D.1 QASP Safe Haven.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Attachment D.1: Low Demand Safe Haven Residential Care - NIHCS

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 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.

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: Karen Williams Department of VA

2780 Airport Dr., Columbus, OH 43219 614-257-5220, Karen.Williams4@va.gov.

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: Jennifer Malott, COR Northern Indiana Health Care System

260-433-1062 Jennifer.Malott@va.gov

CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

(Name/Title/Address/Phone/Email)

Primary:

Alternate:

mailto:Karen.Williams4@va.gov mailto:Jennifer.Malott@va.gov

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.

CONTRACTOR QASP REPORT DATE:_____________________________

Task & Deliverables Standard Acceptable

Quality Level Method of

Surveillance Met AQL/ Did Not

Meet AQL Residential Care Facilities & Management:

(PWS-Tasks and Deliverables section A, 1 through 13)

Facilities meet fire and safety code imposed by the State law, and the Life Safety Code of the National Fire and Protection Association.

Facilities meet the Americans with Disabilities Act (ADA) guidelines for accessible accommodations for Veterans with physical limitations or impairments.

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.

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 bedroom with no more than 2 residents per room.; 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.

Facility provides a safe and sober environment for all residents.

95% 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.

Facility provides appetizing, nutritionally adequate meals three

(3) 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 & Treatment Services:

(PWS- Tasks and Deliverables section B, 1 through 8)

Contractor staffing provides:

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.

A Director of the program and/or facility on call and available for emergencies 24 hours a day, 7 days a week.

A Full-time, Masters Level License Independent Practitioner [such as a Licensed Clinical Social Worker (LCSW), Licensed Clinical Professional Counselor (LCPC) or similar professional as approved by the VA Liaison}. They shall provide ongoing supervision to the facility’s case management personnel and be available to provide clinical services to the residents. They must be on call and available for emergencies 24 hours a day, 7 days a week.

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.

95% of referred cases as outlined in

PSW

Quarterly record review.

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

Each Veteran must have an assigned case manager responsible for coordinating and providing the supportive services specified in the contract. Case Managers should have no more than a ratio of 13:1.

A minimum of 2 staff (one security and one to provide direct support to the residents and one to provide security) must be onsite 24 hours a day, 7 days a week. Security staff must be sufficient to ensure a safe and secure environment for all residents.

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.

The Contractor is expected to provide training to all staff including but not limited to:

a) Motivational Interviewing

b) Critical Time Intervention

c) Safe Haven/Low Demand Model

d) CPI or other verbal de-escalation

Contractor provides case management services to Veterans in the program to include:

individual service planning, psychosocial assessment, screening to ensure veteran is not a danger to self or others during each meeting which will be attempted at least twice weekly along with daily check ins, assisting Veterans with applications and paperwork, assist with scheduling and tracking appointments, assistance with transportation, medication assistance, weekly coordination with VA Liaison, obtain relevant releases of information.

Contractor provides the following clinical/rehabilitative services: daily structured activities and groups to promote skills building and healthy lifestyle, health and hygiene maintenance, professional therapy as needed, support for alcohol/drug free lifestyle or harm reduction, linkage to community services as appropriate.

Admissions, Length of Stay and Discharges:

(PWS- Tasks and Deliverables section C, 1 through 6)

Positive discharges as defined in the Performance Work Statement (PWS)

Administrative discharges as defined in the Performance Work Statement

(PWS)

Negative discharges as defined in the Performance Work Statement (PWS)

Unacceptable discharged as defined in the Performance Statement of Works

(PWS).

75% or greater of Veterans admitted to the facility

Not more than 10% of Veterans admitted to the facility

Not more than 20% or less of Veterans admitted to the facility

0%

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

Records and Reports:

(PWS-Tasks and Deliverables section E, 1 through 3)

Contractor provides daily sign-in sheets signed by Veterans to verify services and invoicing; due dates outlined in PSW

Contractor maintains individual client records to include:

a) Initial psychosocial assessment

b) Individual Service Plan

c) Relevant releases of information

d) Progress notes for each client contact

e) Documentation of Veteran participation in daily group activities

f) Updated Individual Service Plans

g) Discharge summaries

75% during quarterly rating period

Quarterly Veteran record review.

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

h) Entry of data into HMIS within 2 weeks of admission and discharge.

Quarterly

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/documents/CPARS- Guidance.pdf:

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 https://www.cpars.gov/documents/CPARS-Guidance.pdf https://www.cpars.gov/documents/CPARS-Guidance.pdf 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).

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 below.

2. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

Attachment D.1 - Low Demand Safe Haven Residential Care - NIHCS

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS ISSUE

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:

Attachment D.1 - Low Demand Safe Haven Residential Care - NIHCS

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER