S02 - Attachment D3 - QASP Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

HCHV Medical Respite Care – Indianapolis, Indiana

The contractor will be evaluated in accordance with 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: Michelle C. Ford, Michelle.Ford2@va.gov Administrative Contract Specialist: Cierra S. Joshua, Cierra.Joshua@va.gov Organization or Agency: Network Contracting Office 10

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: Kjirsten Kmetz-Morrison, Kjirsten.Kmetz-Morrison@va.gov Organization or Agency: Richard L. Roudebush, VA Medical Center

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager: ____________________________________

Alternate Program Manager: _________________________________

ATTACHMENT D3

mailto:Michelle.Ford2@va.gov mailto:Cierra.Joshua@va.gov mailto:Kjirsten.Kmetz-Morrison@va.gov

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/CS 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. 100% surveillance: As appropriate and annually during facility inspection.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. RANDOM SAMPLING. Documentation will be entered into the patient’s computerized medical record (CPRS) unless dictation services are available and accessible.

d. Verification and/or documentation provided by Contractor. Documentation will be entered into the patient’s computerized medical record (CPRS) unless dictation services are available and accessible.

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

Facility III

IV

IX (a, b)

VI

VII

VIII

(100%) Facility meets fire, safety, Americans with Disabilities Act, licensure, safety and veteran privacy and additional safety for female veterans.

Provides nutritionally adequate meals

100% of care provided within clinical standards of care.

Passing facility inspection and documentation of meeting the performance standards listed under Performance requirement

98% during annual rating period

Direct Observation

Document review

Yes ☐

No ☐

Personnel C (I)(a thru e)

D (I) (a)

Registered Nurse on-site for no less than 5 hours per week.

24 hours/7 days per week medication management.

Case management services on-site, provided by qualified personnel

24/7 residential staffing on-site.

Staff have received required training

100% of all referred cases

100% Random Inspection

Document

Case Management C (III) (a-j) Weekly case management meetings visit with the Veteran.

Goals identified on the Individualized Care Plan (ICP) will be addressed during case management visit and documented in the Veteran’s record.

100% visits occurring weekly.

100% of visits will focus on identified goals.

90%

90%

Document

Occupancy C (IV) (g) Occupancy shall be equal to or greater than 75% throughout the quarter

Contract bed will be occupied 75% of the time.

75% Review of admissions and invoices.

Discharge planning C (IV) (c, i)

C (VI) (a)

55% of Veterans admitted into the program will obtain permanent housing at discharge.

Less than 20% of discharges will be classified as a negative discharge.

Housing needs will be assessed within 72 hours of admission.

Education and assistance with accessing housing resources will be provided during weekly case management meetings.

Contractor will make efforts to engage the Veteran before making a decision to negatively discharge the Veteran from the program.

55% permanent housing exits.

Less than 20% negative exits.

Monthly staff meeting and progress reports.

Review of program outcomes.

Patient Safety C (IV) (o) 100% of critical incidents will be reported within 24 hours.

100% of critical incidents will be reported to the VA in writing within 24 hours.

90% of incident reports received within 24 hours.

Document

Documentation C (III) (a,i)

D (IV) (a)

D (XII)

100% Intake assessment and individual care plans will be documented in patient chart within 72 hours.

100% program admissions and discharges will be reported to the VA within 24 hours.

100% of Veteran absences will be reported to the VA within 24 hours Contracted Program will submit accurate billing to Payment

Center by the 7th of each month.

Veterans will sign-in daily to verify attendance.

100% of documentation will be completed within the required timeframe.

100% of invoices will be submitted on time and without errors.

100% of sign-in sheets will be submitted to the VA monthly and will match the number of days billed.

80% of intakes and care plans will be completed within 72 hours.

80% of admissions and discharges will be reported to the VA within 24 hours.

90% of absences will be reported within 24 hours

85%

85% of Veteran sign-in sheets will match bed days billed on monthly invoice.

Random chart reviews.

Review of monthly invoices.

Review of sign-in sheets, Contractors report of absences, and monthly invoices.

Privacy, Confidentiality and

HIPAA

D (XIII) All (100%) Contractor’s staff comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of

95% compliance;

Contractor shall provide evidence of annual training required by

VAMC,

reports violations per VA Directive 6500.6.

privacy or confidentiality.

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 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 has to 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.

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

See Sample on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

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

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER