D.1 Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP) Intensive Outpatient Program (IOP) Beds

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 ensure 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: Karen Williams

Assigned CS:

Organization or Agency: Network Contracting Office, NCO 10, Columbus, and Cincinnati, Ohio

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: Jordan Facter

Organization or Agency: Cleveland VA Medical Center

3. CONTRACTOR REPRESENTATIVES

Quality Assurance Surveillance Plan (QASP) Intensive Outpatient Program (IOP) Beds

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

Primary:

Alternate:

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 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: Weekly meetings between contractor and VA clinical staff to review all residents’ cases in the IOP currently.

b. PERIODIC INSPECTION. Inspections of the contractor facility will be conducted at a minimum annually to inspect the residential setting and contractor records for VA IOP residents. VA staff will be monitoring compliance with all safety standards per State of Ohio and record keeping per VA standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. All residents will be provided with satisfaction survey at time of discharge. All complaints will be reviewed and responded to by contractor with a summary provided to VA COR.

d. RANDOM SAMPLING. VA clinical staff will review case records for enrolled Veterans. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor.

6. QASP PERFORMANCE REPORT DATE: __________________

Performance Standard Indicator Standard

Acceptable Quality Level

(AQL)

Method of Surveillance

Met/Did Not Meet Acceptable Quality

Level

Invoices

16.5.1

All invoices received from contractor are accurate and submitted by the 15th of the month following the end of billing period.

Invoices received from the contractor are accurate and timely.

95%

Contractor submitted invoices and census report are checked by COR.

Documentation

16.5.2

Contractor will complete an admission form and a discharge form for each veteran resident and submit to VA within 24 hours.

Contractor will submit weekly census reports to

COR.

100% Completion

100%

On a monthly basis, COR reconciles all forms and reports to invoice.

Delivery of Support Services & Placement

16.5.3

Contractor will respond to all referrals within one (1) business day and arrange for admission of approved Veterans within one (1) business day of clinically indicated date by VA staff.

At least 95% of Veterans identified and determined eligible for VA IOP will be admitted within 24 hours of initial assessment

95%

COR will monitor all eligible Veterans completing an initial assessment quarterly.

Reports: Status in Veteran Changes

16.5.4

Contractor will provide VA IOP treatment teams with weekly reports on changes and progress in Veteran’s status and any transportation or follow- up appointment challenges.

100% of VA IOP Veteran residents

100%

Review of contractor submitted reports and contractor’s participation in the weekly VA IOP team meetings (virtually) and quarterly program updates.

Notification of significant events and safety concerns

16.5.6

The contractor shall notify COR of any hospitalization, high risk situation including veterans with suicidal and/or homicidal threats or ideation, episodes of physical or sexual violence, sexual activities, safety concerns, drug activities so that appropriate coordination of care can be facilitated.

100% within 24 Hours or the next business day.

100%

Contractor to provide written summary of notifications quarterly to Contracting Officer Representative (COR).

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

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.

SATISFACTOR

Y:

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 https://www.cpars.gov/pdfs/CPARS-Guidance.pdf tool that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACT

ORY: 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).

8. 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 determine 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.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

CONTRACTOR NAME/TITLE DATE