Attachment 2 - QASP - Jewish Living.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

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 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: Stephanie Gaxiola, LCSW, MPH, 415-420-0712

Organization or Agency: Department of Veteran Affairs, San Francisco Healthcare System, CNH Program

3. CONTRACTOR REPRESENTATIVES

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

Primary: Rosabella Bray, Director of Patient Financial Services, 415-334-2500 x2689

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. 100% surveillance: Monthly random COR/Program Coordinator/LCSW and RN VA patient visits.

b. PERIODIC INSPECTION. Inspections scheduled and reported annually per COR delegation or as needed. Inspections will include a review of nursing and psycho-social patient care and documentation.

c. VALIDATED PATIENT/CUSTOMER COMPLAINTS. Individual patient/family complaints will be reviewed and investigated within 72 hours of receipt. The scope of the investigation will be dependent on the nature and severity of the complaint.

d. RANDOM SAMPLING. Patients medical documentation will be reviewed randomly during monthly COR/Program

Coordinator/LCSW and RN visits.

e. Verification and/or documentation provided by Contractor. Contractor will be required to submit annual proof of

Liability insurance coverage and a copy of a valid State Skilled Nursing Facility Licensure

PERFORMANCE MEASURES

Measures PWS

Reference

Performance

Requirement

Standard Acceptable

Quality Level

Surveillance

Method

Incentive Disincentive

1.) Maintenance of

State/Federal Licensure and

Certifications, and Liability

Insurance.

Section C

Paragraph 7

The Skilled

Nursing Home

(SNF) shall maintain and provide VA with copies of all State /

Federal licensures, certifications, and investigations reports when requested.

Licensure, Certifications, and

Liability

Insurance must be maintained.

Licensure &

Insurance 100%

Certification or waiver required

Random

Inspection documents

a. Continued patient admissions

b. Maintenance of active VA

Contract.

a. Admission hold until the

CNH is compliant with this standard.

b. Termination of Contract

2.) Adherence to the VA’s quality of care standards as noted in the VA’s Contract

Nursing Home Program

Handbook (See VHA

Handbook 1143.2, “VHA

CNH/CNH Oversight

Procedures and Exclusion

Reviews (June 4, 2004) a copy of which is available at:

http://www.va.gov/vhapubli cations/publications.cfm?pu b=2.)

Section C

Paragraph 1

The SNF will adhere to the standards as noted in the referenced handbook.

The SNF will not possess more than

4 out of the 7 exclusionary criteria noted in section 11, d, (1), (a-g) of the afore mentioned handbook

100% Compliance or waiver required

Annual

Inspection

a. Continued

Contract.

a. Admission hold until the

CNH is compliant with this standard.

b. Additional

Oversight.

c. Removal of

VA Patients from the

Contracted SNF

d. Termination of Contract.

3.) Corrective Action Plan

(CAP)/Plan of Correction

Section C

Paragraph 8

The SNF will cooperate with timely development of

Corrective Action

Requested plans will be completed according to outlined criteria in

All (100%). No deviations accepted.

CNH Team reviews CO

Approves when CAP is submitted.

a. Continued

a. Admission hold until CAP is completed.

http://www.va.gov/vhapublications/publications.cfm?pub=2

Plans (CAPs) related to identified deficiencies and related to VA surveys.

the Performance

Work Statement.

b. Maintenance of active VA

Contract.

4.) Reportable Sentinel

Events

Section C

Paragraph

Sentinel Events shall be reported immediately

(within 24 hours.)

Sentinel Events are reported within 24 hours of incident.

All (100%) of

Sentinel Events incidents are within 24 hours of incident. No acceptable deviation.

Direct

Observation and

Documentati on Provided by

Contractor

a. Continued

Contract.

a. Admission hold until the

CNH is compliant with this standard.

5.) VA access to CNH

Facility medical records

Section C

Paragraph

All medical records (including electronic records) concerning the veteran’s care in the CNH Facility will be readily accessible to VA

CNH Team upon request.

All of the CNH

Veteran records will be accessible to the VA CNH

Team

All (100%) No acceptable deviation

Direct

Observation

a. Continued

Contract.

a. Admission hold until the

CNH is compliant with this standard.

b. Termination of Contract.

6.) Notification of CNH

Veteran Death.

Section C

Paragraph notice of any veteran death within 24 hours or on the first business day after a weekend or holiday, and immediately assemble inventory, and safeguard the patient’s personal effects.

All CNH veteran deaths should be reported.

Required

Completion.

Direct

Communicat ion and

Documentati on Provided by

Contractor

a. Continued patient admissions

a. Admission hold until such time the CNH meets this standard.

7.) CNH Veteran

Rehospitalization at any acute facility.

Section C

Paragraph

Notice of any veteran hospitalization within 24 hours of admission.

All hospitalizations will be reported.

Required

Completion

Direct

Communicat ion, Clinical

Review, and

Documentati

a. Continued patient admissions

a. Admission hold until the

CNH is compliant with this standard.

on Provided by

Contractor

8.) Care Coordination Section C Care Coordination, Discharge

Planning and other interventions involve an interdisciplinary approach and is individualized patient centered plan of care.

Care

Coordination, Discharge

Planning and other interventions will be individualized to the Veteran, creating a patient centered plan of care.

Required

Completion

Chart

Review, Direct

Communicat ion from

Contractor

Increase referral from

VA

Patient

Satisfaction

Possible lower quality rating by

VA in CPAR.

9.) Timely Billing

Submission

Sections C

Paragraph

Invoices for care and ancillary services shall be submitted promptly to the authorizing facility by the 15th calendar day following the end of the month in which services were rendered.

Invoices shall be timely and accurate for all items billed.

Required

Completion

Verification and/or documentati on provided by

Contractor when requested

a. Timely reimbursement

a. Possible delays in reimbursement.

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

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.

VERY GOOD:

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also, there should have been NO significant weaknesses identified.

SATISFACTORY:

Performance meets contractual requirements. The contractual performance of the element or sub-element contains 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.

MARGINAL:

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the

GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g.

Management, Quality, Safety or Environmental Deficiency Report or letter).

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 serious 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. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental

Deficiency Reports, or letters).

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 a CONTRACTOR

PERFORMANCE ASSESSMENT REPORT (CPAR).

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. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

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

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.

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

See Sample CDR below.

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

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

5. DATES

a. CDR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY 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.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE