Attachment J - Quality Assurance Surveillance Plan TEMPLATE - - VISN 2 DOWNSTATE HOME OXYGEN SERVICES

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) PERFORMANCE REPORT

Contract Number:
Contract Description: Home Oxygen Services for VISN 2 South Contractor’s Name: , hereafter referred to as the Contractor Performance Period:
ID #
Performance Measure
PWS Ref.
Performance Requirement
Calculation Method
Acceptable Quality Level
Surveillance Method/ Source/ Frequency
Rating
Timely Set-Ups
2.1
8.1
Contractor shall complete all set-ups within 24-hours for all situations within contractor’s control. N = Number of VA patients whose set-ups were completed on time in accordance with requirements, unless circumstances beyond Contractor control.

D = Number of set-ups audited
100%
Periodic Inspection;

All set-ups reviewed

Monthly

Timely RT Visits
2.1
RRT visits shall be completed in accordance with contract (30 day; six month follow-up visits) terms.

*Note that compliance excludes situations outside contract control: patient on travel, patient hospitalization, patient refusal to allow access, inability to reach patient, etc. N = Number of RT Visits completed on time in accordance with requirements, unless circumstances beyond Contractor control.

D = Number of RT visits audited
90%
Periodic Inspection;

All RT visits

Monthly

Completion of Beneficiary Education
Patients will verify they have received all required documents and training from the Contractor per the terms of the contract as stated in Section 10, by signing a statement to that effect. This statement will be made a part of the invoice for each RT visit. N = Number of VA patient files with documentation of patient and/or caregiver signing they received all required documents and training.

D = Number of patients receiving Contractor visit
100%
Periodic Inspection/
Contractor Submitted Data;

Random audit of 5 patients served by Contractor for each service area. If less than 5 patients served, all are audited.

Monthly

Timely RT Notes
13.3
Progress notes shall be entered into Computerized Patient Record System (CPRS) within three business days of visit. N = Number of RT notes completed on time in accordance with requirements

D = Number of RT notes audited
95%
Periodic Inspection;

All RT notes

Monthly

Joint Commission (JC) Standards
16.4
19.1
19.7
Maintain JC accreditation or if not accredited, provides comprehensive monthly reports, approved by the VA, throughout the duration of the contract with specific documentation for each JC standard showing they are in 100% compliance with all applicable JC standards.