36C26119R0038-002.pdf

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: Gary T Basile

Assigned CS: Charles Simon

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: Jennifer Knapp

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

Veteran Intake Contractor shall provide intake packet and complete a through an intake assessment within 72 hours of admissions.

70% Review of Case Notes and Client

File

Individualized Care Plan

Contractor shall work with veteran to develop an

Individualized Care Plan within 72 hours of admissions.

70% Review of Case Notes and Client

File

Permanent Housing

Gaining Permanent Housing is a primary goal of HCHV and a comprehensive Housing Needs Assessment will be completed within 72 business hours of program admission.

Weekly Case Management Session. Veteran received housing resources at least 4 times a month.

70% 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 2 times monthly.

70% Review of Case Notes and Client

File

Discharge Planning

Contractor conducts discharge planning with Veterans and in collaboration with HCHV Staff and submits plan to COR upon actual discharge of Veteran.

70% 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.

70% Review of Case Notes and Client

File

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%

70% Review and

Evaluation of all Required Reports

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

Group Activities Structured group activities will be available to Veterans to attend no less than 2 times per month.

70% Review of Case Notes and Client

File

Employment Services

The Case Manager must provide referrals to all relevant employment opportunities the Veteran is eligible for and interested in.

70% Review of Case Notes and Client

File

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.

100%

Case Note Review and Review and Evaluation of all Required Reports

Referrals, Admissions, Eligibility and

Discharge

Admission notification

Contractor shall notify VA liaison of admission within 24 hours of admission.

100%

Review of Case Notes and Client

File

Signed ROI within 24 hours

Contractor shall obtain a signed ROI within 24 hours of admission.

100%

Review of Case Notes and Client

File

Eligibility Confirmation

Contractor shall obtain a written eligibility confirmation within 24 hours of admission.

100% Review of Case Notes and Client

File

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, substance abuse and addiction disorders.

100% Observation and

Veteran Queries/Complaints

Patient Rights

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%

Review of Case Notes and Client File/ Observation and Veteran Queries/Complaints

3 Therapeutic and Rehabilitative 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

100% Observation and

Veteran queries/complaints dresser; indoor lounging/recreation area, and self-service laundry.

Client record for each Veterans resident

Client records will include all information required in accordance with the PWS and be updated as necessitated by

Veteran progress.

100% Observation and random inspection of documentation

Staff/Qualification/

Accreditation/Licensing Personnel

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

100% Observation and random inspection of documentation

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 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.

Corrective Action Response to

Violation (CARV)

Corrective Action Response to

Violation (CARV)

Contractor will be subject to the CARV. Depending on the nature of the violation Contractor will submit a corrective action plan to the COR (or Designee) within a timeframe designated by the

COR (or Designee) and based on severity of violation (e.g.

Safety issues). The program will be monitored for performance.

70%

Observation, random inspection and Veteran queries/complaints 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