Attachment 13 - Quality Assurance Surveillance Plan.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

1. INTRODUCTION

ICE’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 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 Contractor shall develop a comprehensive program of inspections and monitoring actions and 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 Agreement.

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 representative) will use to evaluate the services the Contractor is required to furnish.

This QASP is based on the premise the Government will validate that the Contractor is complying with ERO-mandated quality standards in operating and maintaining detention facilities.

Performance standards address all facets of detainee handling, including safety, health, legal rights, transportation, food/commissary services, supplies/services, recreational, facility and records management, etc. Good management by the Contractor and use of an approved QCP will ensure that the Facility is operating within acceptable quality levels.

2. DEFINITIONS

Performance Requirements Summary (Attachment A): The Performance Requirements Summary (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) 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 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 Contractor 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 2011 PBNDS with 2016 revisions at http://www.ice.gov/detention-standards/2011 as well as the ACA standards for ALDF. Other standards may also be defined in the Agreement.

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.

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 in accordance with the percentages listed in Attachment 18A - Performance Requirements Summary. The Contractor 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 Contractor 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 Attachment A for a summary list of performance requirements.)

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

The Contractor’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 Contractor’s QCP activities should 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.

The Contractor 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 Contractor 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 Contractor 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

• Records of investigative actions taken

• Equipment inspections

• System tests and evaluation

5. METHODS OF SURVEILLANCE

ICE will monitor the Contractor’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

Contractor’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 detainees.

5.1 Documentation Requirements: The Contractor 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 Contractor 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.

The G-391 Upload Template will be completed and validated by the contractor on a monthly basis so that there are no errors for each of the trips in the G-391 upload template. Errors are indicated by rows, columns, and cells that are highlighted when the vendor checks the validation using the tool. If the COR identifies errors that have not been corrected, they will resend the report to the vendor to fix and resubmit within 5 business days. All reports must align with invoice amounts and dollar values.

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 Contractor 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 the Agreement, 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 shall 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 “Changes” clause. ICE reserves the right to develop and implement new inspection techniques and instructions at any time during performance without notice to the Contractor , 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 is essential for the Contractor to receive full payment as identified in the Agreement. The Contracting Officer may take withholdings or 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 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 Contractor’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 Contractor’s monthly invoice. This may happen when a significant event occurs, when a particular deficiency is noted multiple times without correction, or when the Contractor 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 Contractor has either corrected the deficiency, or made substantial progress in the correction.

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,” but may also relate to a deficiency in the area of “Administration and Management.” In no event will the withhold or deduction exceed 100% of the invoice amount.

8. NOTIFICATIONS

(a) Based on the inspection of the 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 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 correct 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 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 Contractor .

(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 (includes detainees in restraints more than eight hours);

assaults on staff or detainees 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 Facility; escape; weapons discharge; 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); fence damage; power outages; bomb threats; significant environmental problems that impact the Facility 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 include the CDR in its monthly report, with a copy to the Contracting Officer. The CDR will be accompanied by the COR’s investigation report and written recommendation for any withholding. 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 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 Contractor notification that the correction has been made, the COR may re-inspect the Facility. 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 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 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. DETAINEE OR MEMBER OF THE PUBLIC COMPLAINTS

The detainee 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 Contractor for remedy. Upon notification, the Contractor shall be given a pre- specified number of hours 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.

10. ATTACHMENTS

A. Performance Requirements Summary

B. Contract Discrepancy Report

Attachment A – Performance Requirements Summary

FUNCTIONAL AREA PERFORMANCE STANDARD

(PBNDS 2011) WITHHOLDING CRITERIA

Safety Addresses a safe work environment for staff, volunteers, contractors and detainees

PBNDS References: Part 1 -

SAFETY

1.1 Emergency Plans;

1.2 Environmental Health and

Safety;

1.3 Transportation (by Land).

A Contract Discrepancy Report that cites violations of cited PBNDS and PWS (contract) sections that provide a safe work environment for staff, volunteers, contractors and detainees, permits the Contract Officer to withhold or deduct up to 15% of a month invoice until the Contract Officer determines there is full compliance with the standard or section.

Security Addresses protection of the community, staff, contractors, volunteers and detainees 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 and Restraints.

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 Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

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

PBNDS Reference: Part 3 - ORDER

3.1 Disciplinary System.

A Contract Discrepancy Report that cites violations of PBNDS and PWS (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 of section.

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

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.

A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

Activities Addresses contractor 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;

5.4 Recreation;

5.5 Religious Practices;

5.6 Telephone Access;

5.7 Visitation;

5.8 Voluntary Work Program.

A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that reduce the negative effects of confinement permits the Contract Officer to withhold or deduct up to 5% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.

FUNCTIONAL AREA PERFORMANCE STANDARD

(PBNDS 2011) WITHHOLDING CRITERIA

Justice Addresses contractor responsibilities to treat detainees fairly and respect their legal rights

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.

A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that treat detainees fairly and respect their legal rights, 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.

Administration and Management Addresses contractor responsibilities to administer and manage the facility in a professional and responsible manner consistent with legal requirements

PBNDS References: Part 7 - -

ADMIN &

MANAGEMENT

7.1 Detention Files;

7.2 News Media Interviews and

Tours;

7.3 Staff Training;

7.4 Transfer of Detainees;

Accommodations for the Disabled, 4-ALDF-6B-04, 4-ALDF-6B-07

A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that require the Contractor’s administration and management of the facility in a professional and responsible manner consistent with legal requirements, 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 Addresses the adequacy of the detention/correctional officer hiring process, staff training and licensing/certification and adequacy of systems

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-

A Contract Discrepancy Report that cites violations of the ALDF Standards associated with Workforce Integrity and PWS (contract) sections 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 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

A Contract Discrepancy Report that cites violations of the ALDF Standards associated with Detainee Discrimination and PWS (contract) sections 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.

Attachment B – CONTRACT DISCREPANCY REPORT (CDR)

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.)

Discrepancy or Problems include reference to statement of work:

Continued on Attached Continuation Sheet

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