D1 Quality Assurance Surveillance Plan.pdf

F Y12020Q4

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) FY25

Housing Contract: Agency:

QTR

ID Indicator Standard

Acceptable

Quality

Level

Method of Surveillance Rating

1.

Room and Board, including at least three

(3) nutritionally adequate meals a day, 7 days a week and availability of nutritious snacks between meals and bedtime for those requiring or desiring additional food, when it is not medically contraindicated.

Special diets are available for diagnosed medical conditions.

(Reference PWS Section

B)

Upon admission to the program, all services will be provided to each veteran.

100%

Direct Observation, periodic and random inspection (auditing)

Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

[ ] Unsatisfactory

Comments:

2.

(1)Develop an Individualized Service Plan (ISP) with Veteran within the first week of placement, consistent with personal and HCHV program goals, to include plans for placement in transitional or permanent housing within 90 to 180 days of placement for Contract Residential Services, depending on the assessed functional and cognitive capacity of Veteran. (Reference

PWS B 2 (1)

Within 5 business days of admission to the program, all services will be provided to each veteran as indicated by the plan of care.

95%

Direct Observation, periodic and random inspection (auditing)

Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

[ ] Unsatisfactory

Comments:

ID Indicator Standard

Acceptable

Quality

Level

Method of Surveillance Rating

3. Housing (Reference PWS Page 6, Section j)

Upon discharge, status of housing should be reported to the VA Medical

Center under the following categories:

1. Having one’s own apartment, room or house

2. Halfway

House/Institution/o ther residential level of care

3. None

4. Unknown/Other

95%

Direct Observation

(weekly), periodic and random inspection

(auditing)

Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

[ ] Unsatisfactory

Comments:

4. Summary of Veterans’

Responses to all services

(Reference PWS Page

6, Section j)

Upon discharge, a written summary of services will be provided and will include Veterans responses to services within 72 hours of discharge.

Some areas that could be included are:

1. Personal Hygiene

2. Participation in residence activities

3. Response to Case

Management

4. Social/Vocational

Activities

95%

Direct Observation

(weekly), periodic and random inspection

(auditing)

Exceptional

Very Good

Satisfactory

Marginal

Unsatisfactory

Acceptable

Quality

Level

Method of Surveillance Rating

5.

HCHV1:% Exits to Permanent Housing (Reference PWS Page 11, Section i)

Percentage of

Veterans discharged from HCHV CRS programs to permanent housing.

The FY 2025 target is 55% or higher.

This percentage is subject to change based on VACO

HCHV CR program regulations. If there is a change, the

HCHV CR Liaison will communicate any changes to the contractor within 30 days.

55+%

Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

Acceptable

Quality

Level

Method of Surveillance Rating

6.

HCHV2:% Negative Exits (Reference PWS Page 6, Section j)

Percentage of

Veterans with a negative exit from

VHA Health Care for

Homeless Veterans

Contracted

Residential Service

(HCHV CRS) or Low

Demand Safe Haven

(LDSH) programs.

The FY 2025 target is 20%. Lower is better. This percentage is subject to change based on VACO

HCHV CR program regulations. If there is a change, the

HCHV CR Liaison will communicate any changes to the contractor within 30 days.

20% and below

(lower is better)

[ ] Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

Acceptable

Quality

Level

Method of Surveillance Rating

7.

Management of program dropout

(Reference PWS

Page 18, Section

10)

All facilities will encourage Veterans to complete their agreed upon recovery plans prior to discharge.

Outreach efforts

(telephone calls) will be made to encourage AWOL

Veterans to return to the facility, per requirements of

PWS, and documented in

Veteran case record

[ ] Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

[ ] Unsatisfactory

Comments:

Direct Observation

(weekly), periodic inspection (auditing)

8.

All facilities shall be able to meet occupancy requirements as indicated by the licensing authority having jurisdiction and NFPA’s Life

Safety Code as indicated by the VA

Medical Center

Chief, Facilities

Management.

97%

Direct Observation

(annual), periodic and random inspection

(auditing)

Exceptional

Licensing/

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

[ ] Unsatisfactory

Comments:

Occupancy

Certificates

(Reference PWS Page

20, Section 9)

ID

Indicator

Standard

Quality

Level

Method of Surveillance Rating

9.

Patient safety incidents (any event that generates an internal incident report by the contractor) shall be reported to the authorizing VA HCHV liaison via telephone/voicemail within 24 hours.

5, Section i)

All incidents reported within 24 hours.

100%

Direct Observation

(weekly), periodic and random inspection

(auditing)

[ ] Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

10.

Patient safety incidents (any event that generates an internal incident report by the contractor) shall be reported to the authorizing VA HCHV liaison via voicemail within 24 hours.

5, Section i)

All incidents are investigated, confirmed and resolved.

100%

Observation, periodic and random inspection

(auditing)

[ ] Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

11.

Patient complaints about the quality of care are reported to the HCHV Liaison, local Behavioral

Health and Medical

Center Leadership, CAVHS Patient

Advocate, the COR, and the Contractor for resolution.

19, Section 11)

All patient complaints are reported within 24 hours.

99%

User survey, observation and random inspection (auditing)

Exceptional

[ ] Very Good

[ ] Satisfactory

[ ] Marginal

ID

Indicator

Standard

Quality

Level

Method of Surveillance Rating

Exceptional

[ ] Very Good

12.

Providers and staff are familiarized with the process outlined in contractor’s grievance procedures as well as patient rights.

5, Section e)

All providers and staff are educated.

95%

User survey, observation, and random inspection

(auditing)

[ ] Satisfactory

[ ] Marginal

RATINGS

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 method used to notify the contractor of the contractual deficiency.

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 methods used to notify the contractor of the contractual deficiency.