D.1 QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Health Care for Homeless Veterans (HCHV) Contracted Residential Services

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.

1. QASP PERFORMANCE REPORT DATE: __________________

Measures (Tasks)

PWS

Refere nce (Fill-in)

Performance Requirement

Standard Accept able Quality Level

Surveillan ce Method

Met AQL

Did NOT Meet AQL

Record keeping for homeless veterans.

Part IV B., 1.

Daily sign-in sheets are signed by the Veteran.

Individualized Care Plans (ICP’s) are completed within 14 days of admission.

Progress notes are completed for Veterans to outline services provided in accordance with PWS.

Contractor’s records/documen tation regarding provision of services to Veterans reflect accurate and appropriate delivery of treatment and services.

95% Review of Contractor ’s records/do cumentatio n on provision of services to Veterans.

Monthly and Randomly.

YES ☐

NO ☐

Accuracy of Invoices

Part IV B., 2.

Invoices submitted to the COR for payment have the accurate per diem rate, number of bed days billed, dates, and the Contractor identification information.

The invoices will be submitted in conjunction with the daily sign-in sheets to allow the COR to verify the accuracy of the invoice.

Invoices are submitted to the COR by the 10th of each month.

Invoices submitted to the COR for payment will be accurate, submitted timely, and accompanied by daily sign-in sheets and discharge forms to verify the accuracy of invoices.

95% COR

review of the invoices and daily sign-in sheets received by the Contractor on a monthly basis

Discharge Plans

Part IV B., 3.

Veterans are continually engaged in discharge planning with Contractor’s staff, in conjunction with Homeless Program case manager. This discharge planning includes discussion of available and appropriate housing placements and treatment options.

The Contractor’s discharge forms are submitted to the COR on a monthly basis with the daily sign-in sheets and invoice.

The discharge forms are completed accurately to reflect the type of discharge and housing placement upon discharge.

Appropriate discharge planning for Veterans receiving services from the Contractor’s facility is appropriate and ongoing.

Discharge forms are sent to the COR for review.

95% Reviewed by COR with random reviews on a monthly basis.

Homeless Veteran Satisfaction

Part IV B., 4.

Veteran satisfaction rate with the services provided by the Contractor

Complaints received by the Contractor are dispositioned within 24- 48 hours of the complaint by the Contractor

Complaints are reported to the COR within 24-72 hours of the complaint.

Homeless Veterans are satisfied with the services they receive from the Contractor; all Veteran complaints are reviewed, dispositioned, and reported to the COR in accordance with the timeframes identified.

95% Complaint s review by COR on a monthly, quarterly and annual basis

Residential Outcomes

Part IV B., 5.

In conformance with VHA National Homeless Program Performance Measures, at least 55% of Veteran’s discharged from the Contractor’s facility will have a positive exit;

and no more than 20% of Veterans discharged will have a negative exit.

Successful housing placements for Veterans upon discharge

At least 55% for positive exits and no more than 20% for negativ e exits.

Monthly reviews by

COR

Emergency housing and facilities management

Part IV B., 6.

Compliance with the facility meeting fire, safety and Americans with Disabilities Act and Licensure.

Compliance with Veteran privacy guidelines.

The facility has adequate policies and procedures in place to ensure conformity to confidentiality.

Compliance with all applicable safety and privacy standards

100% COR and

HCHV

liaison review monthly, quarterly and annually with direct observatio n, random audits, and periodic inspection.

2. 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:

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).

UNSATISFACTORY: 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).

3. 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 Discrepancy 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 CDR below.

4. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting. The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

5. 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