Quality Assurance Surveillance Plan - QASP.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

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 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: Joshua Barrios

Assigned CS: Lacy Morgan

Organization or Agency: Network Contracting Office (NCO) 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: Jennifer Knapp

3. CONTRACTOR REPRESENTATIVES

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

Primary:

4. PERFORMANCE STANDARDS

a. Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

b. The Performance Requirements Summary Matrix below includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL) on a quarterly basis.

c. Contractor will be held to the same standard as VA personnel through quality assurance and performance monitoring to ensure compliance under this Contract. The Quality Assurance and Performance Monitoring will be governed by the appointed COR who will be responsible for verifying compliance with the terms and conditions of the contract. After the contract is awarded, any incidents as evidenced by the monitoring procedures will be forwarded immediately to the Contracting Officer. In addition, the COR will forward the summary evaluation of the contractor performance to the Contracting Officer once performance ends.

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. There will be quarterly meetings held with the Contractor to discuss any issues. In addition, the COR shall use the following surveillance methods in the administration of this QASP:

a. Observation. Observations will be taken during any and all site visits by any HCHV or VA staff (PWS 1-7, 9).

b. Veteran Queries and Complaints. HCHV staff relies on the Veteran to identify deficiencies. Veterans will be queried as to the services being provided to them. Any identified concerns or complaints are then investigated and validated (PWS 2, 3, 4, 6, 9, 10).

c. Random and Periodic Inspection. Inspections will be accomplished randomly and no less than once per year (PWS 1, 2, 3, 5, 7, 8, 9).

d. Report Reviews/Evaluations. Reviews and Evaluations of required reports will be conducted as received. Deficiencies will be noted and communicated to the Contractor for corrective action (PWS 2, 3, 9).

6. PERFORMANCE REPORT

PWS:

3.1.4 3.1.4.1 3.1.4.2 3.1.4.3 3.1.4.14 3.1.4.15 3.1.4.16 3.1.14.18 3.1.14.18.4 3.1.6

Bed Occupancy >85%

PWS:

3.1.4.2 3.1.5 4.1 4.3 7.2

Program Environment

• Patient rights

• Nature of the Contractors program (i.e. services)

• MAT policy

• Reasonable Accommodation

• Procedures for negative discharge and sanctions

• Grievance and Appeal procedures All policies pertaining to the above is posted conspicuously in contracted facility

PWS:

3.1.9 3.1.5.1

Accreditation/Licensing

PWS:

6.1 6.1.1 6.2

2. 100% of Staff receive training on the following topics 1 time per year

· CPR

· First Aid

· Crisis intervention

· Cultural sensitivity

· Sexual harassment

· Sensitivity to wider issues of homelessness

· Universal Precautions (disease transmission prevention)

· Adult abuse/neglect reporting laws

· Harm Reduction philosophy

· Suicide Prevention

· Medication management

· State and Federal Fair Housing Law and ADA Requirements

· Conflict resolution

· Customer Service

· Professional Boundaries

· Countertransference

· Motivational Interviewing

· Stages of Change

· Severe Mental Illness and Psychopathology

· De-escalation techniques

· Search and Seizure/Probable Cause in the Shelter Setting

· Conservatorship

· Grave Disability Criteria Key Personnel’s resumes must be submitted prior to contract being awarded and as Staff changes. Contractors must submit Staff resume for any key staffing changes within 14 days of Staff change.

PWS:

Veteran queries/ complaints

7. CPAR 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):

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.

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.

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.

8. DOCUMENTING PERFORMANCE

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

b. When unacceptable performance occurs, the COR shall inform the contractor within three (3) days of the unacceptable performance. This will normally be in writing unless circumstances necessitate verbal communication, in which case the notification will occur within one (1) day. In any case the COR shall document the discussion and place it in the COR file.

c. 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.

d. 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.

e. Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. In addition, any performance that is below the standards set-forth in Section 4 may subject the Contractor to the termination for default provision.

9. 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. Performance Assessment Meetings. The COR shall meet with the contractor Quarterly to assess performance and shall provide a written assessment.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

Signature – Contracting Officer’s Representative

Signature – Contractor Program Manager

CONTRACT REPORT

5. DATES

a. CR PREPARED

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER