36C25018Q0581-002.docx

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Emergency Residential Services Battle Creek VA Medical Center
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36C25018Q0581
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36C25018Q0581 QASP.docx

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QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Residential Shelter Bed Services (HCHV)

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. 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: Robert Kay, 734-845-559, robert.kay@va.gov

· Organization or Agency: U.S. Department of Veterans Affairs

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: Daleth C. Jean-Jules 269-966-5600 x31648. email: Daleth.Jean-Jules@va.gov

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor's program manager for this agreement.

a. Program Manager - As assigned by facility

b. Other Contractor Personnel - As assigned by facility

4. PERFORMANCE STANDARDS

Performance standards define minimum performance standards for services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Homelessness Recovery Residential Services

No.
Paragraph in

sow Indicator Performance Standard Standard for Quality Level

Acceptable Quality Level
Method of

Surveillance Incentive

1
B.1
Therapeutic Services provided by contractor to include group therapy, social skills training, AA, NA, vocational counseling as appropriate
100%
95%
Periodic Reviews and spot checks.
Positive past performance rating
2
B.1.
Sufficient staff in number and position qualifications to carry out the policies, responsibilities and programs of the facility. At a minimum, there must be a full-time administrative staff member his/her designee on duty at the premises or residing at the facility and available for emergencies 24 hours a day, 7 days a week
100%
95%
Periodic Reviews, spot checks, direct observation, and customer complaints
Positive past performance rating
3
C.II.
The contractor shall maintain an individual case record on each veteran under this contract. The contractor must comply with the requirements of the "Confidentiality_ of
100%
97%
Periodic Reviews, spot checks, direct observation, and customer complaints
Positive past performance rating

Certain Medical Records" (38USC7732), and the "Confidentiality of Alcohol and Drug Abuse Patient Records" (42 CFR, Part II) when appropriate, and shall be part of the contract.

4
C.I.a
At least two (2) nutritious meals or their equivalent shall be served daily at regular times with not more than a 14 hour span between evening meal and breakfast of the following day. Nutritious snacks between meals and before bedtime, including weekends, shall be offered.
100%
97%
Periodic Reviews, spot checks, direct observation, and customer complaints
Positive past performance rating

Both residential and ambulatory care facilities must conform to the standards of the Life Safety Code (National Fire Protection Association #101) and conform to the fire and safety code imposed by the state law which adequately protects patients, and must meet all city, state and federal requirements concerning licensing and health codes. In all cases, the VA requires a level of safety which conforms to NFPA #101

100%
100%
Period Reviews and spot checks
Positive past performance rating

5. RATING STANDARDS

Shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance.

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION

c. USER SURVEY

d. VALIDATED USER/CUSTOMER COMPLAINTS

e. INSPECTION

f. PERIODIC SAMPLING

g. RANDOM SAMPLING

h. PROGRESS OR STATUS MEETINGS

i. ANALYSIS OF CONTRACTOR'S PROGRESS REPORTS

7. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

See above Acceptable Quality Level & Method of Surveillance located in QASP

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive OR NEGATIVE performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall work with the Contracting Officer (CO) to inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the COR shall document the discussion and place it in the COR file. In order to assure that the contractor receives impartial, fair, and equitable treatment under this agreement, the COR will work with the contractor to increase performance to an acceptable level.

When the COR and CO determines formal written communication is required, the COR and CO shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

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 COR. 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.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings

The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature - Contractor

Signature- Contracting Officer Representative

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER
2. REPORT NUMBER FOR THIS DISCREPANCY
3. TO: (Contracting Officer)
4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY CONTRACTOR:
c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME
TITLE
SIGNATURE
DATE

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

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