D.1 QASP_.pdf

Quality Assurance Surveillance Plan (QASP)

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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: Paula Galvin Organization or Agency: NCO 15

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: Melissa Davison Organization or Agency: Wichita VA Medical Center (VAMC)

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

Alternate:

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4. 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.

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:

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints shall be investigated.

d. RANDOM SAMPLING. Samplings will be determined by the COR and/or VA Program Office.

e. Verification and/or documentation provided by Contractor. Documents may be reviewed during weekly, monthly, annual meetings, and/or inspections.

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6.SAMPLE QASP PERFORMANCE REPORT DATE:__________________

Tailor to specific procurement. Consider the performance measures the VA may have for the service the procurement involves.

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

Transportation 5.f 6.c.13 6.c.15

Transportation is available for admissions, to attend medical/mental health appointments, search for permanent housing and to address other care needs.

100% transportation services

95% Direct Observation and Random Sampling

Incidence Reporting 6.c.16 All incidents reported immediately (within 24 hours). All incidents are investigated, confirmed and resolved.

All (100%) of incident reports shall be reported within 24 hours.

95% Observation, random unannounced inspection (auditing), and patient report.

Patient Safety 6.c.3 6.c.8

Contractor will Screen each Veteran for suicidal and homicidal risk as necessary

Contractor will contact the VA and inform of the incident immediately upon safe to do so.

100% screening 100% Observation;

random, unannounced inspection (auditing), and patient report.

Staffing on Premises 7 There must be, as a minimum, at least one

(1) administrative staff member or designee of equivalent professional capability, on duty on the premises or residing at the house and available for emergencies 24

100% staffing coverage

100% Scheduled and announced site visits, quarterly and annual inspection

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(7) days a week.

Records and Reports 10.a 8.c

Contractor will provide daily sign-in sheets verifying Veterans attendance to the COR.

Contractor will seek approval from the VA Liaison for any extension of BDOC for Veterans approaching the end of their approved

BDOC.

100% usage of sign-in and approval from VA Liaison for all extensions of

BDOC.

95% Direct Observation, Monitored by the COR, observation, QA site visits, inspection.

Complaints 7.m All Veteran complaints or Contract staff conduct incidences shall be reported to the VA Liaison within 24 hours of the complaint or possible Contract staff conduct incidences.

All(100%) of complaints or conduct incidences shall be reported.

100% Monitored by the COR, observation, QA site visits, VA Collaboration 6.c.9 Contractor will coordinate weekly case conferences with Contractor clinical Director, Contractor Case Managers, VA Liaison and other VA Homeless and Contractor staff as necessary.

100% of weekly coordination for case conferences.

95% Monitored by the COR, observation, QA site visits, Admissions 8 4.a

Contractor shall have the ability to accommodate admissions from 8:00am to 9:00pm, seven (7) days per week.

100% compliance 100% Observation, monitored by

COR

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Veterans cannot be denied entry to CERS based solely upon length of current abstinence from alcohol or non-prescribed controlled substances, the number of previous treatment episodes, the time interval since the last program entry, the use of prescribed controlled substances, or legal history.

Discharges 8.e Contractor shall provide discharge planning and referrals for each Veteran, regardless of character of discharge.

Contractor will provide a written discharge report to COR within 24 hours of Veteran’s discharge.

100% compliance 100% Monitored by the COR, observation, QA site visits, Performance Measures 8.i Contractor performance measures will be reviewed quarterly and annually.

Contractor to review data and offer feedback and engagement in strategies to improve performance, as necessary

100% compliance 100% Monitored by the COR, observation, QA site visits, weekly staffing, Page 6 of 9 version 0001 Dated 2/1/2017

Case Management 6.c.4 6.c.5 6.c.7

Develop a highly Individualized Service Plan (ISP) with the Veteran the plan must specifically include provisions for Veteran placement into an appropriate transitional or permanent housing placement within 60- 90 days of admission.

Complete a written ISP within the first 7 days of program admission and signed by the Contractor, the Veteran, and the VA Liaison.

Contractor will conduct weekly case management meetings with Veterans focused on ISP objectives and tasks.

100% of ISP development within the first 7 days of program admission and weekly case management meetings.

95% Monitored by the COR, observation, QA site visits, weekly staffing, Page 7 of 9 version 0001 Dated 2/1/2017

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):

EXCEPTIONAL: 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:

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:

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:

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 Report or letter).

UNSATISFACTO

RY: 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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

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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

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CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

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