Attachment J - QASP TEMPLATE - - VISN 2 DOWNSTATE HOME OXYGEN SERVICES.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) PERFORMANCE REPORT

Contract Number:

Contract Description: Home Oxygen Services for VISN 2 North Contractor’s Name: , hereafter referred to as the Contractor Performance Period:

8.1

D = Number of set-ups audited

All set-ups reviewed

Monthly

*Note that compliance excludes situations outside contract control: patient on travel, patient hospitalization, patient refusal to allow access, inability to reach patient, etc.

N = Number of RT Visits completed on time in accordance with requirements, unless circumstances beyond Contractor control.

D = Number of RT visits audited

All RT visits

D = Number of patients receiving Contractor visit

Contractor Submitted Data;

Random audit of 5 patients served by Contractor for each service area. If less than 5 patients served, all are audited.

D = Number of RT notes audited

All RT notes

19.1 19.7

Random Inspection;

Review of monthly JC compliance report

5=100%, 4=75%, 3=50%, 2=25%, 1=0%.

NDR (no data received) appears as a 0% on the trend graph.

Questions left blank are not calculated into the score.

N = Number of VA patients satisfied with Contractor’s service. Customer Satisfaction survey is to be developed by Contractor and approved by VA

D = Number of VA patients audited for patient satisfaction

Review of all patients that receive set-up and return surveys.

Review of monthly invoice

2.1 13.3

D = Number of RT progress notes audited

Random audit of 5 patients served by Contractor for each service area. If less than 5 patients served, all are audited.

D = Number of RRTs and Service Technicians

State Licensure Boards/Vendor Training Logs

Quarterly/Annual

COR SIGNATURE:

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/pdfs/CPARS-Guidance.pdf p. A2-1):

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.

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.

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.

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).

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).