ATTACHMENT 7 - VISN4 DME QUARTERLY CONTRACTOR PERFORMANCE EVAL REPORT.docx
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About this file
This is a quarterly contractor performance evaluation report template used by the Department of Veterans Affairs Veterans Health Administration VISN 4 to assess durable medical equipment (DME) contractor performance. The form is designated as Attachment 7 and serves as the standardized evaluation instrument for contractors providing DME storage, delivery, installation, and repair services at VISN 4 East medical centers.
The evaluation report captures essential contractor performance metrics across multiple dimensions, including customer service and patient satisfaction compliance with scope of work, timeliness of service delivery, product and service quality, adherence to documentation requirements, adherence to contract schedules and invoicing procedures, and financial oversight of purchase orders and obligations. The form requires the Contracting Officer's Representative (COR) to assess whether the contractor has met expectations for access and service timeliness, document any patient safety incidents or malpractice claims, review service quality concerns, verify compliance with delivery and progress schedules, and note any technical assistance provided. The evaluation includes sections for invoice audits, cost reconciliation against services delivered, identification of uninvoiced services, and escalation of significant issues to the Contracting Officer. The form mandates sign-off by both the rating COR and CO, with certifications that contract documents are maintained, authority limits are understood, and pending requirements for the upcoming quarter are identified. This template was effective as of September 1, 2024.
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Text version
POC NAME:
LOCATION:
SERVICES PROVIDED:
CONTRACTOR:
CONTRACT NO:
PURCHASE ORDER NO:
PERIOD OF PERFORMANCE:
COST / PER UNITS DELIVERED OF SERVICES DURING REPORTING PERIOD:
Review of Contractor Payments, obligations and remaining balances on purchase orders to ensure obligation of money keeps pace with actual usage. Information can be obtained from https://vaww.ipps.fsc.va.gov/prweb/PRWebLDAP1. PLEASE ENSURE INVOICES FROM WEB SITE WITH DATES OF SERVICES ARE UPLOADED TO THE ECMS BRIEFCASE TOTAL $ invoices for period (See invoices in contract file) TOTAL $ not invoiced for services received
COMPLETE INVOICE AUDIT SUMMARY
1. WAS THE CUSTOMER SERVICE/PATIENT SATISFACTION IN ACCORDANCE WITH SCOPE OF WORK?
Yes No - Describe any deficiencies:□
ATTACHMENT 7
VISN4 DME QUARTERLY CONTRACTOR PERFORMANCE EVALUATION REPORT
CRG Appendix F COR Roles/Responsibilities Revision 03 Effective Date: 09/01/2024
Has the contractor met the expectations for access and timeliness of services to meet patient care needs? (e.g. turnaround time for routine vs. emergent services; turnaround time for reports of patient care services, etc.)
YES NO Comments:□
Have there been any patient safety reports from the contractor that have documented injury or harm to our patients?
YES NO Comments:□
Have any VA patients filed any malpractice claims against the contractor?
YES NO Comments:□
Have any patients filed complaints regarding dissatisfaction with care provided by the contractor?
YES NO Comments:□
2. WERE THE CONTRACTOR'S SERVICES/PRODUCTS IN ACCORDANCE WITH SCOPE OF WORK?
Yes No - Describe any deficiencies:□
Have there been any concerns related to the quality of services being provided by the contractor?
YES NO Comments:□
Has the contractor complied with documentation requirements as defined in the contract?
YES NO Comments:□
3. CONTRACTOR FOLLOWED CONTRACT SCHEDULE REPORTING (I.E. TIMELY AND CORRECT INVOICING MATCHING COR RECORDKEEPING, DELIVERY SCHEDULE, PROGRESS SCHEDULE, PERFORMANCE SCHEDULE, ETC.)
Yes No - Describe any deficiencies:□
4. HAVE YOU, AS COR, PROVIDED TECHNICAL ASSISTANCE TO THE CONTRACTOR?
Yes No - Describe why not:□
5. STATE ANY OTHER SIGNIFICANT ISSUES WHICH SHOULD BE BROUGHT TO THE CONTRACTING OFFICER'S ATTENTION.
6. REVIEW OF CONTRACTOR / SUB-CONTRACTOR TRAINING.
A. COR Comments:
Were comments, correspondence, or any additional information provided to the contracting office during this rating period? Yes No□
By signing below, you are certifying that: you have copies of all contract documents required to fulfill your duties, have been briefed and understand the authority (and limits of authority) given you, have received responses to any question or concern given to the contracting officer, have notified the contracting officer of any information that impacts the performance of this contract and understand any pending requirements and related due dates for procurement information in the upcoming quarter:
Name and title of rating COR:
COR Signature: Date:
CO Comments:
CO Signature: Date:
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