QASP for IOP Services.pdf

Quality Assurance Surveillance Plan (QASP)

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V 0002 Revised 12/1/2016

The contractor will be evaluated in accordance with the following:

1. PURPOSE

A 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.

B. 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.

C. 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 f inal determination of the adequacy of the contractor's performance.

Assigned CO: TBD 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 f ile. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government's behalf .

Assigned COR: Yannetta Cooper

3. CONTRACTOR REPRESENTATIVES

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

Primary: Omar Majette Contract Specialist

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Alternate: Danielle Trudeau, Contracting Officer

4. PERFORMANCE STANDARDS

A 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 .

8. 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: The COR shall monitor scheduled semi-annually preventive and corrective maintenance performance standards (100% Inspection) and enter results into the Surveillance Activity Checklist.

B. Periodic Inspection: Inspections shall be unscheduled and/or conducted quarterly, per COR delegation, or as needed.

C. Customer Feedback: May be obtained either f rom the results of formal customer satisfaction surveys or f rom random customer complaints. Customer complaints, to be considered valid, must set forth clearly and in writing, the detailed nature of the complaint, must be signed and forwarded to the COR. The COR shall maintain a summary log of all formally received customer complaints as well as a copy of each complaint in a documentation f ile. The COR shall also keep the tabulated results of all customer satisfaction surveys on f ile and shall enter the summary results into the Surveillance Activity Checklist. Copies of all records shall be submitted to the CO upon receipt for placement in the official contract f ile, and when necessary, determination of actions.

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6. QASP PERFORMANCE REPORT

Performance Requirements Summary The Contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success.

Performance Objective The Contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this

PWS

Standard To identify, prevent, and ensure non-recurrence of defective services.

Performance Threshold Various

Method of Surveillance Various

PRS # 1.

The Contractor shall obtain and display all government occupancy permits and licenses as required listed in Section on Therapeutic and Rehabilitative Environment of Care

The Contractor will display all current government occupancy permits and licenses as required

100%

Annual Inspection

PRS #2

The Contractor shall provide onsite services consistent with Section on Services to be Provided.

Adherence to Environment of Care section

95% Daily Contractor staff inspections and Quarterly

VA

inspections.

PRS #3

Records and reports:

Contractor staff shall have at time of hire and annual training in following area- The Health Insurance Portability and Accountability Act (HIPAA Add

USC7332 42CFR

Maintain medical records and patient confidentiality

100% Quarterly and annual inspections by VA staff

PRS #4

Staffing requirements:

Contractor shall be consistent with Contractor/ Contract staff requirements

Contractor will comply with staffing and personnel sections of the contract

95% Daily inspections by Contractor, staff reports and VA inspections

PRS #5

Contractor shall provide documentation of Veterans presence at time of curfew and beds checks

Contractor will comply with daily site inspections and completion of sign-in sheets

100% Daily staff/veteran sign-in sheets

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PRS #6

Quality of services:

Contractor shall treat Veterans with respect and dignity, and promote Veterans recovery goals

Contractor will provide Quality of Care satisfactory to Veterans.

80% Veteran Satisfaction Surveys

PRS #7

Snacks and Meals:

Contractor shall provide nutritious snacks and meals obtained with Veteran input as appropriate

Contractor will provide Quality of snacks and meals satisfactory to Veterans

80% Veteran Satisfaction Surveys

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TECHNICAL EXHIBIT 2

DELIVERABLES SCHEDULE

Deliverable Frequency # of Copies Medium/Format Submit To First Aid and Cardiopulmonary Resuscitation (CPR) Training Certification

Within 30 days of contract award and/or staff hire and not less than once every two years

1 copy Hard Copy via fax or Electronic copy via encrypted email

COR: Celeste Lopez, Fax 520- 629-4776 or email celeste.lopez@va.

gov

Training certificate of VA Privacy and Information Security Awareness Training and Rules of Behavior, and Privacy and

HIPPA

Within 30 days of contract award and/or staff hire and renew annually

1 copy Hard Copy via fax or Electronic copy via encrypted email

COR: Celeste Lopez, Fax 520- 629-4776 or email celeste.lopez@va.

gov

Contractor will complete a written report of any negative incident

Within 48 hours of notifications to VA

1 copy Hard Copy via fax or Electronic copy via encrypted email

COR: Celeste Lopez, Fax 520- 629-4776 or email celeste.lopez@va.

gov

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TECHNICAL EXHIBIT 3

HISTORICAL WORKLOAD DATA

CLIN DESCRIPTION HISTORICAL NUMBER OF BEDS OCCUPIED IN

CONTRACTED SARRTP PROGRAMS

FY25 FY26 FY27 FY28

0001 IOP BED

0002 CC BED

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):

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

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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 GOVERNME NT. Also, there should have been NO signific ant 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 too/ that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTORY: 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 ineffective.

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.

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Management, Quality, Safety or Environmental Deficiency Reports, or letters).

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7. 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 PERFOR MAN CE ASSESSMEN T 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 CO determine that a formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

C. 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 CR will also state how long after receipt the contractor must present this corrective action plan to the CO.

The Government shall review the contractor's corrective action plan to determine acceptability. 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 corrective action plan.

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

E. During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. The COR shall meet with the contractor as often as needed to assess performance and shall provide a written assessment.

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8. CERTIFICATIONS AND SIGNATURES

CONTRACTING OFFICER'S REPRESENTATIVE

(COR):

By signing below, the COR certifies that they have read and understand the methods to evaluate performance for the stated contract. The COR further certifies that they have been provided with a copy of the contract and any other information required to execute their duties.

Name: Date:

CONTRACTOR:

By signing below, the Contractor certifies that they have read and understand the methods by which their performance will be evaluated for the stated contract.

Name: Date:

Signature: