QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

CONTRACT NO:

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate Contractor actions while implementing this Statement of Work (SOW). It is designed to provide an effective surveillance method of monitoring Contractor performance for each listed objective on the Service Delivery Summary (SDS) in this contract.

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

The 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 (QA) to ensure contract standards are achieved.

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 to Acceptable Quality Level (AQL) defined below for each performance requirement.

PERFORMANCE MEASURE REQUIRED STANDARD ACCEPTABLE SURVEILLANCE UNACCEPTABLE

QUALITY LEVEL METHOD

PERFORMANCE

Accessibility:

Transitional housing services for homeless Veterans shall be provided in accordance with a plan of care and by designated housing staff.

Supervision shall be provided in accordance with VA policy and regulations pertaining to Healthcare for Homeless Veterans.

The Contractor shall be responsible for admitting Veterans, assessing Veterans, (including initial and ongoing assessments), coordinating supervision, evaluating the care and services provided, discharge planning.

The Contractor shall be responsible for providing supervision twenty-four hours a

100% during quarterly rating period.

During interviews with Veterans and weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel

Three (3) or more documented deficiencies per quarter will result in a negative performance rating and 3% deduction of 1 monthly invoice.

day, seven days a week in accordance with VA policy and regulations.

Contractor must ensure that Veterans will have access to the facility at all times.

inspect the Contractor’s facility.

Facility: Maintain a clean, sanitary, and safe environment.

- Clean, sanitary and safe housing shall be provided to Veterans at all times.

- The facility shall include appropriate space for clothing and personal items (dresser, closet space, chair, and mirror)

- Indoor recreation/ lounging areas shall be provides for Veterans.

- Contractor shall make available to Veterans computer with internet access and land line telephone.

- The Contractor shall provide adequate on-site laundry facilities for Veterans to do their own laundry.

- The Contractor shall provide adequate detergent when Veteran is unable to purchase due to lack of money. Health and personal hygiene items shall be make available to residents who cannot provide the necessary items for themselves.

These items include:

sheets, pillows, comforters, towels, 95% during quarterly rating period.

During interviews with Veterans and weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the deficiencies per quarter shall result in a negative performance rating wash cloths, linen, soap, tooth paste, etc.

Provide Supportive

Services: Contractor shall provide supportive group services as required.

– The Contractor shall provide:

(1) Supportive social services, in collaboration with the HCHV program staff, or other contract resources.

(2) Discharge planning – 80% of Veterans discharged from the program enter into permanent and affordable housing.

(3) Instruction in and assistance with personal hygiene.

(4)Monitoring of medications, including locked storage for medication.

(5)Support for an alcohol/drug abuse free lifestyle by maintaining a drug and alcohol free environment.

(6)Assistance with employment search and job placement.

(7) Locked medication storage for all Veteran medication

(8) Signed daily medication log for all dispersed medication.

100% during quarterly rating period.

During interviews with Veterans and weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the deficiencies per quarter will result in a negative performance rating and 3% deduction

Dietary: The dietary needs of all Veterans shall be met in accordance with sound nutritional and medical standards.

(1) At least 3 nutritious meals shall be served daily, at regular times.

(2) Contractor shall provide the residence with food staples such as condiments, rice, sugar, snacks, fresh fruit, etc. These items should be replenished as needed.

(3) Food items shall be prepared, served, and stored under sanitary conditions.

(4)Sanitary procedures shall be established and maintained for washing dishes, cleaning equipment and work areas, and for proper wasted disposal.

(5) The dietary needs of Veterans with verified medical dietary restrictions will be accommodates, i.e.

artificial sweetener available diabetics, adequate supply of fresh fruits and vegetables for vegans, etc.

(6) Menus must be updated and posted weekly in the housing unit

(7) Veterans’ ability to obtain or utilize food stamps shall not be considered

95% during quarterly rating period.

During interviews with Veterans and weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the Contractor’s facility.

Three (3) or more documented deficiencies per quarter shall result in a negative performance rating

Records & Reports:

An individual client record shall be maintained on each

Specific items to be delivered by VA Contractor including any records/reports

95% during quarterly rating period.

During weekly/biweekly visits and random sampling of records, Three (3) or more documented deficiencies per quarter shall result

Veteran admitted under this agreement; which shall include, in addition to reasons for referral, documentation of Veterans’ progress within the program. This record should also include sign-in sheets where applicable.

and manuals to be provided to VA:

(1) All essential identifying data relevant to the resident and his/her family including a socio-cultural assessment.

(2) Data relating to the resident’s admission.

(3) Documentation of medication distribution shall be place in the resident’s record on a weekly basis to include Contractor’s signature, Veteran’s signature date, and time the medication was taken.

(4) Copies of any medical prescriptions issued by VA physicians, including any orders for medications to be taken, if any.

(5) Reports of periodic staffing by treatment team.

(6) Discharge summaries on each resident who leaves the program, to include reason for leaving, the resident’s future plans and follow-up locator information.

(7) Individual case records will be maintained In confidence, as required by title 42, U. S. C., Part II – “Confidentiality of Alcohol and Drug the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the

Abuse Patient Records”.

(8) Records must be accessible to the evaluation study required by congress.

(9) Periodic reports must be provided to the VA, e.g., Fiscal Accountability, as required.

(10) Monthly list of Veterans discharge, with date of discharge, shall be submitted to the VA.

The VA is to be notified of discharges within 24 hours of discharge, either telephonically, email or fax the information to (334)724-6764.

Discharge summaries are to be provided to the VAMC HCHV Liaison within 5 days of discharge from the program.

(11) Customer Satisfaction questionnaires shall be delivered to the Contracting Officer Technical Representative (COR) on a monthly basis.

Staffing: Contractor shall provide supportive group services as required.

(1)Program will be staffed with the appropriate number of licensed professionals to provide for and meet program standards.

(2) At a minimum, there must be one (1) full-time administrative staff member or his/her

100% during quarterly rating period.

During interviews with Veterans and weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the

Three (3) or more documented deficiencies per quarter will result in a negative performance rating and 3% deduction staff designee on duty at the premises or residing at the house and available for emergencies 24 hours/day, 7 days/week.

(3) All staff vacancies must be reported to the VA Liaison and/or COR within 24 hours of Contractor’s knowledge and must be filled within 30 days.

government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the

Transportation:

Contractor shall provide transportation services as required.

(1) Contractor shall provide the Veteran with transportation to recovery focused activities, community and VA appointments, and employment activities (search, interviews, and to/from place of employment when secured).

(2) Contractor shall provide information and instruction on the use of public transportation, if Veteran chooses to utilize this mode of transportation as an option.

(3)Contractors staff will ensure that Veterans do not miss appointments due to lack of transportation

100% during quarterly rating period.

During interviews with Veterans and weekly/biweekly visits and random sampling of records, the VA will ensure facility compliance to the SOW and request that any deficiencies be corrected.

Additionally, at the government’s discretion, chose any time, announced or unannounced to have VA personnel inspect the Contractor’s facility.

Three (3) or more documented deficiencies per quarter shall result

Surveillance: The government’s 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 (CO) for appropriate action.

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 Contracting Officer. The Contracting Officer will notify the Contractor and that notice shall be in writing unless circumstances necessitate verbal communication.

When the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the contracting officer. 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 CO. 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.

Surveillance: The government evaluator shall evaluate the services required by each deliver/task order to ensure complete compliance.

Procedures: The government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the SOW periodically. The evaluator shall record results of inspection, noting the date & time of inspection. If inspection indicates unacceptable performance, the government evaluator shall notify the CO and/or QCI of the deficiencies and have QCI correct those 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.

a. Frequency of Performance Assessment Meetings.

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

COR AND CONTRACTOR ACKNOWLEGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE