D.1 QASP CNH.doc
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- Attached to
- Community Nursing Home Open and Continuous Request for Quote Federal contract opportunity
- Solicitation number
- 36C25724Q0154
About this file
This document outlines a Quality Assurance Surveillance Plan (QASP) for nursing home care services to be provided under an Indefinite Delivery contract with the Department of Veterans Affairs. The QASP defines performance standards and acceptable quality levels for services including providing licensure and certification documents, notifying the VA of hospitalizations or deaths within 24 hours, submitting reports of reportable events and sentinel events concerning VA contract veterans within 24 hours, and maintaining readily accessible and properly formatted medical records. Performance will be monitored through methods such as direct observation, periodic inspections, user surveys, and analysis of reports, with ratings given for acceptable, neutral, or unacceptable performance. Documentation of acceptable or unacceptable performance will be retained in the contracting officer's representative's file.
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| D.2 WD CNH 1973-0121 dated Jun 2023.pdf | ||
| S02 36C25724Q0154 V2.pdf | ||
| D.3 Levels of Care - RUG IV Descriptions.pdf | ||
| D.4 Resource Utilization Groups (RUGs) IV Description (1).docx | DOCX document |
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Text version
Quality Assurance Surveillance Plan (QASP) 36C25724Q0154 Community Nursing Home
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. 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): Frank Mendoza
· Assigned Contract Specialist: Tammy Wilson
· Organization or Agency: U.S. Department of Veterans Affairs
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(S): TBD
c. Other Key Government Personnel – N/A
3. Contractor Representatives
The following employees of the contractor serve as the contractor’s program manager for this contract.
a. Program Manager –TBD
b. Other Contractor Personnel - As assigned by facility
4. Performance Standards Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.
QUALITY ASSURANCE SURVEILLANCE PLAN
Nursing Home Care
| No. |
| Paragraph in PWS |
| Indicator/Performance Standard |
| Standard for Quality Level |
| Acceptable Quality Level |
| Method of Surveillance |
Incentive
| 1 |
| QASP 1 |
| Nursing Home shall provide VA with copies of all State / Federal licensures, certifications, and investigations reports when requested. |
| 100% |
| 100% |
| Periodic Reviews and spot checks |
| Positive past performance rating |
| 2 |
| QASP 2 |
| The Contractor shall cooperate in developing plans of corrective action according to outlined criteria in the Performance Work Statement. |
| 100% |
| 100% |
| Periodic Reviews and spot checks |
| Positive past performance rating |
| 3 |
| QASP 3 |
| Notice of veteran being hospitalized within 24 hours and notice of any veteran death within 24 hours. |
| 100% |
| 95% |
| Periodic Reviews and spot checks |
| Positive past performance rating |
| 4 |
| QASP 4 |
| Notice of all reportable events on VA contract veterans and all facility sentinel events within 24 hours. |
| 100% |
| 100% |
| Periodic reviews |
| Positive past performance rating |
| 5 |
| QASP 5 |
| All medical records concerning the veteran's care in the nursing home a) will be readily accessible to VA, and b) within acceptable standards and practice. |
| 100% |
| 100% |
| Periodic Reviews and spot checks |
| Positive past performance rating |
| 6 |
| QASP 6 |
| Invoices shall be timely and accurate for all items billed. |
| 100% |
| 95% -100% |
| Periodic Reviews and spot checks |
| Positive past performance rating |
5. Incentives/RATING STANDARDS There will be no incentives associated with this contract
6. Methods of QA Surveillance
Various methods exist to monitor performance.
a. DIRECT OBSERVATION
b. PERIODIC INSPECTION
c. USER SURVEY
d. VALIDATED USER/CUSTOMER COMPLAINTS
e. INSPECTION
f. PERIODIC SAMPLING
g. RANDOM SAMPLING
h. PROGRESS OR STATUS MEETINGS
i. ANALYSIS OF CONTRACTOR’S PROGRESS REPORTS
7. Ratings Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:
8. DOCUMENTING PERFORMANCE
a. Acceptable Performance
The Government shall document positive OR NEGATIVE performance. Any report may become a part of the supporting documentation for any contractual action.
b. Unacceptable performance When unacceptable performance occurs, the COR shall work with the Contracting Officer (CO) inform the contractor. This will 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. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the COR will work with the contractor to increase performance to an acceptable level.
When the COR and CO determines formal written communication is required, the COR and CO shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.
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 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.
9. Frequency of Measurement
a. Frequency of Measurement.
During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.
b. Frequency of Performance Assessment Meetings.
The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.
Signature – Contractor
Signature – Contracting Officer Representative See above Acceptable Quality Level & Method of Surveillance located in QASP
� See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.
Community Nursing Home SOP
Original Date: 05/02/2016
File details come from the government source that posted it. Updated .