D.1 QASP.pdf

Quality Assurance Surveillance Plan (QASP)

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: Kayla Haas Organization or Agency: Network Contracting Office 15; Kayla.Haas@va.gov, 913-946-1111

Assigned CS: Patricia Trusler Organization or Agency: Network Contracting Office 15; Patricia.Trusler@va.gov;, 913-946-1115

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: Malinda Peppers Organization or Agency: Marion VA Medical Center; Malinda.Peppers@va.gov ; 618-969-2553 mailto:Kayla.Haas@va.gov mailto:Patricia.Trusler@va.gov mailto:Malinda.Peppers@va.gov

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:

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: Observation may occur on site or through record reviews.

b. PERIODIC INSPECTION. Inspections will be conducted peridocially 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: ___5/28/25______________

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, 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.

100% Direct

Observation including scheduled and unannounced site visits and inspections

Patient Safety 4a (1b), 4 h, 9e (2), Contractors must have emergency and disaster plans with written protocols that are posted to guide staff response to crises including, but not limited to, manmade and natural disasters, episodes of infectious

All contractor staff must be trained on emergency procedures and protocols.

100% Periodic

Inspection, staff training, documentation provided by the

Contractor diseases, physical injury, program participants suicide or suicide attempts, overdoses, and domestic or other violence.

Transportation 5g, 6d(13)(15), 8f

The Contractor will ensure that transportation is available for

Veterans to attend medical/mental health appointments, search for transitional or permanent housing and address other care needs.

Contractor shall assist all Veterans with local transportation through the provision of bus passes, utilization of cab services or use of Contractor transportation.

95% Periodic

Inspection

Veteran complaints

Customer satisfaction feedback

Admissions 6b, 8b Contractor shall have the ability to accommodate admissions from

24 hours per day seven (7) days per week. If unable to verify Veteran's eligiblity during off tour hours, a

Contractor has a process in place to accommodate admissions after normal business hours and on weekends.

100% Periodic

Inspection homeless person should be accepted conditionally"

Individualized Service

Plan (ISP)

6d(4-7) .

10j, m, o

6d(6)

Complete a written

ISP 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 within 3 business days

100%

100%

95%

Periodic

Inspection, random sampling, site visits, periodic inspections, documentation provided by contractor

Case Management 4a(1)c, 6d(12), 9e(3), 10m

Contractor will take primary responsibility for assisting Veterans in completing housing applications and other benefits paperwork as needed

Contractor will assist Veterans in obtaining the needed documentation required for complete applications including but not limited to, birth certificates, driver’s license, income

95% Periodic inspection, site visits, Veteran complaints, participant satisfaction feedback 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.

Therapeutic Services 6d(14-15).

10n

Contractor will provide structured groups and activities to promote social skills building and healthy lifestyles or provide referrals to community agencies offering these groups

Contactor can demonstrate groups & activities that were provided each month and sign-in sheets of

Veteran participation or evidence of referrals to outside offerings.

Documentation of

Veteran’s participation should also be in the

Veteran individual clinical record.

95% Periodic inspection, site visits, documentation provided by the

Suicidal and Homicidal

Risk

6d(8) Screen each

Veteran for

All screenings must be documented in

Inspection, suicidal and homicidal risk.

regular progress notes.

Random

Sampling

Collaborative

Relationship

6d(9) Contractor will participate in weekly case conferences.

100% of updates and changes in

Veterans’ care plans and progress on goals shall be provided to the VA

Liaison.

95% Direct observation, documentation

Critical Incidents 6e Contractor will notify VA through the VA of any critical incident occurring with a

Veteran.

All incidents will be reported within 24 hours of incident, if not sooner.

100% Documentation

Staffing and 24/7 availability

6b, 7, 8b 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 hours a day, 100% compliance 100% Direct

Observation, site visits, periodic seven (7) days a week.

Extensions Beyond 90

Days

2, 6d(4), 8a. 8a (2-

4), 8d-e, 10b, 10j, Contractor seeks approval from the

VA Liaison for any extension of

BDOC for

Veterans approaching the end of their approved BDOC.

Any extension requests beyond 90 days must be submitted within 7 days of the end of approved bed days of care and must be approved by the VA

Liaison.

95% Direct observation, site visits, Discharges 8f-h, 10e(2)(c).

10p

Contractor shall provide discharge planning and referrals for each

Veteran, regardless of character of discharge.

All written discharge reports shall be provided to

COR within 24 hours of Veteran’s discharge.

100% Periodic

Inspection, Random

Sampling, direct observation

Sign-in Sheets 10g(1) Daily sign-in sheets signed by program Veterans, to document and verify Veterans’ presence at the facility for billing purposes.

All sign-in sheets will be provided monthly to the VA

Liaison for review.

95% Direct

Observation, site visits, and

Scheduled and

Unscheduled

Absences

10e Payment for scheduled absences must have the reason documented in the

Veteran’s case file or service plan.

Payments for unscheduled absences must have evidence of active outreach to reengage the

Veteran in their case file or service plan.

All absences must be properly documented.

95% Direct

Observation, site visits, and

Performance Measures 9a, b, c

HCHV

performance metrics and targets will be reviewed quarterly and annually. Any performance measure target not being met will require Contractor to develop an action plan.

Contractor will be expected to complete a written action plan for any performance measure not meeting established targets within 30 days of notification.

inspection

Documentation 10q, 11a expected to enter All Veterans must be entered into

HMIS within 2 weeks of being

95% Direct

Observation, site visits, and

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

10p

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 leaving, the

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

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

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).

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).

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

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

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer)

Patricia Trusler

4. FROM: (Name of COR)

Malinda Perkins

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