Attachment 1 36C24125Q0666 SOW.pdf

VA Connecticut Healthcare System VACHS Fuel Storage Tank (FST) Inspection and Testing Services

STATEMENT OF WORK

UNDERGROUND AND ABOVE GROUND STORAGE TANK

INSPECTION AND TESTING SERVICES

VA CONNECTICUT HEALTHCARE SYSTEM (VACHS)

VA MEDICAL CENTER WEST HAVEN

950 Campbell Avenue West Haven, CT 06516

VA MEDICAL CENTER NEWINGTON

555 Willard Avenue Newington, CT 06111

1) BACKGROUND

a) VA Connecticut Healthcare System West Haven and Newington Campuses require inspection, calibration and testing services for Underground Storage Tanks (UST) and Above Ground Storage Tanks (AST) (a.k.a. Bulk Storage) and all associated system components (e.g., Piping, Day tanks, Automatic Tank Gauging (ATG) systems, overfill protection, spill prevention) to comply with local, state and federal UST and AST regulatory requirements. The Environmental Protection Agency (EPA) and Connecticut Department of Energy and Environmental Protection (CTDEEP) require that all fuel storage systems are maintained in safe and operable conditions.

2) LOCATION OF SERVICES

VA Medical Center West Haven VA Medical Center Newington 950 Campbell Avenue 555 Willard Avenue West Haven, CT 06516 Newington, CT 06111

3) WORK TIME & HOURS

a) Scheduled work shall be completed Monday through Friday and during regular business hours of

8:00 a.m. and 4:30 p.m. and with a minimum 5-day advance notification (e.g., email). No work shall be performed on Government Holidays unless it is authorized by the VA Contracting Officer. Work is to be scheduled in accordance with the schedule submitted under Section 4.

i) US Federal Holidays:

New Year’s Day Martin Luther King Jr. Day President’s Day Memorial Day Juneteenth Independence Day Labor Day Columbus Day Veteran’s Day Thanksgiving Day Christmas Day

4) TASKS

a) The Contractor shall furnish all labor, materials, equipment, tools, supervision, and all incidentals to complete the work for the services described in this document including inspection, calibration, testing, and maintenance of fuel storage systems in full compliance with EPA and CTDEEP Rules and Regulations.

b) The contractor shall conduct an onsite field assessment of all inventory items outlined below (Sections 5 and 6) and shall request specific records necessary to perform the required tasks.

c) The Contractor shall provide a schedule of regulatory inspections, calibrations and testing and self-verify all AST and UST system components and inspection, testing and inspections requirements in accordance EPA and CTDEEP Rules and Regulations. Schedule shall include, but is not limited to the location, inventory item name, descriptive information associated with each inventory items, every test to be addressed for each item, and the time when that work is expected to be performed during the service period. The schedule shall conform to the requirements of Section 3.

d) Contractor shall conduct inspections, calibration and testing for the VACHS fuel storage system inventory of Underground Storage Tanks systems (UST), Above Ground Storage Tank systems (AST), and all associated components to include but not limited to piping, Day Tanks, Automatic Tank Gauge (ATG) systems, overfill protection, spill prevention.

e) Once on site, the contractor shall coordinate all inspections, testing and calibrations with the facility VACHS Safety Department located at each Medical Center.

f) The contractor shall coordinate all placement and removal of Lockout Tagout (LOTO) devices for any energy sources and/ or access Confined Space(s) with the VA Safety Department in compliance with Medical Center Policy 138-07. In addition, the Contractor shall comply with VACHS specific processes, procedures and/ or policies.

g) The contractor shall be responsible for the proper disposal of all waste generated while conducting inspections and testing.

h) If regulatory requirements change during contract performance, a summary written document (and associated presentation) will be drafted, submitted for record and presented on identified changes to the program, the impact to the inventory under service, the changes in the compliance effort and/or any changes to the documentation process and/or documentation as required per EPA and CTDEEP. Only a warranted contracting officer may authorize changes that result in additional cost to the Government.

i) Prior to each contract option renewal year (3 month’s prior), Contractor shall initiate a review with the VA CO, VA COR, and VA GEMS Program Manager of any additional inventory, removal of inventory, replacement of inventory, etc. to be adjusted for contract requirements and to maintain compliance with the EPA and CTDEEP Rules and Regulations.

j) Upon request, Contractor shall provide quotes for repairs needed to address deficiencies identified during testing within 7 business days following the testing period.

k) Operator Training:

i) The Contractor shall provide training to VACHS staff in compliance with CTDEEP training rules and requirements and shall provide trained staff with formal and officially recognized CTDEEP certification of applicable training.

ii) Contractor shall provide onsite operator training and certification to a first and second shift VACHS Staff at both campuses (1st shift only for Newington Campus) as required by CTDEEP for the facility to meet its requirements for Class A, B and C Operators (ref. RSCA Section 22a-449(d)-108(c)(2)).

(1) Class A Operator Training: primary statutory and regulatory responsibility to operate and maintain the underground storage tank system. The Class A Operator’s responsibilities include managing resources and personnel, such as establishing work assignments, to achieve and maintain compliance with regulatory requirements.

(2) Class B Operator implements applicable underground storage tank regulatory requirements in the field. This individual implements the day-to-day aspects of operating, maintaining, and recordkeeping for underground storage tanks at one or more facilities.

(3) Class C Operator is an employee and is, generally, the first line of response to events indicating emergency conditions. This individual is responsible for responding to alarms or other indications of emergencies caused by spills or releases from underground storage tank systems. This individual notifies the Class B or Class A operator and appropriate emergency responders when necessary. Not all employees of the facility are necessarily Class C operators.

iii) Number of anticipated VACHS staff to be trained:

VA Staff for initial Class A/B Operator Trained/Certified: West Haven (8) and Newt (7).

VA Staff for initial Class C Operator Trained/Certified at West Haven (20) and Newt (5).

iv) Onsite refresher training/retraining is required every two (2) years for a minimum of six (6) VACHS at West Haven and six (6) at Newington Campuses to meet facility training as required per CTDEEP (ref. RSCA Section 22a-449(d)-108(c)(2)).

5) West Haven Storage Tank System Inventory and Required testing and Frequency.:

a) AST Tank - Bldg. 39 (GB1) - (x1) 8,000-gal diesel AST – Installed: 2021

i) Testing/Calibration: ATG (Pneumercator ETD 1000 & TMS 2000) – Annually.

ii) 10 Year Review of Tanks: 3rd Party Certified Inspection. (Due 2031)

iii) Pump Controller/Day Tank Inspection per SPCC – Annually. (x3 day tanks).

b) AST Tank - Bldg. 39 (GB1) - (x1) 10,000-gal diesel AST - Installed: 2021

ii) 10 Year Review of Tanks: Third Party Certified Inspection. (Due 2031)

iii) Pump Controller/Day Tank Inspection per SPCC – Annually. (x3 day tanks).

c) UST Tank L - Bldg. 38 (GB2) - (x1) 12,500-gal UST for Emer. Gen Only - Installed: Sept. 1997

i) Initial Hydrostatic testing of Sumps and Spill Buckets.

ii) Pump Controller/Day Tank Inspection per SPCC – Annually. (x2 day tanks).

iii) Testing/Calibration: ATG (Veeder-Root TLS-300C) – Annually.

iv) Tanks and line tightness testing – Annually.

v) Hydrostatic testing of Sumps and Spill Buckets – Every 3 years.

vi) UST Integrity test per CT DEEP regulation 22a-449 (d)-104 – Every 3 years.

d) AST Tank M: Bldg. 65 (Grounds) - (x1) 500-gal diesel AST for Emer Gen Only - Installed: 2009

e) AST Boiler Tank Farm (Boiler Plant) - (x4) 20,000-gal #2 Fuel AST. (Boilers) – Installed: 2018

i) Testing/Calibration: ATG (Pneumercator TMS 3000) – Annually.

ii) 10 Year Review of Farm Tanks: Third Party Inspection. (Due 2028).

f) AST Tank 19 (Gen Bldg. 19) - (x1) 10,000 gal AST - Installed: 2018

i) Testing/Calibration: ATG (Veeder-Root TLS-300C) – Annually.

ii) Pump Controller/Day Tank Inspection per SPCC – Annually.

iii) 10 Year Review Third Party Inspection. (Due 2028).

g) AST Tank Bldg. 1 SPS (Gen 20) – (x1) x 2,000 gal AST- Installed: 2020

h) AST Fuel Tank Base (Gen 30) – (x1) x 2,000-gal diesel AST. for Emer Gen Only- Installed: 2010

6) Newington Storage Tank System Inventory:

a) Submit all documents (e.g., inspection checklist, photos, field reports,) to include but not limited to inspected inventory items identifying data, location data and findings with full detailed descriptions of issues and required corrective actions. Submit all documents and reports timely to the VA Contracting Officer, VA COR, VA Chief Engineer, and VA GEMS Program Manager.

b) UST Tank #4: (Building 11) –(x1) x 6,000-gal diesel UST (Emer Gens Only) – Installed April 1997.

ii) Pump Controller/Day Tank Inspection per SPCC – 2 Tanks Annually.

iii) Testing/Calibration: ATG (Veeder-Root TLS-300C) – Annually.

iv) Tank and line tightness testing – Annually.

vi) UST Integrity testing – Every 3 years.

c) UST Tank #6: (BLDG. 2W) – (x1) x 4,000-gal diesel UST for Emerg Gen Only – Installed April 1997.

ii) Pump Controller/Day Tank Inspection per SPCC – Annually.

iii) Testing/Calibration: ATG (Veeder-Root TLS-300C) – Annually.

iv) Tank and line tightness testing – Annually.

d) UST Tank #7: (Building 2E) - (x1) x 6,000-gal diesel UST for Emerg Gen Only – Installed April 1996.

ii) Pump Controller/Day Tank Inspection per SPCC – Annually.

iii) Testing/Calibration: ATG (Veeder-Root TLS-300C) – Annually.

iv) Tank and line tightness testing – Annually.

7) DESCRIPTION OF INSPECTION CALIBRATION AND TESTING SERVICES:

a) Contractor shall perform all inspection, calibration and testing to maintain compliance with all local, state, and federal fuel storage system and system component inspection, calibration and testing requirements per regulations and guidelines. Specifically, as identified and required by the EPA and/or CTDEEP.

b) Inspection, calibration and testing to include but not limited to (Contractor to identify specifics):

i) Inspections:

(1) Annual Inspections: An annual inspection of all corrosion protection systems must be conducted by a qualified technician.

ii) Calibration:

(1) Leak Detection System Calibration: Any automatic tank gauging systems, interstitial monitoring sensors, and other leak detection equipment must be calibrated according to the manufacturer’s specifications to ensure they are accurately detecting any leaks.

iii) Testing:

(1) Release Detection Testing: Tanks and piping must be tested for leaks using an approved release detection method. This often includes methods such as interstitial monitoring, automatic tank gauging, groundwater monitoring, or statistical inventory reconciliation.

(2) Equipment Testing: Overfill, spill, and release detection equipment must be tested periodically to ensure they are in proper working order:

(3) Containment Sump Testing: Containment sumps used for interstitial monitoring of piping must be tested every 3 years unless they are double-walled.

c) Facility specific Inspection, calibration and testing to include but not limited to:

i) Initial Hydrostatic testing of Sumps and Spill Buckets shall be included in the Base Year and

Option Year 2 of the contract.

ii) Automatic Tank Gauge Testing (ATG)

(1) Veeder-Root (TLS-300C x4)

(2) Pneumercator (TMS 3000, TMS 2000, ETD 1000 & LDE 700)

iii) Hydrostatic Sumps Test

iv) Hydrostatic Spill Buckets Test

v) Tanks and Line Tightness Test

vi) UST Integrity Test

vii) 3rd Party Tank Farm Inspection (collection of storage tank units).

d) For AST, the certified tank Inspections shall include all the elements of the annual inspections, as well as a tank integrity test that is appropriate for the type of AST such as: a hydrostatic test, ultrasonic test, radiographic test, or other non-destructive shell testing method. Tests of the AST piping system will be performed in accordance with the applicable industry standard for the type of piping or as recommended by the piping manufacturer or a qualified piping inspector.

8) SUBMITTALS/DELIVERABLES

a) The contractor shall provide VACHS with schedule of required inspections, frequency, etc., within 14 days of contract award, and/or subsequent option exercise.

b) Contractor shall submit all supporting documentation (e.g., inspection checklist, photos, field reports,) to include but not limited to inspected inventory item identifying data, location data and findings with full detailed descriptions of issues and required corrective actions. Contractor shall submit all documents and reports within seven (7) calendar days to the VA Contracting Officer, VA COR, VA Chief Engineer, and VA GEMS Program Manager.

c) The contractor shall submit two (2) hard copies and electronic copy of all inspection, calibration and testing data/reports/documentation to both the VA COR and VA Safety Office/ GEMS Program Manager within fourteen (14) calendar days of completion of work event and/ or inventory item.

d) Repairs and replacements identified in the generated report shall not be considered for modification or inclusion per this contract. Contractor shall develop a cost and submit a quote as required for effectively packaged repairs with details and line-item cost breakdowns for VACHS review and consideration of work aside for the direct services due per this contract.

e) A Waste Manifest shall be provided to the GEMS Program Manager for any waste generated, including Universal Waste, Hazardous Waste, Used Oil, etc. Report shall be delivered within 14 calendar days of waste disposal.

f) Provide copies of training and certifications for individuals assigned and performing inspections, testing and calibrations per submittal to the VA COR for review and acceptance prior to scheduling work.

g) Provide CTDEEP approval status of the UST Operator Training program to the VA COR for review and acceptance prior to scheduling the operator training.

9) Performance Standards

The contractor shall adhere to the following performance standards which are further outlined in the Quality Assurance Surveillance Plan (QASP):

Objective Standard Method of Surveillance Acceptable Quality

Level

Successful Performance of Inspection, Calibration, Testing and Training.

Service completed in accordance with the proposed/accepted Schedule

Inspection by the COR Timely performance 95% of the time.

Deliverables (Submission) The contractor submits timely deliverables in accordance with the

SOW.

Monthly Inspection by the

COR

Timely submission 95% of the time.

Deliverables (Compliance) The contractor submits deliverables compliant with regulatory authorities outlined in the SOW.

Monthly Inspection by the

COR

Submissions are compliant 100% of the time.

Customer Satisfaction Timely resolution of issues that may arise during the contract

Monthly Inspection by the

COR

95% Timely Resolution of issues that may arise under the contract

10) SPECIAL INSTRUCTIONS

a) Subcontracting of any ensuing award of this solicitation shall not be allowed without written permission of the Contracting Officer. Bidder’s service response on call(s) from unauthorized personnel could result in non-payment of specific services.

b) Contractor Check-in: All employees of the Contractor shall comply with VA Security Management Program and obtain permission of the VA Police and restricted from unauthorized access. Upon arrival, the Contractor shall sign-in at Building 15 in West Haven and Building 3, 3rd Floor in Newington and receive a temporary identification badge prior to performing services at VA Connecticut Healthcare System. The Contractor shall wear visible identification always displaying the name and company ID while on site. All site visits shall be coordinated with the VA COR or assigned POC.

c) Per Directive 1805, smoking, vaping, and smokeless tobacco are prohibited on the grounds of VA facilities, including in vehicles. This Directive applies to all Contractors and their employees.

d) No photography of VA premises is allowed without written permission of the contracting officer.

Patients and staff are not to be photographed at any time. Inventory deficiencies as part of inspections, calibration and testing is allowed and to be submitted with the appropriated documentation but shall not be utilized for any other purpose and will not be share with other that required parties as associated with this contract.

e) VA reserves the right to close or shut down the facilities and order Contractor employees off the premises in the event of a national emergency. The Contractor may return to the site only with the written approval of the VA Contracting Officer.

f) Parking for Contractor and employees shall be in designated areas only. Contractor shall coordinate with VA COR.

g) The Contractor shall confine all operations (including storage of materials) on government premises to areas authorized or approved by the VA Contracting Officer. The Contractor shall confine all operations (including storage of materials) on government premises to areas authorized or approved by the VA Contracting Officer. The Contractor shall hold and save the government, its officers, and agents, free and harmless from liability of any nature occasioned by the Contractor’s performance. Working space and space available for storing materials shall be as determined by the COR. Workers are subject to the rules of the Medical Center applicable to their conduct. Execute work in such a manner as to reduce impacts with work being done by others.

h) Billing: Provide COR with a report or statement of work completed and include statements with request for payment. Statement should include service completed and the date each service item was completed. Labor charges shall be billed hurly, and any unused labor totals will be credited back to the VA Medical Center on the next billing cycle, upon receipt of the service report.

i) In addition, Medical Center Spill Prevention, Control, and Countermeasure (SPCC) Plan requires an Annual Pump Controller/ Day Tank inspection for VACHS inventory of all AST’s associated with generators.

APPENDIX A

INFECTION PREVENTION MEASURES

A. Implement the requirements of VA Medical Center’s Infection Control Risk Assessment (ICRA) team.

ICRA Group may monitor dust, in the vicinity of the construction work, and require the Contractor to take corrective action immediately if the safe levels are exceeded.

B. Establish and maintain a dust control program as part of the Contractor’s infection preventive measures in accordance with the guidelines provided by ICRA Group as specified here. Prior to start of work, prepare a plan detailing project-specific dust protection measures, including periodic status reports, and submit to Project Manager and Facility ICRA team for review for compliance with contract requirements in accordance with Section 01340, SAMPLES AND SHOP DRAWINGS.

1. All personnel involved in the construction or renovation activity shall be educated and trained in infection prevention measures established by the medical center.

C. Medical Center Infection Control personnel shall monitor for airborne disease (e.g. aspergillosis) as appropriate during construction. A baseline of conditions may be established by the medical center prior to the start of work and periodically during the construction stage to determine impact of construction activities on indoor air quality. In addition:

1. The Project Manager and VAMC Infection Control personnel shall review pressure differential monitoring documentation to verify that pressure differentials in the construction zone and in the patient-care rooms are appropriate for their settings. The requirement for negative air pressure in the construction zone shall depend on the location and type of activity.

Upon notification, the Contractor shall implement corrective measures to restore proper pressure differentials as needed.

2. In case of any problem, the medical center, along with assistance from the Contractor, shall conduct an environmental assessment to find and eliminate the source.

D. In general, following preventive measures shall be adopted during construction to keep down dust and prevent mold.

1. Dampen debris to keep down dust and provide temporary construction partitions in existing structures where directed by Resident Engineer. Blank off ducts and diffusers to prevent circulation of dust into occupied areas during construction.

2. Analyze each site during design to determine the effects of blocking HVAC ducts and their impact on existing air handling systems that must remain operational before initiating a dust control program. The method of capping ducts shall be dust tight and withstand airflow.

3. Construct anteroom to maintain negative airflow from clean area through anteroom and into work area where required.

4. High risk patient care areas may require additional measures like air locks, special signage, smoke and negative pressure alarms.

5. Identify these areas clearly on the drawings and work with Medical Center personnel to achieve desired level of isolation suited to the scope of risk involved.

6. Do not perform dust- producing tasks within occupied areas without the approval of the Project Manager. For construction in any areas that will remain jointly occupied by the medical Center and Contractor’s workers, the Contractor shall:

a. Provide dust proof fire-rated temporary drywall construction barriers to completely separate construction from the operational areas of the hospital in order to contain dirt debris and dust. Barriers shall be sealed and made presentable on hospital occupied side. Install a self-closing rated door in a metal frame, commensurate with the partition, to allow worker access. Maintain negative air at all times. A fire retardant polystyrene, 6-mil thick or greater plastic barrier meeting local fire codes may be used where dust control is the only hazard, and an agreement is reached with the Resident Engineer and Medical Center.

b. HEPA filtration is required where the exhaust dust may reenter the breathing zone. Contractor shall verify that construction exhaust to exterior is not reintroduced to the medical center through intake vents, or building openings. Install HEPA (High Efficiency Particulate Accumulator) filter vacuum system rated at 95% capture of 0.3 microns including pollen, mold spores and dust particles. Insure continuous negative air pressures occurring within the work area. HEPA filters should have ASHRAE 85 or other pre-filter to extend the useful life of the HEPA. Provide both primary and secondary filtrations units. Exhaust hoses shall be heavy duty, flexible steel reinforced and exhausted so that dust is not reintroduced to the medical center.

c. Adhesive Walk-off/Carpet Walk-off Mats, minimum 24” x 36”, shall be used at all Interior transitions from the construction area to occupied medical center area. These mats shall be changed as often as required to maintain clean work areas directly outside construction area at all times.

d. Vacuum and wet mop all transition areas from construction to the occupied medical center at the end of each workday. Vacuum shall utilize HEPA filtration.

Maintain surrounding area frequently. Remove debris as they are created. Transport these outside the construction area in containers with tightly fitting lids.

e. The Contractor shall not haul debris through patient-care areas without prior approval of the Resident Engineer and the Medical Center. When, approved, debris shall be hauled in enclosed dust proof containers or wrapped in plastic and sealed with duct tape. No sharp objects should be allowed to cut through the plastic. Wipe down the exterior of the containers with a damp rag to remove dust. All equipment, tools, material, etc. transported through occupied areas shall be made free from dust and moisture by vacuuming and wipe down.

f. Using a HEPA vacuum, clean inside the barrier and vacuum ceiling tile prior to replacement. Any ceiling access panels opened for investigation beyond sealed areas shall be sealed immediately when unattended.

g. There shall be no standing water during construction. This includes water in equipment drip pans and open containers within the construction areas. All accidental spills must be cleaned up and dried within 12 hours. Remove and dispose of porous materials that remain damp for more than 72 hours.

h. At completion, remove construction barriers and ceiling protection carefully, outside of normal work hours. Vacuum and clean all surfaces free of dust after the removal.

E. Final Cleanup:

1. Upon completion of project, or as work progresses, remove all construction debris from above ceiling, vertical shafts and utility chases that have been part of the construction.

2. Perform HEPA vacuum cleaning of all surfaces in the construction area. This includes walls, ceilings, cabinets, furniture (built-in or free standing), partitions, flooring, etc.

1. All new air ducts shall be cleaned prior to final inspection. SPEC WRITER NOTE: On small projects developed at Medical Center, Engineering Officer may tag items to be removed and stored, instead of noting such items on drawings or in specifications.

END OF APPENDIX

APPENDIX B

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE FOR

INCLUSION INTO CONTRACTS, AS APPROPRIATE

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 Contractor personnel safeguard the classified information in their possession while performing work on contracts, programs, bid, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Secretary 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 to ensure VA requirements related to data protection and media sanitization can be met.

If co-mingling must be allowed to meet the requirements of the business need, the Contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct onsite inspections of Contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

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

d. The Contractor/subcontractor must receive, gather, store, back up, maintain, use, 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 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 designation 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;

i. 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 ii. 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 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 A/E 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 A/E anywhere in the Systems including Operating Systems and firmware. The A/E shall ensure that Security Fixes shall not negatively impact the Systems.

j. The A/E 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 7 days.

k. When the Security Fixes involve installing third party patches (such as Microsoft OS patches or Adobe Acrobat), the A/E will provide written notice to the VA that the patch has been validated as not affecting the System within 10 working days. When the A/E is responsible for operations or maintenance of the Systems, they shall apply the Security Fixes within 7 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 vulnerability scanning, system patching and change management procedures, and the completion of an acceptable contingency plan for each system. The contractor’s security control procedures must be equivalent, to those procedures used to secure VA systems. A Privacy Impact Assessment (PIA) must also be provided to the COR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA’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 or 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 enclaved 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, 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 A/E at the end of lease, for trade-in, or other purposes. The options are:

(1) A/E 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 A/E 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 disclosures 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.