36C26118Q0011-004.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: Outpatient Detoxification Services

Contract Number:

Contractor’s Name:

Contract Description: VA Central California Health Care System will provide clean and sober living for

Veterans enrolled in outpatient Substance Abuse Dependency Program (SUDP). The goal of the SUDP is to place Veterans in a community-based, residential environment with sufficient therapeutic services to meet the needs of the Veteran.

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.

The 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:

Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Material

Management

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 Governments behalf.

Assigned COTR: Linda Hayes

Organization or Agency: Department of Veterans Affairs, VA Central California Health Care System

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager

b. Other Contractor Personnel

Title:

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, includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Task

Task Performance

Indicator

Standards Acceptable

Quality

Level

Score

(85, 95, 100%)

Surveillance

Method

1 Occupancy Program will maintain minimum acceptable level of occupancy through collaboration with VA and independent outreach efforts.

85% of occupancy reports shall demonstrate an occupancy rate of 80% or higher for a given month.

95% Periodic

Inspection

2 Admission

Protocol

Program will follow established protocol for proper admission of clients, including obtaining ROI

90% if veterans admitted will have signed

ROI and prior approval by

VA staff documented in the case

95% Direct

Observation prior authorization from VA, completion and submission of the Homes.

management file.

3 Discharge

Protocol

The program will follow protocol for handling and documentation of veteran discharge as established by the Scope of

Work. This shall include notifying the identified VA liaison or designee within

24 business hours and providing supporting

SUDP discharge documentation with 72 business hours.

For irregular/after hour discharges, VA liaison or designee will be notified immediately by leaving a message on

SUDP

administrative phone (559)

225-6100 x

5197; and provide supporting discharge documentation within 24 hours.

85% of the veteran discharges shall be reported to VA liaison within

24 business hours

90% Direct

4 Veterans Safety Program shall follow established

90% of reportable critical adverse

95%

Periodic

Inspection protocol for ensuring appropriate emergency responses are initiated when indicated and that the identified VA

Representative is notified as soon as possible and that a formal written report concerning all adverse incidents involving veterans is provided within

24 business hours.

Reportable critical adverse incidents are defined as:

Assault, sexual assault, abuse or neglect, fire-veteran involved, medical emergency, hospitalization suicide attempt, completed suicide, homicide, death, infectious control, active substance use, possession of weapons, and falls. All staff must be certified in First

Aid and CPR incidents are reported within

24 business hours

5 VA

Coordination

The program is expected to collaborate

75% of veteran charts reviewed will

80% Periodic regularly with the identified

VA liaison and other VA staff as necessary to ensure proper coordination of

VA care, services and resources for the benefit of both individual veterans and the program in general.

demonstrate evidence of collaboration with VA staff/clinics.

6 Invoicing The program will follow the protocol for accurate and timely invoicing established in the SOW. Final invoice shall be submitted to the

Financial

Services Center by the 10th of the following month for certification and payments.

80% of mostly invoices will be submitted to the Financial

Service Center by the 10th of the following month

95% Direct

Observation

7 Medication

Management

Medications and narcotics shall be properly stored, controlled, issued and recorded in compliance with physician orders

90% of all medication will be properly stored

95% Periodic

8 Transportation Contractor shall provide Veteran daily transportation to and from VA.

100% Priviate transportation will be provided to

Veterans for appointments with VA

Clinical Staff.

85% Direct

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.)

Admission Protocol

Transportation

Discharge Protocol

Invoicing

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

Occupancy

Veteran Safety

Mediation Management

VA Coordination

c. USER SERVEY. (Combines elements of validated user complaints and sampling. Survey is conducted to solicit user satisfaction. May also generate inspections.

Reporting and Consumer Satisfaction

d. Analysis of contractor’s progress reports.

Outcomes

6. 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.

90% Positive Performance

85% Neutral Performance

70% Negative Performance

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE (90% Rating)

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

b. UNACCEPTABLE PERFORMANCE (70% Rating)

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 must 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.

8. 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 quarterly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative

Attachments:

1. Contract Performance Report

2. Contract Discrepancy Report

Attachment 1

Contract Performance Report

1. Contract Number:

2. Prepared by: Linda Hayes

3. Date and time of observation:

4. Observation:

Method of surveillance

How frequently you conducted surveillance

Surveillance results

Number of observation

5. Performance Rating (in accordance with QASP, paragraph6):

Signature – Contracting Officer’s Representative Date

Attachment 2

Contract Discrepancy Report (CDR)

TO: (Contractor Program Manager or onsite representative)

FROM: Linda Hayes

1. Contract Number:

2. Date and time observed discrepancy:

3. Discrepancy/Problem/Issue:

4. Corrective action plan:

5. A written corrective action plan (is/is not) required. If a written corrective action plan is required include the following. (The written Corrective Action Plan will be provided to the undersigned no later than (# of days after receipt of this CDR)

Signature – Contracting Officer’s Representative Date

Received by:

Signature – Contracting Program Manager or Onsite Representative Date

Distribution:

(Name and Title – Contracting Officer)

The COR may initiate a CDR at any time, including whenever the number of monthly recorded defects for a performance standard exceeds the allowable number of defects; anytime unacceptable performance is determined critical in nature and requires formal corrective action; and whenever an unfavorable trend is detected in contractor performance.