36C26123R0067 0001.docx

5. PROJECT NUMBER (if applicable)

CODE

7.

ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF

PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE

OF YOUR

ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERE

D CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR

OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendmen t, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED

STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF

CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF

SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) 7/28/2023 662-24-1-826-0004 None Department of Veterans Affairs VA Sierra Pacific Network (VISN 21) VA Pacific Islands Health Care System 711 Kapiolani Blvd Suite 200 Honolulu HI 96813 Department of Veterans Affairs VA Sierra Pacific Network (VISN 21)

VA

Pacific Islands Health Care System 711 Kapiolani Blvd Suite 200 Honolulu HI 96813 To all Offerors/Bidders

36C26123R0067 07-13-2023

X X X

X Solicitation 36C26123R0067 is amended as follows:

1. Added IT Contract Security Clause.

2. Changes to the Performance Work Statement: See sections 22 and 23 (see yellow highlights for changes).

3. Solicitation revisions have been made to the following FAR provisions: (see yellow highlights for changes).

a. ADDENDUM to FAR 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS

b. 52.212-2 EVALUATION—COMME

RCIAL ITEMS (NOV 2021)

c. ADDENDUM TO 52.212-2 EVALUATION—COMMERCIAL ITEMS

4. The quote due date and time remains the same, August 13,2023 at 10 a.m. CDT.

5. Questions and Answers are attached.

Jason T. Hill Contracting Officer

A.1 IT CONTRACT SECURITY

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY

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 COR.

4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT

a. Information systems that are designed or developed for or on behalf of VA at non-VA facilities shall comply with all VA directives developed in accordance with FISMA, HIPAA, NIST, and related VA security and privacy control requirements for Federal information systems. This includes standards for the protection of electronic PHI, outlined in 45 C.F.R. Part 164, Subpart C, information and system security categorization level designations in accordance with FIPS 199 and FIPS 200 with implementation of all baseline security controls commensurate with the FIPS 199 system security categorization (reference Appendix D of VA Handbook 6500, VA Information Security Program). During the development cycle a Privacy Impact Assessment (PIA) must be completed, provided to the COR, and approved by the VA Privacy Service in accordance with Directive 6507, VA Privacy Impact Assessment.

b. The contractor/subcontractor shall certify to the COR that applications are fully functional and operate correctly as intended on systems using the VA Federal Desktop Core Configuration (FDCC), and the common security configuration guidelines provided by NIST or the VA. This includes Internet Explorer 7 configured to operate on Windows XP and Vista (in Protected Mode on Vista) and future versions, as required.

c. The standard installation, operation, maintenance, updating, and patching of software shall not alter the configuration settings from the VA approved and FDCC configuration. Information technology staff must also use the Windows Installer Service for installation to the default "program files" directory and silently install and uninstall.

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

e. The security controls must be designed, developed, approved by VA, and implemented in accordance with the provisions of VA security system development life cycle as outlined in NIST Special Publication 800-37, Guide for Applying the Risk Management Framework to Federal Information Systems, VA Handbook 6500, Information Security Program and VA Handbook 6500.5, Incorporating Security and Privacy in System Development Lifecycle.

f. The contractor/subcontractor is required to design, develop, or operate a System of Records Notice (SOR) on individuals to accomplish an agency function subject to the Privacy Act of 1974, (as amended), Public Law 93-579, December 31, 1974 (5 U.S.C. 552a) and applicable agency regulations. Violation of the Privacy Act may involve the imposition of criminal and civil penalties.

g. The contractor/subcontractor agrees to:

(1) Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies:

(a) The Systems of Records (SOR); and

(b) The design, development, or operation work that the contractor/ subcontractor is to perform;

(1) Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the redesign, development, or operation of a SOR on individuals that is subject to the Privacy Act; and

(2) Include this Privacy Act clause, including this subparagraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a SOR.

h. In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a SOR on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a SOR on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a SOR on individuals to accomplish an agency function, the contractor/subcontractor is considered to be an employee of the agency.

(1) "Operation of a System of Records" means performance of any of the activities associated with maintaining the SOR, including the collection, use, maintenance, and dissemination of records.

(2) "Record" means any item, collection, or grouping of information about an individual that is maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and contains the person's name, or identifying number, symbol, or any other identifying particular assigned to the individual, such as a fingerprint or voiceprint, or a photograph.

(3) "System of Records" means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual.

i. The vendor shall ensure the security of all procured or developed systems and technologies, including their subcomponents (hereinafter referred to as "Systems"), throughout the life of this contract and any extension, warranty, or maintenance periods. This includes, but is not limited to workarounds, patches, hotfixes, upgrades, and any physical components (hereafter referred to as Security Fixes) which may be necessary to fix all security vulnerabilities published or known to the vendor anywhere in the Systems, including Operating Systems and firmware. The vendor shall ensure that Security Fixes shall not negatively impact the Systems.

j. The vendor shall notify VA within 24 hours of the discovery or disclosure of successful exploits of the vulnerability which can compromise the security of the Systems (including the confidentiality or integrity of its data and operations, or the availability of the system). Such issues shall be remediated as quickly as is practical, but in no event longer than days.

k. When the Security Fixes involve installing third party patches (such as Microsoft OS patches or Adobe Acrobat), the vendor will provide written notice to the VA that the patch has been validated as not affecting the Systems within 10 working days. When the vendor is responsible for operations or maintenance of the Systems, they shall apply the Security Fixes within days.

l. All other vulnerabilities shall be remediated as specified in this paragraph in a timely manner based on risk, but within 60 days of discovery or disclosure. Exceptions to this paragraph (e.g. for the convenience of VA) shall only be granted with approval of the contracting officer and the VA Assistant Secretary for Office of Information and Technology.

5. INFORMATION SYSTEM HOSTING, OPERATION, MAINTENANCE, OR USE

a. For information systems that are hosted, operated, maintained, or used on behalf of VA at non-VA facilities, contractors/subcontractors are fully responsible and accountable for ensuring compliance with all HIPAA, Privacy Act, FISMA, NIST, FIPS, and VA security and privacy directives and handbooks. This includes conducting compliant risk assessments, routine vulnerablity scanning, system patching and change management procedures, and the completion of an acceptable contingency plan for each system. The contractor's security control procedures must be equivalent, to those procedures used to secure VA systems. A Privacy Impact Assessment (PIA) must also be provided to the COR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA's network involving VA information must be reviewed and approved by VA prior to implementation.

b. Adequate security controls for collecting, processing, transmitting, and storing of Personally Identifiable Information (PII), as determined by the VA Privacy Service, must be in place, tested, and approved by VA prior to hosting, operation, maintenance, or use of the information system, or systems by or on behalf of VA. These security controls are to be assessed and stated within the PIA and if these controls are determined not to be in place, or inadequate, a Plan of Action and Milestones (POA&M) must be submitted and approved prior to the collection of PII.

c. Outsourcing (contractor facility, contractor equipment or contractor staff) of systems or network operations, telecommunications services, or other managed services requires certification and accreditation (authorization) (C&A) of the contractor's systems in accordance with VA Handbook 6500.3, Certification and Accreditation and/or the VA OCS Certification Program Office. Government- owned (government facility or government equipment) contractor-operated systems, third party or business partner networks require memorandums of understanding and interconnection agreements (MOU-ISA) which detail what data types are shared, who has access, and the appropriate level of security controls for all systems connected to VA networks.

d. The contractor/subcontractor's system must adhere to all FISMA, FIPS, and NIST standards related to the annual FISMA security controls assessment and review and update the PIA. Any deficiencies noted during this assessment must be provided to the VA contracting officer and the ISO for entry into VA's POA&M management process. The contractor/subcontractor must use VA's POA&M process to document planned remedial actions to address any deficiencies in information security policies, procedures, and practices, and the completion of those activities. Security deficiencies must be corrected within the timeframes approved by the government. Contractor/subcontractor procedures are subject to periodic, unannounced assessments by VA officials, including the VA Office of Inspector General. The physical security aspects associated with contractor/ subcontractor activities must also be subject to such assessments. If major changes to the system occur that may affect the privacy or security of the data or the system, the C&A of the system may need to be reviewed, retested and re- authorized per VA Handbook 6500.3. This may require reviewing and updating all of the documentation (PIA, System Security Plan, Contingency Plan). The Certification Program Office can provide guidance on whether a new C&A would be necessary.

