Description
Draft SOW Draft SOW STATEMENT OF WORK HEALTH CARE FOR HOMELESS VETERANS INTENSIVE CASE MANAGEMENT PROGRAM Background: The Health Care for Homeless Veterans (HCHV) Program at VA Palo Alto Health Care System (VAPAHCS) is an outpatient program of the Domiciliary Service, serving homeless Veterans in community-based settings. The HCHV Program seeks (1) qualified Intensive Case Manager (ICM s) to provide ongoing case management services to Veterans identified and referred by the HCHV Program and in coordination with the Care Coordination Project (CCP) of the County of Santa Clara. The primary target populations for ICM services include chronically homeless, chronically mentally ill Veterans, and homeless Veterans determined to be at unique risk based upon their medical and/or mental health needs. To be eligible for ICM case management services, referred Veterans must: Be eligible for VA health care as determined by VA Palo Alto Health Care System Be homeless or chronically homeless based upon all credible indication Be assessed by the ICM to have ongoing medical, mental health, substance abuse, and/or other serious psychosocial conditions or stressors that prevent the Veteran from obtaining and/or maintaining permanent housing on his/her own. Scope of Work: Contractor shall provide a qualified ICM to perform housing search and case management services required in this contract for beneficiaries of the VA Palo Alto Health Care System, Menlo Park Division, located at 795 Willow Road, Menlo Park, CA 94025. The position entails providing housing search services, assistance in housing development tasks, collaborating with community partners on outreach efforts, and on-going, intensive case management services for Veterans referred to the HCHV ICM Program. The ICM supports and enhances VAPAHCS philosophy and goals. They will participate in a multidisciplinary team working with Veterans experiencing homelessness and often accompanying mental health diagnoses including, but not limited to, substance use disorders, post-traumatic stress disorder, severe mental illness, and dual diagnoses. Workload occurs as a result of scheduled and unscheduled requirements for clinical care, in addition to permanent housing development and homeless outreach tasks as assigned. The ICM shall perform all ongoing housing-related and case management services within the scope of this statement of work in the community and on-site using government furnished supplies, facilities and equipment within the Domiciliary Service. This will include an on-site workstation with desktop computer and desktop telephone. Contractor will provide their own vehicle for transportation of self and clients and will receive standard mileage reimbursement at the current government rate not to exceed $5,000 per year. Mileage to begin and end at the duty station of Menlo Park VA unless otherwise determined by HCHV Coordinator/COR/Designee. The government will provide equipment necessary for work while in the community. Qualifications: Contracted Intensive Case Managers are expected to have a combination of education and direct experience that demonstrates expertise in working with homeless and at-risk individuals who may experience barriers to housing stability including medical, mental health, substance use, legal, and financial concerns. At minimum, assigned ICM s shall possess a bachelor s degree from an accredited college or university, preferably in the fields of Social Work, Sociology, Psychology, or other closely related field; and at least 2 years of full-time experience working in a case management capacity serving homeless and at-risk individuals, such as those diagnosed with a severe mental illness (SMI). Please note that there is a strong preference for individuals possessing a master s degree in Social Work or closely related field. Selection of ICM contractor staff shall include a standard interview process and the right of HCHV to request substituted personnel at will. All education and experience will be verified prior to contract award. In addition, ICM contractors must: Possess a valid California Driver s License Reliable personal transportation and proof of adequate insurance Certify that they have no moving violations within the prior 24 months that indicate lack of safety in transporting patients (This may be negotiable dependent upon violation). Be proficient in English, both written and spoken Be proficient in using electronic documentation systems and common office software to engage in and document services Have extensive experience in medical record documentation (SOAP, SMART, SNAP, etc.) Pass a Background and/or Security Investigation ICM personnel performing under this contract shall meet or exceed recognized National Standards as established by the Joint Commission, CARF and shall perform the services in accordance with the ethical, professional, and technical standards of the VA. ICM personnel shall perform services in accordance with ethical, professional, and technical standards of the healthcare industry consistent with VA policy, regulations, procedures and protocol. ICM Personnel shall be technically proficient in the skills necessary to fulfill the requirements stated herein. ICM must be adequately trained in the areas of affordable housing search and working with adults with psychosocial problems. ICM must have knowledge and understanding of Federal policies related to the development of affordable housing. ICM must be knowledgeable with both County HMIS and VA HOMES database. Knowledge Required Ability to provide psychosocial treatment to a wide variety of individuals from various socioeconomic, cultural, ethnic, educational, and other diverse backgrounds. This requires knowledge of human development and behavior (physical and psychological), and the differential influences of the environment, society, and culture. Ability to coordinate or provide mental health, social work, educational, health care, vocational, housing, transportation, advocacy, respite care, and recrea tional services, as needed. Ability to work with patients and families who are experiencing a variety of psychiatric, medical, cognitive, and social problems utilizing case management best practices. Assess the psychosocial functioning and needs of patients and their family members; formulate and implement an individual service plan, identifying the patient s problems, strengths, weaknesses, coping skills, and assistance needed. This requires judgment and skill in utilizing supportive, problem solving, or crisis intervention techniques. Ability to establish and maintain effective working relationships with patients, staff, landlords, property managers, and representatives of community agencies. Ability to communicate effectively, both orally and in writing, with people from varied backgrounds. Basic skill in the use of computer software applications for drafting documents, data management, and tracking. Ability to learn and utilize software programs in use by the CCP program, the COC and Veterans Healthcare Administration (VHA). Knowledge of community and housing resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to effectively coordinate services for the benefit of the Veteran. General knowledge regarding local landlord-tenant law, fair housing, subsidized housing programs, and Housing Quality Standards (HQS). Ability to independently evaluate his/her own practice through participation in performance measurement and review activities, as well as systems improvement efforts. Ability to work independently with little oversight and guidance. Schedule: Intensive Case Managers are expected to provide services under this contract 40 hours per week, typically during regular business hours, Monday through Friday from 8:00 am-4:30 p.m. Differing hours may be needed to accommodate meetings with landlords, patients, and staff. The total hours worked per week will be no more than 40 unless there is a waiver from the COR; ICMs must maintain accurate and detailed timekeeping records for billing purposes. Work under this contract shall be provided at various VAPAHCS locations and in the community. The ICM will be based at the VA Menlo Park Division (MPD) but will regularly work at designated and undesignated community sites throughout Santa Clara and San Mateo Counties. Annual hours required will range from 2000 to 2080 total. Period of Performance & Contract Type: Contract is a Firm Fixed contract Method of Inspection and Acceptance: The Contracting Officer s Technical Representative (COR) will evaluate all deliverables submitted by the ICM. The COR is responsible for certifying invoices for payment for deliverables received and deemed by the COR to be acceptable. A Quality Assurance Surveillance Plan (QASP) will be used by the COR to monitor and ensure contract performance. Description of Work The primary goal of the ICM s work is to enroll and case manage referred, eligible Veterans as part of the Santa Clara County Care Coordination Project (CCP) and assisting Veteran in achieving an appropriate permanent housing placement and stabilization. Case Management of Veterans will be provided at no more than a 1:30 ratio, utilizing a tapered case management approach. ICM s will provide services through weekly case management until housing is achieved and during the first 3 months of tenancy. After the initial 90 days of housing services, case management may be tapered off to 2 times per month or as needed. Service level will then be determined by HCHV Coordinator/Designee and based on a vulnerability index measured response by Veteran. Housing shall be obtained within 90 days of receiving the voucher and retained by Veteran for at least 12 consecutive months. The ICM will perform and coordinate the housing search with Veteran to identify and secure a permanent housing unit, partnering with other supportive community services as necessary. In addition, the ICM may be required to attend outreach events as a part of ongoing enrollment efforts of VAPAHCS. ICMs may not work with Veterans ineligible for Veterans Health Administration benefits. The ICM transports assigned patients as needed to relevant service-related and housing appointments. Where it is appropriate, the ICM will help the participant qualify and arrange for transportation services provided by Outreach. Client-centered services will be provided to Veterans in accordance with CARF accreditation standards, VA Patient Bill of Rights, VA policies, and nationally accepted Housing First and Harm Reduction best practices. ICM will utilize Motivational Interviewing (MI) and Critical Time Intervention (CTI) as appropriate. The service standards and expectations for organizations that are providing intensive case management to chronically homeless persons. The standards include providing intensive case management to help their participants to: obtain perm anent housing within 90 days of receiving the voucher; retain their permanent housing for at least 12 consecutive months; and, Improve their quality of life utilizing the Self-Sufficiency Matrix or VI-SPDAT, or other vulnerability index particularly in the area of increasing income by accessing all available entitlement programs. Additional Tasks Include: Participate in HCHV performance improvement activities including participating in chart audits at HCHV community provider sites. Provide housing search assistance by locating suitable housing in the community and maintaining an inventory of safe, available units accepting rental subsidies; assisting Veterans with completion and submission of rental applications and credit reports; communicating with landlords to secure and maintain housing; conducting outreach to prospective landlords and property management groups on behalf of homeless Veterans with a focus on underutilized areas of Santa Clara County, and educating individuals and organizations on the benefits of leasing to Veterans; meeting Veterans at housing units both for viewing and walk-through purposes; assisting Veterans in obtaining move-in and security deposit assistance, as well as furniture and other household items (ICM is not required to provide transportation of these items); facilitating individual and group housing search classes; creating outreach materials for landlords; maintaining an inventory of housing developments and landlords whom have previously accepted rental subsidies and may have future available units; conducting landlord appreciation efforts and events; participating in Public Housing Authority (PHA) sponsored landlord outreach and appreciation events; serving as a Public Housing Authority (PHA) certified inspector for Veterans housing units (contingent upon approval by the PHA) Provide and document housing-related advice to patients via telephone and in-person using required documentation systems including CPRS, HOMES, HMIS, and/or other required centralized documentation systems that may be developed during the course of contract Complete continuing education to meet his or her professional growth and specialty standards Attend /complete VA mandatory training requirements Participate in scheduled meetings to review and evaluate the services provided to Veterans, identify opportunities to improve the services delivered, and recommend corrective action when problems exist Coordinate with other stakeholders in the VAPAHCS such as the Domiciliary Residential programs, inpatient units and PACT teams Perform necessary administrative duties which include operation of VISTA and computerized electronic patient record (CPRS) Comply with information security policy and procedures Interpersonal relationships ICM works effectively with Veterans, families, co-workers and other health care and housing professionals Hourly requirements are 40 hours per week of services. The majority of work will take place during daytime hours (8:00am-4:30pm). Any changes to this schedule must be approved by the COR Transportation services for the participants will include the following approaches: The ICM transports Veterans as needed to relevant service-related appointments Where it is appropriate, ICM will help the participant qualify and arrange for transportation services Program Referrals The ICM will receive all program participants for the HCHV ICM Program from VAPAHCS or Care Coordination Project. The ICM will locate, reach out to, and engage Veterans in order to determine if the Veteran is eligible for the program. Once eligibility and appropriateness of fit has been confirmed, the ICM will enroll the Veteran and commence case management services while pursuing appropriate rental subsidy through the CCP s Permanent Supportive Housing Program Manager, Soo Jung, or designee. Outcomes The ICM will report on Veteran service status on a monthly basis and provide a completed quarterly Quality Assurance Surveillance Plan (QASP) using the QASP form attached here. Case manage 25 vulnerable, chronically homeless Veterans or Veteran families referred by VAPAHCS (in coordination with the CCP) on a monthly basis. Obtain leasing subsidies and secure permanent housing for up to 25 households. 70% of the Veterans served will remain in permanent housing for at least two years from their program entry date. 85% of Veterans served will increase their self-sufficiency in at least two domains 85% of Veterans served will report reduction in crises and alleviation of symptoms and barriers through accurate case management notes and monthly reports By the end of this contract year of this project, 80% of the program participants will have at least one of the following sources of income: General assistance Supplemental Security Income (SSI) Employment assistance Measurement Methodology Quarterly reviews of Help Management Information System (HMIS) Quarterly QASP Reviews with COR (VA) CPRS (VA) HOMES (VA) Documentation ICM s shall ensure that all enumerated performance objectives are achieved per contract specifications, as demonstrated through regular and ongoing data collection, monthly reporting clearly documenting the achievement of desired outcomes, and quarterly QASP reports. The ICM is required to enter into the Homeless Management Information System (HMIS) database all relevant information for the program participants including the Self-Sufficiency Matrix and VI-SPDAT information (as appropriate) and provide the appropriate reports on a timely basis. In addition, the ICM will enter required data into the VA s Homeless Operations Management and Evaluation System (HOMES), as well as the electronic patient record (CPRS). The ICM will provide additional service-related reports to the COR as requested. ICM must comply with all HOMES documentation requirements which includes but is not limited to: Assessment Intake Treatment Plan Weekly case management notes (or less as clinically appropriate after Veteran is housed) Discharge planning notes Collateral contact notes Notes on outreach activity as appropriate Training: The ICM will attend all trainings required by the VA and the Care Coordination Project (CCP), including HCHV Quarterly Training sessions, TMS, and licensure if appropriate. Including but not limited to: 13.1. All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems: 13.1.1. Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems; 13.1.2. Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training; and 13.1.3. Successfully complete the appropriate VA privacy training and annually complete required privacy training. 13.2. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required. 13.3. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete. 13.4. Complete annual mandatory training by using the mandatory packet, attending training in person, or by going on-line to complete the training. Complete mandatory security training, sign computer security agreement, receive training on the mandatory private policy, and receive copy of the Privacy Directive, VA Directive 6504, Restrictions on Transmission, Transportation and Use of, and Access to VA Data Outside VA Facilities. The Compliance and Business Integrity Training & Education Contract (Revenue Cycle) Employees includes the following training: 13.4.1. Awareness Training: Contractor employees shall complete initial compliance awareness training under this contract as well as complete annual compliance awareness refresher training. At a minimum, CBI awareness training will include the following topics: (a) the revenue cycle, (b) seven elements of an effective compliance program, (c) definition of high-risk areas, and (d) definition of any compliance concerns and how to address a compliance concern. This requirement can be fulfilled by completing the training module available via the following Internet site:  http://www.visn21.med.va.gov/CBI.asp 13.4.2. Remedial Training: When notified, contract employees must complete remedial training and education to address any detected compliance exceptions. 13.4.3. Proof of Training: Contract employees are responsible for submitting proof of awareness and remedial training completed to the Contracting Officer s Technical Representative (COTR) for this contract. The COTR will retain proof of training in accordance with applicable Records Control Schedule. VAPAHC S Rights of Refusal: VAPAHCS reserves the right to refuse to accept any ICM employee who fails to perform in accordance with the contract requirements, or who fails to adapt to the VAPAHCS work environment. VAPAHCS reserves the right to refuse or dismiss contract personnel whose personal or professional conduct jeopardizes patient care or the regular and ordinary operation of the facility. Reasons for refusal or dismissal include, but are not limited to, unsatisfactory performance prior to and/or during the term of the contract, failure to receive favorable adjudication during a VA background investigation, failure to satisfy the requirements of the contract, physical or verbal abuse to patients, staff, or visitors, intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, ethical misconduct, conduct resulting in formal complaints by patients or other staff members, and any other valid reason considered objectionable. Substitution of Personnel The ICM shall utilize the personnel named in its quotation to perform the services required under this contract. In the event that any of the personnel named in the quotation are unable to perform the duties of this task order, for any reason such as death, illness, and resignation from the ICM s employ, the ICM shall promptly submit to the Contracting Officer and COR, in writing, a detailed explanation of the circumstances necessitating the substitution. The ICM shall submit a completed ICM Change form (see ICM Change Request), a resume for the proposed substitute, and any other information that may be needed to approve or disapprove the proposed substitution. Any substitution of personnel will occur without any increase to the contract price and without delay in the performance or delivery of services to the Government. The Government shall have the right to require replacement of any ICM or employee assigned to work on this contract, if the employee is determined not to possess the experience or ability required under the contract, or if said employee is for any other reason found to be unsuitable to perform the work required by the contract. The replacement must meet the Support Personnel requirements stated in the RFQ. Any substitution of personnel will occur without any increase to the contract price and without delay in the performance or delivery of services to the Government. Contractor Personnel Security Requirements - Information Systems Access The C&A requirements do not apply; a Security Accreditation Package is not required. The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract. All Contractor employees, who require access to Department of Veterans Affairs (VA) computer systems and will work more than six (6) months (180 days) under this contract, shall be the subject of a background investigation and must receive a favorable adjudication from the VA SIC.  This requirement is applicable to all subcontractor personnel requiring the same access.  If the investigation is not completed prior to the start date of the contract, the Contractor will be responsible for the actions of those individuals they provide to perform work for VA. Contractor personnel who previously received a favorable adjudication as a result of a Government background investigation may be exempt from this contract requirement provided that they can provide documentation to support the previous adjudication. Proof of previous adjudication must be submitted by the Contractor to VA SIC through the VA Contracting Officer. Proof of previous adjudication is subject to verification by the VA SIC. Some positions maybe subject to periodic re-investigation. For those Contractor employees who will work less than six (6) months (180 days) under this contract, a background investigation is not required; however, such employees will be required to initiate a Special Agreement Check (SAC) for Fingerprint Only prior to providing services under this contract. 16.1 Position Sensitivity - The position sensitivity has been designated as: Low Risk 16.2 Background Investigation - The level of background investigation commensurate with the required level of access is: NACI 16.3 Contractor Responsibilities. In order to conduct a background investigation, the Contractor shall submit or have their contract personnel submit the following required forms to the COTR. The COTR will arrange a time for contract personnel to complete fingerprint verification. The C&A requirements do not apply, and that a Security Accreditation Package is not required: and proceed to the next question. Appendix B The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract. Appendix C 1. GENERAL Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security. 2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS a. A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order. b. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures. c. Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness. d. Custom software development and outsourced operations must be located in the U.S.to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor. e. The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination. 3. VA INFORMATION CUSTODIAL LANGUAGE a. Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1). b. VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA s information is returned to the VA or destroyed in accordance with VA s sanitization requirements. VA reserves the right to conduct on-site inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements. c. Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract. d. The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract. e. The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed. f. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12. g. If a VHA contract is terminated for cause, the associated BAA must also be terminated, and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship. h. The contractor/subcontractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated. i. The contractor/subcontractor s firewall and Web services security controls, if applicable, shall meet or exceed VA s minimum requirements. VA Configuration Guidelines are available upon request. j. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA s prior written approval. The contractor/subcontractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response. k. Notwithstanding the provision above, the contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor is in receipt of a court order or other requests for the above-mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response. l. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COTR. 4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT a. Information systems that are designed or developed for or on behalf of VA at non-VA facilities shall comply with all VA directives developed in accordance with FISMA, HIPAA, NIST, and related VA security and privacy control requirements for Federal information systems. This includes standards for the protection of electronic PHI, outlined in 45 C.F.R. Part 164, Subpart C, information and system security categorization level designations in accordance with FIPS 199 and FIPS 200 with implementation of all baseline security controls commensurate with the FIPS 199 system security categorization (reference Appendix D of VA Handbook 6500, VA Information Security Program). During the development cycle a Privacy Impact Assessment (PIA) must be completed, provided to the COTR, and approved by the VA Privacy Service in accordance with Directive 6507, VA Privacy Impact Assessment. b. The contractor/subcontractor shall certify to the COTR that applications are fully functional and operate correctly as intended on systems using the VA Federal Desktop Core Configuration (FDCC), and the common security configuration guidelines provided by NIST or the VA. This includes Internet Explorer 7 configured to operate on Windows XP and Vista (in Protected Mode on Vista) and future versions, as required. c. The standard installation, operation, maintenance, updating, and patching of software shall not alter the configuration settings from the VA approved and FDCC configuration. Information technology staff must also use the Windows Installer Service for installation to the default program files directory and silently install and uninstall. d. Applications designed for normal end users shall run in the standard user context without elevated system administration privileges. e. The security controls must be designed, developed, approved by VA, and implemented in accordance with the provisions of VA security system development life cycle as outlined in NIST Special Publication 800-37, Guide for Applying the Risk Management Framework to Federal Information Systems, VA Handbook 6500, Information Security Program and VA Handbook 6500.5, Incorporating Security and Privacy in System Development Lifecycle. f. The contractor/subcontractor is required to design, develop, or operate a System of Records Notice (SOR) on individuals to accomplish an agency function subject to the Privacy Act of 1974, (as amended), Public Law 93-579, December 31, 1974 (5 U.S.C. 552a) and applicable agency regulations. Violation of the Privacy Act may involve the imposition of criminal and civil penalties. g. The contractor/subcontractor agrees to: (1) Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies: (a) The Systems of Records (SOR); and (b) The design, development, or operation work that the contractor/subcontractor is to perform; (2) Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the redesign, development, or operation of a SOR on individuals that is subject to the Privacy Act; and (3) Include this Privacy Act clause, including this subparagraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a SOR. h. In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a SOR on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a SOR on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a SOR on individuals to accomplish an agency function, the contractor/subcontractor is considered to be an employee of the agency. (1) Operation of a System of Records means performance of any of the activities associated with maintaining the SOR, including the collection, use, maintenance, and dissemination of records (2) Record means any item, collection, or grouping of information about an individual that is maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and contains the person s name, or identifying number, symbol, or any other identifying particular assigned to the individual, such as a fingerprint or voiceprint, or a photograph. (3) System of Records means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual. i. The vendor shall ensure the security of all procured or developed systems and technologies, including their subcomponents (hereinafter referred to as Systems ), throughout the life of this contract and any extension, warranty, or maintenance periods. This includes, but is not limited to workarounds, patches, hotfixes, upgrades, and any physical components (hereafter referred to as Security Fixes) which may be necessary to fix all security vulnerabilities published or known to the vendor anywhere in the Systems, including Operating Systems and firmware. The vendor shall ensure that Security Fixes shall not negatively impact the Systems. j. The vendor shall notify VA within 24 hours of the discovery or disclosure of successful exploits of the vulnerability which can compromise the security of the Systems (including the confidentiality or integrity of its data and operations, or the availability of the system). Such issues shall be remediated as quickly as is practical, but in no event longer than ____ days. k. When the Security Fixes involve installing third party patches (such as Microsoft OS patches or Adobe Acrobat), the vendor will provide written notice to the VA that the patch has been validated as not affecting the Systems within 10 working days. When the vendor is responsible for operations or maintenance of the Systems, they shall apply the Security Fixes within ____ days. l. All other vulnerabilities shall be remediated as specified in this paragraph in a timely manner based on risk, but within 60 days of discovery or disclosure. Exceptions to this paragraph (e.g. for the convenience of VA) shall only be granted with approval of the contracting officer and the VA Assistant Secretary for Office of Information and Technology. 5. INFORMATION SYSTEM HOSTING, OPERATION, MAINTENANCE, OR USE a. For information systems that are hosted, operated, maintained, or used on behalf of VA at non-VA facilities, contractors/subcontractors are fully responsible and accountable for ensuring compliance with all HIPAA, Privacy Act, FISMA, NIST, FIPS, and VA security and privacy directives and handbooks. This includes conducting compliant risk assessments, routine vulnerability scanning, system patching and change management procedures, and the completion of an acceptable contingency plan for each system. The contractor s security control procedures must be equivalent, to those procedures used to secure VA systems. A Privacy Impact Assessment (PIA) must also be provided to the COTR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA s network involving VA information must be reviewed and approved by VA prior to implementation. b. Adequate security controls for collecting, processing, transmitting, and storing of Personally, Identifiable Information (PII), as determined by the VA Privacy Service, must be in place, tested, and approved by VA prior to hosting, operation, maintenance, or use of the information system, or systems by or on behalf of VA. These security controls are to be assessed and stated within the PIA and if these controls are determined not to be in place, or inadequate, a Plan of Action and Milestones (POA&M) must be submitted and approved prior to the collection of PII. c. Outsourcing (contractor facility, contractor equipment or contractor staff) of systems or network operations, telecommunications services, or other managed services requires certification and accreditation (authorization) (C&A) of the contractor s systems in accordance with VA Handbook 6500.3, Certification and Accreditation and/or the VA OCS Certification Program Office. Government-owned (government facility or government equipment) contractor-operated systems, third party or business partner networks require memorandums of understanding and interconnection agreements (MOU-ISA) which detail what data types are shared, who has access, and the appropriate level of security controls for all systems connected to VA networks. d. The contractor/subcontractor s system must adhere to all FISMA, FIPS, and NIST standards related to the annual FISMA security controls assessment and review and update the PIA. Any deficiencies noted during this assessment must be provided to the VA contracting officer and the ISO for entry into VA s POA&M management process. The contractor/subcontractor must use VA s POA&M process to document planned remedial actions to address any deficiencies in information security policies, procedures, and practices, and the completion of those activities. Security deficiencies must be corrected within the timeframes approved by the government. Contractor/subcontractor procedures are subject to periodic, unannounced assessments by VA officials, including the VA Office of Inspector General. The physical security aspects associated with contractor/subcontractor activities must also be subject to such assessments. If major changes to the system occur that may affect the privacy or security of the data or the system, the C&A of the system may need to be reviewed, retested and re-authorized per VA Handbook 6500.3. This may require reviewing and updating all of the documentation (PIA, System Security Plan, Contingency Plan). The Certification Program Office can provide guidance on whether a new C&A would be necessary. e. The contractor/subcontractor must conduct an annual self-assessment on all systems and outsourced services as required. Both hard copy and electronic copies of the assessment must be provided to the COTR. The government reserves the right to conduct such an assessment using government personnel or another contractor/subcontractor. The contractor/subcontractor must take appropriate and timely action (this can be specified in the contract) to correct or mitigate any weaknesses discovered during such testing, generally at no additional cost. f. VA prohibits the installation and use of personally-owned or contractor/subcontractor owned equipment or software on VA s network. If non-VA owned equipment must be used to fulfill the requirements of a contract, it must be stated in the service agreement, SOW or contract. All of the security controls required for government furnished equipment (GFE) must be utilized in approved other equipment (OE) and must be funded by the owner of the equipment. All remote systems must be equipped with, and use, a VA-approved antivirus (AV) software and a personal (host-based or enclave based) firewall that is configured with a VA approved configuration. Software must be kept current, including all critical updates and patches. Owners of approved OE are responsible for providing and maintaining the anti-viral software and the firewall on the non-VA owned OE. g. All electronic storage media used on non-VA leased or non-VA owned IT equipment that is used to store, process, or access VA information must be handled in adherence with VA Handbook 6500.1, Electronic Media Sanitization upon: (i) completion or termination of the contract or (ii) disposal or return of the IT equipment by the contractor/subcontractor or any person acting on behalf of the contractor/subcontractor, whichever is earlier. Media (hard drives, optical disks, CDs, back-up tapes, etc.) used by the contractors/subcontractors that contain VA information must be returned to the VA for sanitization or destruction or the contractor/subcontractor must self-certify that the media has been disposed of per 6500.1 requirements. This must be completed within 30 days of termination of the contract. h. Bio-Medical devices and other equipment or systems containing media (hard drives, optical disks, etc.) with VA sensitive information must not be returned to the vendor at the end of lease, for trade-in, or other purposes. The options are: (1) Vendor must accept the system without the drive; (2) VA s initial medical device purchase includes a spare drive which must be installed in place of the original drive at time of turn-in; or (3) VA must reimburse the company for media at a reasonable open market replacement cost at time of purchase. (4) Due to the highly specialized and sometimes proprietary hardware and software associated with medical equipment/systems, if it is not possible for the VA to retain the hard drive, then; (a) The equipment vendor must have an existing BAA if the device being traded in has sensitive information stored on it and hard drive(s) from the system are being returned physically intact; and (b) Any fixed hard drive on the device must be non-destructively sanitized to the greatest extent possible without negatively impacting system operation. Selective clearing down to patient data folder level is recommended using VA approved and validated overwriting technologies/methods/tools. Applicable media sanitization specifications need to be preapproved and described in the purchase order or contract. (c) A statement needs to be signed by the Director (System Owner) that states that the drive could not be removed and that (a) and (b) controls above are in place and completed. The ISO needs to maintain the documentation. 6. SECURITY INCIDENT INVESTIGATION a. The term security incident means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access. b. To the extent known by the contractor/subcontractor, the contractor/subcontractor s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant. c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement. d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident. 7. LIQUIDATED DAMAGES FOR DATA BREACH a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract. b. The contractor/subcontractor shall provide notice to VA of a security incident as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination. c. Each risk analysis shall address all relevant information concerning the data breach, including the following: (1) Nature of the event (loss, theft, unauthorized access); (2) Description of the event, including: (a) date of occurrence; (b) data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code; (3) Number of individuals affected or potentially affected; (4) Names of individuals or groups affected or potentially affected; (5) Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text; (6) Amount of time the data has been out of VA control; (7) The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons); (8) Known misuses of data containing sensitive personal information, if any; (9) Assessment of the potential harm to the affected individuals; (10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and (11) Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised. d. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $______ per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following: (1) Notification; (2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports; (3) Data breach analysis; (4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution; (5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and (6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs. 8. SECURITY CONTROLS COMPLIANCE TESTING On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-days notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time. 9. TRAINING a. All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems: (1) Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems; (2) Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training; (3) Successfully complete the appropriate VA privacy training and annually complete required privacy training; and (4) Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document e.g., any role-based information security training required in accordance with NIST Special Publication 800-16, Information Technology Security Training Requirements.] b. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required. c. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.