Attachment 5_Quality Assurance Surveillance Plan.doc
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- Attached to
- Nutrition Care Food Services
- Solicitation number
- W81K04-20-R-0014
- Issued by
-
Department of the Army Medical Command
About this file
This document contains a Quality Assurance Surveillance Plan (QASP) for a nutrition care foodservice contract. The QASP outlines performance standards and inspection methods for services such as therapeutic nutrition education, patient room service, bulk nourishments, dining room services, and cash collection. Acceptable quality levels and methods of inspection including 100% inspection, periodic inspection, and random inspection are defined for each performance requirement. Inspections will be conducted by a Contracting Officer's Representative and performance will be evaluated using a Contractor Performance Assessment Reporting System. Corrective actions and contract discrepancy reports are also addressed.
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Quality Assurance Surveillance Plan (QASP)
For
Nutrition Care Foodservice
1. Purpose.
This Quality Assurance Surveillance Plan (QASP) is a government developed and applied document used to provide a standard of surveillance for monitoring the Nutrition Care Foodservice contract and provides the approach the government will use to conduct surveillance over the performance aspects of the effort. The intent is to ensure that the contractor performs in accordance with performance metrics set forth in the contract documents, that the government receives the quality of services called for in the contract, and that the government only pays for the acceptable level of services received.
2. Scope.
The QASP is put in place to provide government surveillance oversight of the contractor’s quality control efforts to assure they are timely, and effective, and results are performed as specified in the contract. The QASP is not a part of the resulting contract nor is it intended to duplicate the contractor’s internal quality management efforts.
3. Govnment Roles and Responsibilities.
The following personnel shall oversee and coordinate surveillance activities.
3.1. Contracting Officer (KO). The KO is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the Contracting Officer’s Representative (COR) and the contractor. The KO will designate a COR as the government representative for performance management. The number of additional government representatives serving as inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the KO.
3.2. COR. The COR is designated in writing by the KO to act as his or her authorized representative. The COR will assist the KO with the technical administration of the contract to ensure proper government surveillance of the contractor’s performance. Any COR limitations will be identified with the designation letter. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes the contractor deems may affect contract price, terms, or conditions shall be referred to the KO for action. The COR is responsible for quality assurance (QA) monitoring and completion of forms/reports used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the terms and conditions of the contract for inspection.
3.3. Other Key Government Personnel. At each contracted location there may be a Chief, Nutrition Care Division (C, NCD), a Non-Commissioned Officer In Charge (NCOIC) and a person designated as the Quality Assurance Evaluater (QAE). At each contracted location the C, NCD will determine who the QAE will be. The C, NCD may also delegate surveillance data collection to other Government staff. Surveillance data from each location will be provide to the COR for reporting purposes.
3.4. The following employee(s) of the contractor serve as the contractor’s representative for this contract: (Upon award, government will enter name(s)).
4. Inspection Instructions.
4.1. The contractor shall provide and maintain an inspection system acceptable to the government covering the services under this contract. Complete records of all inspection work performed by the contractor will be maintained and made available to the government during contract performance and for as long afterwards as the contract requires.
4.2. If any of the services do not conform to contract requirements, the government may require the contractor to perform the services again in conformity with contract requirements, at no increase in contract amount. When the defects in services cannot be corrected by reperformance, the government may require the contractor to take necessary action to ensure that future performance conforms to contract requirements; and reduce the contract price to reflect the reduced value of the services performed.
4.3. The government has the right to inspect and test all services called for by the contract, to the extent practicable at all times and places during the term of the contract. The government shall perform inspections and tests in a manner that will not unduly delay the.
4.4. If the contractor fails to promptly perform the services again or to take the necessary action to ensure future performance in conformity with contract requirements, the government ma y, by contract or otherwise, perform the services and charge to the contractor any cost incurred by the government that is directly related to the performance of such service; or terminate the contract for default.
4.5. If the government performs inspections or tests on the premises of the contractor or a subcontractor, the contractor shall furnish, and shall require subcontractors to furnish, at no increase in contract price, all reasonable facilities and assistance for the safe and convenient performance of these duties.
5. Methods of Inspection.
5.1. The below listed methods of surveillance may be used in the administration of this QASP. They can occur quarterly, monthly, or as needed. Surveillance may be conducted by the COR, C, NCD, NCOIC, QAE or other designated Government staff. The term COR will be used to represent all government surveillance data collerctors. a. 100% Inspection. The COR may conduct 100% inspections of the work defined in the performance work statement (PWS). The COR will also review information submitted in the required reports defined in the PWS.
b. Periodic Inspection. The government may conduct periodic inspections monthly, quarterly, or on an as-needed basis. The periodic inspection shall be conducted by the COR.
c. Random Inspection. The government may conduct random monitoring by reviewing information/reports required and submitted in accordance with the contract. The random monitoring shall be performed by the COR.
d. Performance Evaluation Meetings. The contractor and the COR will meet as often as necessary to review the contractor’s performance and address any contract discrepancy reports (CDRs) issued during the period. A mutual effort will be made to resolve identified issues.
e. Customer Feedback – The COR may provide and collect customer surveys or complaints regarding performance. A mutual effort will be made to resolve any problems/issues identified.
5. 2. Level of surveillance may be conducted on a monthly, quarterly or as-needed basis and an analysis of the results will determine if the contractor met the standards or did not met the standards identified in the PWS/contract.
6. Performance Requirements Summary (PRS).
| Performance Objective |
| Performance Standard |
| Acceptable Quality Level (AQL) By Site |
| AQL, All sites Combined |
| Method of Inspection |
| Incentive/Discentive |
Para’s 5.1. - 5.1.3. Therapeutic Nutrition Education
| Therapeutic Nutrition Education provided and Competency Assessment documented for all contractors, and their work leaders, involved in the preparation, assembly and delivery of patient trays on a regular or occasional bases. |
| Therapeutic Nutrition Education developed by an RD is provided. Competency is assessed and documented in contractors file. Training and competency assessment conducted during orientation, on contractors approved recurring schedule and on an as needed basis. |
| 95% of applicable contract employees have documentation of training and competency assessment |
| 95% of applicable contract employees have documentation of training and competency assessment |
| Periodic, Random |
| Performance above or below the standard will be documented in the Contractor Performance Assessment Reporting System (CPARS) |
| Procedures in place to prevent patient feeding errors |
| Contractor report or respond to reports of potential unsafe events that might increase the likelyhood of a patient safety event when the event is caught prior to reaching the patient (near misses). Such events may be reported thru the PSR system or to the NCOIC |
| 95% of the time |
| 95% of the time |
| 100% of all reports |
| Performance above or below the standard will be documented in the (CPARS) |
| No patient safety events that reach the patient and may or may not have caused harm. |
| No more than 2 patient safety events per year that reach the patient. |
| No more than 5 patient safety events per year that reach the patient. |
| 100% of all reports |
| Performance above or below the standard will be documented in the (CPARS) |
Para’s 5.3. - 5.3.3. Patient Room Service
| Prepare and deliver Patient Trays |
| Items are prepared IAW regular or therapeutic diet orders and recipes. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Food items on tray match menu selections are correct serving size and temperature. Trays contain correct utensils, condiments, garnish and napkins. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Tray contents are in compliance with all local MTF patient safety policies. Clinical examples include but are not limited to ensuring prohibited service ware is not delivered to psych ward; no identified allergens or restricted items on tray, etc. |
| 99% of the time |
| 99% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Trays are checked to confirm accuracy. |
| 99% of the time |
| 99% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Trays prepared and delivered within 40 minutes of receipt of order. |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Trays delivered to correct patient (if not left with Ward Nurse) |
| 99% of the time |
| 99% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Para 5.3.2.3. Retrieve all tray carts and trays from wards and return to NCD. |
| Trays removed from wards by 9:00AM, 2:00PM and 6:00 PM daily (or as locally agreed upon). No trays on ward longer than 3.5 hours after delivery. |
| 95% of the time. |
| 95% of the time. |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Para 5.4-5.4.6. Bulk Nourishments |
| Assemble, measure, weigh and mix ingredients IAW bulk nourishment ward requirements. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Ensure bulk nourishment items do not exceed expiration date. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Report bulk nourishment use to NC NCOIC |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
Para’s 5.5.-5.5.2.7. MTF Dining Room Services
| Prepare and serve menu items. |
| Menu items prepared IAW PPS or SOP |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Serving and self- service areas set up NLT 5 minutes prior and not earlier than 30 minutes prior to period and IAW PPS |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Proper serving utensils used and portion control maintained. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Proper food temperatures/ food safety maintained |
| 98% of the time |
| 98% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Condiments and service ware available at start of serving period and replenished throughout service. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Paras 5.6-5.6.5.1. Grab and Go Service |
| Provide Grab and Go items IAW PPS or local SOP. Grab and Go items assembled in a timely manner. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
Para’s 5.7.4.-5.7.4.9. Cash Collection
| Accurately enter meal items into Point of Sale System (POS) |
| 98% of the time |
| 98% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Provide correct change to customer. |
| 98% of the time |
| 98% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Customer wait time not to exceed 3 minutes |
| 90% of the time |
| 90% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Maintain a continuous and auditable trail of cash. |
| 100% of the time |
| 100% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Reconcile cash register tapes and cash collected with NC NCOIC. |
| 100% of the time |
| 100% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Cash register reports and cash collected reflect equal amounts. |
| 98% of the time |
| 98% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Discrepancies do not exceed one half of 1% of daily revenue |
| 98% of the time |
| 98% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
Para’s 5.7.5.–5.7.5.12. Cleanliness and Sanitation
| Clean, sanitize food contact surfaces and equipment in food preparation, serving and self-service and storage locations |
| Fully compliant or substantially compliant status received from unannounced Preventive Medicine monthly inspections. |
| No more than two Substantially Compliant or Non-Compliant ratings annually, not to exceed one Non- Compliant rating annually. |
| No more than five Substantially Compliant or Non-Compliant ratings annually, not to exceed three Non- Compliant rating annually. |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Must discuss inspection findings with NCOIC within 3 working days of inspection. |
| 90% of the time |
| 90% of the time |
| Periodic |
| Performance above or below the standard will be documented in the (CPARS) |
| Must achieve Fully Compliant or Substantially Compliant rating on re-inspection (if required due to pervious failed inspection). |
| 99% of the time |
| 99% of the time |
| 100% inspection as required |
| Performance above or below the standard will be documented in the (CPARS) |
| Receive passing grade on routine internal inspections |
| 90% of the time |
| 90% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| All required temperature logs are complete and accurate. |
| 90% of the time |
| 90% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Shall maintain a clean-as-you go operation to reduce potential health risks and contamination. |
| 90% of the time. |
| 90% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Monthly sanitation schedule posted |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Weekly sanitation self-evaluation complete |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
| Routine internal inspection discrepancies corrected on the spot or as directed by NCOIC. |
| 95% of the time |
| 95% of the time |
| Periodic, Random, Customer Feedback |
| Performance above or below the standard will be documented in the (CPARS) |
5.7.6.-5.7.6.6.Supply
| 5.7.6.1. Request supplies needed for PRS and foodservice. |
| Provided list daily or IAW locally established schedule |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| 5.7.6.2.-5.7.6.5.Properly receive, check, store and issue supplies |
| Received deliveries from suppliers, checked items against purchase documents and documented receipts, recorded overages or shortages and reported discrepancies to the NCOIC |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Properly stored, stacked, labeled and rotated supplies and materials |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Issued supplies and materials to work areas, completed proper documentation and maintained accountability of all supplies and materials |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| 5.7.6.6. Maintain inventory control of supplies and materials. |
| Maintains inventory at established stock levels (where applicable) |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Performs perpetual inventory as requested by the NCOIC; submits complete and accurate inventory reports to the NCOIC. |
| 98% of the time |
| 98% of the time |
| 100% Inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Coordinates and conducts joint monthly inventory and submits complete and accurate inventory reports to the NCOIC. |
| 98% of the time |
| 98% of the time |
| 100% Inspection |
| Performance above or below the standard will be documented in the (CPARS) |
5.7.7.-5.7.7.7. Other Training
| Contract employees are trained and assessed for competency |
| Training materials, attendance records and competency assessments up-to-date IAW contractors training schedule and MTF requirements. All materials, records and assessments are available to NCOIC. |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
5.7.8.-5.7.8.16. Inspections, Reports, and Meetings
| 5.6.8.1-5.6.8.2. Inspections |
| Cooperate with inspectors, auditors/ surveyors during inspections, survey and audits. Maintain open access to facilities, records and make available information/documentation for review. |
| 99% of the time |
| 99% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Make corrections to return situation to satisfactory condition, or a plan to correct discrepancy within NCOICs required timeframe. |
| 99% of the time |
| 99% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| 5.7.8.4. Submit DMHRSi data |
| Reports must be accurate, complete and submitted by COB every Friday. |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| 5.6.8.6. Satisfaction Surveys |
| Conduct inpatient satisfaction surveys (where applicable); dining room customer satisfaction surveys, submit site specific report of survey results and comments to NCOIC quarterly. |
| 95% of the time |
| 95% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| Submit consolidated inpatient satisfaction surveys and dining room customer satisfaction surveys results and comments to COR quarterly. |
| 95% of the time |
| 95% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| 5.7.8.8. -5.7.8.9. Prepare and submit daily, monthly, quarterly reports; examples may include QC reports, weekly internal sanitation inspections, etc. |
| Reports must be accurate, complete and on time. |
| 95% of the time |
| 95% of the time |
| Periodic, Random |
| Performance above or below the standard will be documented in the (CPARS) |
| Submit consolidated, summarized QC results to MEDCOM COR quarterly |
| 95% of the time |
| 95% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
| 5.7.8.10. Meeting Participation |
| PM, Site Supervisors, or alternates will be prepared for and participate in scheduled meetings. |
| 95% of the time |
| 95% of the time |
| 100% inspection |
| Performance above or below the standard will be documented in the (CPARS) |
NOTE: IAW PWS Chap 3. The Government is responsible for providing facilities, equipment and maintenance and the SP is responsible for monitoring operability of Government Furnished Equipment and reporting malfunctions to the Government. TB MED 530-TSFC inspection form DD Form 2973 documents inspection of all areas of safety and sanitation. Non-compliance on items relating to the physical facility, installation, maintenance and operability of equipment will not be considered the fault of the CSP unless problems were not reported to the Government, were caused by CSP misuse or failure to properly clean or maintain.
7. Successful Performance.
7.1. Successful performance can be incentivized with favorable past performance ratings and award of follow-on opportunities.
7.2. Acceptable services for performance is demonstrated by an accepted and executed certified invoice.
7.3. The AQL consists of the performance standards established for the services required by the government to meet contract requirements. The AQL will be measurable and structured to permit an assessment of the contractor’s performance.
8. Documentation of Surveillance.
8.1. Effective contract surveillance relies on the COR identifying and documenting discrepancies during performance of routine daily services, or through the contractor’s quality control program. The COR will report discrepancies to the contractor for timely resolution. Survelliance may consist of periodic reports, and customer feedback and timeliness of contract deliverables/reports.
8.2. The COR will maintain a complete QA file which will be retained by the COR for the life of the contract. Information in the QA file will be considered when completing the annual CPARS report.
8.3. Documented surveillance will consist of inspections performed by the COR. All paperwork that supports contract surveillance such as details of inspections or data gathering, conversations or meetings with the contractor, notes and comments that support inspection paperwork, to include quality assurance surveillance reports. . If performance is deemed unacceptable, the COR will inform the contractor. Disagreements or disputes will be referred to the KO for re-address.
8.4. All documentation resulting from surveillance will be made a part of the contract file. The COR must keep the documentation files during the surveillance period, but at the conclusion of the contract and as directed by the KO, the COR must give the files to the KO for inclusion in the official contract file.
9. Corrective Actions.
9.1. The contractor will be provided the opportunity to submit proposed corrective action to resolve the discrepancy. The COR will review proposed corrective action and determine whether or not it is acceptable and whether or not the discrepancy has been corrected. If the discrepancy has been resolved, the COR will notify the contractor and document the quality assurance surveillance checklist.
9.2. The COR will notify the contracting officer of unacceptable performance if any services do not conform to contract requirements. The contracting officer may require the contractor to re-perform the services to conform with contract requirements at no additional cost to the government.
9.3. When unacceptable performance cannot be corrected by re-performance, the government may require the contractor to take action necessary to ensure future performance conforms with contract requirements.
9.4. The government may, by separate contract or otherwise, perform the services and charge the contractor any cost incurred that is directly related to the performance of such service, or issue:
a. Cure Notice
b. Show Cause
c. Terminate the contract for convenience of the government
d. Terminate the contract for cause
10. Certification of Services. Certification of services is performed by the COR via Wide Area Work Flow (WAWF) system. At the end of each billing period, the contractor inputs invoice information into WAWF system. WAWF automatically notifies the appropriate COR via email of pending invoice. COR accesses WAWF and verifies the accuracy of services provided by the contractor. The COR will certifiy the invoice and payment is conducted by the Defense Finance Accounting System (DFAS). If the COR encounters errors in the contractor’s invoice, the COR will reject the invoice, state the reason for rejection and send back to the contractor. If the contractor disagrees with the COR, the issue will be forwarded to the KO for resolution.
11. Contract Discrepancy Report (CDR), Attachment 1 (Optional)
File details come from the government source that posted it. Updated .