C12. Quality Assurance Surveillance Plan RSHV.docx

D.3 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

1. PURPOSE

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

0. What will be monitored?

0. How monitoring will take place.

0. Who will conduct the monitoring?

0. 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 through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities. The work performed under this contract shall be subject to evaluation by the COR/CO via the QASP and the Quality Assessment of Residential Housing for Homeless Veterans Procedures.

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: Contracting Officer’s (CO) Contracting Officer (CO)/Administrator Chinedu Nwauwa, Branch Chief, Services 1 Paul O. Waite, CO Department of Veterans Affairs Department of Veterans Affairs Network Contracting Office (NCO) 6 Network Contracting Office (NCO) 6 100 Emancipation Drive, building 27 100 Emancipation Drive, Building 27 Hampton, Virginia 23667 Hampton, Virginia 23667 Tel: 757-315-3937 Fax 757-728-3132 Tel: 757-315-3983 Fax (757)726-6010 Chinedu.Nwauwa@va.gov paul.waite@v.gov

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: TBD

3. CONTRACTOR REPRESENTATIVES

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

4. METHODS OF QA SURVEILLANCE

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

1. DIRECT OBSERVATION: 100% surveillance Action required via daily reporting.

1. PERIODIC/ RANDOM INSPECTION: Inspections scheduled and reported quarterly per COR delegation or as needed.

1. MONTHLY REPORTS: Reports will be generated monthly by the contractor which the COR will use to track progress of maintenance.

1. VALIDATED USER/CUSTOMER COMPLAINTS: Customer complaint data will be obtained via Customer feedback and will be compiled weekly and reviewed by Service Chief. Any validated complaints against the Contractor which are not resolved within seven business days will be further investigated.

1. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR: Contractor provided documentation will be reviewed via required daily action reporting.

1. ALTERNATE METHOD OF SURVEILLANCE IDENTIFIED: See Surveillance method identified in the surveillance table.

5. INCENTIVE/DISINCENTIVES FOR ACCEPTABLE QUALITY LEVEL (AQL)

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 issues are repetitive or consistent, the government shall take further corrective action or begin termination procedures. Incentives and Disincentives shall be based on exceeding, meeting, or not meeting performance standards.

1. Positive and negative performance will be documented locally (contract file) and/or in the appropriate contractor performance assessment reporting system/database.

1. Noncompliance to contract standards will be corrected at no cost to the government. The government reserves the right and may elect to measure/document negative performance through utilization of a performance report and/or a contract discrepancy report.

1. The contractor shall respond in writing to the Contracting Officer Representative (COR) to all notifications of failure to meet acceptable quality levels within 5 days of issuance by the Contracting Officer Representative and/or the Contracting Officer. The contractor's response shall include the corrective action taken to rectify the problem and the proposed measure to preclude the recurrence of the problem.

6. PERFORMANCE STANDARDS (MEASURES)

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP and the Quality Assessment of Residential Housing for Homeless Veterans Procedures shall be used to determine the level of contractor performance in the elements defined. The 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 is listed below in Table 1. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

ID

Indicator

Quality Level Method of Surveillance

Incentive/ Disincentives

Section 2. General Requirements (b); Inspection and Acceptance, Section (g) (2) a-g

Periodic Inspection Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Two or more issued CDRs may result in reduction of the monthly invoice of 5% and Unfavorable contractor performance evaluation

Section 8. Transpiration

Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Two or more issued CDRs may result in reduction of the monthly invoice of 5% and Unfavorable contractor performance evaluation

Occupancy Program will maintain minimum acceptable level of occupancy through collaboration with VA and Coordinated Entry referrals.

Section 2: General Requirements (q) VA National Data base occupancy reports for the program shall demonstrate a rate of 80% or higher for a given quarter.

Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Admission

Program shall follow referral and admission process which includes admission of veterans who have were provided by written authorization of COR/HCHV Liaison only.

Section 4. Referrals 100% will only admit those referred form VA in writing and will have complete admission information in the veteran’s case management file.

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Independent Service Plan A case manager will complete with the veteran an independent service plan ( ISP) that includes: 1) Barriers 2) Service needs 3) strengths 4) Specific services provided including duration and outcomes 5) Documentation of referrals 6) Benefits to be achieved as a result of program participation.

Section 2. General Requirements (e); Section 11: 3. Clinical Care: (g)

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements: Case Management:

Clinical Chart Reviews A case manager will meet with the veteran to review progress notes directly related to Veteran’s Individual Service Plan (ISP) progress including their therapeutic and rehabilitative referrals , discharge plan, resource acquisition and access and engagement of appropriate providers of physical and mental health care services.

Section 2. General Requirements (e

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Financial Plan

The program in collaboration with the veteran shall develop an individualized financial plan which reflects employment and non-employment income and benefits and including means and methods of increasing monthly income and responsibly managing existing income. This Financial Plan should include identifying needed referrals for both potential benefits and employment assistance where appropriate.

Section 2: General Requirements (l) 80% of eligible veterans will have a Financial Plan developed within 7 days of admission.

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Group Activities

The program will provide access to group activities focusing on development of successful living patterns. This may involve but shall not be limited to groups such as: Alcoholics/Narcotics Anonymous, vocational counseling, financial management, personal hygiene, permanent housing search, etc.

Section 2: General Requirements (f)

Direct Observation Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Discharge Planning The program shall in coordination with the veteran formulate an initial Discharge Plan within 7 days which identifies the veteran’s projected housing outcome upon discharge. The Plan should identify the activities to be undertaken while in program to achieve this outcome.

Section 2. General Requirements (e)

Inspection

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Discharge Documents The program will follow the identified VA Process for addressing and documenting a veteran’s planned or unplanned discharge. This includes notifying the identified VA HCHV Liaison and COR within 24 business hours and providing supporting Exit Summary documentation within 1 business day.

Section 2: General Requirements (o)

Inspection

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Discharge Outcomes

Program shall work to ensure positive veteran outcomes at all times. A positive outcome is any discharge to a more stable level of care or housing. Cases that involve veterans being discharged to an equivalent level of housing or leaving the program within 7 days of entering shall be exempted.

Section 2. General Requirements (q)

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

General Requirements:

Complaints handling

Program shall implement a COR approved quantitative and qualitative survey tool for veterans to provide feedback. This survey tool shall be publicized visibly within residential and common areas and participation shall be encouraged by staff.

Section 7. Complaints Handling

Random Sampling

Observation

Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Conduct- Critical Adverse Incidents Program shall notify the VA Representative regarding critical adverse incidents involving veterans within 24 business hours. Reportable critical adverse incidents are defined as: death, suicide/suicide attempt, fire (veteran involved) or sexual or physical assaults.

Section 6: Conduct (e)

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Conduct

Program shall notify the VA Representative regarding incidents involving veterans within 48 business hours. Reportable are defined as falls, abuse or neglect, hospitalization, infection control (bed bugs, TB, etc.), active substance abuse and possession of weapon.

Section 6: Conduct (e) 90% of all other incidents are to be reported to VA staff within 48 business hours. A copy shall be maintained in the patient’s chart.

Random Sampling Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

On-site Staffing Program shall have a qualified designated staff person on duty 24 hrs. a day 7 days per week at the approved site.

Section 3. Personnel

Veteran reporting Incentives: Favorable contactor performance evaluation, Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Billing -Invoicing The program will follow the protocol for accurate and timely invoicing established which may require VA representative review and approval prior to submission. Final invoice shall be submitted to the identified Financial Services Center by the 10th of the following month for certification and payment.

Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

Disincentive: A Contract Discrepancy Report (CDR) may be issued on the first instance of failure to provide the acceptable level

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:

Positive outcome: 98% or greater successful completion/outcome.

Acceptable outcome: 97%-95% Successful completion/outcome.

Unacceptable outcome: Less than 95% successful completion/outcome.

8. 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 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.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the CO. The CO will in turn review and submit to the contractor's program manager for corrective action.

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. See Sample CDR below.

NETWORK CONTRACTING OFFICE (NCO) 6

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER

DATES

4. DISCREPANCY OR PROBLEM (Describe in detail; Include reference in PWS / Directive. Attach continuation sheet if necessary.)

5. SIGNATURE OF CONTRACTING OFFICER’S REPRESENTATIVE (COR)

8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION, AND ACTIONS TO PREVENT RECURRENCE (Attach continuation sheet if necessary.)

11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN (Acceptable response/plan, partial acceptance of response/plan, rejection. Attach continuation sheet if necessary)

12. GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.)

CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

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

b. Frequency of Performance Assessment Meetings.

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.

REVISIONS TO QASP: revisions to the surveillance plan are the joint responsibility of the COR and the Contracting Officer.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

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