QASP-Home Oxygen 3-2025.pdf

Quality Assurance Surveillance Plan (QASP)

The contractor will be evaluated in accordance with the following:

For: Beckley VA Medical Center Home Oxygen Services

Contract Description: Provision of home oxygen care services to eligible Veterans at the Beckley VA Medical Center.

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.

b. Contracting Officer’s Representative (COR) – The Home Oxygen Coord./COR responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The Home Oxygen Coord. 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: David Nunley Organization or Agency: VA

Page 2 of 10 Version 0007 Dated 02/18/2018

3. CONTRACTOR REPRESENTATIVES

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

Primary:

X

Page 3 of 10 Version 0007 Dated 02/18/2018

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 Home Oxygen Coord./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 Home Oxygen Coord. 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.

6. QASP PERFORMANCE REPORT DATE:

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method Met AQL/DID

NOT MEET

AQL- CPAR

RATING/ADD

COMMENTS

New Patient Set- Up

2.4a The Contractor shall provide the initial set-up within 24 hours of request from the COR or designee (dependent on Veteran’s availability), to include weekends and holidays; this response time shall also apply to service calls.

100% Scheduled Initial setup within 24hrs.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and

VALIDATED

USER/CUSTOMER

COMPLAINT

Operation Manual 2.5.

The Contractor shall provide the Operation manual for all equipment to the Patient and/or caregiver upon delivering any equipment. ..

100% of the time the contractor provides the operation manual to patients at new equipment setup.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and

VALIDATED

Contractor Visits 7.0 Contractor visits will be conducted in performance of this contract and completed by a Certified Respiratory Therapist (CRT) or a Registered Respiratory Therapist.

100% of the time Contractor performs within their scope during patient visits.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and

VALIDATED

Electric Service 2.6 b,c The Contractor shall 100% the 95% VERIFICATION AND/OR ensure the electrical outlets in the patient’s home meet the requirements of the contractor’s equipment standards and immediately report unsafe conditions to the COR or designee.

contractor shall complete safety check requirements and immediately report unsafe electrical conditions that will require alterations to the patient’s home for set-up.

DOCUMENTATION

PROVIDED BY

CONTRACTOR

Refusal of Services

9.6.b Contractor shall report refusal (Against Medical Advice-AMA) of oxygen equipment or supplies prescribed by the

VA

100% contractor will provide notification of refusal of service to COR or designee.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and RANDOM SAMPLING of Contractor Reports

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

100% of the time at time of visit and in writing within 1 business day

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and

Contractor Reports

Home Visit Documentation

2.7 The Contractor shall

provide evaluation.

and written report of home visits performed by the Contractor’s staff to the COR by the 10th of each month.

100% of the time the contractor will provide home visit reports by the 10th business day of the month following service.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR:

RANDOM SAMPLING

Periodic Equipment Evaluation

2.7, 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

100% the contractor will conduct equipment evaluations within 5 business days of visit.

95%

RANDOM SAMPLING

ventilators and quarterly visits to tracheostomy patients.

Equipment Inventory VA owned

14.1 The Contractor shall

provide a complete inventory of all VA-owned equipment and supplies monthly to the COR..

100% of the time the contractor will provide the complete VA inventory equipment list monthly.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and

Reports

Emergency Services

2.6, 5.0, 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.

100% of the time contractor shall report life threatening situations (i.e.

911, police, etc.)

shall be reported to the proper authorities immediately.

95% VERIFICATION AND/OR

DOCUMENTATION

CONTRACTOR

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.

100% Contractor shall provide the COR patient satisfaction reports within the 5th working day after the conclusion of the quarter.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR and

VALIDATED

Infection Control Report

9.4, 11.10 The Contractor shall collect, trend, and report on data related to the Contractor’s Infection Control Program

100% Contractor shall provide the COR infection control reports within the 5th working day after the conclusion of

95% VERIFICATION AND/OR

DOCUMENTATION

the quarter.

Periodic Performance Review Report

9.1 The Contractor shall

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

100% Contractor shall provide the COR the performance review report reports within the 5th working day after the conclusion of the quarter.

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

100% of the time Contractor initial notification shall be within one business day of a sentinel event or issues with a follow-up official report within 5 business days

95% VERIFICATION AND/OR

DOCUMENTATION

Oxygen Refills 8, 10 Contractor shall provide notice that a patient has not been home for two consecutive monthly visits

100% Contractor shall provide COR notification within two (2) workdays of the 2nd consecutive missed visit.

95% VERIFICATION AND/OR

DOCUMENTATION

Contractor Employee Training

11.3 – 11.9 Contractor shall provide the COR with documentation competency of those individuals

100% of the time the contractor will provide the COR the contractor training reports quarterly.

95% VERIFICATION AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR -

PERIODIC INSPECTION

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

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

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 has to 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

SIGNED:

X

Prosthetic Chief

COR NAME/TITLE

SIGNED:

CONTRACTOR NAME/TITLE DATE

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

CONTRACTOR:

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

CONTRACTING

OFFICER