P01 QASP Home Oxygen FY 21 - VAMHCS.pdf

Attachment 2

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Quality Assurance Surveillance Plan (QASP)

The contractor will be evaluated in accordance with the following:

For: The VA Maryland Healthcare System Home Oxygen Services

Contract Description: Provision of Home Oxygen and CPAP services to eligible Veterans in the VA

Maryland Healthcare System.

The contractor will be evaluated in accordance of the following:

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 through contract modification. 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: Crystal Hinton

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 .

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Assigned Clinical COR: Daniel Whit Assigned Administrative COR: Christian Flickinger Organization or Agency: VA

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary: Christian Flickinger, DHA

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4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

5. 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.

a. DIRECT OBSERVATION. Direct observation by VA personnel during visits to warehouse facilities as well as Veteran homes.

b. PERIODIC INSPECTION. Inspections will be conducted both scheduled and unscheduled.

c. VALIDATED USER/CUSTOMER COMPLAINT: Complaints received from customers reported to contractor and VA will be logged and submitted to the contractor for immediate resolution/corrective action. Contract will monitor complaints monthly and report to the COR on a quarterly basis.

d. RANDOM SAMPLING: Option to be used in reviewing vendor employee and Veteran folders to ensure proper documentation is being maintained.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR: Receipt/evaluation of reports required in Performance Work Statement, Attachment D.

f. Other: Patient home inspection, patient satisfaction/complaints, monthly review of invoices for accuracy, timeliness of equipment delivery, accuracy of required documentation submitted, and adherence to Joint Commission Standards.

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6. QASP PERFORMANCE REPORT DATE: May 7, 2021

Measures PWS

Reference

Performance

Requirement

Standard Acceptable

Quality

Level

Surveillance

Method Met AQL/DID

NOT MEET AQL-

CPAR

RATING/ADD

COMMENTS

New Patient Set-ups

2.4 a b c d

2.6 a d 9.2a

10.14

Contractor shall report unsafe conditions observed in the home and precludes the installation of oxygen service to include fire safety hazards, oxygen safety hazards, patient abuse by family or caregivers or any instance that places the patient or the contractor’s staff in immediate danger.

Contractor shall provide written documentation of any home where smoke alarms not present and fully functional

At time of set-up and written documentation by 1 business day

95% VERIFICATION

AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR:

Electric Service 2.6 b c Contractor shall ensure that electric service in the residence can handle the additional power load caused by installation and use of the oxygen concentrator

Within 24 hours for safety hazards involving electrical services

100% VERIFICATION AND/OR

DOCUMENTATION

Refusal of

Services

9.6 b Contractor shall report refusal

(Against Medical Advice-AMA) of oxygen equipment or supplies prescribed by the VA

Verbal report within 1 hours and signed form within 10 business days of the following month

100% VERIFICATION AND/OR

DOCUMENTATION

Patient Visits 2.6 a

9.2 a

Contractor shall report patient who is non-compliant with safety guidelines set forth in education and orientation material or risk of self-harm or harm or to others

At time of visit and in writing within 1 business day

100% VERIFICATION AND/OR

DOCUMENTATION

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Home Visit

Documentation

2.7 The Contractor shall provide

evaluation and written report of home visits performed by the

Contractor’s staff

By 10th business day of the month following service

95% VERIFICATION AND/OR

DOCUMENTATION

Periodic

Equipment

Evaluation

2.4 a

2.7

7.1

The Contractor shall have a

CRT/RRT visit the patient to reassess equipment compliances, educational needs, etc. for Home

Oxygen Patients at least once annually and monthly for Patients on ventilators and quarterly visits to tracheostomy patients

Within 5 business days of visit

95% RANDOM SAMPLING

Equipment

Inventory VA owned

14.1 -14.9 The Contractor shall provide a complete inventory of all VA-owned equipment and supplies

Monthly 95% VERIFICATION AND/OR

DOCUMENTATION

CONTRACTOR

Emergency

Services

2.6

5.1 – 5.5

9.2 , 9.6

The Contractor shall report special incidents occurring during a home visit to include finding patients in need of emergency medical assistance, safety hazards that do not fall into the category of presenting immediate life-threating danger to the patient or Contractors staff, inability to contract a patient within a reasonable period of time, and any other incident meeting the

Contractors written polity for incident reporting according to Joint

Commission accreditation standards.

Within 24 hours. Life threatening situations (i.e.

911, police, etc.) shall be reported to the proper authorities immediately.

100%

VERIFICATION AND/OR

DOCUMENTATION

Customer

Satisfaction Report

9.3 The Contractor shall collect

satisfaction data from VA contracted patients and their families on a quarterly basis in accordance with

Joint Commission standards

When requested the second month of every quarter for the

HRCT

meeting.

100% VERIFICATION AND/OR

DOCUMENTATION

Infection Control

Report

9.4 The Contractor shall collect, trend, and report on data related to the

When requested the second month

100% VERIFICATION AND/OR

DOCUMENTATION

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Contractor’s Infection Control

Program of every quarter for the

HRCT

meeting.

PROVIDED BY

CONTRACTOR

Periodic

Performance

Review Report

9.1 The Contractor shall provide a

written, quarterly report addressing all Joint Commission Standards for improving organizational performance

When requested the second month of every quarter for the

HRCT

meeting.

95% VERIFICATION AND/OR

DOCUMENTATION

Emergency Patient

Safety Reports

9.6 The Contractor shall provide the

following emergent Patient safety reports throughout the contract period; Sentinel Event, Refusal of

Service, Patient Abuse or Neglect, Non-compliant Behavior

Initial notification shall be within one business day of when the Contractor is aware of the event or issues with a follow-up official report within 5 business days

100% VERIFICATION AND/OR

DOCUMENTATION

Oxygen Refills 2.8 Contractor shall provide notice that a patient has not been available for the quarterly visits.

Within two (2) workdays of the 2nd consecutive attempted contact for visit.

100% VERIFICATION AND/OR

DOCUMENTATION

Contractor

Employee Training

11.3- 11.9 Contractor shall provide the COR with documentation competency of those individuals providing patient instruction and of the orientation training of contract staff

Quarterly 100% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR –

PERIODIC INSPECTION

Monthly Tech

Report

2.7

7.2

VA shall perform audit of monthly tech reports for proper documentation on 100% of new patients and 10% of all active patients

Quarterly 95% VERIFICATION AND/OR

DOCUMENTATION

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Home Visit

Compliance

11.1 VA shall conduct home visits to

observe contractor’s compliance with set-up/delivery of home O2 pursuant with contract requirements, veteran’s compliance with Home O2 program requirements on at least five Veterans on the program

Quarterly 100%

DIRECT OBSERVATION

PERIODIC INSPECTION

Traveling Veterans 4.1 – 4.4 The vendor will arrange for all travel oxygen needs.

As authorized by COR or representative

100% VERIFICATION AND/OR

DOCUMENTATION

Site Visit 11.1 VA shall conduct site visits of

Contractor’s facility to observe contractor’s compliance with contract requirements

Quarterly 100% PERIODIC INSPECTION -

DIRECT OBSERVATION -

RANDOM SAMPLING

Patient Treatment

Files

11.1 VA shall conduct review of Veteran

patient treatment files to determine how many patients need additional vendor documentation regarding current prescription, Liter flow, Plan of Care, No smoking education and any other documents needed.

Quarterly 100% RANDOM SAMPLING

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7. CPAR RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/pdfs/CPARS-Guidance.pdf p. A2-1):

EXCEPTIONAL: Performance meets contractual requirements and exceeds many to the

Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.

VERY GOOD:

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.

SATISFACTORY:

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.

MARGINAL:

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTO

RY: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffect ive.

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An

Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental

Deficiency Reports, or letters).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

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8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR

PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the CO shall document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Report (CR) and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CR in writing. The CR will specify if the contractor is required to prepare an action plan to document how the contractor shall correct the identified issue and avoid a recurrence. The CR will also state how long after receipt the contractor must present this action plan to the CO. The Government shall review the contractor's action plan. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s action plan.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

See Sample CR on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

Administrative COR: Clinical COR:

Christian M. Flickinger, DHA Daniel Whitt, RRT-ACCS, RRT-NPS Chief , Prosthetics Chief , Respiratory

SIGNED:

CONTRACTOR NAME/TITLE DATE

VHABALWHITTD

Highlight

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CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS ISSUE

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY

c. ACTION COMPLETE

6. Issue Identified: (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE.

(Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

NOTIFIED

COR

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CONTRACTING

OFFICER