36C26119Q0911-003.pdf

D.1 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

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 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

100% Review of Case Notes and Client File of barriers and goal preparations to enter permanent housing will be addressed with

Veterans in each

Case Management

Session

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 toward discharge goals. Case

Manager will meet with each Veteran on a weekly basis

95%

Observation and Veteran queries/complaints and

Case Notes

Discharge Planning

Contractor conducts discharge planning with

Veterans and in collaboration 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

2 Supportive Services Transportation

Assistance

Veterans receive assistance with transportation to and from Medical and Dental

Appointments.

95% Observation and Veteran queries/complaints

Opportunities for

Veterans to participate in spiritual worship

Contractor will provide opportunities for

Veterans to attend worship services offsite.

95% Observation and Veteran

3 Rehabilitative

Program Environment

Environment should be conducive to the

Veteran’s rehabilitative potential. Support will be provided through Individual and Group

Sessions focusing on individual’s overall recovery effort

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

4 Residential Room and Board

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.

95% Observation and Veteran queries/complaints

5 Referral Process

Ability to receive and place Veterans on short-term notice

Contractor shall provide rapid, often same day residential placement.

95% Observation and Random

Inspection

Records and Report

Client record for each

Veterans resident

Client records will include all information required in accordance with the Statement of

Work (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 HMIS system for each program participant

95% Observation and random inspection of data systems

Quarterly Reports

Reports shall be provided to the

Liaison on a

Quarterly Basis in accordance with the QASP, no later than the 15th day of the month following the end of the quarter.

95% Review of Report

7 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, 95% Observation and Veteran and stored under sanitary conditions.

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

9 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

10 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

11 Patient Satisfaction Patient Complaints

All patient complaints regarding quality

95% Veteran queries/ complaints of care are reported to the COR within

24 business hours.

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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

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.

8. 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.

9. 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