Attach_B_-Quality_Assurance_Surv._Plan.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Spiritual Counselor Services

Contract Number:

Contract Description: The Spiritual Counselor will provide spiritual services by assess the individual patient’s cultural/spiritual awareness, conducting spiritual groups including sweat lodge activities, modify treatment plans and participating in treatment team. Counselor will validate competency of other staff regarding spiritual activities. Spiritual counselor will follow a

16 week curriculum and document in the electronic healthcare system.

Contractor’s Name:

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 CO:

Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Materiel

Management

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: Eugena Crossland

c. Other Key Government Personnel – Michelle McGinn, Gage Riddoch and or Dr. Berkley will function as Performance Monitors and Clinical Quality experts on behalf of the COR to monitor performance.

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – Vincent Berkley, Medical Director

b. Other Contractor Personnel – Michelle McGinn, LPC

Title: Deputy CEO

c. Other Contractor Personnel – Gage Riddoch

Title: Clinical Psychologist

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.

Task ID Indicator Standard

Acceptable

Quality

Level

Method of

Surveillance Incentive

Clinical

Information

Return

The Spiritual

Counselor will assess the individual patient’s cultural/spiritual awareness and may make treatment recommendations regarding spiritual/traditional matters as it pertains to treatment planning.

The assessment will be entered into

BH GUI

within 10 days after admission.

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

The Spiritual

Counselor shall facilitate group sessions utilizing a culturally 16 week curriculum to increase knowledge of cultural awareness and practices and will provide a record of group

. The group will be entered into

BH GUI

within 10 days after running group

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

The Spiritual

Counselor shall provide monthly sweat lodge ceremonies on two separate days for male and female patients in accordance with facility policy.

. The group will be entered into

BH GUI

within 10 days after running group

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

Quality

Care

Must document in

Electronic

Healthcare record

Within

10days of care provided

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

Task ID Indicator Standard

Acceptable

Quality

Level

Method of

Surveillance Incentive

Maintain license

CPR and Drivers

License

At all times 100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

Patient

Safety

Patient safety incidents must be reported to the authorizing VA medical center and the COR.

All incidents reported immediately

(within 24 hours.)

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

Patient safety incidents must be investigated, confirmed and resolved.

All incidents are investigated, confirmed and resolved.

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

Maintain safety and integrity of sweat lodge and follow policy on running sweat lodge

Ensure structure is safe and follow all

EOC

standards.

Weather is appropriate and safe to run ceremony

100%

Observation and random inspection

(auditing)

Exercise of

Option

Period and past performance

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution. as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. 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.

Direct Observation, random inspection, chart auditing, incident reports and satisfactions surveys

a. DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.)

The assessment will be entered into BH GUI within 10 days after admission, The group will be entered into BH GUI within 10 days after running group, Ensure structure is safe and follow all

EOC standards. Weather is appropriate and safe to run ceremony

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

d. VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

All incidents reported immediately (within 24 hours.) All incidents are investigated, confirmed and resolved.

e. 100% INSPECTION. (Evaluates all outcomes.)

f. PERIODIC SAMPLING. (Variation of random sampling. However, sample is only taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected. Since sample is not entirely random, it cannot be applied to total activity performance.) The assessment will be entered into BH GUI within 10 days after admission, The group will be entered into BH GUI within 10 days after running group, Ensure structure is safe and follow all EOC standards. Weather is appropriate and safe to run ceremony

g. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.

The assessment will be entered into BH GUI within 10 days after admission, The group will be

h. Progress or status meetings.

8. 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:

9. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive 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 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.

When the COR determines formal written communication is required, the COR 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.

10. 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 minimally annually to assess performance and shall provide a written assessment.

Chart audits, group observations, and primary source verification of licensure and driver’s license, patient and parent satisfaction surveys, webcidents

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative