ATTACHMENT 1 - QUALITY ASSURANCE SURVEILLANCE PLAN (QASP).pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: Health Care for Homeless Veterans Contract Emergency Residential Services (HCHV CERS)

Contract Number: TBD

Contract Description: VA provides assessment and referral services to Veterans and facilitates Veteran access to a broad range of medical, mental health, and rehabilitative services. Assisting Veterans to have shelter as they link to and access these services is crucial to the mission of VA.

Contractor will provide short-term emergency housing, meals, case management, and other supportive services to homeless Veterans who need immediate housing placement as they seek permanent housing, medical care, and other resources/services that target underlying factors contributing to homelessness and improve their overall health status using the Health Care for Homeless Veterans Contract Emergency Residential Services program model of care.

To be eligible for placement in the program, Veterans must be homeless or at imminent risk of homelessness and be eligible and registered for VA services. Veterans are required to have a signed Release of Information between the VA and Contractor staff, meet with a VA Social Worker to complete the HCHV intake procedure, and be agreeable to work on a long-term housing plan.

Veterans who are referred for admission to the program by VA are authorized for an initial service period of up to 90 days unless otherwise specified. Extensions of this initial service period may be approved by VA based on clinical justification and targeted housing plan needs.

Contractor’s Name: TBD (hereafter referred to as Contractor)

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 based on the premise that 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. This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contracted programs’ activities while implementing the Performance Work Statement (PWS) incorporated into the contract. It is designed to provide an effective surveillance method of monitoring Contractor 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. 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: Larry Facio Organization or Agency: VA, NCO 21 – Health Care Resources I

Assigned CS: Joshua Barrios Organization or Agency: VA, NCO 21 – Health Care Resources I

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: Allen Hearn, LCSW, COR Organization or Agency: VA Sierra Nevada Health Care System

c. Other Key Government Personnel – Alternate COR: Christina McCoy, COR Organization or Agency: VA Sierra Nevada Health Care System

HCHV Liaison: Allen Hearn, LCSW, HCHV Liaison Organization or Agency: VA Sierra Nevada Health Care System

3. CONTRACTOR REPRESENTATIVES

The following employees of the Contractor serve as the Contractor’s program manager for this contract:

a. Program Manager – TBD

b. Other Contractor Personnel – TBD

c. Other Contractor Personnel – TBD

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 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, incentives and disincentives. The Government shall use these standards to determine contracted performance and shall compare Contractor performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

5. 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. (Can be performed periodically or through 100% surveillance.)

• Occupancy

• Referrals/Admissions Decisions

• Exits to Permanent Housing

• Negative Exits

• Timely Submission of Monthly Invoices

• Daily Census Sign-In Sheets

• Prompt and Accurate Communication with VA

b. PERIODIC INSPECTION. (Inspections for HCHV CERS Programs will occur quarterly or more)

• Care Planning

• Case Management and Documentation of Supportive Services

6. QASP PERFORMANCE REPORT

Performance Indicators

PWS

Ref

Performance Measure

Acceptable Quality Level

Method of Assessment Incentive Disincentive

Occupancy 3.3.1.

3.3.1.1.

Contractor shall meet the minimum acceptable level of occupancy of

HCHV CERS

funded beds at all times. When minimum occupancy is not met, Contractor conducts outreach at least twice monthly to maintain satisfactory occupancy rate.

Accepted:

Minimum average rate of occupancy shall be 80% for any given quarter.

Preferred: 90-

100% occupancy

Direct observation using quarterly review of NEPEC data, daily census reports, and/or monthly billing.

Informal review of outreach events/activities. The annual review will not be based on the quarterly reports but on entire year occupancy.

At its discretion, the

Government may choose at any time to have VA personnel inspect Contractor’s records, announced or unannounced.

Positive ratings in quarterly reports and annual

CPARS

review.

Maximum occupancy may result in increase in program size if funds are available.

Negative ratings in quarterly reports and annual CPARS

Low occupancy may result in reduction in program size.

Referrals/Admissions Decisions

2.4.2.3.

3.4.1.9.

7.3.

Contractor shall provide notification of all admissions decisions on the same day of referral and/or within 24 hours after receipt of referral as outlined in the

PWS.

Accepted: 80% or more required notifications are received within requisite timeframe.

Preferred: 90%-

100% notifications

Direct observation using

VA

Liaison/COR/Contractor correspondence records and monthly referral reports.

Positive ratings in quarterly reports and annual

Annual

Negative ratings in quarterly reports and

PWS

Ref

Performance Measure

Acceptable Quality Level

Method of Assessment Incentive Disincentive received within requisite timeframe review will not be based on quarterly reports but on the entire year’s data.

Care Planning 3.3.3.

7.5.

Contractor will engage each Veteran in a collaborative assessment of needs, including barriers to stable housing, and create an initial plan of care to address those needs within 14 days of admission. Plan will be updated at least once every 60 days throughout admission.

Accepted: At least 80% of

Veterans who remain in program 14 days or more will have completed initial care plans in Contractor chart within 14 days of admission and will have updates of initial plans at least once every 60 days when indicated.

100% will meet minimum expectations noted above.

Periodic Inspection (quarterly or more) by chart review.

choose at any time to have VA personnel inspect Contractor’s records, announced or unannounced.

