S06 - A00001 Attachment - Final PD - Esignv.3a 6-16-25.pdf

PRODUCT DESCRIPTION

DEPARTMENT OF VETERANS AFFAIRS

Veteran’s Health Administration Veterans Integrated Services Network 17

Texas Valley Coastal Bend Health Care System (740)

Home Health E-Signature Platform

Date: 01/28/2025

VA-24-00056551

PD Version Number: 1.5

TAC Number: VA-24-00056551

1.0 PRODUCT REQUIREMENTS

I. Background: The Department of Veterans Affairs (VA), Veterans Health Administration (VHA) currently has many vendors and providers submitting documents for electronic signature which require repeated routing for reviews and multiple emails.

This is an administrative burden VHA is seeking to reduce through a streamlined process.

Patient Care/Home Health Orders are signed by the clinician to meet the Center for Medicare and Medicaid Services requirements. This was originally completed by sending the orders through interoffice mail and the provider wet signing the documents.

The documents were then routed back to the Geriatrics Program Support Assistant (PSA) who mailed them back to the vendor. VHA then moved to a digital process using Adobe Acrobat, secured folders in the S drive, and encrypted email. This process is cumbersome.

1. Two file clerks receive the orders, review them for accuracy, add a digital signature, log it into a tracker, and place them in the clinician’s folder.

2. The providers experience several Host Function Table errors during the digital signature process.

3. The Program Support Assistants review the documents to ensure they are signed, drop them into the Health Information Management Service (HIMS) folder for upload to the Computerized Patient Record System, email the documents back to the vendor, and update the tracker.

The PSAs currently spend 100 minutes weekly reviewing the documents for signature, updating the tracker, and returning to the vendor. While they will still need to pull the documents for upload to HIMS, the rest of the time they were previously spending can be reallocated to Outcome and Assessment Information Set uploads and other administrative duties for the Community Nursing Home and Care Coordination Teams.

VA is seeking to eliminate the majority of this workload to be able to absorb requesting Release of Information documents for our Home-Based Primary Care (HBPC) and Geriatric Patient Aligned Care Team (GERIPACT) patients that are currently being completed by the HBPC and GERIPACT Registered Nurses (RN). This will allow the RNs to provide more appointments within their scope of practice.

Home Health/Patient Care Order Signature Cloud based platform for Texas Valley Coastal Bend Veterans’ Health Care System (TXVCBHCS)

II. Requirements: VA requires a digital signature cloud-based platform. The

Contractor shall provide the specific deliverables described below within the current performance period.

Account access is required for a minimum of 76 users, including 1 account for site coordinators.

Table 1 – Veterans Integrated Services Network (VISN) 17 Facilities/Locations for the Home Health E-Signature Platform Software as a Service (SaaS)

VISN 17 Facility Name Address Number of Accounts

Harlingen Outpatient Clinic 2106 Treasure Hills Blvd, Harlingen, TX 78550 and 2601 Veterans Drive, Harlingen, TX 78550

McAllen VA Clinic 901 East Hackberry Avenue, McAllen, TX 78501 16 Laredo VA Clinic 4602 N. Bartlett Ave, Laredo, TX 78501 5 Corpus Christi West Point VA Clinic

925 South Padre Island Drive. Corpus Christi, TX 78416-2536

Brownsville VA Clinic 5700 N Expressway, Texas Coastal Professional Building, Ste 101, Brownsville, TX 78526-4354

The Contractor shall provide the following:

1. Quality Control Plan – The quality control plan shall include 99.9% availability, trouble ticket response times according to severities.

2. A one-time 2-hour training session for up to 20 personnel using Microsoft Teams or Cisco Webex, which includes training materials.

3. Users’ manual and Quick Start Guide for users to start using system immediately. User guide shall provide reference material for deeper understanding of the product.

4. A Technical Kickoff briefing with meeting notes following the Kickoff meeting at the start of the effort.

Product Requirements

1. The product shall be a stand-alone platform. Integration to other VA systems shall be unnecessary at this time.

2. Pricing shall be by registered accounts.

3. Expectation of approximately 20,000 documents (including multi-page) will be signed annually under this effort.

4. Home Health agencies will be providing forms for VA signature. Product shall accept forms for signature and upload to the patient electronic medical record.

5. Data required, for searches and queries, for each file shall be at a minimum:

Patient Last Name, First Name, Date of Service.

6. The product shall be able to be filtered on: patient name, date received, date processed, current status (received, signed, returned with corrections), number of days, Submitted by, and Document Identification.

7. VA requires Two factor signature. Additional information can be found at:

https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/pim83c03.pdf#page=43.

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Deliverables:

A. Quality Control Plan B. Training materials.

C. Users’ Manual and Quick Start Guide D. Technical Kickoff Meeting Briefing with Meeting Notes

III. Period of Performance: The work shall begin within five calendar days of award.

The period of performance of this contract shall consist of one 12-month base period with four 12-month option periods.

1.1 SALIENT CHARACTERISTICS

1. The cloud-based platform must be able to provide a vendor account for creating and sending home health orders that require clinician signatures.

2. The cloud-based platform must allow users to create an account and log in to review home health orders.

3. The cloud-based platform must be able to reject/return documents to the vendor with the ability to submit comments while allowing the signature process to continue for other documents also in the queue.

4. The cloud-based platform must be capable of electronically signing multiple pages from different vendors with a single click.

5. The cloud-based platform must enable the editing of a clinician’s name in situations where the provider is unavailable to sign due to unforeseen circumstances such as Family Medical Leave Act or VA departure, among others.

6. The cloud-based platform must be able to return signed orders to the vendor with a single click.

7. The cloud-based platform must be able to display the status of the orders sent through the system.

8. The cloud-based platform must be able to download orders in portable document format and upload them to the electronic medical record.

1.2 SAAS AND FEDERAL RISK AND AUTHORIZATION MANAGEMENT

PROGRAM (FedRAMP) REQUIREMENTS

1.2.1 If the solution is not FedRAMP Authorized:

1. The information system solution selected by the Contractor shall comply with the

Federal Information Security Management Act (FISMA).

2. The Contractor shall comply with FedRAMP requirements Moderate Impact as mandated by Federal laws and policies, including making available any documentation, physical access, and logical access needed to support this requirement.

3. The Contractor shall provide a SaaS product as defined by the following criteria:

SaaS is an application delivery model in which the application is hosted on a cloud infrastructure outside the security boundary of VA and is provided to the Cloud Service Customer (CSC) over the internet. The CSC uses the SaaS https://www.fedramp.gov/agency-authorization/ offering via a thin-client interface, such as a web-browser or a program interface.

The CSC subscribes to the SaaS offering and is only responsible for minor in-app customizations. The Cloud Service Provider (CSP) offering the application is responsible for management of the application, safeguarding of data stored or processed by the application, and all elements of the underlying infrastructure.

Additionally, the CSP is responsible for all on-going compliance. In order to qualify as SaaS for use at VA, and to align with FedRAMP requirements, the hosting for the offering must conform to the NIST 800-145 definition of Cloud Computing and thus contain following key characteristics:

• On-Demand Self-Service: The CSP fully automates the provisioning of both the customer interface and the underlying cloud components of the SaaS offering. In some cases, to the CSP may provision internal resources manually, while providing the CSC an automated interface to request and track the service.

• Broad Network Access: The SaaS capabilities are available over the internet or over a network that is available from all access points the CSC requires.

The SaaS offering is accessible through common platforms (e.g., mobile phones, tablets, laptops, and workstations).

• Resource Pooling: The computing infrastructure supporting the SaaS offering is shared among more than one CSC using a multi-tenant model, and resources are dynamically assigned depending on customer demand.

• Rapid Elasticity: Computing capabilities are automatically provisioned and released in a manner that scales with customer demand. In some cases, the scaling of resources may not be fully automated, but it should be fast enough to support the needs of the CSC, which the CSC would have to define.

• Measured Service: Resource usage, such as storage, processing, bandwidth, and user activity are measured and reported on in a manner that is relevant to the SaaS offering.

The SaaS offering must be hosted within the United States and data stored/processed/transmitted within the offering must remain within the United States. CSPs should be aware of FedRAMP and ready to partner with VA through the SaaS FedRAMP Authorization process.

4. Following guidance from the Federal CIO, VA will utilize existing Joint Authorization Board Authority to Operate (JAB ATO) or agency ATO issued by another agency as a starting point for FedRAMP requirements. If neither of those exist, VA will sponsor The Cloud Service Provider for a FedRAMP Authorization.

VA will be using the FedRAMP baselines as a starting point, since they are specifically tailored for cloud services.

5. The Contractor shall, where applicable, assist with the VA ATO Process to help achieve agency authorization of the cloud service or migrated application at the impact level required by VA to utilize the product. For this solution the required impact level is: Moderate Impact.

6. The Contractor shall comply with FedRAMP requirements surrounding data location within the Continental United States. FedRAMP specifies data location requirements in the High Baseline as part of control SA-9 (5); however, FedRAMP does not provide or specify data location requirements for other baselines.

7. The Contractor shall complete a FedRAMP System Security Plan (SSP) and supporting documentation including required attachments within 75 calendar days after contract award. (If Data Security Categorization is High Impact, this will be due 94 calendar days after contract award.)

8. The Contractor shall develop a VA specific system boundary diagram including any integration and connectivity components that will be known as a VA Implementation Diagram (VAID) demonstrating the proposed implementation of this system at VA. The Contractor shall provide the VAID within 10 calendar days of contract award.

9. The Contractor shall complete a Third-Party Assessment Organization (3PAO) Security Assessment Plan (SAP) within 90 calendar days after contract award. (If Data Security Categorization is High Impact, this will be due after 113 calendar days after contract award.)

10. The Contractor shall complete a 3PAO Security Assessment Report (SAR) within 90 calendar days after the SSP is accepted by VA. (If Data Security Categorization is High Impact, this will be due 113 calendar days after the SSP is accepted by VA.)

11. The Contractor shall work with VA Subject Matter Expert (SME) to test the validity of the Incident Response Plan (IRP) and ensure proper troubleshooting of issues that may arise. This should be completed within 30 calendar days of the SSP being delivered.

12. The Contractor shall afford VA access to the Contractor’s and CSP ‘s facilities, installations, technical capabilities, operations, documentation, records, and databases.

13. If new or unanticipated vulnerabilities are discovered by either VA or the Contractor, or if existing safeguards have ceased to function, the discoverer shall immediately bring the situation to the attention of the other party in accordance with Addendum B, VA Information, and Information System Security/Privacy Language.

14. The Contractor shall comply with data management requirements.

15. Successful issuance of a VA ATO will be required before live VA data can be used in the system.

16. The Contractor shall participate in FedRAMP Continuous Monitoring activities as outlined by FedRAMP’s Continuous Monitoring Strategy Guide found on the FedRAMP website.

17. The Contractor shall participate in monthly Agency and FedRAMP Sustainment meetings following the granting of a VA ATO.

18. The Contract shall provide continuous monitoring activities including, but not limited to scans, security artifacts, and monthly Plan of Action and Milestones (POAM) reports as outlined by VA and FedRAMP requirements.

Deliverables:

A. FedRAMP SSP and required Attachments B. VA Implementation Diagram: This is a VA specific architecture diagram demonstrating the proposed implementation of this system at VA (VAID)

C. 3PAO SAP

D. 3PAO SAR

E. Plan of Action and Milestones Monthly Reports

1.2.2 If the solution is FedRAMP Authorized but not VA Authorized:

1. The information system solution selected by the Contractor shall comply with

FISMA.

2. The Contractor shall comply with FedRAMP requirements as mandated by

Federal laws and policies, including making available any documentation, physical access, and logical access needed to support this requirement

3. The system must be FedRAMP Authorized at no less than the Moderate Impact.

4. The Contractor shall, where applicable, assist with the VA ATO Process to help achieve agency authorization of the cloud service or migrated application.

5. The Contractor shall provide confirmation of their FedRAMP SSP and supporting documentation completion via their repository ID number and a link for VA to download the SSP and all required artifacts within 5 calendar days of contract award.

6. The Contractor shall work with a VA Subject Matter Expert to develop a VA specific system boundary diagram including any integration and connectivity components for VA use. This will be known as the VAID and demonstrate the proposed implementation of this system at VA. The Contractor shall provide the VAID within 10 calendar days of contract award.

7. The Contractor shall provide the results of their most recent 3PAO SAP within 10 calendar days of contract award.

8. The Contractor shall complete a 3PAO SAR within 10 calendar days after the SSP is accepted by VA.

9. The Contractor shall provide VA with the most recent monthly scans for the production environment within the authorization boundary and their scan upload schedule for FedRAMP within 30 calendar days of contract award.

10. The Contractor shall provide their availability to participate in monthly continuous monitoring meetings to be scheduled following successful VA ATO within 30 calendar days of contract award.

11. The Contractor shall work with VA SMEs to test the validity of the IRP and ensure proper troubleshooting of issues that may arise. This should be completed within 30 calendar days of the SSP being delivered.

12. If new or unanticipated vulnerabilities are discovered by either VA or the Contractor, or if existing safeguards have ceased to function, the discoverer shall immediately bring the situation to the attention of the other party in accordance with Addendum B, VA Information and Information System Security/Privacy Language.

13. The Contractor shall comply with data management requirements.

14. Successful issuance of a VA ATO will be required before live VA data can be used in the system.

15. The Contractor shall participate in FedRAMP Continuous Monitoring activities as outlined by FedRAMP’s Continuous Monitoring Strategy.

16. The Contractor shall participate in monthly Agency and FedRAMP Sustainment meetings following the granting of a VA ATO.

17. The Contractor shall provide continuous monitoring activities including, but not limited to scans, security artifacts, and monthly POAM reports as outlined by VA and FedRAMP requirements.

Deliverables:

A. IRP Table Top Scenario

B. VAID

C. FedRAMP SSP and required Attachments

D. 3PAO SAP

E. 3PAO SAR

F. POAM Monthly Reports

1.2.3 If the solution is FedRAMP Authorized and VA Authorized:

1. The information system solution selected by the Contractor shall comply with FISMA and have a current VA authorization.

2. The Contractor shall comply with FedRAMP requirements as mandated by Federal laws and policies, including making available any documentation, physical access, and logical access needed to support this requirement.

3. The FedRAMP Authorization level and existing VA ATO should be no less than the level required for this use case which has been defined as Moderate Impact.

4. The Contractor shall, where applicable, assist with the VA ATO Sustainment Process to help maintain health and quality of agency authorization of the cloud service or migrated application.

5. The Contractor shall exclusively provide licenses and/or accounts to FedRAMP authorized and VA authorized environments.

6. The Contractor shall afford VA access to the Contractor’s and CSP’s facilities, installations, technical capabilities, operations, documentation, records, and databases.

7. If new or unanticipated vulnerabilities are discovered by either VA or the Contractor, or if existing safeguards have ceased to function, the discoverer shall immediately bring the situation to the attention of the other party in accordance with Addendum B, VA Information and Information System Security/Privacy Language. VA Privacy and Security deliverables as directed by the VA System owner.

8. The Contractor shall comply with data management requirements.

9. Successful issuance of a VA ATO will be required before live VA data can be used in the system.

10. The Contractor shall participate in FedRAMP Continuous Monitoring activities as outlined by FedRAMP’s Continuous Monitoring Strategy Guide found on the FedRAMP Website.

11. The Contractor shall participate in monthly Agency and FedRAMP Sustainment meetings following the granting of a VA ATO.

Deliverables:

A. 3PAO SAR

B. Continuous Monitoring Monthly Scans C. POAM Monthly Reports.

2.0 NOTICE OF THE FEDERAL ACCESSIBILITY LAW AFFECTING ALL

INFORMATION AND COMMUNICATION TECHNOLOGY (ICT)

PROCUREMENTS (SECTION 508)

On January 18, 2017, the Architectural and Transportation Barriers Compliance Board (Access Board) revised and updated, in a single rulemaking, standards for electronic and information technology developed, procured, maintained, or used by Federal agencies covered by Section 508 of the Rehabilitation Act of 1973, as well as our guidelines for telecommunications equipment and customer premises equipment covered by Section 255 of the Communications Act of 1934. The revisions and updates to the Section 508-based standards and Section 255-based guidelines are intended to ensure that information and communication technology (ICT) covered by the respective statutes is accessible to and usable by individuals with disabilities.

SECTION 508 – INFORMATION AND COMMUNICATION TECHNOLOGY (ICT)

STANDARDS

The Section 508 standards established by the Access Board are incorporated into, and made part of all VA orders, solicitations and purchase orders developed to procure ICT.

These standards are found in their entirety at: https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule/text-of-the-standards-and-guidelines. A printed copy of the standards will be supplied upon request.

Federal agencies must comply with the updated Section 508 Standards beginning on January 18, 2018. The Final Rule as published in the Federal Register is available from the Access Board: https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule.

https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule/text-of-the-standards-and-guidelines https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule/text-of-the-standards-and-guidelines https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule/text-of-the-standards-and-guidelines https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule https://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule

The Contractor shall comply with “508 Chapter 2: Scoping Requirements” for all electronic ICT and content delivered under this contract. Specifically, as appropriate for the technology and its functionality, the Contractor shall comply with the technical standards marked here:

E205 Electronic Content – (Accessibility Standard -WCAG 2.0 Level A and AA Guidelines)

E204 Functional Performance Criteria E206 Hardware Requirements E207 Software Requirements E208 Support Documentation and Services Requirements

2.1 COMPATABILITY WITH ASSISTIVE TECHNOLOGY

The standards do not require installation of specific accessibility-related software or attachment of an assistive technology device. Section 508 requires that ICT be compatible with such software and devices so that ICT can be accessible to and usable by individuals using assistive technology, including but not limited to screen readers, screen magnifiers, and speech recognition software.

2.2 ACCEPTANCE AND ACCEPTANCE TESTING

Deliverables resulting from this solicitation will be accepted based in part on satisfaction of the Section 508 Chapter 2: Scoping Requirements standards identified above.

The Government reserves the right to test for Section 508 Compliance before delivery.

The Contractor shall be able to demonstrate Section 508 Compliance upon delivery.

2.3 HIPAA COMPLIANCE

HIPAA compliance is required. The Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the National Standards to Protect the Privacy and Security of Protected Health Information (PHI). As required by HIPAA, the Department of Health and Human Services (HHS) has promulgated rules governing the security and use and disclosure of protected health information by covered entities, including the Department of Veterans Affairs (VA). In accordance with HIPAA, the Contractor may be required to enter a Business Associate Agreement (BAA) with VA, but VACO has recognized CNH Facilities as an entity that does not require a BAA if they are conducting health care on VA’s behalf. The CNH care program qualifies as a medical service, so no BAA is required. All non-FAX forms of electronic exchange (for example, by email) will require VA approved encryption of the data and additional approval from the VA Information Security Officer. The Contractor shall immediately report any violations of this security section to the COR. The COR will report any violations of this security section to the VA Privacy Officer and VA Information Security Officer immediately.

Business associates must follow VHA privacy policies and practices when applicable.

All contractors and business associates must receive privacy training annually.

3.0 INFORMATION TECHNOLOGY USING ENERGY-EFFICIENT PRODUCTS

3.1 EPEAT

EPEAT product compliance is not required in this acquisition.

3.2 ENERGY STAR

Energy Star compliance is not required in this acquisition.

3.3 FEMP

FEMP or FEMP low standby power product compliance is not required in this acquisition.

4.0 SHIPMENT OF HARDWARE OR EQUIPMENT

N/A

5.0 GENERAL REQUIREMENTS

5.1 VA TECHNICAL REFERENCE MODEL

The Contractor shall support the VA enterprise management framework. In association with the framework, the Contractor shall comply with OIT Technical Reference Model (VA TRM). The VA TRM is one component within the overall Enterprise Architecture (EA) that establishes a common vocabulary and structure for describing the information technology used to develop, operate, and maintain enterprise applications. Moreover, the VA TRM, which includes the Standards Profile and Product List, serves as a technology roadmap and tool for supporting OIT. Architecture & Engineering Services (AES) has overall responsibility for the VA TRM.

5.2 SOCIAL SECURITY NUMBER (SSN) REDUCTION

The Contractor solution shall support the Social Security Number (SSN) Fraud Prevention Act (FPA) of 2017 which prohibits the inclusion of SSNs on any document sent by mail. The Contractor support shall also be performed in accordance with Section 240 of the Consolidated Appropriations Act (CAA) 2018, enacted March 23, 2018, which mandates VA to discontinue using SSNs to identify individuals in all VA information systems as the Primary Identifier. The Contractor shall ensure that any new IT solution discontinues the use of SSN as the Primary Identifier to replace the SSN with the Integrated Control Number (ICN) in all VA information systems for all individuals. The Contractor shall ensure that all Contractor delivered applications and systems integrate with the VA Master Person Index (MPI) for identity traits to include the use of the ICN as the Primary Identifier. The Contractor solution may only use a Social Security Number to identify an individual in an information system if and only if the use of such number is required to obtain information VA requires from an information system that is not under the jurisdiction of VA.

5.3 INTERNET PROTOCOL VERSION 6 (IPV6)

The Contractor solution shall support Internet Protocol Version 6 (IPv6) based upon the memo issued by the Office of Management and Budget (OMB) on November 19, 2020 (https://www.whitehouse.gov/wp-content/uploads/2020/11/M-21-07.pdf). IPv6 technology, in accordance with the USGv6 Program (https://www.nist.gov/programs-projects/usgv6-program/usgv6-revision-1), NIST Special Publication (SP) 500-267B Revision 1 “USGv6 Profile” (https://doi.org/10.6028/NIST.SP.500-267Br1), and NIST SP 800-119 “Guidelines for the Secure Deployment of IPv6” (https://doi.org/10.6028/NIST.SP.800-119), compliance shall be included in all IT infrastructures, application designs, application development, operational systems and sub-systems, and their integration. In addition to the above requirements, all devices shall support native IPv6 and dual stack (IPv6 / IPv4) connectivity without additional memory or other resources being provided by the Government, so that they can function in a mixed environment. All public/external facing servers and services (e.g.

web, email, DNS, ISP services, etc.) shall support native IPv6 and dual stack (IPv6 / IPv4) users and all internal infrastructure and applications shall communicate using native IPv6 and dual stack (IPv6 / IPv4) operations.

5.4 SOFTWARE AND LICENSING REQUIREMENTS

The Contractor shall be responsible for the provision of all software licenses and any associated licensing maintenance required for any development, delivery, integration, operation, and/or maintenance associated with its proposed application(s), software products, software solution, and/or system including, but not limited to, any and all application(s), software and/or software products that comprise, are a part of, or integrate with the Contractor’s proposed application(s), software products, software solution, and/or system for the life of any resulting contract.

5.5 POSITION/TASK RISK DESIGNATION LEVEL(S)

Position Sensitivity and Background Investigation Requirements by Service Task/Item Number

Service Task/ Item Number

Tier1 / Low Risk Tier 2 / Moderate Risk

Tier 4 / High Risk

1.0 1.1 1.2 https://www.whitehouse.gov/wp-content/uploads/2020/11/M-21-07.pdf file://R04.med.va.gov/V03/EAS/Users/vhaeasWymbsk/TEMPLATES--NEW%20TAC%20PROCESS/PWS%20TEMPLATE%20(DO%20NOT%20TOUCH)%20-%20In%20Process%20Revisions/DO%20NOT%20TOUCH%20(next%20version/IPv6/(https:/www.nist.gov/programs-projects/usgv6-program/usgv6-revision-1 file://R04.med.va.gov/V03/EAS/Users/vhaeasWymbsk/TEMPLATES--NEW%20TAC%20PROCESS/PWS%20TEMPLATE%20(DO%20NOT%20TOUCH)%20-%20In%20Process%20Revisions/DO%20NOT%20TOUCH%20(next%20version/IPv6/(https:/www.nist.gov/programs-projects/usgv6-program/usgv6-revision-1 https://doi.org/10.6028/NIST.SP.500-267Br1 https://doi.org/10.6028/NIST.SP.800-119

The Tasks identified above and the resulting Position Sensitivity and Background Investigation requirements identify, in effect, the Background Investigation requirements for Contractor individuals, based upon the tasks the particular Contractor individual will be working. The submitted Contractor Staff Roster must indicate the required Background Investigation Level for each Contractor individual based upon the tasks the Contractor individual will be working, in accordance with their submitted proposal.

POINTS OF CONTACT (The information below will be provided at a later date.)

VA Program Manager:

Name:

Address:

Voice:

Email:

Contracting Officer’s Representative:

Name:

Address:

Voice:

Email:

Contracting Officer:

Name:

Address:

Voice:

Email:

Contract Specialist:

Name:

Address:

Voice:

Email:

INFORMATION SECURITY CONSIDERATIONS:

The Assessment and Authorization (A&A) requirements do not apply and a Security Accreditation Package is not required

ADDENDUM B – VA INFORMATION AND INFORMATION SYSTEM

SECURITY/PRIVACY LANGUAGE

APPLICABLE PARAGRAPHS TAILORED FROM: THE VA INFORMATION AND

INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE, VA HANDBOOK

6500.6, APPENDIX C, MARCH 12, 2010

B1. 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.

B2. 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 (e.g. Business Associate Agreement, Section 3G), 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 CO 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 CO must also be notified immediately by the Contractor or Subcontractor prior to an unfriendly termination.

B3. VA INFORMATION CUSTODIAL LANGUAGE

1. 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 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).

2. 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 information is returned to 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.

3. 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 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 CO within 30 days of termination of the contract.

4. 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 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.

5. 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.

6. 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.

7. If a VHA contract is terminated for cause, the associated Business Associate Agreement (BAA) must also be terminated and appropriate actions taken in accordance with VHA Directive 1605.05, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship.

8. 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.

9. The Contractor/Subcontractor’s firewall and Web services security controls, if applicable, shall meet or exceed VA minimum requirements. VA Configuration Guidelines are available upon request.

10. 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 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 CO for response.

11. 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 CO for response.

12. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require Assessment and Authorization (A&A) or a Memorandum of Understanding-Interconnection Security Agreement (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.

B4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT

1. 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 VA Handbook 6500, Risk Management Framework for VA Information Systems – Tier 3: VA Information Security Program, and the TIC Reference Architecture). During the development cycle a Privacy Impact Assessment (PIA) must be completed, provided to the COR, and approved by the VA Privacy Service in accordance with Directive 6508, Implementation of Privacy Threshold Analysis and Privacy Impact Assessment.

2. The Contractor/Subcontractor shall certify to the COR 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 VA. This includes Internet Explorer 11 configured to operate on Windows 10 and future versions, as required.

3. 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.

4. Applications designed for normal end users shall run in the standard user context without elevated system administration privileges.

5. 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, Risk Management Framework for VA Information Systems – Tier 3: VA Information Security

Program and VA Handbook 6500.5, Incorporating Security and Privacy in System Development Lifecycle.

6. 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.

7. The Contractor/Subcontractor agrees to:

a. 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:

i. The Systems of Records (SOR); and

ii. The design, development, or operation work that the Contractor/Subcontractor is to perform;

b. 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

c. Include this Privacy Act clause, including this subparagraph (c), in all subcontracts awarded under this contract which requires the design, development, or operation of such a SOR.

8. 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.

a. “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.

b. “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.

c. “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.

9. 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, hot fixes, 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.

10. 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, based upon the severity of the incident.

11. When the Security Fixes involve installing third party patches (such as Microsoft

OS patches or Adobe Acrobat), the vendor will provide written notice to 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 based upon the requirements identified within the contract.

12. 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 CO and the VA Assistant Secretary for Office of Information and Technology.

B5. 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 COR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA network involving VA information must be in accordance with the TIC Reference Architecture and reviewed and approved by VA prior to implementation. For Cloud Services hosting, the Contractor shall also ensure compliance with the Federal Risk and Authorization Management Program (FedRAMP).

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 A&A of the Contractor’s systems in accordance with VA Handbook 6500.3, Assessment, Authorization and Continuous Monitoring of VA Information Systems 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 security 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 CO and the ISO for entry into the VA POA&M management process. The Contractor/Subcontractor must use the VA 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 A&A of the system may need to be reviewed, retested and re-authorized per VA Handbook 6500.3.