FRESNO HCHV QUALITY ASSURANCE SURVEILLANCE PLAN.pdf

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.

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: Larry Facio, Contacting Officer, 916-923-4553, larry.facio@va.gov

Assigned CS: Joshua Barrios, Contract Specialist, 916-923-4559, joshua.barrios@va.gov

Organization or Agency: NCO 21

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: Michael Ostash, COR, 559-231-0402, michael.ostash@va.gov

Organization or Agency: VA Central California Health Care System

3. CONTRACTOR REPRESENTATIVES

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

Primary: Charles Haywood, 559-281-5438, chuckhaywood65@yahoo.com mailto:larry.facio@va.gov mailto:joshua.barrios@va.gov mailto:michael.ostash@va.gov mailto:chuckhaywood65@yahoo.com

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 in Section 6. 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. Direct observation shall be performed periodically or through 100% surveillance. Analysis of the referral paperwork and Veterans health care record which is sent by referring parties, including interagency, and self-referrals. Analysis of the entry and exit reports sent to the COR from the Contractor. (Evaluates outcomes on a quarterly basis)

• Total Number of Veterans Served

• Discharge Outcomes (e.g. # or % of veterans discharged to more stable housing, increased income/ benefits, occupancy, etc.)

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

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints from veterans served, and agency personnel shall be passed to the Contractor’s quality control inspector (QCI) for correction.

d. RANDOM SAMPLING. Verification and/or documentation provided by Contractor. The contractor shall be expected to utilize nightly sign-in bed logs for the purpose of verifying a Veteran’s attendance in the program on a daily basis. These logs are to be submitted to the VA Liaison monthly, along with invoices reflecting total bed nights for a given month and the corresponding amount that the Contractor is owed, to ensure accuracy in billing practices. All excused and unexcused absences will be clearly documented on the monthly attendance log including reason for any excused absence (e.g. medical needs). No payment will be made without the nightly sign-in bed logs and invoice having first been approved by the identified VA Liaison or designee.

6. QASP PERFORMANCE REPORT

Measures PWS Reference

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT

MEET AQL-

CPAR RATING/ADD

COMMENTS

Occupancy Occupancy of contracted beds is expected to be maintained at a minimum rate of 70% over the course of any given quarter, with a preferred rate of 90% or higher not be less than 50% throughout the quarter.

100% during quarterly rating period.

Sign in and sign out sheets.

Review of NEPEC data and monthly billing.

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

Outreach:

Contractor will be expected to engage in community outreach efforts for the purpose of identifying homeless veterans who may be eligible and in need of this offender re-entry program.

70% bed occupancy during the quarterly rating period, with a preferred rate of 90% or higher.

100% during quarterly rating period

Sign in and sign out sheets will be reviewed monthly, and overall census will be reviewed quarterly

Care Planning:

The program will engage the veteran in a collaborative assessment of needs, including barriers to stable housing, and create an initial written care plan.

100% of assessments will be completed within the first 72 hours after admission.

100% during quarterly rating period

Review of case notes and client file

Recovery:

The Contractor is expected to support the Veteran in gaining and applying knowledge of the recovery process, and to provide individual and group sessions focusing specifically on the treatment of mental health and substance use disorders, as well as providing other supports as needed to facilitate progress in the individual’s overall recovery effort.

100% of veterans served should attend group psychosocial assessments.

100% during quarterly rating period

Medication Management:

Medications and narcotics shall be properly stored, controlled, issued and recorded in compliance with physician orders.

Contractor shall submit their plan to ensure safe and effective management of medications within the facility as an element of their proposal in response to this solicitation.

100% of veterans served will have proper storage and monitoring of medications.

Medication management plan will be available for review.

100% during quarterly rating period

Plan addresses storage, control, and issuance of medications

• Review of medication log

• Review of plan

Case Management:

Individual case management and/or professional counseling efforts are expected to flow from the initial written care plan. At a minimum, Veterans are expected to engage in individual case management/counseling meetings three or more times per month. Case management and/or counseling is expected to be substantive work focusing on the needs identified during the initial assessment and care planning process. Progress notes documenting case management/counseling activities should demonstrate, at a minimum, consistent focus on housing stabilization, increased income and financial planning, and engagement in physical and mental health care services as indicated.

100% of Veterans who remain in the program 72 hours will have an intake and written Care Plan. Care Plan must be completed within 5 days of admission.

75% of Veterans will engage in individual case management meeting 3 x per month;

all Care Plans are documented in the client file.

100% during quarterly rating period

• 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

Treatment:

Ongoing VA substance abuse treatment will be required of all veterans in Contract Substance Abuse Transitional Living program.

100% of Veterans will be referred to VA mental health treatment when appropriate.

100% during quarterly rating period

Financial Planning:

Structured activities should be provided to support Veterans in developing a short and long- term plan to understand and effectively deal with their current

100% of veterans should have financial planning discussion within 30 days of

100% during quarterly rating period financial situation and how to possibly improve it.

All Veterans should be referred to apply for any and all financial resources for which they may be eligible, including (but not limited to): VA Benefits (Service Connected Compensation/NSC Pension), Social Security/SSI. etc.

admission into the program.

Group Activities:

Structured group activities should be available to Veterans admitted to the program. At a minimum, Veterans should plan to attend two or more such activities per week. Examples of appropriate group activities include:

group therapy (Cognitive Behavioral, Motivational Interviewing), relapse prevention, life skills training, social skills training, Alcoholics Anonymous, Narcotics Anonymous, vocational counseling, and permanent housing search groups.

75% of Veterans will participate in group activities 2 x per month.

To be led by Contractor.

100% during quarterly rating period

• Documentation in Care Plan

• Care Plan reviews

• Interviews with

Veterans

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel

Permanent Housing Search:

Specific assistance should be provided in identifying and developing potential housing resources for successful housing placement at discharge.

75% to Permanent Housing, Grant & Per Diem or other Transitional Living Program

15% to other HCHV Contract or Emergency Housing service

10% to unknown/Streets

100% during quarterly rating period

• Entry/Exit Forms

• VA notes shortly after exit

• Client reports, or other information sources

The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel

7. 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 or Environmental Deficiency Reports, or letters).

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

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS ISSUE

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