D.4 Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: HUD-VASH Housing Placement and Case Management Services in Marin, Mendocino, Lake, and Sonoma Counties, CA

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

Contract Description: An agency contracts with San Francisco VA to provide case management and housing placement services to Veterans in the HUD/VASH program based at the Santa Rosa Community-Based Outpatient Clinci (CBOC) and serving HUD-VASH enrolled veterasn in Marin, Mendocino, lake, and Sonoma CA Counties.

Contractor’s Name: <Program 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 Material Management

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: <Upon Award, Government will enter name>

c. Other Key Government Personnel – - <Upon award, Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COTR to monitor performance.>

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – <Upon Award, Government will enter name>

b. Other Contractor Personnel – <Upon Award, Government will enter name>

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 Section x, pp.xx 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).

Performance Indicators

PWS

Ref Performance Measure

Acceptable Level of Quality

Method of Assessment

Psychosocial Assessment

3.4.3.1. Psychosocial Assessment: The

contractor case manager is responsible for utilizing the “Social Work Psychosocial Assessment Note” template in CPRS. This assessment will be completed before the Veteran receives the HUD-VASH voucher from the local Public Housing Authority. The psychosocial assessment is updated when there are significant changes in the Veteran’s status or condition, but at a minimum of once every year.

100% Quarterly chart review

Social Work Treatment Plan

3.4.3.2. Social Work Treatment Plan: The

contractor case manager is

100% Quarterly chart review

3.4.3.3.

responsible for utilizing the “HUD- VASH SW Treatment Plan Note” template and progress note title in CPRS. The SW Treatment Plan will be completed at the same time the initial Psychosocial Assessment is completed. In addition, the case manager will use a collaborative approach in completing the plan with the Veteran. The Treatment Plan should be updated annually or when there are significant changes in the Veteran’s status or condition. For example, when Veteran goes from homeless to permanent housing, this is considered “significant change” and a review and update in Treatment Plan is required. Care should be taken to develop measurable goals, which are revisited during regular meetings between the case manager and the Veteran.

Contractor shall review the Treatment Plan at least every ninety (90 days) in a clinical meeting with VA Liaison and document changes in treatment plans in consultation with the Veteran and the VA liaison.

Patient Visits 4.2.1. The minimum frequency of home visits with Veterans are based on acuity level 2-5 frequncy of case management visit requirements (attachment 8) and will be followed accordingly. Acuity levels should be updated as needed, but at a minimum Quarterly with VA Liaison and Contractor. No changes in acuity level will occur without concurrence from VA liaison.

100% Quarterly chart review

Assistance with Finding and maintaining Housing

7.1.3

7.1.4

Accompany Veteran to any Public Housing Authority appointments including annual certifications, briefings, and interim appointments.

Contractor shall assist Veteran in completing and submitting PHA and other Federal, local and state entitlement program paperwork (e.g.

Social Security, food stamps, utility assistance, etc.)

Advocate with landlords on behalf of the Veteran to maintain a lease and advise any potential landlords that the contractor shall be providing assistance and case management and case conferences services to the Veteran in order to help the Veteran remain successfully housed. Contractor shall ensure that the Veteran has completed the VA release of permitted information so communication between the landlord, Contractor, and VA can occur as needed.

Life Skills Education

14. Contractor shall provide life skills education and assistance to Veterans that include:

a. Budgeting/Money Management Assistance

b. Locating local food banks

c. How to use coupons

d. Budget billing for utilities

e. Advice on how to maintain a clean and safe residence

f. Socialization

g. Spirituality – where and how to access these services if desired

h. Schedule of free/low cost community activities

i. Planned evening and weekend

Psychosocial events

j. Community volunteer opportunities

k. Peer/tenant support group

l. Instruction on how to be a good neighbor/tenant

m. Mental Health Wellness Self-

Management / mental health recovery living skills (if applicable)

n. Relapse prevention and harm reduction (if applicable)

o. Healthy lifestyle/living

p. Access to community resources

q. Parenting/family living skills (if applicable)

r. Family reunification and/or development of relevant social support networks

s. Assist with obtaining legal assistance-free/low cost resources such as:

t. Obtaining a driver’s license

u. Locating child support

v. Identifying the local liaison with

VJO (Veterans Justice Outreach) program

w. Locating the local specialty or treatment court

x. Assistance with light house cleaning, shopping, and cooking.

Documentation in Medical Record

2.1.13.

2.1.19.

Contractor will receive cases from HUD-VASH program and will confirm that the Veteran meets the criteria for admission into the HUD-VASH program, which includes ability to live independently. The Contractor must complete Homeless Operations Management and Evaluation (HOMES) documentation, consistent with the HOMES Reporting Policy, including but not limited to changes to admission, housing, voucher, or employment status, and Computerized Patient Records System (CPRS) encounter documentation including but not limited to a screening/admission note, treatment plan, release of information forms, housing service agreement, suicide risk assessment, Advanced Directive Discussions, and safety plan. Contractor shall document using the SOAP format for all clinical notes and ensure all CPRS encounters are entered after the service provided but no later than 72 hours of service in accordance with SFVAHCS HUD- VASH Documentation Policy.

The Contractor shall meet the same performance measures set forth for the VA by the VHA Homeless Program Office located in the technical manual “Performance Measures and Metrics”, this requirement shall include any subsequent updates and/or revisions, to include standards set forth in the VA Supportive Housing Target and Business Rules, including the responsibility to update the Employment Tracker in HOMES, our most recently added performance measure.

Quarterly review of HOMES data

Documentation in HOMES

2.1.15. Contractor shall document Veteran

encounters and change of Veteran status in the HOMES system within 72-hours of occurrence.

100% Quarterly Review of HOMES Data

Negative Incidents

3.4.6.

12.1.

Contractor will notify SFVA of any negative incident occurring with Veteran within one (1) working hour of being aware of the incident.

Contractor will complete a written incident report within eight (8) working hours of notification, which may include VA Report of Contact documentation. Incidents include but are not limited to: death, fire, drug / police raid, suicide / suicide attempt, 911 call (police / fire dept. / paramedics / other), severe medical illness / emergency, severe psychiatric illness / emergency, sexual assault, act of violence by Veteran against other(s), abusive behavior by Veteran against staff, act of violence by other(s) against Veteran, abusive behavior by staff against veteran, accident, medication problems or adverse drug reactions, or other untoward events.

100% Receipt of Incident Reports and

QuarterlyChart Review

VA

Collaboration and Case Coordination

2.1.18. Contractor shall participate in and

coordinate with the VA COR/Liaison during weekly case conferences regarding updates and changes in the Veteran’s care plans to foster a collaborative relationship with the VA and Contractor in meeting the Veteran’s needs. Case conferencing may be done in person or by telephonic conference calls as determined by the VA COR.

100% Direct Observation

Staff and Credentialing

2.1.9.

16.2.

16.3.7.

2.1.2

The Contractor shall provide full staffing as outlined in contract within 60 days of the contract award either through existing staff or new hires.

The Contractor personnel shall maintain active standings with the licensing boards governing their respective professions.

Team staff composition must include case managers with credentials of Masters Level Social Worker (MSW), Licensed Clinical Social Workers (LCSW), Masters Level Marriage and Family Therapists (MFT) or Licensed Marriage and Family Therapists (LMFT). Team staff composition may be a combination of MFT, LMFT, MSW, and LCSW. The contractor Supervisor must be a Licensed

100% Review of staffing plan, licensure website; Viewing licensure document.

5. METHODS OF QASP SURVEILLANCE

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

a. QUARTERLY CHART REVIEW: Supervisor will randomly review a selection of worker’s progress notes in CPRS (electronic medical record) and productivity record.

• Psychosocial Assessment

• Social WorkTreatment Plan

• Patient Visits

• Assistance with Finding Housing

• Documentation in Medical Record

• Negative Incidents

b. QUARTERLY REVIEW OF HOMES DATA: Supervisor will review the HOMES data to ensure Veteran information is entered timely.

• Documentation in HOMES

d. CASE CONFERENCES: Discussion of housing search process.

• Assistance with Finding Housing

e. REVIEW OF STAFFING: Supervisor will review staffing assigned to HUD VASH and review California BBS Website for California LCSW for agency workers; other state websites for out-of-state licensure/ certifications.

• Staffing

f. VIEWING LICENSURE DOCUMENT: Supervisor will ask the agency for a copy of the current license.

16.4.1.

Clinical Social Worker (LCSW) or Licensed marriage and Family Therapist. Unlicensed MSW and MFT staff shall register with an accredited state licensing board and be working to obtain official license in accord with state board regulations.

Staffing responsibilities are described as follows:

LCSW, MSW, LMFT, and MFT, including an LCSW or LMFT contract supervisor, must be full-time on staff and assigned to the HUD-VASH contract. Schedule must permit 24-hour supervision of case management personnel for the purposes of clinical oversight, documentation and crisis management. The licensed independent practitioner must be available for team conferences as requested by the local VA Medical Center HUD-VASH program.

• Staffing

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:

EXCEPTIONAL:

96-100%

Performance significantly exceeds contract requirements to the Government’s benefit.

SATISFACTORY:

91-95%

Performance meets contractual requirements.

UNSATISFACTORY:

Below 95%

Performance does not meet contractual requirements.

7. 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

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 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 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 or designee shall confer with the contractor quarterly to assess performance and shall provide a written assessment.

<After award, both the contractor’s Program Manager and the COR shall sign this document.>

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative

Attachments:

1. Contract Performance Report

2. Contract Discrepancy Report

Attachment 1

Contract Performance Report

1. Contract Number:

2. Prepared by: (Name of COR) <insert name>

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 Representative Date

Attachment 2

Contract Discrepancy Report (CDR)

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

FROM: (Name of COR) <insert name>

1. Contract Number: <insert number>

2. Date and time observed discrepancy:

3. Discrepancy/Problem/Issue:

<Describe in detail. Identify any attachments.>

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 Representative Date

Received by:

Signature – Contracting Program Manager or Onsite Representative Date

Distribution:

<Name & Title - Contracting Officer>

<The COR 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.>