36C26120Q0034-003.pdf

Quality Assurance Surveillance Plan (QASP) (Residential and Transitional)

The contractor will be evaluated in accordance with the following:

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:

Organization or Agency:

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: Rosario Chaidez, COR, Program Analyst, Mental Health

Organization or Agency: VA Northern California Health Care System, Mental Health Service

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary: Rosario Chaidez, Program Analyst, Mental Health Service

Alternate: Mae Lanette Johnson, Administrative Officer, Mental Health

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined.

Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

5. INCENTIVES/DEDUCTS

Favorable contactor performance evaluation which may result in renewed contract.

Unfavorable contractor performance evaluation which may result in non-renewal of the contract.

6. 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. DIRECT OBSERVATION. 100% surveillance:

Analysis of the referral paperwork and Veterans health care record which is sent by referring parties, including interagency, and self-referrals. Analysis of the entry and exit reports sent to the COR from the Contractor.

(Evaluates outcomes on a quarterly basis)

• Total Number of Veterans Served

• Discharge Outcomes (e.g. # or % of veterans discharged in more stable condition)

b. PERIODIC INSPECTION. Inspections scheduled and reported annually per COR delegation or as needed.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints from veterans served, and agency personnel shall be passed to the Contractor’s quality control inspector (QCI) for correction.

d. RANDOM SAMPLING.

e. Verification and/or documentation provided by Contractor. The contractor shall be expected to invoice monthly to ensure accuracy in billing practices. Invoices will be validated through VA log of referrals made to the program.

RESIDENTIAL PERFORMANCE STANDARDS -

Performance Indicators PWS Ref Standard Acceptable Level of

Quality Method of Assessment

Care Planning Sec 8.1.3.1

Care plans developed within 5 days of admission for all Veterans referred.

100% during annual rating period

Reviewed during routine on-site inspections.

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

Medication Management Sec 8.1.3.3

All prescription medications are properly stored in a locked/controlled manner so that they are issued in compliance with physician orders.

100% during rating period

Visual inspection during routine inspections

Review of policies of Contracted Program The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted

Case Management

Sec 8.1.3.4

Individual case management and/or professional counseling efforts are expected to flow from the initial written care plan. At a minimum, Veterans are expected to engage in individual case

100% during rating period

Documentation in progress notes/records

Care Plan reviews

Interview with veterans

Ref Standard Acceptable Level of

Quality Method of Assessment management/counseling meetings three or more times per month. Case management and/or counseling are expected to be substantive work focusing on the needs identified during the initial assessment and care planning process. Progress notes documenting case management/counseling activities should demonstrate, at a minimum, consistent focus on addiction recovery. Other areas of focus may include self-care, adaptive coping strategies, and mental health and employment preparation.

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

Group Activities

8.1.3.6

Structured group activities should be available to Veterans admitted to the program. At a minimum, Veterans should plan to attend one or more such activities daily. Such groups will have a primary focus on substance use disorder recovery (such as Motivational Interviewing, relapse prevention, Alcoholics Anonymous, Narcotics Anonymous, etc.). Additional

100% during quarterly rating period

Documentation in progress notes/records

Care Plan reviews

Interviews with Veterans

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel

Quality Method of Assessment groups are encouraged and may include: Cognitive Behavioral, life skills training, social skills training, vocational counseling, and permanent housing search groups.

Discharge Planning

8.1.3.7 9.6

Discharge plans that promote ongoing recovery efforts. Final plan will list what services (through VA or other agencies) the Veteran will engage in upon leaving the contracted program.

100% during quarterly rating period

Documentation in progress notes/records

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.

VA Coordination:

Contractor will collaborate with the VA program staff by conducting meetings as needed. In addition to working collaboratively with VA clinical staff, the Contractor will submit accurate billing to VA Payment Center by the 10th of each month.

8.1.3.8

1. VA staff will document meetings with contract program staff and keep any notes in administrative file

2. Contracted Program will submit accurate billing to the VA Payment Center by the 10th of each month

100% during quarterly rating period

COR records

Review of SOW compliance

Review of incident reports

Review of documentation

Quality Method of Assessment

Procedure for discharges:

VA staff to be notified of discharge within 24 business hours.

Confirmation email followed by discharge paperwork.

Unexcused Absence:

Veterans MUST be discharged after 24 hours if they have not received prior approval to leave program for that time frame. Contractor will inform VA staff of any unexcused absence within 24 hours.

Excused Absences:

Veterans may be granted an excused absence on a case by case basis.

Payment will only be made for the first 24 hours of an excused absence.

Excused absences are defined as hospitalization, incarceration, visit to family, work related issue pre-approved. Any excused absence after 24 business hours will not be billed to the VA. Unexcused absences are not paid for by the VA.

Incident Reporting:

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

9.6

9.5

3. 100% of Veterans admitted will have prior approval by VA Staff

4. 100% will have signed ROI in case management files

5. 100% of Veterans who are discharged will be reported to the VA within 24 business hours of discharge

6. 100% of all critical incidents related to assault, suicidality and death will be reported within 24 business hours

9. 90% of all other critical incidents are to be reported to VA staff within 24 business hours

INCIDENT DEFINED AS:

- Falls, Slips or Trips

Invoices

Interviews with veterans

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel

Quality Method of Assessment

(including on ice or snow)

- Assault (to Veteran or Staff)

- Elderly/Dependent Adult Abuse or Neglect

- Sexual Assault

- Fire (Veteran Involved)

- Medical Emergency (911 Calls)

- Hospitalization

- Suicide or Suicide Attempt

- Homicide

- Death

- Infectious Control (Bed Bugs, TB, etc.)

- Active Substance Abuse

- Observation/ Possession of Weapons

- If Medications are Lost, Stolen or Misused.

FACILITY 10.0 Must properly maintain a clean and sober living environment and ensure its facilities are in compliance with California laws and codes. Must be licensed by the State of California.

100% compliant during rating period.

Visual inspection during routine inspections

TRANSITIONAL PERFORMANCE STANDARDS -

Ref Standard Acceptable Level of

Quality Method of Assessment

Recovery Focus Sec 8.1.4.1

House meeting and social activities foster recovery-oriented relationships.

Residents are encouraged to attend self-help groups and/or outside services (at VA, community 12 step meetings, etc)

100% during annual rating period

Reviewed during routine on-site inspections.

Interviews with Veterans

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel

Medication Management Sec 8.1.4.2

All prescription medications are properly stored in a locked/controlled manner so that they are issued in compliance with physician orders.

100% during rating period

Visual inspection during routine inspections

Review of policies of Contracted Program The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted

Group Activities/House Meetings

8.1.4.3

Structured group activities and/or regular house meetings should be available to Veterans admitted. At a minimum, Veterans should plan to attend

100% during quarterly rating period

Documentation in progress notes/records

Care Plan reviews

Quality Method of Assessment two or more such activities each week. Examples of appropriate meetings include 12 step meetings, peer support meetings, life skills discussions, etc.

Interviews with Veterans discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted

Discharge Planning

8.1.4.4 9.6

Discharge plans that promote ongoing recovery efforts. The program is expected to assist with development of an individualized recovery plan.

100% during quarterly rating period

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.

VA Coordination:

Contractor will collaborate with the VA program staff (Mental Health Treatment Coordinator –MHTC) by conducting meetings as needed. In addition to working collaboratively with VA clinical staff, the Contractor will submit accurate billing to VA Payment Center by the 10th of each month.

Procedure for discharges:

VA staff to be notified of discharge

8.1.4.5

1. VA staff will document meetings with contract program staff and keep any notes in VA medical records

2. Contracted Program will submit accurate billing to the VA Payment Center by the 10th of each month

3. 100% of Veterans admitted will have prior approval by VA

100% during quarterly rating period

COR records

Review of SOW compliance

Review of incident reports

Review of documentation

Invoices

Interviews with veterans

Quality Method of Assessment within 24 business hours.

Confirmation email followed by discharge paperwork.

Unexcused Absence:

Veterans MUST be discharged after 24 hours if they have not received prior approval to leave program for that time frame. Contractor will inform VA staff of any unexcused absence within 24 hours.

Excused Absences:

Veterans may be granted an excused absence on a case by case basis.

Payment will only be made for the first 24 hours of an excused absence.

Excused absences are defined as hospitalization, incarceration, visit to family, work related issue pre-approved. Any excused absence after 24 business hours will not be billed to the VA. Unexcused absences are not paid for by the VA.

Incident Reporting:

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

9.6

9.5

Staff

4. 100% will have signed ROI in case management files

5. 100% of Veterans who are discharged will be reported to the VA within 24 business hours of discharge

6. 100% of all critical incidents related to assault, suicidality and death will be reported within 24 business hours

7. 90% of all other critical incidents are to be reported to VA staff within 24 business hours

INCIDENT DEFINED AS:

- Falls, Slips or Trips (including on ice or snow)

- Assault (to Veteran or Staff) discretion, choose any time, announced or unannounced, to have VA personnel

Quality Method of Assessment

- Elderly/Dependent Adult Abuse or Neglect

- Sexual Assault

- Fire (Veteran Involved)

- Medical Emergency (911 Calls)

- Hospitalization

- Suicide or Suicide Attempt

- Homicide

- Death

- Infectious Control (Bed Bugs, TB, etc.)

- Active Substance Abuse

- Observation/ Possession of Weapons

- If Medications are Lost, Stolen or Mis-Used.

FACILITY 10.1 Must properly maintain a clean and sober living environment and ensure its facilities are in compliance with California laws and codes. Must be licensed by the State of California.

100% compliant during rating period.

Visual inspection during routine inspections

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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 and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using

CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor.

This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

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 CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.

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

9. FREQUENCY OF MEASUREMENT

During the contract performance, the Contract Liaison 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 Contract Liaison shall meet with the Contractor quarterly to assess performance and shall provide a written assessment to be reviewed by the COR.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Rosario Chaidez, Program Analyst, MH______4/4/2019__________

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE