QASP updated 07.09.2025.pdf

QASP – Quality Assurance Surveillance Plan

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

HEALTHCARE FOR HOMELESS VETERANS (HCHV) SERVICE

DEPARTMENT OF VETERANS AFFAIRS

VAMC Lexington, KY

FOR

HEALTHCARE FOR HOMELESS VETERANS (HCHV) SERVICE

INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contractor actions while implementing this SOW.

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 operating, maintaining, and repairing facilities and that a service contract to provide the service is the best means of achieving that objective.

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.

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.

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

FOR

HEALTHCARE FOR HOMELESS VETERANS (HCHV) SERVICE

1. This checklist shall be filled out by the Contractor and submitted to the COR or his representative by the third [traditional] workday following the end of each performance month.

2. Contractor shall sign and date the completed form.

3. COR/Representative shall countersign and date, if in agreement with report. If there are discrepancies, COR/Representative shall so note the Objective and discrepancies noted on this form.

4. COR shall retain original. Contractor, COR Representative, and Contract Specialist shall receive copies of the form.

See the last page for a more detailed list of actions under this quality assurance plan.

MONTH/YEAR: ________________________________

Performance Objective

Standard SOW Para Frequency of Actions

Performance Threshold/Number of Valid Complaints

Actual Performance (check if threshold met. Attach explanation if not)

Penalty imposed After/% Penalty Imposed

Veteran Absent without Leave

Agency to notify VA facility by the next working day if the veteran is absent overnight without approved leave.

As Indicated Each occurrence that a veteran is absent a second night and the VA facility is not notified by next working day.

After second night, 2% of contract for month.

All significant incidents including those involving law enforcement, hospitalization, or emergency services will be reported to the VA within 4 hours.

As Indicated 2nd issue of non-compliance, 2% of monthly contract

Incident reporting and tracking

Section G - Absences and Cancellatio ns

Any time emergency services are called to facility or veteran is taken for emergent medical care

Section G - Absences and Cancellatio ns

VHALEXCraddC Cross-Out

Ensure programming and individual time is provided each week

Agency to provide weekly scheduling matrix to VA liaison 1x per quarter or as it is updated

Section E Program ming

Quarterly at minimum and as programmin g is updated

Each time the schedule is permanently changed, VA is notified within 7 days

3rd issue of non compliance annually, referrals will be suspended until matrix is provided and reviewed by VA

Ensure adequate food for 3 meals a day and healthy snacks are available

Food is available for breakfast, lunch and dinner daily. Healthy snacks are easily accessible.

As Needed Second time in a month contractor staff are told.

3rd valid complaint annually, Corrective action plan will be implemented and referrals will be suspended until meals and snacks are provided

Area must be kept free of dirt, grime, mold, or other hazardous substances and damages that noticeably detract from the overall appearance.

As needed Second day from when reported to contractor staff

3rd complaint anually, 1% of monthly contract

Identified Issues on Inspections

As Indicated and annually

Contractor will allow annual inspections to be conducted, as well as monthly environment of care and unscheduled nutrition inspections

If issues have not been corrected in allotted time, referrals will be suspended until work is completed.

SUBMITTED: _____________________________________ Date: _________________ Contractor

CONCURRED: _____________________________________ Date: _________________ COR/COR Representative

OR: See Below for Discrepancies (Forward a copy to Contract Specialist)

Section C Require ments

Maintain Cleanliness of Facility

Section K - Facility/ Safety

All issues will be resolved from inspections within the time period specified, unless extended by the

COR.

Section M - Inspection and Acceptance

Review, correct, and update… Below

SURVEILLANCE: The COR will appoint a Quality Assurance (QA) person to receive complaints from compound personnel and pass them to the contractor for correction.

STANDARDS: General standards of performance are published in the SOW. More specific standards are noted in the QASP Table above. Violation of these standards and customer complaints shall not exceed the thresholds cited above for each performance objective.

The QA shall notify the Contract Specialist 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 performance objectives exceed the customer complaint thresholds. In most cases, this requirement is satisfied by submission of the monthly report. Continued non-compliance may require more a more formal memorandum stating the severity of the violations along with records of discussion with the Contractor.

PROCEDURES: Any Veterans Administration employee that observes unacceptable services, either incomplete or not performed, for any of the above performance objectives should immediately contact the QA and the QA will complete appropriate documentation to record the complaint. The QA will consider the complaint valid upon receipt from the complainant. The QA should inform the complainant of the approximate time the unacceptable performance will be corrected and shall advise the complainant to contact the QA if not corrected. The QA will consider customer complaints as resolved unless notified otherwise by the customer. The QA shall verbally notify the Contractor to pick up a copy of the complaint. The Contractor will be given two hours after verbal notification to correct the unacceptable performance. If the Contractor disagrees with the complaint after investigation of the site and challenges the validity of the complaint, the Contractor will notify the QA who will conduct an investigation to determine the validity of the complaint.

If the QA determines the complaint as invalid, he will document the written complaint of the findings and notify the customer. The QA will retain the annotated copy of the written complaint for his/her files. If after investigation the QA determines the complaint as valid, the QA will inform the Contractor and the Contractor will be given an additional hour to correct the customer complaint. A customer complaint will not be recorded if proper and timely correction of the unacceptable condition(s) is accomplished – unless the complaints become routine. The Contractor shall return the written complaint document, properly completed with actions taken, to the QA, who will file the complaint for monitoring future recurring performance. Recurring complaints are not permitted. If repeat customer complaints are received for the same deficiency – and they exceed the threshold for number of complaints - during the service period, the QA should contact the Contract Specialist for appropriate action. The Contract Specialist and Contracting Officer are the only persons permitted to authorize deductions from a Contractor’s invoice.

Corrective Actions: If unsatisfactory performance occurs in the same category for two consecutive months, the Contractor shall submit a plan for corrective action to the Contracting Officer. The COR, COR Representative, and Contract Specialist shall also receive a copy of the plan. The COR and COR Representative will monitor that (those) activities closely in that month to ensure that the Contractor follows through with the corrective action plan, and they will note compliance with or deviation from that plan in the month that corrective action plan is initiated.

Consequences for Continued Unsatisfactory Performance: If the Contractor fails to achieve satisfactory performance in at least two of the performance objective areas, the Contracting Officer has the prerogative, upon the recommendation of the COR, to issue a Cure Notice to the Contractor. If the poor performance continues, the Contracting Officer may terminate the contract for cause and re-solicit the Healthcare for Homeless Veterans (HCHV) Service requirement. The former Contractor shall be barred from participation in any re-solicitation action.