D.1 Quality Assurance Surveillance Plan (QASP).pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Healthcare for Homeless Veterans Transitional Housing

Contract Number: < Upon award, Government will enter contract number>

Contract Description: The contractor shall provide 20 Residential Contract beds for Veterans enrolled in the HCHV Program. The contractor will also provide therapeutic and supportive services, room and board, and laundry facilities.

Contractor’s name: <Enter your company name.> (hereafter referred to as the contractor).

1. PURPOSE

To specify the systematic methods for evaluating performance of the Health Care for Homeless Veterans (HCHV) program.

A. Scope:

Transitional Housing program will provide immediate housing to eligible Veterans enrolled in and referred by the HCHV Program. The contractor will provide the following:

ROOM AND BOARD: Room and Board to include a bed and other furnishings such as a dresser, storage, and personal linens (towels and bed sheets). Meals to include two (2) nutritionally adequate meals a day, 7 days a week and availability of nutritious snacks between meals and bedtime for those requiring or desiring additional food, when it is not medically contraindicated.

LAUNDRY FACILITIES: Laundry facilities for residents to do their own laundry or to have laundry done.

THERAPEUTIC AND SUPPORTIVE SERVICES: Therapeutic and Supportive Services determined to be needed by each individual Veteran referred for treatment as stated in the plan developed by the contractor, with input from the Veteran and the VA HCHV Program Coordinator (or designee). Services which the contractor shall furnish:

(1) Structured group activities as appropriate - examples include group therapy, social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling and physical activities as appropriate.

(2) Collaboration with the VA program staff, which will provide supportive psychosocial services.

(3) Individual professional counseling, including counseling on self-care skills, adaptive coping skills and, as appropriate, vocational rehabilitation counseling, in collaboration with VA program and community resources.

(4) Assistance to develop responsible living patterns, to maintain an acceptable level of personal hygiene and grooming, and to achieve a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

(5) Support for an alcohol/drug abuse-free lifestyle provided in an environment conducive to social interaction and the fullest development of the resident's potential.

(6) Assistance to gain and to apply knowledge of the illness/recovery process in an environment supportive of recovery models.

(7) A program that promotes community interaction.

In addition, the Contractor shall collaborate with the VA program staff, who will conduct treatment and discharge planning reflecting a team assessment of health, psychosocial and vocational needs and the involvement of residents' families and appropriate community resources in resolving problems and setting goals. The Contractor shall have the right to discharge beneficiaries to preserve the health and safety of other beneficiaries and staff. The HCHV Coordinator will be immediately notified of such discharge by the next business day. Other routine discharges due to rule violations will be cleared through the HCHV Coordinator. In emergent situations, the contractor will evaluate and link veterans to an appropriated level of care management.

The Contractor shall maintain an individual record on each veteran placed in the facility by the HCHV Program. The Contractor shall comply with the requirements of the Confidentiality of Medical Records (38 USC 4132) and the Confidentiality of Alcohol and Drug use of a veteran (42 CFR part II) when appropriate and is considered a part of this contract. All case records will be made available on a need to know basis to appropriate VAMC staff members involved with the treatment program of the veteran concerned.

B. Monitoring of Facility and Program:

Prior to the award of a contract and annually during the contract term, a multidisciplinary VA team consisting of a social worker, dietitian, registered nurse, a representative of the VA Police, and a Facilities Management Safety Officer, and other subject matter experts as determined necessary by the medical center director or HCHV Coordinator shall conduct a survey of the Contractor’s facilities to be used to provide Veterans food, shelter, and therapeutic services to assure the facility provides quality care in a safe environment.

Inspections may also be carried out at such other times as deemed necessary by the Department of Veterans Affairs.

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: Bennett Smith Assigned CS: Phyllis Shealey

Organization or Agency: Department of Veterans Affairs, Network Contracting Office 16, Overton Brooks VA Medical Center

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: Kelly Herpin

c. Other Key Government Personnel – Other HCHV staff

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager - <Enter name.>

b. Other Contractor Personnel - <Enter name(s) or delete these lines if not applicable> Title: <Enter title(s) or delete these lines if not applicable.>

4. PERFORMANCE STANDARDS

The Contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement.

These thresholds are critical to mission success.

Performance Objective

Standard

Performance

Threshold

Method of Surveillance

Room and board to include a bed and other furnishings such as a dresser, storage, and personal linens. Meals to include at least two nutritionally adequate meals a day, 7 days a

Daily

95%

Monthly menus are to be submitted for approval by Healthcare for Homeless Veterans Case Manager.

week and availability of nutritious snacks between meals and bedtime. Meal and snack choices must include foods appropriate options for diabetic and hypertension diets.

Observation and random inspection.

Availability of laundry facilities for residents to do their own laundry or to have.

100%

Observation and random inspections

Therapeutic and Rehabilitative Services determined to be needed by each individual Veteran referred for treatment as stated in the plan developed by the contractor, with input from the Veteran and the VA Homeless Program Coordinator (or designee).

100%

Observation, random inspection and progress review

Assistance to develop responsible living patterns, to maintain an acceptable level of personal hygiene and grooming, and to achieve a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships

Daily 100% . Observation, random inspection and progress review

Confidentiality of all patient information

Daily 100% Observation and random inspection

Compliant with the NFPA life safety code

At all times 100% Observation and random inspection

Contract personnel will be, by education and training, qualified to provide the Basic Services and Supplemental Services

At all times 95% Observation and random inspection

5. INCENTIVES

The Government shall use Renewed Ordering Periods as incentives.

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. (Can be performed periodically or through 100% surveillance.)

1-14

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

1-14

d. PROGRESS MEETINGS.

Monthly meeting with Contracting staff and Veterans.

3 & 6

8. 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:

9. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

Direct observation, periodic inspections, and progress meetings.

Quarterly Reports will be used to reflect the rating of “exceeds, meets, or does not meet a given standard. These reports will be combined to incorporate into the annual inspection assessment.

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

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 COR. The Government shall review the contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

10. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature –Contractor

Signature – Contracting Officer’s Representative

Signature – Contracting Officer