G099--RFP 3/1 - SDVOSB set aside

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

For Community Emergency Residential Services for the Clarksburg VA Medical Center

Contract Number: [upon award, Government will enter contract number]

Contractor s Name: [upon award, Government will enter the Contractor s name] (hereafter referred to as the contractor)

PURPOSE

The purpose of the Quality Assurance Surveillance Plan (QASP) is to provide guidance on how the quality of services provided under this contract will be monitored.

SCOPE

The areas to be addressed under the QASP are to be as follows:

Clinical Information Compilation & Maintenance

Clinical Records

Quality Care

Patient Safety

Patient Satisfaction

Placement and Program Completion Outcomes

BACKGROUND

There is an increasing need to provide transitional housing and supportive services to homeless veteran who present with a disabling condition. The VA HCHV Programs have developed and expanded to become the largest integrated provider of homeless services in the country. The Clarksburg VAMC has a goal of ending homelessness among veterans, and all Veterans who are chronically homeless or newly homeless and are ready to be housed will be housed within 6 months of admission into the program. In an effort to support the VA s Zero Tolerance on homelessness among Veterans, Clarksburg VAMC is seeking Community Emergency Residential Service placement options for chronically homeless and or homeless Veterans.

Many of these Veterans have multiple conditions that make it hard for them to succeed in shelters and or get out of homelessness to self-sufficiency without assistance. These conditions may include mental illness, substance use disorders, and other serious medical conditions. The Health Care for Homeless Veterans (HCHV) Contracted Beds for Community Emergency Residential placement with supportive services is an opportunity to rapidly reduce Veteran s homelessness, particularly those who present with a disabling condition that require intense case management assistance to move to long-term and or permanent housing.

QUALITY CHECKPOINTS

Task

ID

Indicator

Standard

Acceptable Quality Level

Method of Surveillance

Incentive

Clinical Information compilation and Maintenance

1

Individual clinical record shall be created and maintained on each Veteran placed under contract.

Immediately upon admission.

100%

Observation and random inspection (auditing or any other method that was proposed in your solution.

Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution. Performance Action Plan.

2

Compliance with requirements of the

Confidentiality of Medical Records (38 USC 4132), as well as Alcohol and Drug Abuse Veterans Records (42 CFR, Part II) when

appropriate.

Ongoing and no exceptions. Upon Admission and prior to admission of a Veteran

100%

Observation and random inspection (auditing or any other method that was proposed in your solution.

Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution.

3

Records shall be maintained in a locked file accessible only to designated contract staff and available to appropriate VA staff members involved with the Veterans Care.

Upon admission and continuously thereafter. No exceptions.

100%

Observation and random inspection (auditing or any other method that was proposed in your solution.

Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution.

4

Records should be retained by the contracted facility for a three-year period following termination care.

To be filed within 30 days of discharge

100%

Observation and random inspection (auditing or any other method that was proposed in your solution.

Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution.

All clinical records shall include

5

Identifying data relevant to Veteran and his/her family including psychosocial

Upon admission or within 5 days of admission and continuously thereafter. No exceptions. Psychosocial to be submitted to appropriate VA Staff within 7 days following admission

90%

Observation and random inspection (auditing or any other method that was proposed in your solution.

Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution.

6

Completed treatment plans with goals focusing on removing barriers to housing during specific period of stay.

To be completed within 24 hours of admission and submitted to VA staff.

90%

Observation and random inspection (auditing) or any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

7

A minimum of one weekly progress note addressing progress

toward goals identified in the Treatment Plan.

Completed weekly and entered in HMIS.

95%

Observation and random inspection (auditing) or any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

8

Completed discharge summaries to include progress made during

residential

period, reason for leaving, future plans and follow up locator.

To be completed the same day of discharge and submitted to appropriate VA

staff.

95%

Observation and random inspection (auditing) or any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

9

All Veteran serve by the program must be entered into the appropriate Homeless Information Management System. (HMIS)

Must complete a vulnerability Index and Service Priority Assessment Tool (VI-SPDAT)

To be competed at time of entry.

To be completed within 7 days of entry

85%

85%

Running Census Report on the HMIS system

Exercise of option period, timely payment of invoices and past performance.

Quality Care

10

Veteran s discharge shall only occur during VA Business hours of Monday through Friday 8:00 am to 4 pm except for medical or security reasons (a person is admitted to the hospital or the safety of others is threatened).

To be implemented immediately upon start up and thereafter

95%

Observation and random inspection (auditing) of any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

11

Care is provided by designated Shelter Veteran Case Manager.

Staff should be in place prior to program start up and thereafter

90%

Observation and random inspection (auditing) of any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

12

Veterans will complete the program within 6 months.

Veteran will move into permanent housing

60%

Discharge summary, chart review

Option not exercised, census decrease and CPARS evaluation reflect unfavorable.

Patient Safety

13

Patient safety incidents must be reported to the authorizing VA Medical Center and the COR or designee

All incidents reported immediately (within 24 hours)

95%

Observation and random inspection (auditing) of any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

14

Patient safety incidents must be investigated confirmed and resolved

All incidents are investigated confirmed and resolved within 48hrs.

95%

Observation and random inspection (auditing) or any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

15

Patient safety incidents investigations, conclusions and findings must be reported to the authorizing VA medical center and the COR or designee

Updates and findings of patient safety incident investigations are provided continuously

95%

Observation and random inspection (auditing) or any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

Patient Satisfaction

16

Patient complaints about the quality of care are reported to the COR or designee and the Contractor for resolution

All patient complaints are reported and updated within 24 hours

95%

User Surveys, observations and random inspections (auditing) or any other method that was proposed in your solution.

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

17

Providers, Veterans and staff are familiarized with the process outlined in contractor s grievance procedures as well as patient rights.

All providers and staff are educated

Veterans are brief on grievance procedures upon admission.

100%

User Surveys, observations and random inspections (auditing) or any other method that was proposed in your solution.

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

Placement and Program Completion Outcomes

18

Treatment Goals must be focused on removing the barriers to Permanent Housing

Veterans completing the program moved to permanent Housing

60%

Data collection and reports from contractor. Surveillance of homeless data base.

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

19

Treatment goals must be focused on increased income/benefits

Veteran completing the program have increased their benefits/income

50%

Veteran and case manager self-report. Progress notes

Exercise of option period and past performance and/or any other incentive that was proposed in your solution.

Facility/ Living Quarters

21

Providers and staff correct all environmental violations/ deficiencies identified by the Safety Specialist and Environmental Inspectors.

Within 30 days of notice.

98%

User Surveys, observations and random inspections (auditing) or any other method that was proposed in your solution

Exercise of option period and past performance and/or any other incentive that was proposed in your solution

GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities:

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: Linda Smith

Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Material Management

Contracting Officer s Technical Representative (COR): The COR is responsible for technical administration on 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: Amber Kovach

Other Key Government Personnel

CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor s program manager for this contract:

Program Manager: XXX

Other Contractor Personnel (including title): XXX

INCENTIVES

The Government shall use Exercise of Option Period and past performance and/or any other incentive that was proposed in your solution as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

METHODS OF QUALITY ASSURANCE SURVEILLANCE

Various methods exist to monitor performance. The COTR or their designee shall use the surveillance methods listed below in the administration of this QASP:

DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.)

PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [daily, weekly, monthly, quarterly, or annually] or unscheduled as required)

VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

100% INSPECTION. (Evaluates all outcomes)

PERIODIC SAMPLING. (Variation of random sampling. Sample is only taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected. Since sample is not entire random, it cannot be applied to total activity performance.)

RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.)

DOCUMENTING PERFORMANCE

ACCEPTABLE PERFORMANCE

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

UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR or their designee shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR or their designee shall document the discussion and place it in the COR or their designee file.

When the COR or their designee determines formal written communication is required, the COR or their designee 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 must present this corrective action plan to the COR. The Government shall review the contractor s corrective action plan o determine acceptability.

Any CDRs may become part of the supporting documentation for any contractual action deemed necessary by the CO.

FREQUENCY OF MEASUREMENT

Frequency of Measurement

During contract performance, the COR or their designee will periodically analyze whether the neglected frequency or surveillance is appropriate for the work being performed.

Frequency of Performance Assessment Meetings

The COR or their designee shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

[After award, both the contractor s Program Manager and the COTR shall sign this document.]

Contractor Program Manager Name Signature Date

Contracting Officer Technical Representative Name Signature Date