Attachment I - QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

CONTRACT RESIDENTIAL

FOR: Contract Residential; Health Care for Homeless Veterans Services

CONTRACT DESCRIPTION: The John D. Dingell VA Medical Center located in Detroit, MI, requires a contractor who can provide care, treatment and rehabilitative services to homeless veterans with or without a mental health or substance use disorder diagnosis in a community-based treatment facility offering a safe and secure environment that supports their rehabilitation goals. The Contractor will be required to provide therapeutic and rehabilitative services but will not be required to provide detoxification or other hospital level treatment – those services will be provided by the VA at VA facilities.

CONTRACT NUMBER: TBD

CONTRACTOR’S NAME: TBD

1. PURPOSE

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

i. What will be monitored.

ii. How monitoring will take place.

iii. Who will conduct the monitoring?

iv. How monitoring efforts and results will be documented.

b. This Quality Assurance Surveillance Plan (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.

c. This Quality Assurance Surveillance Plan (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.

Organization/Agency: NCO 10 Contracting Office – Healthcare Resources Team Assigned CO: Brandi Holland | brandi.holland2@va.gov Assigned Contract Specialist: Jennifer Bowden | jennifer.bowden@va.gov

b. Contracting Officer’s Technical Representative (COR) - The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The Contracting Officer’s Representative (COR) shall keep a quality assurance file.

The Contracting Officer’s Representative (COR) is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

mailto:brandi.holland2@va.gov mailto:jennifer.bowden@va.gov

Assigned Primary Contracting Officer’s Representative (COR):

Yolanda Spencer-Dandridge, Chief, HCHV Services/Contract Officer Representative 313-576-4854 | yolanda.spencer-dandridge@va.gov John D. Dingell VAMC | 4646 John R. | Detroit, Michigan 48021

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

a. Program Manager -_______________________________________

b. Other Contractor Personnel - _______________________________

Title: __________________________________________________

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 Standard

Performance Threshold/

Acceptable Quality Level

Method of Surveillance

Emergency Housing Facilities & Management:

1. Facilities meet fire and safety code imposed by the State law, and the Life Safety Code of the National Fire and Protection Association.

2. Facilities meet the Americans with Disabilities Act (ADA) guidelines for accessible accommodations for Veterans with physical limitations or impairments.

3. Facilities are licensed as required for the particular setting under State or Federal authority, and must meet all applicable local, state, and Federal requirements concerning licensing and health codes.

100% during annual rating period

Annual VA team inspection.

Impromptu Liaison inspection

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s facility.

mailto:yolanda.spencer-dandridge@va.gov

4. Facilities ensure the safety and privacy (HIPPA compliant) of Veterans and/or Veteran families with a clean and comfortable environment of care.

Facility provides:

a.) a designated bed that is used exclusively by the individual Veteran from the time of admission to the time of discharge;

situated in a room that affords the Veteran safety, privacy and security;

b.) a safe and secure place for each Veteran to store his/her belongings that is readily accessible to the Veteran (such as a locking closet, a locking armoire, a locker, etc.);

c.) laundry facilities for Veterans to do their own laundry at no cost to the Veteran.

5. Facilities will ensure additional safety and privacy mechanisms for female veterans by:

a) Separate and secure sleeping arrangement (unit or wing) for each gender

b) Separate and secure bathroom arrangements for each gender

c) Screening procedures and criteria for sex offenders and

d) Common areas (lounges, laundry rooms, group rooms) with appropriate security arrangements.

6. Facility provides a safe and sober environment for all residents.

7. Facility provides appetizing, nutritionally adequate meals three times per day in a setting that encourages social interaction and nutritious snacks between meals and at bedtime must be available for those requiring or desiring additional food, when it is not medically contraindicated. All food is stored, handled and served in a safe and sanitary manner that meets accepted industry standards and guidelines.

Staffing & Supportive Services:

1.Contractor staffing provides:

a. A full-time administrative staff member on duty or residing at the residence and available for emergencies 24 hours a day, 7 days a week. Note: security staff alone, whether employed directly by the contractor or subcontracted by the contractor, is not sufficient to meet this requirement.

b. Sufficient case management personnel to provide

100% of referred cases

Veteran interview and/or administrative team meetings.

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s records.

Review of staff logs/sign-in and sign-out sheets.

the necessary therapeutic interventions and activities and to ensure a meaningful integration of these efforts with those provided in the residential setting.

Each Veteran must have an assigned case manager responsible for coordinating and providing the supportive services specified in the contract. Supportive Services based on Veteran’s identified goals will begin within 24 hours of admission and will be modified as needed throughout residential stay.

c. Evidence that the contractor site is supervised/monitored 24 hours per day 7 days per week.

d. At least one staff or security member with Cardio-Pulmonary Resuscitation (CPR) certification on site and available in an emergency during each shift, 24 hours per day.

2. Contractor provides coordinated case management to include psychosocial assessment and individual service planning; assisting Veterans with appointments, paperwork and linkages to needed

100% of randomly selected cases

Annual review of staff training-certifications.

Monthly Veteran record reviews resources;

transportation to appointments;

medication management.

3. Contractor provides daily structured groups and activities to promote skills building and healthy lifestyle.

Quarterly Veteran record reviews

Records and Reports: 1. Contractor provides daily sign-in sheets signed by Veterans to verify services and invoicing. Invoicing shall be submitted within seven days of the month’s end.

2. Contractor will provide daily notification or admissions and discharges.

3. Contractor maintains individual client records to include:

a. Initial psychosocial assessment

b. Individual Service Plan

c. Progress notes for each client contact

d. Documentation of Veteran participation in daily group activities

e. Updated Individual Service Plans

f. Discharge summaries submitted within 24 hours.

g. Documented outreach should be conducted weekly, no less than 20 hours a month.

100% during quarterly rating period reviewed.

Quarterly Veteran record review.

Monthly review for fiscal/billing documentation

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor records.

Quarterly Review of Veteran records

4. Timely entry of Veteran data into HMIS System.

Housing Placement: A. In accordance with VA National Performance Monitors 55% exits to permanent housing.

B. Negative exits will not be greater than 20%

55% or greater Quarterly Veteran record reviews & NEPEC data

5. 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 yearly 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.

h) Periodically, COR will review charts of homeless Veterans to ensure accuracy with respect to length of stay, outcomes, and services provided by the Contractor.

6. 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.

All elements of the Performance Work Schedule are consistently met, prior to due dates, zero gaps in locum coverage and zero substantiated complaints on locum psychiatrist performance.

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.

Majority of the elements of the Performance Work Schedule are consistently met, prior to due dates, minimum gaps in locum coverage occur and no more than one substantiated compliant on locum psychiatrist performance.

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.

Elements of the Performance Work Schedule are consistently met, due dates are met, minimum gaps in locum coverage occur and no more than one substantiated compliant on a specific locum psychiatrist performance.

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.

Elements of the Performance Work Schedule are met, due dates are met within a reasonable time frame with plan of correction, gaps in locum coverage are reoccurring yet short, and substantiated complaints on locum psychiatrist performance are effectively managed to the government’s satisfaction.

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.

Elements of the Performance Work Schedule are not met to the government’s satisfaction, ineffective plans of resolution exist for missed due dates, gaps in locum coverage are reoccurring and allow for gaps in direct patient care coverage, and substantiated complaints on locum psychiatrist performance are ineffectively managed to the government’s satisfaction.

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 Environmental

Deficiency Reports, or letters).

7. 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. The COR shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. 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 must 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.

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

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings shall be conducted quarterly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s files.

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. The COR shall meet with the Contractor semi-annually to assess performance.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

COR NAME/TITLE DATE

CONTRACTOR NAME/TITLE DATE