D.11 Quality Assurance Surveillance Plan QASP-.docx

QUALITY ASSURANCE

SURVEILLANCE PLAN

POP ___

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

Healthcare for Homeless Veterans (HCHV) Contracted Emergency Residential Services (CERS) Low Demand Safe Haven (LDSH)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contracted programs’ activities while implementing this Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring the Contractor’s performance.

The QASP provides a systematic method to evaluate the services the Contractor is required to furnish.

This QASP is based on the premise, the Government desires to maintain a quality standard in providing emergency housing and supportive services to its Veterans. The resulting contract is considered the best means of achieving that objective.

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 and the fidelity of the awarded contract is conserved.

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 aspect is the driver for product quality. The Contractor is required to develop a comprehensive program of required services, 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.

· How often 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. Copies of the original QASP and revisions shall be provided to the Contractor and Government officials implementing surveillance activities.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

PERFORMANCE STANDARDS

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 and disincentives. 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.

SURVEILLANCE: The Government Quality Assurance (QA) person and the COR shall use the surveillance methods listed below in the administration of this QASP.

a. Direct Observation. Direct observation shall be performed periodically or through 100% surveillance. All Performance Standards

b. Periodic Inspection. Evaluate outcomes on a periodic basis. Inspections may be scheduled Daily, Weekly, Monthly, Quarterly, Annually or unscheduled, as required. All Performance Standards

c. Progress or status meetings. All Performance Standards

d. Complaints. Complaints from agency personnel shall be passed to the Contractor's Quality Control Inspector (QCI) for correction. All Performance Standards

STANDARD: Customer complaints shall not exceed the thresholds cited above for each performance objective. The Government’s QA personnel shall notify the Contracting Officer for appropriate action in accordance with FAR 52.212.4, Contract Terms and Conditions-Commercial Items (May 1997) or the appropriate Inspection of Services clause, if any of the above service areas exceed the customer complaint thresholds.

DOCUMENTING PERFORMANCE

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

b. Unacceptable performance: When unacceptable performance occurs, the COR shall inform the Contractor. This shall 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.

The COR will review with the Contractor any discrepancies, concerns or non-compliance and follow up with formal written communication if the concern cannot be resolved within 72hours and shall specify if the Contractor is required to prepare a Corrective Action Plan (CAP) to document how the Contractor shall correct the unacceptable performance and avoid a recurrence. The correspondence shall also state how long after receipt the Contractor has to present this CAP to the COR. The Government shall review the Contractor's CAP to determine acceptability.

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

SURVEILLANCE: The Government evaluator shall evaluate the services required by each delivery/task order to ensure complete compliance.

PROCEDURES: The Government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the Performance Work Statement (PWS) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If the inspection indicates unacceptable performance, the Government evaluator shall notify the CO and/or QCI of the deficiencies within 3 business days and have QCI correct said deficiencies. The Contractor shall be given notification to correct the deficiencies within a 30 days or, on a case-by-case basis. The CO shall have the final authority on the amount of time the Contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

FREQUENCY OF MEASUREMENT: During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings will be conducted quarterly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s files

The COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative

Signature – Contracting Officer

CONTRACT INTEGRITY:

Inspections VA will conduct an inspection of the Contractor’s facilities to evaluate the Veteran’s food, shelter, safety, medication procedures and therapeutic services to assure the facility provides quality care in a safe and sober environment.

Unannounced site visits HCHV CRS National requires these visits to evaluate quality of services, safety, cleanliness of the site and chart reviews.

1. Annual approved/passed inspects (and as needed).

2. Quarterly unannounced site visits.

100% during quarterly rating period

· Multidisciplinary team to evaluate the Contracted program yearly based upon standards regarding: Facilities, Law, Nursing, Nutrition and Clinical components.

· COR/HCHV CRS Liaison to review directive standards to ensure Contractor is in compliance.

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

ADMISSIONS, LENGTH OF STAY, AND DISCHARGES

Occupancy It is expected that Contractor beds will be maintained at an average minimum of an 85% occupancy rate but at a preferred rate of 90% as calculated based upon number of bed nights available per POP. If this rate is not consistently attained a Performance Improvement Plan (PIP) will be developed by the Contractor as part of the QASP. This will be reviewed weekly during the meeting minutes conference.

Outreach Contractor outreach should include street outreach efforts and are not inclusive of Veteran referrals gained through in-reaching at the Welcome Center or other VA clinics.

Same Day Admission The Contractor shall provide Veterans SAME DAY admission to housing and services to 9pm daily from direct referrals and VA consults. For any direct referral placement denials, Contractor to provide reason.

1. Occupancy shall be equal to or greater than 85% throughout the quarter.

2. Perform Outreach in the community at minimum 2x/week to ensure appropriate occupancy

3. Document outreach efforts monthly

4. Denial Tracker, forwarded every Monday by 9am.

100% during quarterly rating period

· Review of HOMES data and monthly billing.

· Sign-in logs.

· Informal review of outreach events.

· Reviewing the daily census and monthly billing. Consult with Contractor regarding direct referral denials.

· Occupancy rates reviewed weekly during meeting minutes conference.

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

ADMISSIONS, LENGTH OF STAY, AND DISCHARGES:

Patient Rights The Contractor shall have reasonable rules governing life and activities in the facility. Veterans will be provided a copy of the rules at intake. Contractor will post the rules in a location readily accessible to Veterans and visitors. These rules must include detailed Patient Rights and the procedures that the Contractor has in place to protect the Veterans rights and dignity. This includes reasonable accommodation compliance in accordance with the Americans with Disabilities Act, the Federal Fair Housing Amendments Act, and the California Fair Employment and Housing Act.

All Veterans must receive an intake packet within 36 business hours of their admission.

1. 100% of Veterans receive education about and written information on the following upon intake:

· Patient rights

· Nature of the Contractors program (i.e. services: Curfew Policy and Bed Check, etc)

· Reasonable Accommodation

· Procedures for negative discharge and sanctions

· Grievance and Appeal procedures

· Release of Information form

· Pet Policy, if applicable

· Fire Drill/Disaster Plans Policy

· Evacuation Plan for emergencies for alternate location and resident accountability.

All policies pertaining to the above is posted conspicuously in contracted facility

· Review of policies

· Review of intake packet

· Interview with Veterans

· Validated Staff/Veteran complaints

· Daily census is managed if Veterans are relocated

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

THERAPEUTIC AND REHABILITATIVE SERVICES:

Group Activities:

Examples include permanent housing search groups, financial management classes, group therapy, social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling and physical activities as appropriate. The focus of these groups will be to provide Veterans assistance in developing successful living patterns, maintaining an acceptable level of personal hygiene and grooming, and to achieving a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

1. Contractor shall provide 4 groups/month.

2. 75% of Veterans will participate in group activities 2 x per month. To be led by Contractor, or by outside entity such as AA, agency will monitor and collate sign-in sheets and document.

100% during quarterly rating period

· Contractor must maintain sign in logs for attendance/evidence of groups, to be reviewed.

· Documentation added in Veteran’s program chart reviews.

· Interview with Veterans

· Review of monthly activity calendar.

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

THERAPEUTIC AND REHABILITATIVE SERVICES Case Management:

The Contractor 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 Contractor will work with admitted Veterans to create an Individualized Service Plan (ISP) reflecting their goals and objectives.

The Contractor will actively participate in Veteran Case Conferences and shall provide HCHV COR Liaison with regular reports on changes in Veteran’s status, including all changes and observations concerning the Veteran’s needs.

CM will also support the Liaison with meeting with the Veteran’s in separate meeting if they are not able to attend the Case Conference.

1. 90% of Veterans who remain in the program will complete an intake with requisite information (see PWS) and written Individual Service Plan (ISP) within one week of program admission.

2. 75% of Veterans will engage in individual case management meetings 1 x per week/4 x per month; all Veteran’s program record are documented in the Veteran’s file.

3. 75% of Veterans will complete a thorough Housing Assessment as outlined in PWS within 72 hours of program admission.

4. ISPs completed for 100% of admitted Veterans whose stay is beyond 7 days it is updated every 30 days.

5. 95% HSR Safety Plans are completed by Contractor and VA liaison within one week of admission and reviewed with veteran on a weekly basis.

6. 100% Case Conferences held monthly or as needed to review all Veterans on the CM case load.

· ISP and Care Plan reviews

· Interview with Veterans

· HSR Safety plan reviewed weekly by the Liaison

· Face to face conferences

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

THERAPEUTIC AND REHABILITATIVE SERVICES:

Permanent Housing Education provided to Veterans regarding how to obtain low cost housing

1. 95% of Veterans will have their housing needs will complete a thorough Housing Assessment within 72 business hours of admission, which will include information outlined in the PWS.

2. 75% of Veterans will be educated about how to obtain a free credit report

3. 75% of Veterans will be educated about “Tenant Portfolio”

4. 75% of Veterans will participate in educational activities and will be provided resources on permanent housing 4 x per month

5. 100% of Veterans housing and discharge plans will be updated/confirmed weekly.

100% during quarterly rating period

· Documentation in Veteran’s program record. Veteran’s program record reviews.

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

THERAPEUTIC AND REHABILITATIVE SERVICES:

Financial Planning:

Contractor will provide counseling on means and methods to increase Veteran’s income through a variety of avenues such as SSI, NSC pension, GR and/or employment opportunities. Counseling may be performed internally or externally.

Counseling or referral records must be kept for both internal counseling and for meetings Veterans participate in off-site.

Employment Services:

Contracted Program will provide a referral to EDD and assist Veteran by providing a job search log with leads when available.

1. 65% of Veterans will have a Financial Plan developed within 30 days of admission

2. 65% of Veterans will participate in ongoing financial planning groups or individual case management with a focus on increasing income 4 x per month

3. 100% of eligible Veterans that are unemployable or do not have income will be referred for NSC pension, VA service connection, SSI benefits, and any other financial benefits within 30 days admission.

4. 100% of eligible Veterans will be referred for employment

5. 65% of eligible Veterans will participate in employment related activities, such as job fairs, resume writing workshop with a focus on obtaining employment.

100% during quarterly rating period

· Documentation in Veteran’s program record and weekly case management notes.

· Veteran’s program record reviews

· Records of Bank Statements

· Award letters from SSI and VA

· Scorecard review

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

THERAPEUTIC AND REHABILITATIVE SERVICES:

Medication Management:

Contractor shall securely store and monitor all medications.

1. 100% of admitted Veterans to surrender their prescribed/OTC medication. If a Veteran requires it on their person, documentation is noted as such.

2. All medication is kept in a lockable cabinet for privacy and safety.

100% during quarterly rating period

· Medication logs are maintained for THP RN review at any time.

· Medication room will be inspected by THP RN at any time.

· Personal locked boxes maintained by the Veterans will be inspected by the THP RN at any time.

THERAPEUTIC AND REHABILITATIVE SERVICES:

Discharge Planning:

Contracted Program’s case managers will provide assistance with discharge planning for every Veteran. Housing needs will be assessed within three (3) days of admission and resources coordinated for discharge to a successful community placement. Securing permanent housing will be the discharge goal for every Veteran and every effort to meet or exceed Performance measures will be made.

1. 100% of Veterans must have a discharge plan within two weeks of admission which integrates permanent housing options

2. 100% of Veterans will be referred to HUD-VASH, SSVF, rapid rehousing, and/or other community housing resources for independent housing within the first month of admission

3. Performance Measures:

· HCHV1 (Ind. Housing)- >55%

· HCHV2 (Neg. Exits) - <20%

· Bed Occupancy 85% or greater

· Length of Stay ≤ 90 Days

· VA Benefit Applications Pending -15%

· Non-VA Benefits Pending -8%

100% during quarterly rating period

· Documentation in Veteran’s program record.

· Veteran’s program record reviews.

· Interview with Veterans

· HOMES data

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

Records and Reports:

VA Coordination:

Contracted Program will provide collaboration with the VA program staff by conducting a meeting 2-4 times per month. These meetings will be held by Contracted Program Staff and VA program staff to discuss how to coordinate services to Veterans enrolled in the program, outreach needs, and program development. In addition to working collaboratively with VA clinical staff, the Contracted Program will submit accurate billing to VA Payment Center by the 10th day of each month.

Procedure for daily accountability:

Veterans to sign in daily during their stay for accountability. Sign-in sheets to be verified by program staff, signed and returned to VA staff for billing verification.

Procedure for intakes:

The Contractor shall provide Veterans SAME DAY admission to housing and services daily to 9pm.

Admissions must be approved by the VA Liaison who will determine eligibility of Veteran prior to no later than 24 hours after admission or next business day.

1) Admission information to be provided to VA staff within 24 business hours of admission. Confirmation email and paperwork to be e-mailed within 24 hours or by the next business days.

Procedure for discharges:

VA staff to be notified of discharge within 24 business hours or next business day. Confirmation email followed by discharge paperwork.

Unexcused Absence:

Contractor reserves the right to discharge Veteran after 24 hours if they have not received prior approval to leave program for that timeframe. Case managers will inform VA staff of any unexcused absence within 24 business hours via email to discuss disposition of Veteran. However, the Contractor is encouraged to hold the bed for 3 days to look for the homeless Veteran prior to discharge; consultation with the assigned liaison is required. Unexcused absences are not paid for by VA.

Excused Absences:

Veterans may be granted an excused absence on a case by case basis. Payment will only be made for the first consecutive 96 hours of an excused absence. Veterans can be out of the program up to 14 consecutive days, however only the first 4 days are paid.

Excused absences are defined as tasks for housing search, hospitalization, short term incarceration, visit to family/family reunification, work-related issues including military requirements and must be pre-approved. Any excused time after consecutive 96 hours will not be billed to the VA. The CERS Liaison may authorize payment for excused absences up to 96 hours.

Timeliness of Response Contractor shall respond to all VA inquiries immediately/at the next available opportunity. Phone calls or emails should be responded to immediately or within 24 hours.

Incident Reporting:

Program staff to report to VA staff incidents within 24 business hours or next business day.

1. Contracted Program will submit accurate billing to Payment Center by the 10th business day of each month.

2. 100% will have signed ROI in case management files

3. 100% of Veterans sign in daily to receive payment for that day

4. 85% of Veterans who are discharged will be reported to the VA within 24 business hours of discharge via email; document attempts of locating the Veteran are allowable up to 3days.

5. 90% of all Veterans discharges will have HOMES discharge paperwork completed within 72 business hours of discharge

6. 90% of critical incidents related to assault, suicidality and death will be reported within 24 business hours

INCIDENTS DEFINED AS:

Falls Assault (to Vet or Staff) Elderly/Dependent Adult Abuse or Neglect Sexual Assault Fire- Patient involved Medical Emergency- 911 Calls Hospitalization Sexual Assault Suicide Suicide Attempt Homicide Death Infectious control (bed bugs, TB, etc.)

Active Substance Abuse Observation/Possession of weapons

100% during quarterly rating period

· COR records

· PWS compliance

· HOMES data

· Review of incident reports

· Review of HR documentation (CPRS)

· Invoices

· Sign-in logs

· Documentation in Veteran’s program record review.

· Interview with Veterans

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

CONTRACT STAFFING:

Personnel The contractor will employ sufficient personnel to carry out the policies, responsibilities, and the program for the facility per contract requirements.

Each position (program manager, clinical supervisor, case managers, monitors and security) will be staffed per contract requirements.

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 PWS.

Staff Training:

The Contractor will provide at least one qualified staff person on-site at all times who is BLS trained.

The Contractor will ensure staff are trained on topics specified within the contract or retrained as requested by the VA.

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 at time of hire and yearly thereafter:

· CPR

· First Aid

· Suicide Prevention

· Cultural sensitivity

· Sensitivity to wider issues of homelessness

· Motivational Interview

· Crisis intervention

· Conflict resolution

· De-escalation techniques

· Boundaries

· Sexual harassment

· Child abuse/neglect reporting laws

· Adult abuse/neglect reporting laws

· Harm Reduction philosophy

· Medication management

· Universal Precautions (disease transmission prevention)

· Search and Seizure/Probable Cause in the Shelter Setting

· State and Federal Fair Housing Law and ADA Requirements

3. Key Personnel’s resumes must be submitted prior to contract being awarded and as Staff changes prior to their employment and for VA approval.

4. Contractor must notify COR/HCHV Liaison in writing within 3 business days if personnel are unable to perform the duties assigned due to death, illness, resignation, or absconding from Contractor’s employ.

5. Contingency plans providing staff coverage and back up in the event of absence or vacancy and forwarded to the Liaison 100% during quarterly rating period

· Documentation in Veteran’s program record

· Review of policies

· Interview with Veterans

· Validated Staff/Veteran complaints

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