D.1 QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

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 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.

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. 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 used exclusively by the individual Veteran from the time of admission to the time of discharge; 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.

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 ☐

6. Facility provides appetizing, nutritionally adequate meals three times per day in a setting 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. A full-time administrative staff member on duty or residing at the residence and available for emergencies 24 hours a day, 7 days a week. Note: security staff alone, whether employed directly by the contractor or subcontracted by the contractor, is not sufficient to meet this requirement.

b. A Director of the program and/or equivalent on call and available 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.

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. Security staff onsite 24 hours a day, 7 days a week. Security

100% during annual rating period.

Quarterly record review.

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

staff must be sufficient to ensure a safe and secure environment for all residents.

f. 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.

2. Contractor provides coordinated case management to include psychosocial assessment and individualized care 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. Individualized Care Plan

c. Progress notes for each client contact

d. Documentation of Veteran participation in daily group activities

e. Updated Individualized Care Plans

f. Discharge summaries

3. Timely entry of data into HMIS

100% during quarterly rating period

Quarterly or Randomly 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:

National Performance Monitors

A. Positive permanent housing discharges as defined in the Performance Work Statement

(PWS)

B. Negative discharges as defined in the Performance Work Statement

(PWS)

A. 50% or greater of Veterans admitted to the facility;

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

Quarterly 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.

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