QASP - LONG TERM 11.15.23.pdf

Attachment 2

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Quality Assurance Surveillance Plan (QASP)

The contractor will be evaluated in accordance with the following:

For: Louis A. Johnson (LAJ) VA Medical Center Home Oxygen Services

Contract Description: Provision of home oxygen and respiratory care services to eligible Veterans at the LAJ 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.

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.

Assigned COR: Amy Criss Organization or Agency: VA

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3. CONTRACTOR REPRESENTATIVES

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

Primary: Amy Criss:

(add signature)

X Amy M. Criss Prosthetic Representative

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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: November 4, 2020

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

9 b.

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 The Contractor will provide education to each veteran at the time of set-up, and assess the need for reinforcement during visits. This information is to be presented verbally, in demonstration and material covered will be in written form to be left with the beneficiary/care giver.

The Contractor will notify the COTR/designee or prescribing physician during the home visit if the Contractor’s staff determines that the presence of oxygen in the home presents such a danger that the oxygen must be removed, or in the case of an initial set-up, not placed in the home.

At time of set-up and written documentation by 5 business day

95% VERIFICATION

AND/OR

DOCUMENTATION

PROVIDED BY

CONTRACTOR:

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Electric Service 14 The Contractor will check the adequacy of the electrical outlets in the patient’s home and immediately report unsafe conditions to the COTR or designee. The VA will not be responsible or liable for any unsafe electrical conditions caused by the Contractor. Any alterations to the veteran’s residence will be the responsibility of the veteran. If ordered equipment cannot be safely installed, the COTR or designee may provide an alternative oxygen delivery system after approval until new prescription can be obtained. If no alternative is available the COTR or designee will notify the prescribing VA physician within 48 hours.

Within 48 hours for safety hazards involving electrical services

100% VERIFICATION

AND/OR

DOCUMENTATION

Refusal of Services

10 Contractor shall report refusal 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 30 a-g At least once every quarter, the Contractor staff member will visit the VA beneficiaries to reassess equipment compliance, educational needs, etc. A written report will include at a minimum the following data: (a-g)

At time of visit and in writing within 1 business day

100% VERIFICATION

AND/OR

DOCUMENTATION

Home Visit Documentation

30 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

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Periodic Equipment Evaluation

The Contractor shall have a CRT/RRT visit the patient to reassess equipment compliances, educational needs, etc. for Home Oxygen Patients at least once quarterly 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

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

Monthly 95% VERIFICATION

AND/OR

DOCUMENTATION

CONTRACTOR

Emergency Services

10 Reporting special incidents found or 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-threatening danger to the patient or Contractors staff, inability to contact a patient within a reasonable period of time, and any other incident meeting the Contractors written policy for incident reporting according to 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

10 The Contractor shall collect satisfaction data from VA contracted patients and their families on a quarterly basis in accordance with Joint Commission standards

Within the 5th working day at the conclusion of the quarter

100% VERIFICATION

AND/OR

DOCUMENTATION

Infection Control Report

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

Within the 5th working day at the conclusion of the quarter

100% VERIFICATION

AND/OR

DOCUMENTATION

Periodic Performance Review Report

10 The Contractor shall provide a written, quarterly report addressing all Joint Commission Standards for

Within the 5th working day at the conclusion of the quarter

95% VERIFICATION

AND/OR

DOCUMENTATION

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Emergency Patient Safety Reports

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

Contractor Employee Training

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

Home Visit Compliance

27 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 17 The vendor will arrange for all travel oxygen needs.

As authorized by COR or representative

100% VERIFICATION

AND/OR

DOCUMENTATION

Site Visit 27 VA shall conduct site visits of Contractor’s facility to observe contractor’s compliance with contract requirements

Quarterly 100% PERIODIC

INSPECTION -

DIRECT

OBSERVATION -

RANDOM

Patient Treatment Files

10 VA shall conduct review of Veteran patient treatment files to determine how many patients need additional vendor documentation regarding

Quarterly 100% RANDOM

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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 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

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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 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:

(sign here)________________________________

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

11/15/23

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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

CONTRACTING

OFFICER

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