D.1 QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

Attachment D.1 - Health Care for Homeless Veterans (HCHV)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate Contractor actions while implementing this Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring Contractor performance for each listed objective on the Service Delivery Summary (SDS) in this contract.

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

PURPOSE

The Contractor, 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 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.

In this contract the quality control program is the driver for product quality. The Contractor 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 Contractor to success. This QASP explains the following:

• What shall be monitored

• How 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 contractor through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

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: Karen Williams Department of VA

2780 Airport Dr., Columbus, OH 43219 614-257-5220, Karen.Williams4@va.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 Primary COR: Kjirsten Kmetz-Morrison, COR Richard L. Roudebush VAMC 1481 W. 10th Street Indianapolis. IN 46202 317-988-1408 Kjirsten.Kmetz-Morrison@va.gov

3. CONTRACTOR REPRESENTATIVES

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

(Name/Title/Address/Phone/Email)

Primary:

Alternate:

mailto:Karen.Williams4@va.gov

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 is incorporated within this QASP to include performance standards and disincentives. The Government shall use these standards to determine Contractor performance and shall compare Contractor performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

Task Standard

Performance Threshold/ Acceptable

Quality Level

Method of Surveillance

Performance Acceptable/

Unacceptable

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.

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

Facility provides: a.) a designated bed that is 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. Facility provides a safe and sober environment for all residents.

6. Facility provides appetizing, nutritionally adequate meals three times per day in a setting

100% during annual rating period

Annual VA team inspection.

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

YES ☐

NO ☐

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. One staff member on duty on the premises or residing at the facility and available for emergencies 24 hours a day, 7 days a week..

b. An administrative/clinical Designee that will be available for consultation for emergencies 24 hours a day, 7 days a week.

c. A professionally credentialed clinical supervisor available to make regular onsite visits and provide ongoing supervision of cases to case management personnel. The clinical supervisor must be on call and available for emergencies 24 hours a day, 7 days a week.

d. Sufficient case management personnel to provide 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.

e. 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.

95% of referred cases

Quarterly record review.

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

2. Contractor provides coordinated case management to include psychosocial assessment and individual service planning;

assisting Veterans with appointments, paperwork and linkages to needed resources;

transportation to appointments;

medication management.

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

Records and Reports: 1. Contractor provides daily sign-in sheets signed by Veterans to verify services and invoicing.

2. 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

3. Timely entry of data into HMIS

95% during quarterly rating period

Quarterly Veteran record review.

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

Housing Placement: A. Positive discharges as defined in the current Technical Manual Homeless Performance Measures and Metrics.

B. Negative discharges as defined in the Technical Manual Homeless Performance Measures and Metrics

A. 55% or greater of Veterans admitted to the facility (per-centage is adjusted annually by the VA Homeless program office)

B. Not more than 20% of Veterans admitted to the facility

Semi-annual record review from the date of contract award.

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

SURVEILLANCE

The Contracting Officer Representative (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 COR for correction. All Performance

Standards

STANDARD

Customer complaints shall not exceed the thresholds cited above for each performance objective. The COR shall notify the Contracting Officer (CO) for appropriate action.

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.

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

PROCEDURES

The COR shall inspect to ensure Contractor compliance with the appropriate section of the Performance Work Statement (PWS) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the COR shall notify the CO of the deficiencies within 3 business days. 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.

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

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

COR AND CONTRACTOR SIGNED ACKNOWLEDGEMENT OF QASP

X________________________________________________________________________ Kjirsten Kmetz-Morrison DATE

X________________________________________________________________________ Contractor NAME/TITLE DATE

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

QUALITY ASSURANCE SURVEILLANCE PLAN