Quality Assurance Surveillance Plan (QASP).pdf

QUALITY ASSURANCE SURVEILLANCE PLAN for HCHV Contract Housing

Quality Assurance Surveillance Plan For

Contract Housing

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contractor actions while implementing this Statement of Work (SOW). It is designed to provide an effective surveillance method of monitoring contractor performance for each listed objective on the Service

Delivery Summary (SDS) in this contract.

The QASP provides a systematic method to evaluate the services the contractor is required to furnish.

The QASP is based on the premise, the government desires to maintain a quality standard in providing primary care/mental health services to its patients. The resulting contract is considered the best means of achieving that objective.

PURPOSE

The contractor, and not the government, is responsible for management and quality control actions to meet the terms of the contract. The role of the government is Quality Assurance (QA) to ensure contract standards are achieved.

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. In this contract, the quality control program is the driver for product quality. The contractor is required to develop a comprehensive program of inspections and monitoring actions. The first major step to ensuring a “self-correcting” contract is to ensure that the quality control program, approved at the beginning of the contract, provides the measures needed to lead the contractor to success.

This QASP explains the following:

1. What shall be monitored?

2. How monitoring shall take place.

3. Who shall conduct the monitoring?

4. How monitoring efforts and results shall be documented.

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. Copies of the original QASP and revisions shall be provided to the contractor and government officials implementing surveillance activities.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

1.1 Performance Management Approach

1.1.1 The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by Health Care for Homeless Veterans (HCHV) Program to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved.

Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

1.1.2 Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.2 Performance Management Strategy

1.2.1 The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

1.3.2 The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make determination regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer

The contracting officer (CO) 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 CO will designate one full-time COR as the government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the CO.

2.2 The Contracting Officer’s Technical Representative

The contracting officer’s technical representative (COTR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COTR limitations are contained in the written appointment letter. The COTR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COTR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COTR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary.” [Adjust the following sentences to reflect the instant acquisition.] If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract. If the contractor exceeds the service or performance level, it is eligible to receive an incentive or award fee as stated in the contract. Failure to meet the required service or performance level will result in a deduction from the monthly amount.

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are (include those that apply)

➢ Random monitoring, which shall be performed by the COTR/COR designated inspector.

➢ 100% Inspection – Each month or as needed, the COTR/COR, shall review the generated documentation and enter summary results into the Surveillance Activity Checklist.

➢ Periodic Inspection – COTR/COR typically performs the periodic inspection monthly.

4.2 Customer Feedback

The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems but the customer always has the option to communicate complaints to the COR, as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COTR/COR. The COTR/COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form – Customer Complaint

Investigation.

Customer feedback may also be obtained from the results of formal contractor customer satisfaction surveys and from random customer complaints.

4.3 Acceptable Quality Levels

The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities such as those involving Housing of Homeless Veteran and the National Homeless Performance Measures, the desired performance level is established at 100 percent. Other levels of performance are keyed to the relative importance of the task to the overall mission performance at Health Care for Homeless Veterans (HCHV)

Program.

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and are assessed using the performance monitoring techniques shown in the Attachments.

5.2 Monitoring Forms

The government’s QA surveillance, accomplished by the COR, will be reported using the sample monitoring forms in Attachments1, 2, 3 and 4. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results per HCHV

National Performance Measures, and HCHV Monthly Technical Reports and Contractor’s Satisfaction feedback, etc. The COR will retain a copy of all completed

QA surveillance forms.

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

a. Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels. The contractor will be held responsible to meet the current HCHV PM’s. Consequences of not meeting PM’S include an immediate action plan with weekly measures/metrics and withholding of admissions until the contractor meets HCHV PM’s/goals.

6.1.1 Reporting

6.1.2 At the end of each month, the contracted facility will prepare a technical written report for the COR or HCHV liaison summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s submitted monthly report and the completed monthly technical report (Attachment 4), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

6.2 Reviews and Resolution

6.2.1 The COR may require the contractor’s project manager, or a designated alternate, to meet with the COR and other government IPT personnel as deemed necessary to discuss performance evaluation. The COR will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the COR as often as required or per the contractor’s request and as stated in the Statement of Work (SOW). The agenda of the reviews may include:

➢ Monthly performance assessment data and trends

➢ Issues and concerns of both parties

➢ Projected outlook for upcoming months and progress against meeting or exceeding expected performance measures, including a corrective action plan

➢ Recommendations for improved efficiency and/or effectiveness

6.2.2 The QAR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

6.2.3 The COR and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the PCO/ACO.

Formatted: No bullets or numbering

PERFORMANCE STANDARDS

Performance standards define desired services. The government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards. The performance requirements summary matrix is incorporated within this QASP to include performance standards and disincentives. The government shall use these standards to determine contractor performance to Acceptable Quality Level (AQL) defined below for each performance requirement.

See Attachments 1-4 below:

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

PERFORMANCE THRESHOLD/

TASK STANDARD ACCEPTABLE QUALITY LEVEL METHOD OF SURVEILLANCE

Access: Transitional housing services for homeless veterans shall be provided in accordance with a plan of care and by designated housing staff.

Supervision shall be provided in accordance with VA policy and regulations pertaining to

Healthcare for Homeless

Veterans.

The contractor shall be responsible for admitting veterans, assessing veterans, (including initial and ongoing assessments), care planning (including the care-planning process), coordinating supervision, evaluating the care and services provided, and discharge planning.

100% during quarterly rating period.

Bi-weekly or PRN visits and annual Inspections to include a random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected. Additionally, at the government’s discretion, at any time, announced or unannounced the contractor will allow VA personnel to inspect the contractor’s facility.

Dietary: The dietary needs of all veterans shall be met in accordance with sound nutritional and medical standards.

At least 3 nutritious meals shall be served daily, at regular times with in-between meal snacks and bedtime snack if not medically contraindicated. Bag lunches are to include all food groups. Food items shall be prepared, served, and stored under sanitary conditions.

Sanitary procedures shall be established and maintained for washing dishes, cleaning equipment and work areas, and for proper wasted disposal.

90% during quarterly rating period.

The government will conduct bi-weekly, bi- monthly or prn and annual visit inspections of the contract’s facility. The government may, at its discretion, choose any time, announced or unannounced, to have

VA personnel inspect the contractor’s facility. The facility will provide an accounting of all meal plans, at least for the past month, for VA staff to review.

Facility: Clean and sanitary housing shall be provided to all veterans.

All services provided under this contract shall be delivered in a clean and sanitary environment.

90% during quarterly rating period.

During weekly, bi- monthly or prn and annual visits the contractor will provide a random sampling of records, the VA will ensure facility compliance to the

SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose

Compliance with the latest edition of 42 CFR and National Fire

Protection Association

(NFPS) 101, Life Safety must be maintained.

Structured group activities, as appropriate, e.g., social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling, physical activity, living and self-care. Veterans shall be provided with opportunities to participate in spiritual worship, counseling, treatment, social skill enhancement and knowledge of the process of illness and recovery.

The contractor shall not receive reimbursement for services provided which have not been previously approved by the contracting officer.

any time, announced or unannounced to have VA personnel inspect the contractor’s facility. The facility will provide an accounting of all groups and activities, at least for the past month, for VA staff to review.

Records & Reports: An individual client record will be maintained on each veteran admitted under this agreement;

which will include, in addition to reasons for referral, documentation of veterans’ progress within the program as well as high risk suicide status, any special accommodation needs or dietary needs. This should also include sign-in sheets whenever possible.

Specific items to be delivered by VA contractor including any records/reports and manuals to be provided to VA:

(1) All essential identifying data relevant to the resident and his/her family including a socio-cultural assessment and high-risk suicide status.

(2) Data relating to the resident’s admission including income and

95% during quarterly rating period.

During weekly/bi-weekly or bi- monthly or prn and annual visits and random sampling of records, the

VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the contractor’s facility.

disability application status to include PHQ9 on admission and every

30 days or as indicated.

(3) Copies of any medical prescriptions issued by

VA physicians, including any orders for medications to be taken, if any.

(4) Reports of weekly staffing by treatment team.

(5) Discharge summaries on each resident who leaves the program, to include reason for leaving, the resident’s future plans and follow-up locator information.

(6) Individual case records will be maintained in confidence, as required by title 42, U. S. C., Part II – “Confidentiality of Alcohol and Drug

Abuse Patient Records”.

(7) Records will be accessible to the evaluation study required by congress. (8)

Periodic reports will be provided to the VA, e.g., Fiscal Accountability, as required.

(9) Monthly list of veteran’s discharges, with date of discharge, shall be submitted to the

VA. The VA is to be notified of discharges within 24 hours of discharge, either telephonically or fax the information to (843)579-

3885.

Discharge summaries are to be provided to the

CHS HCHV staff within

3 days of discharge from the program.

(10) Customer

Satisfaction questionnaire monthly delivered to the

Contracting Officer

Technical Representative

(COTR).

Staffing: At a minimum, there must be a full-time administrative staff member or his/her staff designee on duty at the premises or residing at the house and available for emergencies

24 hours/day, 7 days/week.

Program will be staffed with the appropriate number of licensed healthcare professionals to provide for and meet standards.

100% during quarterly rating period.

During weekly/bi-weekly or bi- monthly or prn and annual visits and random sampling of records, the

VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the contractor’s facility.

Transportation:

Contractor shall provide

Veterans with transportation to community and CHS

VAMC for all assigned activities, all scheduled meetings and appointments, including job interviews and work assignments, inclement

100% during quarterly rating period

During weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected. Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the contractor’s facility.

weather, etc. via van transport or bus tickets until the Veteran is no longer in the program. If public transportation is not available (i.e.

weekdays, after hours, weekends, holidays, etc.), transportation will be provided by the

Contractor. This transportation provision will not be based on the

Veteran’s income or lack thereof.

Community Independent

Placement Upon

Discharge

Contractor shall successfully house upon discharge 85% of

Veterans discharged to community

90% during quarterly rating period

During weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected. Additionally, at the government’s discretion, chose any time, independent placement within VA specified time frame for Veteran discharge.

announced or unannounced to have VA personnel inspect the contractor’s facility. Successfully housed will be document in veteran’s records and upon completion of Veteran Exit form.

Veteran Stakeholder

Satisfaction

Contractor shall distribute Opinion Poll surveys to Veterans randomly to determine satisfaction with services and /or suggestions for improvement, 80% minimum satisfaction during quarterly rating period

Veteran Stakeholder completion of Opinion Poll survey

Surveillance: The government’s QA person and the COTR shall use the surveillance methods listed below in the administration of this QASP.

a. Direct Observation - Direct observation shall be performed periodically or through 100% surveillance. All performance standards.

b. Periodic Inspection - Evaluate outcomes on a periodic basis. Inspections may be scheduled daily, weekly, monthly, quarterly, annually or unscheduled, as required. All performance standards.

c. Progress or status meetings - All performance standards.

d. Complaints - Complaints from agency personnel shall be passed to the contractor’s quality control inspector (QCI) for correction. All performance standards.

e. Standard: Customer complaints shall not exceed the thresholds cited above for each performance objective. The government’s QA personnel shall notify the Contracting Officer (CO) for appropriate action in accordance with FAR 52.212.4, Contract Terms and Conditions – Commercial Items (May 1997) or the appropriate inspection of services clause, if any of the above service area exceed the customer complain thresholds.

DOCUMENTING PERFORMANCE

a. Acceptable Performance – The government shall document performance. Any report may become a part of the supporting documentation for any contractual action.

b. Unacceptable performance – When unacceptable performance occurs, the COTR shall inform the contractor. This shall normally be in writing unless circumstances necessitate verbal communication. In any case, the COTR shall document the discussion and place it in the

COTR file.

When the COTR determines formal written communication is required, the COTR shall prepare a Contract Discrepancy Report (CDR) and present it to the contracting officer. In turn, the CO shall present the CDR to the contractor’s contracting personnel.

The contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long, after receipt, the contractor must present this corrective action plan to the COTR. The government shall review the contractor’s corrective action plan to determine acceptability.

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

Surveillance: The government evaluator shall evaluate the services required by each deliver/task order to ensure complete compliance.

Procedures: The government evaluator shall inspect to ensure contractor compliance with the appropriate section of the SOW periodically.

The evaluator shall record results of inspection, noting the date & time of inspection. If inspection indicates unacceptable performance, the government evaluator shall notify the CO and/or QCI of the deficiencies and have QCI correct those deficiencies. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

Frequency of Measurement: During contract performance, the COTR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

a. Frequency of Performance Assessment Meetings.

The COTR shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

Signature, Contractor Program Manager

Signature, Contracting Officer’s Technical

Representative

Signature, Contracting Officer

ATTACHMENT 2a: SAMPLE QUALITY ASSURANCE

MONITORING FORM

HCHV BI-WEEKLY INSPECTION

SITE:

DATE:

BATHROOMS Ye s

No N/ A

Corrective Action due

Date action completed

Clean toilets

Mold in/around bath tub/tiles

Clean around toilet bowl

No mold/mildew (bathroom & a/c registers/etc.)

Bathrooms: Fixtures in working order

Bathrooms: Water source, hot and cold working properly

Other:

KITCHEN/MENUS/NUTRITION Ye s

No N/ A

Corrective Action due

Date action completed

Kitchen: Clean stove and oven and refrigerator

Kitchen: Food items stored properly in cabinets and refrigerator (exp dates clearly marked, food goods labeled with identity & sealed) with no spoilage

Kitchen: Food items (meats) in deep freeze have current expiration dates

Kitchen: Food items handled properly during preparation/service

Kitchen: Food items safe from potential contamination, i.e. Shell eggs are not cracked or dirty

Kitchen: Clean counter tops/floors

Kitchen: Clean cabinets/tables and sink

Kitchen: Thermometer in the refrigerator & Freezer & Temp logs current

Kitchen: Microwave, dishwasher, sink clean

Kitchen: Condition of pots, pans, eating and cooking utensils: safe

Kitchen: Chemicals properly secured, labeled, and dated (no chemicals stored by food)

Kitchen: No mold/mildew in kitchen

Kitchen: Area free of evidence of pest infestation i.e. droppings /waste contamination (trash cans have lids & no leakage noted, no shipping cartons in food area

Kitchen: Employee hygiene and practice (hand washing station/signs posted)

Kitchen: Hair nets/Ball Caps, no cell phones in cooking area & covers for bottom shelves

Kitchen: Area free of potential injury or safety hazards, i.e. No dangerous areas for slipping, falling

Kitchen/Dining: Number of dining chairs accommodates number of Vets in house

Kitchen: Overall appearance of kitchen and dining area clean & tidy including clean walls, floors & ceilings

Kitchen: Water source, hot and cold working properly

Kitchen: Menus Posted

Menu plan is what is served

Balanced nutrition meal plan

Kitchen: Alternative meal plan for special needs. i.e. diabetes, HTN, etc.

Kitchen: Temperatures appropriate and recorded on log (thermometer available for reheating)

SAFETY Ye s

No N/ A

Corrective Action due

Date action completed

Fire extinguisher up to date

Fire exit marked & visible

Smoke detectors working (date last checked by facility staff/batteries changed)

Evacuation plans posted (exit plan)

Alarm system working (date last checked by facility staff)

Review of Fire Drills to include facility conducted one fire drill per month-covering all shifts per quarter (PLEASE DOCUMENT ON INSPECTION SHEET SHIFT COVERED!)

Date:

Windows secure

Elevator inspection up to date

Individual house or facilities have completed Emergency Numbers posted in location all vets are aware of!

Facility free of potential injury or safety hazards, i.e. No dangerous areas for slipping, falling

Accessible Entrance/Exits

No extension cords or outlet extensions to increase available plug ins/Cable cords secured

Specific facility security system: surveillance: (camera, video, door alarms), bed checks, doors locked, who has keys.

Electrical closets/stairwells clear

First aid kits readily available

BEDROOMS No N/ A

Corrective Action due

Date action completed

Bed made

Clean carpet/closets

Cob webs

Furniture dusted

Personal items stored properly in appropriate containers with no cardboard boxes or paper bags.

Closets clutter free & no combustible materials

ENVIRONMENT Ye s

No N/ A

Corrective Action due

Date action completed

Gutters intact & clutter free (last time facility cleaned)

Screen door secure

Working flood lights

House Pressure washed (date last cleaned)

Yard maintenance

Extermination schedule available (date last exterminated)

SATISFACTION Ye s

No N/ A

Corrective Action due

Date action completed

Satisfaction boxes posted

Placement Suggestion Form and HCHV Placement Facts posted

STAFFING Ye s

No N/ A

Corrective Action due

Date action completed

Staffing pattern according to grant (24/7 number available for all Veterans to contact staff member)

SECURE MEDICATION Ye s

No N/ A

Corrective Action due

Date action completed

Medication under lock and key

Meds not in refrigerator w/ food

OTHER Ye s

No N/ A

Corrective Action due

Date action completed

Suicide Prevention policy in place and Hotline number posted in facility

Patient Rights and Grievance Form posted

Daily sign in/out logs in place and up to date paperwork/documentation with PHI secured

Current Census See Scoreboard

Current Discharges See Scoreboard

Current Problems/Incident Reports

Veteran complaints insect bites

OVERALL CLEANLINESS Ye s

No N/ A

Corrective Action due

Date action completed

Dust/Lint in dryer vents

Light fixtures covered, in good repair

No evidence of mold/mildew (a/c registers, other areas of house)

Furniture without rips/tears

Appearance clean & tidy including clean walls, floors & ceilings (no carpet spots and no Ceiling/tile leaks)

Smoking area Clean

Overall Facility: Free of evidence of pest infestation i.e. droppings /waste contamination (trash cans with no leakage noted)

No Unusual Odors

ATTACHMENT 2b: SAMPLE QUALITY ASSURANCE

MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer

Complaint

LEVEL OF SURVEILLANCE (Check):

Monthly Quarterly As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: ______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (Check): Meets Standards

Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________

ATTACHMENT 3: QUALITY ASSURANCE

MONITORING

The Homeless Operations, Management, and Evaluation System (HOMES) is VA’s primary platform for collecting intake, progress, and outcome information for homeless Veterans as they move through the VA’s system of care. The contractor will be required to meet the HCHV National and VISN Perfromance

Measures and required metrics.

1. Percentage of Veterans Discharged to Permanent Housing Arrangements

2. Percentage of Veterans Discharged with a Negative Exit

3. Explanation of Above Monitors:

HCHV1: Percent of Exits to Permanent Housing

Indicator Description:

Percentage of Veterans discharged from Health Care for Homeless Veterans Contracted Residential Services (HCHV CRS) or Low Demand Safe Haven (LDSH) programs to permanent housing.

Population: Veterans exiting HCHV CRS or LDSH programs in FY 2019.

Target and Business Rules:

The FY 2019 target is 53%. HCHV CRS or LDSH programs are designed to provide low-demand housing services to Veterans as they transition to other programs or to PH.

Escalating Targets and Stop Light Formatting for Homeless Scorecard:

53% or above (Green) 52-48% (Yellow) 47% or below (Red)

Denominator:

Number of Veterans with an exit date from a HCHV CRS or LDSH program between 10/1/18 and 9/30/19.

• HOMES data source: Residential Treatment Entry Form item 3b, options 2 or 5.

• HOMES data source: Residential Treatment Exit Form item 1, exit date is between 10/1/18 and 9/30/19, inclusive.

Denominator Inclusions:

Veteran is included in the denominator if Veteran has an exit date from a HCHV CRS or LDSH program between 10/1/18 and 9/30/19.

o HOMES data source: Residential Treatment Exit Form, item 1, exit date is between 10/1/18 and 9/30/19, inclusive.

Denominator Exclusions:

Veteran is excluded from the denominator under any of the following circumstances:

1. Veteran has a Length of Stay (LOS) of seven days or less.

o HOMES data source: Residential Treatment Exit Form, item 1 and exit date-entry date is = or <7.

2. Veteran is deceased at discharge.

o HOMES data source: Residential Treatment Exit Form, item 2, option 8.

3. Veterans who have been discharged due to threatened/actual violence to self or others.

o HOMES data source: HOMES Residential Treatment Exit Form, item 2a, option

1 (Threatened/actual violence to self or others).

4. Veteran is transferred to another residential program due to the temporary or permanent suspension of program operations. This exclusion will be entered manually into a spreadsheet titled “RT Manual Exclusions” located on the VSSC Secure Site after consultation with the HCHV National Program Office. (NOTE: same process as HMLS3). If the Veteran is readmitted to HCHV, after the noted exclusion date, the Veteran should be included in the measure based on the new admission date.5. Veteran is placed into a hospital or other residential non-psychiatric medical facility, long-term care facility or nursing home, or psychiatric hospital or other psychiatric facility.

o HOMES data source: Residential Treatment Exit Form, item 3, options 17, 18, or 19.

4. Veterans who have been transferred to another HCHV CERS or LDSH program due to need for a more intensive level of contract residential care.

o HOMES data source: Residential Treatment Exit Form item 2 is option 4 (Veteran required a more intensive level of care than offered at this program); and o HOMES Data Source: Residential Treatment Entry Form item 3a has a date within one day of program exit, and 3b is option 2 (CERS) or 5 (LDSH).

5. Veterans who have been placed into a hospital or other residential non-psychiatric medical facility, long-term care facility or nursing home, or psychiatric hospital or other psychiatric facility.

o HOMES data source: Residential Treatment Exit Form, item 3, options 17, 18, or 19.

6. Veteran has a Length of Stay (LOS) > 7 days and < 31 days in an HCHV Contract

Residential Services program (excluding Low Demand Safe Haven) and exits to a residential treatment, transitional housing, HCHV CRS, or LDSH program.

o HOMES data source: Residential Treatment Exit Form item 1, exit date-entry date is > 7 days and < 31 days, and item 3 is option 11, 12, 13, 14, 15, 16, 21, or 22.

Numerator:

Number of Veterans who exit directly to permanent housing upon leaving a HCHV CRS or LDSH programs in FY 2019.

1. HOMES data source: Residential Treatment Exit Form, item 3, options 1-7 or 9.

Numerator Exclusions: None

Veteran Level Report Fields and Naming Conventions:

Row, HOMES ID, Veteran Name, SSN, Program Code, Entry Date, Exit Date, Housing Code, Length of Stay (Days), Exclusion

Exclusion Codes:

1. Veteran has a Length of Stay (LOS) of seven days or less.

2. Veteran is deceased at discharge.

3. Veteran discharged due to threatened/actual violence to self or others.

4. Veteran is transferred to another residential program.

5. Veteran is placed into a hospital, long-term care facility of nursing home.

6. Veteran is transferred to another HCHV CERS or LDSH program due to need for more intensive care.

8. Veteran has a Length of Stay (LOS) > 7 days and < 22 days in HCHV CERS.

Rationale/background:

VHA’s Plan to End Veteran Homelessness calls for residential and transitional housing programs to place a primary focus on discharging Veterans directly to permanent housing in the community.

HCHV2: Percent Negative Exits

Indicator Description:

Percentage of Veterans with a negative exit from VHA Health Care for Homeless Veterans Contracted Residential Service (HCHV CRS) or Low Demand Safe Haven (LDSH) programs.

Population: Veterans exiting HCHV CRS or LDSH programs in FY 2019.

Target and Business Rules: The FY 2019 target is 23%. Lower is better.

Escalating Targets and Stop Light Formatting for Homeless Scorecard:

23% or below (Green) 24-25% (Yellow) 26% or above (Red)

Denominator:

Number of Veterans with an exit date from a HCHV CRS and LDSH program between 10/1/18 and 9/30/19.

2. HOMES data source: Residential Treatment Entry Form, item 3b, options 2 or 5.

3. HOMES data source: Residential Treatment Exit Form, item 1, exit date is between 10/1/18 and 9/30/19, inclusive.

Denominator Inclusions:

Veteran is included in the denominator if Veteran has an exit date from a HCHV CRS or LDSH program between 10/1/18 and 9/30/19.

o HOMES data Source: Residential Treatment Exit Form, item 1, exit date is between 10/1/18 and 9/30/19, inclusive.

Denominator Exclusions:

Veteran is excluded from the denominator under any of the following circumstances:

1. Veterans who have been discharged from HCHV CRS or LDSH program due to threatened/actual violence to self or others.

o HOMES data source: Residential Treatment Exit Form, item 2a, option 1 (Threatened/actual violence to self or others).

2. Veteran is deceased at discharge.

o HOMES data source: Residential Treatment Exit Form, item 2, option 8.

3. Veteran is placed into a hospital or other residential non-psychiatric medical facility, long-term care facility or nursing home, or psychiatric hospital or other psychiatric facility.

o HOMES data source: Residential Treatment Exit Form, item 3, options 17, 18, or 19.

4. Veteran has a Length of Stay (LOS) of seven days or less.

o HOMES data source: Residential Treatment Exit Form, item 1 and exit date-entry date is = or <7.

5. Veteran is transferred to another residential program due to the temporary or permanent suspension of program operations. This exclusion will be entered manually into a spreadsheet titled “RT Manual Exclusions” located on the VSSC Secure Site after consultation with the HCHV National Program Office. (NOTE: same process as HMLS3). If the Veteran is readmitted to HCHV, after the noted exclusion date, the Veteran should be included in the measure based on the new admission date.

6. Veterans who have been transferred to another HCHV CERS or LDSH program due to need for a more intensive level of contract residential care.

o HOMES data source: Residential Treatment Exit Form item 2 is option 4 (Veteran required a more intensive level of care than offered at this program); and o HOMES Data Source: Residential Treatment Entry Form item 3a has a date within one day of program exit, and 3b is option 2 (CERS) or 5 (LDSH).

Numerator:

Number of exits from HCHV CRS or LDSH programs in which the Veteran was asked to leave because of a violation of program rules (excluding exits due to threatened/actual violence to self or others), failure to comply with program requirements, or left the program without consulting staff.

o HOMES data source: Residential Treatment Exit Form item 2, options 3 (If 2a= 2, 3, or 4; Veteran was asked to leave because of violation of program rules or failure to comply with program requirements) or 6 (Veteran left the program by his/her own decision, without consulting staff).

Numerator Exclusions: None

Veteran Level Report Fields and Naming Conventions:

Row, HOMES ID, Veteran Name, SSN, Entry Date, Exit Date, Program Code, Exit Reason, Exclusion

Exclusion Codes:

1. Veteran has a Length of Stay (LOS) of seven days or less.

2. Veteran is deceased at discharge.

3. Veteran discharged due to threatened/actual violence to self or others.

4. Veteran is transferred to another residential program.

5. Veteran is placed into a hospital, long-term care facility or nursing home.

6. Veteran is transferred to another HCHV CERS or LDSH program due to need for more intensive care.

Rationale/background:

VHA’s Plan to End Veteran Homelessness calls for residential and transitional housing programs to place a focus on successful completion of residential programming and effectively ending homeless among Veterans served in these programs.

ATTACHMENT 4: QUALITY ASSURANCE MONITORING

Monthly Technical Report Monitoring- Sample

Goal #1 Residential Stability

Objectives/Expected

Results

Data

Source

Data

Collect ed By

No. In

Sample

Size

Metric Actual

Result

Analys is

Action

Plan

Objective/Acti vity not met:

Reason for variance

Improvemen ts/ Changes to Practice

Projected improvem ent (%) by next quarter

Certifi ed by

HCHV

GPD

staff:

Meg

Boyle

1.Sign in and out log of residents, daily

Program

Records

Progra m Staff

95% of sign in sheets will be completed

95%% goal is met continue yes n/a continue current practice remain the same

2.Negative results on drug and alcohol screening

Program

Records

Progra m Staff

94% negative 90% goal met continue no n/a continue current practice

3. Attend mandatory

AA/NA community meetings 5-9/week

Program

Records

Progra m Staff

95% will attend meetings

95% goal is met continue yes n/a continue current practice

4. Daily resident responsibilities

Observan ce

Progra m Staff

95% will attend to daily responsibilit ies (do chores, etc.)

95% goal is met continue yes n/a continue current practice

5. Attend and participate in biweekly case management sessions

Program

Records

Progra m Staff

95% will participate in case management sessions

95% goal is met continue yes n/a continue current practice

6. Socialization with residents and community

Program

Records

Progra m Staff

50% will participate in socialization

50% goal is met continue yes n/a continue current practice

Goal # 2 Increased

Skill/Income

Objectives/Expected

Results

Data

Source

Data

Collect ed By

No. In

Sample

Size

Metric Actual

Result

Analys is

Action

Plan

Objective/Acti vity not met:

Reason for variance

Improvemen ts/ Changes to Practice

Projected improvem ent (%) by next quarter

Certifi ed by

HCHV

GPD

staff:

Meg

Boyle

1. Work with VA

Homeless program staff and assess barriers

VA

Records

VA

staff and progra m staff

95% will work with

Homeless program staff

95% goal is met continue yes n/a to be determined based on metrics established to be determined based on metrics established

2. Participation in employment search/training

Program

Records

Progra m Staff

50% will participate in employment search/traini ng

13/29 neede d to increa se incom e.

54% of those did.

goal is met continue yes small sample size to be determined based on metrics established improve

3. Search for permanent housing

Program

Records

Progra m Staff

60% will search for permanent housing

62% goal is met continue yes n/a to be determined based on metrics established to be determined based on

4. Skill development and progress.

Program

Records

Progra m Staff

50% will participate in skill developmen t and progress

55% goal is met continue yes n/a to be determined based on metrics established to be determined based on

Goal # 3 Self

Determination

1. Improve work skill Program

Records

Progra m Staff

50% will improve work skill

50% met goal n/a n/a n/a encourage greater goal attainment during biweekly case management continue TW

2. Increase frequency of social interaction

Program

Records

Progra m Staff

50% will increase frequency of social interaction

50% met goal n/a n/a n/a continue with current plan continue TW

3. Positive use of unscheduled time

Program

Records

Progra m Staff

85% will have positive use of unscheduled time

69% goal not met small sample size, 11-

16 were housed successful ly, 5/16 left AMA or jail not met small sample size, outstandi ng warrants provide access to increased activities, second chance continue TW

4. Employment Program

Records

Progra m Staff

50% will secure employment

50% met goal n/a n/a n/a assist with job search continue TW

5. Financial structure Program

Records

Progra m Staff

95% with income required to save with

Case

Manager

95% met goal n/a n/a n/a continue with current plan continue TW