36C26118Q0096-005.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: HUD/VASH Case Management Contract

Contract Number: <Upon Award, Government will enter contract number>

Contract Description: An agency contracts to provide case management services to Veterans in the HUD/VASH program, located in San Francisco & San Mateo Counties, CA.

Contractor’s Name: <Program Name> (hereafter referred to as the contractor)

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: <Upon Award, Government will enter name>

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 Government’s behalf.

Assigned COR: <Upon Award, Government will enter name>

c. Other Key Government Personnel – - <Upon award, Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COTR to monitor performance.>

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – Joanne Peters, LCSW, Chief of SWS, SFVAMC

b. Other Contractor Personnel – Kim Babcock, LCSW, Associate Chief, SFVAMC

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, paragraph Section x, pp.xx in the Performance Work Statement (PWS), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Performance Indicators

PWS

Ref Performance Measure Acceptable Level of Quality Method of

Assessment

Psychosocial Assessment

3.4.3.1. A Psychosocial Assessment will be

completed within 30 days of program admission and will be updated yearly or when there are significant changes in Veteran’s status or condition.

95% Quarterly chart review

Social Work Treatment Plan

3.4.3.2. A Treatment Plan will be completed

within 30 days of the Psychosocial Assessment. Treatment Plan will be discussed with Veteran on a regular basis, addressing goals during home visits and face-to-face meetings with Veteran. Treatment Plans are reviewed every 90 days with Veteran and VA Liaison. Treatment plans reviews will be updated annually or when there are significant changes in a Veteran’s status or treatment needs.

95% Quarterly chart review

Patient Visits 4.2.1. The minimum frequency of home visits with Veterans are based on acuity level (attachment 1) and will be followed accordingly. Acuity levels should be updated as needed, but at a minimum Quarterly with VA Liaison and Contractor. No changes in acuity level will occur without concurrence from VA liaison.

95% Quarterly chart review

Assistance with Finding Housing

5. Contractor provides direct assistance to Veteran in finding and leasing appropriate housing including assisting in obtaining documentation as required by PHA securing security deposits.

95% Quarterly chart review and case conferences

Life Skills Education

13. Contractor will provide life skills education and support to Veterans as needed, including but not limited to:

a. Budgeting

b. Apartment maintenance

(cleanliness, safety, minor repairs, etc.)

c. How to be a good neighbor/tenant

d. Mental Health Wellness Self- Management / mental health recovery living skills (if applicable)

e. Relapse prevention (if applicable)

f. Healthy lifestyle/living

g. Community resources and how to access

h. Parenting/family living skills (if applicable)

i. Family reunification and/or development of relevant social support networks

j. Recreation/Community Integration

k. Transportation resources

Documentation in Medical Record

2.1.13.

Worker documents services/interventions in VA medical record (CPRS) as soon as they occur, but no longer than 72 hours.

Follows all documentation requirements as per SFVA policy.

Documentation in HOMES

2.1.15. HOMES entries must entered within

timelines mandated as per VA HUD/ VASH Documentation policy No719.

95% Quarterly review of HOMES data

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. QUARTERLY CHART REVIEW: Supervisor will randomly review a selection of worker’s progress notes in CPRS (electronic medical record) and productivity record.

• Psychosocial Assessment

• Social WorkTreatment Plan

• Patient Visits

Negative Incidents

3.4.6. Contractor will notfy VA staff of any

negative incident occurring with Veteran within 1 working hour of being aware of incident (ie, death, fire, drug/police raid, suicide/suicide attempt, emergency medical or mental health events, arrests, etc.).

Contractor will complete a written incident report within 8 working hours of notification, which may include VA Report of Contact.

95% Quarterly chart review

Staff and Credentialing

15.2.

15.3.7.

15.4.1.

The Contractor shall provide full staffing as outlined in contract within 60 days of the contract award either through existing staff or new hires.

The Contractor personnel shall maintain active standings with the licensing boards governing their respective professions.

Staffing responsibilities are described as follows:

LCSW (50%) and MSW (50%), including an LCSW contract supervisor, must be full-time on staff and assigned to the HUD-VASH contract. Schedule must permit 24-hour supervision of case management personnel for the purposes of clinical oversight, documentation and crisis management. The licensed independent practitioner must be available for team conferences as requested by the local VA Medical Center HUD-VASH program.

95% Review of licensure website; Viewing licensure document.

• Assistance with Finding Housing

• Documentation in Medical Record

• Negative Incidents

b. QUARTERLY REVIEW OF HOMES DATA: Supervisor will review the HOMES data to ensure Veteran information is entered timely.

• Documentation in HOMES

d. CASE CONFERENCES: Discussion of housing search process.

• Assistance with Finding Housing

e. REVIEW OF STAFFING: Supervisor will review staffing assigned to HUD VASH and review California BBS Website for California LCSW for agency workers; other state websites for out-of-state licensure/ certifications.

• Staffing

f. VIEWING LICENSURE DOCUMENT: Supervisor will ask the agency for a copy of the current license.

• Staffing

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:

EXCEPTIONAL:

96-100%

Performance significantly exceeds contract requirements to the Government’s benefit.

SATISFACTORY:

91-95%

Performance meets contractual requirements.

UNSATISFACTORY:

Below 95%

Performance does not meet contractual requirements.

7. 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 COTR. 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 or designee shall confer with the contractor quarterly to assess performance and shall provide a written assessment.

<After award, both the contractor’s Program Manager and the COR shall sign this document.>

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: (Name of COR) <insert name>

3. Date and time of observation:

4. Observation:

<Examples of items to include in a report are:

• Method of surveillance.

• How frequently you conducted surveillance.

• Surveillance results.

• Number of observations.>

5. Performance Rating (in accordance with QASP, paragraph 6):

Signature – Contracting Officer’s Representative Date

Attachment 2

Contract Discrepancy Report (CDR)

TO: (Contractor Program Manager or onsite representative) <insert name>

FROM: (Name of COR) <insert name>

1. Contract Number: <insert number>

2. Date and time observed discrepancy:

3. Discrepancy/Problem/Issue:

<Describe in detail. Identify any attachments.>

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 not later than <# days after receipt of this CDR.>

Signature – Contracting Officer’s Representative Date

Received by:

Signature – Contracting Program Manager or Onsite Representative Date

Distribution:

<Name & 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.>