36C24521Q0514.docx

36C24521Q0514

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

DUNS:

DUNS+4:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

06-10-2021 Rachael Hallock 304-263-0811 ext. 2033 06-23-2021 14:00

EDT

Department of Veterans Affairs Network Contracting Office

NCO5

510 Butler Avenue, Building 308B Martinsburg WV 25405

X

813920 $16.5 Million

N/A

36C245 Department of Veterans Affairs Network Contracting Office

NCO5

510 Butler Avenue Martinsburg WV 25405 36C245 Department of Veterans Affairs Network Contracting Office

NCO5

510 Butler Avenue, Building 308B Martinsburg WV 25405

PAYMENT WILL BE MADE BY

FSC e-Invoice Payment Invoice must be submitted electronically http://www.fsc.va.gov/einvoice.asp

See CONTINUATION Page

This RFQ is to provide re-accreditation services to 40 VHA Radiation Oncology Services. See Performance Work Statement below for further details.

Period of Performance will be a base plus two years.

Please provide location(s) where employees will be working.

Service Contract Labor wages to determined at a later date.

Questions are due no later than 6/16/2021 by 3:30 PM EST.

This solicitation will close 6/23/2021 at 2 PM EST.

Late submissions will not be accepted.

See CONTINUATION Page x

Allison Lewis

VA-VHA-2020-2303D336

Table of Contents

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C245 Department of Veterans Affairs Network Contracting Office

NCO5

510 Butler Avenue, Building 308B Martinsburg, WV 25405

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

PAYMENT WILL BE MADE BY

FSC e-Invoice Payment Invoice must be submitted electronically http://www.fsc.va.gov/einvoice.asp

B.2 PERFORMANCE WORK STATEMENT- VHA Radiation Oncology Practice Accreditation

1. Scope of Work: The contractor shall provide all resources necessary to accomplish the deliverables described in the performance work statement, except as may otherwise be specified. To continue a comprehensive accreditation process by a national recognized external accrediting body for all VHA Radiation Oncology Programs. The contractor shall provide accreditation surveys to (41) VHA Radiation Oncology Programs to include a thorough third party, impartial peer review and evaluation of patient care. The off-site and onsite surveys include at a minimum review of following data;

· Staffing levels, qualifications and credentials of radiation oncologist(s) and medical physicist(s),

· On-site availability of Radiation Oncologist(s) and medical physicist(s),

· Radiation treatment management data that include: history & physical/consultation, treatment sections, patient evaluation, treatment summary and follow-up from cases randomly selected and anonymized on electronic submission,

· Medical Physicis operation that include treatment chart documentation, treatment simulation, treatment planning, treatment plan evaluation, and patient-specific QA.

· Quality Control Program: instrumentations, simulation/treatment machine/quality assurance, treatment planning and general quality assurance and quality management,

· Practice’s Policy and Procedures, Practice’s Continuous Quality Improvement initiatives.

· Clinical data backup storage and recovery policies Recommendations of findings shall be based on nationally recognized guidelines, including American College of Radiology (ACR) technical standards, ACR Appropriateness Criteria and the American Association of Physics in Medicine (AAPM) Task Group reports and technical standards.

The surveyors shall consist of board-certified radiation oncologists and board certified medical physicists, and act as data collectors only. All data from the survey application and the on-site survey shall be compiled and submitted for final recommendations regarding accreditation to a review committee of the contractor, which at a minimum shall be composed of experienced board-certified radiation oncologists and medical physicists.

In addition to the accreditation survey report, the contractor shall provide individualized Practice Quality Improvement (PQI) report to all full-time VHA radiation oncology physicians and VHA medical physicists employed by Veterans Affairs Medical Centers (VAMC) at no additional charge. If any corrective action measures are identified, the final report will request additional documentation that demonstrates that these have been appropriately addressed. When this documentation is submitted and reviewed, a certificate of satisfactory completion of the PQI project will be issued to each participating radiation oncologist and medical physicist.

3. Background: The Under Secretary for Health requested on-site accreditation inspections of all VHA facilities providing radiation oncology services. In response to this request, Patient Care Services contracted with the American College of Radiology to conduct a second round of accreditation surveys. Initiated after January 1, 2008, these surveys were completed over a three-year period ending in FY2011. The product was to have a 3-year accreditation or recommendations for improvement in practice and patient outcomes to meet or exceed national standards and ensure high quality healthcare in all VHA Radiation Oncology program for all Veterans. The re-accreditation process goes in 3-year cycles The accreditation process shall be designed to promote quality and be educational in nature. It shall include at a minimum an on-site survey performed by a board certified radiation oncologist and board-certified medical physicist.

The contractor shall provide a Practice Quality Improvement (PQI) program for the VHA radiation oncologist(s) and medical physicist(s) to fulfill Part IV, Evaluation of Performance in Practice for Maintenance of Certification (MOC) for the American Board of Radiology (ABR). The PQI program will not require the submission of any additional cases but there must be at least 2 cases reviewed for PQI per physician during the on-site survey.

Following the survey, a final report and certificate of satisfactory completion of practice assessment shall be issued to each participating radiation oncologist and medical physicist. If any recommended action measures are identified, the final report shall request additional documentation that demonstrates that such measures have been appropriately addressed.

4. Performance Period: The period of performance is Base Year beginning July 1, 2021 through June 30, 2022 with two additional option years. Work at the government site shall not take place on Federal holidays or weekends unless directed by the Contracting Officer (CO).

5. Type of Contract: Firm-Fixed-Price

6. Place of Performance: VHA Radiation Oncology Programs applying for accreditation, or re-accreditation prior to initial accreditation expiration, must submit an application through the Contractors’ secure website.

The application should consist of submission of facility treatment and equipment information, staffing levels and qualifications, and physics Quality Assurance/Quality Control documentation. If deficiencies are noted or missing items identified, the facility will be contacted so that any missing items can be submitted before the on-site survey is scheduled.

When the application is complete, the date of the on-site survey will be confirmed. At this time, the facility will receive a notice to submit cases (Census Data Form) from which 10 (or more) will be selected for review during the site visit. The on-site survey is conducted over one business day (for a single facility)

B. CONTRACT AWARD MEETING

The contractor shall not commence performance on the tasks in this Performance Work Statement until the Contracting Officer (CO) has conducted a kickoff meeting or has advised the contractor that a kickoff meeting is waived.

C. GENERAL REQUIREMENTS

1. For every task, the contractor shall identify in writing all necessary subtasks (if any), associated costs by task, and together with associated sub milestone dates. The contractor's subtask structure shall be reflected in the technical proposal and detailed project management plan (PMP).

2. All written deliverables will be phrased in layperson language. Statistical and other technical terminology will not be used without providing a glossary of terms.

3. When survey date is confirmed, The Contractor staff will ask the facility to submit cases of definitively treated patients who have recently completed treatment at applying facility and have had at least one follow up visit. The Contractor will send an email message that will prompt the Radiation Oncology Center to complete the appropriate census data sheets when facility receives confirmation of the survey dates. During the on-site survey, 10 cases will be reviewed. ID numbers, not patient names, will be submitted for 5 breast, 5 prostate, 5 head and neck, 5 lung and 5 “generic” disease sites (Colo-rectal, seminoma, brain, Hodgkin’s disease, cervix, etc.) on the census data sheets provided. If facility does not have 5 cases from a disease site (such as head and neck), additional generic cases may be submitted. To ensure that all physicians in the practice are reviewed, physician initials must be included with patient ID numbers. A minimum of 2 cases per physician will be reviewed. In addition, cases selected should include all treatment modalities offered at applying facilities, such as intensity modulated radiotherapy (IMRT), prostate seed implants, stereotactic radiosurgery, etc. For all cases, patient records including simulation information, DRRs, port films (hard copies if appropriate), and CT planning documentation will be made available for the surveyors. If the facility has electronic images and/or medical records, facility will provide electronic access to this information.

The surveyors will need to have their own laptops with wireless internet access for data collection on site.

Each VHA Radiation Oncology Center will provide a designated “navigator” for the physician and medical physicist surveyors for electronic medical records/digital imaging systems chart review. All surveyors shall complete VA TMS Training: VA Privacy Awareness, Information Security Training, and Rules of Behavior, and Privacy and HIPAA Training prior to their initial survey, and update annually. All surveyors must provide training certificates to both point of contact designated by the contractor and the National Radiation Oncology Program Office Contracting Officer’s Representative (COR).

4. During the visit, the surveyors will tour the facility, verify the information submitted in the facility’s application, conduct an interview with the Chief/Medical Director of Radiation Oncology, the chief physicist, department administrator, chief therapist, dosimetrist, nurse and other key personnel, and collect information about the facility’s patient treatment policies and procedures, safety initiatives and review the selected cases.

The radiation oncologist and medical physicist will review charts and document responses to a set of questions developed by the contractor. Chart reviews should include components such as complete and signed prescriptions, consent forms, pathology reports, history and physical, physician management during treatment and follow up, appropriateness of treatment, simulation/treatment planning and dosimetry activities. At the end of the day, the surveyors will again meet with the group for a brief “exit” interview. This is primarily to clarify any issues prior to their departure; the team may not provide their recommendations at this time since that will be the Contractor’s Review Committee decision, which will be made following review of the results of the survey.

A comprehensive review of the facility’s physics program will be included as part of the application process and verified during the on-site survey. The Chief Therapeutic Medical Physicist is responsible for the design and implementation of the physics quality management program at VA. The following areas will require documentation submitted with the application:

· Documentation of compliance with appropriate AAPM/ACR/ASTRO recommendations and technical practice standards.

· Documentation of treatment planning system quality assurance program based on AAPM technical standards

· Independent Verification of Output of each clinical beam

· Documentation of end-to-end testing of all advanced procedures such as, IMRT, SBRT, and SRS.

In addition, during the on-site survey, the qualified medical physicist’s documentation of the following will be reviewed:

· Procedures for instrument calibration and periodic instrument constancy checks

· Procedures to verify the manufacturer’s specifications and to establish baseline performance values for radiation therapy equipment

· Quality management program for radiation therapy equipment, simulators, treatment planning systems, and monitor unit calculation algorithms

· Monitor unit calculation procedures and protocols

· Physics chart check protocol for reviewing treatment delivery

· Procedures for checking the integrity of mechanical and electrical patient care devices

· Radiation protection program as it pertains to radiation oncology

· Calculations related to patient dosimetry and/or physics measurements when such needs arise or per clinician’s requests.

· Equipment repair/maintenance records and follow up actions

· New equipment acquisition plan

D. SPECIFIC MANDATORY TASKS AND ASSOCIATED DELIVERABLES

Deliverable One: Accrediting body will award a three-year certificate or recommendations for practice improvement to be addressed by site through a Corrective Action Plan. A decision and final report will be completed within 12 weeks of the survey date and sent to the Medical Center Director, Service Chief/Medical Director of Center’s Radiation Oncology Service/Section and COR for the National Radiation Oncology Program.

Task Two: For payment purposes, all VHA Radiation Oncology Centers will be classified within the accrediting body fee schedule. Upon verified receipt of the required report by the COR, and submittal of proper invoices, the accrediting body obligation will be payable whether full, deferred, or denied accreditation is rendered to the VHA Radiation Oncology Center.

Deliverable Two: Reports submitted to COR as required in paragraph D, Deliverable One, and submittal of proper invoices.

Task Three: Assessment of Performance in Practice for the Maintenance of Certification (MOC) program for the American Board of Radiology (ABR) both for the radiation oncologist(s) and medical physicist(s) through the Radiation Oncology Practice Accreditation Program.

Deliverable Three: Final report and certificate of satisfactory completion of practice assessment will be issued to each participating radiation oncologist.

VHA Radiation Oncology Centers

E. SCHEDULE FOR DELIVERABLES

1. The contractor shall complete the Delivery Date for each deliverable specified.

2. If for any reason the scheduled time for a deliverable cannot be met, the contractor is required to explain why (include the original deliverable due date) in writing to the Contracting Officer Representative (COR), including a firm commitment of when the work shall be completed. This notice to the COR shall cite the reasons for the delay, and the impact on the overall project. The COR will then review the facts and issue a response in accordance with applicable regulations.

F. CHANGES TO PERFORMANCE WORK STATEMENT

Any changes to this Performance Work Statement shall be authorized and approved only through written correspondence from the CO. A copy of each change will be kept in a project folder along with all other products of the project. Costs incurred by the contractor through the actions of parties other than the CO shall be borne by the contractor.

G. REPORTING REQUIREMENTS

1. The Accrediting Body will ensure the confidentially of all patient and employee information and shall be liable in the event of breach of confidentiality. Any person who discloses confidential information from the VA may be criminally liable for violations under this regulation. All materials are confidential and are protected under the Privacy Act of 1974, Title 38 U.S.C., Sections 5701, 5705 and 7332.

2. The Contractor survey reports are protected under 38.U.S.C. 5705 which provides that records and documents created by VHA as a part of a designed medical quality assurance program are confidential and privileged and may not be disclosed to any person or entity except when specifically authorized by the statute.

3. The Contractor shall provide VHA with the full assurance that security measures have been implemented. Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements will be exercised in their business dealing with Protected Health Information (PHI). A business associate agreement (BAA) will ensure that the accrediting team and body will appropriately safeguard the PHI received from the application for accreditation.

4. In addition to deliverables specified above, the Accrediting Body is also required to provide the COR with accreditation process summary reports every three months (quarterly Oct-Nov-Dec, Jan-Feb-Mar, Apr-May-Jun, Jul-Aug-Sep). The Contractor shall submit quarterly reports to COR by the 15th of the next month after the end of each quarter.

5. The progress report will cover all work completed during the preceding quarter and will present the work to be accomplished during the quarter. The report must identify any problems, which arose, and a statement explains how the problem was resolved.

6. If for any reason a deliverable cannot be delivered as scheduled, the Contractor is required to submit a request for a time extension to the Contracting Officer. This request will cite the reasons for the delay, the impact on the overall project, and the impact on the cost of this project. The CO will consider each request based on its merits, and will, if appropriate, issue a modification to the task order. The Contractor is required to proceed as originally scheduled until such modification is issued

H. TRAVEL

Travel for the accrediting survey team members is covered in the price for each site visit.

I. GOVERNMENT RESPONSIBILITIES

Each VHA Radiation Oncology Center will provide, private office/conference room space for on-site visit, telephone service, and procedural guides, reference materials and program documentation as specified in scope of work.

J. CONTRACTOR EXPERIENCE REQUIREMENTS – KEY PERSONNEL

K. EVALUATION AND AWARD FACTORS: Award shall be made to the offer representing the best value to the Government considering technical and price factors as stated below.

Offerors shall include in their proposal’s specific information relative to the evaluation factors listed below to ensure proper evaluation of their proposal.

1. Past performance must be able to show:

· Three radiology accreditations for a facility of equal size within the last five years.

· The number of new facilities surveyed for accreditation per year.

· The number of facilities surveyed for the renewal of accreditation per year.

· The total number of facilities surveyed for radiology accreditation to date.

2. Must have national BAA at time of award.

3. Qualification and experience requirements of radiation oncologist and medical physicist surveyors, including:

· Selection criteria for the surveyors

· Training of the surveyors in the accreditation process

4. Training of the surveyors in the accreditation process.

5. Specialized skills, expertise, knowledge of the surveyors and review committee. Please provide capability statement.

K. VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE SECURITY

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.

1. ACCESS to VA INFORMATION AND VA INFORMATION SYSTEMS

1. 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.

1. 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.

1. 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.

1. Custom software development and outsourced operations must be 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.

1. 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.

1. 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 onsite 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 COR.

4. TRAINING

a. All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

1) Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems.

2) Successfully complete the VA Privacy and Information Security Awareness and Rules of Behavior training and annually complete required security training;

3) Successfully complete the appropriate VA Privacy and HIPAA training and annually complete required privacy training; and

4) Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document – e.g., any role-based information security training required in accordance with NIST Special Publication 800-16, Information Technology Security Training Requirements.]

b. The contractor shall provide to the contracting officer and/or the COR a copy of the training certificates prior to assignment of a site-visit and annually thereafter, as required.

c. Failure to complete the mandatory annual training 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.

5. 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.

6. 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. However, it is the policy of VA to forgo collection of liquidated damages in the event the contractor provides payment of actual damages in an amount determined to be adequate by the agency.

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 $37.50 per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:

(1) Notification;

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

(3) Data breach analysis;

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

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

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

8. SECTION 508

The contractor shall comply with Section 508 of the Rehabilitation Act (29 U.S.C. § 794d), as amended by the Workforce Investment Act of 1998 (P.L. 105-220), 8/7/1998.

In December 2000, the Architectural and Transportation Barriers Compliance Board (Access Board), pursuant to Section 508(2)(A) of the Rehabilitation Act Amendments of 1998, established Information Technology accessibility standards for the Federal Government. Section 508(a)(1) requires that when Federal departments or agencies develop, procure, maintain, or use Electronic and Information Technology (EIT), they shall ensure that the EIT allows Federal employees with disabilities to have access to and use of information and data that is comparable to the access to and use of information and data by other Federal employees. The Section 508 requirement also applies to members of the public seeking information or services from a Federal department or agency.

Section 508 text is available at:

http://www.opm.gov/HTML/508-textOfLaw.htm http://www.section508.gov/index.cfm?FuseAction=Content&ID=14

N. CONFIDENTIALITY AND NONDISCLOSURE

It is agreed that:

One Item

Accrediting body will notify facilities 9 months in advance of anniversary date of last Radiation Oncology accreditation survey to keep on 3-year cycle, and coordinate site visit dates with VHA facility.

Quantity

Delivery Date

Cycle begins upon award date of contract

Two

Within 12 weeks after the site survey date

Final report and certificate of satisfactory completion of practice assessment will be issued to each participating radiation oncologist and medical physicist after their specific site receives accreditation.

B.3 PRICE/COST SCHEDULE

ITEM INFORMATION

Radiation Oncology Practice Evaluation Services

Assessment of Performance in Practice for the Maintenance of Certification (MOC) program for the American Board of Radiology (ABR) for VHA Radiation Oncology Physicians

Assessment of Performance in Practice for the Maintenance of Certification Program for the American Board of Radiology (ABR) for VHA Medical Physicist(s)

Radiation Oncology Practice Evaluation

Assessment of Performance in Practice for the Maintenance of Certification (MOC) program for the American Board of Radiology (ABR) for VHA Radiation

Assessment of Performance in Practice for the Maintenance of Certification

Radiation Oncology Practice Evaluation