Attachment E - QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Contract:

Contractor:

The contractor’s performance will be evaluated in accordance with the following QASP.

Contract Description: Medical Respite Transitional Housing for Homeless Veterans

The Contractor will be expected to provide safe community-based transitional housing and quality services for homeless Veterans.

Supportive services provided include room and board, transportation, case management, life skills training, sobriety maintenance and mental health and medical recovery education, vocational and housing counseling services to aid the Veterans in reaching goals of attaining permanent housing.

1. Quality Assurance Surveillance Plan

a. Purpose

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

• What shall be monitored

• How monitoring shall take place

• Who shall conduct the monitoring

• How monitoring efforts and results shall 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.

Quality Assurance Surveillance Plan (QASP)

Contract #:

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.

b. Government Roles and Responsibilities

i. The following personnel shall oversee and coordinate surveillance activities.

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.

Contracting Officer:

ii. 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.

COR:

Alternate COR:

c. Contractor Representatives

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

Name:_________________________________

Title:__________________________________

Contact:________________________________

Name:_________________________________

Title:__________________________________

Contact:________________________________

d. 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 are listed below. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Measures PWS

Reference

Indicator Standard Acceptable

Quality

Level

Method of

Surveillance

Comments

BASIC

SERVICES

2.a Room and

Board

Housing accommodations which are accessible to the Veteran 24 hours per day, 7 days per week.

Accommodations include a bed and other furnishings, such as a dresser, storage locker or designated secured space, and personal linens (pillows, sheets, blankets, towels/washcloths, etc.). The furnishings shall be maintained in good working condition.

100% Direct

Observation by

COR/Veteran

Feedback

BASIC

SERVICES

2.b Menus/

Nutrition

Nutrition including at least 3 appetizing, nutritionally adequate meals per day, 7 days per week and availability of snacks of nourishing quality

(e.g. fruits, vegetables, protein sources), between meals and at bedtime, with appropriate medical and cultural accommodations.

100% Direct

Observation by

2.c Laundry

Facilities

Laundry facilities and detergent for residents to do their own laundry or to have laundry done, at no charge to the Veteran at minimum on time per week.

95% Direct

Observation by

2.e Therapeutic and

Rehabilitative

Services

Quality case management and therapeutic services outlined in an individualized, person-centered care plan developed collaboratively. New plans are completed within 5 business days of Veteran’s admission and all plans are updated monthly.

95% Direct

Observation by

COR/Veteran

Feedback/Chart reviews

2.e)i Therapeutic and

Rehabilitative

Services

The Contractor shall engage the

Veteran in a collaborative psychosocial assessment to inform the initial plan of care.

The psychosocial assessment and initial care plan are expected to be completed within 5 business days of Veteran's admission to the program and are documented in the Veteran’s chart.

100% Direct

Observation by

COR/Veteran

2.e)v, 2.e)vi

Therapeutic and

Rehabilitative

Services

The Contractor shall provide individual case management meetings at least once per week that focus, at minimum, on housing search and stabilization, income and financial planning, self-care and adaptive coping skills, any necessary coordination of ongoing participation in care provided by

VA or community medical, mental health, and/or substance use disorder providers, and ongoing discharge planning.

95% Direct

Observation by

COR/Veteran

Case management meetings are appropriately document in the

Veteran’s chart. Reasons for any missed meetings are also documented in the Veteran’s chart.

Special attention will be made to address High Suicide Risk

(HSR) Veterans and contracted case manager will review the

HSR Safety Plans with these

Veteran on at least a monthly basis with the review documented in the Veteran’s chart.

BASIC

SERVICES

2.h Medication

Monitoring

Monitoring and safe storage of all Veteran medications to include storage in a medication room behind two locks, properly labeled, and logged. Medication administration records reflect at least weekly medication checks by staff and are signed by

Veterans and staff.

95% Direct

Observation by

COR/Contractor

Report/Veteran

Report/Chart

TRANSPOR-

TATION

2.j Transportation Transportation services are provided for admission to the facility and for all care-plan-related appointments, at no additional cost to the

Government and at no cost to the

Veteran. Care-plan-related

95% Direct

Observation by appointments include all items identified in the PWS

STATUS AT

DISCHARGE

7.b Housing, Employment, Income, and

Clinical

Improvement

Status at Exit

The Contractor will complete

HOMES Residential Treatment

Exit Form at the time of program discharge. The completed form will be submitted to the VA

Liaison/COR or designee within

2 business days of a Veteran discharge.

95% Direct

Observation by

COR/Contractor

Report/Veteran

Report

HCHV

Performance

Measures

2.o Performance

Measures

The Contract program will be expected to meet the minimum target values for HCHV performance metrics as listed below.

i. HCHV1 - % of exits to permanent housing >55%

(exemption for medical respite program, tracked for information and planning purposes)

ii. HCHV2 - % Negative exits

<20%

iii. Bed occupancy – 85% or greater

iv. Length of stay ≤60 days

Meets or exceeds standard for this quarter

HOMES Data

QUALITY

CARE

6.d, 6.h, 6.e

Absences &

Cancellations

The Contractor shall notify the authorizing VA of any Veteran absences from the facility.

Notice of scheduled absences should be submitted to the VA

Liaison/COR or designee prior to the absence and notice of unscheduled absences should be submitted within 24 hours of the missed curfew.

The Contractor shall be responsible for notifying the VA

Liaison/COR or designee within

1 business day that a discharge has occurred and providing the written report of the discharge within 2 business days.

The contractor shall only bill for absent days as approved by VA

Liaison/COR in accordance with the requirements of the PWS.

95% Direct

Observation by

COR/ written communication from Contractor

DOCUMENT-

ATION

7.f Veteran census

The Contractor shall maintain a daily census sign-in sheet to verify the Veteran’s attendance in the program on a daily basis.

The contractor shall be responsible for collecting

Veteran participant signatures on a daily basis such that the census is updated in real time. All excused and unexcused absences shall be clearly documented on

100% Direct

Observation by

COR/COR

monitoring/written the sign-in sheet, including the reason for the excused absence.

This information is to be provided to the VA

Liaison/COR or designee upon request and as a part of the monthly billing process.

6.a, 6.b Length of Stay The length of stay at the

Contractor facility will be initially authorized for up to 60 days. Some Veterans may be considered for extensions of their time in the program up to a total length of stay of 6 months, depending on the needs of the

Veteran. The contractor shall request such extensions in writing at least 5 business days prior to the 60th day or the expiring extension.

95% Direct

Observation by

COR/COR

monitoring/written

6.c Length of Stay The Contractor is expected to complete routine clinical reviews to determine the continued need for medically enhanced services for each Veteran. The Contractor is required to notify the VA

Liaison/COR or designee of a

Veteran’s readiness for step-down placement within 1 business day of this

95% Direct

Observation by

COR/COR

monitoring/written determination, even if prior to the 60th day of the stay.

QUALITY

CARE

3.a.ii Personnel At least one staff member is on duty on the premises providing awake supervision of residents and staff 24 hours per day, 7 days per week. This staff member must have sufficient professional experience and authority to make decisions regarding the facility and the residents and/or must have the ability to contact an offsite administrator in case of an emergency 24 hours per day, 7 days per week.

95% Direct

Observation by

COR/COR

monitoring

3.iii, 3.iv Personnel/

Licensing

Case management staff is sufficient to meet the needs of the Veterans and the requirements of the program.

The staff has the appropriate education, experience, training, and credentials required by the

PWS. If licensed, the license is active and in good standing.

Sufficient medical personnel with appropriate experience, 100% Direct

Observation by

COR/COR

monitoring licensing, and credentialing are available to meet the medical needs of Veterans placed in the medical respite program.

Typically, a registered nurse or higher medical professional will be on site daily. Medical staff licenses are active and in good standing.

VETERAN

SAFETY

8.b Incident

Reporting

All critical incidents, as identified in the PWS, involving

Veterans in the contract program must be reported to the VA within 24 hours. A written report, including responses and follow-up actions, is sent to the

VA Liaison/COR within 2 business days.

95% Direct

Observation by

COR/COR

monitoring and random inspection

(auditing) /written

POLICY 4.l, 3.f, 3.g

Confidentiality The facility must provide secure storage for all Veterans’ personal health information in a locked room and locked filing cabinet.

Personal health information stored electronically must be in accordance with current federal standards.

Contractor staff complete training related to privacy and

HIPAA and comply with all related laws, regulations, policies and procedures.

95% Direct

Observation by

COR/Veteran

Feedback and random inspection

(auditing)

VETERAN

SATISFACT-

ION

10.b Complaints

Handling

The Contractor shall notify the

VA Liaison/COR or designee of all Veteran complaints within 24 hours. All complaints shall be investigated promptly. After investigation and disposition, the

Contractor shall respond to the

VA Liaison/COR or designee within five (5) business days with the results of the investigation and the proposed resolution or course of action.

95% Direct

Observation by

COR/Veteran

Feedback, User survey, and random inspection

(auditing)

FACILITY 4.e, 4.k, 4i

Facility The building must meet the requirements of the applicable residential occupancy chapters of the current version of NFPA

101, National Fire Protection

Association’s Life Safety Code.

Portable fire extinguishers shall be installed at the facility and inspected, tested, and maintained in accordance with the applicable NFPA fire codes.

The facility shall be kept clean, free of dirt, grime, mold, clutter, and/or other hazardous substances and damage that noticeably detracts from the overall appearance.

95% Monthly environmental of care rounds conducted by VA staff; annual VA multidisciplinary inspection. Direct

Observation by

The facility shall be equipped with operational air conditioning

/heating systems. In the event these systems are not operational for any reason, it is expected that the Contractor have the system repaired and operational within 5 business days. During extreme weather conditions if the air conditioning or heating system cannot be repaired in 24 hours, alternate accommodations must be arranged.

The facility shall be equipped with first aid equipment, necessary personal protective equipment (PPE) as identified in the PWS.

SAFETY 9.g, 9.i, 9.j, 9.k

Safety/Policy The Contractor shall maintain disaster and emergency plans with written protocols that are posted to guide staff responses to crises

The Contractor shall develop rules that are simple, consistent, and should focus on staff and resident safety. The rules shall be enforceable, relate to the living situation, and provide opportunities for engagement.

Rules should be clearly

95% Direct

Observation by

COR and Monthly environmental of care rounds conducted by VA staff; annual VA multidisciplinary inspection communicated to Veterans at admission with reminders given as needed. When possible, infractions are to be used to engage Veterans, not simply as grounds for service termination or discharge.

The facility shall have adequate policies and procedures, which are enforced, to ensure that drugs, weapons, and other similar items are not permitted on the premises.

Regular room checks shall occur, at least weekly, with a strong focus on maintaining a safe environment that promotes the well-being of all Veterans.

*NOTE: All data will be collected by COR.

Follow up needed:

None needed

Safety to inspect facility

Dietician to inspect kitchen

Nursing to follow up medication management

COR to review area on next visit:

Corrective Action Plans:

Review Date:

Deficiencies noted in ________________________ have not been corrected.

Next Inspection:

Staff signature: __________________________________ Date: ________________

COR signature: __________________________________ Date: ________________

a. Incentives/Disincentives

The Government shall use favorable contractor performance evaluations as incentives. The Government shall report unfavorable contractor performance as disincentives. Disincentives shall include documentation of any performance issues. If repetitive or consistent the government shall take further corrective action or begin termination procedures.

Incentives/disincentives shall be based on exceeding, meeting, or not meeting performance standards.

b. Procedures and Methods of Surveillance

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

i. Direct Observation. COR will conduct at a minimum, bi-monthly site surveillance of Contractor Facilities, including direct conversations and feedback from Veterans and Contractor staff.

ii. Complaints. Any complaint data is reviewed by the COR. COR will conduct investigation and provide necessary information of validated complaints to CO. COR will initiate Corrective Action Plan, to be completed by Contractor, as COR deems necessary.

iii. User Survey. Veterans in Contractor program are provided anonymous survey to complete prior to discharge from program (see USPEQ section). Contractors may implement additional surveys, as needed.

iv. PERIODIC INSPECTION. COR will conduct monthly site inspections including facilities, chart review, medication administration/record keeping, and nutrition areas of Contractor program. Some inspections may be unannounced.

c. 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 to rate performance through each period of performance under the contract. The ratings will be recorded in the Contract Performance Assessment Reporting System (CPARS) on an annual basis.

Performance Rating

Definition

Exceptional Performance meets contractual requirements and exceeds many to the government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

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.

Marginal Performance does not meet some contractual requirements.

The contractual performance of the element or sub-element being evaluated 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.

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 contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

d. Documenting Performance

I. ACCEPTABLE PERFORMANCE

The Government will document positive performance in the Contractor Performance Assessment Reporting System

(CPARS).

II. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall inform the Contracting Officer (CO). This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR and the CO shall document the discussion and place it in their respective file.

Performance deficiencies may be reported to the Contractor with the use of the Corrective Action Report (CAR) shown below in the Attachments section. The Corrective Action Report requests corrective action from the Contractor to resolve the subject issues of the report. The report and the Contractor’s response to the report will be retained and may be reflected in the Contractor’s performance assessment record (CPAR) for the applicable period of performance.

e. Frequency of Measurement

During contract performance, the COR will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

The COR shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

SIGNATURES:

Date

Contracting Officer, NCO 6

COR

Alternate COR

Name: Date

Contractor Representative

QASP ATTACHMENTS

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY MAJOR MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

ACCEPTED REJECTED

12. CLOSE DATE