QASP - Maui HCHV.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: 6 Bed Emergency Housing located on the Island of Maui (HI)

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 6 Emergency beds for homeless Veterans on Maui, 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: Margaret Gavigan

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 below is developed from the Performance Work Statement and includes performance standards. The Government shall use these standards to determine contractor performance and scores shall not be below 95%.

Quality Assurance Surveillance Plan (QASP)

Performance Standards

Obj.

Objective Reference

Performance Indicator

Standard 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 their demonstrated independent outreach efforts.

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

Review of the bed occupancy data.

Invoice Data Sheets

2.7.2 Program Services- Entry Assessment and Admission

Contractor will follow the established VA protocol for the 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 Service.

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

Periodic VA and Site data review.

Random Sampling of Documents.

2.7.2 Program Services – Entry Assessment and Admission

Contractor will maintain a comprehensive case management file.

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

Periodic VA and Site data review.

by Liaisons.

2.7.3

Program

Services

Case

Management

-Housing

Support Plan

Contractor will complete a comprehensive assessment of the

Veteran’s needs and develop a Housing

Support Plan with the Veteran to be submitted to VA with 7 days of admission.

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.

Periodic VA and

Site data review.

Random

Sampling.

Review of HSP in

CPRS.

2.7.3

Services

Case

Management

Contractor will submit a Monthly

Housing Support Summary which documents 3 or more meetings with the

Veteran per month and outlines the specific actions taken by the Case

95% of Veterans will have individual case management meetings 3 or more times per month as documented in the

Periodic VA and

-Periodic

Reviews

Manager and Veteran to achieve the goals identified in their Housing Support

Plan.

Veteran’s case management file. Review of HSP in

CPRS.

6 2.7.3.2

Program

Services

Case

Management-

Resource

Acquisition

Contractor will provide Veterans direct and ongoing assistance to support the

Veteran’s access of housing options, financial and supportive programs such as SS, SSDI, General Assistance, Medicaid, etc. and document this activity in the Monthly Summary submitted to VA.

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.

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.

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 Veterans are discharged 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.

HOMES data

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 Veterans leave services through a negative discharge.

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

*Subject to a decrease per VA

Central Office

HOMES data

2.7.3.8

Program

Services

Case

Management

-Reporting and

Consumer

Satisfaction

Contractor will distribute and encourage the completion of the Consumer

Satisfaction questionnaire (uSPEQ) or other VA service satisfaction tools requested at a response rate of 25% of eligible respondents.

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 survey only once a year.

Receipt of

Questionnaires per quarter per

Veteran’s length of stay.

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

Emergency Housing Liaison.

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

Periodic VA and

Site data review.

Veteran CPRS file reviewed for an authorized extension if over

90 days.

13 2.3.3.12

Program

Services Case

Management –

Provision of

Structured

Group

Activities

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

Support Plan.

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

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

Requirements

Case Managers

Contractor will have an adequate number of qualified, designated case managers whose primary role is to assist their assigned Veterans at the site(s).

100% of the time a qualified staff person will be on duty at the approved site. Case Manager to

Veteran ratio will not exceed 1:15

(unless specifically authorized by

VA HCHV Program).

Periodic

Inspection

Review of staffing site assignments by name.

15 3.2.2

Contracted

Staff

On- site

Staffing

Contractor will have a designed qualified staff person assigned on duty at 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.

Periodic

Inspection.

Review of staffing logs.

3.3

Contractor Staff

Training

Contractor will assure that staff persons assigned to provide services to Veterans in the EH program have completed initial and ongoing training as required and submit an annual training log to the COR annually and on request with the staff names, when training was received or if scheduled.

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.

Training log submission

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 Outcomes 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.

Outcomes

6. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE (95% and 100% Ratings)

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.

7. 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) Margaret Gavigan

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) Margaret Gavigan

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.>