36C26119Q0132-003.docx

QUALITY ASSURANCE

SURVEILLANCE PLAN – FY2019

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

Contracted Emergency Residential Services (CERS)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contracted programs’ activities while implementing this Statement of Work (SOW). It is designed to provide an effective surveillance method of monitoring Contractor performance.

The QASP provides a systematic method to evaluate the services the Contracted Program is required to furnish.

This QASP is based on the premise, the Government desires to maintain a quality standard in providing emergency housing and supportive services to its patients. The resulting contract is considered the best means of achieving that objective.

PURPOSE

The Contracted Program, 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 Contracted Program accomplishes the work. Rather, the QASP is created with the premise that the Contracted Program 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 Contracted Program 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 Contracted Program to success. This QASP explains the following:

· What shall be monitored.

· How monitoring shall take place.

· How often monitoring shall take place.

· Who shall conduct the monitoring.

· How monitoring efforts and results shall be documented.

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 Contracted Program. Copies of the original QASP and revisions shall be provided to the Contractor and Government officials implementing surveillance activities.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the Contracted Program exceeds, meets or does not meet these standards. The Performance Requirements Summary Matrix is incorporated within this QASP to include performance standards and disincentives. The Government shall use these standards to determine Contracted performance and shall compare Contracted performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

SURVEILLANCE: The Government quality assurance (QA) person and the COR 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 Contractor's quality control inspector (QCI) for correction. All Performance Standards

STANDARD: Customer complaints shall not exceed the thresholds cited above for each performance objective. The Government’s QA personnel shall notify the contracting officer for appropriate action in accordance with FAR 52.212.4, Contract Terms and Conditions-Commercial Items (May 1997) or the appropriate Inspection of Services clause, if any of the above service areas exceed the customer complaint thresholds.

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’s contracting personnel.

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

SURVEILLANCE: The Government evaluator shall evaluate the services required by each delivery/task order to ensure complete compliance.

PROCEDURES: The Government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the Government evaluator shall notify the CO and/or QCI of the deficiencies within 3 business days and have QCI correct said deficiencies. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the Contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

FREQUENCY OF MEASUREMENT: During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings will 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 COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment.

· Review of NEPEC data and monthly billing

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

2. Document outreach efforts monthly 100% during quarterly rating period

· Sign-in logs

· Informal review of outreach events

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Increased Income (eligible Veterans):

Contracted Program will provide counseling on means and methods to increase Veteran income through a variety of avenues such as SSI, NSC pension, GA and employment opportunities. Counseling may be performed internally or externally. Counseling or referral records must be kept for both internal counseling and for meetings Veterans participate in off-site.

Employment assistance:

Contracted Program will provide a referral to EDD and assist Veteran by providing a job search log with leads when available.

1. 100% of eligible Veterans will be referred for NSC pension, SSI benefits, and any other financial benefits.

2. 65% of Veterans will participate in ongoing financial planning groups or individual case management with a focus on increasing income 2 x per month

3. 100% of eligible Veterans will be referred for employment

100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

· Records of Bank Statements

· Award letters from SSI and VA

· Case Management Notes

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Case Management:

Contracted Program will provide individual case management and/or professional counseling, including counseling on stabilizing housing, increasing income and increased access to medical /mental health treatment through the VA or other agencies. The goals of case management may also focus on developing successful living patterns, maintaining an acceptable level of personal hygiene and grooming, and achieving a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

1. 90% of Veterans who remain in the program 72 hours will have an intake with requisite information (see SOW) and written Care Plan.

2. 75% of Veterans will engage in individual case management meetings 4 x per month; all Care Plans are documented in the client’s file.

3. 100% of Veterans identified as HSR will have a bi-weekly HSR plan reviewed by the Contractor

· Care Plan reviews

· Interview with Veterans

· HSR Safety plan review

· Case Management Notes

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Group Activities:

Examples include permanent housing search groups, financial management classes, group therapy, social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling and physical activities as appropriate. The focus of these groups will be to provide Veterans assistance in developing successful living patterns, maintaining an acceptable level of personal hygiene and grooming, and to achieving a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

1. 75% of Veterans will participate in group activities 2 x per month. To be led by Contractor, or by outside entity such as AA, agency will monitor and collate sign-in sheets

100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

· Case Management Notes

· Interview with Veterans

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Permanent Housing Education provided to Veterans regarding how to obtain low cost housing

1. 95% of Veterans will have their housing needs assessed and documented within 72 business hours of admission

2. 75% of Veterans will be provided resources on permanent housing 4 x per month 100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records

Discharge Planning:

Contracted Program’s case managers will provide assistance with discharge planning for every Veteran. Housing needs will be assessed within five days of admission and resources coordinated for discharge to a successful community placement. Securing permanent housing will be the discharge goal for every Veteran and every effort to meet or exceed the TQI and/or Performance/Descriptive measures will be made.

1. 100% of Veterans must have a discharge plan within two weeks of admission which integrates permanent housing options

2. 100% of Veterans must apply for a minimum of two GPD programs, or one residential inpatient program and/or independent housing within the first month of admission

3. Performance/TQI Measures:

· HCHV1 (Ind. Housing)- >50%

· HCHV2 (Neg. Exits) - <25%

· Bed Occupancy -85%

· Length of Stay ≤ 90 Days

100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

· Interview with Veterans

· Review of monthly activity calendar

· NEPEC data

· Case Management Notes

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

VA Coordination:

Contracted Program will provide collaboration with the VA program staff by conducting a meeting 2-4 times per month. These meetings will be held by Contracted Program Staff and VA program staff to discuss how to coordinate services to clients enrolled in the program, outreach needs, and program development. In addition to working collaboratively with VA clinical staff, the Contracted Program will submit accurate billing to VA Payment Center by the 7th of each month.

Procedure for daily accountability:

Veterans to sign in daily during their stay for accountability. Sign-in sheets to be verified by program staff, signed and returned to VA staff for billing verification.

Procedure for intakes:

No admissions will be approved without consent of VA Liaison who will determine eligibility of Veteran prior to admission.

1) ROI to be signed and eligibility determined by VA staff prior to admission

2) Admission information to be provided to VA staff within 24 business hours of admission. Confirmation email and paperwork to be faxed.

Procedure for discharges:

VA staff to be notified of discharge within 24 business hours. Confirmation email followed by discharge paperwork.

Unexcused Absence:

Contractor reserves the right to discharge Veteran after 24 hours if they have not received prior approval to leave program for that timeframe. Case managers will inform VA staff of any unexcused absence within 24 business hours via email to discuss disposition of Veteran.

Excused Absences:

Veterans may be granted an excused absence on a case by case basis. Payment will be made for the first 24 hours of an excused absence. Payment will only be made for the first 72 hours of an excused absence if there is a compelling medical or mental health need and the excused absence is verified a priori. Excused absences are defined as hospitalization, incarceration, visit to family, work related issue pre-approved.

Timeliness of Response Contractor will have a dedicated phone line for VA .

Incident Reporting:

Program staff to report to VA staff incidents within 24 business hours.

1. Contracted Program will submit accurate billing to Payment Center by the 7th of each month.

2. 100% will have signed ROI in case management files

3. 100% of Veterans sign in daily to receive payment for that day

4. 85% of Veterans who are discharged will be reported to the VA within 24 business hours of discharge via email

5. 90% of all Veterans discharges will have HOMES discharge paperwork completed within 72 business hours of discharge

6. 90% of critical incidents related to assault, suicidality and death will be reported within 24 business hours

INCIDENTS DEFINED AS:

Falls Assault (to Veteran or Staff) Elderly/Dependent Adult Abuse or Neglect Sexual Assault Fire (Veteran Involved) Medical/Psychiatric Emergency (911 Calls) Hospitalization Suicide or Suicide Attempt Homicide Death Infectious Control (TB, etc.)

Active Substance Abuse on contractor property Observation/ Possession of Weapons

· COR records

· SOW compliance

· NEPEC data

· Review of incident reports

· Review of HR documentation (CPRS)

· Invoices

· Sign-in logs

· Documentation in Care Plan

· Care Plan reviews

· Interview with Veterans

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Patient Rights The Contractor shall have reasonable rules governing life and activities in the facility. Veterans will be provided a copy of the rules at intake. Contractor will post the rules in a location readily accessible to clients and visitors. These rules must include detailed Patient Rights and the procedures that the Contractor has in place to protect the Veterans rights and dignity. This includes reasonable accommodation compliance in accordance with the Americans with Disabilities Act, the Federal Fair Housing Amendments Act, and the California Fair Employment and Housing Act.

1. 100% of Veterans receive education about and written information on the following upon intake:

· Patient rights

· Nature of the Contractors program (i.e. services)

· MAT policy

· Reasonable Accommodation

· Procedures for negative discharge and sanctions

· Grievance and Appeal procedures All policies pertaining to the above is posted conspicuously in contracted facility 100% during quarterly rating period

· Documentation in Care Plan

· Review of policies

· Review of intake packet

· Interview with Veterans

· Validated Staff/Veteran complaints

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Personnel The contractor will employ sufficient personnel to carry out the policies, responsibilities, and the program for the facility. There must be, at a minimum, at least one administrative staff member, or Designee of equivalent professional capability, on duty on the premises or residing at the facility and available for emergencies 24 hours a day, 7 days a week. The Contractor shall assign to this contract personnel that by education and training (and, when required, certification or licensure) are qualified to provide the Basic Services and Supplemental Services required by this SOW.

Staff Training: Contractor will provide at least one qualified staff person on-site at all times .

1. Facility Staff is fully trained and Staffed 24 hours a day, 7 days a week

2. 100% of Staff receive training on the following topics 1 time per year

· CPR

· First Aid

· Crisis intervention

· Cultural sensitivity

· Sexual harassment

· Sensitivity to wider issues of homelessness

· Universal Precautions (disease transmission prevention)

· Adult abuse/neglect reporting laws

· Harm Reduction philosophy

· Suicide Prevention

· Medication management

· State and Federal Fair Housing Law and ADA Requirements

· Conflict resolution

· Customer Service

· Professional Boundaries

· Countertransference

· Motivational Interviewing

· Stages of Change

· Severe Mental Illness and Psychopathology

· De-escalation techniques

· Search and Seizure/Probable Cause in the Shelter Setting

· Conservatorship

· Grave Disability Criteria

3. Key Personnel’s resumes must be submitted prior to contract being awarded and as Staff changes. Contractors must submit Staff resume for any key staffing changes within 14 days of Staff change.

100% during quarterly rating period

· Documentation in Care Plan

· Review of policies

· Interview with Veterans

· Validated Staff/Veteran complaints

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.

Failure to perform duties herein will have the contractor be subject to contract termination.

100% during quarterly rating period

· Review of Quarterly QASP data

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program’s records.