Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: 3B2 Contracted Emergency Housing

Contract Number:

Contract Description: VA Pacific Island Health Care System’s Critical Care Program will provide board and room in 3 emergency beds for Veterans to improve their overall health, stability and housing situation.

Contractor’s 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: Emily Trinh

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

b. Contracting Officer’s Technical 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: Kianna AhLeeSam & Jessica Balandran

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

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 2,3,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

Task

Task Performance

Indicator

Standard Acceptable

Quality

Level

Score

90,95, 100%

Surveillance method

1 Meals Program will provide 3 meals daily identified on posted menus.

3 daily meals will be provided 100% of the time which are 95% consistent with menu.

100% Observation and direct veteran contact

2 Transportatio n

Program will provide or secure transportation for participants to scheduled meetings and appointments.

Transportation to scheduled meetings/appointments

100% of the time.

100% Available transportation and contact with veterans regarding appointment attendance.

Occupancy

Program will maintain minimum acceptable level of occupancy through collaboration with VA.

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

100% Review of the

NEPEC quarter data

Eligibility

Program will follow established protocol for proper admission of clients, including obtaining a Release of

Information (ROI) and submitting to the VA representative to assure veteran eligibility for VA benefits.

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

100% Periodic file

Inspection

Random Sampling

Admission

Program shall submit the necessary VA admission information and document

VA acceptance into the contracted program.

95% will have complete admission information and

VA acceptance in the veteran’s case management file.

Case

Management

-Housing

Support Plan

A case manager will complete with the veteran a collaborative assessment of needs, including barriers to stable housing and create a Housing Support

Plan (HSP) to address and prioritize those concerns within 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.

100% Periodic file

-Monthly

Reviews

A case manager will meet with the veteran to review the veteran’s Housing

Support Plan (HSP) progress including their Financial Plan, Discharge Plan, resource acquisition and access and engagement of appropriate providers of physical and mental health care services.

75% of veterans will have individual case management meetings 3 or more times per month as documented in the veteran’s case management file.

100% Periodic file

The program will provide referral and direct assistance where necessary to

75% of veterans who have financial and/or supportive

8 Management-

Financial

Assistance support the veteran’s access of financial and supportive programs such as SS, SSDI, General Assistance, Food

Stamps, VA Benefits, etc.. as identified in the Housing Support Plan needs identified in their

HSP, will be referred to the appropriate agencies as documented in the veteran’s case management file.

Management –

Assistance

The program will provide referral and direct assistance where necessary to support the veteran’s access to employment.

100% of veterans who request and/or are eligible will be referred for employment or employment search assistance as documented in the veteran’s case management file.

100% Periodic file

Management –

Assitance

The program in collaboration with the veteran shall develop an individualized

Financial Plan which reflects employment and non employment income and benefits and including means and methods of increasing monthly income and responsibly managing existing income. This

Financial Plan should including identifying needed referrals for both potential benefits and employment assistance where appropriate.

80% of eligible veterans will have a Financial Plan developed within 7 days of admission.

5.0 B Program

Services –

Case

Management

-Group

Activities

The program will provide access to group activities focusing on development of successful living patterns. This may involve but shall not be limited to groups such as:

Alcoholics/Narcotics Anonymous, vocational counseling, financial management, personal hygiene, permanent housing search, etc.

75% of veterans will participate in group activities 2 or more times per month as documented in the case management file.

5.0 Program

Services-

Case

Management -

Veteran’s

Status

The program shall collaborate regularly with the VA liaison to ensure the awareness of the veteran’s progress toward the desired outcomes outlined in the Housing Support Plan.

The program will provide to the VA Representative a monthly written status reports on the veterans in program.

5.0 Program

Services-

Case

Management-

- Discharge

Planning

The program shall in coordination with the veteran formulate an initial

Discharge Plan within 7 days which identifies the veteran’s projected housing outcome upon discharge. The

Plan should identify the activities to be undertaken while in program to achieve this outcome.

95% of veterans will have a

Discharge Plan by the program day 7 in their case management file.

-Discharge

Documents

The program will follow the identified

VA Process for addressing and documenting a veteran’s planned or unplanned discharge. This includes notifying the identified VA

Representative or designee within 24 business hours and providing supporting Exit Summary documentation with 48 business hours.

The program will have informed the VA representative within 24 business hours of veterans who have left the program and will have submitted Exit

Summaries within 48 hours for 95% of discharged veterans.

Program shall work to ensure positive veteran outcomes at all times. A positive outcome is any discharge to a

50% of veteran discharges will be to a positive, more

-Discharge

Outcomes more stable level of care or housing.

Cases that involve veterans being discharged to an equivalent level of housing or leaving the program within

7 days of entering shall be exempted.

stable housing arrangement. Random Sampling

-Reporting and Consumer

Satisfaction

Program shall distribute and encourage the completion of the Consumer

Satisfaction uSPEQ questionnaire to eligible veterans and return to the VA

Contract Housing Coordinator.

25% of veterans who have resided in the program for longer than 14 days will have completed and submitted thru the program a uSPEQ questionnaire.

100% Receipt of

Questionnaires per quarter per veteran’s length of stay.

-Veteran’s

Safety

Program shall notify the VA

Representative regarding critical adverse incidents involving veterans within 24 business hours. Reportable critical adverse incidents are defined as:

death, suicide/suicide attempt, fire

(veteran involved) or sexual or physical assaults.

100% of critical adverse incidents are reported within 24 business hours.

Management -

Veteran’s

Safety

Progran shall notify the VA

Representative regarding incidents involving veterans within 48 business hours. Reportable are defined as falls, abuse or neglect, hospitalization, infection control (bed bugs, TB, etc.), active substance abuse and possession of weapon.

90% of all other critical incidents are to be reported to VA staff within 48 business hours.

On-site

Staffing

Progran shall have a qualified designated staff person on duty 24 hrs.

a day 7 days per week at the approved site.

Qualified designated staff person on duty 24 hrs. a day

7 days a week at the site.

100% Unannounced

Periodic visits

Veteran participant reporting

Billing -

Invoicing

The program will follow the protocol for accurate and timely invoicing established which may require VA representative review and approval prior to submission. Final invoice shall be submitted to the identified Financial

Services Center by the 10th of the following month for certification and payment.

95% of monthly invoices will be submitted to the

Financial Service Center by the 10th of the following month.

100% Date of Submission for Invoicing

Certification

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP. The COR can work in collaboration with the VA Homeless Program COR to monitor contractor’s performance.

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

Meals

Transportation

Admission Protocol

Case Management

Improvement of Financial

Group Activities

On-site Staffing

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.)

Transportation

Occupancy

Admission Protocol

Care Planning’

Case Management

On-Site Staffing

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% Negative Performance

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 (90% Rating)

When unacceptable performance occurs, the COR shall inform the contractor. This will 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 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 COR. 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 COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

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

Signature – Contractor Program Manager

Signature – Contracting Officer’s Technical Representative

Attachment 1

Contract Performance Report

1. Contract Number:

2. Prepared by: (Name of COR)

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 COR)

1. Contract 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 COR 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.>