D.2 Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: Emergency Housing on Oahu

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

Contract Description: VA Pacific Island Health Care System’s Health Care for Homeless Veterans will provide board, room, support and case management in emergency beds for homeless veterans on Oahu to facilitate there recorvery, improve their overall health, stability and housing situation.

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

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. 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: <Upon award, Government will enter name>

Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Materiel Management

b. Contracting Officer’s Technical Representative (COTR) – The COTR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COTR shall keep a quality assurance file. The COTR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COTR: Patrick Maher

c. Other Key Government Personnel -

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager –

b. Other Contractor Personnel –

Title:

4. 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, paragraph A2,A3,A4,A5 in the Performance Work

Statement (PWS), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality

Level (AQL).

Quality Assurance Surveillance Plan (QASP)

Performance Standards

Task

Task

Reference

Performance

Indicator

Standard Acceptable

Quality

Level

Score

90,95, 100%

Surveillance method

2.7.2.

Program

Services-

Occupancy

Contractor will maintain minimum acceptable level of occupancy through collaboration with VA and independent outreach efforts.

VA National Data base occupancy reports for the program shall demonstrate a rate of 80%* or higher for a given quarter.

*Subject to increase per VA

Central office

90% Review of the bed occupancy data per quarter.

2.7.2

.Program

Services-

Eligibility

Contractor staff will follow established

VA protocol for proper admission of clients, including obtaining a Release of

Information (ROI) and submitting to the

VA representative to assure veteran eligibility for VA benefits.

95% of veterans admitted will have a signed Release of Information and VA eligibility determination in the veteran’s case management file.

90% Periodic VA and

Site data review.

Random

Sampling

2.7.2.

Program

Services –

Admission

Contractor staff shall submit the necessary VA admission information and document VA acceptance into the contracted program.

95% will have complete admission information and

VA acceptance in the veteran’s case management file.

2.7.3.

Program Services

Case

Management

-Housing

Support Plan

Contractor staff will complete with the veteran an assessment of needs, including barriers to stable housing and create a Housing Support Plan (HSP) to address and prioritize those concerns within 7 days of admission. In addition

HUD-VASH residents will have a

Collaboration Plan.

95% of veterans will have a completed Housing Support

Plan written by day 7 in the veteran’s case management file. HUD-VASH residents will have a Collaboration

Plan. All will be submitted to the EH VA representative.

90%

Periodic VA and

Site data review.

2.7.3.

Program Services

Case

Management

-Periodic

Reviews

Contractor staff will meet with the veteran to review the veteran’s Housing

Support Plan (HSP) progress including their Financial Plan, Discharge Plan, resource acquisition and access and engagement of appropriate providers of physical and mental health care services.

95% of veterans will have individual case management meetings 3 or more times per month as documented in the veteran’s case management file.

90% Periodic VA and

Site data review.

Random

Sampling

6 2.7.3.1

Program Services

Case

Management-

Resource

Contractor staff will provide direct and ongoing assistance to support the veteran’s access of financial and supportive programs such as SS, SSDI, General Assistance, Food Stamps, VA

95% of veterans who have financial and/or supportive needs identified in their

HSP, will be referred to the appropriate agencies as

90% Periodic VA and

Site Data review.

Acquisition Benefits, Medicaid, employment etc.. as identified in the Housing Support Plan documented in the veteran’s case management file.

2.7.3.1

Case

Management –

Financial Plan and Budgeting

Contractor staff in collaboration with the veteran shall develop an individualized

Financial Plan which reflects employment and non employment income and benefits including the means and methods of increasing monthly income and responsibly managing existing income. This Financial Plan should including identifying needed referrals for both potential benefits and employment assistance.

90% of eligible veterans will have a Financial Plan developed within 7 days of admission.

2.7.3.7

Case

Management -

Veteran’s

Progress Note

Submission

Contractor staff will collaborate regularly with the VA liaison to ensure the awareness of the veteran’s progress toward the desired outcomes outlined in the Housing Support Plan. A monthly progress note on that progress and the efforts of the veteran and contractor shall be submitted monthly.

The program will provide to the VA Representative a monthly written status reports on the veterans in program.

2.7.3.8a

Case

Management

-Positive

Discharge

Outcomes

Contractor staff will target 50% or more of discharges from Emergency Housing are positive to permanent housing.

50%* or more of veteran discharges per quarter will be to a positive move to permanent housing.

*Subject to an increase per

VA Central Office.

SIte data review.

10 2.7.3.8c

- Case

Management

-Negative

Discharge

Outcomes

Contractor staff will target 20% or less of discharges from Emergency Housing are negative.

20%* or less of veteran discharges per quarter will be negative.

*Subject to a decrease per

VA Central Office

SIte data review.

2.7.3.9

Program Services

Case

Management

-Reporting and

Consumer

Satisfaction

Contractor staff shall distribute and encourage the completion of the

Consumer Satisfaction uSPEQ questionnaire or other VA requested tool to eligible veterans and return to the VA

Contract Housing Coordinator.

25% of veterans who have resided in the program for longer than 14 days will have completed and submitted thru the program a uSPEQ questionnaire.

100% Receipt of

Questionnaires per quarter per veteran’s length of stay.

12 2.3.3.11

Program Services

Case

Management –

Length of Stay

Contractor staff will limit the veteran stays in Emergency Housing to 90 days unless authorized by the VA EH representative.

100% of veterans will be limited to 90 day stays unless authorized by the VA representative.

3.3.1

Contractor Staff

– On-site

Staffing

Contractor will have a qualified designated staff person on duty at the approved site 24hrs. a day, 7 days a week.

100% of the time a qualified staff person will be on duty at the approved site.

100% Periodic

Inspection

3.4

Contractor Staff -

Training

Contractor will assign staff to this contract who have at minimum received initial and periodic training in the areas required in this contract.

100% of all assign staff will have receive initial and period traing as demonstrated by the submission of a training log annually..

100% Training log submission

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COTR shall use the surveillance methods listed below in the administration of this QASP.

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

Admission Protocol

Case Management

Improvement of Financial

Group Activities

Discharge Protocol

Veteran Safety

Invoicing

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled

[Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

Occupancy

Admission Protocol

Care Planning’

Case Management

Improvement of Financial Situation

Group Activities

Discharge Planning

Discharge Protocol

VA Coordination

c. USER SURVEY. (Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.)

Reporting and Consumer Satisfaction

d. PERIODIC SAMPLING. (Variation of random sampling. However, sample is only taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected. Since sample is not entirely random, it cannot be applied to total activity performance.)

Veteran Safety

e. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.

Admission Protocol

Care Planning

Case Management

Group Activities

Discharge Planning

Discharge Protocol

VA Coordination

f. Analysis of contractor's progress reports.

6. 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:

100% Positive Performance

95% Neutral Performance

90% Negatuve Performance

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE (100% Rating)

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

b. UNACCEPTABLE PERFORMANCE (90% Rating)

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

When the COTR determines formal written communication is required, the COTR 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 COTR. 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.

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

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

b. Frequency of Performance Assessment Meetings.

The COTR shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Technical Representative

Attachments:

1. Contract Performance Report

2. Contract Discrepancy Report

Attachment 1

Contract Performance Report

1. Contract Number: <insert number>

2. Prepared by: (Name of COTR) Patrick Maher

3. Date and time of observation:

4. Observation:

<Examples of items to include in a report are:

• Method of surveillance.

• How frequently you conducted surveillance.

• Surveillance results.

• Number of observations.>

5. Performance Rating (in accordance with QASP, paragraph 6):

Signature – Contracting Officer’s Technical Representative Date

Attachment 2

Contract Discrepancy Report (CDR)

TO: (Contractor Program Manager or onsite representative) <insert name>

FROM: (Name of COTR) Patrick Maher

1. Contract Number: <insert number>

2. Date and time observed discrepancy:

3. Discrepancy/Problem/Issue:

4. Corrective action plan:

5. A written corrective action plan <is/is not> required. <If a written corrective action plan is required include the following.> The written Corrective Action Plan will be provided to the undersigned not later than

<# days after receipt of this CDR.>

Signature – Contracting Officer’s Technical Representative Date

Received by:

Signature – Contracting Program Manager or Onsite Representative Date

Distribution:

<Name & Title - Contracting Officer>

<The COTR may initiate a CDR at any time, including whenever the number of monthly recorded defects for a performance standard exceeds the allowable number of defects; anytime unacceptable performance is determined critical in nature and requires formal corrective action; and whenever an unfavorable trend is detected in contractor performance.>