Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP)

Residential Treatment Services for San Francisco VA Health Care System

The contractor will be evaluated in accordance with the following:

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 will monitoring take place?

• Who will conduct the monitoring?

• How will monitoring efforts and results 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 through contract modification. 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 | Emily.Trinh@va.gov

Organization or Agency: Network Contracting Office 21

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: Martin Cruz | Martin.Cruz@va.gov

Organization or Agency: San Francisco VA Health Care System mailto:Emily.Trinh@va.gov mailto:Martin.Cruz@va.gov

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary Program Manager:

Name: ____________________________

Title: _____________________________

Email: _____________________________

Phone: ____________________________

Alternate Program Manager:

Name: ____________________________

Title: _____________________________

Email: _____________________________

Phone: ____________________________

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 the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating.

At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

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. Direct observation shall be performed periodically or through 100% surveillance. All Performance Standards.

b. PERIODIC INSPECTION. Evaluate outcomes on a periodic basis. Inspections may be scheduled Daily, Weekly, Monthly, Quarterly, Annually, or unscheduled as required. All Performance Standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints from agency personnel will be passed to the Contractor’s quality control inspector (QCI) for correction. All Performance Standards.

Standard: Customer complaints shall not exceed the thresholds cited above for each performance objective. The Government’s QA personnel shall notify the Contracting Officer for appropriate action in accordance with FAR 52.212-4 Contract Terms and Conditions – Commercial Products or Commercial Services or the appropriate Inspection of Services clause, if any of the above service areas exceed the customer complaint threshold.

PROCEDURES: The Government evaluator shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the Government evaluator shall notify the CO and/or QCI of the deficiencies within 3 business days and have QCI correct said deficiencies. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the Contractor has to correct the deficiency. The evaluator shall not issue a receiving report accepting the services for the month in question until all deficiencies have been corrected.

FREQUENCY OF MEASUREMENT: During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings will be conducted quarterly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor's files

6. SAMPLE QASP PERFORMANCE REPORT DATE:__________________

Task Performance Standard Performance Threshold/

Acceptable Quality Level Method of Surveillance

Residential Room and Board

The facility shall provide nutritious meals. Food shall be prepared, served and stored under sanitary conditions. The facility shall provide storage space in an onsite refrigerator for veterans to store personal food. The facility shall establish and maintain sanitary procedures for washing dishes, cleaning equipment and work areas, and disposing of waste. At least three nutritious meals or their equivalent shall be served daily at regular times with not more than a 14 hour span between evening meal and breakfast of the following day. Snacks of nourishing quality, i.e. fruits, shall be offered between meals or bedtime.

100% Not less than quarterly Inspections, conducted by VA COR and program management clinical staff. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program's records

Residential Room and Board

Room and board shall be maintained its cleanliness, i.e., bed sheets are clean and changed regularly. Janitorial services and laundry facilities are available.

100% Not less than quarterly Inspections, conducted by VA COR and program management clinical staff. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program's records

Contract Personnel The contractor shall employ sufficient professional staff and other personnel to carry out the policies and procedures of the program.

There will be, at a minimum, an employee on duty on the premises, or residing at the program and available for

100% Not less than quarterly Inspections, conducted by VA COR and program management clinical staff. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the Contracted Program's records

Therapeutic Services

The contractor will provide individualized rehabilitative and recovery services determined to be needed by the resident in a plan developed by the contractor in consultation with the Veteran and the VA case manager and/or other appropriate VA staff. Services which the contractor must be able to furnish, either directly or by referral to VA or community resources, include:

Group Activities: Structured group activities as appropriate -examples include group therapy, social skills training, Alcoholics

Anonymous, Narcotics Anonymous, vocational counseling and physical activities as appropriate.

VA Coordination: Coordination and referral to appropriate Veterans

Affairs health, mental health, and other services, including VA residential treatment programs for addiction, homelessness, and/or

PTSD, as well as outpatient treatment as recommended by VA providers. Veterans should have access to a phone line and should be able to access their voicemails at regular intervals in order to ensure that they attend recommended medical and mental health appointments.

The contractor should communicate in a timely way with VA staff about notable clinical events, such as intoxication, unexpected departure from the facility, new medical or mental health symptoms, etc.

Case Management: Individual counseling, including counseling on self care skills, adaptive coping skills and, as appropriate, vocational rehabilitation counseling, in collaboration with VA program and community resources. Counseling will include support for an alcohol and drug abuse-free lifestyle.

Living Skills: Assistance to develop responsible living patterns and to achieve a more adaptive level of psychosocial functioning, upgraded social skills, and improved personal relationships.

100% compliance Not less than quarterly Inspections, conducted by VA COR and program management clinical staff. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel

Discharge Planning: The facility case managers, in conjunction with the VA Case Manager, will provide assistance with discharge planning.

Housing needs will be assessed upon arrival and resources will be coordinated for discharge to a successful community placement.

Length of stay is to be determined by VA clinicians.

Management of Medications: Medications and narcotics shall be properly stored, controlled, issued and recorded in compliance with physicians' orders.

Clinical Issues: A written protocol will be established and reviewed with SFVAMC clinicians with a plan for managing medical and behavioral emergencies, including severe alcohol withdrawal

(delirium tremens), self harm and violence, management of intoxication, and severe psychiatric symptoms.

Veterans are not to be accepted into a VA contracted bed without receipt and review of all referring documentation, including a mental health evaluation and TB screening documentation

Records and Reports

The facility/contractor shall maintain an individual client record on each veteran admitted under this contract. All case records shall be secured and confidential.

The contractor shall make available to the VA, documentary information deemed necessary by the VA to conduct utilization review audits for the mandated national evaluation study as required by Section 2 of Public Law 100-6; to verify quality of care for Veterans, to assure confidentiality of care for Veterans, to assure confidentiality of Veteran record information, and to determine the completeness and accuracy of financial records. The facility shall maintain an individual client record on each Veteran admitted under this contract.

The facility shall comply with the requirement of the "Confidentiality of Alcohol and Drug Abuse Patient" (42 CFR, Part II) and the

"Confidentiality of Certain Medical Records" (38 USC 4132). All case records shall be secured and confidential. Records will be made

100% Not less than quarterly Inspections, conducted by VA COR and program management clinical staff. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel available on a need-to-know basis to appropriate VA staff members involved with the treatment program of the Veterans concerned. The files shall include: Reasons for referral; All essential identifying data relevant to the resident and his/her family including a socio-cultural assessment, weekly progress reports or notes, TB screening results, and documentation of any case management interventions or patient care conferences; Copies of any medical prescriptions issued by physicians, including orders, if any, for medications to be taken; Final summaries on each resident who leaves the program, to include reasons for leaving, urine toxicology results as indicated, the resident's future plans, and follow-up locator information.

Billing Submits invoices that accurately reflect patient information and contract prices in a timely manner.

95% Reconciliation of clinical records with contractor billing by program administrative staff with COR review.

7. 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/cparsweb/assets/documents/CPARS_User_Manual.pdf

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).

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cpars.gov%2Fcparsweb%2Fassets%2Fdocuments%2FCPARS_User_Manual.pdf&data=05%7C02%7C%7C1299a8a1556647c9c9b208dd897915ec%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638817875334440754%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=6A9MQEEm9YUvO1cWqDUn1sC8wYUJvuCVqG%2F2AhW8s1E%3D&reserved=0

UNSATISFACTORY:

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 contractor of the contractual deficiencies

(e.g. Management, Quality, Safety or Environmental Deficiency Reports, or letters).

8. DOCUMENTING PERFORMANCE

a. The VA 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 REPORTING SYSTEM (CPARS).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This shall normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO.

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

The contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long after receipt the contractor has to present this corrective action plan to the CO. The VA 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.

See Sample on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT

RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

a. CONTRACTOR

NOTIFIED

b. COR c.

CONTRACTING

OFFICER