D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP).docx

QUALITY ASSURANCE SURVEILLANCE PLAN

Purpose: This is a non-personnel services contract to provide veterans with residential treatment and case management to include supportive housing to thirty-six (36) veterans for the SLVHCS, New Orleans, LA. The Government shall not exercise any supervision or control over the contract service providers performing the services herein.

Contract/Order Number:

Contract/Order Description:

The Contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform residential treatment and case management for Veterans participating in the SLVHCS Substance Abuse Treatment Program (SATP) as defined in this Performance Work Statement except for those items specified as Government furnished property and services. The Contractor shall perform to the standards in this contract. It is essential that the contractor maintain a therapeutic environment by housing all patients in the same facility. The contractor must be a State Licensed Intensive Outpatient Treatment Program offering a 12 step Modality Addiction Recovery Program.

Contractor’s Name: To Be Entered by Offeror

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"; which the Government may review and revise it on a regular basis; however, all changes shall be coordinated 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/order 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/order. The CO is ultimately responsible for the final determination of the adequacy of the Contractor’s performance.

Assigned CO: XXXXXXX, Contracting Officer Organization: Department of Veterans Affairs, Office of Acquisition and Operations, Technology Acquisition Center

b. Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the contract/order and shall assure proper Government surveillance of the Contractor’s performance. The COR shall keep a quality assurance file. This file shall contain all quality assessment reports. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Catherine Matthews, 629 Southeast Louisiana Veteran Healthcare System, Catherine.Matthews2@va.gov

c. Other Key Government Personnel – Will Spates, 629 Southeast Louisiana Veteran Healthcare System, William.Spates@va.gov

3. CONTRACTOR REPRESENTATIVES

The following employees of the Contractor serve as the Contractor's program manager for this contract.

4. 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, below includes performance standards. The Government will use to determine Contractor performance and shall compare Contractor performance to the Acceptable Quality Level (AQL). The standards will be updated as required throughout the life of the contract.

PRS # 1.

The Contractor shall provide quality mental health therapeutic treatment and case management (PWS 4.5.3.a.(3) & 5.1)

Ongoing clinical monitoring and chart reviews coinciding with weekly meeting collaborations and yearly facility inspection visits. If performance falls below the indicated threshold, the program manager shall notify COR, contractor shall develop action plan to increase performance level to acceptable threshold.

PRS # 2

The Contractor shall provide Clinical Information return to facility as indicated in PWS. (PWS 4.5.3. a (1).

If performance falls below the indicated threshold, the program manager shall notify COR, contractor shall develop action plan to increase performance level to acceptable threshold.

PRS # 3

The Contractor must ensure patient safety for all the residents assigned. (PWS 1.1.3 & 5.16.)

The Contractor must report patient safety incidents to the Case Manager Program or the on-call psychiatrist within 24 hours.

PRS # 4

The Contractor must ensure all assigned staff has ample qualifications. (PWS 1.2.4; & 4.5.3.a (4)

The Contractor’s hired staff perform all assigned duties and available on site.

PRS # 5

The Contractor must provide patient satisfaction survey to the patient. (PWS 5.18.)

The Contractor shall provide patient satisfaction survey results reported to SLVHCS on at least a quarterly basis.

PRS #6

The Contractor shall comply with all Performance Based Service Assessments (PBSA) located in the QASP. (PWS 5.19 & PBSA attachment Technical Exhibit 3).

100 Percent Inspection: Appropriate for tasks that occur infrequently. Inspect and evaluate performance each time task is performed Validated Customer Complaint: Complaints must be validated.

5. METHODS OF QA SURVEILLANCE

The following surveillance methods will be used in administrating this QASP,

a. Direct Observation

1. b. Customer Feedback b. Review of Medical Records All Customer complaints will be validated and documented and monitored daily. Average Acceptable

a. This assessment will be placed in the COR’s QA file.

2. On-Site Surveillance

a. The Program Manager will monitor and review the contractor performance weekly. This assessment will be placed in the COR’s QA file.

6. ACCEPTABLE LEVELS OF PERFORMANCE (ALP) RATING

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:

A. OUTSTANDING PERFORMANCE — PERFORMANCE GREATLY EXCEEDS CONTRACT REQUIREMENTS.

B. SATISFACTORY PERFORMANCE - MEETS CONTRACT REQUIREMENTS

C. MARGINAL PERFORMANCE - MEETS MINIMUM CONTRACT REQUIREMENTS, BUT SOME MARERIAL ASPECTS OF THE CONTRACTORS PERFORMANCE WERE LESS THAN SATISFACTORY

D. UNACCEPTABLE — PERFORMANCE WAS POOR AND/OR DID NOT SATISFY THE CONTRACT REQUIREMENTS

7. DOCUMENTING PERFORMANCE

When unacceptable performance occurs, the COR shall notify the Contractor. Unless circumstances necessitate verbal communication, notification should be in writing. In any case the COR shall document the discussion and place a copy of the written statement in the COR file. When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (COR), and present a copy it to the Contractor's program manager and the Contracting Officer.

The Contractor shall acknowledge receipt of the correspondence in writing. The COR will specify if the Contractor is required to prepare a corrective action plan detailing how unacceptable performance will be reconciled. The COR will also document how long after notification the Contractor has to submit the corrective plan. The Government shall then review the Contractor's response to determine acceptability.

8. FREQUENCY OF MEASUREMENT

a. Contractor Performance Evaluations will be submitted quarterly by the COR for the previous three month period. During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. The COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment in the form of a performance evaluation report. The performance evaluation shall be submitted to the Contracting Officer.

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