36C26118Q9597-002.docx
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- 36C26118Q9597
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36C26118Q9597 S02 Attachment 1 - Quality Assurance Surveillance Plan (QASP).docx
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| 36C26118Q9597-000.docx | DOCX document |
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QUALITY ASSURANCE SURVEILLANCE PLAN
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 through contract modification. 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: TBD
Assigned CS: TBD
Organization or Agency: Network Contracting Office (NCO) 21
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: TBD
3. CONTRACTOR REPRESENTATIVES
The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.
Primary:
4. PERFORMANCE STANDARDS
a. Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.
b. The Performance Requirements Summary Matrix below includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL) on a quarterly basis.
c. Contractor will be held to the same standard as VA personnel through quality assurance and performance monitoring to ensure compliance under this Contract. The Quality Assurance and Performance Monitoring will be governed by the appointed COR who will be responsible for verifying compliance with the terms and conditions of the contract. After the contract is awarded, any incidents as evidenced by the monitoring procedures will be forwarded immediately to the Contracting Officer. In addition, the COR will forward the summary evaluation of the contractor performance to the Contracting Officer once performance ends.
5. METHODS OF QA SURVEILLANCE
Various methods exist to monitor performance. There will be quarterly meetings held with the Contractor to discuss any issues. In addition, the COR shall use the following surveillance methods in the administration of this QASP:
a. Observation. Observations will be taken during any and all site visits by any HCHV or VA staff (items 1-7, 9).
b. Veteran Queries and Complaints. HCHV staff relies on the Veteran to identify deficiencies. Veterans will be queried as to the services being provided to them. Any identified concerns or complaints are then investigated and validated (items 2, 3, 4, 6, 9, 10).
c. Random and Periodic Inspection. Inspections will be accomplished randomly and no less than once per year (items 1, 2, 3, 5, 7, 8, 9).
d. Report Reviews/Evaluations. Reviews and Evaluations of required reports will be conducted as received. Deficiencies will be noted and communicated to the Contractor for corrective action (items 2, 3, 9).
6. PERFORMANCE REPORT
| Item |
| Task |
| Indicator |
| Standard |
| Acceptable Quality Level |
| Method of Surveillance |
| 1 |
| Case Management Services |
| Ability to receive and place Veterans on short-term notice |
| Contractor shall provide rapid, often same day residential placement. |
| 95% |
| Observation and Random Inspection |
| Individualized Care Plan |
| Contractor shall work with veteran to develop an Individualized Care Plan within 72 hours of intake, identifying strengths, barriers, and goals |
| 100% |
| Review of Case Notes and Client File |
| Financial Planning |
| Financial Planning activities both individually and in group settings to discuss short and long-term financial goals at least 4 times monthly |
| 75% |
| Review of Case Notes and Client File |
| Employment Services Referrals |
| Referrals for employment opportunities will be made for each eligible veteran. All structured activities that support Veteran in applying for employment as will be documented. |
| 100% |
| Review of Case Notes and Client File |
| Permanent Housing |
| Gaining Permanent Housing is a primary goal of HCHV and a comprehensive housing assessment will be completed within 72 business hours of program admission in the ISP. Identification of barriers and goal preparations to enter permanent housing will be addressed with Veterans in each Weekly Case Management session. |
| 100% |
| Review of Case Notes and Client File |
| Compliance in completing progress reports as directed by COR or other HCHV staff. |
| Contractor provides Progress Reports in the delineated format and in accordance with timelines established by the COR. |
| 95% |
| Review and Evaluation of all Required Reports |
| Scheduled visits with each Veteran and designated open office hours |
| Contractor shall schedule open office hours and periodic visits with each Veteran to discuss progress towards discharge goals. It is expected that each veteran will meet with a case manager at least 3 times monthly while in the Contract program. |
| 95% |
| Observation and Veteran queries/complaints and Case Notes |
| Discharge Planning |
| Contractor conducts discharge planning with Veterans within14 days of admission, outlining goals, objectives, tasks, and dates of completion. Contractor will collaborate with HCHV Staff and submits plan to COR upon actual discharge of Veteran. |
| 95% |
| Periodic Review and Evaluation of Discharge Plans |
| Veteran Discharges |
| Paperwork for discharging a Veteran from any HCHV Program is required within 24 business hours from known discharge. |
| 85% |
| Review and Evaluation of all Required Reports |
| TQI Measures |
| TQI measures must be met to receive the highest Past Performance Rating which are: |
Independent Housing 50%; Negative Exits <20%;
Bed Occupancy >85%;
Length of Stay < 90 days;
Employed at exit 30%;
VA Benefit App Pending for eligible Veterans 15%;
Non-VA Benefit Pending for eligible Veterans 8%
| 100% |
| Review and Evaluation of all Required Reports |
| Grievance Procedure |
| Programs must have written policies and procedures for resolving grievances, including a statement regarding the client’s right to request reasonable accommodation. Each Veteran shall receive a copy of grievance policies and procedures upon intake. |
| 95% |
| Case Note Review and Review and Evaluation of all Required Reports |
| 3 |
| Supportive Services |
| Transportation |
| Contractor is expected to assist with transportation to include helping the Veteran access public transportation |
| 95% |
| Observation and Veteran queries/complaints |
| Storage, monitoring, issuance, and documentation of prescription drugs |
| Contractor will safeguard VA prescribed medications for Veterans and issue them for self-administration at the prescriptive times. A log of medications management will be kept. |
| 100% |
| Observation and random Inspection of documentation |
| Opportunities for Veterans to participate in spiritual worship |
| Contractor will have onsite worship services and/or provide transportation for Veterans to attend worship services offsite. |
| 95% |
| Observation and Veteran queries/complaints |
| 4 |
| Therapeutic and Rehabilitative |
| Program Environment |
| Environment should be conducive to the Veteran’s rehabilitative potential. Support will be provided through individual and group sessions focusing on mental health and substance use disorders. |
| 100% |
| Observation and Veteran queries/complaints |
| Group Activities |
| Structured group activities will be available to Veterans to attend no less than 2 times per month. |
| 75% |
| Observation and random Inspection of documentation |
| 5 |
| Housing |
| Safe, clean, and sanitary housing for all Veteran residents |
| Contractor provided room and board shall include a minimum per Veteran / family member of one single bed, storage space, and one dresser; indoor lounging/recreation area, and self-service laundry. |
| 100% |
| Observation and Veteran queries/complaints |
| 5 |
| Records and Report |
| Client record for each Veterans resident |
| Client records will include all information required in accordance with the SOW and be updated as necessitated by Veteran progress. |
| 95% |
| Observation and random inspection of documentation |
| Critical Incident |
| All critical incidents involving Veteran residents will be immediately reported via telephone. A written report will be provided within 24 hours of the incident. See PWS for specifics. |
| 100% |
| Observation and random inspections |
| Utilization of the Homeless Management Information System (HMIS). |
| Contractor will utilize and update the system as directed by the COR/HCHV program staff. |
| 95% |
| Observation and random inspection of data systems |
| 6 |
| Dietetic Services |
| The dietary needs of all Veteran residents shall be met in accordance with sound nutrition consistent with USDA standards. |
| Veteran residents shall be provided three nutritious meals and two snacks per day; Food shall be prepared, served, and stored under sanitary conditions. |
| 100% |
| Observation and Veteran queries/complaints |
| 7 |
| Qualifications/Accreditation/Licensing of Contractor Staff |
| Contract shall provide sufficient staff in the number and position with the qualifications necessary to meet the Statement of Work and the Nevada State guidelines. |
| Contractor shall possess a Nevada State Business License; Any professional staff shall be certified or licensed by the Nevada Board of Examiners; All technical and professional staff shall be Basic Life Support certified. |
| 95% |
| Observation and random inspection |
| 8 |
| Facility |
| Contractor facility conformance to all state and federal requirements as pertains to licensing, safety, and health codes. |
| Per the SOW, facility shall: maintain conformance to all city, county, state and federal licensing requirements and health codes; meet Fire Safety and Joint Commission standards; have a current occupancy permit; meet ADA requirements. |
| 95% |
| Periodic Inspections |
| 9 |
| Veteran Resident Safety |
| Identification, Reporting, and Resolution of facility safety Issues |
| All identified safety issues shall be investigated immediately and corrected in a timely manner appropriate for the incident. |
| 95% |
| Observation, random inspection and Veteran queries/complaints |
| Identification, Reporting, and Resolution of Veteran Safety Incidents |
| Any incident involving an injury or severe illness to a Veteran shall be reported immediately after occurrence to the COR. Initial notification shall be via telephone with a follow-up written report provided within 24 hours. |
| 10 |
| Patient Satisfaction |
| Patient Complaints |
| All patient complaints regarding quality of care are reported to the COR within 24 business hours. |
| 95% |
| Veteran queries/ complaints |
7. CPAR RATINGS ASSIGNED TO QASP ITEMS:
Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/pdfs/CPARS-Guidance.pdf p. A2-1):
| EXCEPTIONAL: |
| Performance meets contractual requirements and exceeds many to the |
Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.
Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However, a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.
| VERY GOOD: |
| Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective. |
Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.
| SATISFACTORY: |
| Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory. |
Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.
| MARGINAL: | |
| Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented. | |
| Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the | contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter). |
| UNSATISFACTORY: | |
| Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective. | |
| Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or | Environmental Deficiency Reports, or letters). |
8. DOCUMENTING PERFORMANCE
a. The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.
b. When unacceptable performance occurs, the COR shall inform the contractor within three (3) days of the unacceptable performance. This will normally be in writing unless circumstances necessitate verbal communication, in which case the notification will occur within one (1) day. In any case the COR shall document the discussion and place it in the COR file.
c. 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.
d. 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.
e. Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. In addition, any performance that is below the standards set-forth in Section 4 may subject the Contractor to the termination for default provision.
9. FREQUENCY OF MEASUREMENT
a. Frequency of Surveillance. During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.
b. Performance Assessment Meetings. The COR shall meet with the contractor Quarterly to assess performance and shall provide a written assessment.
10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP
Signature – Contracting Officer’s Representative
Signature – Contractor Program Manager
CONTRACT REPORT
| 1. CONTRACT NUMBER |
| 2. REPORT NUMBER FOR THIS DISCREPANCY |
| 3. TO: (Contracting Officer) |
| 4. FROM: (Name of COR) |
5. DATES
a. CR PREPARED
| b. RETURNED BY CONTRACTOR: |
| c. ACTION COMPLETE |
6. Issue Identified (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 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.
13. GOVERNMENT ACTIONS
14. CLOSE OUT
| NAME |
| TITLE |
| SIGNATURE |
| DATE |
CONTRACTOR NOTIFIED
COR
CONTRACTING OFFICER
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