Attachment B - QASP.docx

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: Edward Ferkel- Contracting Specialist, Services 3 (Community Support Services Phone : 570-332-2888; Edward.ferkel@va.gov Organization or Agency: Department of Veterans Affairs | Regional Procurement Office East | Network Contracting Office 4 3900 Woodland Ave | Philadelphia, PA 19119

b. Point of Contact (POC) – The POC is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The POC shall keep a quality assurance file. The POC is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned POC: Jillian Harris (215) 823-5800 ext 207461; 215-821-0620, jillian.harris@va.gov Organization or Agency: Philadelphia CMCVAMC, Social Work Service #122

3. CONTRACTOR REPRESENTATIVES

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

Primary: N/A Alternate: N/A

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. POCs 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. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The POC shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. 100% surveillance: Surveillance will be accomplished through HCHV coordinator and POC presence.

b. PERIODIC INSPECTION. Inspections scheduled and reported annually per POC delegation or as needed. Inspections will follow HCHV guidelines put forth by National Center on Homelessness Among Veterans (NCHAV).

c. VALIDATED VETERAN FEEDBACK. POC will maintain a file of any written or verbal complaints or compliments filed by Veterans or staff .

d. Verification and/or documentation provided by Contractor. Review and verification of files will be conducted during scheduled inspections and as needed by POC and HCHV Coordinator.

e. RANDOM INSPECTION: The POC and CO may, at their discretion, choose any time to conduct surveillance for quality performance.

Quality Assurance Surveillance Plan (QASP) Contract#

Page 5 of 11 Revised 8/8/2023

7. QASP PERFORMANCE REPORT DATE:__________________

Reference Performance Requirement

Method

Met AQL/ Did not meet AQL

CPAR Rating/ Add Comments

Veterans with temporary residential placement which shall include the following:

a.On-site recuperative medical care and medication management by a Licensed Practical Nurse (LPN) or Registered Nurse (RN). Medication management shall be available twenty-four (24) hours per day/seven (7) days per week.

b.On-site case management services by a Human Services Professional.

c.On-site mental health services by a Mental Health Provider.

d.On-site residential staffing twenty-four (24) hours per day/seven (7) days per week. Contractor shall at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined in this Statement of Work (SOW). When hiring personnel, Contractor shall keep in mind that the stability and continuity of the workforce is essential.

Contractor shall provide designated onsite furnished office to VA Liaison.

Direct Observation

Accommodations shall include a bed, and other furnishings for clothing and personal properties such as a dresser, storage locker or designated secured space, and personal linens (towels, pillows, blankets and bed sheets, etc.). Contractor will allow Veterans to store personal belongings for at least seventy-two (72) hours after formal discharge on-site. Contractor will provide hygiene supplies and laundry facilities. Contractor will provide internet/computer access.Contractor will provide access to phone and mail service.

Direct Observation

Contractor will perform criminal background checks on all staff members. Contractor must have a policy prohibiting staff from establishing sexual and/or financial relationships with program Veterans.

Contractor will provide clinical staff personal on-site at all times who have current training and orientation on the identified topics in SOW. Staff shall receive and document—at a minimum—one-time training per year on these subjects.

Staff and subcontractors will provide services consistent with VA’s Core Values: Integrity, Commitment Advocacy Respect and Excellence (ICARE).

I CARE (va.gov) I CARE - Through Veterans' Eyes - Bing video All required training is complete on time by contractor’s employee(s) with documentation available upon request by VA Liaison.

Contractor provides Key Personnel updates in monthly report

Direct observation

The Contractor is able to provide admissions to eligible homeless Veterans on the same day, 24/7 hrs.

To be eligible for placement in HCHV contract beds, all Veterans must be homeless or at imminent risk of becoming homeless and be eligible and registered for VHA services.

The VA Liaison or designee is responsible for determining eligibility of Veterans prior to acceptance by the Contractor for services It is understood that the eligibility of Veterans to be cared for under this contract will require medical care and treatment services over and above the level of room and board. It is also understood that Veterans may need more intensive case management than the general population.

Contractor provides Referrals updates in case management Bi weekly report

Therapeutic, rehabilitative, and recovery services, including but not limited to:

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

-Instruction in and assistance with health, personal hygiene, and other activities of daily living, social skills training -Assistance in coordinating care with VA providers in the event of ongoing medication non-compliance or medical need

- Patient health education in areas such as sleep, nutrition, coping with chronic illnesses, and pain management Assistance with the use of VA Tele-Health as needed -Assistance with adaptive exercise; such as chair exercises, for patients who are disabled -Assistance with storage and monitoring of prescription medications -Support for an alcohol/drug abuse-free lifestyle -Opportunities to participate in spiritual worship

Contractors provides updates on trends in monthly reports

Direct Observation,

1.II f.

1.II i.

1.II j.

1.V Contractor will collect and maintain all mandated documents and evaluation data required by the VA National Center on Homelessness Among Veterans. Contractor shall maintain proper documentation verifying services and case management efforts made by all team members Contractor shall provide the VA Liaison with a written report of program activities on a monthly basis. The report should contain, at minimum, the following information:

a. Total Number of Veterans Served

b. Program Completion Rates

c. Outcomes (e.g. # or % of Veterans discharged to independent housing, increased income/benefits, occupancy, etc.)

d. Other pertinent information, such as: quality improvement projects, changes in staffing or business practices, systems or resource concerns, etcetera.

Contractor will be required to keep Veteran files for minimum of 3 years post discharge from program for auditing purposes.

Contractor grievance handling

A. I.

Contractor meets all applicable life/safety codes and other standards/compliance requirements as determined by VA, including Americans with Disabilities Act accessibility.

Contractor shall be responsible for ensuring the continuity and stability of the workforce to carry out the policies, contract responsibilities, and the program for the facility.

Veterans are entitled to reasonable privacy and confidential treatment of personal, social, financial, medical, and behavioral/mental health records, except as necessary to further treatment, information and referral services and in compliance with the resident’s consent to release information.

Veterans’ rights must be protected against all forms of discrimination, including those based on race, religious creed, color, national origin, ancestry, language, disability (physical or mental health), medical condition, marital status, familial status, age, gender expression, sexual orientation, source of income, or political affiliation. Veterans will be free from retaliation

Contractor to provide evidence of annual training required by VAMC, reports violations per VA Directive 6500.6.

All Contracted employees comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA.

Direct observation Favorable contactor performance evaluation.

Immediate removal from contract

Immediate removal from contract

1.IV h It is expected that Contractor beds will be maintained at an average minimum of an 80% occupancy rate but at a preferred rate of 100% as calculated based upon number of beds available per quarter. If this rate is not consistently attained, a corrective Action Plan (CAP) will be developed by the Contractor as part of the QASP and/or process improvement plan in consultation with the VA Contracting Office and VA Liaison.

Contractors will maintain occupancy by engaging in outreach services and will be knowledgeable about outreach best practices generally accepted in the community.

Daily Census (including nightly signoff) to verify Veteran’s attendance is submitted to the VA Liaison daily

Additional discharge requirements include ensuring follow-up appointments are scheduled prior to discharge and if/when needed permanent housing will be the primary discharge goal for every Veteran.

All Veterans must have a discharge plan within 72 business hours of admission. Although discharge planning should have primary goals of permanent housing, referrals to lower levels of care may be required, based on the Veteran’s clinical needs and housing readiness.

Contractor will provide discharge planning case management support so that the veteran can achieve housing goals; including but not limited to:

-Assistance obtaining income documentation -Assistance obtaining personal identification -Assistance applying for housing programs or public assistance programs, such as Medicare or Medicaid as appropriate -Assistance applying to transitional housing referrals may include VA GPD housing programs, community transitional housing programs, residential inpatient programs, and/or other Contracted Residential Service programs.

All final discharge summaries/HOMES exit forms will be provided to the VA Liaison within 24 business hours of discharge.

Contractor’s case management written bi-weekly reports The report should contain, at minimum, the following information: referrals, status of referrals, veteran’s readiness and response to care, discharge trends

VA Homeless Performances Measure Scorecard

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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.

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.

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.

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 POC and the CO determines formal written communication is required, the POC 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 (POC or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting.

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

10. POC AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

POC NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

Quality Assurance Surveillance Plan (QASP)

CONTRACT DISCREPANCY REPORT

5. DATES:

6. ISSUE(S) IDENTIFIED:

Describe in detail. Include reference to PWS Directive; attach continuation sheet, if necessary

10. CONTRACTOR RESPONSE AS TO CAUSE 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

13. GOVERNMENT ACTIONS

14. CLOSE OUT

CONTRACTOR NOTIFIED

POC

CONTRACTING OFFICE

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