Attachment 2- QASP- Hale Ho Aloha.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

1. PURPOSE

a. 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.

b. 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.

c. 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. 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 Contracting Officer (CO): Gary T. Basile, Contracting Officer, 916-923-4537

Assigned Contract Specialist (CS): Jonathan Locklear, Contract Specialist, 916-923-4552

Organization or Agency: Network Contracting Office (NCO) 21

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: Terry Leong, CFA Administrative Officer, 808-433-4806

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

Program Manager: Bryce Sumida, Administrator, 808-524-1955 x128, bsumida@halehoaloha.com

PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

No. Paragraph in PWS

Indicator/Performance

Standard

Standard for

Quality

Level

Acceptable

Quality

Level

Method of

Surveillance1

1 (C)(12) Nursing Home shall provide

VA with copies of all State /

Federal licensures, certifications, and investigations reports when requested.

100% 100% Periodic

Reviews and spot checks

2 (C)(13) The Contractor shall cooperate in developing plans of corrective action according to outlined criteria in the

Performance Work Statement.

100% 100% Periodic

Reviews and spot checks

3 (C)(16) Notice of veteran being hospitalized within 72 hours and notice of any veteran death within 24 hours or immediately the first business day after a weekend or holiday.

100% 95% Periodic

Reviews and spot checks

4 (C)(18) Notice of all reportable events on VA contract veterans and all facility sentinel events within

24 hours or immediately the first business day after a weekend or holiday.

100% 100% Periodic reviews

5 (C)(20) All medical records concerning the veteran's care in the nursing home a) will be readily accessible to VA, and b) within acceptable standards and practice.

100% 100% Periodic

Reviews and spot checks

6 (C)(30) Invoices shall be timely and accurate for all items billed.

100% 95% -100% Periodic

Reviews and spot checks

4. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. There will be quarterly meetings held with the

Contractor to discuss any issues. In addition, the COR shall use the following surveillance methods in

1 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

the administration of this QASP:

a. Direct Observation. Observation will be taken during any and all site visits by a VA staff.

b. Periodic Inspection. Formal evaluations shall be done annual or as needed. Inspections may be announced or unannounced.

c. Validated User/Customer Complaints. VA staff relies on the Veteran to identify deficiencies.

Veterans will be queried as to the services being provided to them. Any identified concerns or complaints are then investigated and validated.

d. Random Sampling. Random sampling of patient names listed on the monthly detailed invoice shall be verified in CPRS.

e. Progress or status meetings. There will be quarterly meetings held with Contractor to discuss any issues.

6. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

The rating method may depend on the monitoring techniques you select. One rating method may be used for all standards or multiple methods may be used.

Exceptional

Performance significantly exceeds contract requirements to the Government's benefit

Satisfactory

Performance meets contractual requirements

Unsatisfactory

Performance does not meet contractual requirements

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

• The Government shall document positive OR NEGATIVE performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

• When unacceptable performance occurs, the COR shall work with the Contracting Officer

(CO) inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the COR shall document the discussion and place it in the COR file. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the COR will work with the contractor to increase performance to an acceptable level.

• When the COR and CO determines formal written communication is required, the COR and CO shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

• The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability.

• Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Representative