D.3 - QASP.docx

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Q402--Seeking New CNH AR (Jackson)
Solicitation number
36C25625Q0389
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About this file

This document is a Quality Assurance Surveillance Plan (QASP) for a Medicaid nursing home care contract with the Department of Veterans Affairs (VA). The QASP outlines performance monitoring methods for a Community Nursing Home (CNH) contract, specifically for veterans' care in Arkansas (AR). Key government personnel include Contracting Officer Jennifer Adams and Ordering Officer Sean Ferguson from the VA.

The QASP establishes six primary performance indicators that will be monitored, including requirements for: providing state/federal licensure documentation, developing corrective action plans, reporting veteran hospitalizations and deaths within specified timeframes, documenting reportable events, maintaining accessible medical records, and submitting accurate invoices. Surveillance methods include periodic reviews, spot checks, direct observation, inspections, and user surveys. Performance will be rated on an acceptable quality level scale, with unacceptable performance potentially resulting in a Contract Discrepancy Report (CDR) and required corrective action plans. The document is effective as of 12/19/2022 and is marked as Revision 03.

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File Type Posted
D.1 - LEVELS OF CARE.pdf PDF
D. 2 - VA FORM 10-7078.pdf PDF
D.4 - WAGE DETERMINATION 2015-5141 12232024.pdf PDF
36C25625Q0389.docx DOCX document
D.5 - WD 1973_0121 nonstandard AR rev 61 12-23-2024.pdf PDF

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Medicaid QASP Contract Number: TBD Time Period: _____________________

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 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): Jennifer Adams, 601-206-6955

· Organization or Agency: U.S. Department of Veterans Affairs

b. The CNH Personnel/Social Worker designated by the CO as an Ordering Officer (OO) shall be responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The OO shall keep a quality assurance file. The OO is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned OO(S)/COR: Sean Ferguson, 479-443-4301, Ext. 63467.

c. Other Key Government Personnel - Shirley Thurston, 479-444-5065

QUALITY ASSURANCE SURVEILLANCE PLAN

Nursing Home Care

No.
Paragraph in PWS
Indicator/Performance Standard
Standard for Quality Level
Acceptable Quality Level
Method of Surveillance[footnoteRef:2] [2: See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.]

Rating

1
(B)(9)
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
2
(B)(10)
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
3
(B)(13)
Notice of veteran being hospitalized within 72 hours and notice of any veteran death within 24 hours or immediately the first business day after a weekend or holiday.
100%
95%
Periodic Reviews and spot checks
4
(B)(15)
Notice of all reportable events on VA contract veterans and all facility sentinel events within 24 hours or immediately upon the first business day after a weekend or holiday.
100%
100%
Periodic reviews
5
(B)(17)
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
6
(B)(21)
Invoices shall be timely and accurate for all items billed.
100%
95% -100%
Periodic Reviews and spot checks

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager – As assigned by facility

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.

5. INCENTIVES/RATING STANDARDS

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

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:

See above Acceptable Quality Level & Method of Surveillance located in QASP

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 OO shall work with the Contracting Officer (CO) who will inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the OO/VA Coordinator shall document the discussion and place it in the OO/VA Coordinator’s file. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the OO will work with the contractor to increase performance to an acceptable level.

When the CO determines formal written communication is required, the OO/VA Coordinator 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 OO/VA Coordinator. 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 and the CO will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The OO and CO shall meet with the contractor as needed to assess performance and provide a written assessment.

Signature – Contractor

Signature Ordering Officer/VA Coordinator

Signature – Contracting Officer

Effective Date: 12/19/2022 Revision: 03 Page 1 of 5

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