About this file

This is a Quality Assurance Surveillance Plan (QASP) for contracted residential emergency housing services provided to homeless veterans under the Health Care for Homeless Veterans (HCHV) program operated by the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 2. The QASP establishes systematic methods for evaluating contractor performance across four primary service categories: Emergency Housing Facilities & Management, Staffing & Supportive Services, Housing Placement outcomes, and Records & Reports management.

The QASP defines performance standards with 100% acceptable quality levels across most operational requirements, including facility compliance with fire safety codes, ADA accessibility guidelines, state licensing requirements, and maintenance of clean and safe environments. Staffing requirements mandate 24/7 on-site availability of full-time personnel, director on-call status, professionally credentialed clinical supervision, adequate case management personnel, security staff, and CPR-certified personnel per shift. Housing placement metrics establish targets of 85% or greater positive discharges, maximum administrative discharges of 10% or less, maximum negative discharges of 5% or less, and zero unacceptable discharges per six-month period. The government will employ direct observation, periodic inspections, random sampling of patient files, validated user complaints, and contractor documentation verification as surveillance methods, with inspection frequencies ranging from monthly to annually. The Contracting Officer is Veronica Baldwin and the Contracting Officer's Representative is Cristina Balbo, LCSW. Performance ratings are classified as Exceptional, Very Good, Satisfactory, Marginal, or Unsatisfactory, with deficiencies documented through Contract Discrepancy Reports requiring corrective action plans when performance does not meet acceptable quality levels.

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Other files

File Type Posted
36C24226R0065 0002.docx DOCX document
36C24226R0065 0001.docx DOCX document
D.8 WAGE DETERMINATION.pdf PDF
D.2 INFORMATION SECURITY RULES OF BEHAVIOR.docx DOCX document
36C24226R0065.docx DOCX document
D.5 HCHV INSPECTION FORM.pdf PDF
D.7 REQUEST FOR EXTENSION OF PER DIEM FORM.pdf PDF
D.6 INCIDENT REPORT FORM.pdf PDF
D.3 PAST PERFORMANCE REFERENCE INFORMATION.docx DOCX document
D.4 KEY PERSONNEL.docx DOCX document

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Quality Assurance Surveillance Plan (QASP) Health Care for Homeless Veterans (HCHV) Contracted Residential Services 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; Contracted Emergency Residence program model . 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: Veronica Baldwin Organization or Agency: Department of Veterans Affairs/NCO 2

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: Cristina Balbo, LCSW

3. CONTRACTOR REPRESENTATIVES

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

Primary: Cristina Balbo, LCSW

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. INCENTIVES / DEDUCTIONS

The Government shall use past performance as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards

6. 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. (For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

c. VALIDATED USER/CUSTOMER COMPLAINTS

d. RANDOM SAMPLING (For example, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR

Task
PWS
Standard
Acceptable Quality Level
Surveillance

Method

Frequency
Incentive

Disincentive (Deduction)

Emergency Housing Facilities & Management
6.2.
Facilities must meet fire and safety code imposed by the State law and the Life Safety Code of the National Fire and Protection Association.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Emergency Housing Facilities & Management
6.3
Facilities meet the Americans with Disabilities Act (ADA) guidelines for accessible accommodations for Veterans with physical limitations or impairments.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Emergency Housing Facilities & Management
6.2
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.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Emergency Housing Facilities & Management
6.9
Facility provides a clean, safe and sober environment for all residents.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Emergency Housing Facilities & Management
6.8.1
Facilities ensure the safety and privacy of Veterans with a clean and comfortable environment of care, including: a designated bed for each Veteran; safe and secure storage for belongings; laundry facilities.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Emergency Housing Facilities & Management
8.
Facility provides appetizing, nutritionally adequate meals three times per day and snacks between meals and at bedtime; and includes all food is stored, handled and served in a safe and sanitary manner that meets accepted industry standards and guidelines.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Emergency Housing Facilities & Management
7.
Facility provides a consistent and sufficient supply of drinking water. The drinking water should meet all relevant health and safety standards.
100%
VA team inspection
Annually
Positive Past Performance
Negative Past Performance
Task
PWS
Standard
Acceptable Quality Level
Surveillance

Method

Frequency
Incentive

Disincentive

Staffing & Supportive Services
9.1.1
Contractor staffing provides a full-time staff member on duty or residing at the residence and available for emergencies 24 hours per day, 7 days per week.
100%
VA team inspection and review of Contractor staffing records
Quarterly
Positive Past Performance
Negative Past Performance
Staffing & Supportive Services
9.1.2
Contractor staffing provides a Director of the program and/or facility, on call and available for emergencies 24 hours per day, 7 days per week.
100%
VA team inspection and review of Contractor staffing records
Quarterly
Positive Past Performance
Negative Past Performance
Staffing & Supportive Services
9.1.3
Contractor staffing provides 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 per day, 7 days per week.
100%
VA team inspection and review of Contractor staffing records
Annually
Positive Past Performance
Negative Past Performance
Staffing & Supportive Services
9.1.4
Contractor staffing provides sufficient case management personnel for each Veteran to have an assigned case manager responsible for providing the necessary therapeutic interventions and activities, and coordinating services specified in the performance work statement.
100%
Review of Contractor staffing records and Veteran case management records.
Quarterly
Positive Past Performance
Negative Past Performance
Staffing & Supportive Services
9.1.1
Contractor staffing must provide security staff and/or security surveillance and monitoring onsite 24 hours per day, 7 days per week, sufficient to ensure a safe and secure environment for all residents.
100%
VA team inspection and review of Contractor staffing records
Annually
Positive Past Performance
Negative Past Performance
Staffing & Supportive Services
9.1.6
Contractor staffing must provide at least one staff or security member with Cardio-Pulmonary Resiscitation (CPR) certification on and site and available in an emergency during each shift, 24 hours per day.
100%
VA team inspection and review of Contractor staffing records
Annually
Positive Past Performance
Negative Past Performance
Task
PWS
Standard
Acceptable Quality Level
Surveillance

Method

Frequency
Incentive

Disincentive

Staffing & Supportive Services
9.1.4
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 related to storing of controlled substances..
100%
Inspection (auditing) of Veteran case management records
Quarterly
Positive Past Performance
Negative Past Performance
Staffing & Supportive Services
10.1.1
Contractor provides daily structured groups and activities to promote skills building and healthy lifestyle.
100%
VA team inspection and review of Veteran case management records
Quarterly
Positive Past Performance
Negative Past Performance
Housing Placement
12.1
Contractor will achieve the required rate of positive discharges (as defined in the Performance Work Statement) of Veterans admitted to the facility
85% or greater
Inspection (auditing) of Veteran records
Semi-annually
Positive Past Performance
Negative Past Performance
Housing Placement
12.2
Contractor will not exceed the maximum rate of administrative discharges (as defined in the Performance Work Statement) of Veterans admitted to the facility
10% or less
Inspection (auditing) of Veteran records
Semi-annually
Positive Past Performance
Negative Past Performance
Housing Placement
12.3
Contractor will not exceed the maximum rate of negative discharges (as defined in the Performance Work Statement) of Veterans admitted to the facility
5% or less
Inspection (auditing) of Veteran records
Semi-annually
Positive Past Performance
Negative Past Performance
Housing Placement
12.4
Contractor will not have any unacceptable discharges (as defined in the Performance Work Statement) of Veterans admitted to the facility
Zero (0) instances in a 6 month period.
Inspection (auditing) of Veteran records
Semi-annually
Positive Past Performance
Negative Past Performance
Task
PWS
Standard
Acceptable Quality Level
Surveillance

Method

Frequency
Incentive

Disincentive

Records & Reports
15
Contractor provides daily sign-in sheets signed by Veterans to verify services and invoicing
100%
Inspection (auditing) of Contractor and Veteran records
Monthly
Positive Past Performance
Negative Past Performance
Records & Reports
15.1
Contractor maintains individual client records to include: initial psychosocial assessment; individual service plan; progress notes for each client contact; documentation of Veteran participation in daily group activities; updates individual service plans; discharge summaries
100%
Inspection (auditing) of Veteran records
Quarterly
Positive Past Performance
Negative Past Performance
Records & Reports
15
Contractor makes timely entries of data into HMIS.
100%
Inspection (auditing) of Contractor records and files.
Quarterly
Positive Past Performance
Negative Past Performance

7. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

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 thecontractual 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 orEnvironmental Deficiency Reports, or letters).

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 perparing 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 Discrepancy Report (CDR), 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 CDR in writing. The CDR 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 CDR 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. 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 negotiated 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.

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