QASP Final 3-2025.pdf

QUALITY ASSURANCE SURVEILLANCE

PLAN FOR

VAPORHCS Contracted HUD-VASH Housing

Placement and Case Management Services

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 performance for the stated contract.

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.

1. 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. 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.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO will 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 will 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: NCO 20 Contract Specialist Organization or Agency: Department of Veterans Affairs, Veterans Health Administration Network Contracting Office 20

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: Katie Balske

c. Other Key Government Personnel -< Upon award, Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COR to monitor performance.> program manager

For Portland,

3. Contractor Representatives The following employees of the Contractor serve as the Contractor’s program manager for this contract.

Program Manager –

4. 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.

Section PWS Reference Minimum Standard

Acceptable Quality Levels

Review Period Method Used

Staffing

3.4

3.2.2

3.2.3

Contractor competency folders are up to date for their staff, including copies of immunization records, professional licenses, trainings, etc.

The Contractor shall provide staffing at a level to ensure that all services listed in the contract are met for each Veteran receiving service under this contract. The Contractor shall have staff who are trained to provided services as identified. The Contractor shall ensure that sufficient staff remain available to provide services for the term of this contract. The VA staffing standard is 35 to 1.

Contractor proposals should meet or exceed this standard.

The Contractor shall ensure there is coverage for staff when they are out on planned or unplanned leave, Contractor staff turns over, during recruitment and shall notify the VA COR/Liaison of this plan.

100%

Annually, 60 days of new staff hire or as needed

Monthly

Review of competency folders, Contractor reports, TMS

Resumes must be VA approved prior to working on contract. VA will utilize OR7, case conferencing, spreadsheets, updated current staff working on contract and Contractor reporting

Case conferencing, Contractor reporting

Documentation

4.1

4.3

4.4, 4.4.1, 4.4.2, 4.4.3, 4.4.4, 4.4.5

4.5

4.6

4.8

6.2.5

6.2.11

The Contractor shall complete and update Homeless Operations Management and Evaluation (HOMES) documentation and be consistent with the “HOMES Reporting Policy”. All required information is included using designated HOMES forms. Veteran updates are made in HOMES within forty-eight (48) hours of occurrence. The Contractor shall meet local, regional and national reporting requirements.

The Contractor shall document all case management encounters in CPRS and meet or exceed the number of contacts based on Veteran’s acuity level assignment during quarterly case conference meetings (also reference 8.7 in the PWS). All documentation is due in the Veteran’s EHR within 48 hours of the encounter.

Initial Treatment Plans and updates are completed within specified time frames and identify strengths, needs and treatment goals.

The Contractor shall complete a Biopsychosocial Assessment within 60 days of the Veteran signing their lease.

The Contractor shall complete Clinical Reminders when due, including Tobacco, Depression PHQ-2, PHQ-9, Suicide Risk Screen C-SSRS, Alcohol Audit C, Homelessness/Food Insecurity Screening, Advance Directive, Toxic Exposure Screening, Offer Overdose Education and Naloxone and any subsequent screenings completed by VAPORHCS CRS HUD-VASH program. Clinical Reminders are completed using designated note titles and templates in EHR and according to VAPORHCS policy.

The Contractor shall document all encounters with Veterans in EHR within 48 hours of the encounter.

If there is an immediate concern regarding the Veteran, the note shall be entered immediately for other providers to have access to the note and any concerns which might impact service delivery.

Documentation and encounters shall be entered accurately.

C-SSRS/CSRE are completed within seventy-two

(72) hours of initial meeting with Veteran, preferably at first meeting. All documentation is due in EHR within forty-eight (48) hours of encounter or same day for high risk situations.

The Contractor shall complete all necessary VA Release of Information (ROI) forms per VA Policy and prior to contact with person or entity listed on ROI. The Contractor shall update ROI forms annually or more frequently if indicated by VA Policy or ROI expiration date. VA ROI forms must be documented and uploaded into EHR for VA and Contractor to be able to communication with PHA, 90%

80%

Record Review, HOMES, contractor reporting, case conferencing contractor reporting, case conferencing

Record Review, contractor reporting, case conferencing

Record Review, contractor reporting, case conferencing

Record Review, contractor reporting, case conferencing

Record Review, case conferencing

Documentation

6.2.12

6.4

Landlords, Emergency contacts, additional household members and other ROIs needed to assist in Veteran’s are. If Veteran declines completing ROI, this much be documented in EHR.

All documentation shall be submitted in EHR within 48 hours of encounter.

The Contractor shall enter consults into the EHR within forty-eight (48) hours of the encounter. The Contractor is responsible for following up on consult and coordinating with Veteran and other providers until consult completion.

The Contractor shall notify VA of any negative incident occurring with the Veteran within twenty-four (24) hours of being informed or aware of the incident. The Contractor shall complete a written incident report in the format indicated by the VA within 24 hours of notification. The Contractor shall provide documentation, as required by the VA COR/Liaison describing the incident. Local incident report protocols shall be followed and documentation completed depending on type of incident.

Case Management

6.2.1

6.2.4

6.2.10

6.5

6.6

Contractor carries responsibility for interviewing, counseling and case management of identified Veterans who are at risk.

The Contractor shall utilize counseling strategies to include crisis intervention, case management and Motivational Interviewing with Veterans, including both short- and long-term services, working toward the long-term goal of housing stability and graduation/discharge from HUD-VASH.

The Contractor shall utilize VA and community resources to connect Veteran to services once a need has been identified. Contractor will connect the Veteran to the appropriate resource within 30 days of the identification of the need. The Contractor shall document all resources and referrals provided to Veteran in EHR within 48 hours of encounter.

The Contractor shall provide monthly written status reports, a Summary Spreadsheet, to the VA COR/Liaison by the 5th of each month to ensure quality assurance of case management services per the PWS requirements. The Summary Spreadsheet shall include, at minimum, patient data, (names, last four digits of SSN or other identification number), type of services performed, with date service(s) performed, Veteran’s acuity level, name and contact information of the Case Manager assigned to each Veteran through secure means that protects the Veterans’ confidentiality.

Updated and accurate information will be included in the Summary Spreadsheet.

The Contractor shall meet with VA COR/Liaison weekly for quality assurance, case consultation case conferencing

Record Review, Receipt and review of reports, contractor reporting contractor reporting

Case

Management

6.7 and caseload status updates.

The Contractor case managers shall attend HUD- VASH weekly meetings, unless otherwise discussed with the COR.

contractor reporting

Housing Placement and

Stabilization Duties

7.1.1

7.1.2

7.1.3

7.1.4

The Contractor shall assist Veteran in completing Public Housing Authority (PHA) voucher application, appointments and steps to obtain a HUD-VASH voucher. The Contractor shall assist the Veteran in submitting completed HUD-VASH voucher application to PHA for processing and voucher issuance.

The Contractor shall assist Veterans to obtain the needed documentation required by the PHA to include but not limited to, birth certificates, driver’s license or government issued photo ID, income verification and any additional information required by the Housing Authority and/or potential landlord. If these documents cannot be obtained, efforts made to obtain them must be clearly documented. All documentation is due in the Veteran’s EHR within 48 hours of the encounter.

The Contractor shall accompany Veteran to any PHA appointments including voucher issuance, annual certifications, briefings, and interim appointments, as clinically indicated. In cases where the Veteran is unable to access or use existing public transportation networks or other community provided transportation, the Contractor shall provide transportation in Contractor-owned or operated vehicles for Veteran to attend appointments at the VA, at the Public Housing Authority, benefits agencies, with landlords, relating to housing searches, or relating to medical care. The Contractor shall assist Veteran in completing and submitting PHA documentation and other Federal, local, and state entitlement program paperwork (e.g. Social Security, SNAP benefits, utility assistance, etc.). All documentation is due in the Veteran’s EHR within 48 hours of the encounter.

The Contractor shall provide hands on assistance to support Veteran in finding suitable housing within the appropriate catchment area of the PHA for which they have applied. Assistance to include but not limited to, transporting Veteran around neighborhoods to locate vacant apartments;

helping Veteran conduct online housing searches if locally available; advocacy with potential landlords; assisting Veteran in obtaining necessary items to establish a household (i.e. move in costs, not limited to accessing outside funding for deposits, utility deposits and furnishings as well as budgeting for this). Assistance provided as clinically indicated by assessment of level of need, acuity level, stage of case management, independence and Veteran autonomy. All documentation is due in the Veteran’s EHR within 48 hours of the encounter.

Housing

Placement and Stabilization

Duties

7.1.6

Contractor will work collaboratively with the Veteran to obtain housing within 90 days of receipt of voucher.

65% reporting, case conferencing

Case Management

Visits

8.1

8.4

8.5

8.7

The Contractor shall conduct case management visits with Veterans based on the clinically appropriate stage of case management in accordance with VHA Directive 1162.05(2) and VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages and any subsequent updates.

Case management provided in accordance with Veteran’s individualized Treatment Plan.

In the event the Contractor is unable to locate the Veteran for the required number of visits, the Contractor shall document all attempts to contact the Veteran including face-to-face attempts, VVC, phone calls and/or letters sent to the Veteran. This should include dates and times in the VA Electronic Health Record as verification of services rendered and to show due diligence has been exercised.

Contractor challenges in completing case management visits with Veterans shall be discussed by the Contractor with VA COR/Liaison during weekly case conference meetings.

The Contractor shall perform home visits to HUD- VASH apartments to verify whether Veterans reside in healthy residences. The Contractor shall provide appropriate support and education to Veterans who are not maintaining a hygienic residence.

On a minimum of a quarterly basis, based on the documented needs of the Veteran, a joint clinical case conference between the VA COR/Liaison and Contractor, VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages, and VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program”, the VA COR/Liaison shall designate the Case Management Stage and corresponding minimum visit requirement for each Veteran the Contractor services under this contract. No reduction in the visit schedule shall occur without concurrence from the VA COR/Liaison. However, if a Veteran presents with an urgent need for increased contact, the Contractor shall act to provide services based on the presenting needs prior to review with the VA COR/Liaison.

Quarterly

Contractor Discharge

Requirements

11.1

The Contractor shall document in the VA medical record a discharge plan, a minimum of one (1) month prior to a Veteran’s discharge date. The discharge plan shall be shared with the Veteran and shall include all the required elements as defined in VHA Directive 1162.05(2), “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program” and

Record Review &

HOMES

Contractor Discharge

Requirements

11.1.1

11.1.10

VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages and Graduation/Discharge checklist. The Contractor shall notify the VA COR/Liaison, PHA and others deemed necessary in writing (via email) utilizing the appropriate Discharge Letter template. The Contractor shall complete the Discharge note template in EHR within forty-eight (48) hours of the discharge encounter with the Veteran.

The Contractor shall not discharge Veterans from case management services without prior approval from VA COR/Liaison.

Contractor shall work with Veteran, landlord and PHA to minimize the number of negative discharges from the VASH program. Utilizing the Treatment Plan, VA services and community resources to address any barriers that the Veteran encounters while maintaining housing. The Contractor shall monitor their discharge rate and patterns in order to ensure the negative discharge rate falls below the performance threshold.

<14% reporting, case conferencing Record Review, HOMES, contractor

5. INCENTIVES: The Government will use positive past performance and continued performance with the incumbent as incentives. Incentive shall be based on exceeding, meeting or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE: The Government quality assurance (QA) person and the COR shall use the various surveillance methods listed below in the administration of this QASP.

a. Direct Observation. Direct observation shall be performed periodically or through 100% surveillance.

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

c. Progress or status meetings, case conferences and staff meetings.

d. Customer Feedback – Customer feedback may be obtained either from the results of formal customer satisfaction surveys or from random customer complaints. Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed and forwarded to the COR. The COR shall maintain a summary log documentation file. The COR shall also keep the tabulated results of all customer satisfaction surveys on file and shall enter the summary results into the Surveillance Activity Checklist.

(Copies of all records shall be submitted to the CO upon receipt for placement in the official contract file, and when necessary, determination of actions.)

7. 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.

8. 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