D.1 Quality Assurance Surveillance Plan (QASP) 02.docx

D.1 Quality Assurance Surveillance Plan (QASP) – Dayton VAMC (552) – HCHV CERS Contract 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: Karen Williams karen.williams4@va.gov Assigned CS: Ronald Michael Morgan ronaldmichael.morgan@va.gov Organization or Agency: Network Contracting Office NCO 10

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: Dianne Smith-Foster Assigned Alternate COR:

Organization or Agency: Dayton VAMC – Dayton, OH

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternate:

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. (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. (For example, off-site contracts may require the contractor to provide information on services provided to patients).

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6.SAMPLE QASP PERFORMANCE REPORT DATE: __________________

Measures

PWS Reference

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Method of Surveillance Met AQL/Did Not meet CPAR rating/Add Comments

Outcome Measures:

Veterans Medical Records

#6-d: Case Management Services

Task 1. Upon review by HCHV Liaison or designee, all Veterans medical records reflect appropriate treatment provisions, and plan of care.

Veterans’ records reflect appropriate treatment provisions.

100%

VA HCHV Outreach Social Worker in collaboration with HCHV Contractor, at minimum, sees each Veteran monthly and reviews their chart to determine that contracted services are being provided accordingly.

#14: Inspection and Acceptance

Task 2. Upon review by HCHV Liaison, or designee, all Veteran's medical records reflect adherence to agreed upon treatment guidelines and standards.

Veteran’s records reflect adherence to agree upon treatment guidelines and standards.

95%

VA Social Worker, HCHV Liaison, COR, and/or designee performs a chart review, at a minimum bi-annually, on a sample of program participants and compiles results for review by the HCHV Liaison or designee.

Measures

PWS Reference

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Met AQL/Did Not meet CPAR rating/Add Comments

Outcome Measures:

HCHV CERS Discharge Plans

#8-f: Admissions, Length of Stay and Discharges

Task 3: Upon review by HCHV Liaison, or designee, appropriate discharge plans are made for Veterans (including those discharged for non- compliance).

Appropriate discharge plans are made for Veterans (including those discharged for non-compliance) with goal of keeping Veterans engaged in treatment.

On a quarterly basis, Contractor coordinates with HCHV Liaison, or designee, to ensure that Veterans placed in Health Care for Homeless Veterans (HCHV) residential treatment are connected to the continuum of care at discharge and throughout Veterans Individualized Recovery Plan.

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Method of Surveillance Met AQL/Did Not meet CPAR rating/Add Comments

Outcome Measures:

HCHV CERS Outcomes

#8-e, f(2), g: Admissions, Length of Stay and Discharges

Task 5. Upon review of HCHV CERS Discharge forms, successful discharge rates will be monitored.

At least 55% of Veterans discharged from the Contract Housing will have a successful discharge.

55% (As aligned with HPO Homeless Scorecard Metric)

All Veterans discharged from residential treatment will have a discharge or exit form completed and this will be monitored quarterly.

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Met AQL/Did Not meet CPAR rating/Add Comments

Deliverables Delivery of Support Services

#6-d: Case Management Services

Supportive Services based on Veteran’s identified goals will begin within 24 hours of admission and will be modified as needed throughout residential stay

100% of all Veterans admitted to VA HCHV Programs

Monthly review meeting of Veterans treatment plan and progress towards goals. Contractor to provide verbal and/or written updated goals to COR, VA Liaison, or designee

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Met AQL/Did Not meet CPAR rating/Add Comments

Deliverables Bed census

#16: Billing

Submitted by the 7th day of each month, but not before the 1st day of the month to the COR.

95%

95%

Monthly Invoice due by 7th of the month, but not before the first day of each month.

Deliverables Service Plans

6-d(1)(4); 9-f(1)(2), Service Plans required within seven calendar days of admission for each Veteran. All service plans require Veteran, and Contractor designee signatures. The goal of service plans should be housing focused but also stabilization of mental health/substance use disorder. All extensions of above require approval of VA and are based on individualized clinical needs of the Veteran.

100% of all Veteran admissions have service plans within 7 days of admission with the goal of housing and stabilization of mental health/substance use disorder as appropriate.

Weekly review meeting of Veterans treatment plan and progress towards goals shall occur between the VA Liaison and/or HCHV Outreach staff verbally and/or face-to-face. These meetings shall be supportive of the Veteran. The Contractor shall also meet with the Veteran weekly regarding treatment plan progress and provide any updates to the Veteran’s service plan in writing in the clinical record and notify the VA Liaison or designee.

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Met AQL/Did Not meet CPAR rating/Add Comments

Deliverables Reports: Changes in Veteran Status

#6-d: Case Management Services

Contractor will provide HCHV Liaison or designee with weekly verbal reports on changes and progress in Veteran’s status and any transportation or follow- up appointment challenges.

100% of VA HCHV CERS Veteran residents

Weekly verbal review meeting with HCHV Liaison or designee of Veterans treatment plan and progress towards goals. Contractor to provide written updated goals in the Veteran’s clinical record for review by the HCHV Liaison or designee

Performance Requirements

Standard Acceptable Quality Level

(AQL)

Met AQL/Did Not meet CPAR rating/Add Comments

Deliverables Notification of significant events

The contractor shall notify HCHV Liaison/COR of any high-risk situation including Veterans with suicidal and/or homicidal threats or ideation, episodes of physical or sexual violence, sexual activities, safety concerns, drug activities so that appropriate coordination of care can be facilitated.

100% within 24 Hours

Weekly review meeting of Veterans treatment plan and progress towards goals. Contractor to provide verbal notification to HCHV Liaison or designee and written updated goals to be documented in the HCHV CERS clinical record.

Deliverables Safety of Residents and Staff

4-c; 8

Contractor shall notify HCHV Liaison, COR, and/or designee immediately if there are safety concerns related to Veterans or staff.

100% within 24 hours

Weekly review meeting of Veterans treatment plan and progress towards goals. Contractor shall provide written documentation of Veteran safety issues in the HCHV CERS Clinical record and verbal and written updated goals to HCHV Liaison or designee

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):

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.

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.

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.

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).

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.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

________________________________________ DATE: _____________________

Dianne Smith-Foster, MSW, LISW-S, FAC-COR I, COR

SIGNED:

________________________________________ DATE: ____________________

SIGNED:

________________________________________ DATE: ____________________

CONTRACTOR NAME/TITLE