements of standard at a level no less than acceptable (See section 6 of A rating of Deficient on any three of the standards permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

A rating of At-Risk on any of the standards permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

Detainee Discrimination (10%) (Addresses the adequacy of policies and procedures to prevent discrimination against detainees based on their gender, race, religion, national origin, or disability) Discrimination Prevention 4-ALDF-6B-02-03 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 (DCMP) procedures and based upon the performance standard

• Periodic reviews in accordance with the attached performance monitoring tool (see attached) Performance fully complies with all elements of standard at a level no less than acceptable (see Section 6 of the QASP) A rating of Deficient on the standards permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

A rating of At-Risk on any of the standards permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines the QASP)

• Monthly review of corrective action plan results.

• Ad-hoc reviews as needed

• CDRs there is full compliance with the standard or section.

Transition: The Government may withhold or deduct monthly invoiced amount for failure to meet the Transition Plan in accordance with the vendor’s technical quote as follows:

Number of Working Days after the date in the Transition Plan the Contractor was to assume full performance.

Amount Withheld or Deducted from the monthly invoice.

1 to 5 Working Days Up to 5% withhold 6 to 10 Working Days Up to 10% withhold 11 to 15 Working Days Up to 15% withhold or deducted* 16 to 20 Working Days and beyond Up to 20% withhold or deducted* 21 Working Days and beyond Up to 25% withhold or deducted*

* The Government may deduct amounts from the invoice if it determines the Contractor is failing to make substantial progress in meeting the schedule. The decision to withhold or deduct invoice amounts is solely at the discretion of the Government. Deducted amounts are not recoverable by the Contractor.

Appendix B - 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 SOW / Directive: Attach continuation sheet if necessary.)

5. SIGNATURE OF CONTRACTING OFFICER’S TECHNICAL 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

B-1

C-2

Appendix C – Performance Monitoring Tool

D

W

M

Q

DETENTION STANDARD

Rating A/D/R

Corrective Action Required / Comments

Due Date

1. Emergency Plans

A.

Staff trained

B.

Written plans

C.

A complete set of emergency plans is available

D.

Staff work stoppage plan is available

2. Environmental Health and Safety

Staff trained to prevent contact with blood and bodily fluids

Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal

Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken

All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations

DETENTION STANDARDS

A/D/R Corrective Action Required / Comments

3. Transportation (Land Transportation)

Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review

Officers use a checklist during every vehicle inspection

Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents

Two officers with valid Commercial Drivers Licenses, (CDL’s) required in any bus transporting residents

E.

Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles

18. Use of Force and Restraints

Policy governing immediate/calculated use of force

All use of force incidents documented and reviewed

Video tapes of incidents preserved/catalogued for 2 1/2 yrs.

Resident is seen by medical immediately after incident

Facility subscribes to prescribed confrontation avoidance procedures

F.

Staff trained in use of force techniques

G.

Appropriate procedures in place for using 4 point restraints

H.

Medical staff consulted prior to deploying OC spray in calculated use of force situations

I.

All electronic stun devices inventoried and used by facility must be approved by ICE National Firearms and Tactical Training Unit

DETENTION STANDARDS

A/D/R Corrective Action Required / Comments

19. Disciplinary Policy

Rules of conduct/sanctions provided in writing

Incident reports investigated within 24 hours

Disciplinary panel adjudicate infractions

Disciplinary sanctions are in accordance with standards

Staff representation available