Attachment 4 - QASP - CERS Pinellas County.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

For: HCHV Contract Residential Services

Contract Number: TBD

Contract Description: Contracted emergency residential shelter beds.

Contractor’s name: TBD (hereafter referred to as the 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 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: Annette Whitfield-Johnson Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Materiel Management

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: Alison Wojtkun

c. Other Key Government Personnel: Stephanie Adams, HCHV Liaison; Blossom Kapper, HCHV Coordinator; Yvonne Morales, Homeless Section Chief

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

4. 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, paragraph IV in the Performance Work Statement (PWS), includes performance standards.

The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Task ID Indicator Standard Acceptable

Quality Level

Method of Surveillance Incentive

Rating

Foundational Requirements

The Contractor shall offer 24-hour supervised environment to include a clean, safe, home-like setting, semi-private or private room with bath access, communal dining with three meals/day and healthy snacks, laundry facilities on site including soaps, and a climate-controlled indoor recreational area for reading, writing, watching television, playing games, relaxing, and/or socializing.

Upon admission and throughout stay. 100%

Observation and random inspection (auditing)

Exercise of Option Period and past performance

Exceptional

Very Good

Satisfactory

Marginal

Unsatisfactory

Comments:

Quality Level

Each Veteran shall be furnished with a bed, pillow, sheets, pillow case, bath towel, face cloth, hand towel, blankets, linens, a place to hang clothes, dresser drawers, and a locked cabinet/drawer for medications and valuables.

Observation and random inspection (auditing)

Exercise of Option Period and past

The residential setting will provide appropriate access and services for female Veterans. The residential setting will maintain and adjust environments to support women Veterans’ dignity, respect, and safety. Physical and psychosocial privacy must be provided to women Veterans. Separate, safe, and secure sleeping arrangements for women Veterans are required, as are safe and secure bathroom arrangements. In mixed-gender units, this includes but is not limited to, proximity to staff and door locks. Gender-specific personal care and hygiene products are to be provided.

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

The Contractor shall provide face-to-face check in on each shift (3 shifts per 24 hours) to ensure that the resident is alert, oriented, and not in distress. Shift reports shall be completed to ensure that the information about the resident’s care is handed off from shift to shift. Check-in intervals shall be increased for residents recently discharged from an inpatient treatment setting.

Observational check-in 3x per day (each 8 hr shift) and written daily shift reports

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Therapeutic and Rehabilitative Services

6 Daily community meeting conducted by staff. Daily meeting 100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

Method of Surveillance Incentive Rating

Structured activities including a variety of therapeutic group, physical, and recreational activities. Examples would include WRAP, Seeking Safety, Life Skills, Coping Skills, Anger Management, Hygiene, Preventative Health Education, and Leisure Skills.

At least weekly 100%

Observation and random inspection (auditing)

Exercise of Option Period and past performance

Exceptional

Very Good

Satisfactory

Marginal

Unsatisfactory

Comments:

8 Medication Monitoring

Monitoring of medications to include reconciliation of medication by qualified staff, assignment to a level of medication management, and random inspections of medication in the resident’s possession to ensure compliance.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past performance

Exceptional

Very Good

Satisfactory

Marginal

Quality Level

Method of Surveillance Incentive Rating

Professional counseling, as required, including emphasis on self-care skills, adaptive coping skills, and, as appropriate, vocational counseling, in collaboration with VA and other community resources.

At least weekly and documented in chart. 95%

Observation and random inspection (auditing)

Exercise of Option Period and past performance

Exceptional

Very Good

Satisfactory

Marginal

Unsatisfactory

Comments:

Support for substance use recovery via alcohol and drug screenings. Written policy and procedure for type of screenings used.

Regular, random, or as clinically indicated and used as a therapeutic, learning tool.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past performance

Exceptional

Very Good

Satisfactory

Marginal

Quality Level

Transportation assistance to and from the Bay Pines VA Healthcare System, employment and housing opportunities, court appointments, and therapeutic recreational activities. Transportation assistance may include, but not limited to transportation via facility vehicle, providing bus passes or taxi voucher.

Regularly, as indicated in treatment goals.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

12 Discharge Planning

Discharge planning will begin at admission and will involve the Veteran.

95%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

Documentation

13 Census documentation Provide VA liaison with a current census at least 3x/week

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

The contractor must comply with the requirements of “Confidentiality of Certain Medical Records” (38 U.S.C 7332), and the “Confidentiality of Alcohol and Drug Abuse Patients Records” (42 CFR, Part II) when appropriate. This is to include: no re-disclosure of patient information, maintaining all records in a secure location, only making records available on a need-to-know basis to appropriate VA staff members involved with the treatment program of the Veterans concerned, and ensuring all email notifications and documents will be sent to the VA designee using a unique case number (no social security numbers or Veteran names may be sent via email).

Upon admission and throughout stay. 100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

15 Admission assessment

At admission, essential data relevant to Veteran, information, history of homelessness and anticipated length of stay.

95%

Observation and random inspection (auditing)

Exercise of Option Period and past

A record or log of medical orders or prescriptions issued by physicians. VA and facility staff will coordinate a system to ensure that a change in medication such as discontinued prescriptions is communicated.

Acquired at admission and updated throughout stay as clinically indicated.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

Treatment Plan includes: Strengths, Needs, Abilities, and Preferences, including needs beyond scope of program, and referrals made for additional services; Specific, Measurable, Attainable, Realistic, Timely goals in the words of the Veteran and to include housing. Interventions should identify who is responsible for implementation, frequency/duration of intervention, and techniques/methods/services used.

Completed within 3 days of admission and updated at least weekly. Goals should be reasonable enough to accomplish in 30 days. Written policy and procedure.

95%

Observation and random inspection (auditing)

Exercise of Option Period and past

Transition Plan should identify: current progress recovery or move towards well-being; gains achieved during program participation; need for support systems or other types of services that will assist in continuing recovery, well-being, or community integration; information on the continuity of medication; referral information such as contact name, telephone number, location, hours, days of services when applicable; communication of information on options and resources available if symptoms recur; and additional services needed.

Completed within 3 days of admission and updated throughout stay/as clinically indicated.

Written policy and procedure.

95%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

Participation in clinical individual and/or group meetings.

At least weekly and, in the event of missed clinical individual or group meetings, documentation should reflect the reason for lack of participation and efforts to engage the Veteran, as appropriate.

95% and random inspection (auditing)

Exercise of Option Period and past

Discharge summaries include: a description of changes realized during the Veteran’s stay in the residential program, reason for leaving (must document planned or unplanned), future plan, aftercare plan, and specific follow-up contact information.

Completed within 3 days of discharge. 95%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

Incident Reporting 21

The Contractor shall be responsible for compliance with following VA policies and procedures regarding incident reporting for Critical Adverse Events.

-Critical Adverse Events shall be verbally reported by phone to the VA Liaison or representative as soon as possible, no later than one hour from the time of the contract staff learning of the incident. Receipt of a voicemail will not be an acceptable substitution for the verbal notification requirement.

-Critical Adverse Events occurring after normal business hours shall be reported to the Administrator on Duty (AOD) by phone at (727) 410- 7925 as soon as possible, no later than one hour from the time of the contract staff learning of the incident.

-A written incident report shall be filed as soon as possible on the same calendar day of the required verbal notification, either by fax or encrypted email.

100% and random inspection (auditing)

Exercise of Option Period and past

Quality Level

The Contractor shall be responsible for compliance with following VA policies and procedures regarding incident reporting for Non-Critical Adverse Events.

-Non-critical Adverse Events shall be reported by phone to the VA Liaison or representative on the date of the event.

-Non-critical Adverse Events occurring after normal business hours shall be reported by the following business day no later than 10:00 am.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Payment 23

Payment for the Residential Care Program will be made on a monthly basis for services rendered.

Admission, discharges, and unauthorized absences should be reported to the VA Liaison or designee by the close of business on the day of the event. If the event occurs overnight, the VA Liaison or designee should be notified the following morning. If the event occurs on a weekend, notification shall take place by 10:00 am Monday morning.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Quality Level

24 Timely Invoicing

Monthly invoices and any necessary justification documents shall be received no later than the fifteenth calendar day of the subsequent month.

100%

Observation and random inspection (auditing)

Exercise of Option Period and past

Performance Measures 25

The Contractor shall be responsible for maintaining compliance with VA performance metrics, including but not limited to Exits to Permanent Housing, Negative Program Exits and Employment at Exit.

Contractor will meet designated performance measure target each year as outlined by the Homeless Program Office.

100%

Observation and review of monthly Homeless Services Scorecard updates

Exercise of Option Period and past

Quality Level

The Contractor will be responsible for developed a corrective action plan if performance measures are under target.

Corrective action plan submitted to VA liaison by the 15th of each month where the target was not met for the previous month (for example, corrective action plan due September 15th if August’s targets were not met).

100% Monthly Progress meetings

Exercise of Option Period and past

Training Requirements 27

All contractor employees and subcontractor employees requiring access to VA information shall complete the required training before being granted access to VA information.

-Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior relating to access to VA information.

-Successfully complete TMS trainings (1) Privacy and HIPAA VA10203 and (2) Information Security and Rules of Behavior VA10706 training within 1 week of hire and annually thereafter.

100% and random inspection (auditing)

Exercise of Option Period and past

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

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

Performance Standards 1-27

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

Performance Standards 1-24, 27

c. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.

Performance Standards 1-24, 27

d. Progress or status meetings.

Performance Standard 26

8. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used: Fully Met, Partially Met, Not Met

9. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive 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 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 determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

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.

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

10. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

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

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative