Attachment 7 - Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP) West Palm Beach VAMC

Medical Respite CERS Program 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: Peter Bedard, Peter.Bedard@va.gov

Organization or Agency: VISN 08 Contracting Office

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: Gina S. Nunez, LCSW

Organization or Agency: West Palm Beach VA Health Systems, Health Care for Homeless Veterans Program (HCHV)

3. CONTRACTOR REPRESENTATIVES

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

Primary: Gina S. Nunez, LCSW, Coordinated Entry Specialist & COR

Secondary: Darian Newbeck, LCSW

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 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

The Government shall use past performance as incentives to exercise option periods. Incentives shall be based on ratings received on the 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. 100% surveillance: (if this method is used, define how surveillance will be accomplished.)

VA assigned liaison will be present at program site weekly and will review records and procedures as appropriate.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

(Define what and how often it will be inspected. For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

Annual inspection of facilities will be coordinated by VA liaison and COR to include environmental safety, police/security staff, nutritionist and clinical review team.

Quarterly inspections by COR.

Unannounced/as-needed inspections by COR or other clinical review team members.

25% of patient charts reviewed annually.

c. VALIDATED USER/CUSTOMER COMPLAINTS. If this method is used, explain how data will be collected and reported.

Residents are asked about their subjective safety and comfort level in the program at each monthly care plan review.

COR assesses for customer complaints at every check-in with Veteran; at least monthly.

d. RANDOM SAMPLING. If this method is used, define what and how often it will be sampled. (For example, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

A minimum of 25% of client files will be reviewed annually to ensure that VA policies are being adhered

to. The Liaison and COR may conduct random record reviews throughout the year as indicated.

20% of client rooms may be viewed at any given inspection period to check for medication storage compliance and other indicators of patient safety.

e. Verification and/or documentation provided by Contractor. Review PWS and if this method of surveillance is selected, define how documentation will be verified and how assessment will be conducted. (For example, off-site contracts may require the contractor to provide information on services provided to patients).

Monthly billing spreadsheets, admissions, discharges, and census/bed tracker sent by contractor and reviewed by COR.

Residential staff log used to track engagement efforts, interventions, and check-ins with Veterans;

reviewed by COR quarterly or randomly as needed.

Incident reports submitted by Contractor and reviewed by COR, when incidents occur.

SAMPLE PERFORMANCE MEASURES

The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

ID

TASK

INDICATOR

STANDARD

ACCEPTABLE

QUALTIY LEVEL

METHOD OF

SURVEILLANCE

Access:

Contractor shall provide rapid, emergency, residential placement

Contractor possesses the ability to place Veterans on the same day of the referral from the VA

90%

Observation and random inspection

Housing Services:

12.1.8

Contractor shall provide sufficient personnel to assure security

Contractor has staffing available on‐site 24 hours a day, 7 days a week

100%

Facilities:

12.1.4

The Contractor shall provide clean and sanitary housing shall be provided to all Veteran Residents.

‐One single bed per occupant ‐Privacy for care and self care needs

‐Storage space with lock

‐One dresser with at least two drawers

‐Linen and towels ‐Hygiene products

‐Indoor recreation/lounging areas

‐On‐site laundry facilities and laundry detergent

‐Access to phone and mail service

‐Wheelchair accessibility

95%

Clinical Staffing:

14.2.1 employ at minimum a Case Manager at 1:12 maximum ratio that is designated to working with Veteran program

‐Assistance with obtaining income if needed

‐Assistance with obtaining necessary identification and records

‐Enrollment of eligible Veteran Residents on the Housing and Urban Development Section 8 list, or updating Veteran information if appropriate

‐Discharge planning to appropriate community housing, including referrals and application assistance.

13.2

‐Education and assistance with medication management and compliance, with follow up with VA medical staff as appropriate;

‐Assistance with coordinating care with VA providers in the event of ongoing medication non‐ compliance or medical need;

A Program Nurse shall also be assigned to the program at least 35‐hours a week designated to the Recuperative and Post Clinical Care part of the Program.

‐Patient health education in areas such as sleep, nutrition, coping with chronic illnesses, and pain management;

‐Monitoring of vital signs, with follow‐up with VA medical staff as appropriate;

inspection

‐Assistance with the use of VA Tele‐Health as needed;

Assistance with adaptive exercise, such as chair exercises, for patients who are disabled.

‐i.e.: social skills training, Therapeutic and

Specialized individual and group support addressing the needs of the severely mentally ill and/or medically frail Veterans, including linkages with VA programs and community resources to achieve a more adaptive level of psychosocial functioning, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling;

‐Support for an alcohol/drug abuse‐ free lifestyle;

‐Instruction in and assistance with health, personal hygiene, and other

Rehabilitative Services:

improved maintenance of physical and mental health, and improved personal relationships.

activities of daily living;

‐Storage and monitoring of prescription medications;

13.2.1, 13.3.4

‐Individualized professional counseling;

‐Opportunities to participate in spiritual worship.

Intake, Treatment

Planning, and

Discharge

13.3.2, 13.3.3

An intake assessment and care plan, with preliminary discharge goals in accordance with the approved timeframe for the contracted Residential stay.

Intake completed within 3 business days of a Veteran's admission to the Recuperative Care Program and treatment plan within 14 days.

Discharges must be completed and submitted to VA Liaison within 3 business days of Veteran exiting the program.

Dietary:

The dietary needs of all veterans shall be met in accordance with sound nutrition and medical standards, At least three nutritious meals shall be served daily, at regular times, with not more than a 14 hour time span between the evening meal and breakfast the next day; ‐Food items shall be prepared, served, and stored under sanitary conditions;

12.5.2

‐Sanitary procedures shall be established and maintained for washing dishes, cleaning equipment and work areas, and for proper waste disposal.

Records and Reporting:

13.4.3

Homeless Operations Management and Evaluation Systems (HOMES) Exit Form shall be completed and provided to the VA Liaison.

Provided to the VA within one business day of a Veteran Resident's discharge from the facility.

inspection

Veterans' data shall be entered into the Homeless Management Information Systems

(HMIS)

Entered in accordance with HMIS Data Standards.

inspection

Extensions beyond the initial authorized period shall be requested in writing by the Contractor, with justification of the Veteran's need and updated treatment plan.

Approvals shall be authorized in writing by the VA Liaison/COTR.

Provided to VA prior to the expiration of the current treatment plan.

inspection

The following shall be provided to the VA Liaison/COTR:

‐ A valid current unrestricted license in their respective profession for all contracted staff as applicable;

Quality Care:

All providers of clinical services must be credentialed in accordance with the appropriate state licensing boards.

‐Credentials and qualifications of staff for the job;

‐A current competency assessment checklist;

‐Proof of knowledge and skills required to provide care for certain patient populations, as appropriate;

inspection

3. ‐Current performance evaluation supporting ability of contractor personnel to successfully perform the work required in this solicitation;

‐Listing of relevant continuing education for the last two years.

Patient Safety:

13.4.6

Major incidents involving Veteran Residents shall be reported to the VA Liaison/COTR

Incidents must be reported as soon as it is safe to do so after occurrence, via telephone. An incident report shall be provided by the Contractor within one business day of the incident.

investigate and resolve all Veteran Resident safety incidents.

Updates, findings, and conclusions of Veteran Resident safety incident investigations are to be provided continuously to the VA Liaison/COTR (at least once a week until resolution).

Patient Satisfaction:

13.4.8

Patient complaints about the quality of care are reported to the COTR.

Providers and staff are familiarized with the process outlined in Contractor's grievance procedures as well as patient rights.

All patient complaints are reported immediately (within 24 business hours) All providers and staff are educated.

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 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 COR and the CO determines 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 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 Measurement.

The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting.

The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Digitally signed by GINA NUNEZ Date: 2024.01.09 11:59:56 -05'00' Adobe Acrobat version: 2023.006.20320

COR NAME/TITLE: Gina S. Nunez, LCSW, Coordinated Entry Specialist DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

GINA NUNEZ