QASP.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Mortuary Services for Unclaimed or Indigent Veterans VA Salt Lake City Health Care System (VHSLCHCS)

1.0 Purpose

This Quality Assurance Surveillance Plan (QASP) provides the Government’s methodology for monitoring contractor performance and ensuring all requirements of the Performance Work Statement (PWS) in PWS v3 are met.

It outlines:

· What will be monitored

· How monitoring will occur

· Who will conduct surveillance

· How results will be documented

· Required corrective actions This QASP does not dictate how the Contractor performs the work; the Contractor is responsible for internal quality control, while the Government conducts quality assurance.

2.0 Roles and Responsibilities

Contracting Officer (CO)

· Overall authority for contract administration

· Enforces compliance with contract terms Contracting Officer Representative (COR)

· Primary surveillance official

· Conducts inspections, evaluations, records findings

· Coordinates with technical experts

· Reports deficiencies and recommends corrective actions

Technical Subject Matter Expert (SME)

· Advises COR on mortuary technical standards

· Participates in inspections when needed Station Quality Assurance

· Reviews PWS and QASP compliance

· Supports COR in independent verification activities

3.0 Surveillance Methods

Surveillance will be conducted using one or more of the following methods:

3.1 Random Inspections

Unscheduled checks of mortuary preparation, storage, transport vehicles, and documentation.

3.2 Scheduled Inspections

Periodic inspections aligned with performance events (pick‑up, embalming completion, cremation completion, delivery to cemetery, burial/inurnment completion).

3.3 Customer Feedback

Feedback from VA personnel interacting with contractor services.

3.4 Document Review

Review of logs, licenses, permits, staffing records, quality control records, and contractor submissions (semi‑annual QC reports).

3.5 On‑Site Facility Inspections

Includes inspection of:

· Facility cleanliness, safety, accessibility

· Refrigeration units

· Transport vehicles

· Embalming room compliance

3.6 Case Timeline Tracking

Tracking of the full case lifecycle from notification to burial/inurnment completion, to verify compliance with the 10-calendar-day standard.

4.0 Performance Requirements & Acceptable Quality Levels (AQLs) The following table aligns directly to the PWS requirements in PWS v1.

4.1 Services Summary Table (SST)

5.0 Surveillance Frequency

6.0 Documentation and Reporting

6.1 Surveillance Records

The COR will maintain:

· Inspection logs

· Case Timeline Logs

· Deficiency reports

· Corrective action requests

· Contractor responses

· Follow‑up verification records

6.2 Monthly Summary

COR compiles monthly performance summary reports for CO review.

6.3 Deficiency Notification

If performance does not meet contract standards:

· COR issues a Contract Discrepancy Report (CDR)

· Contractor provides a Corrective Action Plan (CAP) within specified period

· COR validates the correction

7.0 Corrective Actions

When performance falls below standards:

1. Immediate Notification – COR informs Contractor of deficiency.

2. Corrective Action Plan – Contractor must propose resolution steps and timelines.

3. Follow‑up Surveillance – COR verifies correction and documents results.

4. Escalation – Severe or repeated failures reported to CO for contractual remedies.

8.0 Acceptance Criteria

Performance is considered acceptable when:

· All mandatory PWS requirements are met

· AQL thresholds are achieved

· No serious health, safety, or privacy violations occur

· Contractor fulfills submission of all required deliverables (QCP, permits, reports)

9.0 Updates to the QASP

This QASP may be updated:

· When PWS changes

· When performance issues require new surveillance measures

· When COR or CO identify new high‑risk areas Approval authority includes the Service Chief, Station QA, COR, and CO.