QASP CERS 3 Bed Emergency Final Signed.pdf

VACHS CERS

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

Contracted Emergency Residential Services (CERS)

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate Contractor actions while implementing this Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring Contractor performance under this contract.

The QASP provides a systematic method to evaluate the services the Contractor is required to furnish.

This QASP is based on the premise, the Government desires to maintain a quality standard in providing primary care/mental health services to its patients. The resulting contract is considered the best means of achieving that objective.

PURPOSE

The Contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. The role of the Government is quality assurance to ensure contract standards are achieved.

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. In this contract the quality control program is the driver for product quality. The Contractor is required to develop a comprehensive program of inspections and monitoring actions. The first major step to ensuring a “self-correcting” contract is to ensure that the quality control program approved at the beginning of the contract provides the measures needed to lead the Contractor to success. This QASP explains the following:

What shall be monitored.

How monitoring shall take place.

Who shall conduct the monitoring.

How monitoring efforts and results shall be documented.

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.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document shall ensure a robust quality assurance program.

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 is incorporated within this QASP to include performance standards and disincentives. The Government shall use these standards to determine Contractor performance and shall compare Contractor performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

Task Standard Performance

Threshold/ Acceptable

Quality Level

Method of Surveillance

Occupancy Maintain 85% Occupancy or higher 85% Review of Admissions/ discharges each month

Exits to Permanent Housing

Contractor expected to promote a focus on achieving stable housing for all Veterans referred for care; exits to permanent housing will be monitored as an indicator of overall program quality.

55% or > Review of program discharges

Support to Maintain Housing (Negative Discharge Rate)

Contractor expected to facilitate Veteran completion of the HCHV CRS program to maximum extent possible, while still maintaining program integrity and safety.

Negative exits which are defined as discharges involving Veterans being asked to leave the program due to rule violation or otherwise leaving the program without consulting program staff in any way.

20% or < Review of program discharges

Discharge planning Post-discharge plan will be completed at least 30 days prior to discharge

80% Review of program records

Communication with Veterans

Administration

Contractor shall provide all requested reports on time, completely and correctly

Negative incidents/sentinel events will be reported within 24 hours

90%

95%

Receipt and VA review of reports

INVOICING: In addition to existing QASP requirements, the following weighted scale will be used by the Homeless Liaison and Contract Officer Representatives (CORs) to adjust monthly invoices when the requirements listed in the CERS PWS and/or the VA agreed upon individual service plan for the Veteran have not been fully met by the contractor. All other scenarios outside the ones listed below will be reviewed and approved by the facility Contracting Officer Representative (COR) and Contracting Officer on a case by case basis.

SURVEILLANCE: The Government quality assurance (QA) person and 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. All Performance Standards

b. Periodic Inspection. Evaluate outcomes on a periodic basis. Inspections may be scheduled Daily, Weekly, Monthly, Quarterly, Annually or unscheduled, as required. All Performance Standards

c. Progress or status meetings. All Performance Standards

d. Complaints. Complaints from agency personnel shall be passed to the Contractor's quality control inspector (QCI) for correction. All Performance Standards

STANDARD: Customer complaints shall not exceed the thresholds cited above for each performance objective. The Government’s QA personnel shall notify the contracting officer for appropriate action in accordance with FAR 52.212.4, Contract Terms and Conditions- Commercial Items (May 1997) or the appropriate Inspection of Services clause, if any of the above service areas exceed the customer complaint thresholds.

DOCUMENTING PERFORMANCE

a. Acceptable Performance: The Government shall document 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 shall 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 Contracting Officer (CO). In turn, the CO shall present the CDR to the Contractor’s contracting personnel.

The Contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long after receipt the Contractor has to present this corrective action plan to the COR. The Government shall review the Contractor's corrective action plan to determine acceptability.

Any CDRs will become a part of the supporting documentation for any contractual action deemed necessary by the CO.

SURVEILLANCE: The Government evaluator shall evaluate the services required by each delivery/task order to ensure complete compliance.

PROCEDURES: The Government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the Government evaluator shall notify the CO and/or QCI of the deficiencies within 3 business days and have QCI correct said deficiencies. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the Contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

FREQUENCY OF MEASUREMENT: During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings will be conducted monthly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s files

The COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contracting Officer’s Representative

Signature – Contracting Officer