36C25019R0010-002.pdf

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

For: Health Care for Homeless Veterans Services

Contract Number: To Be Determined

Contract Description: The purpose of this contract is to provide emergency housing services, rapid housing linkage and case management for homeless Veterans to the Department of Veterans Affairs, Cleveland, Ohio.

Contractor’s name: To Be Determined

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: Davina Perry Assigned Administrative Contracting Officer: N/A Organization or Agency: Contracting, 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 with guidance from the technical representative. The Technical Representative shall keep a quality assurance file. The COR or the Technical Representative is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned Primary COR: Lashone Lemon, LISW‐S

Technical Representative: Cynthia Moore, MSSA, LISW‐S

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager – To Be Determined

b. Other Contractor Personnel – To Be Determined

4. PERFORMANCE STANDARDS

Performance measures are comprised of performance indicators (some characteristic of a deliverable that can be measured) and performance measures (a mark, measure or benchmark that government personnel use as a point of comparison when evaluating contractor performance). The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these measures.

The Performance Requirements Summary Matrix, paragraph ‘C’ in the Performance‐Based Statement of Work (PWS), includes performance measures. The Government shall use these measures to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Task ID Indicator Standard Acceptable

Quality Level

Reports due to COTR

(List dates)

Method of Surveillance Incentive

Homeless Veterans Medical Records

Upon review of HCHV Homeless Veterans medical records reflect appropriate treatment provisions and plan of care

100% of Individual Veteran Records will receive a score of 85% using the Chart Audit Tool

100% Quarterly

Upon review by the Community Outreach Division (COD) Coordinator or designee, 20% of program files or 3 files (whichever is greater) will be reviewed.

Files will be evaluated using the HCHV Chart Audit Tool Methodology outlined in Performance Standards

Potential to Exercise option period

Residential Outcomes 2

Upon review of HCHV shelter discharge forms, average program length of stay will be monitored

Average Length of Stay of 50 days

+/- 5% Quarterly

COR or designee will review all exits within the quarter.

Methodology outlined in Performance Standards

Potential to exercise option period

Quality Level

Reports due to COTR

(List dates)

Method of Surveillance Incentive

Upon review of HCHV Residential invoices, bed utilization rates will be monitored

Average Bed utilization rate is 90%

+/- 5% Quarterly

COR or designee will review all exits within the quarter.

Methodology is outlined in Performance Standards

Potential to exercise option period

Upon review of HCHV Residential Treatment Discharge Forms, discharge rates will be monitored

At least 75% of Veterans exited from contract beds will have a Non- Homeless Exit Designation

+/-5% Quarterly

All Veterans discharged from residential treatment will have a discharge form completed.

This will be monitored using Northeast Program Evaluation Center (NEPEC) reports.

Non-Homeless Exit destination defined in Performance Standard

Potential to

Quality Level

Reports due to COTR

(List dates)

Method of Surveillance Incentive

Upon review of HCHV Residential Treatment Discharge Forms, discharge to housing will be monitored

At least 40% of Veterans exited from contract beds will have a Preferred Housing Destination

+/-5% Quarterly

All Veterans discharged from residential treatment will have a discharge form completed.

This will be monitored using Northeast Program Evaluation Center (NEPEC) reports.

Preferred Hosing Destination defined in Performance Standard

Potential to

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance measures.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The Program Manager shall use the surveillance methods listed in the administration of this QASP. Prior to the award of a contract and annually during the contract term, a multidisciplinary VA team shall conduct a survey of the Contractor’s facilities for Veterans’ food, shelter, and therapeutic services to assure the Contractor provides quality care in a safe environment.

Inspections will also be carried out at least quarterly as part of the Quality Assurance Surveillance Plan. and at such other times as deemed necessary by the Contracting Officer.

The inspection of the Contractor facilities will include the following:

a) General observation of residents to determine if they maintain an acceptable level of personal hygiene and grooming.

b) Assessment of whether the facility meets applicable fire, safety and sanitation standards.

c) Determining whether the facility is in attractive surroundings conducive to social interaction and the fullest development of the resident's rehabilitative potential.

d) Observation of facility operations to see if appropriate organized activity programs are available during waking hours (including evenings) and degree to which a high level of activity is observed in the facility, such as individual professional counseling, physical activities, assistance with health and personal hygiene.

e) Seeking evidence of facility‐community interaction, demonstrated by the nature of scheduled activities or by information about resident flow out of the facility, e.g., community activities, volunteers, local consumer services, etc.

f) Observation of staff behavior and interaction with residents to determine if they convey an attitude of genuine concern, caring and safety.

g) Inspecting the types of meals and other nutrition provided to residents to see if appetizing, nutritionally adequate meals are provided in a setting, which encourages social interaction and if nutritious snacks between meals and bedtime are available for those requiring or desiring additional food, when it is not medically contraindicated.

Making a spot check of Veterans’ records to ensure accuracy with respect to Veterans’ length of stay and services provided to the Veterans.

The annual inspection will be conducted by a multi‐disciplinary team composed of the HCHV Program Coordinator, the VA ACC Safety Coordinator, Law Enforcement, Nursing, and Dietary. The Performance measure for these inspections is 100% compliance. Any noted deficiencies must be corrected within a given time frame established by the inspection team. These corrections are confirmed by a second inspection.

THE CONTRACTORCONTRACTOR WILL BE ADVISED OF THE FINDINGS OF THE INSPECTION TEAM. IF DEFICIENCIES ARE NOTED DURING ANY INSPECTION, THE CONTRACTORCONTRACTOR WILL BE GIVEN A REASONABLE TIME TO TAKE CORRECTIVE ACTION AND TO NOTIFY THE CONTRACTING OFFICER THAT THE CORRECTIONS HAVE BEEN MADE. A CONTRACT WILL NOT BE AWARDED UNTIL NOTED DEFICIENCIES HAVE BEEN ELIMINATED. FAILURE BY THE CONTRACTOR TO TAKE CORRECTIVE ACTION WITHIN A REASONABLE TIME WILL BE REPORTED TO THE VA CONTRACTING OFFICER. IF CORRECTIONS ARE NOT MADE TO THE SATISFACTION OF THE VA, THE CONTRACTING OFFICER WILL CONSULT WITH THE APPROPRIATE OFFICIALS SO THAT SUITABLE ARRANGEMENTS CAN BE MADE TO DISCONTINUE PLANS TO AWARD A CONTRACT, OR TO DISCHARGE OR TRANSFER PATIENTS AND TO TERMINATE THE EXISTING

CONTRACT, AS APPROPRIATE

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:

Exceeded Expectations Met Expectations Did Not Meet Expectations

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive 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 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.

When the COR determines formal written communication is required, the COR 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‐ Evaluation criteria is evaluated quarterly.

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 annually to assess performance and shall provide a written assessment.

Signature of Offeror / Contractor

Signature of COR

Name and Title of Signer (Type or Print)

Date Name of COR (Type or Print) Date