J-2_QASP.pdf

HSCEDM-16-R-00002

Amendment 10

J-2 – Quality Assurance Surveillance Plan (QASP)

Functional

Area

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria

Staffing*

Vendor shall have scheduled* and working* on-site*, 100% of the position codes listed in J-1-Site Staffing Matrix and as updated in future contract modifications according to J-3– Position Descriptions.

The count of the number of position codes listed as vacant or filled as per J-11- Site Status Report

An employee shall keep the same position code for the duration they are employed on the contract unless otherwise approved in writing by the Contracting Officer’s Representative.

No other criteria other than filled or vacant as per J-11 Site Status Report is used to assess deductions.

Any new position added to the contract will be measured on the 46th day after the award of the modification.

Monthly staffing percentages are determined by averaging the weekly percentages presented by the vendor. The monthly staffing percentage is used to determine the deductions.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of position codes at each site as per J-11-Site Status Report will be scheduled and working on-site.

Level: Full performance:

Criteria: At each individual field site, 100% of all position codes are filled. 90.0% of all HQ position codes.

Deduction:

None

Level: Less than Full Performance:

Criteria: At each individual field site, less than 100% of all position code(s) are filled.

89.9% or less of all HQ position codes are filled.

Deduction:

The government will deduct an amount equal to the contractual value of the unfilled position code(s).

Level: Critical:

Criteria: Individual field sites have attained staffing deficiencies outlined in the Critical Staffing Level document (see attached).

Deduction:

The government will deduct an amount equal to the contractual value of the unfilled position code(s) plus the cost, if any, of contracted and unused bed-space due to a medically understaffed facility directly associated with the vendors’ poor performance to meet this functional area.

The government will in good faith attempt to avoid reducing the number of detainees using reasonably available resources.

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria e-QIP Submission for

Contract Modification

Staff

Additions

Vacancy

The Contractor will have thirty (30) calendar days from the date of the fully executed contract modification, or effective date of a vacancy, to submit an e-QIP initiation request (with position code) for qualified candidates for those positions.

The e-QIP Submission, and Start Date Functional Area timelines are applicable thereafter to staff added under a contract modification, or vacancy.

The number of calendar days from the date of the fully executed contract modification, or vacancy, until the submission of e- QIP initiation request for qualified candidates for those positions.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of contract modification staff additions, or vacancies, will have e-QIP initiation requests submitted for qualified candidates within thirty (30) calendar days.

Metrics will be reported in

CPARS.

Backfill* For

Nursing Staff

The Contractor will provide RN and LVN/LPN backfill for contractor Shift-Call-Out’s*

Count of the number of Shift - Call Out’s successfully and unsuccessfully backfilled.

A Call Out shift will be considered successfully backfilled if 50% of that shift has been staffed

J-11-Site Status Report. Vendor shall provide the completed report to the government weekly.

Other methods of surveillance may be used.

100% of Shift - Call Out’s requiring backfill will receive backfill.

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria e-QIP Submission

Vendor shall ensure candidate submits a complete (no missing standard documentation) e- QIP security packet (electronic and hard copy) to the IHSC COR within ten (10) calendar days after receiving notice of e-QIP initiation.

Hard copy e-QIP packets will be mailed to the IHSC COR utilizing a mail tracking method through the U.S.P.S, FedEx, UPS or other service provider of equal scope and ability.

Number of complete (no missing standard documentation) e- QIP packets received by the IHSC COR within ten (10) calendar days of notification of e- QIP initiation.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of candidates submit complete electronic and hard copy e-QIP (security) packets to the IHSC COR s within ten (10) calendar days after receiving notice of e-QIP initiation.

Start Dates

Contractor shall ensure staff are on-site and working (start date) within thirty (30) calendar days of notification of initial favorable fitness determination.

Exceptions may be granted on a case by case basis, only if approved in writing by COR.

Number of calendar days between notification of initial favorable fitness determination and when that employee is on-site and working.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of start dates (on-site and working) shall occur within thirty (30) calendar days of notification of initial favorable fitness determination.

Credentialing*

The Vendor shall submit, to on-site Key Personnel, and for the Government Technical Monitors review, a complete credentialing packet for each employee hired, no less than three (3) calendar days before the employee is on-site and working.

The number of complete and incomplete credentialing packets received, no less than three calendar days before the employee is on-site and working.

Government Technical Monitor will review credentialing packet documentation received from the vendor through on-site Key Personnel each month.

Government Technical Monitor will document and report their findings to the COR’s via email.

100% of credentialing packets are complete when reviewed by the Government Technical Monitor Prior to the start of contract staff.

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria

Other methods of surveillance may be used.

Privileging* for Licensed Independent

Providers (LIP’s)

Contractor shall present the government with a complete privileging packet, as per J-6- Credentialing and Privileging, no less than ten (10) Business days before start date.

complete and incomplete privilege application packets received ten (10) Business days before start date of candidate.

J-11-Site Status Report.

Contractor shall provide this competed report to the government weekly.

Other methods of surveillance may be used.

100%. The government will be provided a complete and accurate privileging application ten

(10) Business days prior to candidate’s start date.

Competency Assessment

(CA)

Vendor staff shall complete the Competency Assessment with no discrepancies between the PD performance requirements and actual demonstrated performance during the CA period within ten (10) working days.

Staff not successfully completing the CA will be not be considered as qualified.

Position codes assigned to staff unsuccessfully completing their CA will be considered as having been vacant as of the prior effective date of resignation or termination assigned to that position code.

successful/ unsuccessful, discipline specific, competency assessments completed.

The Vendor shall report to the government on a weekly basis the status of their staff currently in the competency assessment period by name and position code. To include start date and scheduled end date of the assessment period.

Staff not completing the orientation and competency assessment will be clearly identified in J-11-Site Status Report.

Other methods of surveillance may be used.

100% of staff completing the competency assessment demonstrates no discrepancies between the PD performance requirements and actual demonstrated performance.

Deliverables

100% of deliverables in F-4 –

Date of receipt of deliverables and

E-mail receipt to IHSCCOR mailbox

100 % receipt of completed

< 100% compliance will result in 0.25%

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria

Deliverables Table will be completed by due date.

corresponding due dates.

or other method as required deliverables withholding of the entire monthly invoice.

1. The Contractor is responsible for performance of ALL terms and conditions of the contract. The performance measures outlined in this QASP will be used to determine Contractor performance in each Functional Area.

2. The Government performs surveillance to determine Contractor performance and guide the Contracting Officer as to withholding or deduction, if any. Withholdings or Deductions, when applied, will be a sum of applicable withholdings or deductions for each functional area.

3. Where an asterisk is present next to a word in the QASP there is a corresponding definition in Contract Section C-34 – Glossary, specific to the implementation of the QASP.

4. Within 48 hours of the occurrence of Critical-level deficient performance, the Contractor must provide a corrective action plan to the COR and Contracting Officer. During a period of Critical-level deficient performance, the Contractor will provide the COR and Contracting Officer daily updates describing all actions taken to address and correct the deficient performance, and the results of those actions. Upon providing notice to the Contractor, the Government may utilize all resources available, including other contractors, in order to fill critical-level staffing shortages until the government is satisfied that the Contractor is able to resume acceptable performance.

5. Funds may be deducted from a monthly invoice as per the QASP. The Contractor will be notified immediately if such a situation arises. The Contracting Officer in consultation with the ICE Program Office will determine the amount of any deduction. The assessment of deductions does not preclude the Contracting Officer from initiating other applicable contract actions and remedies, if applicable.

Definitions:

Critical: Staffing levels have dropped below levels required to maintain full compliance with American Correctional Association (ACA), National Commission on Correctional Healthcare (NCCH) standards, or Family Residential Standards. This staffing level puts the facility in a high risk of the need to relocate the population and/or to reduce services offered at the site.

Deduction: Amount of monthly invoice reduction as the result of a deficiency. Amounts deducted are not recoverable.

Field positions: All positions, other than Headquarters positions located in Washington, DC.

Head Quarters (HQ): All Headquarters positions located in Washington DC.

Less Than Full Performance: Staffing levels have dropped below the optimal levels required to maintain full compliance with American Correctional Association (ACA), National Commission on Correctional Healthcare (NCCH) standards or Family Residential Standards (FRS). This level of performance negatively impacts morale for both the Contractor and Federal employees, and may also affect the quality of care at the sites. It is important that the contractor provide 100% staffing.

Withholding: Amount of monthly invoice payment withheld pending correction of a deficiency. Funds withheld from payment are recoverable if the COR and Contracting Officer confirm resolution/correction, and should be included in the next month’s invoice.