D.5 QASP - Health Care Homeless Veterans.pdf

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:

Organization or Agency: Department of Veterans Affairs (VA), Network Contracting Office 23 (NCO 23)

a. 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:

Organization or Agency: St. Cloud VA Health Care System, St. Cloud, MN

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager:

Alternate Program Manager:

36C26325Q0971

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. 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% Inspection : accomplished by physically observing contract performance.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

Government employees may observe work performance, may randomly select patient files, may interview patients.

All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Government employee(s) may observe work performance, may interview patients, and will review any complaints as required or necessary.

d. RANDOM SAMPLING. Patient treatment files to be reviewed will be randomly selected and over the period of services.

All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. The government may review invoices, documentation provided or created by contract employees, or any documentation provided through the contract.

6. QASP PERFORMANCE REPORT DATE:

Measures SOW Reference

Performance Requirement Accept able

Quality Level

Surveillance Method Met AQL/Did Not Meet

AQL- CPARS

RATING/ADD

COMMENTS

Occupancy C. 5. Facility maintains a current occupancy permit and is in compliance with existing State safety codes for health and sanitation.

100% during quarterly rating period

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

Basic Services Room and Board

C. 1. a) At intake, all Veterans will be provided a furnished room including bed, storage such as dresser, shelves, and/or closet, provides linens (sheets and towels), and toiletries.

100% during quarterly rating period

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

Nutrition/Meals C. 1. b) All Veterans will be provided three eating opportunities daily. On weekends holidays/weekends, the contractor has the option of preparing a “brunch” meal in place of breakfast and lunch. Meals will be appropriate to dietary need.

100% during quarterly rating period

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

Laundry C. 1. c) All Veterans have access to laundry facilities, or the program provides laundry services.

100% during quarterly rating period

Informal interviews with Veterans

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

Case Management:

Contracted Program will provide a documented record of individual case management. This will include a documented admission summary reflecting the reason for referral, identifying information including his/her admission date, social/cultural vocational status, family or significant other, goals for change, anticipated length of stay, and a list of prescribed medications.

Documented case management will include counseling on stabilizing

C. 2. 1. 90% of Veterans who remain in the program 72 hours will have an intake with requisite information (see SOW) and written Care Plan.

2. 75% of Veterans will engage in individual case management meetings 4 x per month;

all Care Plans are documented in the client’s file.

3. 95% of Care Plans are completed by Contractor and VA liaison w/in 72 business hours of intake and reviewed bi-monthly.

4. Individual records will comply with requirements of confidentiality to be maintained by the contractor on each Veteran under contract place

100% during quarterly rating period

Documentation in Care Plan

• Quarterly Care Plan reviews

• 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.

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.

Abstinence Support C. 2. b) (1) & (7)

The contractor will demonstrate daily efforts to monitor Veteran use of alcohol or other substances.

100% during quarterly rating period

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

Increased Income C. 2. b) (9) All Veterans are provided with counseling and establish goals related to increasing income, including assessment of vocational goals

100% during quarterly rating period

Documentation in Care Plan

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

Group Activities:

Examples may include permanent housing search groups, financial management classes, group therapy, social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling and physical activities as appropriate.

C. 3. a) (1)

Veterans will be offered and encouraged to 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

100% during quarterly rating period

• Documentation in Care Plan

• Quarterly Care Plan reviews

• 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.

Discharge Planning:

Contracted Program’s case managers will aid with discharge planning for every Veteran. Housing needs will be assessed within five 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 the Target Quality Indicators.

C. 2. (1) Performance/TQI Measures:

• HCHV1 (Ind. Housing)- >40%

• HCHV2 (Neg. Exits) - <30%

• Length of Stay ≤ 63 Days

100% during quarterly rating period

Documentation in Care Plan

• Care Plan 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.

Staffing C. 4. The contractor will employ sufficient professional staff to carry out the policies, responsibilities, and programs of the facility. In a residential living facility, there must be a fulltime administrative staff member or designee of equivalent professional capability on duty, on the premises or residing in facility and available for emergencies 24 hours a day, 7 days a week. The facility will provide adequate staff to provide 24-hour supervision and care.

100% Annual Inspection of facility records.

Veteran report

Staff Training C. 4. b) Contractor will provide at least one staff person on-site at all times who has had training and orientation on the following topics. Staff shall receive and document—at a minimum—one-time training per year on these subjects.

100% of required training shall be provided

Annual inspection of records.

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 clients 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 7th 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:

No admissions will be approved without consent of VA Liaison who will determine eligibility of Veteran prior to admission.

Procedure for discharges:

VA staff to be notified of discharge within 24 business hours.

Confirmation email followed by discharge paperwork.

C. 2. & 3. 1. Contracted Program will submit accurate billing to Payment Center by the 7th 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

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.

100% during quarterly rating period

COR records

• SOW compliance

• NEPEC data

• Review of incident reports

• Review of HR documentation (CPRS)

• Invoices

• Sign-in logs

• Documentation in Care Plan

• Care Plan reviews

• 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.

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. Payment for unexcused absences of up to 48 hours if the program demonstrates assertive outreach to reengage the Veteran.

Excused Absences:

Veterans may be granted an excused absence on a case-by-case basis.

Excused absences are defined as hospitalization, incarceration, visit to family, work related issue pre-approved. The CERS Liaison may authorize payment for excused absences up to 72 hours if there is a compelling medical or mental health need and the excused absence is verified a priori.

Timeliness of Response Contractor will have a dedicated phone line for

VA.

Incident Reporting:

Program staff to report to VA staff incidents 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

Attachment D.1

6. 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):

EXCEPTIONAL: Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

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.

VERY GOOD: Performance meets contractual requirements and exceeds some to the Government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

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.

SATISFACTORY:

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

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.

MARGINAL:

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTORY:

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

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 orEnvironmental Deficiency Reports, or letters).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

7. 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.

See Sample on following page.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE.

(Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER