Sample QASP.pdf

Attachment 13, Quality Assurance Surveillance Plan (QASP) 36C25521R0016

NURSING HOME CARE SERVICES

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:

1. What will be monitored? 2. How monitoring will take place? 3. Who will conduct the monitoring? 4. 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 will coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions will be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES: The following personnel will oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO will 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 will 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. Assigned CO: The CO will be identified at time of award of any agreement made as a result of this VISN-wide solicitation.

c. Organization or Agency: Department of Veteran Affairs

d. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and will assure proper Government surveillance of the contractor’s performance. The COR will 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.

e. Assigned COR: The assigned COR will be identified at the time of award. A delegation letter will be provided to the Contractor identifying the COR and the duties assigned, and limitations of duties.

Organization or Agency: Department of Veteran Affairs, specific Medical Center will be identified with each requirement identified.

3. CONTRACTOR REPRESENTATIVES: Contractors will name the applicable employee(s) to serve as the contractor’s program manager(s) for the purpose of management of this contract. Contractor representatives are identified in section B.1.

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 will 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 and in Section B.6. The Government shall use these standards to determine contractor performance and 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. INCENTIVES/DEDUCTS: The Government will use past performance reports as incentives. Incentives will be based on ratings received on the performance standards.

6. METHODS OF QA SURVEILLANCE: Various methods exist to monitor performance. The CO and COR will use the surveillance methods listed below in the administration of this QASP. The CO and COR may receive input from other VA staff in all methods of surveillance. The CO, at any time during contract performance, may perform any of the observations, inspections or meetings identified herein in conjunction with, in absence of, or in lieu of the COR, or other CNH-related staff identified in this

QASP.

a. DIRECT OBSERVATION. Surveillance will be accomplished through site visits; interviews with the veterans, the veteran families, and staff; medical records reviews, invoice and billing documentation, placement and medications documentation, and will be performed by COR and in conjunction with VA staff directly associated with CNH facility patient care.

b. PERIODIC INSPECTION. Inspections scheduled, monthly visits/inspections will be documented by the COR and in conjunction with VA staff directly associated with CNH facility patient care. Veterans may be interviewed, patient records and treatment goals may be reviewed, including provider visit documentation, continuity of care, safety, clinical nutrition, nursing, social work services, as well as any results of state surveys. Also includes invoice reviews and handling.

c. RANDOM INSPECTION. Unscheduled inspections – The COR and CNH Review Team may conduct random inspections. Veterans may be interviewed, patient records and treatment goals may be reviewed, including provider visit documentation, continuity of care, safety, clinical nutrition, nursing, social work services, as well as any results of state surveys. Also includes invoice reviews and handling.

d. VALIDATED USER/CUSTOMER COMPLAINTS. Veteran or family complaints will be reviewed and addressed within seven (7) days of receipt. Contract discrepancies may be addressed using the Contract Discrepancy Report. This includes continuity of care, safety, clinical nutrition, nursing, social work services, as well as any results of state surveys. Also includes invoice reviews and handling. User and Customer complaints may be monitored by the COR, CNH Review Team or Contracting Officer.

e. PROGRESS OR STATUS MEETINGS. Meetings may be requested by either the Contracting Officer, Contractor or the COR and will be used to update status and/or progress of health care of the veterans placed at the facility and overall contract performance and management.

6.1.1 Performance Object Category

Measurement / Task

Contract Location Reference

Performance Requirement

Performance Standard – from Section B.1 Acceptable Performance

Surveillance Method

Incentive Disincentive

Contract Administration (administrative functions)

1, Level of Care Changes

1.3.1.1 Request Level of

Care Change When Appropriate

Make timely requests for Level of Care Change when deemed necessary after periodic patient assessments / physical exams to the Contracting Officer’s Representative and receiving Level of Care Approval prior to performance of changed Level of Care.

100% Direct Observation

Favorable performance evaluation

Unfavorable performance evaluation

6.1.2 Performance Object Category

Measurement / Task

Contract Location Reference

Performance Requirement

Performance Standard – from Section B.4 Acceptable Performance

Surveillance Method

Incentive Disincentive

Price Schedule (other functions)

2. Transportation 4.14 Request VA Transportation through VA Travel Office

Make timely travel requests to VA Travel Office sufficient for patient appointments to prevent delayed, missed or rescheduled appointments, and preventing short-notice non-emergency transportation.

90% Direct Observation, User Complaints

Favorable performance evaluation

Unfavorable performance evaluation

3. Hospitalization 4.17 Hospitalizations and Hospitalization Needs Notifications

Make timely notifications to VA for hospitalizations and needs for hospitalization to the VA’s CNH Team Social Worker, Nursing or COR staff within stated times.

100% Direct Observation, Periodic Inspection, Random Inspection

Favorable performance evaluation

Unfavorable performance evaluation

6.1.3 Performance Object Category

Measurement / Task

Contract Location Reference

Performance Requirement

Performance Standard – from Section B.5 Acceptable Performance

Surveillance Method

Incentive Disincentive

Performance Work Statement (PWS)(Patient Care)

4. Provision of Care Standards

5.2 Meeting Patient

Care Needs within Standards of Care

Provision of health care meeting the needs of patients, promoting maximum well-being, ensuring total medical care, including nursing and psycho-social needs in accordance with Medicare and Medicaid Standards.

100% Direct Observation, Periodic Inspection, Random Inspection, User Complaints, Progress or Status Meetings

Favorable performance evaluation

Unfavorable performance evaluation

5. Medical Records

5.7 Creation, Maintenance and Retaining Accurate Medical Records

Maintain accurate medical records with necessary documentation for each patient

100% Direct Observation, Periodic Inspection, Random Inspection

Favorable performance evaluation

Unfavorable performance evaluation

6. Minimum Data Sets (MDS)

5.8 Physical Assessment

of patients

Assessment of patients upon admission and periodically thereafter, and provide completed assessments to the VA within 14 calendar days.

100% Direct Observation, Periodic Inspection, Random Inspection

Favorable performance evaluation

Unfavorable performance evaluation

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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).

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

8. DOCUMENTING PERFORMANCE

a. The Government will 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 will 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.

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

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting. The COR will communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

Attachment 13, Quality Assurance Surveillance Plan (QASP)