D.1 QASP.docx

The contractor will be evaluated in accordance with the following:

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 monitoring will take place.

· Who will conduct the monitoring?

· 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.

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: Paschal L. Dawson | paschal.dawson@va.gov Organization or Agency: VA

Assigned CS: George L. Sherrin | George.sherrin@va.gov Organization or Agency: VA

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: Dr. Kate Elie | kate.elie@va.gov Organization or Agency: VA

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:

Quality Assurance Surveillance Plan (QASP)

4. PERFORMANCE STANDARDS

The contractor is responsible for the 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.

5. 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: Observation may occur on site or through record reviews.

b. PERIODIC INSPECTION. Inspections will be conducted periodically and can be unannounced or scheduled. The VA can request to conduct an on-site inspection and file review at any time.

c. CUSTOMER COMPLAINTS/FEEDBACK. All complaints and participant feedback that is submitted by verified customers either through the Contractor or the VA will be reviewed.

d. RANDOM SAMPLING: All Veteran files can be reviewed at any time. During unannounced or scheduled inspections, a random sampling of Veteran files will be pulled to review.

e. DOCUMENTATION PROVIDED BY CONTRACTOR: All documentation and correspondence provided by the contractor can be reviewed to include but not limited to: incident reports, discharge summaries, case consultation progress emails or notes, sign-in sheets, emergency plans, staff training, personnel plans etc

6. QASP PERFORMANCE REPORT DATE:

Measures

PWS

Reference Performance Requirement Standard Acceptable Quality Level (AQL) Surveillance Method Met or Did Not Meet AQL

CPAR RATING & COMMENTS

Periodic Inspections 4 a,b,c, 9 d, e (1-8) Visual safety and sanitation inspection; review of emergency and disaster plan, audit of selected Veterans’ clinical records; and review of Veteran complaints and participant feedback.

For any deficiency that is noted during inspections, plans of correction with timeframes to correct the deficiency must be submitted by the Contractor within 15 days of notification.

Grievance process to address Veteran complaints with Contractor providing a response to the complaint to the VA within 3 business days 100% Direct Observation including scheduled and unannounced site visits and inspections

4h, 9e (2),

8f The Contractor will ensure that transportation is available for Veterans to attend medical/mental health appointments, search for transitional or permanent housing and

Veteran complaints Customer satisfaction feedback address other care needs.

Any denial of admission will be submitted in writing to the VA Liaison within 24 hours with justification based on safety concerns.

controlled Any denial of admission will be submitted in writing to the VA Liaison within 24 hours with justification based on safety concerns. The

Periodic Inspection Veteran complaints substances, number of treatment episodes, time interval since the last program entry, legal history, or use of prescribed controlled substances.

Abstinence from alcohol or drugs cannot be a condition of admission or continued stay date of admission must be approved by the VA Liaison for billing purposes.

10j,m,o

6d(6) Complete a written ISP with the primary goal of obtaining housing signed by the Contractor, the Veteran, and the VA Liaison.

Review ISP in a clinical meeting with the Veteran.

All completed ISP shall be completed within the first 7 days of program admission.

All ISP reviews shall be completed every 30 days.

All updated ISPs shall be communicated to the VA Liaison 100%

100%

95% Periodic Inspection, random sampling, site visits, periodic inspections, documentation provided by contractor within 3 business days

6d(12), 9e(3), 10m

certificates, driver’s license, income verification and any additional information required by housing resources and potential income supports. Case management services will be documented in the Veterans individual clinical record.

10n

sign-in sheets of

Documentation of Veteran’s participation should also be in the Veteran individual clinical record.

provided by the contractor

plans and progress on goals shall be provided to the VA Liaison.

8a. 8a (2- 4), 8d-e, 10b, 10j,

10p

character of discharge.

Payments for unscheduled absences must have evidence of active outreach to reengage the Veteran in their case file or service plan.

performance metrics and targets will be reviewed quarterly

4a(1)c, 10g(2), 10i

10p Contractor expected to enter Veterans into HMIS system

The Contractor shall maintain an individual clinical record on each Veteran housed under this contract

A final discharge summary on each Veteran who leaves the program to include a description of beneficial changes realized during the residential period, reasons for All Veterans must be entered into HMIS within 2 weeks of being entered into the contract and within 2 weeks of being discharged from the contract.

All individual clinical records will contain an initial biopsychosocial assessment completed within 7 days of program admission.

Discharge summary should be entered within 2 weeks of Veteran being discharged

leaving, the Veteran’s future plans, after-care referrals and connections, and follow up locator information.

periodic inspections

7. CPAR 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/pdfs/CPARS- Guidance.pdf p. A2-1):

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.

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.

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.

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).

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 REPORT (CPAR).

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 on the following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

5. DATES

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

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

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER