Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: HUD-VASH Case Management and Housing Placement Services, San Francisco, CA

Contract Description: The U.S. Department of Veterans Affairs (VA) is seeking a contractor to assist with the provision of housing placement and case management services through the U.S. Department of Housing and Urban

Development (HUD) – VA Supportive Housing (VASH) program. The program is a partnership between HUD and

VA to place and maintain homeless Veterans in permanent, community-based housing using HUD Section 8

Housing Choice Vouchers (HCV) that are paired with ongoing VA case management services. Many of these

Veterans have co-morbid conditions that include serious mental illnesses, substance use disorders, and other serious medical conditions. VA intends to engage a Contractor to provide to provide housing placement services in San

Francisco County, CA, along with ongoing case management services to HUD-VASH eligible Veterans and their families.

Contractor’s Name: TBD

(hereafter referred to as 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 based on the premise that the Government desires to maintain a quality standard in providing emergency housing and supportive services to its patients. The resulting contract is considered the best means of achieving that objective. This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contracted programs’ activities while implementing the Performance Work Statement (PWS) incorporated into the contract. It is designed to provide an effective surveillance method of monitoring Contractor 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: Joleo Dianala

Organization or Agency: VHA, NCO 21 – Health Care Resources II

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: Paul Meier, LCSW, COR

Organization or Agency: Social Work Service, SFVAHCS

c. Other Key Government Personnel –

Alternate COR: Sara Saltzman-Schoenfeld, LCSW, COR

HUD-VASH Clincial Liaison: Amada Arrendondo, LCSW, VASH Supervisor

HUD-VASH program Director: Nicholas Madsen, LCSW, VASH Program Director

HUD-VASH Contract Support: Kim Babcock, LCSW, Associate Chief of Service

3. CONTRACTOR REPRESENTATIVES

The following employees of the Contractor serve as the Contractor’s program manager for this contract:

Program Managaer Other Personnel

Name: Name:

Title: Title:

Email: Email:

Phone Numbeer Phone Numbeer

4. PERFORMANCE STANDARDS

The Contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of

Contractor performance in the elements defined. 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, incentives and disincentives. The Government shall use these standards to determine contracted performance and shall compare Contractor performance to the Acceptable Quality Level (AQL) defined below for each performance requirement.

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.

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

• PHQ9, Columbia, Behavioral Contract

• Timely Submission of Monthly Invoices

b. PERIODIC INSPECTION. (Inspections for HUD-VASH case Management Programs will occur quarterly or more)

• Home Visits

• Psychosocial Assessments and Treatment Plans

• Case Management and Documentation of Services

6. QASP PERFORMANCE REPORT

Performance

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

Method of

Assessment Incentive Disincentive

Home Visits

Based on Acuity

Level

9.2

The Contractor shall visit each Veteran face-to-face at the intervals required by the

HUD-VASH Directive and local Standard Operating

Procedures. Face-to-face visits shall be conducted in accordance with local behavioral health and safety flags. Visits which are not required to take place in the

Veteran’s home may occur in the community, at the

Contractor agency, or a place mutually agreed upon by the

Veteran and Case Manager.

Phone contacts, while an acceptable way to communicate with the

Veteran, are not considered visits in meeting the minimum visit requirements for any acuity level. In the event the

Contractor is unable to locate the Veteran for the required number of visits, the

Contractor will document face-to-face attempts, phone calls, and letters sent to the

Veteran including dates and times in Electronic Health

100% Excel spreadsheet showing client, acuity level in

HOMES and dates of visits

Positive ratings in quarterly reports and annual

CPARS

review.

Negative ratings in quarterly reports and annual CPARS

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

Method of

Assessment Incentive Disincentive

9.9

Record as verification of services rendered.

There are five basic levels of case management: Intensive, Stabilization, Maintenance, Preparation for Discharge and

Graduation/Discharge.

Acuity Level 5 – Intensive.

The HUD-VASH Case

Management team works with the Veteran to obtain clinical stability. At a minimum, weekly home visits are required, but even more frequent interactions may be needed.

Acuity Level 4 –

Stabilization. At this stage, Veterans are more adept at managing their housing responsibilities and their physical, mental health, and substance use disorders are more stable as the Veteran works on addressing those issues that are most likely to lead to housing instability. At least twice a month home visits are required, with additional interactions as needed.

Acuity Level 3 - Maintenance.

Case management services ensure that needed treatment, support, and mentoring assistance continue after placement in housing. Home visits need to occur at least every month, once the

Veteran demonstrates stability, independence, and improved coping skill use and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

Method of

Assessment Incentive Disincentive recovery. Other interactions, such as phone calls, may be indicated.

Acuity Level 2 - Preparation for Discharge. Veterans who have functioned at a very independent level for at least one year and sustained a low acuity level may be considered for this phase to practice and plan for discharge from HUD-VASH.

Case management can be provided in the home, community, or at the medical center. During this phase, contacts are to occur at least quarterly and the focus of case management would address steps towards graduation from case management, and/or discharge

Acuity Level 1 -

Graduation/Discharge.

Graduation is for Veterans who no longer need the case management services in

HUD-VASH, and thus, the

Veteran is not required to participate in case management. A Veteran is discharged from HUD-VASH when he/she is no longer participating in case management. If the Veteran is retaining the HUD-VASH voucher for financial purposes only, he or she is considered in graduation status.

Psychosocial

Assessments

4.2

The Contractor will comply with additional documentation and/or data reporting as required by San Francisco VA

100%

Spreadsheet completed by contractor tracking

Positive ratings in quarterly reports and

Negative ratings in quarterly reports and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

7.3.1.

Health Care System based on changing or subsequent local, VISN, or national HUD-

VASH requirements.

Additional required documentation includes but is not limited to initial and annual Psychosocial

Assessment.

Provide psychosocial assessments to identify treatment needs which affect

Veteran’s adjustment to their environment, and establish treatment goals with the primary purpose of obtaining and maintaining housing.

psychosocials for each client annual

Annual review will not be based on quarterly reports but on the entire year’s data.

annual CPARS review.

Social Work

Treatment Plan

7.3.2.

7.3.3.

Actively involving the

Veteran and their family or significant others in coordination with the team members, based on the psychosocial assessments, develop HUD-VASH Social

Work Treatment Plans with the Veteran using his/her language whenever possible, ensuring he/she has a copy of the plan including goals for clinical treatment and discharge from case management; The initial

HUD-VASH Social Work

Treatment Plan must be completed within 2 weeks of admission.

Contractor shall integrate

Social Work Treatment

Planning with relevant VA health and mental health services. Contractor shall refer as needed to VA

100%. Tracker sheet completed by contractor

Positive ratings in quarterly reports and annual review will be based on all charts reviewed throughout the year.

Negative ratings in quarterly reports and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

7.2.2.

Medical Facilities, VA

Regional Offices, and community-based agencies for a variety of services that may include health care, entitlements, vocational assistance, education, recreation, and any other needed assistance.

Review and update the HUD-

VASH Social Work

Treatment Plan with the

Veteran quarterly and document the review and any changes to the plan in the VA medical record.

Patient Health

Questionnaire-

(PHQ9)

4.2 The Contractor will comply

and/or data reporting as required by San Francisco VA

Health Care System based on changing or subsequent local, VISN, or national HUD-

VASH requirements.

Additional required documentation includes but is not limited to, Patient Health

Questionnaire-9.

100% Tracker sheet contractor

At its discretion, the

Government may choose at any time to have VA personnel inspect

Contractor’s records, announced or unannounced.

Positive ratings in quarterly reports and annual review will be based on all records reviewed throughout the year.

Negative ratings in quarterly reports and annual CPARS review.

Columbia -

Suicide Severity

Rating Scale

Screener

(C-SSRS

Screener) and/or data reporting as required by San Francisco VA

Health Care System based on changing or subsequent local, VISN, or national HUD-

VASH requirements.

Additional required documentation includes but is not limited to Columbia

Suicide Severity Rating Scale-

Screener.

Tracker sheet

Government may choose at any time to have VA personnel inspect

Contractor’s records, Positive ratings in quarterly reports and annual review will be based on all records reviewed

Negative ratings in quarterly reports and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level announced or unannounced.

throughout the year.

Columbia

Suicide Risk

Evaluation -

Comprehensive

(C-SRE

Comprehensive) and/or data reporting as required by San Francisco VA

Health Care System based on changing or subsequent local, VISN, or national HUD-

VASH requirements.

Additional required documentation includes but is not limited to Columbia

Suicide Severity Rating Scale-

Comprehensive.

Government may choose at any time to have VA personnel inspect

Contractor’s records, Positive quarterly reports and annual review will be based on all records reviewed throughout the year.

Negative ratings in quarterly reports and annual CPARS review.

Behavioral

Contract

4.2. The Contractor will comply

with additional documentation and/or data reporting as required by San Francisco VA

Health Care System based on changing or subsequent local, VISN, or national HUD-

VASH requirements.

Additional required documentation includes but is not limited to initial and annual Behavioal Contract.

Government may choose at any time to have VA personnel inspect

Contractor’s records, quarterly reports and annual review will be based on all records reviewed throughout the year.

Negative ratings in quarterly reports and annual CPARS review.

Clinical Case

Management /

Housing First

7.2.1.

5.1.

Ensure consistency of team services to enhance staff ability to engage and form relationships with Veterans and provide consistent and highly skilled interventions in keeping with the principles of

Housing First.

Government may choose at any time to have VA personnel

Positive ratings in quarterly reports and annual review will

Negative ratings in quarterly reports and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

Method of

Assessment Incentive Disincentive

Housing First is an approach that centers on providing homeless individuals with housing quickly, while providing services and treatment as needed. What differentiates a Housing First approach from other strategies is an immediate need and primary focus on helping individuals and families quickly access and sustain permanent housing. Housing

First programs share four critical elements:

A variety of services are delivered primarily following a housing placement to promote housing stability and individual well-being;

Services are time-limited or long-term depending upon the individual need;

Housing is not contingent on compliance with services.

Participants must comply with a standard lease agreement and are provided with the services and supports necessary to help them to obtain and maintain housing and reintegrate into the community.

inspect

Contractor’s records, be based on all records reviewed throughout the year.

Documentation in the VA

Electronic

Medical Record

System and

HOMES (VA

Homeless

Operations and

Management

4.1.

The Contractor must complete

Homeless Operations

Management and Evaluation

(HOMES) documentation, consistent with the HOMES policies, and Electronic

Health Record (EHR) documentation, in accordance

Quarterly

Chart Review

HCS

Documentation

Report quarterly reports and annual

Negative ratings in quarterly reports and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

Method of

Assessment Incentive Disincentive

Evaluation

System) with national and local policies. This EHR documentation may include, but not be limited to: changes to admission, housing, voucher, or employment status, encounter documentation, screening/admission notes, release of information forms, housing service agreements, suicide risk assessments, Advanced Directive

Discussions, discharge notes and safety plans. Contractor shall document encounters using the Subjective, Objective Assessment Plan

(SOAP) format for all clinical notes and ensure all encounters are entered within

72 hours of service in accordance with national and local policies. In addition to documenting contact with the

Veteran, the Contractor shall also document in the HER evidence of collateral contacts with individuals and agencies engaged to support the

Veteran’s housing and recovery needs.

SF VA

Productivity review will be based on all records reviewed throughout the year.

Timely

Submission of

Monthly

Invoices

35 The Contractor shall submit invoices billing for services by the 5th of the month following the month the services were provided. If the 5th of the month follows on a weekday or a holiday, the Contractor shall submit invoices billing for services on the next business day.

COR Quarterly

Invoice

Tracking

VA Invoice

Payment

Processing

System

Positive ratings in quarterly reports and annual

Negative quarterly reports and

Indicators

PWS

Ref Performance Measure

Acceptable

Quality

Level

6. CPARS RATINGS ASSIGNED TO QASP ITEMS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/pdfs/CPARS-

Guidance.pdf p. A2-1):

EXCEPTIONAL Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective. Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.

VERY GOOD

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective. Note: To justify a

Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.

SATISFACTORY

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory. Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.

MARGINAL

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented. Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the

GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or

Environmental Deficiency Report or letter).

UNSATISFACTO

RY:

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective. Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating.

An Unsatisfactory rating should be supported by referencing the management tools used to notify the https://www.cpars.gov/pdfs/CPARS-Guidance.pdf%20p.%20A2-1 https://www.cpars.gov/pdfs/CPARS-Guidance.pdf%20p.%20A2-1 contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental

Deficiency Reports, or letters).

8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using

CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If Contractor performance does not meet the Acceptable Quality level, 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 and the CO determine formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the CO.

The CO will in turn review and will present to the Contractor's program manager for corrective action.

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. The CO shall also assure that the Contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the Contractor’s performance and the acceptability of the Contractor’s corrective action plan.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Surveillance.

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

b. Frequency of Performance Assessment Meetings.

COR/Liaison/Designee shall meet with Contractor quarterly to assess performance.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative