QASP Crestwood Manor San Jose IDIQ - UPDATED FORM 5.2.23.pdf

Medicare and Medicaid QASP

Effective Date: 12/19/2022 Revision: 03 Page 1 of 6

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 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 Contracting Officer (CO): Gary Basile, (916) 923-4537 Assigned Contract Specialist: Cynthia Diezel, (916) 923-4567 Organization or Agency: U.S. Department of Veterans Affairs

b. The CNH Personnel/Social Worker designated by the CO as an Ordering Officer (OO) shall be responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The OO shall keep a quality assurance file. The OO is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned OO(S): Victoria Gledhill, LCSW CNH Coordinator; (650) 493-5000 Ext. 68424

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c. Other Key Government Personnel - Deirdre McNamara, LCSW CNH Coordinator; (650) 493-5000 Ext. 62207 Pamela Weiner, LCSW CNH Coordinator; (650) 493-5000 Ext. 65998 Cathy Canfield, RN, CNH Nurse; (650) 493-5000 Ext. 65697

1 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

QUALITY ASSURANCE SURVEILLANCE PLAN

Nursing Home Care

No. Paragrap h in PWS

Indicator/Performanc e Standard

Standar d for Quality Level

Acceptabl e Quality Level

Method of Surveillance

Incentive

1 (C)(9) Nursing Home shall provide VA with copies of all State / Federal licensures, certifications, and investigations reports when requested.

100% 100% Periodic Reviews and spot checks

Positive past performanc e rating

2 (C)(10) The Contractor shall cooperate in developing plans of corrective action according to outlined criteria in the Performance Work Statement.

100% 100% Periodic Reviews and spot checks

Positive past performanc e rating

3 (C)(13) Notice of veteran being hospitalized within 72 hours and notice of any veteran death within 24 hours or immediately the first business day after a weekend or holiday.

100% 95% Periodic Reviews and spot checks

Positive past performanc e rating

Revision: 03 Page 3 of 6

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – Michelle Smith, Contract Supervisor; (209) 955-2364; msmith@cbhi.net

b. Other Contractor Personnel - Gail McDonald, Administrator, (408) 275-1010, gmcdonald@cbhi.net

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.

4 (C)(15) Notice of all reportable events on VA contract veterans and all facility sentinel events within 24 hours or immediately upon the first business day after a weekend or holiday.

100% 100% Periodic reviews

Positive past performance rating

5 (C)(17) All medical records concerning the veteran's care in the nursing home a) will be readily accessible to VA, and b) within acceptable standards and practice.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

6 (C)(21) Invoices shall be timely and accurate for all items billed.

100% 95% - 100%

Periodic Reviews and spot checks

Positive past performance rating

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5. INCENTIVES/RATING STANDARDS

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance.

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION

c. USER SURVEY

d. VALIDATED USER/CUSTOMER COMPLAINTS

e. INSPECTION

f. PERIODIC SAMPLING

g. RANDOM SAMPLING

h. PROGRESS OR STATUS MEETINGS

i. ANALYSIS OF CONTRACTOR’S PROGRESS REPORTS

7. 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:

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

See above Acceptable Quality Level & Method of Surveillance located in QASP

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The Government shall document positive OR Negative performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the OO shall work with the Contracting Officer (CO) who will inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the OO/VA Coordinator shall document the discussion and place it in the OO/VA Coordinator’s file. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the OO will work with the contractor to increase performance to an acceptable level.

When the CO determines formal written communication is required, the OO/VA Coordinator and CO 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 OO/VA Coordinator.

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.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the and the CO will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The OO and CO shall meet with the contractor as needed to assess performance and provide a written assessment.

Signature – Contractor

Revision: 03 Page 6 of 6

Signature Ordering Officer/VA Coordinator

Signature – Contracting Officer