e. The contractor/subcontractor must conduct an annual self assessment on all systems and outsourced services as required. Both hard copy and electronic copies of the assessment must be provided to the COR. The government reserves the right to conduct such an assessment using government personnel or another contractor/subcontractor. The contractor/subcontractor must take appropriate and timely action (this can be specified in the contract) to correct or mitigate any weaknesses discovered during such testing, generally at no additional cost.

f. VA prohibits the installation and use of personally-owned or contractor/ subcontractor-owned equipment or software on VA's network. If non-VA owned equipment must be used to fulfill the requirements of a contract, it must be stated in the service agreement, SOW or contract. All of the security controls required for government furnished equipment (GFE) must be utilized in approved other equipment (OE) and must be funded by the owner of the equipment. All remote systems must be equipped with, and use, a VA-approved antivirus (AV) software and a personal (host-based or enclave based) firewall that is configured with a VA-approved configuration. Software must be kept current, including all critical updates and patches. Owners of approved OE are responsible for providing and maintaining the anti-viral software and the firewall on the non-VA owned OE.

g. All electronic storage media used on non-VA leased or non-VA owned IT equipment that is used to store, process, or access VA information must be handled in adherence with VA Handbook 6500.1, Electronic Media Sanitization upon: (i) completion or termination of the contract or (ii) disposal or return of the IT equipment by the contractor/subcontractor or any person acting on behalf of the contractor/subcontractor, whichever is earlier. Media (hard drives, optical disks, CDs, back-up tapes, etc.) used by the contractors/ subcontractors that contain VA information must be returned to the VA for sanitization or destruction or the contractor/subcontractor must self-certify that the media has been disposed of per 6500.1 requirements. This must be completed within 30 days of termination of the contract.

h. Bio-Medical devices and other equipment or systems containing media (hard drives, optical disks, etc.) with VA sensitive information must not be returned to the vendor at the end of lease, for trade-in, or other purposes. The options are:

(1) Vendor must accept the system without the drive;

(2) VA's initial medical device purchase includes a spare drive which must be installed in place of the original drive at time of turn-in; or

(3) VA must reimburse the company for media at a reasonable open market replacement cost at time of purchase.

(4) Due to the highly specialized and sometimes proprietary hardware and software associated with medical equipment/systems, if it is not possible for the VA to retain the hard drive, then;

(a) The equipment vendor must have an existing BAA if the device being traded in has sensitive information stored on it and hard drive(s) from the system are being returned physically intact; and

(b) Any fixed hard drive on the device must be non-destructively sanitized to the greatest extent possible without negatively impacting system operation. Selective clearing down to patient data folder level is recommended using VA approved and validated overwriting technologies/methods/tools. Applicable media sanitization specifications need to be pre-approved and described in the purchase order or contract.

(c) A statement needs to be signed by the Director (System Owner) that states that the drive could not be removed and that (a) and (b) controls above are in place and completed. The ISO needs to maintain the documentation.

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 COR 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.

8. SECURITY CONTROLS COMPLIANCE TESTING

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-day's notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time.

9. 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 Cyber Security Awareness and Rules of Behavior training and annually complete required security training;

(3) Successfully complete the appropriate VA privacy 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 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.

c. 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.

