D.1 Quality Assurance Surveillance Plan QASP FY2023 02.docx

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.

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:

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: Courtney Stepp

Organization or Agency: Cincinnati VA Medical Center

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternative:

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. 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 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).

QASP PERFORMANCE REPORT DATE: __________________

The goal of service plans should be housing focused but also stabilization of mental health/substance use disorder.

· Cincinnati CERS liaison, or designee, will conduct random review of HMIS data to ensure this requirement is correct

The contractor shall comply with the principles listed in 38 CFR 17.707(b) to provide housing and supportive services in a manner that is free from discrimination

· CERS liaison will review admissions/deflections with contractor weekly

Upon review of HCHV CERS, discharge forms will be monitored Veteran’s LOS will not exceed 90 days without approval from VA.

At least 55% of Veterans will exit to permanent housing. No more than 20% will exit have negative exits

Case Management/Supportive Services: section 6 paragraphs d1-d16

Contracted Program will provide individual case management and/or professional counseling, including counseling on stabilizing housing, increasing income and increased access to medical /mental health treatment through the VA or other agencies. The goals of case management may also focus on developing successful living patterns, maintaining an acceptable level of personal hygiene and grooming, and achieving a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

The goal of case management services is to help Veterans obtain permanent housing that they will be able to maintain. Education will be provided to Veterans regarding how to obtain low-cost housing

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

Contractor HCHV case manager must provide weekly case management services to all Veterans at CERS

· Care Plan reviews

· Interview with Veterans

· HSR Safety plan review

Veteran Satisfaction section 4 paragraph a

All Veteran complaints are resolved in a timely manner by the contractor.

Veterans’ complaints about the quality of care are measured by an evaluation form administered by the COR or designee.

Discharge Planning: section 8 paragraphs a, f, g

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

100% of Veterans must have a discharge plan within two weeks of admission which integrates permanent housing options

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

Cincinnati CERS liaison, or designee, to be notified of discharge within 24 business hours.

95% during quarterly rating period

· Documentation in Care Plan

· Care Plan reviews

· Interview with Veterans

· On a quarterly basis, CERS Liaison, or designee, ensures 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.

Assault (to Veteran or staff), Elderly/dependent adult abuse or neglect, sexual assault, fire (Veteran involved), medical/psychiatric emergency, hospitalization, suicide or suicide attempt, homicide, death, infectious control, active substance abuse, possession of weapons

Contractor must record Veteran attendance

It is the Contractor’s responsibility to have appropriate systems of verification of services in place to justify invoices and payments.

Site visits by VA staff will periodically include a spot check of records to ensure Contractor invoices accurately reflect the Veteran’s length of stay.

Personnel section 7 paragraphs 1-6

The contractor will employ sufficient personnel to carry out the policies, responsibilities, and the program for the facility. There must be, at a minimum, at least one administrative staff member, or Designee of equivalent professional capability, on duty on the premises or residing at the facility and available for emergencies 24 hours a day, 7 days a week. The Contractor shall assign to this contract personnel that by education and training (and, when required, certification or licensure) are qualified to provide the Basic Services and Supplemental Services required by this SOW.

1. Facility Staff is fully trained and Staffed 24 hours a day, 7 days a week

2. 100% of Staff receive training on the following topics 1 time per year

· CPR

· First Aid

· Crisis intervention

· Cultural sensitivity

· Sexual harassment

· Sensitivity to wider issues of homelessness

· Universal Precautions (disease transmission prevention)

· Child abuse/neglect reporting laws (if shelter provides services to children)

· Adult abuse/neglect reporting laws

· Harm Reduction philosophy

· Suicide Prevention

· Medication management

· State and Federal Fair Housing Law and ADA Requirements

· Conflict resolution

· De-escalation techniques

· Search and Seizure/Probable Cause in the Shelter Setting

3. Key Personnel’s resumes must be submitted prior to contract being awarded and as Staff changes. Contractors must submit Staff resume for any key staffing changes within 14 days of Staff change.

100% during quarterly rating period

· Documentation in Care Plan

· Review of policies

· Interview with Veterans

· Validated Staff/Veteran complaints

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).

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.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

________________________________________ DATE: ______________________

Joshua Runtenelli, COR

SIGNED:

________________________________________ DATE: ______________________

Courtney Stepp, Alternate COR

SIGNED:

________________________________________ DATE: ______________________

Contractor’s Representative