G099--HUD VASH Case Management Services

SOURCES SOUGHT NOTICE This is a Sources Sought Notice (SSN) ONLY. The U.S. Government is conducting market research only to determine the availability of qualified sources capable of providing HUD VASH Case Management Services for the VA Puget Sound Healthcare System. Potential Contractors are invited to provide a response via e-mail to Contract Specialist at [email protected] by June 1, 2022 12:00 pm (PT). Responses will be used to determine the appropriate strategy for a potential acquisition. Please clearly identify any information your company considers sensitive or proprietary. This notice is issued solely for information and planning purposes - it does not constitute a Request for Quotation/Proposal (RFQ/RFP), or a promise to issue an RFQ/RFP in the future. This notice does not commit the U.S. Government to contract for any supply or service. Further, the U.S. Government is not seeking quotes, or proposals at this time and will not accept unsolicited quotes in response to this sources sought synopsis. The U.S. Government will not pay for any information or administrative costs incurred in response to this notice. Submittals will not be returned to the responder. Not responding to this notice does not preclude participation in any future RFQ, if any is issued. BACKGROUND: HUD-VASH is designed to serve homeless Veterans and their families. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance abuse disorders, and other serious medical conditions. VA intends to engage a Contractor to provide housing placement services to VA referred Veterans and their families. NAICS: 624229 - Other Community Housing Services Interested potential Contractors please provide the following. 1) Company Name, address, point of contact, phone number, email address, and DUNS Please indicate business size: Small Disadvantage Business (SDB)____ 8(a)____ Historically Underutilized Business Zone (HUBZone)____ Service-Disabled Veteran-Owned Small Business (SDVOSB)____ Veteran-Owned Small Business (VOSB)_____ Economically Disadvantaged Women-Owned Small Business (EDWOSB)_____ Women-Owned Small Business concerns (WOSB)_____ Small Business_____ Large Business_____ Please state if you possess a Federal Supply Schedule (FSS)__________________. 2) Please submit a brief capability statement (maximum three pages) with enough information to demonstrate to the Veterans Affairs that your business has the required licensed clinical social worker, case managers, housing specialist to provide the case management services stated in the attached Draft Performance Work Statement. **Draft Performance Work Statement**. 1.OVERVIEW The U.S. Department of Veterans Affairs (VA) has a requirement for a Contractor to assist with the provision of housing placement, via case management services, through the US Department of Housing and Urban Development Veterans Affairs Supportive Housing (HUD-VASH) program for the following Puget Sound catchment regions: Pierce County, WA King County, WA Snohomish County, WA HUD-VASH is designed to serve homeless Veterans and their families. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance abuse disorders, and other serious medical conditions. VA intends to engage a Contractor to provide housing placement services to VA referred Veterans and their families. Entities that are interested in providing Veterans and their families these services should be aware that HUD-VASH is a national program serving Veterans and their families throughout the country. This program continues to expand and has become one of the largest VA interventions to assist homeless Veterans. It is also the first VA homeless program that offers services to both the Veteran and their family. It represents one of VA s most significant efforts to achieve the President s goal of ending homelessness among Veterans. Through this contract, the VA seeks to support HUD-VASH by expediting placement of Veterans and their families in affordable, permanent housing for the Puget Sound catchment regions listed above. This housing must meet the criteria for inclusion in HUD s Section 8 voucher program. 2.BACKGROUND Through HUD-VASH, VA provides case management services to Veterans and their families and facilitates their placement into subsidized housing through the Section 8 voucher program administered by HUD. VA s goals and objectives for this program include housing placement and the provision of supportive services designed to enhance the housing stability and independent living skills of homeless Veteran families occupying permanent housing nationwide. At a minimum, the housing placement Contractor working with HUD- VASH is expected to provide the following housing placement assistance to facilitate the transition of Veterans and their families out of homelessness: coordination with the local Public Housing Authority (PHA); identification of landlords with available housing eligible for Section 8 rental; assistance with housing application process; identification of placement barriers for referred Veterans (including credit and/or unresolved legal issues found during application process); identification and assistance in obtaining resources to facilitate move into Section 8 housing (including funds for security deposits and utility turn-ons). Veterans enter this program in 2 ways: Veterans presently on VASH Interest List and referred by VA as eligible for program. Community Outreach by contractor to chronically homeless Veterans and approved by VA as eligible for VA services and meeting HUD-VASH qualifications. 3.TASKS AND ASSOCIATED DELIVERABLES Base Year: Task 1A: Contractor shall identify staff, draft implementation plan and be available for a one hour weekly conference call with VA Liaisons. The implementation plan shall outline the steps needing to be accomplished prior to Task 1C. Deliverable 1A: The Contractor shall provide a staffing report, the current implementation plan incorporating VA comments and meeting minutes. These items shall be due on a weekly basis until Task1B is completed. Task 1B: The contractor shall ensure that each case worker has completed VA s VASH orientation and training and has gone through all required security procedures. The Contractor shall complete the medical center s outlined VASH orientation: The Contractor shall complete the medical center s WOC status security measures Background screening Privileging and credentialing process Medical record access and training HOMES access and training Deliverable 1B: The Contractor shall provide a detailed report of the completion of the above task elements prior to the start of Task 1C. Deliverable 1B is due no later than 60 days from Notice of Award. Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken. Task 1C: The Contractor shall provide case management services that shall conform to the following required elements for all enrolled Veterans: The Contractor shall engage the Veteran in the VASH process: Contractor carries responsibility for interviewing, counseling and case management of identified Veterans who are at risk - providing psychosocial assessments to identify treatment needs which affect the Veterans adjustment to their environment, and establish treatment goals. Utilize counseling strategies to include crisis intervention and case management including both short and long-term services. The Contractor shall assess the psychosocial and environmental needs or dysfunction secondary to or exacerbating the social, substance or psychiatric problems, which might contribute to readjustment to community. Establishes and maintains a consistent (number of contacts based on individual treatment plan which is subject to review by VA) therapeutic relationship with the patient, family, staff, and community programs/agencies. The Contractor is responsible to formulate case- management treatment goals and plans that address identified needs, stressors and problems. The Contractor shall conduct high-risk screening, psychosocial assessment and treatment planning; actively involving the Veteran and their family or significant others, in coordination with the team members, based on the psychosocial assessments, including goals for clinical treatment. The Contractor coordinates and documents clinical case management and psychosocial services and documents the overall effectiveness of the case management services provided. The above is not limited to: Develop with Veteran and VA liaison an Individual Service Plan to be signed by all parties. Plan shall be written within the first 2 weeks of program admission. Plans to be reviewed every 90 days in a clinical meeting with VA Liaison. Changes in plan/discharge from the program must be done in consultation with the VA liaison: Contractor shall maintain professional boundaries with Veteran Contractor shall maintain written documentation of any and all contacts with Veteran and any ancillary contacts. Records will be kept in a secured locked area. Contractor shall integrate treatment planning with relevant VA health and mental health services. Number of home visits per month will be based on the joint clinical case conference with VA liaison to take place every 90 days. No changes in visit schedule will occur without concurrence from VA liaison. Helping/completing PHA/SSA paperwork; The Contractor shall help/assist Veterans to obtain the needed documentation required by the PHA to include but not limited to, birth certificates, driver s license, income verification and any additional information required by housing authority and or potential landlord. If these documents cannot be obtained, efforts made to obtain them must be clearly documented. The Contractor shall accompany/ensure the Veteran attends voucher sessions. If unable to accompany the Veteran, efforts are made to accommodate Veteran s attendance and these efforts are documented. Provide hands on assistance to enable Veteran to find suitable housing, assistance to include but not limited by, transporting Veteran around neighborhoods to locate vacant apartments, and helping Veterans do on line housing searches if locally available; advocacy with potential landlords; assisting with Veteran obtaining necessary accoutrements to establish a household. The Contractor shall provide life skills education/support to Veterans either through individual or group sessions (if not done at the Veteran s residence, contractor must arrange for transportation) in areas, not limited to: Budgeting Apartment maintenance, for instance how to keep clean and maintain residence How to be a good neighbor/tenant Relapse prevention (if applicable) Healthy lifestyle/living Community resources and how to access T he Contractor shall provide transportation for clients to attend appointments, PHA, SSA, landlords and benefits, which also includes assistance in obtaining bus passes, subsidized transportation services, and other identified needed services and entitlements. The Contractor shall advocate with potential landlords on behalf of the Veteran. Contractor shall advise any potential landlord that their agency shall be following the Veteran once housed. T h e Contractor shall assist Veteran in securing necessary funding for move in costs, not limited to accessing outside funding for deposits, utility deposits, and furnishings as well as budgeting for this. T he Contractor shall assist Veteran in the establishment of utilities. T he Contractor shall notify VA of any adverse events incident occurring with a Veteran within 24 hours of being informed/aware of the incident, if not sooner. Contractor shall complete a written incident report within 48 hours of notification. T h e Contractor shall attend all subsequent meetings between the Vet and the housing authority including annual certifications, MOVE briefings, interim appointments, etc. Deliverable 1C: The Contractor shall provide to the Contracting Officer Representative (COR) a monthly report detailing the activities and progress for each patient enrolled in the homeless case management program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Task 1D: The Contractor shall provide follow up case management serves to enroll Veterans to ensure that eligible Veterans remain in suitable housing until discharged from the program. Veterans will be discharged from the case management portion of VASH upon successful community reintegration. All discharges from case management must be approved by the VA liaison. Deliverable 1D: The Contractor shall provide to the COR a monthly report detailing the activities and progress at monitoring that Veterans enrolled in the in the case management program maintain suitable housing until formally discharged from the program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken. 3.2 Option Year One (1) 3.2.1 Task 2A: The Contractor shall provide case management services for all enrolled Veterans that meets with the required elements listed in Task 1C. Deliverable 2A: The Contractor shall provide to the COR a monthly report detailing the activities and progress for each patient enrolled in the homeless case management program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken Task 2B: The Contractor shall provide follow up case management serves to enroll Veterans to ensure that eligible Veterans remain in suitable housing until discharged from the program. Veterans will be discharged from the case management portion of VASH upon successful community reintegration. All discharges from case management must be approved by the VA liaison. Deliverable 2B: The Contractor shall provide to the COR a monthly report detailing the activities and progress at monitoring that Veterans enrolled in the in the case management program maintain suitable housing until formally discharged from the program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken Option Year Two (2): 3.3.1 Task 3A: The Contractor shall provide case management services for all enrolled Veterans that meets with the required elements listed in Task 1C 3.3.2 Deliverable 3A: The contractor shall provide to the COR a monthly report detailing the activities and progress for each patient enrolled in the homeless case management program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken 3.3.3Task 3B: The contractor shall provide follow up case management serves to enroll Veterans to ensure that eligible Veterans remain in suitable housing until discharged from the program. Veterans will be discharged from the case management portion of VASH upon successful community reintegration. a.All discharges from case management must be approved by the VA liaison. Deliverable 3B: The contractor shall provide to the COR a monthly report detailing the activities and progress at monitoring that Veterans enrolled in the in the case management program maintain suitable housing until formally discharged from the program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: a. Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran b. Brief summary of activity for that visit c. Dates of every clinical note entry made in the clinical chart d. Summary of any adverse events that have taken place with Veteran in the past month and any follow-up action taken. 3.4 Option Year Three (3): Task 4A: The Contractor shall provide case management services for all enrolled Veterans that meet the required elements listed in Task 1C Deliverable 4A: The contractor shall provide to the COR a monthly report detailing the activities and progress for each patient enrolled in the homeless case management program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken 3.4.3 Task 4B: The contractor shall provide follow up case management serves to enroll Veterans to ensure that eligible Veterans remain in suitable housing until discharged from the program. Veterans will be discharged from the case management portion of VASH upon successful community reintegration. All discharges from case management need to be approved by the VA liaison. Deliverable 4B: The contractor shall provide to the COR a monthly report detailing the activities and progress at monitoring that Veterans enrolled in the in the case management program maintain suitable housing until formally discharged from the program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: a. Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran b. Brief summary of activity for that visit c. Dates of every clinical note entry made in the clinical chart d. Summary of any adverse events that have taken place with Veteran in the past month and any follow-up action taken Option Year Four (4): 3.5.1 Task 5A: The Contractor shall provide case management services for all enrolled Veterans that meet the required elements listed in Task 1C Deliverable 5A: The contractor shall provide to the COR a monthly report detailing the activities and progress for each patient enrolled in the homeless case management program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran Brief summary of activity for that visit Dates of every clinical note entry made in the clinical chart Summary of any adverse events that have taken place with Veteran in the past month and follow-up action taken Task 5B: The contractor shall provide follow up case management serves to enroll Veterans to ensure that eligible Veterans remain in suitable housing until discharged from the program. Veterans will be discharged from the case management portion of VASH upon successful community reintegration. All discharges from case management have to be approved by the VA liaison. Deliverable 5B: The contractor shall provide to the COR a monthly report detailing the activities and progress at monitoring that Veterans enrolled in the in the case management program maintain suitable housing until formally discharged from the program. The report will contain the Veteran s name and social security number and admit date. It will contain all clinical activity that has taken place in regards to the Veterans care for that month which includes: a. Dates of every Veteran contact in the last month which will reflect the agreed upon number of visits for that particular Veteran b. Brief summary of activity for that visit c. Dates of every clinical note entry made in the clinical chart d. Summary of any adverse events that have taken place with Veteran in the past month and any follow-up action taken Evaluation of Services/ Evaluation of performance: Contractor services performance shall be evaluated by the Government using the attached Quality Assurance Surveillance Plan (QASP). This QASP provides a systematic method to evaluate performance for the stated contract. 4. CONTRACTOR REQUIRMENTS Contractor shall be staffed by the following: Licensed Clinical Social Worker either full time or part time on staff. Schedule must permit adequate supervision of case management personnel, for the purposes of clinical oversight, documentation, crisis management. Must be available for team conferences. Agree to Without Compensation (WOC) status within the VA system Agree to entering information into the HOMES system Supervise all non-clinical/non licensed employees to ensure quality of care. Case managers shall be Masters level clinicians, licensed to practice independently, OR actively working towards Masters level licensure as verified via the Washington State Department of Health. Housing Specialist with five-years experience working with homeless individuals and with Public housing Authorities. The Housing Specialists must be knowledgeable in the area of community resources and have experience in housing placement. T h e Contractor shall ensure that sufficient staff is available to provide the documented needs of the Veterans as well as the ability to make home visits consistent with treatment plans and the needs of the Veteran. The VA staffing standard is 35 to 1. Contractor proposals should meet or exceed this standard Contractor shall have procedures in place to ensure Veterans clients have 24/7 access to case management services which shall include crisis management and referral. Confidentiality and Record keeping (please see FAR 52.224-1 and 52.224-2): The Contractor is a VA contractor and shall assist in the provision of health care to patients seeking such care from or through VA. As such, the Contractor is considered as being part of the Department health care activity. Contractor is considered to be a VA contractor for purposes of the Privacy Act, Title 5 U.S.C. 552a. Further, for the purpose of VA records access and patient confidentiality, Contractor is considered to be a VA contractor for the following provisions: Title 38 U.S.C. 5701, 5705, and 7362. Therefore, Contractor may have access, as would other appropriate components of VA, to patient medical records including patient treatment records pertaining to drug and alcohol abuse, HIV, and sickle cell anemia, tothe extent necessary to perform its contractual responsibilities. However, like other components of the Department, and notwithstanding any other provisions of the contract, the Contractor is restricted from making disclosures of VA records, or information contained in such records, to which it may have access, except to the extent that explicit disclosure authority from VA has been received. The Contractor is subject to the same penalties and liabilities for unauthorized disclosures of such records as VA. The records referred to above shall be and remain the property of VA and shall not be removed or transferred from VA except in accordance with U.S.C.551a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records) and federal laws, rules and regulations. Subject to applicable federal confidentiality or privacy laws, the Contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over Contractor, may have access to VA s records, at VA s place of business on request during normal business hours, to inspect and review and make copies of such records. 5.SECURITY REQUIREMENTS: 5.1GENERAL 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. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS 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. 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. 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. 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. 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. VA INFORMATION CUSTODIAL LANGUAGE Information made available to the contractor/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 will be used only for those purposes & 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). 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. 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. 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. 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. 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. 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 PHI, there is no business associate relationship. 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. 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. 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. 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. 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 COR. INFORMATION SYSTEM DESIGN AND DEVELOPMENT 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. 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. 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. Applications designed for normal end users shall run in the standard user context without elevated system administration privileges. 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. 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. The contractor/subcontractor agrees to: 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: The Systems of Records (SOR); and The design, development, or operation work that the contractor/subcontractor is to perform; 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 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. 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. 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. 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. 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. 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. 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 3 calendar days. 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 3 calendar days. 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. 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. 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. 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. 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. 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. 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. SECURITY INCIDENT INVESTIGATION 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. 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. 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. 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. LIQUIDATED DAMAGES FOR DATA BREACH 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. 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. Each risk analysis shall address all relevant information concerning the data breach, including the following: Nature of the event (loss, theft, unauthorized access); Description of the event, including: date of occurrence; data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code; Number of individuals affected or potentially affected; Names of individuals or groups affected or potentially affected; 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; Amount of time the data has been out of VA control; The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons); Known misuses of data containing sensitive personal information, if any; Assessment of the potential harm to the affected individuals; Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and 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. 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 $500.00 per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following: Notification; One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports; Data breach analysis; 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 necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs. 5.8 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. TRAINING 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: 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; Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training; Successfully complete the appropriate VA privacy training and annually complete required privacy training; and 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.] The contractor shall provide to the contracting officer and/or the COR 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. 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.