(End of Clause)

B.3 PERFORMANCE WORK STATEMENT (PWS)

Special Mode Transportation (SMT) San Francisco Veterans Affairs Health Care System (SFVAHCS) 7/27/2023

1. GENERAL INFORMATION AND SCOPE OF WORK

A. The contractor shall provide all Non-Emergency, Special Mode Ground Transportation services as identified within the performance work statement (PWS) for beneficiaries of San Francisco Veteran Affairs Health Care System (SFVAHCS), and its associated healthcare facilities. The Contractor shall provide all transport vehicles, personnel, management, supplies, transportation, fuel, equipment, reports, and anything else necessary to successfully furnish Non-Emergency Special Mode Transportation service as identified in the Price and Cost Schedule and the PWS in accordance with all terms, conditions, and provisions stated herein. The Contracting Officer (CO) will exercise final authority over all aspects of any resultant contract.

B. The contractor’s responsibility shall cover non-emergent medical transportation services with VA San Francisco Health Care System. The Contractor shall transport ambulatory and non-ambulatory beneficiaries on gurneys, stair chairs, litters, wheelchairs, secure car w/attendant, alternate safe beneficiary handling equipment, and/or Geri chairs to and from and vice-versa the San Francisco VA Health Care System, Veterans’ residences, community nursing homes, or any other VA-authorized care facilities including the extended care facilities and the nine outlying community-based outpatient clinics (CBOCs), 365 days a year, 24 hours a day to include Federal Holidays.

1) The major facility is the San Francisco Veterans Affairs Health Care System (SFVAHCS) located at 4150 Clement Street, San Francisco, CA 94121. Approximately 90% of transports will be to or from the SFVAHCS.

C. The successful vendor is required to continuously be compliant with the requirement contained herein, and meet or exceed the standards of, but not limited to the Joint Commission and California State Department of Health Regulations. The following facilities shall be covered under this PWS; however, their physical addresses may change during the life of the contract, and this list may expand in conjunction with the Mission Act:

The nine CBOC locations are:

1) Santa Rosa North CBOC at 3841 Brickway Blvd, Santa Rosa, CA 95403

2) Eureka CBOC at 930 West Harris Street, Eureka, CA 95503

3) Ukiah CBOC at 630 Kings Court, Ukiah, CA 95482

4) Clearlake CBOC at 15145 Lakeshore Drive, Clearlake, CA 95422

5) San Bruno CBOC at 1001 Sneath Lane, Suite 300 3rd Floor, San Bruno, CA 94066

6) Downtown San Francisco CBOC at 401 3rd Street, San Francisco, CA 94107

7) Oakland CBOC at 2221 Martin Luther King Jr. Way, Oakland, CA 94612

8) Twenty First Street VA Clinic at 525 21st Street, Oakland, CA 94612

9) Santa Rosa South CBOC at 2285 Challenger Way, Santa Rosa, CA 95407

D. Historically, the SFVAHCS averages 975 round trips per month to and from the SFVAHCS. Ninety percent of trips are within a 40-mile radius of the SFVAHCS. Currently, there are 30-35 transport vehicles and 30-35 drivers utilized per day for this requirement. Please note, historical figures are provided for informational purposes only and are not guarantees for the level of work required under this contract. The demand may fluctuate significantly based on veteran and organizational needs.

E. Hours of Performance

1) Most trips are required during Normal Business Hours of 8:00AM-4:00 P M, Monday through Friday, excluding Federal Holidays.

2) Services may also be required after Normal Business Hours or on weekends when a beneficiary is discharged.

2. CONTRACTOR PERFORMANCE AND QUALIFICATIONS

A. The Contractor shall provide non-emergency transportation services on an “as needed” basis. Services may be required 24-hours per day/7-day a week, 365 days a year, within the State of California. The contractor shall provide all manpower, equipment, vehicles, fuel, materials and supplies to include all PPE required even in health pandemics at no additional cost. The contractor will provide supervision necessary to perform all tasks. Vehicles shall have appropriate fuel capacity to complete the transport without stopping for refueling, unless making a transport beyond the capability of the fuel tank of the vehicle.

B. The Contractor shall adhere to the Department of Veteran Affairs regulations and the policies, procedures, and regulations of SFVAHCS.

C. The Contractor shall meet all requirements of Federal, State, and City codes regarding operation of this type of business for the entire area to be covered by this service. The contractor shall ensure that drivers hold current Cardiopulmonary Resuscitation (CPR) certifications. The Contractor shall maintain licensure/certification with the state of California throughout the life of the contract. In the event the license/certification lapses or expires, this could be cause for termination of the contract or discontinuance of further ordering of services from the Contractor.

D. The contractor shall maintain documentation demonstrating they meet all requirements of Federal, State, County, and City codes regarding operation of this type of service for the entire coverage area. Documentation shall be made available to the VA immediately upon request by the Contracting Officer for the duration of this contract and applies to any sub-contractors employed by the contractor.

E. The Contractor, upon request, shall provide quality data and information related to services for participation in SFVAHCS Performance Improvement Programs when requested to do so. Upon request the contractor shall also provide documentation of the competency of staff that shall be providing the contracted services. The Contractor shall ensure employees providing work on this contract are fully trained and competent to perform the required work; they shall also maintain records that document competence/performance level of employees working on this contract. Upon request, the contractor shall provide a current copy of their competency assessment checklist and annual performance evaluation to the Contracting Officers’ Representative (COR) for each contractor employee working on this contract.

F. Drug Testing Policy - The Contractor shall have internal policies and procedures for identifying and preventing employee drug and alcohol abuse. Copies of these policies and procedures shall be provided to the COR upon request.

G. Records and certifications shall be maintained by the contractor and shall be available to VA for inspection upon request.

H. During the period of performance, if the Contractor proposes to add-on or replace personnel to perform contract services, the Contractor shall submit the required evidence of training, certifications, licensing, and any other qualifications to the Contracting Officer. At no time, will the Contractor utilize add-on or replacement personnel to perform contract services who do not meet the personnel qualifications of the contract.

I. Contractor shall provide “door to door” assisted service for all patients to and from their designated appointments. Patients shall be picked up on the ward, in their homes, in the clinics, or at other areas designated by the VA and taken to the authorized destination or appointment. Assistance in maneuvering stairs and other barriers shall be provided by the driver and/or authorized attendant when necessary.

J. The Contractor shall provide an attendant upon request of the VA. The VA shall put the Contractor on notice with medical condition and special needs to determine the training and qualifications that the attendant needs. Contractor is responsible to ensure that proper staffing is used when transporting bariatric patients in a timely matter. The Contractor shall ensure that each person employed is trained, qualified, and certified to perform the duties required, including CPR certification and appropriate training for handling dementia patients, or other mental health problems.

K. Random spot checks of service will be performed by SFVAHCS Contracting Officer (CO), Contracting Officer Representative (COR).

3. CONTRACTOR PERSONNEL QUALIFICATIONS

A. “Contractor Employees” (from this point shall be referred to as “The Contractor”) shall always conduct themselves in a business-like manner while on VA premises and interacting with VA beneficiaries and VA staff.

B. Attire: The Contractor shall wear an identifying badge with name, function, and a photograph of the employee. The Contractor will wear an appropriate and professional uniform. Contractor personnel performing contract services shall always meet qualifications, as specified in Section 4.0.

1) Contractor employees shall be well-groomed, clean, and neat in appearance; clothes properly fitted, uniform appearance with nametags, and appropriately dressed for the work to be done. Contractor employees shall not wear clothing with slogans, drawings, or language which could be construed as being lewd, obscene, profane, racially offensive, sexually suggestive, and anti-American or which advocates the use of illegal drugs or other unlawful conduct.

C. Within seven (7) days after receipt of award notification, the Contractor shall provide evidence of required training certifications, licenses, and any other qualifications required for this contract. These individuals must complete a VA issued security check within thirty (30) days from the Government’s receipt of the list of names.

D. The Contractor shall ensure the following personnel requirements are met:

1) Ensure and certify personnel performing the services required under this contract are properly licensed and fully trained in the use of the vehicle and equipment that shall be used in carrying out contracted services.

2) Each vehicle shall be operated with proper personnel for adequate patient care.

E. All contractor personnel shall have continuous training to maintain their appropriate levels of competency, including HIPPA, infectious control, and CPR training to ensure that they know how to deal with Veterans in various health situations.

F. Whenever there is a change in personnel, evidence of training, certifications, and licenses shall be presented to the COR prior to start of work. The Contractor shall not employ drivers who do not meet the personnel qualifications of this contract.

G. The Contractor shall have and be vaccinated prior to performance of work:

1) Health examinations including annual Tuberculosis (TB) skin test result, also known as PPD;

2) Either received the Hepatitis B vaccine series or is immune as a result of acquired infection or have been offered and refused the vaccinations; Received measles-mumps-rubella (MMR) vaccine. Combined vaccine (MMR) is the vaccine of choice if individuals are likely to be susceptible to more than one of the three diseases and is required for all persons born after 1956;

3) A negative PPD within the last (6) months, or if a known reactor, a negative chest X-ray within the past year;

4) A history of varicella (chicken pox) or, if unknown, results of a varicella antibody test. If non-immune, must be vaccinated with varivax (chicken pox);

5) Received COVID-19 vaccination and booster vaccine, unless validated exemption received.

H. The Contractor Shall have received training in Universal Precautions and Blood Borne Pathogens, COVID-19 Protocol, Hazardous Material Management, Life Safety Management (fire preparedness), and Prevention and Management of Disruptive Behavior (PMDB).

I. The Contractor shall be able to obtain a security clearance within 60 days of contract award. Security clearances and fingerprinting are conducted by the SFVAHCS at no cost to the contractor.

4. CONTRACTOR DRIVER(S) QUALIFICATIONS

A. The Contractor shall be responsible for using appropriate driver screening and selection criteria when employing drivers. Such screening shall include but not limited to testing drivers for prohibited drug use and alcohol misuse; a criminal background check, to the maximum extent permitted by California state law, and Department of Motor Vehicle record screening.

B. The Contractor shall possess a valid commercial driver’s license with passenger endorsement in accordance with Federal, State, and local government requirements.

C. The Contractor shall complete the Standard and Advanced First Aid Course by a recognized National Organization such as American Red Cross or American Heart Association.

D. The Contractor shall have completed Basic Life Support Cardiopulmonary Resuscitation (CPR) or equivalent and shall be capable of providing necessary assistance when required.

E. The Contractor shall be trained and experienced to assist the beneficiary to properly disconnect/re-connect oxygen tubing for transport when necessary.

F. Common Courtesy. The Contractor shall be courteous to VA beneficiaries and shall not smoke while transporting beneficiaries.

G. Beneficiaries may bring a reasonable amount of equipment, such as folding wheelchair, consumable medical supplies, required durable medical equipment and personal suitcase. When transporting beneficiaries to or from medical facilities, the Contractor shall ensure that the beneficiary's personal effects are properly accounted for and delivered with the beneficiary as required. Drivers are not allowed to place any personal effects or other material in a passenger’s lap. The belongings can be placed in a secure/safe location in the vehicle.

H. The Contractor (or authorized attendant) shall observe the patient during transport. Any indication of a significant change in the patient’s condition shall be communicated immediately to the VA Medical Center serving the patient. Emergent diversions to the nearest appropriate medical facility are allowed and shall be communicated to the VA immediately. All diversions from destination, emergent or otherwise, shall be reported by the Contractor to the COR or authorized designee within 1 hour and followed up with a patient safety report.

I. The Contractor shall determine upon arrival at the Beneficiary/Patient pick-up point, if the condition of the Beneficiary/Patient scheduled for pick-up is different than what was stated on the travel request, the contractor shall immediately notify the VA Travel Section and/or Administrative Officer of the Day (AOD) for further instruction in Patient Transport mode.

J. If a Beneficiary/Patient being transported declines to be properly seat-belted, he/she shall not be transported. The Transportation Assistants should be notified promptly and may discuss such safety requirement with the Beneficiary/Patient via Telephone and/or in person. If the patient removes the securing devices during the trip, the transportation office should be notified of this upon contractor employee’s arrival at destination.