ATTACHMENT D.1_QASP-FINAL- RESIDENTIAL SERVICES- COMMUNITY BASED EMERGENCY RESIDENTIAL SERVICES.pdf

ATTACHMENT D.1 – Quality Assurance Surveillance Plan (QASP)

Transitional Residential Treatment and Emergency Housing Services for the VA Health Care for Homeless Veterans (HCHV) Program – Houston, TX

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: Stephanie Keo

Organization or Agency: Department of Veterans Affairs (VA), Network Contracting Office 16 (NCO 16)

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: Gabrielle Profit

Organization or Agency: Michael E. DeBakey Department of Veterans Affairs Medical Center (MEDVAMC), Houston, TX.

3. CONTRACTOR REPRESENTATIVES

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

Primary: Gabrielle Profit, Gabrielle.profit@va.gov, 713-560-9479 mailto:Gabrielle.profit@va.gov,

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 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.

QUALITY ASSURANCE SURVEILLANCE PLAN

ID

Indicator /

Performance Standard Section in PWS

Acceptable

Quality

Level

Method of

Surveillance Incentive / Disincentive

Provider Quality

Performance

(Requirement)

Section 3.3

Contractor

Furnished Items and

Responsibilities

95% Direct

Observation

Past performance/ Unfavorable contractor performance evaluation. A Contract

Discrepancy Report (CDR) will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Qualifications of Key

Personnel.

B.3.3.4 Personnel 95% Direct

Observation

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Contractor shall notify the VA of all Absences and Cancellations.

B.3.7

Absences and

Cancellation

95%

Periodic sampling of time and attendance sheets

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Performance Standard Section in PWS

Acceptable

Quality

Level

Method of

Surveillance Incentive / Disincentive

Contractor shall treat all

Veterans with dignity and respect.

B.3.8

Contractor/Staff

Conduct/Complaints

Handling

95% Direct

Observation

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Contractor shall provide

Veterans with transportation to and from the CAVHS for appointments.

B.3.2

Scope of Work 95%

Direct

Observation, Periodic and

Random sampling

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Contractor shall maintain its facilities in accordance with all fir and safety codes.

B.3.10

Facility 95%

Direct

Observation, Periodic and

Random sampling

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor

Contractor shall pass annual facility inspections.

B.3.11

Inspection of Facility

Program

95%

Direct

Observation, Periodic and

Random sampling

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Contractor shall make maximum effort to ensure Veterans are placed into Permanent

Housing.

Section 3.3

Contractor

Furnished Items and

Responsibilities 55%

Direct

Observation, Periodic and

Random sampling

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in performance evaluation

Performance Standard Section in PWS

Acceptable

Quality

Level

Method of

Surveillance Incentive / Disincentive

The contractor shall only receive referrals that are approved by the VA for emergency/transitional housing services.

B.3.6

Central Arkansas

Veterans’ healthcare system will provide.

95% Direct

Observation

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Contractor shall performance services outlined in Security

Incident Investigation

Section.

B.3.15.6

Security Incident

Investigation

95%

Periodic

Sampling, Direct

Observation, and Random

Sampling

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in unfavorable contractor performance evaluation.

Contractor shall perform services as outlined in the Liquidated Damages for Data Breach Section.

B.3.15.7

Liquidated Damages for

Data Breach

98%

Periodic

Sampling, Direct

Observation, and

Random

Sampling.

Past performance/ Unfavorable contractor performance evaluation. A CDR will be issued on the first instance of failure to provide the acceptable level of service. Two or more issued CDRs may result in

5. INCENTIVES/RATING STANDARDS

Incentives will 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. Surveillance will be accomplished by physically observing contract performance.

b. PERIODIC INSPECTION. Inspections scheduled and reported annually per COR delegation or as needed. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Customer complaint data is compiled quarterly and reviewed by the contractor employee’s designated director of services – any validated complaints against a

Contractor that are not resolved within the required seven day period will be further investigated. Review of contractor reports.

d. RANDOM SAMPLING. Patient treatment files to be reviewed will be randomly selected and cover the period of services. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor.

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 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.

c. 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. See Sample CDR below.

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED b. RETURNED

BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

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 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:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE