ATTACHMENT 2 - QUALITY ASSURANCE SURVEILLANCE PLAN (QASP).docx

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Q999--LOCUM-Hemodialysis-36C249-22-AP-0719 - 603
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36C24922Q0251
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?.## QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Quality Assurance Surveillance Plan 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: Dewana M. Raynor Organization or Agency: Department of Veterans Affairs, Network Contracting Officer - 9

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: Tiffany Young, Administrative Officer/COR Organization or Agency: Department of Veterans Affairs, Robley Rex VA Medical Center

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager: Tiffany Young, Administrative Officer/COR Alternate Program Manager: None Assigned

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

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

c. VALIDATED USER/CUSTOMER COMPLAINTS.

d. RANDOM SAMPLING.

e. Verification and/or documentation provided by Contractor.

6. QASP PERFORMANCE REPORT DATE: April 27, 2022

Measure
PWS Reference
Performance Requirement
Standard
Acceptable Quality Level
Surveillance Method
Incentive
Timeliness of Treatments
4.5.4.1
All Treatments will be performed in accordance w/VAMC physician’s orders in terms of timeliness and duration of treatment.
All treatments are performed according to VAMC physician orders.
100%
Validated customer complaints. COR will investigate all reported complaints (COR)
For complaints determined valid, payment for that day of coverage will be reduced by 50%
Mandatory Education Requirements completed (TMS)
4.5.4.2
Each clinician assigned to this contract is required to complete their annual mandatory TMS training (i.e. to be due on anniversary date of their start date).
All contractors trainings are completed timely.
90%
Periodic Inspection. COR will use TMS Report.
Suspension or termination of all physical and/or electronic access privileges and removal from work on the contract, until training is completed.
Contractor personnel will perform weekly bacteria cultures of RO and Dialysis machines
4.5.4.3
Cultures performed weekly, 100% of the time. Results communicated weekly to Medical Service Office.
Cultures are performed weekly, 100% of the time. Results communicated weekly to COR or designee.
100%
Verification and/or documentation provided by Contractor. Weekly results will be logged and maintained in medical service
Noncompliance may result in unfavorable contractor performance evaluation, which could result in not exercising option year period.
Documentation of bacteria culture results, action plan for results not meeting standards
4.5.4.4
Documentation of bacteria culture results requiring action (biweekly testing), any results falling outside AAMI standards will be documented, findings, action plans, and follow-up to the plans will be documented on the log sheet. Monthly reports will be provided to the Medical Service office.
Documentation of bacteria culture results requiring action (biweekly testing), any results falling outside AAMI standards are documented, findings, action plans, and follow-up to the plans will be documented on the log sheet.
95%
Verification and/or documentation provided by Contractor. Results will be logged monthly and maintained in medical service
Noncompliance may result in unfavorable contractor performance evaluation, which could result in not exercising option year period.
Documentation requirements
4.5.4.5
Treatment documentation shall be entered into CPRS electronically and signed within 24 hours
All treatment documentation is entered into CPRS electronically and signed within 24 hours.
95%
Periodic Inspection. COR will utilize Vista ^TIU notes report.
Payment for services rendered for patients without documentation will be withheld. For untimely documentation, payment for that day of coverage will be reduced by 50%
Staff Competencies
4.5.4.6
Contractor will provide copies of Nursing Staff’s Annual Competencies, performance evaluations, License and BLS cards
Contractor must provide copies of Nursing Staff’s Annual Competencies, performance evaluations, License and BLS cards for each contractor listed on the contract.
100%
Periodic Inspection. COR will review Employee file review (COR)
Suspension or termination of all privileges and removal from work on the contract, until competency information is provided to the VAMC.

7. CPAR RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual: https://www.cpars.gov/documents/CPARS-Guidance.pdf.

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 thecontractual 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).

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 (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 Report (CR), 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 CR in writing. The CR 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 CR 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. 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.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample on following page.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Tiffany Young, Administrative Officer/COR DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

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 Identified (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 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.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME
TITLE
SIGNATURE
DATE

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

END OF QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

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