Attachment D.2 - DOM Catering Contract QASP.pdf

Domiciliary Residential

Rehabilitation Treatment Program Catering

QASP: Quality Analysis Surveillance Plan

INTRODUCTION:

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contractor actions while implementing this Performance Work Statement (PWS). The QASP provides a systematic method to evaluate the services the contractor is required to furnish.

The QASP is based on the premise, the government desires to maintain a quality standard in providing primary care/mental health services to its patients. The resulting contract is considered the best means of achieving that objective.

PURPOSE:

The contractor, and not the government, is responsible for management and quality control actions to meet the terms of the contract. The role of the government is Quality Assurance (QA) to ensure contract standards are achieved.

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. The contractor is required to develop a comprehensive program of inspections and monitoring actions to ensure quality control.

This QASP explains the following:

What shall be monitored?

How monitoring shall take place.

Who shall conduct the monitoring?

How monitoring efforts and results shall be documented.

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.

Careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

PERFORMANCE STANDARDS:

Performance standards define desired services. The government performs surveillance to determine if the contractor exceeds, meets, or does not meet these standards. The performance requirements summary matrix is incorporated within this QASP to include performance standards and disincentives. The government shall use these standards to determine contractor performance to Acceptable Quality Level (AQL) defined below for each performance requirement.

Task Standard Performance Threshold/Acceptable Quality

Method of Surveillance

The dietary needs of all veterans shall be met in accordance with sound nutritional and medical standards as outlined in the VHA directive in PWS (Attachment D.5).

At least 3 nutritious meals will be served daily, at regular times with in between snacks/ 8pm snacks as deemed medically necessary. Bag lunches are to include all food groups. Food items shall be prepared, served, and stored under sanitary conditions. Sanitary procedures shall be established and maintained for washing dishes, cleaning equipment and work areas as well as proper waste disposal. Special meals shall be provided on federal holidays.

90% during quarterly rating period

The government will preform quarterly inspections (at a minimum- these can be increased if needed per government discretion) to assess kitchen sanitation.

Quarterly EOC rounds will also assess kitchen sanitation and provide report of errors that need to be corrected. The contractor will perform weekly inspections for the government to review at time of our inspection. Tray assessments will be completed by the government 3x month to assess food quality, temperature, and acceptability.

The government will provide an updated snack list to contractor as new patients are admitted/assessed.

Special meal menu and nutrient analysis shall be provided by the contractor to the government 30 days in advance of the special meal.

Records & Reports:

The contractor shall maintain adequate records and reports for CO, COR, or RD review to aid in evaluation of the contract.

The Contractor shall maintain up to date records on the following:

- Material Safety Data Sheets (MSDS).

- Weekly Sanitation inspections using Attachment D.9- Food Safety and Sanitation Audit.

- Daily temperature logs of all refrigerators and salad bar at least 3x day.

-Daily temp logs for dish machine reflecting in range temps, 3x day for proper sanitation of dishes as indicated on dish machine.

- Daily temp logs for all foods prepared (Cook’s Log reflecting final temp of food as it is prepared and tray line log reflecting holding temps >135.)

-Four, 6-week cycle menus shall be submitted to the COR for review on yearly basis with corrections made and returned as indicated in the PWS.

-Submit before the 15th of the month the cost analysis with actual meals served for COR review.

Cleaning/maintenance records of all equipment outlined in Attachment D.6-

90% during quarterly rating period.

During weekly/bi-weekly or bi- monthly and annual visits and random sampling of records, the VA will ensure facility compliance to the PWS and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the contractor’s facility.

Kitchen Equipment at the Domiciliary.

-Contractor shall provide the CO/COR with all necessary paperwork for background inspections for each employee within a week of a new hire.

-Contractor shall provide records of training documentation to the CO/COR within a week of hire and yearly as needed.

Staffing: At a minimum, there must always be at least one Serv-Safe certified food handler (foodservice worker) and one Serv-Safe certified manger (cook/manager) on duty while the kitchen is open from 5:30am to 7pm. If sufficient contracted staff has not arrived 30 min to a given mealtime- the government will initiate the contingency plan.

100% during quarterly rating period.

During weekly/bi-weekly or bi- monthly or prn and annual visits and random sampling of records, the VA will ensure facility compliance to the PWS and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the contractor’s facility.

Veteran Stakeholder Satisfaction:

The government shall provide veterans with three opportunities for feedback regarding foodservice: monthly satisfaction survey in Community Meeting, as well as monthly Customer satisfaction Survey specific to nutrition, and through Suggestion boxes throughout the facility.

70% minimum satisfaction during quarterly rating period

- Veteran Customer Survey -Veteran Customer Satisfaction Survey (specific to foodservice) -Veteran Suggestion boxes throughout the facility.

-Veteran suggestions taken during tray assessment

The government CO/COR/RD will work with contracting to find a reasonable solution to patient complaint/concerns.

completed 3x month as well.

Contractor shall provide feedback/resolution to Veteran concerns within a week of receiving this complaint.

Surveillance: The COR shall use the surveillance methods listed below in the administration of this QASP.

Direct Observation - Direct observation shall be performed periodically or through 100% surveillance. All performance standards.

Periodic Inspection - Evaluate outcomes on a periodic basis. Inspections may be scheduled daily, weekly, monthly, quarterly, annually, or unscheduled, as required. All performance standards.

Progress or status meetings - All performance standards.

Complaints - Complaints from agency personnel shall be passed to the contractor for correction.

All performance standards.

Standard: Customer complaints shall not exceed the thresholds cited above for each performance objective. The government’s QA personnel shall notify the Contracting Officer (CO) for appropriate action in accordance with FAR 52.212.4, Contract Terms and Conditions – Commercial Items (May 1997) or the appropriate inspection of services clause, if any of the above service area exceed the customer complain thresholds.

DOCUMENTING PERFORMANCE:

Acceptable Performance – The government shall document performance. Any report may become a part of the supporting documentation for any contractual action.

Unacceptable performance – When unacceptable performance occurs, the COR shall inform the contractor. This shall 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.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the Contracting Officer. In turn, the CO shall present the CDR to the contractor’s contracting personnel.

The contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long, after receipt, the contractor must 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.

Surveillance: The government evaluator shall evaluate the services required by each deliver/task order to ensure complete compliance.

Procedures: The government evaluator shall inspect to ensure contractor compliance with the appropriate section of the PWS periodically. The evaluator shall record results of inspection, noting the date & time of inspection. If inspection indicates unacceptable performance, the government evaluator shall notify the CO and/or QCI of the deficiencies and have QCI correct those deficiencies. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

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

a. Frequency of Performance Assessment Meetings.

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

SAMPLE CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER ____________________

2. REPORT NUMBER FOR THIS DISCREPANCY _________________________

3. TO (Contractor and Manager's Name) _______________________

4. FROM (Name of COR) ______________________

5. DATES (YYYYMMDD)

a. PREPARED ________________ b. RETURNED BY CONTRACTOR____________

c. ACTION COMPLETE _________________

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS; attach continuation sheet if necessary.)

7. SIGNATURE OF CONTRACTING OFFICER__________________

8a. TO (Contracting Officer) __________________

b. FROM (Contractor)_______________________

9. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO

PREVENT RECURRENCE. (Cite applicable Q.C. program procedures or new Q.C. procedures.

Attach continuation sheet(s) if necessary.)

10. SIGNATURE OF CONTRACTOR REPRESENTATIVE_________________________

b. DATE (YYYYMMDD) _________________

11. GOVERNMENT EVALUATION (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary)

12. GOVERNMENT ACTIONS (Reduced payment, cure notice, show cause, other