Positive ratings in quarterly reports and annual review will be based on all charts reviewed throughout the year.

Negative ratings in quarterly reports and annual CPARS review.

Case Management & Documentation of

Supportive Services

3.3.4.

7.4.

Contractor will provide individual case management meetings that focus, at a minimum, on housing stabilization, increased income and access to/engagement in care through appropriate providers of physical and mental health services.

Contractor shall document all case management and supportive service interventions in each Veteran’s individual case record.

Accepted: At least 80% of Veterans will engage in individual case management meetings at least once per week which will be documented in individual case records.

100% of Veterans participate in weekly case management sessions that are documented in individual case records.

Periodic inspection (quarterly or more) by chart review; Veteran self-report.

choose at any time to have VA personnel inspect Contractor’s records, announced or unannounced.

Positive ratings in quarterly reports and annual review will be based on all charts reviewed throughout the year.

Negative ratings in quarterly reports and annual CPARS review.

Exits to Permanent Housing

3.3.9. Exits to permanent

housing will be monitored as an indicator of overall program quality utilizing data provided by the VHA Support

Service Center’s Homeless Service

Accepted:

Within 5% of the target value as established by

VHA Homeless Program Office at the start of each fiscal year.

Target values for

Exits to

Direct Observation using quarterly and annual review of

NEPEC data.

Positive quarterly reports and annual

Negative ratings in quarterly reports and

PWS

Ref

Performance Measure

Acceptable Quality Level

Method of Assessment Incentive Disincentive

Scorecard at the established target rate for exits to this type of housing.

Permanent Housing can vary from year to year and will be communicated to Contractor at the start of each fiscal year. (e.g., FY23 target value =55%).

Preferred: Total

% of Exits to Permanent

Housing is equal to or greater than target value established at the start of each fiscal year.

review will not be based on quarterly reports but on the entire year’s data on exits to permanent housing.

Negative Exits 3.3.10. Negative Exits, which shall be defined as discharges involving Veterans being asked to leave the program due to rule violation or otherwise leaving the program without consulting program staff, shall be monitored on a continuous basis utilizing data provided by the VHA Support

Service Center’s Homeless Service Scorecard at the established target rate for these types of exits.

Accepted:

Within 5% of the target value as established by

VHA Homeless Program Office at the start of each fiscal year.

Target values for Negative Exits can vary from year to year and will be communicated to Contractor at the start of each fiscal year. (e.g., FY23 target value =20%).

Preferred: Total

% of Negative Exits is less than the target value established at the start of each fiscal year.

Direct Observation using quarterly and annual review of

NEPEC data, Positive quarterly reports and annual review will not be based on quarterly reports but on the entire year’s data on negative exits.

Negative ratings in quarterly reports and annual CPARS review.

Timely Submission of Monthly Invoices

7.12. Invoices due to VA

Liaison, COR or designee by the 5th of the month immediately following the billing period in question and, once

Accepted: 80% or more of invoices are submitted by the 10th of the month and 100% submitted within the calendar

Direct observation using COR Quarterly Invoice

Tracking Report and VA Invoice Payment Processing System

Positive ratings in quarterly reports and annual

Negative quarterly reports and

PWS

Ref

Performance Measure

Acceptable Quality Level

Method of Assessment Incentive Disincentive approved, are due in Tungsten Network (electronic billing system) by the 10th of the month immediately following the billing period in question.

month immediately following the billing period in question.

100% of invoices are submitted by the 10th of the month immediately following the billing period in question.

Daily Census Sign-In

Sheets 3.4.6.

7.10.

Contractor will submit daily census sign-in sheets or other mutually agreed upon equivalent method for verifying Veteran bed utilization no less than once weekly and up to daily per VA designation.

100% of enrolled Veterans will be accounted for as described in PWS for each billable day of service by sign-in sheet or other mutually agreed upon equivalent method for verifying Veteran bed utilization.

Direct observation of daily census sign-in sheets or other mutually agreed upon equivalent method for verification of monthly invoicing.

Positive ratings in quarterly reports and annual

CPARS

review. Full payment for all billable days of service.

Negative ratings in quarterly reports and annual CPARS review.

Unpaid days of service when Veteran bed utilization is not verified by sign-in sheet or other mutually agreed upon equivalent method.

Prompt & Accurate Communication with

VA

3.3.8.

3.4.1.

3.4.7.

3.4.8.

3.4.9.

3.4.11.

Contractor notification and reporting on entries and exits, absences from program, critical incidents, extension requests, and grievances follow requisite timeframes as outlined in PWS.

Accepted: 80% or more required notifications are received within requisite timeframe.

100% notifications received within requisite timeframe

Direct observation using VA Liaison/COR records, CPRS, review of reporting tools received such as incident reports and entry/exit forms, and Veteran self-reports.

Positive ratings in quarterly reports and annual

CPARS

review. Full payment for all eligible days of service.

Negative ratings in quarterly reports and annual CPARS review.

Suspension of payment for days of service deemed ineligible due to improper authorization.

6. CPARS 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.

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf%20p.%20A2-1

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 COR shall inform the Contractor.

This will 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 and the CO determine formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the 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 COR. 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

a. Frequency of Surveillance.

During contract performance, COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

COR/Liaison/Designee shall meet with Contractor quarterly to assess performance.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative