36C26120Q1110_FIRE PROTECTION_ Performance Work Statement.docx

PERFORMANCE WORK STATEMENT

VA SIERRA NEVADA HEALTH CARE SYSTEM

654-21-1-6093-0005 FIRE PROTECTION TESTING, INSPECTION,

AND MAINTENANCE/REPAIR SERVICE

Part 1

General Information

1. General: This is a non-personnel services contract to provide 654-21-1-6093-0005 Fire Protection Testing, Inspection, and Maintenance/Repair Service. The Government shall not exercise any supervision or control over the contract service providers performing the services herein. Such contract service providers shall be accountable solely to the contractor who, in turn is responsible to the Government.

1.1 Description of Services/Introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform 654-21-1-6093-0005 Fire Protection Testing, Inspection, and Maintenance/Repair Service as defined in this Performance Work Statement (PWS) except for those items specified as government furnished property and services. The contractor shall perform to the standards in this contract.

1.2 Background: VA Sierra Nevada Healthcare System (VASNHCS) has a requirement to ensure the fire protection system (suppression, damper, wet & dry standpipes) are properly maintained, tested, inspected, and repaired per The Joint Commission (TJC) EC.02.03.05, National Fire Protection Association (NFPA) 25, NFPA 12A, NFPA 13, NFPA 72, NFPA 80, NFPA 90A, NFPA 96, NFPA 105, and as per State and Federal requirements.

1.3 Objectives: Ensure that the fire protection system are properly maintained, tested, inspected, and repaired per the requirements listed in 1.2 Background.

1.4 Scope of work:

1. General

a. This will be for the base period of October 1, 2020 through September 30, 2021 and subsequent option periods, if exercised:

i. Option Year 1: October 1, 2021 through September 30, 2022

ii. Option Year 2: October 1, 2022 through September 30, 2023

iii. Option Year 3: October 1, 2023 through September 30, 2024

iv. Option Year 4: October 1, 2024 through September 30, 2025

b. Normal work hours for contractor work shall be performed Monday thru Friday, 0800 – 1530 excluding federal holidays. Some work such as testing, inspection, and repairs may be conducted after hours to mitigate any impacts that would affect patient care such as with the Ansul testing. These will be noted on this PWS. Any overtime work not noted on this PWS will require a quote/proposal and must be approved by the contracting officer (CO), contracting officer’s representative (COR), or designated representative.

c. Contractors are requested and highly encouraged to conduct a site visit to the hospital to have a complete understanding of what this contract entails.

d. The contractor, without additional expense to the Government, shall obtain all licenses, permits, and insurance required to perform the work in this contract and shall comply with all current, applicable federal, state, and local laws, to include the ability to perform all inspections, testing, maintenance, and repairs with a State of Nevada license. Evidence of insurance, licenses, and permits shall be provided to the CO and COR before work commences.

i. Inspection, testing, maintenance, and repair service shall be provided by qualified personnel (NFPA 25, Section 3.3.24 and 4.1.1.2). Qualified personnel shall be competent and capable persons shown to have met the requirements and training for this field and area of inspection, testing, maintenance, and repairs (NFPA 25, Section 3.3.34).

2. Contractor staff:

a. The contractor shall ensure that their personnel comply with all VASNHCS policies to include but is not limited to: parking in the appropriate/authorized spaces with special consideration to ensure that they are not parking in veteran/patient spaces; and no smoking (not authorized at all on hospital grounds).

b. The contractor will ensure that all staff comply with hospital employees with regards to entering the hospital at the specified entrance and provide answers to questions such as: (coughing, shortness of breath, fever, chills, etc., and be required to wear a mask while on hospital grounds).

i. Note: the contractors are encouraged to provide their own masks (non-valved) to wear in the hospital.

c. All contractors, if they do not have a current badge for VASNHCS must check in with the VA police and get a 24-hour badge (daily if needed) prior to all work.

3. Codes and standards:

a. The publications listed below form a part of this contract. The fire protection system testing, inspection, maintenance, and repairs shall meet the requirements of the most current and latest (to include, but is not limited to): code editions published, all manufacturer guidelines, The Joint Commission, Veteran’s Affairs memorandums, State of Nevada, and industry standards as applicable, and in the case of conflicting standards, the most stringent shall apply. All documentation shall include information as required per The Joint Commission and NFPA requirements.

i. The Joint Commission EC.02.03.05, EP’s 11, 12, 13, 14, 18, and 28 (documentation).

ii. NFPA 25 – Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Current Edition 2020

iii. NFPA 12A – Standard on Halon 1301 Fire Extinguishing Systems. Current Edition 2018

iv. NFPA 13 – Standard for the Installation of Sprinkler Systems. Current Edition 2019

v. NFPA 72 – National Fire Alarm and Signaling Code. Current Edition 2019 (OI&T area only)

vi. NFPA 80 – Standard for Fire Doors and Other Opening Protectives. Current Edition 2019

vii. NFPA 90A – Standard for the Installation of Air-conditioning and Ventilating Systems. Current Edition 2018

viii. NFPA 96 – Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Current Edition 2017

ix. NFPA 105 – Standard for Smoke Door Assemblies and Other Opening Protectives. Current Edition 2019

b. All testing, inspections, and maintenance will adhere to and meet the dates per TJC requirements, otherwise, not doing so will impact the VA’s Joint Commission accreditation, and this cannot happen.

4. Service:

a. All preventive maintenance (PM), testing, and inspections shall follow the frequency requirement noted below in section 5. Unless specifically noted by the COR, the contractor must comply with the schedule to ensure compliance per TJC and NFPA requirements.

i. All contractor work shall be escorted by a VASNHCS staff member to the appropriate location of service. All PMs, testing, and inspection shall be scheduled at least 30 days prior to the service.

b. For each deficiency, repair, or necessary maintenance (beyond PMs) that is identified as a result of an inspection, testing, or PM and as described by this PWS shall be submitted as a proposal for review by the COR or designated representative. Known PMs prescribed by code should not warrant a proposal but should be performed as part of this contract, unless noted in the scope below. All proposals must be received within 48 hours of initial request and must be detailed with specific information, ensuring that material, labor, travel, etc., are listed as separate line items.

5. Frequency requirement (for PM’s, testing, and inspection): (Note: all dates will comply with VASNHCS’s last documented test, inspection, and/or maintenance date completed.)

a. Quarterly

i. Four times per year: +/- 10 days from the last completed. (i.e., January 15, April 15, July 15, October 15. No sooner than the 6th day of the month and no later than the 25th day of the month listed above as an example.)

b. Semi-annual (every six months)

i. Twice a year: +/- 20 days from the last completed. (i.e., October 15, 2020, April 15, 2021). No sooner than the 20 days prior to and no later than 20 days after the day of the month listed above as an example.)

c. Annual

i. Once per year: +/- 30 days from the last completed. (i.e., April 15, 2020. No sooner than the 30 days prior to and no later than 30 days after April 15, 2021.)

d. Tri-annual (36 month)

i. Every three years: +/- 45 days from the last completed. (i.e., April 15, 2020. No sooner than the 45 days prior to and no later than 45 days after April 15, 2023)

e. Five and six year

i. Every five or six years: +/- 45 days from the last completed. (i.e., April 15, 2020. No sooner than 45 days prior to and no later than 45 days after April 15, 2025 or April 15, 2026, respectively.)

6. Inspection/Testing required (note: the frequency requirement (section 5)) all testing/inspections must be followed, unless otherwise noted or unforeseen circumstances arise that is out of all parties control.

a. Ansul System

i. One building/Two locations

1. Dietetics (Bldg 1/C2338)

2. Canteen (Bldg 1/C1321)

ii. Semi-annual (to be conducted after hours 1630-2000 (estimated))

iii. May and November

b. Fire Pump Test

i. One building/One location

1. Pipe shop (Bldg 1/C0330)

ii. Annual

iii. November

c. Halon System

i. One building/One location

1. OI&T Mechanical Closet (Bldg 12/B2267)

ii. Semi-annual

iii. April and October

d. Preaction System

i. One building/One location

1. OI&T Mechanical Closet (Bldg 12/B2267)

ii. Quarterly

iii. January, April*, July, October* (*these will be done at the same time as 6c (Halon System).

e. Hangars, seismic bracing, pipe fittings, sprinkler heads, high temp heads, corrosive environments, internal obstruction testing of fire sprinkler mains, interior inspection of all alarm valves, gauges, and hang inspection tags as applicable per NFPA 25.

i. Nine buildings/Various locations

1. Due +/- 30 days in October (date TBD per last documented inspection)

a. Bldg 1, 5, and 6

2. Due +/- 30 days in March (date TBD per last documented inspection)

a. Bldg 1A

3. Due +/- 30 days in September (date TBD per last documented inspection)

a. Bldg 7

4. Due +/- 30 days in December (date TBD per last documented inspection)

a. Bldg 1D, 4, 10, 12

ii. Annual

f. 5-year inspection of Hangars, seismic bracing, pipe fittings, sprinkler heads, high temp heads, corrosive environments, internal obstruction testing of fire sprinkler mains, interior inspection of all alarm valves, gauges, and hang inspection tags as applicable per NFPA 25.

i. Throughout hospital

ii. To be completed in 2021 (+/- 45 days from 11-8-2021)

g. 5-year water flow test for wet standpipe

i. Six buildings/11 locations

1. CS6-Center Penthouse Stairwell Riser (Bldg 1)

2. CS1-5th Floor North Stairwell Riser (Bldg 1)

3. DS1-3rd Floor North Stairwell Riser (Bldg 1A)

4. HS1-3rd Floor Northwest Stairwell Riser (Bldg 1D)

5. GS1-5th Floor Stairwell Riser (Bldg 1D)

6. GS3-3rd Floor-ICU Stairwell Riser (Bldg 1D)

7. BS1-6th Floor North Stairwell Riser (Bldg 12)

8. BS2-6th Floor South Stairwell Riser (Bldg 12)

9. FS1-2nd Floor Northwest Stairwell Riser (Bldg 6)

10. FS2-2nd Floor Southeast Stairwell Riser (Bldg 6)

11. GS2-3rd Floor Stairwell Riser -OR Stairwell (Bldg 5)

ii. To be completed in 2022 (+/- 45 days from 08-30-2022)

h. 5-year hydrostatic and water flow test for dry standpipe systems

i. Two buildings/Four locations

1. CS2 North Stairwell Riser (Bldg 1)

2. CS5 South Stairwell Riser (Bldg 1)

3. East Stairwell Riser (New parking garage)

4. West Stairwell Riser (New parking garage)

ii. To be completed in 2024 (+/- 45 days from 07-31-2024)

i. 5-year Preaction system obstruction test

i. One building/One location

1. OI&T Mechanical Closet (Bldg 12/B2267)

ii. To be completed in 2025 (+/- 45 days from 07-20-2025)

j. 6-year Damper system

i. 346 Dampers/Eight buildings/Nine locations/Various Floors

1. Due April 2021 (+/- 45 days from 04-09-2021)

a. Bldg 6, 6 Dampers, Floors 1-2

2. Due December 2023 (+/- 45 days from 12-29-2023)

a. Bldg 10, 7 Dampers, Floor 1

3. Due May 2024 (+/- 45 days from 05-22-2024)

a. Bldg 5, 3 Dampers, Floor 2

4. Due June 2024 (+/- 45 days from 06-25-2024)

a. Bldg 1, 133 Dampers, Floors 1-6

b. Bldg 1A, 10 Dampers, Floors 1-3

c. Bldg 4, 13 Dampers, Floor 1

5. Due June 2024 (+/- 45 days from 06-27-2024)

a. Bldg 1D(G), 73 Dampers, Floors 1-3

b. Bldg 1D(H), 40 Dampers, Floors 1-2

6. Due August 2024 (+/- 45 days from 08-24-2024)

a. Bldg 12, 61 Dampers, Floors 1-6

ii. To be completed 2021, 2023, 2024

7. Five and six-year inspection requirements (per NFPA standards)

a. (As per 6f): Hangers, seismic braces, pipe fittings, sprinkler heads, high temp heads, corrosive environments, internal obstruction testing of fire sprinkler mains, interior inspection of all alarm valves, strainer filters, restricted orifices, check valves, gauges, and hang inspection tags as applicable per NFPA 25.

i. Five-year inspection of hangers, seismic braces, pipe fittings.

1. Inspect sprinkler pipe and fittings

a. Inspect for mechanical damage, external conditions, misalignment or trapped sections, condition of low-point drains (automatic or manual), and protection for rubber-gasketed fittings

2. Inspect sprinkler pipe hangers, seismic braces, and supports

a. Inspect for condition, secure attachment to structural supports and piping, and damaged or missing hangers, braces, and supports.

3. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

ii. Five-year inspection of sprinkler heads, high temp heads, corrosive environments.

1. Inspect sprinklers to determine if replacement is required.

a. Inspect for leakage, corrosion detrimental to sprinkler performance, physical damage, loss of fluid in the glass bulb heat responsive element, loading detrimental to sprinkler performance, paint other than that applied by the sprinkler manufacturer.

2. Inspect escutcheons and cover plates to determine if replacement is required.

a. Inspect for recessed, flush, concealed or missing escutcheon or cover plate.

3. Inspect for clearance below sprinkler deflectors as per NFPA 25 and NFPA 13

4. Inspect supply of spare sprinklers.

iii. Five-year internal obstruction testing of fire sprinkler mains.

1. Assess internal condition of fire sprinkler mains at accessible points on the mains, but at no less than the minimum four points – system valve, riser, cross main, and branch line.

2. Assess for the presence of foreign organic and inorganic material of fire protection system piping.

3. Tubercles or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).

4. If presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, a complete flushing program shall be conducted by qualified personnel.

5. If foreign organic and/or inorganic material is found in any system in a building, all systems shall be assessed.

iv. Interior inspection of all alarm valves, strainer filters, and restricted orifices.

1. Inspect internally all alarm valves and their associated strainers, filters, and restriction orifices.

v. Interior inspection of check valves.

1. Inspect internally and verify that all of the valve’s components operate correctly.

vi. Inspect gauges.

1. Inspect all gauges

2. Test gauges with a calibrated gauge

vii. Hang inspection tags as applicable per NFPA’s.

b. (As per 6g): Water flow test for wet standpipe.

i. Conduct flow test on all automatic standpipe systems to verify that the required flow and pressure are available at the hydraulically most remote hose valve outlet(s) while flowing the standpipe system demand.

1. Where a flow test of hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test.

2. Class I and Class III standpipe system demand shall include 500 gpm (1892 L/min) for the most remote standpipe and 250 gpm (946 L/min) for each additional standpipe until the total system demand is simultaneously flowing. (Note: line 7.b.i.6 or 7 below).

3. The 250 gpm (946 L/min) required from each additional Class I and Class III standpipe shall be allowed to be flowed from the most convenient hose valve on that standpipe. (Note: line 7.b.i.6 or 7 below).

4. Where the 250 gpm (946 L/min) cannot be flowed from each additional Class I and Class III standpipe, the authority having jurisdiction shall determine where the additional flow can be taken.

5. Class II standpipe system demand shall include 100 gpm (379 L/min) for the most remote standpipe connection.

6. The standpipe system demand shall be based on the design criteria in effect at the time of the installation.

7. Where the standpipe system demand cannot be determined, the authority having jurisdiction shall determine the standpipe system demand.

8. Inspect components of standpipe and hose systems: hydraulic design information sign, hose connections, piping, and, if applicable, hose, hose nozzle, and hose storage device.

9. Inspect and test standpipes, sprinkler connections to standpipes, or hose stations equipped with pressure-reducing valves or pressure-regulating valves.

10. Include all quarterly and annual inspections and test items

c. (As per 6h): Hydrostatic test for dry standpipe.

i. Conduct hydrostatic tests of not less than 200 psi (13.8 bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar) on all manual standpipe systems and all semiautomatic dry standpipe systems, if applicable, including piping in the fire department connection.

1. The hydrostatic test pressure shall be measured at the low elevation point of the individual system or zone being tested.

2. Where provided, waterflow alarm and supervisory alarm devices shall be tested.

3. Include all quarterly and annual inspection and test items

d. (As per 6i): Obstruction inspection and internal for Preaction system

i. Provide inspection as required by Title 19, Health & Safety Code and the local authority having jurisdiction including a 5-year obstruction inspection and a 5-year internal inspection of (1 Preaction system), to include:

1. Flushing of the fire department connections, if required per NFPA and system design.

2. Removing the end of one cross main and the end of one branch line for the purpose of looking for obstructions.

3. Provide and internal inspection of main riser check valve, alarm valve, Preaction valve, deluge valve or dry pipe valve and their associated strainers, filters, and restriction orifices, as applicable as indicated in NFPA 25.

4. All certifications will be issued after any and all deficiencies found at time of inspection are corrected and repaired.

e. (As per 6j): Damper test.

i. Fire and smoke dampers are to be inspected and tested to ensure they operate properly and are in good operating condition. The inspection must in accordance with NFPA 80 standards.

1. Operate all dampers (with fusible links removed where applicable) to verify they fully close.

2. Check latch, if provided, and lubricate moving parts as necessary

3. Verify that fire or smoke damper operation is not obstructed.

4. Verify that there is no interference due to rust, bent tracks, misalignment, damaged frames, or defective hinges or parts.

5. Replace any fusible link that is damaged or painted, using a link of the same size, temperature, and load rating.

6. Provide documentation showing all fire and smoke damper inspection and testing, the location of the damper, date of inspection, the name of the inspector, any deficiencies discovered and if any repairs are required beyond the above stated requirements.

8. Records

a. The contractor will not have any access to Government computers or systems. The certification and accreditation requirements do not apply and that a security accreditation package is not required.

b. The contractor will provide reports, documentation, photos of all testing, inspections, maintenance, and repairs to the COR and designated representative within 48 hours upon completion.

c. The service report shall contain the following (all requirements as per TJC EC.02.03.05/EP 28):

i. Name of the activity (to include, but is not limited to: testing, inspection, maintenance, repairs, etc.,).

ii. Date of activity/inspection.

iii. Inventory of devices, equipment, or other items.

iv. Required frequency of the activity

v. Name and contact information, including affiliation, of the person who performed the activity.

vi. NFPA standard(s) referenced for the activity.

vii. Results of the activity.

viii. Test conducted, including a description of the test procedure and the instrument(s) used.

ix. Parts replaced (description, part#).

x. Summary of findings/test results and comparison to relevant NFPA requirement(s) and/or best practice standards within the health care engineering.

xi. Where practical and helpful, the report shall include photographs that help to explain any unusual conditions or areas needing attention.

xii. Practical recommendations for any corrective actions for improvement of the health care environment.

9. Security and records management disclaimer

a. The Certification and Accreditation requirements do not apply, and a Security Accreditation Package is not required.

b. Security:

i. General:

1. 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.

ii. 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.

2. 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.

3. 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.

4. 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.

5. 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.

iii. 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 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).

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’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.

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 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.

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 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.

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 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.

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’s 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’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.

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 contracting officer for response.

12. 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.

iv. Security Incident Investigation:

1. 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.

2. 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.

3. 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.

4. 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.

v. Liquidated Damages For Data Breach:

1. 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.

2. 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.

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

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

b. (2) Description of the event, including:

i. (a) date of occurrence;

ii. (b) data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code;

c. (3) Number of individuals affected or potentially affected;

d. (4) Names of individuals or groups affected or potentially affected;

e. (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;

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

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

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

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

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

k. (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.

i. 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. (1) Notification;

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

3. (3) Data breach analysis;

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

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

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

vi. Training:

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

a. (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;

b. (2) Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training;

c. (3) Successfully complete the appropriate VA privacy training and annually complete required privacy training; and

d. (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.]

2. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required.

3. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.

vii. The contractor will not have any access to the Department of Veteran Affairs computer system or Protected Health Information (PHI)/Personally Identifiable Information (PII).

c. Records management:

i. Applicability: This clause applies to all contractors whose employees create, work with, or otherwise handle Federal records, as defined in section B, regardless of the medium in which the record exists.

ii. Definitions: “Federal Record” as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

1. The term Federal record:

a. includes VA records.

b. does not include personal materials.

c. applies to records created, received, or maintained by contractors pursuant to their VA contract.

d. may include deliverables and documentation associated with deliverables.

iii. Requirements:

1. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. Chapters. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

2. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

3. In accordance with 36 CFR 1222.32, the contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

4. The VA Sierra Nevada Health Care System (VASNHCS) and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of VASNHCS or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701.

5. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, the contractor must report to VASNHCS. The agency must report promptly to NARA in accordance with 36 CFR 1230.

6. The contractor shall immediately notify the appropriate Contracting Officer (CO) upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the contract documents. The contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to VASNHCS control or the contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the CO or address prescribed in the contract documents. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

7. The contractor is required to obtain the CO's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The contractor (and any sub-contractor) is required to abide by Government and VASNHCS guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

8. The contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with VASNHCS policy.

9. The contractor shall not create or maintain any records containing any non-public VASNHCS information that are not specifically tied to or authorized by the contract.

10. The contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the FOIA.

11. VASNHCS owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which VASNHCS shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

12. Training. All contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take VHA-provided records management training. The contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

13. Flow down of requirements to Subcontractors:

a. The contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this contract document, and require written subcontractor acknowledgment of same.

b. Violation by a subcontractor of any provision set forth in this clause will be attributed to the contractor.