Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

Project Title: Health Care for Homeless Veterans (HCHV) Contracted Emergency Residential Services

Contract Number: New Requirement: Name of contractor to be completed upon reward

Contract Description: Contractor will provide a California licensed care facility (RCFE) for homeless veterans in Contra Costa, Solano, Yolo, Sacramento, or West Placer Counties. Such a contracted program should include the following services: room and board with individual rooms, needs assessment, service planning, provision of meals, general case management, and Acts of Daily Living (ADLs) and Independent Acts of Daily Living (IADLs) care to homeless Veterans who may be dealing with any number of psychosocial stressors, including, but not limited to: serious mental illnesses, substance use disorders, lack of financial resources, familial discord, etc.

Contractor’s Name: New Requirement: Name of contractor to be completed upon reward:

(hereafter referred to as the contractor)

INTRODUCTION

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.

• Method and frequency of surveillance.

• Who will conduct surveillance

• How surveillance efforts and data will be documented.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the expectation 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, the Government desires to maintain a quality standard in providing residential 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: NCO Medical Sharing CO

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

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: Homeless Contracts Coordinator (COR)

c. Other Key Government Personnel – The Program Manager & Homeless Supervisor, Other Homeless Contracts Coordinator (secondary COR)

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. They are comprised of performance indicators (some characteristic of a deliverable that can be measured) and performance measures (a mark, measure or benchmark that government personnel use as a point of comparison when evaluating contractor performance). The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The PWS (or SOW) identifies the requisite performance indicators. The Government shall use the corresponding standards below to determine contractor performance in relation to those indicators and shall compare contractor performance to the Acceptable Quality Level (AQL), also identified below, to determine overall contractor performance score.

Performance Indicators

PWS

Ref Performance Measure Acceptable Level of Quality Method of

Assessment Incentive Dis-incentive

Occupancy C.3.1 Program will maintain minimum acceptable level of occupancy through collaboration with VA and independent outreach efforts.

Accepted:

occupancy shall not average less than 80% for any given quarter.

Preferred: 90- 100%

Direct Observation Quarterly reports based on each quarter. The annual review will not be based on the quarterly reports but on entire year occupancy.

Positive Past Performance In CPARS review. And increase in program size if funds are available.

Negative Past Performance In CPARS review. And possible reduction in program size.

Care Planning

C.3.2 The program will engage the veteran in a collaborative assessment of needs, including barriers to stable housing, and create an initial plan to address those concerns within 14 days of admission.

Accepted: At least 75% of Veteran charts reviewed will demonstrate that a comprehensive written care plan was completed by day 14.

Preferred: 100%

Periodic Inspection

(quarterly or more). The annual review will be based on the percent of the total charts reviewed throughout the year.

Positive Past Performance in CPARS review.

Negative Past Performance in CPARS review.

Case Management

C.3.3 Program will provide individual case management and/or professional counseling that focuses, at a minimum, on housing stabilization, increased income, and access to and engagement in care through appropriate providers of physical and mental health care services.

Accepted: At least 75% of Veterans will engage in individual case management meetings 3 (or more) x per month.

Preferred: 100%

Periodic Inspection

(quarterly or more). The annual review will be based on the percent of the total charts reviewed throughout the year.

Positive Past Performance in CPARS review.

Negative Past Performance in CPARS review.

Housing C.3.5 Discharge to permanent, housing shall be monitored as an indicator of contractor’s efforts to achieve positive outcomes for all Veterans referred.

Accepted: At least 35% of all Veteran discharges will be to a permanent housing arrangement.

Preferred: 55% or higher.

Direct Observation quarterly and annually. The annual review will not be based on the quarterly reports but on entire year exits to housing.

Positive Past Performance in CPARS review.

Negative Past Performance in CPARS review.

Negative Exits

C.3.6 Negative exits, which shall be defined as discharges involving

Veterans being asked to leave the program due to rule violation or otherwise leaving the program without consulting program staff in any way, shall be monitored on a continuous basis.

Accepted: 30% of all Veteran discharges will meet criteria to be defined as negative exits.

Preferred: 20% or less.

Direct Observation quarterly and annually. The annual review will not be based on the quarterly reports but on entire year exits to housing.

Positive Past Performance in CPARS review.

Negative Past Performance in CPARS review.

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.)

• Occupancy

• Permanent Housing

• Negative Exits

b. PERIODIC INSPECTION. (Inspections for HCHV CERS Programs will occur quarterly or more)

• Care Planning

• Case Management

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:

Occupancy: receives 20% if meets preferred measure, 18% if meets accepted measure, and 0% to 17% if measured failed for the year.

Care Planning: receives 20% if meets preferred measure, 18% if meets accepted measure, and 0% to 17% if measured failed for the year.

Case Management: receives 20% if meets preferred measure, 18% if meets accepted measure, and 0% to 17% if measured failed for the year.

Permanent Housing: receives 20% if meets preferred measure, 18% if meets accepted measure, and 0% to 17% if measured failed for the year.

Negative Exits: receives 20% if meets preferred measure, 18% if meets accepted measure, and 0% to 17% if measured failed for the year.

91-100% Positive Performance 80-90% Neutral Performance

< 80% Negative Performance

7. DOCUMENTING PERFORMANCE

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

a. POSITIVE PERFORMANCE (91-100% Rating), NEUTRAL PERFORMANCE (81-90% Rating)

Positive and Neutral Performance will be recorded in CPARS review.

c. UNACCEPTABLE PERFORMANCE (80% Rating or below)

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 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 Surveillance

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.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative