ATTACHMENT_01_ MIA _-_QASP _PRS _CDR.doc

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Attachment 01

QUALITY ASSURANCE SURVEILLANCE PLAN

1. INTRODUCTION

ICE’s Quality Assurance Surveillance Plan (QASP) is based on the premise that the Service Provider, and not the Government, is responsible for the day-to-day operation of the Family Case Management Services program and all the management and quality control actions required to meet the terms of the Agreement. The role of the Government in quality assurance is to ensure performance standards are achieved and maintained. The Service Provider shall develop a comprehensive program of review and monitoring actions and document its approach in a Quality Control Plan (QCP). The Service Provider’s QCP, upon approval by the Government, will be made a part of the resultant Agreement.

This QASP is designed to provide an effective surveillance method to monitor the Service Provider’s performance relative to the requirements listed in the Agreement. The QASP illustrates the systematic method the Government (or its designated representative) will use to evaluate the services the Service Provider is required to furnish.

This QASP is based on the premise the Government will validate that the Service Provider is complying with federal statutes and regulations, ICE ERO policies and mandated quality standards, and contract deliverables, in operating and maintaining ICE ERO Family Case Management Services program. Performance standards address all facets of program participant services, including educational, mental and physical health, cognitive awareness, and substance abuse services, etc. Good management by the Service Provider and use of an approved QCP will ensure that the Family Case Management Program is operating within acceptable quality levels.

2. DEFINITIONS

Acceptable Quality Level: The minimum level of quality that will be accepted by ICE to meet the performance standard.

Case Management Services: Services provided by a program or vendor used to meet the needs of a family unit.

Contracting Officer’s Representative (COR): The COR interacts with the Service Provider to inspect and accept services/work performed in accordance with the technical standards prescribed in the Agreement. The Contracting Officer issues a written memorandum that appoints the COR. Other individuals may be designated to assist in the review and quality assurance surveillance activities.

Community Case Manager (CCM): The CCM provides case management services to family units upon enrollment.

Corrective Action Plan: A program’s detailed remedy to correct deficiencies in the program’s compliance with federal licensing regulations and other legal requirements identified by the licensing agency or other state or federal agency within the prescribed period of time.

Deduction: Funds may be deducted from a monthly invoice for an egregious act or event, or if the same deficiency continues to occur. The Service Provider will be notified immediately if such a situation arises. The Contracting Officer in consultation with ERO will determine the amount of the deduction. Amounts deducted are not recoverable.

Deficiency: An observation or result that indicates a program is non-compliant with statutory law, a regulation, a contractual agreement, or [ICE ERO] policy and procedures.

Family Service Plan: A written plan which identifies the needs, objective, and service linkages provided to program participants.

Measures: The method for evaluating compliance with the standards.

Performance Requirements Summary (Attachment A): The Performance Requirements Summary (PRS) communicates what the Government intends to qualitatively review. The PRS is based on the program goals and market research of similarly situated programs and services. The PRS identifies performance standards grouped into five functional areas, and quality levels essential for successful performance of each requirement. The PRS is used by ICE when conducting quality assurance surveillance to guide the program review process.

Withholding: Amount of monthly invoice payment withheld pending correction of a deficiency. See Attachment A for information on the percentages of an invoice amount that may be withheld for each functional area. Funds withheld from payment are recoverable (See Sections 7 and 8) if the COR and Contracting Officer confirm resolution or correction, and should be included in the next month’s invoice.

4. QUALITY CONTROL PLAN

The Service Provider shall develop, implement, and maintain a Quality Control Plan (QCP) that illustrates the methods it will use to review its performance to ensure it conforms to the performance requirements. This includes review methods and schedules that are consistent with the regular reviews conducted by ERO. The reports and other results generated by the Service Provider’s QCP activities should be provided to the COR as requested. (See Attachment A for a summary list of performance requirements.) Such reviews shall be performed by the Service Provider to validate its operations, and assure ICE that the services meet the performance standards.

The frequency and type of the Service Provider’s reviews should be consistent with what is necessary in order to ensure compliance with the performance standards.

The Service Provider is encouraged not to limit its review to only the processes outlined in the Statement of Objectives, Statement of Work/Performance Work Statement, and Attachment A of this document; however, certain key documents shall be produced by the Service Provider to ensure that the services meet the performance standards. Some of the documentation that shall be generated and made available to the COR for review is listed below; however, the list is intended as illustrative and is not all-inclusive. The Service Provider shall develop and implement a program that addresses the specific requirement of each standard and the means it will use to document compliance.

• Written policies and procedures to implement and assess operational requirements of the standard

• Documentation and record keeping to ensure ongoing operational compliance with the standards (e.g.; Family Service Plans, group session logbooks, participant files, reports, etc.)

• Staff training records

• Contract discrepancy reports (CDRs)

• Investigative reports

• Medical records

• Records of investigative actions taken

• System tests and evaluation

· Unannounced observations of program operation

· Interview case management staff, service provider program staff, and clients and program participants

· Review the program’s internal audit reports

5. METHODS OF SURVEILLANCE

The government will conduct routine, follow-up, and unscheduled ad hoc reviews as necessary. The government may also maintain an on-site presence in some program locations in order to conduct more regular or frequent monitoring. Review and monitoring may involve direct observation of Family Case Management Program conditions and operations, review of documentation (including QCP reports), and/or interviews of Family Case Management staff, Service Provider personnel and program participants.

5.1 Documentation Requirements: The Service Provider shall develop its own documentation as prescribed for in the Statement of Objectives, Statement of Work/Performance Work Statement, and Attachment A of this document. In addition to the documentation prescribed by in these documents, the Service Provider shall also develop and maintain documentation that demonstrates the results of its own internal audits and reviews as prescribed in its QCP. The Government may review 100% of the documents, or a representative sample, at any point during the period of performance.

6. FUNCTIONAL PERFORMANCE AREAS AND STANDARDS

To facilitate the performance review process, the required performance standards are organized into five (5) functional areas. Each functional area represents a proportionate share (i.e., weight) of the monthly invoice amount payable to the Service Provider based on meeting the performance standards. Payment withholdings and deductions will be based on these percentages and weights applied to the overall monthly invoice.

The government may, consistent with the scope the Agreement, unilaterally change the functional areas and associated standards affiliated with a specific functional area. The Contracting Officer will notify the Service Provider at least 30 calendar days in advance of implementation of the new standard(s). If the Service Provider is not provided with the notification, adjustment to the new standard shall be made within 30 calendar days after notification. If any change affects pricing, the Service Provider may submit a request for equitable price adjustment in accordance with the “Changes” clause. The government reserves the right to develop and implement new review techniques and instructions at any time during performance without notice to the Service Provider, so long as the standards are not more stringent than those being replaced.

7. FAILURE TO MEET PERFORMANCE STANDARDS

Performance of services in conformance with the PRS standards is essential for the Service Provider to receive full payment as identified in the Agreement. The Contracting Officer may take withholdings or deductions against the monthly invoices for unsatisfactory performance documented through surveillance of the Service Provider’s activities gained through site review, reviews of documentation (including monthly QCP reports), interviews and other feedback. As a result of its surveillance, the Service Provider will be assigned the following rating relative to each performance standard:

Using the above standards as a guide, the Contracting Officer will implement adjustments to the Service Provider’s monthly invoice as prescribed in Attachment A.

Rather than withholding funds until a deficiency is corrected, there may be times when an event or a deficiency is so egregious that the Government deducts (vs. “withholds”) amounts from the Service Provider’s monthly invoice. This may happen when a significant event occurs, when a particular deficiency is noted multiple times without correction, or when the Service Provider has failed to take timely action on a deficiency about which he was properly and timely notified. The amount deducted will be consistent with the relative weight of the functional performance area where the deficiency was noted. The deduction may be a one-time event, or may continue until the Service Provider has either corrected the deficiency, or made substantial progress in the correction.

Further, a deficiency found in one functional area may tie into another. For example, a deficiency would be noted in “Home Visits”, but may also relate to a deficiency in “Administration and Management” In no event will the withholding or deduction exceed 100% of the invoice amount.

8. NOTIFICATIONS

(a) Based on the review of the Service Provider’s performance, the COR will document instances of deficient or at-risk performance (e.g., noncompliance with the standard) using the CDR located at Attachment B. To the extent practicable, issues should be resolved informally, with the COR and Service Provider working together. When documentation of an issue or deficiency is required, the procedures set forth in this section will be followed.

(b) When a CDR is required to document performance issues, it will be submitted to the Service Provider with a date when a response is due. Upon receipt of a CDR, the Service Provider shall immediately assess the situation and either correct the deficiency as quickly as possible or prepare a corrective action plan. In either event, the Service Provider shall return the CDR with the action planned or taken noted. After the COR reviews the Service Provider’s response to the CDR including its planned remedy or corrective action taken, the COR will either accept the plan or correction or reject the correction or plan for revision and provide an explanation. This process should take no more than one week. The CDR shall not be used as a substitute for quality control by the Service Provider.

(c) The COR, in addition to any other designated ICE official, shall be notified immediately in the event of all emergencies. Emergencies include, but are not limited to family unit violence, medical emergency of a family unit, or if a family unit leaves the program without consent.

(d) If the COR concludes that the deficient or at-risk performance warrants a withholding or deduction, the COR will include the CDR in its monthly report, with a copy to the Contracting Officer. The CDR will be accompanied by the COR’s investigation report and written recommendation for any withholding. The Contracting Officer will consider the COR’s recommendation and forward the CDR along with any relevant supporting information to the Service Provider in order to confirm or further discuss the prospective cure, including the Government’s proposed course of action. As described in section 7 above, portions of the monthly invoice amount may be withheld until such time as the corrective action is completed, or a deduction may be taken.

(e) Following receipt of the Service Provider’s notification that the correction has been made, the COR may re-inspect the Family Case Management Services program. Based upon the COR’s findings, he or she will recommend that the Contracting Officer continue to withhold a proportionate share of the payment until the correction is made, or accept the correction as final and release the full amount withheld for that issue.

(f) If funds have been withheld and either the Government or the Service Provider terminates the Agreement, those funds will not be released. The Service Provider may only receive withheld payments upon successful correction of an instance of non-compliance. Further, the Service Provider is not relieved of full performance of the required services hereunder; the Agreement may be terminated upon adequate notice from the Government based upon any one instance, or failure to remedy deficient performance, even if a deduction was previously taken for any inadequate performance.

(g) The COR will maintain a record of all open and resolved CDRs.

9. PROGRAM PARTICIPANT OR MEMBER OF THE PUBLIC COMPLAINTS

The program participant and the public are the ultimate recipients of the services identified in this Agreement. Any complaints made known to the COR will be logged and forwarded to the Service Provider for remedy. Upon notification, the Service Provider shall be given a pre-specified number of hours after verbal notification from the COR to address the issue. The Service Provider shall submit documentation to the COR regarding the actions taken to remedy the situation. If the complaint is found to be invalid, the Service Provider shall document its findings and notify the COR.

10. APPENDICES

A.

Performance Requirements Summary

B.

Contract Discrepancy Report

Enrollment Orientation

Establish policy and procedures to ensure delivery of clear and accurate program information to newly enrolled families

Case Management

Addresses the creation and maintenance of processes to ensure access and/or delivery of services and compliance with immigration obligations SOO Performance Objectives sections 1 (bullet 6) and 3 – 8

Evidence of inadequate case management practices permits the Contract Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with contract requirements. Timely and thorough development of a family service plan (FSP) for participating family units upon enrollment is necessary to satisfy this requirement. Coordination of access and/or delivery of services consistent with the FSP are also necessary. Moreover, the contractor must also implement demonstrable, proactive measures to promote compliance with immigration obligations.

Data Tracking and Reporting Addresses the creation and maintenance of case records, data system(s), and reporting procedures consistent with contract requirements

Workforce Integrity

Addresses the adequacy of the personnel hiring processes, staff training and licensing/certification

Participant Discrimination

Addresses the adequacy of policies and procedures to prevent discrimination against program participants that is prohibited by Federal law

Mobilization: The Government may withhold or deduct monthly invoiced amount for failure to meet to the Mobilization Plan as follows:

* The Government may deduct amounts from the invoice if it determines the Contractor is failing to make substantial progress in meeting the schedule. The decision to withhold or deduct invoice amounts is solely at the discretion of the Government. Deducted amounts are not recoverable by the Contractor.

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER

2. TO: (Contractor and Manager Name)

3. FROM: (Name of COR)

DATES

CONTRACTOR NOTIFICATION

4. DISCREPANCY OR PROBLEM (Describe in Detail: Include reference in PWS / Directive: Attach continuation sheet if necessary.)

5. SIGNATURE OF CONTRACTING OFFICER’S TECHNICAL REPRESENTATIVE (COR)

6. TO: (COR)

7. FROM: (Contractor)

8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. ATTACH

CONTINUATION SHEET IF NECESSARY. (Cite applicable Q.A. program procedures or new A.W. procedures.)

9. SIGNATURE OF CONTRACTOR REPRESENTATIVE

10. DATE

11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet if necessary)

12. GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.)

CLOSE OUT

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER