QASP - KONA.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: 5 Bed Emergency Housing in Kailua-Kona, Hawaii

Contract Number: <Upon award, Government will enter contract number>

Contract Description: VA Pacific Island Health Care System’s Health Care for Homeless Veterans will provide board, room, support and case management in 5 Emergency beds for homeless veterans in Kailua-Kona, Hawaii to improved their housing situation.

Contractor’s Name: <Enter your company name> (hereafter referred to as the contractor)

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. 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: <Upon award, Government will enter name>

Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Materiel Management

b. Contracting Officer’s Technical Representative (COTR) – The COTR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COTR shall keep a quality assurance file. The COTR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COTR: Patrick Maher

c. Other Key Government Personnel -

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager –

b. Other Contractor Personnel –

Title:

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, paragraph A2,A3,A4,A5 in the Performance Work Statement (PWS), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Quality Assurance Surveillance Plan (QASP)

Performance Standards

Obj.

Objective Reference

Performance Indicator

Standard Acceptable Quality Level

Score 90,95, 100%

Surveillance method

2.7.1 Program Services- Outreach

Contractor will maintain minimum acceptable level of 80% occupancy through collaboration with VA and independent plan for outreach activities.

VA National Data base occupancy reports for the program shall demonstrate a rate of 80%* or higher for a given quarter.

*Subject to increase per VA Central office

90%

Review of the bed occupancy data per quarter.

Invoice Date Sheets

2.7.2 .Program Services- Entry Assessment and Admission

Contractor will follow established VA protocol for eligibility documentation, including arranging a Clinical Interview where requested, and promptly complete and return documentation for eligibility determination and program acceptance for HCHV Emergency Housing Services.

95% of veterans admitted will have a signed Release of Information and VA eligibility determination in the veteran’s case management file.

100%

Periodic VA and Site data review.

Random Sampling of CPR Documents.

2.7.2.

Program Services – Entry Assessment and Admission

Contractor will maintain a comprehensive case management file.

This file will include documentation of VA acceptance of veteran into the contracted program.

95% will have complete admission information and VA acceptance in the veteran’s case management file.

100% Periodic VA and

Random Sampling by Liaisons

2.7.3.

Program

Services

Case

Management

-Housing

Support Plan

Contractor will complete a comprehensive assessment of the veteran’s needs and with the veteran develop a Housing Support Plan (HSP) to be submitted to VA within 7 days of admission. The HSP shall address and prioritize the needs identified and address barrier. In addition HUD-VASH residents will have a Collaboration Plan.

95% of veterans will have a completed Housing Support Plan written by day 7 in the veteran’s case management file. HUD-VASH residents will have a

Collaboration Plan. All will be submitted to the EH VA representative.

90%

Periodic VA and

Site data review.

Random Sampling

Review of HSP in

CPRS.

5 2.7.3.

Services

Contractor will submit in their Monthly

Housing Support Summary documentation of meeting with the

95% of veterans will have individual case management meetings 3 or more times per

90% Periodic VA and

Case

Management

-Periodic

Reviews veteran 3 or more times per month and identify the specific actions taken by the

Case Manager and veteran during the month to achieve the goals identified in the HSP.

month as documented in the veteran’s case management file.

6 2.7.3.2

Program

Services

Case

Management-

Resource

Acquisition

Contractor will document in their

Monthly Housing Summary the direct and ongoing assistance to support the veteran’s access of housing options

(Section 8/HUD-VASH or other Housing

Assistance Programs), financial and supportive programs such as SS, SSDI, General Assistance, Food Stamps, VA

Benefits, Medicaid, employment etc.. as identified in the Housing Support Plan. .

90% of veterans who have financial and/or supportive needs identified in their HSP, will be referred to the appropriate agencies as documented in the veteran’s case management file.

90% Periodic VA and

Site Data review.

Random Sampling

2.7.3.6

Services

Case

Management -

Veteran’s

Monthly

Progress

Summary

Submission

Contractor will submit to VA a monthly summary which describes the activities and status of the efforts of both the veteran and the site case manager in achieving the veteran’s goals identified in the Housing Support Plan. This review should including the veteran’s Financial

Plan, Discharge Plan, resource acquisition and access and engagement of appropriate providers of physical and mental health care services.

100% of the time the program will provide to the VA

Representative a monthly written status reports on the veterans in program.

Site Data review.

2.7.3.7

Program

Services

Case

Management –

Discharge

Planning – Exit

Summary

Contractor will submit to VA a completed Exit Summary within 36 business hours of a veterans’ departure or discharge from Emergency Housing.

100% of the itme the program will provide to the VA

Representative an Exit Summary in a timely basis.

Site Data review.

2.7.3.7

Services

Case

Management

-Positive

Discharge

Outcomes

Contractor will achieve the VA Central

Office (VACO) metric which requires 55% or more of discharges at to permanent housing.

55%* or more of veteran discharges per quarter will be to permanent housing as defined by

VACO..

*Subject to an increase per VA

Central Office.

Monthly HCHV

HUB review on

Discharges.

10 2.7.3.7

Services - Case

Management

-Negative

Discharge

Outcomes

Contractor will achieve the VA Central

Office (VACO) metric which requires that

20% or less of discharges are negative.

20%* or less of veteran discharges per quarter will be negative.

*Subject to a decrease per VA

Central Office

Monthly HCHV

HUB review on

Discharges.

2.7.3.8

Program

Services

Case

Management

Contractor will distribute and encourage the completion of the Consumer

Satisfaction uSPEQ questionnaire or other VA service satisfaction tools requested at a response rate of 25% of

25% of veterans who have resided in the program for longer than 14 days will complete and submit a uSPEQ questionnaire. A

Veteran need to complete this

90% Receipt of

Questionnaires per quarter per veteran’s length of stay.

-Reporting and

Consumer

Satisfaction eligible respondents. survey only once a year. Quarterly number of uSPEQs received from the site.

12 2.3.3.10

Program

Services Case

Management –

Length of Stay

Contractor staff will limit the veteran stays in Emergency Housing to 90 days unless authorized in writing by the VA

EH representative.

100% of veterans will be limited to 90 day stays unless authorized in writing by the VA representative.

90% Periodic VA and

Site data review.

Veteran CPRS file reviewed for an authorized extension if over

90 days.

13 2.3.3.12 Contractor will provide or provide access to structured group activities no less than twice per month and document the attendance at the group activity in their submitted Monthly Housiing Support

Plan. A daily and weekly event schedule will be posted at the site to identify these structured group activities and community integration events.

80% of the veterans will attend a structured group activity no less than twice per month.

90% Period Inspection of the site to review posted schedule.

Review of

Monthly Housing

Support Plan for documentation of

Group attendance.

3.2.1

Contractor Staff

– Case

Managers

Contractor will have an adequate number of qualified primary case managerd whose primary role is to assist veterans in the program.

designated staff person on duty at the approved site 24hrs. a day, 7 days a week.

100% of the time a qualified staff person will be on duty at the approved site. Contractor will submit upon request the personel assignment and FTE for the site.

100% Periodic

Inspection

Review of staffing site assignments by name.

15 3.2.2

Contracted

Staff

-On- site

Staffing

Contractor will have a qualified designed staff person assigned to be on duty for coverage at each of the approved site 24 hours per day, 7 days a week.

100% of the time a qualified designated staff person will be assigned to be on duty for coverage at site 24/7.

100% Periodic

Inspection.

Review of staffing site assignments by name.

3.3

Contractor Staff

- Training

Contractor will assure that staff persons assigned to provide services to veterans in the EH program have completed the initial and ongoing training as required in the contract and submit to the COR upon request the staff names, when training was received or if scheduled. As staff changes are made this training will be updated completion will be updated.

100% of all assign staff will have receive initial and period training as demonstrated by the submission of a training log annually and as staff changes are made.

100% Training log submission

Review of the annual training completed and timelines for planned training.

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COTR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.)

Admission Protocol Case Management Improvement of Financial Group Activities Discharge Protocol

Veteran Safety Invoicing

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

Occupancy Admission Protocol Care Planning’ Case Management Improvement of Financial Situation Group Activities Discharge Planning Discharge Protocol

VA Coordination

c. USER SURVEY. (Combines elements of validated user complaints and random sampling.

Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.)

Reporting and Consumer Satisfaction

d. PERIODIC SAMPLING. (Variation of random sampling. However, sample is only taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected.

Since sample is not entirely random, it cannot be applied to total activity performance.)

Veteran Safety

e. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.

Admission Protocol Care Planning Case Management Group Activities Discharge Planning Discharge Protocol VA Coordination

f. Analysis of contractor's progress reports.

6. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

100% Positive Performance

95% Neutral Performance

90% Unacceptable Performance

85% Correction Required with this notification

<80% Discrepancy Report to be Submitted

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE (100% Rating)

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE (below 90% Rating)

When unacceptable performance occurs, the COTR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COTR shall document the discussion and place it in the COTR file.

When the COTR determines formal written communication is required, the COTR shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor's program manager.

The contractor shall acknowledge receipt of the CDR in writing. The CDR will 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 will also state how long after receipt the contractor has to present this corrective action plan to the COTR. 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.

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COTR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COTR shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Technical Representative

Attachments:

1. Contract Performance Report

2. Contract Discrepancy Report

Attachment 1

Contract Performance Report

1. Contract Number: <insert number>

2. Prepared by: (Name of COTR) Patrick Maher

3. Date and time of observation:

4. Observation:

<Examples of items to include in a report are:

• Method of surveillance.

• How frequently you conducted surveillance.

• Surveillance results.

• Number of observations.>

5. Performance Rating (in accordance with QASP, paragraph 6):

Signature – Contracting Officer’s Technical Representative Date

Attachment 2

Contract Discrepancy Report (CDR)

TO: (Contractor Program Manager or onsite representative) <insert name>

FROM: (Name of COTR) Patrick Maher

1. Contract Number: <insert number>

2. Date and time observed discrepancy:

3. Discrepancy/Problem/Issue:

4. Corrective action plan:

5. A written corrective action plan <is/is not> required. <If a written corrective action plan is required include the following.> The written Corrective Action Plan will be provided to the undersigned not later than <# days after receipt of this CDR.>

Signature – Contracting Officer’s Technical Representative Date

Received by:

Signature – Contracting Program Manager or Onsite Representative Date

Distribution:

<Name & Title - Contracting Officer>

<The COTR may initiate a CDR at any time, including whenever the number of monthly recorded defects for a performance standard exceeds the allowable number of defects; anytime unacceptable performance is determined critical in nature and requires formal corrective action; and whenever an unfavorable trend is detected in contractor performance.>