Attachment D4 QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

EMERGENCY SHELTER BED SERVICES, OFFENDER

ALEDA E. LUTZ VA MEDICAL CENTER

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. 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: Robert Kay

Organization or Agency: Contracting, Department of Veterans Affairs

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 Primary COR: Carly Huffman LMSW, CCFC, COR

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – Carly Huffman LMSW, CCFC, COR

b. Other Contractor Personnel - None

4. 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 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 Para in

SOW

Indicator/Performa nce Standard

Standard for Quality

Level

Acceptable

Quality Level

Method of

Surveillance Incentive

1. Case

Record

B.1.

The contractor shall maintain an individual case record on each veteran under this contract. The contractor must comply with the requirements of the

"Confidentiality_ of Certain

Medical

Records"

(38USC7732),

and the

"Confidentiality of Alcohol and

Drug

Abuse Patient

Records" (42 CFR, Part II) when appropriate.

100% 95%

Monthly checks of

Veterans Records by COR.

Positive past performance rating.

2.

Therapeutic

Services

Part II

A. 2. a.

Therapeutic Services provided by contractor to include group therapy, social skills training, AA, NA, vocational counseling as appropriate.

100% 95%

Periodic Review of

Case Files and spot checks of services.

Positive past

3.

Discharge

Plans

Part II

A. 2. j.

Upon review by

COR, appropriate discharge plans are made for Homeless

Veterans for residential treatment

(including those discharged for non-compliance).

100% 95%% Period Review of

Discharges by COR

Positive past

4. Staffing II.E.1

Sufficient staff in number and position qualifications to carry out the policies, responsibilities and programs of the facility. At a minimum, there must be a full-time administrative staff member his/her designee on duty at the premises or residing at the facility and available for emergencies 24 hours a day, 7 days a week.

100% 95%

Periodic Spot

Checks by COR and Staff

Positive past

5. Meals II.A.1.c.

Veterans shall have appetizing, nutritional meals provided in a setting that encourages social interaction.

Meals shall 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.

100% 95%

Periodic Spot

Checks by COR and Staff. Veteran

Complaints.

Positive past

5. INCENTIVES

The Government shall use Positive Performance Ratings as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The Program Manager shall use the surveillance methods listed in the administration of this QASP. Prior to the award of a contract and annually during the contract term, a multidisciplinary VA team shall conduct a survey of the Contractor’s facilities for Veterans’ food, shelter, and therapeutic services to assure the Contractor provides quality care in a safe environment. Inspections will also be carried out periodically as part of the

Quality Assurance Surveillance Plan and at such other times as deemed necessary by the

Contracting Officer.

The inspection of the Contractor facilities will include the following:

a) General observation of residents to determine if they maintain an acceptable level of personal hygiene and grooming.

b) Assessment of whether the facility meets applicable fire, safety and sanitation standards.

c) Determining whether the facility is in attractive surroundings conducive to social interaction and the fullest development of the resident's rehabilitative potential.

d) Observation of facility operations to see if appropriate organized activity programs are available during waking hours (including evenings) and degree to which a high level of activity is observed in the facility, such as individual professional counseling, physical activities, assistance with health and personal hygiene.

e) Seeking evidence of facility-community interaction, demonstrated by the nature of scheduled activities or by information about resident flow out of the facility, e.g., community activities, volunteers, local consumer services, etc.

f) Observation of staff behavior and interaction with residents to determine if they convey an attitude of genuine concern, caring and safety.

g) Inspecting the types of meals and other nutrition provided to residents to see if appetizing, nutritionally adequate meals are provided in a setting, which encourages social interaction and if nutritious snacks between meals and bedtime are available for those requiring or desiring additional food, when it is not medically contraindicated.

Making a spot check of Veterans’ records to ensure accuracy with respect to Veterans’ length of stay and services provided to the Veterans.

7. 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:

• Excellent

• Very good

• Satisfactory

• Marginal **

• Poor**

** Documentation with exact dates, times (specifics, not just generalization of what problems are) if ranked lower than satisfactory.

Contractor Representative

Carly Huffman, COR

Contracting Officer Representative

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