S02 D.1 Quality Assurance Surveillance Plan QASP 36C25725Q0003.docx

TITLE: Temporary Shelter and Supportive HCHV Services - El Paso TX

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: Carlos Jaquez Organization or Agency: Department of Veterans Affairs – VHA RPO West – NCO 17

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: Narvell Amey

a. Organization or Agency: Department of Veterans Affairs – EPVHCS – El Paso Texas VA Medical Center.

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternate:

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.

0. DIRECT OBSERVATION. 100% surveillance: Staff and management’s direct observation of methods, process adherence, and quality during the performance of contractual duties.

0. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Clinical or operational reports and/or ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

0. VALIDATED USER/CUSTOMER COMPLAINTS. Each customer complaint will be investigated by the Department Administrative Officer. Methods of investigation include the examination of the medical record, EDIS data, and statements provided by the patient, other staff/patients, and the contract personnel. Final determination on the validity of the complaint’s rests with the Department Section Chief.

0. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

0. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Random inspection quarterly to assess the progress of their work for the need to utilize available option years If needed. This information will be obtained from the Department Section Chief.

D.1 Quality Assurance Surveillance Plan (QASP) – RFQ 36C25725Q0003

Item

Task

Section

Indicator

Standard Acceptable Quality Level Method of Surveillance

Case Management Services 3.7.5

Ability to receive and place Veterans on short-term notice

Contractor shall provide rapid, often times same day residential placement

95% Observation and random inspection

7.1

Compliance in completing progress reports as directed by COR or other HCHV staff Contractor provides Progress Reports in the delineated format and in accordance with timelines established by the COR

Review and Evaluation of all Required Reports

Supportive Services

3.7.11

Housing

3.7.9

Records and Reports

7.3

Observation and random inspection of documentation

7.6 Utilization of the Homeless Operations Management and Evaluation System (HOMES) and the Homeless Management Information System (HMIS).

If applicable, Contractor will utilize and update these systems as directed by the COR/HCHV program staff

Observation and random inspection of data systems

Dietetic Services

3.16

Observation and Veteran queries/ complaints

Facility

3.3 3.4 3.5 3.6

Contractor facility conformance to all state and federal requirements as pertains to licensing, safety, and health codes.

Per the PWS, facility shall: maintain conformance to all city, county, state and federal licensing requirements and health codes; meet Fire Safety; have a current occupancy permit; meet ADA requirements

Periodic Inspections

Veteran Resident Safety

3.7.1

Identification, Reporting, and Resolution of facility safety Issues All identified safety issues shall be investigated immediately and corrected in a timely manner appropriate for the incident.

Observation, random inspection, and Veteran queries/ complaints

17.1

Identification, Reporting, and Resolution of Veteran safety Incidents Any incident involving an injury or severe illness to a Veteran shall be reported immediately after occurrence to the COR. Initial notification shall be via telephone with a follow-up written report provided within 24 hours.

Observation, random inspection, and Veteran queries/ complaints

Patient Satisfaction

9.1

Patient Complaints All patient complaints regarding quality of care are reported to the COR within 24 business hours

Veteran queries/ complaints

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/documents/CPARS-Guidance.pdf

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.

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).

7. 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 CO shall inform the contractor. This will 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 Report (CR), and present it to 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 CR in writing. The CR 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 CR will also state how long after receipt the contractor has to present this corrective action plan to the CO. 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 CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR on the following page.

COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Narvell Amey, COR Date

SIGNED:

Contractor Name, Title Date

CONTRACT DISCREPANCY REPORT

5. DATES

a. CDR PREPARED

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

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.)

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

a. CONTRACTOR NOTIFIED

b. COR

c. ONTRACTING OFFICER