Attachment 4 - QASP.pdf

Updated 09/22/25 HM 1

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

Residential Contract Services (Emergency Housing)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate Contractor actions while implementing this Statement of Work (SOW). 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.

This QASP is based on the premise, the Government desires to maintain a quality standard in providing primary care/mental health services to its patients. The resulting contract is considered the best means of achieving that objective.

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 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.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

Updated 09/22/25 HM 2

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 and disincentives. 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

Method of Surveillance (The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s records.)

Clinical care services to include; working with homeless Veterans and finding them permanent housing and linkage and referrals to other community services.

Provision of or linkage to services needed to enable the person served to perform daily living activities including but not limited to budgeting, meal planning, personal care, financial services, medical or other healthcare, assistive technology assessment, or, other identified needs.

Completion of documentation needs.

Work toward assisting Veteran in obtaining their goals.

Work toward assisting Veteran in obtaining cash income or non-cash benefits.

Assist Veteran with transportation.

Discharging Veterans from program in a timely manner.

Contractor shall be responsible for providing VA with bed census reports on each veteran.

It will be the responsibility of the contractor to meet applicable performance metrics.

Notify VA through their Contracted Residential Services program liaison of any negative incident occurring with a Veteran.

Contractor possesses the ability to place veterans on the same day as the referral from the VA.

90% Observation and Random Inspection.

Contractor has staffing on-site 24 hours a day, seven (7) days a week.

100% Observation and Random Inspection.

Completion of ROI 95% Observation and Random Inspection.

Bed census reports shall be due daily for each veteran occupying a bed unless the day is a holiday or weekend, in which case it shall be due the next business day.

100% Receipt of submitted Bed Census Reports.

End-of-month bed census reports must be submitted to the VA by the 5th calendar day of every month for the appropriate reporting period.

100% Receipt of End of Month Bed Census Reports.

Daily census sign-in sheet to verify attendance in the program.

95% Observation and Random Inspection.

Intake completed within three

(3) business days of admission.

95% Observation and Random Inspection.

Treatment plan completed within 14 days of admission.

95% Observation and Random Inspection.

Extension request provided to VA prior to 60-day increments.

100% Receipt of submitted extension request.

Discharges completed and submitted to VA liaison within one (1) business days of the veteran exiting the program.

100% Receipt of submitted discharge form.

HMIS entered for all program participants.

95% Observation and Random Inspection.

(100%) All patient complaints reported within 24 hours.

95% Observation and Random Inspection.

Complete a verbal incident report within 24 hours of occurrence.

100% Observation and Random Inspection.

Complete and submit a written incident report within 1 business day of occurrence to Residential Services Liaison.

100% Internal Tracking.

Assistance with obtaining income and necessary identification and records, enrollment in housing services, discharge planning to appropriate community housing.

95% Observation and Random Inspection.

Single bed per occupant, privacy for care and self-care needs, storage space with

95% Observation and Random Inspection

Updated 09/22/25 HM 3

Notify (COR) or representative of staff start and end dates and submit proper documentation for contract employees.

Ensure that contract employees complete required trainings and submit proof of trainings to COR or representative.

lock, one (1) – two (2) draw dresser, linen and towels, hygiene products, indoor recreation/lounging area, on-site laundry facilities and detergent, access to phone and mail service, wheelchair accessibility Special skills training, AA/NA counseling, support for an alcohol/drug free lifestyle, Instruction/assistance in activities of daily living, medication storage, professional counseling, opportunities for spiritual worship.

95% Observation and Random Inspection

At least three (3) nutritious meals shall be served per day, not more than 14 hours between the evening meal and breakfast the next day;

sanitary procedures and conditions shall be established.

95% Observation and Random Inspection.

(100%) Valid current license in their respective profession, credentials and qualifications, competency checklist, performance evaluations.

95% Observation and Random Inspection.

Percent of Veterans discharged to Independent Housing.

>= 55% Internal Tracking System

Percent of Veterans discharged with a negative program exit.

<= 20% Internal Tracking System

Occupancy Rate. >= 85% Internal Tracking System Recording of medications taken at intake.

95% Observation and Random Inspection

Satisfaction Survey’s completed and provided to Liaison for any Veteran residing in program past 30 days.

95% Periodic review and during random checks.

Resume will be sent to COR or designee for all contract staff assigned to work on contract. For new hires, resume will be sent 15 days prior to staff start date.

100% Upon new hire of staff

Contractor will provide notification within 3 business days to Contracting Officer’s Representative (COR) or designee when contract staff is no longer assigned working with the contract.

100% Upon discharge of staff

Complete and submit within 30 days of hire, training certificates indicating completion of required VA trainings (VA Privacy and Information Security Awareness Training and Privacy and HIPAA Training).

100% Upon new hire of staff

Report that has Total Number Veterans Served, Percent of Veterans Discharged to Independent Housing, Percent of Negative Discharges

100% Receipt of Report.

Updated 09/22/25 HM 4

SURVEILLANCE: The Government quality assurance (QA) person and the COTR 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.

c. Progress or status meetings. All Performance Standards

d. Complaints. Complaints from agency personnel shall be passed to the Contractor's quality control inspector (QCI) for correction. All Performance Standards

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 COTR shall inform the Contractor. This shall normally be in writing unless circumstances necessitate verbal communication. In any case the COTR shall document the discussion and place it in the COTR file.

When the COTR determines formal written communication is required, the COTR 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’s contracting personnel.

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 COTR. The Government shall review the Contractor's corrective action plan to determine acceptability.

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

SURVEILLANCE: The Government evaluator shall evaluate the services required by each delivery/task order to ensure complete compliance.

PROCEDURES: The Government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the Government evaluator shall notify the CO and/or QCI of the deficiencies within 3 business days and have QCI correct said deficiencies. 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. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

Updated 09/22/25 HM 5

FREQUENCY OF MEASUREMENT: During contract performance, the COTR 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 COTR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Technical Representative

Signature – Contracting Officer