ATTACHMENT D1 QUALITY ASSURANCE SURVEILLANCE PLAN.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Substance Use Disorder Services (SUDS), Intensive Outpatient Program Housing

Contract Number: 667-24-2-812-0064

Contract Description: The contractor shall provide 19 Residential Contract beds for

Veterans enrolled in the SUDS Program. The contractor will also provide therapeutic and supportive services, room and board, and laundry facilities.

Contractor’s name: Overton Brooks VA Medical Center (hereafter referred to as the contractor).

1. PURPOSE

To specify the systematic methods for evaluating performance of the Substance Use

Disorder Services (SUDS) Intensive Outpatient Program Housing.

A. Scope:

SUDS Intensive Outpatient Program Housing contract will provide room, board, transportation, and other SUDS treatment supportive services to patients enrolled in SUDS. They will provide the following:

ROOM AND BOARD: Room and Board to include a bed and other furnishings such as a dresser, storage, and personal linens (towels and bed sheets). Meals to include three (3) nutritionally adequate meals a day, 7 days a week and availability of nutritious snacks between meals and bedtime for those requiring or desiring additional food, when it is not medically contraindicated.

LAUNDRY FACILITIES: Laundry facilities for residents to do their own laundry or to have laundry done. Coinage will be available for those without adequate funds to complete laundry tasks.

THERAPEUTIC AND SUPPORTIVE SERVICES: An introduction to all available recovery-based programs, supportive social activities, and individual counseling as required to facilitate overcoming resistance to engagement in treatment or rehabilitative services. The contractor shall furnish:

(1) Monthly meeting for collaboration with the VA program staff, IOP

Veterans, and a representative of housing per Joint Commission recommendations.

(2) Contractor will provide supportive psychosocial services.

(3) A drug and alcohol-free setting and consistent support for drug and alcohol-free lifestyle. The contractor will have a system to do admission and random breathalyzers as needed. The Veterans

Affairs Medical Center (VAMC) will provide random drug screening and additional screenings upon request, in a timely manner.

(4) Contract will utilize process of both signing in and out of the facility.

a IOP veterans are to be routinely monitored for presence within housing.

b Veterans are provided limited time to be off-site by signing out with family member or designated person.

c Free time is limited to Saturdays and Sundays Noon thru 5 pm.

d Violations are to be reported to SUDS Coordinator next business day.

e Behavior Contracts may be in place which dictate no ability to be signed out.

(5) Assistance to develop responsible living patterns, to maintain an acceptable level of personal hygiene and grooming, and to achieve a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

(6) Support for an alcohol/drug abuse-free lifestyle provided in an environment conducive to social interaction and the fullest development of the resident’s potential.

(7) A program that promotes community interaction. The SUDS

Coordinator and Contract will develop meeting attendance list to ensure Veterans receive a minimum of five off-site meetings to consist of Alcoholics Anonymous, Narcotics Anonymous, and

Celebrate Recovery.

(8) Contract will provide meetings on-site twice per week.

In addition, the Contractor shall collaborate with the VA program staff, who will conduct treatment and discharge planning reflecting a team assessment of health, psychosocial and vocational needs and the involvement of residents’ families and appropriate community resources in resolving problems and setting goals.

The Contractor shall maintain an individual record on each veteran placed in the facility by the SUDS Coordinator. The Contractor shall comply with the requirements of the Confidentiality of Medical Records (38 USC 4132) and the

Confidentiality of Alcohol and Drug use of a veteran (42 CFR part II) when appropriate and is considered a part of this contract. All case records will be made available on a need-to-know basis to appropriate VAMC staff members involved with the treatment program of the veteran concerned.

B. Monitoring of Facility and Program:

Prior to the award of a contract and annually, quarterly during the contract term, and unannounced visits by a multidisciplinary VA team. This team may consist of a social worker, dietitian, registered nurse, a representative of the VA Police, and a

Facilities Management Safety Officer, and other subject matter experts as determined necessary by the medical center director or SUDS Coordinator. A survey of the Contractor’s facilities used to provide Veterans food, shelter, and therapeutic services to assure the facility provides quality care in a safe environment will be conducted during these inspections. Inspections may also be carried out at such other times as deemed necessary by the Department of

Veterans Affairs.

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: Billy Morris

Organization or Agency: Department of Veterans Affairs, Network Contracting Office

16, Overton Brooks VA Medical Center

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: Anna Michelle Talley, LCSW-BACS, COR, SUDS Coordinator

c. Other Key Government Personnel – Other SUDS staff

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager - Anna Michelle Talley, LCSW-BACS, COR, SUDS Coordinator

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, does meet or does not meet these standards.

The Performance Requirements Summary Matrix, paragraph B.3 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

1.1

Therapeutic and Supportive Services individualized as stated in the plan developed by the contractor, with input from the Veteran and VA SUDS Program Coordinator or designee.

Daily 100%

Observation, random inspection and progress review.

Continued Ordering Period

1.1

Drug and alcohol-free setting and consistent support for drug and alcohol-free lifestyle. To include random breathalyzers as needed.

Daily 100% Observation and random inspection.

Continued Ordering Period

1.2

Provide housing and supportive services free from religious discrimination.

daily 100% Observation and random inspection.

Continued Ordering

Period

1.3

Provide each Veteran appropriate space and security for themselves and their belonging.

At all times 100%

Observation and random inspection.

Continued Ordering

Period

Medications

4.5.1

Any refusal of medication will be reported during daily morning report to SUDS staff.

Daily 100% Observation and random inspection.

Continued Ordering

Period

4.5.2 Provide close

monitoring of medication.

Daily 100%

Observation and random inspection.

Continued Ordering

Period

Specialized Medical Resources Provided to VA Medical Center

5.9 Confidentiality of

all patient information.

Daily 100%

Observation and random inspection.

Continued Ordering

Period

Facility

6.3

Laundry Facilities Availability of laundry facilities for residents to do their own laundry.

Washers and dryers will be provided at no cost to veteran.

Daily 100% Observation and random inspection.

Continued Ordering Period

6.5.2.1 Compliant with

the NFPA life safety code.

At all times 100%

Observation and random inspection.

Continued

6.5.2.1

Compliant with the American with Disabilities

Act.

At all times 100%

Observation and random inspection.

Continued Ordering

Period and past performance and/or any other incentive that was proposed in your solution.>

6.5.1.4

Provides adequate heating and or cooling of facility and electrical sources for use.

At all times 100%

Observation and random inspection.

Continued

5. INCENTIVES

The Government shall use Exercise of Option Periods as incentives.

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.

Direct observation, periodic inspections, and progress meetings.

a. DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.) 1-14

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.) 1-14

c. PROGRESS MEETINGS. Monthly meeting with Contracting staff and Veterans.

3 & 6

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:

Quarterly Reports will be used to reflect the rating of “exceeds, meets, or does not meet a given standard. These reports will be combined to incorporate into the annual inspection assessment.

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 must 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 as needed to assess performance and shall provide a written assessment.

Signature –Program Manager

Signature – Contracting Officer’s Representative

Signature – Contracting Officer