ATTACHMENT I - QUALITY ASSURANCE.docx

QUALITY ASSURANCE

SURVEILLANCE PLAN FY___

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

Contracted Emergency Residential Services (CERS)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contracted programs’ activities while implementing this Statement of Work (SOW). It is designed to provide an effective surveillance method of monitoring Contractor performance..

The QASP provides a systematic method to evaluate the services the Contracted Program is required to furnish.

This QASP is based on the premise, the Government desires to maintain a quality standard in providing emergency housing and supportive services to its patients. The resulting contract is considered the best means of achieving that objective.

PURPOSE

The Contracted Program, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. The role of the Government is quality assurance to ensure contract standards are achieved.

This QASP does not detail how the Contracted Program accomplishes the work. Rather, the QASP is created with the premise that the Contracted Program 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. In this contract the quality control program is the driver for product quality. The Contracted Program is required to develop a comprehensive program of inspections and monitoring actions. The first major step to ensuring a “self-correcting” contract is to ensure that the quality control program approved at the beginning of the contract provides the measures needed to lead the Contracted Program to success. This QASP explains the following:

· What shall be monitored.

· How monitoring shall take place.

· How often monitoring shall take place.

· Who shall conduct the monitoring.

· How monitoring efforts and results shall be documented.

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 Contracted Program. Copies of the original QASP and revisions shall be provided to the Contractor and Government officials implementing surveillance activities.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the Contracted Program exceeds, meets or does not meet these standards. The Performance Requirements Summary Matrix is incorporated within this QASP to include performance standards and disincentives. The Government shall use these standards to determine Contracted performance and shall compare Contracted performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

SURVEILLANCE: The Government quality assurance (QA) person and the COR shall use the surveillance methods listed below in the administration of this QASP.

a. Direct Observation. Direct observation shall be performed periodically or through 100% surveillance. All Performance Standards

b. Periodic Inspection. Evaluate outcomes on a periodic basis. Inspections may be scheduled Daily, Weekly, Monthly, Quarterly, Annually or unscheduled, as required. All Performance Standards

c. Progress or status meetings. All Performance Standards

d. Complaints. Complaints from agency personnel shall be passed to the Contractor's quality control inspector (QCI) for correction. All Performance Standards

STANDARD: Customer complaints shall not exceed the thresholds cited above for each performance objective. The Government’s QA personnel shall notify the contracting officer for appropriate action in accordance with FAR 52.212.4, Contract Terms and Conditions-Commercial Items (May 1997) or the appropriate Inspection of Services clause, if any of the above service areas exceed the customer complaint thresholds.

DOCUMENTING PERFORMANCE

a. Acceptable Performance: The Government shall document 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 shall 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 Contracting Officer (CO). In turn, the CO shall present the CDR to the Contractor’s contracting personnel.

The Contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long after receipt the Contractor has to present this corrective action plan to the COR. The Government shall review the Contractor's corrective action plan to determine acceptability.

Any CDRs will become a part of the supporting documentation for any contractual action deemed necessary by the CO.

SURVEILLANCE: The Government evaluator shall evaluate the services required by each delivery/task order to ensure complete compliance.

PROCEDURES: The Government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the Government evaluator shall notify the CO and/or QCI of the deficiencies within 3 business days and have QCI correct said deficiencies. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the Contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

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 will be conducted quarterly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s files

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

Signature – Contractor Program Manager

Signature – Contracting Officer’s Technical Representative

Signature – Contracting Officer

ADMISSIONS, LENGTH OF STAY, AND DISCHARGES

Occupancy It is expected that Contractor beds will be maintained at an average minimum of an 85% occupancy rate but at a preferred rate of 90% as calculated based upon number of bed nights available per quarter. If this rate is not consistently attained a Performance Improvement Plan (PIP) will be developed by the Contractor as part of the QASP and/or process improvement plan. This will be reviewed weekly during the meeting minutes conference.

· Review of NEPEC data and monthly billing

· Occupancy rates reviewed weekly during meeting minutes conference

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

ADMISSIONS, LENGTH OF STAY, AND DISCHARGES

Outreach Contractor outreach should include street outreach efforts and are not inclusive of Veteran referrals gained through in-reaching at the Welcome Center or other VA clinics.

1. Perform outreach, including street outreach, at community sites 2 x per month to ensure appropriate occupancy

2. Document outreach efforts monthly 100% during quarterly rating period

· Sign-in logs

· Informal review of outreach events

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

THERAPEUTIC AND REHABILIATTIVE SERVICES

Group Activities:

Examples include permanent housing search groups, financial management classes, group therapy, social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling and physical activities as appropriate. The focus of these groups will be to provide Veterans assistance in developing successful living patterns, maintaining an acceptable level of personal hygiene and grooming, and to achieving a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

1. 75% of Veterans will participate in group activities 2x per month. To be led by Contractor, or by outside entity such as AA, agency will monitor and collate sign-in sheets and document in Veteran’s Care Plan and weekly case management meetings.

1.

100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

· Interview with Veterans

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

THERAPEUTIC AND REHABILIATITVE SERVICES

Case Management:

Contracted Program will provide individual case management and/or professional counseling, including counseling on stabilizing housing, increasing income and increased access to medical /mental health treatment through the VA or other agencies. The goals of case management may also focus on developing successful living patterns, maintaining an acceptable level of personal hygiene and grooming, and achieving a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

2. 90% of Veterans who remain in the program will complete an intake with requisite information (see SOW) and written Individual Service Plan (ISP) within one week of program admission.

3. 75% of Veterans will complete a thorough Housing Assessment as outlined in SOW 11.4.1. within 72 hours of program admission.

4. 75% of Veterans will engage in individual case management meetings 4x per month; all updates to Care Plans are documented in the client’s file.

5. 95% HSR Safety Plans are completed by Contractor and VA liaison within one week of admission and reviewed with veteran on a weekly basis

· Care Plan reviews

· Interview with Veterans

· Weekly HSR Safety plan review

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

THERAPEUTIC AND REHABILITATIVE SERVICES

Permanent Housing Search Education provided to Veterans regarding how to obtain low cost housing

1. 95% of Veterans will complete a thorough Housing Assessment within 72 business hours of admission, which will include information outlined in 11.4.1 of SOW.

2. 75% of Veterans will be educated about how to obtain a free credit report

3. 75% of Veterans will be educated about “Tenant Portfolio”

4. 75% of Veterans will participate in educational activities and will be provided resources on permanent housing 4x per month 100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

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

THERPEUTIC AND REHABILITATIVE SERVICES

Financial Planning Contracted Program will provide counseling on means and methods to increase Veteran income through a variety of avenues such as SSI, NSC pension, GA and employment opportunities. Counseling may be performed internally or externally. Counseling or referral records must be kept for both internal counseling and for meetings Veterans participate in off-site.

Employment Services:

Contracted Program will provide a referral to EDD and assist Veteran by providing a job search log with leads when available

1. 100% of eligible Veterans that are unemployable or do not have income will be referred for NSC pension, VA service connection, SSI benefits, and any other financial benefits upon admission.

2. 100% of eligible Veterans will be referred for employment

3. 65% of Veterans will have a Financial Plan developed within 30 days of admission

4. 65% of Veterans will participate in ongoing financial planning groups or individual case management with a focus on increasing income at minimum, 4 x per month

5. 65% of eligible Veterans will participate in employment related activities, such as job fairs, resume writing workshop with a focus on obtaining employment.

100% during quarterly rating period

· Documentation in Care Plan and weekly case management notes

· Care Plan reviews

· Records of Bank Statements

· Proof of income award letters

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

ADMISSIONS, LENGTH OF STAY, AND DISCHARGES

Discharge Planning:

Contracted Program’s case managers will provide assistance with discharge planning for every Veteran. Housing needs will be assessed within five days of admission and resources coordinated for discharge to a successful community placement. Securing permanent housing will be the discharge goal for every Veteran and every effort to meet or exceed the Performance measures will be made.

1. 100% of Veterans must have a discharge plan within two weeks of admission which integrates permanent housing options

2. Performance/TQI Measures:

· HCHV Permanent Housing: 55%

· HCHV Negative Exits: < 20%

· Bed Occupancy 85% or greater

· Length of Stay ≤ 180 Days

· VA Benefit Applications Pending -15%

· Non-VA Benefits Pending -8% 100% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

· Interview with Veterans

· Review of monthly activity calendar

· NEPEC data

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

RECORDS AND REPORTS

Contracted Program will provide collaboration with the VA program staff by conducting a meeting 2-4 times per month. These meetings will be held by Contracted Program Staff and VA program staff to discuss how to coordinate services to clients enrolled in the program, outreach needs, and program development. In addition to working collaboratively with VA clinical staff, the Contracted Program will submit accurate billing to VA Payment Center by the 7th of each month.

Procedure for daily accountability:

Veterans to sign in daily during their stay for accountability. Sign-in sheets to be verified by program staff, signed and returned to VA staff for billing verification.

Procedure for intakes:

The Contractor shall provide Veterans SAME DAY admission to housing and services Monday through Sunday from 8am to 8pm.Veteran healthcare eligibility and date of admission shall be approved and confirmed by the VAGLAHS HCHV Liaison within 2 business days.

The VA liaison is ultimately responsible for confirming a Veterans healthcare eligibility within 24-hours of admission notification.

1) Admission information to be provided to VA staff within 24 business hours of admission. Confirmation email and paperwork to be e-mailed within (3) business days.

Procedure for discharges:

VA staff to be notified of discharge within (3) business days. Confirmation email followed by discharge paperwork.

Unexcused Absence:

Contractor reserves the right to discharge Veteran after 24 hours if they have not received prior approval to leave program for that timeframe. Case managers will inform VA staff of any unexcused absence within 24 business hours via email to discuss disposition of Veteran. Unexcused absences are not paid for by VA.

Excused Absences:

Veterans may be granted an excused absence on a case by case basis.

Excused absences are absences approved by the Program Director and can be approved for family reunification, military requirements, employment and housing search needs for examples.

Incident Reporting Program staff to report to VA staff incidents within 24 business hours.

1. Contracted Program will submit accurate billing to Payment Center by the 7th of each month.

2. 100% will have signed Release of Information (ROI) for VA in case management files

3. 100% of Veterans will sign in daily in order for contracted program to receive payment for that day

4. 85% of Veterans who are discharged will be reported to the VA within 24 business hours of discharge via email

5. 90% of all Veterans discharges will have HOMES discharge paperwork completed within 72 business hours of discharge

6. 90% of critical incidents related to assault, suicidality, and death will be reported within 24 business hours

INCIDENTS DEFINED AS BUT ARE NOT LIMITED TO THE FOLLOWING:

Falls Assault (to Vet or Staff) Elderly/Dependent Adult Abuse or Neglect Sexual Assault Fire- Patient involved Medical Emergency- 911 Calls Hospitalization Sexual Assault Suicide Suicide Attempt Homicide Death Infectious control (bed bugs, TB, etc.)

Active Substance Abuse Observation/Possession of weapons 100% during quarterly rating period

· COR records

· SOW compliance

· NEPEC data

· Review of incident reports

· Review of HR documentation (CPRS)

· Invoices

· Sign-in logs

· Documentation in Care Plan

· Care Plan reviews

· Interview with Veterans

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

ADMISSIONS, LENGTH OF STAY, AND DISCHARGES

Intake Packets All Veterans must receive an intake packet within 36 business hours which includes, at minimum, the following information:

· Description of the Contractors services.

· Grievance Policy.

· Release of Information form

· Emergency procedures.

· Patient rights and Reasonable Accommodation.

1. 100% of Veterans receive education about and written information on the following within 36 business hours:

· Description of the Contractors services

· Grievance Policy

· Release of Information form

· Emergency Procedures

· Patient Rights and Reasonable Accommodation

All policies pertaining to the above is posted conspicuously in contracted facility 100% during quarterly rating period

· Documentation in Care Plan

· Review of policies

· Review of intake packet

· Interview with Veterans

· Validated Staff/Veteran complaints

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

STAFFING

Personnel The contractor will employ sufficient personnel to carry out the policies, responsibilities, and the program for the facility.

The Professionally credentialed clinical supervisor shall be on-site 40 hours per week to provide ongoing supervision to case management personnel, clinical assessment, and crisis intervention. The Clinical supervisor has a dual role as the Program Director and shall oversee the day to day needs of the program.

The program director/clinical supervisor shall be on call and available for emergencies: 24 hours a day, every day, including holidays.

Case management staff are to be on-site 40 hours per week, inclusive of weekends.

The Contractor shall have six (6) support staff onsite, 24 hours a day, every day, including holidays; two (2) per shift. At least one staff member on duty per shift shall be Cardio-Pulmonary Resuscitation (CPR) certified.

Security staff will conduct hourly rounds with daily logs submitted, including time of round initiated and time of completion and if any findings were noted. Security staff can be utilized as on-site support staff.

Staff Training: Contractor will ensure that all staff are signed up for TMS and complete trainings per contract standards.

1. Facility Staff is fully trained and Staffed 24 hours a day, 7 days a week

2. 100% of Staff receive training on the following topics 1 time per year (VA31167) Rules of Behavior (ROB).

(VA10176) VA Privacy and Information Security Awareness.

(VA 1023) Privacy and HIPPA training.

(VA-33770) Suicide Prevention – S.A.V.E. Training for Employees –Enduring.

(VA-36537) Psychosocial Treatments for Substance Use Disorders-Enduring or (VA35817) Promoting Patient Engagement in Substance Use Disorders Treatment – Enduring Material (VA-361072018) Homelessness: Whole Health and Homelessness.

(VA-35480) Foundations of Motivational Interviewing.

(VA-4188207) Cultural Competence – Becoming Culturally Competent.

(VA-358042018) Homeless: LGBT Cultural Competence and Veteran Homelessness.

(NFED-3854619) Sexual Harassment Prevention for Employees.

The Contractor should also train their staff in the following at the time of hire and annually thereafter:

Housing First Professional Boundaries, Customer Service and Countertransference Crisis Interventions Conflict Resolution & De-escalation Techniques Harm Reduction Medication Monitoring Stages of Change Universal Precautions (disease transmission prevention)

3. Contractor must notify COR/HCHV Liaison in writing within 3 business days if personnel are unable to perform the duties assigned due to death, illness, resignation, or absconding from Contractor’s employ.

100% during quarterly rating period

· Documentation in Care Plan

· Review of policies

· Interview with Veterans

· Validated Staff/Veteran complaints

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