Attachment 1 SCRM 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

Performance

Threshold/

Acceptable

Quality Level

Surveillance

Method

Performance

Acceptable/

Unacceptable

8.25.1 Emergency

Housing Program and

Management

Program provides a safe and sober environment for all residents

100%

VA team inspection

YES ☐

NO ☐

8.25.2 Emergency

Housing Program and Management

Program ensures the safety and privacy of Veterans with a clean and comfortable environment of care, including: A designated bed for each Veteran, safe and secure storage for belongings, and laundry facilities

8.25.3 Emergency

Housing Program and Management

Program provides appetizing, nutritionally adequate meals three time per day and snacks between meals and at bedtime; all food is stored, handled and served in a safe and sanitary manner that meets accepted industry standards and guidelines.

8.25.4 Staffing and

supportive services

Contractor provides a full-time administrative staff member on duty and on-site and available for emergencies 24 hours per day, 7 days per week.

inspection and review of contractor staffing records

8.25.5 Staffing and

Contractor provides a Director of the program and/or facility on-call and available for emergencies 24 hours per day, 7 days per week

100% VA team inspection and review of contractor staffing records

8.25.6 Staffing and

Contractor must provide security staff and/or security surveillance and monitoring on-site 24 hours per day, 7 days per week, sufficient to ensure a safe and secure environment for residents

100% VA team review of contractor staffing

8.25.7 Staffing and

Contractor provides coordinated case management and rehabilitative services to include psychosocial assessment and individual service planning;

assisting Veterans with appointments, paperwork, and linkages to needed resources and transportation o appointments

Inspection

(auditing) of

Veteran case management

8.25.8 Staffing and

Contractor provides daily structured group activities to promote skills building and healthy lifestyle review of Veteran case management

8.25.9 Housing

placement

Contractor will achieve the required rate of positive discharges

(as defined in the Performance

Work Statement) of Veterans admitted to the facility

55%

Veteran records, review of performance outcomes between

COR and contractor staff

8.25.10 Housing

Contractor will not exceed the maximum rate of administrative discharges (as defined in the

Performance Work Statement) of

Veterans admitted to the facility.

15% or less

Veteran records, review of performance outcomes between

COR and

8.25.11 Housing

Contractor will not exceed the maximum rate of negative discharges (as defined in the

Performance Work Statement) of

Veterans admitted to the facility

20% or less

Veteran records, review of performance outcomes between

8.25.12 Housing

Contractor will not have any unacceptable discharges (As defined in the Performance Work

Statement) of Veterans admitted to the facility

Zero instances during the rating period

Veteran records, review of performance outcomes between

8.25.13 Records and

reports

Contractor provides sign-in sheets signed by Veterans to verify services and invoicing by the fifth calendar day of each month contractor and

Veteran records

8.25.14 Records

and reports

Contractor maintains individual client records to include Initial psychosocial assessment, individual service plan, progress notes for each client contact, documentation of Veteran participation in daily group activities, updates to individual services plans, and discharge summaries

Inspecting

Veteran records

8.25.15

Maintain an active medication list for each Veteran contractor records and files

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