D.1 Quality Assurance Surveillance Plan (QASP).pdf

Attachment D.1

QUALITY ASSURANCE SURVEILLANCE PLAN

Health Care for Homeless Veterans (HCHV) for the Chillicothe VAMC

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate Contractor actions while implementing this Performance Work Statement (PWS). 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.

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 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:

• What shall be monitored

• How monitoring shall take place

• Who shall conduct the monitoring

• How monitoring efforts and results shall 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 through contract modification. Copies of the original QASP and revisions shall be provided to the Contractor and Government officials implementing surveillance activities.

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. The Government shall use these standards to determine Contractor’s performance and shall compare Contractor’s performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

Task Standard

Performance

Threshold

Surveillance Method

Performance Acceptable/

Unacceptable

A. Records and reports

Daily sign-in sheets signed by Veterans. Individualized

Care Plan (ICP) within 14 days of admission, progress notes for each client, documentation of Veteran participation in daily group activities, discharge summaries within 3 days of discharge and entry of

Veteran data into HMIS system.

95% of randomly selected cases

Review by

Chillicothe

VAMC Liaison either randomly or at minimum quarterly

YES ☐

NO ☐

B. Staffing and

Support

Services

Facility shall be staffed

24/7, Program Manager shall be available as needed 24/7. Facility shall employ sufficient staff to support Veterans in accomplishing goals outlined in ICP. At least one

Key Personnel, certified in cardio-pulmonary resuscitation

(CPR) will be on site 24/7.

98% of the time

On site visits by

VAMC Liaison either randomly or at a minimum quarterly

C. Housing

Placement:

National

Performance

Monitors for

HCHV

Programs

Contractor will follow the

Homeless Services

Scorecard provide to them by the VA Chillicothe

VAMC Liaison, at the beginning of each fiscal year. Current fiscal year

HCHV targets are as follows:

a-Veteran discharges shall be 55% or greater to permanent housing.

b-Veteran discharges shall be 20% or less negative exits (as defined in Homeless

Services Scorecard).

Veteran

Discharges

55% or greater to permanent housing and Veteran discharges shall be 20% or less negative exits

(as defined in

Homeless

Services

Scorecard)

Quarterly data record review by the Chillicothe

VAMC Liaison in conjunction with the Contractor.

D. Emergency

Housing Facilities

& Management

Facility meets or exceeds all requirements of fire, safety, licensure, Veteran privacy, and standards established by the Americans with

Disabilities Act.

98% of the time.

On-site visits by

VAMC Liaison and /or other VA officials, either randomly or at a minimum quarterly.

SURVEILLANCE

The Chillicothe VAMC Liaison 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 COR for correction. All Performance

Standards

STANDARD

Customer complaints shall not exceed the thresholds cited above for each performance objective. The Chillicothe VAMC Liaison shall notify the Contracting Officer Representative (COR) for appropriate action.

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 COR shall inform the Contractor. This shall 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 Contracting Officer (CO). In turn, the CO shall present the CDR to the Contractor.

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

PROCEDURES

The Chillicothe VAMC Liaison shall inspect to ensure Key Personnel compliance with the appropriate section of the Performance Work Statement (PWS) periodically. The Chillicothe VAMC Liaison shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the

Chillicothe VAMC Liaison shall notify the COR of the deficiencies within 3 business days. Key Personnel shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The COR shall have the final authority on the amount of time the Key Personnel has to correct the deficiency.

FREQUENCY OF MEASUREMENT

During contract performance, the Chillicothe VAMC Liaison shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings shall be conducted quarterly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s files

The Chillicothe VAMC Liaison shall meet with the Key Personnel quarterly to assess performance and shall provide a written assessment.

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