S02 D.1 Quality Assurance Surveillance Plan QASP.docx

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G004--Temporary Shelter HCHV Service (STX)
Solicitation number
36C25723Q0664
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This document outlines a Quality Assurance Surveillance Plan (QASP) for a federal contract to provide Transitional Housing for Homeless Veterans in San Antonio, Texas. The contractor will be evaluated on key performance standards including timely notification of absences or medical emergencies involving referred veterans, completion of treatment plans and discharge summaries, maintenance of HIPAA compliance, and provision of three meals per day meeting USDA guidelines. Surveillance methods involve direct observation, periodic inspections of clinical records and operational reports, validated user complaints, and random sampling. Contract performance will be assessed quarterly by the Contracting Officer's Representative and rated in the Contractor Performance Assessment Reporting System as exceptional, very good, satisfactory, marginal, or unsatisfactory based on achievement of acceptable quality levels.

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36C25723Q0664 0002.docx DOCX document
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TITLE: Transitional Housing for Homeless Veterans – San Antonio, 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: Lamar Elliott

a. Organization or Agency: Department of Veterans Affairs – STVHCS – Audie L. Murphy 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 36C25723Q0664

Measures

PWS

Reference (Sec & pp) Performance Requirement

Standard
Acceptable Quality Level
Surveillance

Method

Incentive
Disincentive/Deduct
Documentation of qualifications of “Key Personnel”
Contractor Staff – pp 16b
Annual evaluation of clinical competencies
Provide to COR annually -Evidence of satisfactory competencies
95%
100% inspection
Favorable contactor performance evaluation
Unfavorable contractor performance evaluation
Notification of unauthorized absence from facility of referred Veteran
Absences and Cancellations – pp 11a & b
CRS Liaison notification by Contractor within 1 business day
Provide to CRS Liaison within 1 business day Notification of absence from facility of referred Veteran
95%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Notification of medical emergency of referred Veteran
Critical Incidents and Medical Emergencies – pp 5c
CRS Liaison notification by Contractor within 1 business day
Provide to CRS Liaison within 1 business day Notification of medical emergency of referred Veteran
95%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Notification of incident involving referred Veteran
Reporting – pp 15d
CRS Liaison notification by Contractor within 1 business day
Provide to CRS Liaison within 1 business day Notification of incident involving referred Veteran
95%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Notification of termination of services to a referred Veteran
Discharge Planning – pp 5a vii
CRS Liaison notification by Contractor within 1 business day
Provide to CRS Liaison within 1 business day Notification of termination of referred Veteran
95%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Quality Assurance, Performance Improvement, Resident Satisfaction
Reporting – pp 15a.ii
Provide to COR quarterly documented reports
Provide to COR quarterly - QA reports, PI reports and Satisfaction surveys
95%
100% Inspection & Customer Complaints
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Individual Treatment Plans / updates
Additional Services Required – pp 5a i
Complete Plan within 10 business days of program admission and Updates every 30 days thereafter
Provide to CRS Liaison initial treatment plan and monthly -Individual Treatment Plan & Updates
95%
100%

Periodic Sampling and Random Sampling

Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Discharge Summary
Additional Services Required – pp 5a.vii
Completion within 2 business days of Discharge from program
Provide to CRS Liaison within 2 business days - Discharge Summary
95%
100%

Periodic Sampling and Random Sampling

Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Facility maintenance and fire safety
Facility - pp 19a-e

Maintain annual documentation of compliance

Provide to CRS Liaison annually - Evidence of compliance
95%
100%

Inspection

Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation

HIPAA/Privacy Compliance for all Records

Inspection of Facility and Program – pp 18a & pp 26
Veteran records are kept in locked and secure locations
Evidence of compliance
95%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Invoicing
Billing – pp 22

Within 10 business days of the end of each month services were provided, the vendor shall provide itemized invoicing

All itemized invoices provided within 10 days of end of each month services delivered
90%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation
Nutrition
Basic Services Required of Contractor pp 4c
Provide 3 meals a day that meet USDA guidelines and provide snacks of nourishing quality
Evidenced of compliance
95%
100% inspection
Favorable contactor performance evaluation.
Unfavorable contractor performance evaluation

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/documents/CPARS-Guidance.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).

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 orEnvironmental Deficiency Reports, or letters).

8. 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.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Lamar Elliott, Program Analyst Date

SIGNED:

Contractor Name, Title Date

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