Attach_D_-_Dietician_QASP.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Dietician Services

Contract Number:

Contract Description: The Indian Health Service is an agency within the U.S. Department of Health and Human Services, and is responsible for providing federal health services to American Indians and Alaska Natives. Desert Visions is a residential youth program which provides substance abuse and healthcare to adolescents. It is a 24hr/7 day week operation located in Sacaton Az. Dietary/nutritional services for Desert Visions and Nevada Skies Youth Wellness Centers. Service includes dietary assessments, screening, assessing, and reassessing for nutritional needs, and menu planning. Vendor will also provide technical assistance in ordering and maintaining an inventory of dietary supplies, inspecting kitchen sanitation and food handling procedures. Provide kitchen staff in services and training for competency validation. This service must be provided by a vendor that can meet the performance specifications established by The Joint Commission.

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: Barbatunde Coker

c. Other Key Government Personnel – Michelle McGinn, Deputy CEO, Eugena Crossland, CEO Dr. Berkley Medical Director, Joan Parrish Quality Manger/Infection Prevention 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 – Eugena Crossland Title: CEO

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.

Competency and validation is maintained on employees.

Training will be documented and signed off for all staff participating

Quality Care

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 or paper note. Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee

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

Maintain license CPR, Must document in Electronic Healthcare record and paper documentation, Must document in Electronic Healthcare record and paper documentation, Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee

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

Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee

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

The assessment will be entered into BH GUI or paper note. Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee Maintain license CPR, Must document in Electronic Healthcare record and paper documentation, Must document in Electronic Healthcare record and paper documentation,

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 or paper note. Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee Maintain license CPR, Must document in Electronic Healthcare record and paper documentation, Must document in Electronic Healthcare record and paper documentation,

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

The assessment will be entered into BH GUI or paper note. Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee Maintain license CPR, Must document in Electronic Healthcare record and paper documentation, Must document in Electronic Healthcare record and paper documentation,

h. Progress or status meetings.

The assessment will be entered into BH GUI or paper note. Competency and validation is maintained on employees and training will be documented and signed off for all staff participating. Document approval and recommendation monthly with Medical Director, Inspection and report per visit/inspection to supervisor of kitchen and/or CEO/Designee

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:

Chart audits, group observations, and primary source verification of licensure and, patient and parent satisfaction surveys, webcidents, Inspection report audits

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.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative