D.1 Attachment QASP Quality Assurance Surveillance Plan.docx
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- Attached to
- G-004 HealthCare for Homeless Veterans (HCHV) for Battle Creek, MI VA Medical Center 36C25025Q0507
- Solicitation number
- 36C25025Q0507
About this file
This document is a Quality Assurance Surveillance Plan (QASP) for Health Care for Homeless Veterans (HCHV) Services at the Battle Creek VA Medical Center. The QASP outlines performance standards and surveillance methods for monitoring contractor performance, with key requirements including maintaining at least 85% bed occupancy, achieving 55% of veterans exiting to permanent housing, and limiting negative exits to 20% or less. Quarterly performance evaluations will assess contractor performance across multiple domains such as housing facilities, staffing, supportive services, therapeutic services, documentation, and meal provisions.
The document specifies detailed performance metrics, including requirements for facility safety, case management, record-keeping, training, housing placement, and therapeutic services. Surveillance will be conducted through methods like direct observation, periodic inspection, random sampling, and verification of contractor-provided documentation. Performance will be rated using a CPARS rating system ranging from Exceptional to Unsatisfactory, with the Contracting Officer (Angela Higgins) and Contracting Officer's Representative (Daleth Jean-Jules) responsible for overseeing the contract's implementation and performance evaluation.
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Other files
| File | Type | Posted |
|---|---|---|
| D.2 Attachment Wage Determination 2015-4847.docx | DOCX document | |
| Solicitation 36C25025Q0507.docx | DOCX document | |
| D.4 Attachment Past Performance Questionnaire.docx | DOCX document | |
| D.3 Attachment Contractor Cert of Compliance Immigration.docx | DOCX document | |
| D.5 Attachment 852.222-71 Compliance with Executive Order 13899.docx | DOCX document |
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QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)
Health Care for Homeless Veterans (HCHV) Services Battle Creek VAMC
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 will monitoring take place?
· Who will conduct the monitoring?
· How will monitoring efforts and results 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.
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: Angela Higgins Administrative Contract Specialist: Angela Higgins Organization or Agency: Network Contracting Office 10
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: Daleth Jean-Jules, Email: Daleth.Jean-Jules@va.gov, Phone: (269) 966-5600 X31648 Organization or Agency: Battle Creek, VA Medical Center (BCVAMC)
3. CONTRACTOR REPRESENTATIVES
The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.
Primary Program Manager: __________________________________
Alternate Program Manager: _________________________________
PERFORMANCE STANDARDS
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 shall be used to determine the level of contractor performance in the elements defined. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.
The Performance Requirements are listed below in Section 6. 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.
4. METHODS OF QA SURVEILLANCE
Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.
a. DIRECT OBSERVATION. 100% surveillance: 100% surveillance: observation of direct patient care episodes, monitoring of patient records and charting, and peer review.
b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. (semi-annually). For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)
c. VALIDATED USER/CUSTOMER COMPLAINTS.
d. RANDOM SAMPLING. Semi-annual (For example, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)
e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR.
5. QASP PERFORMANCE Report DATE: _____________________________
VHA National HCHV Program Office performance measures must be met each Fiscal Year (FY) in order to receive the highest performance rating. These include the following:
· HCHV1 (Discharge to Independent Housing) – FY26 target is 55% of Veterans Exiting HCHV Contract bed are Exited to Permanent Housing as reported by VHA HCHV Liaison (metric criteria to be shared by VHA each FY).
· HCHV2 (Discharge with Negative Exits) – FY26 target is no more than 20% of Veterans Exiting from HCHV Contract bed result in a Negative Exit (defined as Veterans asked to leave because of violation of program rules [excluding exits due to threatened/actual violence to self or others]; failure to comply with program requirements; or left the program without consulting staff) as reported by VHA HCHV Liaison (metric criteria to be shared by VHA each FY).
HCHV performance measures and targets are set by the VA HCHV program office and may be adjusted annually. Changes to Targets will be communicated to the HCHV Contractor at the beginning of a new Period of Performance. HCHV Liaisons will review HCHV performance measures with the Contractor on a quarterly basis.
All TQI measures must be met in order to receive the highest past performance rating. These include the following:
· Bed Occupancy > 85%, preferred 90%
· Length of Stay ≤ 60 Days
Quality Assurance Surveillance Plan
| Measure |
| PWS |
Para.
Performance Requirement
| Standard |
| Acceptable Quality Level |
| Surveillance |
Method
Frequency Met AQL/DID NOT MEET AQL-
CPARS RATING/ADD COMMENTS
| Housing Facilities & Management |
| U.2. |
| (100%) Facility meets fire, safety, Americans with Disabilities Act, licensure, safety and Veteran privacy and additional safety for female Veterans. Provides sober environment and at least three nutritious meals, 7 days a week will be provided for the Veteran. In addition, there will be availability of snacks of nourishing quality (e.g., fruits, vegetables, protein sources, etc.), between meals and bedtime for those requiring or desiring additional food, even when it is not medically indicated. |
| 100% Passing facility inspection and documentation of meeting the performance standards listed above. |
| (100%) during annual rating period. |
| Random Inspection of records. VA team Inspection |
| Quarterly |
| Yes ☐ |
No ☐
| Staffing & Supportive Services |
| U.1. |
| Full-time administrative staff on duty and sufficient case management personnel. The contractor shall provide evidence of site supervision with at least one staff or security member. Coordinated case management to include psychosocial assessment and assist Veterans with appointments, paperwork and transportation and structured group activities. |
| Passing random inspection and documentation of meeting the performance standards listed above |
| 100% of randomly selected cases |
| Random Inspection |
| Quarterly |
| Yes ☐ |
No ☐
| Records and Reports |
| U.1.II. |
| Daily sign-in sheets signed by Veterans. Psychosocial assessment, individual service plan, progress notes for each client, documentation of Veteran participation in daily group activities and entry of Veteran data into HMIS system. |
| Passing random inspection and documentation of meeting the performance standards listed above |
| 100% of randomly selected cases |
| Random Inspection |
| Quarterly |
| Yes ☐ |
No ☐
| Mandatory Training |
| U.1.III |
| Contractor shall complete all required training on time per VAMC policy. |
| All (100%) of required training is complete on time by contractor employees(s) |
| 100% completions, no deviations |
| Periodic Sampling |
| Quarterly |
| Yes ☐ |
No ☐
| Housing Placement |
| U.1.IV. |
| In accordance with VA National Performance Monitors 55% exits to permanent housing. Negative exits will not be greater than 20%. |
| Passing random inspection and documentation of meeting the performance standards listed above |
| 55% or greater of National Performance monitors and not less than 20% of negative exits. |
| Quarterly or Random record review & HOMES data |
| Quarterly |
| Yes ☐ |
No ☐
| Occupancy |
| e.VIII |
| 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. |
| HCHV CRS Bed Utilization Report |
| 85% or greater of the Bed Utilization Rate per quarter |
| Quarterly Review of Occupancy Rate |
| Quarterly |
| Yes ☐ |
No ☐
| Length of Stay |
| e.X. |
| Contractor that ensure that a permanent housing placement goal is in the Veteran’s Individual Service Plan and a planned discharge within 60 days or less |
| HCHV CRS Bed Utilization Report |
| ≤ 60 Days |
| Quarterly Review of Length of Stay |
| Quarterly |
| Yes ☐ |
No ☐
| Therapeutic Services |
| U.1.V |
| Therapeutic Services provided by contractor to include group therapy, social skills training, AA, NA, vocational counseling as appropriate. |
| 100% |
| 95% |
| Periodic Sampling |
| Quarterly |
| Yes ☐ |
No ☐
| Staffing |
| U.1.VII |
| 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 Sampling |
| Quarterly |
| Yes ☐ |
No ☐
Documentation
| U.1.VIII. |
| 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, and shall be part of the contract.
| 100% |
| 95% |
| Periodic Sampling |
| Quarterly |
| Yes ☐ |
No ☐
| Meals |
| U.1.V!X. |
| At least three (3) nutritious meals or their equivalent shall be served daily at regular times with not more than a 14-hour span between evening meal and breakfast of the following day. Nutritious snacks between meals and before bedtime, including weekends, shall be offered. |
| 100% |
| 97% |
| Periodic Sampling |
| Quarterly |
| Yes ☐ |
No ☐
6.
7. CPARS RATINGS ASSIGNED TO QASP ITEMS:
Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/documents/CPARS-Guidance)
| EXCEPTIONAL: |
| Contractor always meets the standard. 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. |
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: |
| Contractor almost always meets the standard, always performs over the Acceptable Quality Level. 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. |
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: |
| Contractor occasionally meets the standard, but more often meets the Acceptable Quality Level. 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. |
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: | |
| Contractor most often meets the Acceptable Quality Level, occasionally does not meet the Acceptable Quality Level and CDRs have been reported. 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. | |
| 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 Reports or letters). |
| UNSATISFACTORY: |
| Contractor has history of not meeting Acceptable Quality Level. Significant efforts have been made to bring Contractor into performance. 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. |
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).
8. 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 REPORTING SYSTEM (CPARS).
b. 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 Report (CR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.
The contractor shall acknowledge receipt of the CR in writing. The CR 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 CR will also state how long after receipt the contractor has to 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.
Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR below.
9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP
SIGNED:
COR NAME/TITLE DATE
SIGNED:
CONTRACTOR NAME/TITLE DATE
CONTRACT REPORT
| 1. CONTRACT NUMBER |
| 2. REPORT NUMBER |
| 3. TO: (Contracting Officer) |
| 4. FROM: (Name of COR) |
5. DATES
a. CR PREPARED
| b. RETURNED BY CONTRACTOR: |
| c. ACTION COMPLETE |
6. Issue Identified (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 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.
13. GOVERNMENT ACTIONS
14. CLOSE OUT
| NAME |
| TITLE |
| SIGNATURE |
| DATE |
CONTRACTOR NOTIFIED
COR
CONTRACTING OFFICER
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