Attachment 1 QASP Lincoln.pdf

Attachment 1: Quality Assurance Surveillance Plan (QASP)

The contractor will be evaluated in accordance with the following:

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 through contract modification. 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:

NCO 23 Contracting Office

Organization or Agency: Department of Veterans Affairs, Veterans Health Administration

b. Contracting Officer’s 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:

Nominated by VA Nebraska-Western Iowa Health Care System

Organization or Agency: Department of Veterans Affairs, Veterans Health Administration

3. CONTRACTOR REPRESENTATIVES:

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract:

Primary: ______________________________________

Alternate: __________________________________

Quality Assurance Surveillance Plan (QASP)

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. Review of facility, personnel qualifications, and all required documentation.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

c. CUSTOMER REPORTING: Verbal, email or other reports of timeliness of response to admission referrals.

d. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR: Review of state agency reports when requested.

6. SAMPLE QASP PERFORMANCE REPORT

PERFORMANCE MEASURES

Measures PWS Reference

Performance Requirement Standard Acceptable

Quality Level Surveillance

Method (at least monthly)

Met AQL / Did Not meet AQL

1 - Qualifications of Key Personnel D.1.

All Staff are Qualified, trained and orientated who provide the contracted services to the VA.

100% Certification of

Key Personnel if required by state or policy.

100% No deviations accepted.

Direct Observations, Verification /

Documentation by Contractor

3 – Timely Response to Referral Requests D.2.

All Referral Requests are responded to promptly, either accepted or Not

Accepted

100% of all referrals responded to within 2 business Day.

95% Direct Observation, Customer Reporting

4- Individual Care Plan (case record) D.6

Each Veteran entered into services has an Individual Care

Plan Developed.

100% Within 14 days of entry.

100% No deviations accepted.

Direct Observation, Customer Reporting

5 – Documentation D.6.

Complete documentation per

PWS including documentation submitted with

Invoices. Retention of documentation for 7 years from final expenditure report.

All Required Documents shall be submitted to the

COR upon request.

Submission of invoices will follow policy.

100% No deviations accepted.

Direct Observation

6 – Life Safety Code Compliance D.7.

Facility shall maintain compliance with Life Safety Code

Facility Meets NFPA Life

Safety Code Standards

100% No deviations accepted.

Verification / Documentation by Contractor

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

EXCEPTIONAL:

Performance meets contractual requirements and exceeds many to the elements for the Government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.

SATISFACTORY:

Performance meets contractual requirements. The contractual performance meets all of the element or sub-element requirements with some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.

UNSATISFACTORY

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains problem(s) for which the contractor’s corrective actions appear or were ineffective.

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating.

8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR

PERFORMANCE ASSESSMENT REPORT SYSTEM (CPARS).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. A Contract Report (CR) form may be used to document unacceptable performance.

c. The contractor shall prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. tractor has to present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.

d. Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR below.

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED: b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE:

6.ISSUE OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO

PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting. The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance. The chart in paragraph 6 of this QASP will be reported quarterly.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME / TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE