QUALITY ASSURANCE SURVEILLANCE PLAN - QASP.doc

Quality Assurance Surveillance Plan (QASP) Project Title: VAPIHCS HCHV Emergency Housing Medical Respite Program Contract Number: <Upon award, Government will enter contract number> Contract Description: VA Pacific Island Health Care System’s Health Care for Homeless Veterans will provide board, room, support and case management in Emergency Housing Medical Respite beds for Homeless Veterans to improved their housing situation.

Contractor’s Name: <Enter your company 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.

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.

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 below is developed from the Statement of Work and includes performance standards. The Government shall use these standards to determine contractor performance and scores shall not be below 95%.

Quality Assurance Surveillance Plan (QASP) Performance

Requirements Score

90,95, 100% Surveillance method

1. Contractor will maintain level of 80% occupancy through collaboration with VA and their demonstrated independent outreach efforts. (PROGRAM SERVICES - E.2.8.)

Review of the bed occupancy data.

Invoice Data Sheets

2. Contractor will follow the established Referral Process. If a Veteran is self-referred, promptly respond and collaborate with VA HCHV Team. (CASE MANAGEMENT SERVICES - E.3.3-4.)

Periodic VA and Site data review.

Random Sampling of Documents.

3. Contractor will adhere to same-day admissions 100% of the time. (PROGRAM SERVICES - E.2.9. & CASE MANAGEMENT SERVICES - E.3.3.d.)

Periodic VA and Site data review.

Random Sampling by Liaisons.

4. Contractor will complete a comprehensive assessment of the Veteran’s needs and develop a Housing Support Plan with the Veteran to be submitted to VA with 7 days of admission. (CASE MANAGEMENT SERVICES - E.3.8.)

Periodic VA and Site data review.

Random Sampling.

Review of HSP in CPRS.

5. Contractor will submit a Monthly Housing Support Summary which documents 3 or more meetings with the Veteran per month and outlines the specific actions taken by the Case Manager and Veteran to achieve the goals identified in their Housing Support Plan. (CASE MANAGEMENT SERVICES - E.3.5.g.)

Periodic VA and Site data review.

Random Sampling Review of HSP in CPRS.

6. Contractor will provide Veterans direct and ongoing assistance to support the Veteran’s access of housing options, financial and supportive programs such as SS, SSDI, General Assistance, Medicaid, etc. and also obtain required documents for permanent housing applications. (CASE MANAGEMENT SERVICES - E.3.7.)

Periodic VA and Site Data review.

Random Sampling Review of HSP in CPRS.

7. Contractor will submit to VA a completed Exit Summary within 48 business hours of a Veteran’s departure or discharge from Emergency Housing. (CASE MANAGEMENT SERVICES -E.3.13.)

Periodic VA and Site Data review.

Random Sampling Review of HSP in CPRS.

8. Contractor will achieve the VA Central Office (VACO) metric which requires that 20% or less of Veterans leave services through a negative discharge. (PROGRAM SERVICES - E.2.11.)

Periodic VA and Site data review.

HOMES Scorecard data

9. Contractor staff will limit the Veteran stays in Emergency Housing to 90 days. Stays over 90 days must have an extension authorized in writing by the VA Emergency Housing Liaison. (PROGRAM SERVICES – E.2.12.)

Periodic VA and Site data review.

Veteran CPRS file

10. Contractor will provide or provide access to structured group activities no less than twice per month and document the attendance at the specific group activity in their submitted Monthly Housing Support Plan. (CASE MANAGEMENT SERVICES - E.3.11.)

Period Inspection

Review of Monthly HSP

11. Contractor will have an adequate number of qualified case managers at the site(s). Case Manager to Veteran ratio will not exceed 1:15 (unless specifically authorized by VA HCHV Program). (PERSONNEL - E.5.1.)

Periodic Inspection Review of staffing assignments

12. Contractor will have a designated qualified staff on duty at the approved site 24 hours per day, 7 days a week. (PERSONNEL - E.5.3.)

Periodic Inspection

Review of staffing logs

13. Contractor will submit training log to the COR annually and on request to ensure required trainings have been completed. (PERSONNEL - E.5.7.)

Training log submission

Annual Inspections

14. Contractor will ensure the maintenance of site facility and make corrections as needed from initial, annual, unannounced or cursory inspections. (ENVIRONMENT OF CARE - E.4.)

Periodic Inspection

15. Contractor will provide 3 nutritous meals per day of nourishing quality and 1 snack to Veterans admitted to the program. (PROGRAM SERVICES - E.2.4.)

Periodic Inspection

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.)

Admission Protocol

Case Management

Improvement of Financial

Group Activities

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.)

Occupancy

Admission Protocol

Care Planning

Case Management

Improvement of Financial Situation

Group Activities

Discharge Planning

Discharge Protocol

Outcomes

VA Coordination c.

PARTICIPANT SATISFACTION. (Combines elements participant complaints volunteered or during interview. 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.

Outcomes 6.

DOCUMENTING PERFORMANCE

a.

ACCEPTABLE PERFORMANCE (95% and 100% Ratings) The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b.

UNACCEPTABLE PERFORMANCE (below 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.

7.

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.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative

Attachments:

1. Contract Performance Report

Contract Discrepancy Report

Attachment 1

Contract Performance Report

1.

Contract Number: <insert 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 Representative Date

Attachment 2 Contract Discrepancy Report (CDR) TO: (Contractor Program Manager or onsite representative) <insert name>

FROM: (Name of COR) 1.

Contract Number: <insert 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 Representative Date

Received by:

Signature – Contracting Program Manager or Onsite Representative Date

Distribution:

<Name & Title - Contracting Officer>

SHAPE \* MERGEFORMAT

<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.>