Attachment 1 HCHV CERS QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

Health Care for Homeless Veterans (HCHV)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate Contractor actions while implementing this Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring Contractor performance for each listed objective on the Service Delivery Summary (SDS) in this contract.

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

PURPOSE

The Contractor, 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 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. In this contract the quality control program is the driver for product quality.

The Contractor 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 Contractor to success. This QASP explains the following:

• What shall be monitored

• How monitoring shall take place

• Who shall conduct the monitoring

• How monitoring efforts and results shall 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.

PERFORMANCE STANDARDS

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

Task Standard

Performanc e

Threshold/ Acceptable

Quality Level

Surveillance Method

Performanc e

Acceptable/ Unacceptab le

A. Records keeping for homeless

Veterans

1. 95% of daily sign-in sheets are signed by the

Veteran;

2. 95% of Individualized

Care Plans (ICP’s) are completed within 14 days of admission

3. 95% of progress notes are completed for

Veterans to outline services provided in accordance with PWS

95% of randomly selected cases

Review by Saginaw VAMC staff monthly, quarterly, and annually with random reviews

YES ☐

NO ☐

B. Accuracy of

Invoices

1. 95%)Invoices submitted to the COR for payment have the accurate per diem rate, number of bed days billed, dates, and the Contractor identification information.

2. 95% of the invoices will be submitted in conjunction with the daily sign-in sheets to allow the COR to verify the accuracy of the invoice.

3. 95% of invoices are submitted to the COR by the tenth of each month.

95% of the time

COR monthly

C. Discharge

Plans

1. 95% Veterans are continually engaged in discharge planning with

Contractor’s staff, in conjunction with

Homeless Program case manager. This discharge planning includes discussion of available and appropriate housing placements and treatment options.

2. 95% of the Contractor’s discharge forms are submitted to the COR on a monthly basis with the daily sign-in sheets and invoice.

3. 95% of the discharge forms are completed accurately to reflect the type of discharge and housing placement upon discharge.

COR on a monthly basis

D. Homeless Veteran Satisfaction

1. 95% Veteran satisfaction rate with the services provided by the

Contractor;

2. 95% of complaints received by the

Contractor are dispositioned within 24-

48 hours of the complaint by the

Contractor;

3. 95% of complaints are reported to the COR within 24-72 hours of the complaint

Review by COR on a monthly, quarterly, and annual basis

E. Residential

Outcomes

1. In conformance with

VHA National Homeless

Program Performance

Measures; at least 55% of Veteran’s discharged from the Contractor’s facility will have a positive exit;

2. no more than 20% of those Veterans discharged from the

Contractor’s facility will have a negative exit.

55% positive exits; no more than 20% negative exits

Monthly review by COR

F. Emergency housing and facilities manageme nt

1. 100% compliance with the facility meeting fire, safety and Americans with

Disabilities Act, and

Licensure

2. 100% compliance with

Veteran privacy guidelines.

The facility has adequate policies and procedures in place to ensure conformity to confidentiality

100% of the time

COR and HCHV Liaison review monthly, quarterly, and annually with random audits

SURVEILLANCE

The Contracting Officer Representative (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 COR for correction. All

Performance Standards

STANDARD

Customer complaints shall not exceed the thresholds cited above for each performance objective. The COR shall notify the Contracting Officer (CO) for appropriate action.

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.

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

PROCEDURES

The COR shall inspect to ensure Contractor compliance with the appropriate section of the Performance Work Statement (PWS) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the COR shall notify the CO of the deficiencies within 3 business days. 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.

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 shall 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.

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY CONTRACTOR: c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER