36C24118Q0379-004.doc

VA Connecticut Healthcare System

Fy18 Mental Health Service Line

Scope of Service Mental Health Service Line of VA Connecticut Healthcare System, Contractual Services for the Provision of Substance Abuse Beds and Emergency Shelter Beds for our Homeless Veterans I. Introduction:

VA Connecticut Healthcare System, Mental Health Service Line is committed to meeting the temporary housing needs of our homeless veterans. Mental Health is an integral component of overall health care and housing is a critical piece which is often missing.

The temporary emergency housing needs subsumed under this scope are normally provided by numerous housing sources which cumulatively do not have adequate availability to serve our ever growing homeless veteran population. VA Connecticut Healthcare System, Mental Health Service Line, Errera Community Care Center Firm/ Teams within the outpatient setting provides mental health evaluation assessment, treatment and housing assistance for our veterans working on their own individual recovery plan. These additional temporary shelter housing beds located with the West Haven/Milford/Bridgeport community are needed to better serve our homeless population struggling to work on their own individual mental health recovery needs. These beds offer additional access to serving our homeless veteran. These temporary shelter beds for Homeless Veterans are needed and being sought within the West Haven, Milford, Bridgeport communities in Connecticut and need to be able to accommodate and serve men, women and families.

II. Service Provision & Nature of Responsibilities

· Provide access for 3 Substance abuse beds with a LOS up to 90 days and monitored and tracked with VA Liaison.

· Provide access for 3 emergency shelter beds with a LOS up to 90 days for our Homeless Veterans which will be monitored and tracked with a VA liaison.

· Bed utilization and referrals are for both men and/or women Veterans as well as families.

· Facility will provide all linen including sheets, towels, pillows and blankets during LOS.

· 3 meals per day including a hot lunch at noon.

· Collaborate with the designated VA clinical liaisons for all veteran referrals.

· Obtain a signed release of information from the Veteran for verbal communication during LOS, reciprocal with VA. If release is rescinded, Veteran is to be removed from the VA bed status.

· Provide case management services in collaboration with the VA Mental Health providers while the veterans are housed in the designated beds.

· Assessment, Evaluation, Discharge and Referral Assistance as needed and indicated.

· Maintain safe environment and pass pre-and annual inspection of facility by VA approved site team.

· Collaborate with VA outpatient Mental Health providers to arrange for follow-up and aftercare services.

· Collaborate daily with VA Liaison regarding bed occupancy and bed availability.

· Communicate to the VA liaison who will in turn communicate to the MH provider if veteran is discharged &/or doesn’t return to the bed status within 24 hours.

· Comply with VHA confidentiality and HIPPA guidelines.

· Work in concert with the MH Service Line Manager &/or designee of VA Connecticut Healthcare System and the Firm Director, Errera Community Care Center

· Accept veteran transfer post evaluation with a VA Connecticut’s Mental Health provider.

· Agree to return veteran back to VA Connecticut Healthcare System if medically indicated for inpatient hospitalization as long as it’s not deemed medically emergency at which time 911 would be contacted and transfer to the nearest and most appropriate hospital is warranted.

· Maintain current professional liability insurance III. Reporting All providers will comply with agency directives, circulars, procedures and policies, maintain records and statistics, and carry out assigned caseloads and treatment for veterans referred for service provision under this agreement. Comply with JCAHO reporting standards and documentation requirements.

IV. Work Environment The mental health providers will be working to focus on serving the immediate housing needs of our homeless Veteran population. The work may require a combination of settings from his/her personal sedentary office to shared space in the residential care setting. The work is typically performed in an adequately lighted and climate controlled facility. May require occasional travel for transfer assistance &/or treatment consultation. All providers are expected to follow safety procedures and utilize good judgment at all times.

V. Physical Demands.

The work is primarily sedentary, although some physical effort may be required.

VI. Purpose of Contacts

Contacts are to provide mental health referral services and assistance to veterans as referred under this agreement. Providers/Case Managers will liaison with VA agencies which may include consultants, contractors, primary providers, program officials, &/or business executives.

VII. Customer Service

Meet the needs of our homeless veterans referred for temporary housing and receiving treatment at VA Connecticut outpatient services while supporting the VA and Mental Health Missions. Consistently communicates and treats customers (veterans, their representatives, visitors, and all VHA staff) in a courteous, tactful, and respectful manner. Provides the customer with consistent information according to established mental health policies and procedures. Handles conflicts and problems in dealing with the customer constructively and appropriately.

VIII. Confidentiality Protect printed and electronic files containing sensitive data in accordance with the provisions of the Privacy Act of 1974 and other applicable laws, federal regulations, VA statutes and policy, and VHA policy, JCAHO and HIPPA. Protect the data from unauthorized release or from loss, alteration, or unauthorized deletion. Signed releases are required for the sharing of verbal &/or written information between VA and SCRC under this agreement.

IX. VA Connecticut Agrees to Provide:

· Clinical Consultation & Guidance as needed to collaborate and assist each veteran.

· Provide collaborative assistance for transfer assistance and coordination.

· Provide as needed appropriate transportation &/or transportation assistance i.e. bus tokens for transfer from VA Connecticut to Vendor for service assistance.

· Obtain necessary release of information for referral assistance and communication.

· Allow any provider under this scope to attend educational training and seminars provided or sponsored by VA Connecticut, which would improve or enhance the staff’s expertise and provide skill building.

· Perform daily contact with Vendor liaison to discuss bed availability. VA agrees to allow the facility to utilize any of the 7 unoccupied reserved beds for their need if and only if VA liaison &/or designee notifies the facilities Liaison of VA’s lack of intent to occupy any of the beds during a 24 hour period. VA agrees to release any of the three unused beds by 5:00 p.m.

· VA only agrees to financially reimburse the Vendor for BDOC (Bed Days of Care-utilization) occupied by veterans under this agreement via the standard five reserved bed status. If any of the five beds remain unoccupied, VA is not financially responsible.

· We reserve the right to increase the need of emergency beds as the need arises with modification.

III. Contract Security according to VA Handbook 6500.6 Appendix A Modified

1. GENERAL

· Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

· a. A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only

· To the extent necessary to perform the services specified in the contract, agreement, or task order.

· b. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

· c. Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a

· Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness.

· d. Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state\ where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor.

· e. The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor’s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

3. VA INFORMATION CUSTODIAL LANGUAGE

· a. Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data

· - General, FAR 52.227-14(d) (1).

· b. VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor’s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct on site inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

· c. Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

· d. The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract.

· e. The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

· f. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

· g. If a VHA contract is terminated for cause, the associated BAA must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship.

· h. The contractor/subcontractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated.

· i. The contractor/subcontractor’s firewall and Web services security controls, if applicable, shall meet or exceed VA’s minimum requirements. VA Configuration Guidelines are available upon request.

· j. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA’s prior written approval. The contractor/subcontractor must refer all

· requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response.

· k. Notwithstanding the provision above, the contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records

· and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor is in receipt of a court order or other requests for the above mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response.

· l. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COTR.

· 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.

6. SECURITY INCIDENT INVESTIGATION

· a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify\ the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

· b. To the extent known by the contractor/subcontractor, the contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

· c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

· d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

7. LIQUIDATED DAMAGES FOR DATA BREACH

· a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

· b. The contractor/subcontractor shall provide notice to VA of a “security incident” as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

· c. Each risk analysis shall address all relevant information concerning the data breach, including the following:

· (1) Nature of the event (loss, theft, unauthorized access);

· (2) Description of the event, including:

· (a) date of occurrence;

· (b) data elements involved, including any PII, such as full name, social security number,

· date of birth, home address, account number, disability code;

· (3) Number of individuals affected or potentially affected;

· (4) Names of individuals or groups affected or potentially affected;

· (5) Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text;

· (6) Amount of time the data has been out of VA control;

· (7) The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons);

· (8) Known misuses of data containing sensitive personal information, if any;

· (9) Assessment of the potential harm to the affected individuals;

· (10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and

· (11) Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised.

· d. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $______ per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:

· (1) Notification;

· (2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports;

· (3) Data breach analysis;

· (4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution;

· (5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and

· (6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs.

Sub abuse beds and Emergency Homeless Beds-- contractual scope of service