ATTACHMENT 2 - QASP - MENTAL HEALTH EVALUATIONS.pdf

Quality Assurance Surveillance Plan (QASP)

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: NETWORK CONTRACTING OFFICE / NCO21

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: Vanessa Baca

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

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternate:

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract.

COR’s 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 contractor performance evaluation may result in renewed contract.

Unfavorable contractor performance evaluation may result in non-renewal of 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 AUDIT OF EVALUATION PAPERWORK. 100%: The contractor is to evaluate patients who may be considered by the Veterans Affairs Mather Emergency Department (ED) staff as an immediate danger to themselves or others within 60 minutes of being called by the ED. Analysis of the Mental Health Evaluation at VA Mather ED and supporting forms will be completed on each patient and faxed to the Behavioral Health Inpatient Care Unit (BHICU). The evaluation should show sound social work and psychiatric principles. The assigned contract Program Managers will audit the paperwork. Evaluation paperwork is completed under HIPAA Privacy and Security Rules.

b. PERIODIC INSPECTION. Contractor is responsible for providing licensed Mental Health professionals who are competent to evaluate patients for placement in a BHICU. BIHCU utilizes specific admission guidelines. Contractors maintain competency.

c. CUSTOMER SERVICE. Contractor agrees to provide services that meet or exceed the standards as established by the Joint Commission and the Department of Veterans Affairs.

Complaints from veterans served and VA personnel shall be passed to the Contractor’s Quality Control Inspector (QCI) for review. The VA and the Contractor may have quarterly meetings to discuss issues.

d. LEGAL FORMS. If required when the evaluation is completed, the contractor will initiate the voluntary or involuntary legal hold forms in accordance with the California Welfare and Institutions, Code 5150. By law of the State of California, the application for 72 Hour Detention for Evaluation and Treatment must be complete. The Contractor can communicate with the ED Physician or On-Call Psychiatrist for clarification.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. The contractor shall be expected to utilize the forms provided by the Behavioral Health Intensive Care Unit (BHICU). The VA will maintain a log of the time contractor receives first notification to the completion of patient visit. This will assist in documenting contractor performance to meet the ED’s requests. The Contractor will, before the end of each month, provide the upcoming month’s list of contractor on-call primary and secondary staff. Any changes to the on-call list will be made known to the BHICU representative and the ED.

PERFORMANCE MEASURES

Measures PWS Refere nce

Standard Acceptable Quality Level

Surveillance Method

1 – ED Request for Evaluation 4.6.4.3 Mather ED will contact the Social Worker on-call to complete a psychiatric assessment of a patient that is medically cleared in the Mather ED within 60 minutes.

Contractors are available Monday thru Friday from 4:30pm to 8am. Weekends and Holidays are 24 hours from 8am to 8am.

No more than two failures to meet the timeline.

Validated Evaluation forms.

Contractor meets availability timeframes.

2 – Psychiatric Evaluation 4.6.4.5 Sound psychiatric principles are applied.

The Behavioral Health Inpatient Care Unit (BHICU) psychiatric admission guidelines will be used to determine if the patient meets psychiatric inpatient, medical admission, or neither.

On-Call Psychiatrist is available for consultations.

Data is accurate and timely.

Validated commendations, complaints, customer surveys or feedback.

3 – Evaluation Forms 4.6.4.6 Written results of the assessments are completed in a timely manner. The Social Worker will complete the assessment forms and make recommendations to the ED Physician and/or On-Call Psychiatrist.

HIPAA Privacy and Security Rules apply at all times.

No more than two failures to complete paperwork. No more than two validated complaints or incidents.

Validated commendations, complaints, customer surveys or feedback.

4 – Legal Forms 4.6.4.1 Demonstrates knowledge of California Welfare & Institution codes when completing legal forms.

All legal forms will be accurate, complete, legible, and timely.

Validated commendations, complaints, customer surveys or feedback.

5 – Interpersonal Communication/ Customer Service

4.6.4.2 Handles administrative issues

professionally with ED staff, other on-call staff, patient, patient’s family, and Administrative Officer of the Day (AOD) when called in for assessment or during phone conversations.

The upcoming month’s on-call schedule will be provided prior to the end of the current month.

Faxes all assessment forms completed by contractor to the BHICU whether the patient is admitted or not.

Maintains a courteous and helpful attitude when dealing with external and internal customers

Validated commendations, complaints, customer surveys or feedback.

7 – Professionalism 4.6.4.4 Ensure training is kept current. Routine on-time for clinical assignments. Completes required CME in specialty area. Maintains active BLS training.

Satisfactory rating = 100% during rating period.

Timecards.

Confirmation of current BLS.

Attestation of completed CME.

8 – Patient Access 4.6.4.7 The Contractor shall provide contract LCSW(s) in accordance with the operating hours and VA clinical schedule outlined in the PWS.

Contract LCSW is on-time and available to perform services 100% of the time.

Periodic sampling of Time and Attendance Sheets.

9 – Maintains Licensing and Registration

4.6.4.8 All 100% licensing for contract LCSWs

shall be provided as they are renewed.

Licensing and Registration information must be kept current.

All LCSWs licensing, registrations, and certifications must be kept current 100% of the time and proof provided upon renewal.

No acceptable deviation

Periodic sampling.

Random sampling.

10 – Privacy, Confidentiality, and

HIPAA

4.6.4.9 All 100% contractor LCSWs comply with

all laws, regulations, policies, and procedures relating to Privacy, Confidentiality, and HIPAA

100% compliance;

no deviations

Periodic sampling.

Contractor shall provide evidence of annual training by

VANCHCS.

Contractor reports violations per VA Directive 6500.6.

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 Contracting Officer (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 Contracting Officer’s Representative (COR) and the CO determine 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 CDR’s 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 Program Manager (PM) 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 Program Manager 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: Vanessa Baca, Program Analyst 8/5/2024

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE