Draft Statement of Work.pdf

STATEMENT OF WORK (SOW) Tri-Annual (36-Month) Emergency Power

Supply System (EPSS) Load Test Las Vegas VA Medical Center

1. PURPOSE

The purpose of this Statement of Work (SOW) is to define the requirements to

Perform the Tri-Annual (36-Month) Emergency Power Supply System (EPSS) test at the Las Vegas VA Medical Center (LVVAMC) in accordance with VHA

Directive 1028, Facility Electrical Power Systems. Period of performance is

Sunday October 11, 2026, and is located at SNHC VA Medical Center 6900 North

Pecos Road, Las Vegas Nevada 898086

This test is intended to verify the reliability, capacity, performance, and operational readiness of the facility’s Level 1 EPSS during a simulated total loss of normal utility power, under sustained load, for a continuous duration of not less than four

(4) hours.

2. APPLICABLE REFERENCES

All work performed under this SOW shall comply with the following, as adopted by VHA Directive 1028:

• VHA Directive 1028 – Facility Electrical Power Systems

• NFPA 110 – Standard for Emergency and Standby Power Systems

• NFPA 99 – Health Care Facilities Code

• The Joint Commission EC.02.05.07

Where requirements differ, the most stringent requirement shall apply.

3. SYSTEMS COVERED

This SOW applies to the Essential Electrical System (EES) and Emergency Power

Supply System (EPSS) serving the Las Vegas VA Medical Center, including:

• Six (6) Cummins diesel generators rated at 2,000 kW each

• Generator parallel and control systems

• Automatic Transfer Switches (ATS) Total 64

• Life Safety, Critical, and Equipment Branches

• Associated distribution equipment necessary to support EPSS operation

4. SCOPE OF WORK

4.1 Test Planning and Coordination

The Contractor shall:

1. Coordinate the test with:

• VA Engineering Service

• Facility leadership

• Local Utility Power Company (UPC)

2. Ensure all testing is conducted in a planned and controlled manner, minimizing risk to patients, staff, visitors, and VA property, as required by

VHA Directive 1028.

3. Verify readiness of the EPSS prior to testing, including generator availability and system operability.

4. Contractor will deliver and stage all required equipment a minimum of 24-

72 hours prior to the scheduled dark start. Final connections and system readiness checks shall be completed immediately prior to test execution within the approved outage window.

4.2 Utility Power Interruption

In accordance with VHA Directive 1028 requirements, the Contractor shall:

1. Initiate the test by creating a total loss of normal utility power.

2. Coordinate with the UPC to open the main utility service disconnect supplying the medical center.

3. Maintain the utility disconnect in the open position for the full duration of the test.

4.3 EPSS Response Verification

The Contractor shall observe and document:

1. Automatic starting of all emergency generators.

2. Proper operation of all ATS’s and equipment.

3. Restoration of power to the Life Safety and Critical Branches within 10 seconds of power interruption, as required for Type 1 and Type 2 Essential

Electrical Systems.

4. Stable generator operation, synchronization, and load sharing.

4.4 Four-Hour Continuous Load Test

The Contractor shall:

1. Operate the EPSS continuously for a minimum of four (4) hours.

2. Ensure generators are operated under load, meeting not less than 30% of generator nameplate or derated capacity, consistent with NFPA 110 and

VHA Directive 1028.

3. Monitor and record generator performance parameters, including:

• Load (kW)

• Voltage

• Frequency

• Engine operating conditions

Contractor will provide equipment and technical support for the Dark Start testing and inspection schedule for Sunday, 11 October 2026. Contractor will provide the proper and electrical rated components for that test date. The following equipment will be provided.

The contractor shall furnish service manuals and/or test equipment for the performance of this contract. It is the responsibility of the contractor to bring the appropriate equipment, parts and/or supplies necessary to complete the work as required. The contractor shall be familiar with and follow maintenance guidelines contained in current technical service manuals for all equipment and sub-assemblies listed. manuals shall include but not be limited to schematics, diagrams, written procedures and parts lists.

All work shall be performed, and equipment shall function in conformance with all VA safety standards, manufacturer’s/industry standards, the latest published edition of NFPA-99, FDA, OSHA, Joint Commission, and other applicable national standards. The COR may facilitate a copy of VA safety standards to the Contractor upon request

Contractor personnel shall present a neat appearance and be easily recognized as contractor employees. This may be accomplished by wearing distinctive clothing bearing the name of the company. Contractor field service personnel shall be dressed to present a clean, neat appearance always when performing under this contract.

Personnel performing maintenance and repair services must be fully qualified, competent, technicians. “Fully qualified and competent” is defined as factory trained and at a minimum two (2) years of experience to work on each specific model of equipment assigned.

The contractor shall be required to update competency information throughout life of the contract as changes to contractor’s staff occur. New employee credentials, experience with maintenance/repair of specific equipment to be maintained, period with contractor, the ability to use diagnostic software and computerized hardware for maintenance of assigned equipment, and other appropriate documentation of competency must be submitted and approved by the COR prior to any new employee commencing any work on this contract.

4. Identify and document any alarms, abnormal conditions, or deficiencies.

4.5 Facility Operations Validation

As required by VHA Directive 1028, the test shall also validate:

• The facility’s ability to operate while restricted to EPSS power

• Engineering staff response and monitoring

• Coordination with clinical areas during emergency power conditions.

4.6 RESTORATION OF NORMAL POWER

Upon completion of the four-hour test period, the Contractor shall:

1. Coordinate with the UPC to restore normal utility power.

2. Verify proper ATS retransfer to normal power.

3. Confirm stable system operation following retransfer.

4. Observe proper generator cooldown and shutdown.

5. SAFETY REQUIREMENTS

All work shall be performed in compliance with:

• NFPA 70E electrical safety requirements

• OSHA electrical safety standards

• VHA Directive 1028 energized work controls

• And Facility guidelines pertaining to High and Low Voltage Equipment.

No energized work shall be performed without appropriate authorization and safeguards as required by the directive.

6. DOCUMENTATION AND REPORTING

The Contractor shall provide written documentation including:

1. Confirmation of test date and duration

2. Verification of utility power interruption

3. Generator load and performance data

4. ATS transfer time records

5. Identification of deficiencies, if any

6. Certification that the test meets VHA Directive 1028, NFPA 99, NFPA 110, and Joint Commission requirements

Documentation shall be provided to VA Engineering Service for records retention and compliance reporting.

7. ACCEPTANCE CRITERIA

The Tri-Annual EPSS test shall be considered acceptable when:

• A full loss of utility power is successfully simulated

• EPSS supports facility operation for at least four continuous hours

• Load requirements are met

• All required data and documentation are completed

• Deficiencies are identified and tracked for corrective action

8. AUTHORITY AND OVERSIGHT

The VA Medical Center Director and Chief Engineer, acting under authority of

VHA Directive 1028, shall approve, oversee, and accept the execution of this

SOW.

9. ROLES & RESPONSIBILITIES

Role Responsibility

Medical Center Director Authority Having Jurisdiction, approval

Chief Engineer Technical oversight and compliance

Engineering Staff Monitoring and documentation

Contractor Execution, testing, reporting & mitigation

Utility Power Company Utility disconnects and restoration

10. DELIVERABLES

ID Deliverable Format Due

D-1 Pre-Test Coordination Summary PDF Before Test

D-2 Utility Power Loss Confirmation PDF Test Day

D-3 ATS & Generator Performance

Data

PDF 5 Days

D-4 4-Hour Load Test Results (30%) PDF 5 Days

D-5 Deficiency Log PDF Final

D-6 Final EPSS Compliance Report PDF + Hard Copy 10 Days

11. REQUIREMENTS:

A. contractor will provide equipment and technical support for the dark start testing and inspection schedule for Sunday, 11 October 2026. contractor will provide the proper and electrical rated components for that test date. The following equipment will be provided by the contractor but not limited to;

load bank system, transformers, electrical components, wires and braces/mounting devices. The contractor will deliver, set up and remove all equipment supporting that day’s event. in addition, the contractor will provide a knowledgeable and experience technician to service and maintain hooked up equipment. The contractor must set up and ensure operational equipment is accomplished several days before the event day. This is to ensure their equipment is prep and ready for this critical testing and inspection. The contractor will provide the labor, materials, equipment and supervision needed to complete this task. Any modifications or additional requirements not included in this service contract must have approval from the COR or designee. If date changes for some reason; weather conditions, natural disaster, medical emergency treatment, patient support and any medical situation and condition, contractors will stand by and support until the dark start event is fully in compliance. Furthermore, contractor must be available for an alternate date should the inspection and testing not performed or accomplished.

B. Below are equipment/components required for the dark start event furnished by contractor to include labor:

12. CONTRACTOR RESPONSIBILITIES:

A. contractor employees. The contractor shall not employ personnel for work on this contract if such employee is identified with the contractor as a potential threat to the health, safety, security, general well-being or operational mission of the installation and its population.

B. The contractor shall furnish service manuals and/or test equipment for the performance of this contract. It is the responsibility of the contractor to bring the appropriate equipment, parts and/or supplies necessary to complete the work as required. The contractor shall be familiar with and follow maintenance guidelines contained in current technical service manuals for all equipment and sub-assemblies listed. manuals shall include but not be limited to schematics, diagrams, written procedures and parts lists.

C. All work shall be performed, and equipment shall function in conformance with all VA safety standards, manufacturer’s/industry standards, the latest published edition of nfpa-99, FDA, OSHA, joint commission, and other applicable national standards. the COR may facilitate a copy of VA safety standards to the contractor upon request.

D. Contractor personnel shall present a neat appearance and be easily recognized as contractor employees. This may be accomplished by wearing distinctive clothing bearing the name of the company. Contractor field service personnel shall be dressed to present a clean, neat appearance always when performing under this contract.

E. personnel performing maintenance and repair services must be fully qualified, competent, technicians. “Fully qualified and competent” is defined as factory trained and at a minimum two (2) years of experience to work on each specific model of equipment assigned.

F. The contractor shall be required to update competency information throughout life of the contract as changes to contractor’s staff occur. new employee credentials, experience with maintenance/repair of specific equipment to be maintained, period with contractor, the ability to use diagnostic software and computerized hardware for maintenance of assigned equipment, and other appropriate documentation of competency must be submitted and approved by the COR prior to any new employee commencing any work on this

11. LOCATION OF EMERGENCY GENERATORS

VA southern Nevada healthcare system (VASNHS), central energy plant building #2, 6900 north Pecos Road, North Las Vegas, Nevada 89086.

13. Service Response Times: the following service response times shall be adhered to at all times identified below. No additional costs will be associated with any service or maintenance performed after hours or on the weekends.

Location of

6 generators building # 3

N

6 Cummins

2000 kw generators

A. Two-hour maximum callback for service calls made during normal work hours, Monday through Friday. normal work hours are between the hours of

6:00am and 5:00pm.

B. Eight-hour maximum callback for service calls made after 5:00pm, in no case later than 6:00am of the following normal workday, Monday through

Friday.

C. Twelve-hour telephone callback required for calls made on weekends or national holidays (Friday after 5:00pm through 6:00am of the next working day).

D. On site response shall be within 4 hours of first call for service, Monday through Friday, including after 5:00pm when authorized by cor.

E. On site response for calls received during weekend hours and holidays shall be no later than 11:00am of the next working day.

14. Failure to comply, failure to perform any of the services, as set forth in this contract, will be considered grounds for invoking termination for default procedures.

15. Re-performance:

A. If performance does not conform to the contract specifications, the VA healthcare center’s COR or the contracting officer shall require the contractor to perform the service again to conform to the contract specifications, at no cost to the government. When the defects in service cannot be corrected by re-performance, the VA Medical facility may require the contractor to call in a senior technical engineer from the manufacturer or from a different company. the contractor shall incur and absorb all expenses for consultation outside the contractor’s organization.

B. Repeated malfunctions of any system component or subsection more than three (3) times within one (1) quarter is not acceptable. The contractor is responsible for repairing all faulty equipment and identifying the nature and cause of repeated failures. the contractor in this situation must either:

1. make repairs in such a manner that the identified problems are corrected to the extent that repeated failures are eliminated.

2. prove that the equipment is not faulty and an external cause for the problem exists and provide recommendations for resolution.

3. provide repair services from the original equipment manufacturer at the contractor’s expense.

16. Check–in and out on service calls at the VA facilities:

access: access to work areas, and performance monitoring, will be provided by

VA energy plant maintenance personnel. After hours response will be monitored by VA central energy plant operators, 702-791-9000 extension

16900. in all cases, VA central energy plant operator shall be notified of any changes which may affect the response time of vital equipment.

for repairs or services required on weekends, holidays or after normal working hours, the contractor’s repairman is required to check-in and check-out upon arrival and departure at security service and with COR, if available, or the on-duty supervisor of the department, prior to effecting repairs. The procedures defined above are mandatory and will be strictly enforced.

17. National holidays: The contractor is not required to provide services on the following national holidays, nor shall the contractor be paid for these holidays:

New Year’s Day January 1 martin Luther king ‘s birthday Third Monday in January president’s day Third Monday in February

Memorial Day last Monday in May

Juneteenth June 19

Independence Day July 4

Labor Day First Monday in September

Columbus Day Second Monday in October veterans’ day November 11

Thanksgiving Day Fourth Thursday in November

Christmas day December 25

When a holiday falls on a Sunday, the following Monday shall be observed as a legal holiday by US government agencies. When a holiday falls on a Saturday, the preceding Friday shall be observed as a legal holiday by US government agencies. also included would be any other day specifically declared by the president of the United States as a national holiday.

18. Overtime and holidays: any overtime or holiday pay that may be entitled to contractor personnel performing under this contract shall be the sole responsibility of the contractor and shall not be billed to nor reimbursed by the government.

19. Parking policy: it is the responsibility of contractor personnel to park only in designated parking areas. Parking information is available from the VA police. The

VA shall not invalidate or make reimbursement for parking violations of contractor's personnel under any circumstances.

20. Smoking policy: contractor personnel may smoke only outside the medical center fence line.

21. Ordering activity: contractor shall not accept any instructions issued by any person other than the CO or COR/Contracting Officer acting within the limits of his/her authority.

22. Changes to contract: only those services specified herein are authorized. Before performing any service of a non-contractual nature, contractor shall advise the co of the reason(s) for the additional work and/or service.

23. Complaints: Contractor shall promptly and courteously respond to complaints within

3 working days. including complaints brought to contractor’s attention by the co.

contractor shall maintain a written record of all complaints, both written and oral showing the identity of the individual, the nature of the complaint, and contractor’s response. contractor shall permit the government to inspect such records upon reasonable notice.

24. Badges: all contractor personnel shall be required to wear VA, always provided with identification (i.d.) badges above the waist while on the VA grounds. Contractors shall be required to coordinate with COR to obtain the VA provided i.d. badges for all staff. All VA provided I.D. badges shall be returned at the end of the contract or upon completion of service. failure to wear id badges may result in removal from federal property.

25. Compliance, Risk management, and Accountability

a. Regulatory Compliance: the contractor shall comply with all applicable federal, state, local, VA, VHA, VISN 21, and VASNHS policies, directives, codes, regulations, and procedures applicable to the work performed under this contract.

b. Protection of patient care operations: all work shall be performed in a manner that does not disrupt or compromise patient care, clinical operations, staff safety, visitor safety, utility reliability, emergency power readiness, or life safety systems. The contractor shall immediately notify the COR of any condition that may impact patient safety, facility operations, or the medical center mission.

c. Infection control compliance: the contractor shall comply with applicable VA infection control requirements, including infection control risk assessment (ICRA) requirements when applicable. contractor activities shall be coordinated to prevent contamination of patient care environments and operational spaces.

d. Utility and electrical risk control: the contractor shall ensure that all activities involving electrical systems, emergency power systems, fuel systems, load banks, temporary equipment, utility interruption, restoration, or system testing are performed in a controlled manner to prevent damage to VA infrastructure, unintended outages, unsafe conditions, or operational disruption.

e. Emergency response coordination: the contractor shall coordinate with VA engineering, VA police, the COR, facility leadership, and other designated VA personnel in the event of abnormal conditions, system failure, equipment failure, privacy/security incident, emergency, or any condition affecting patient care or facility operations.

f. Contractor liability: the contractor shall be responsible for damages to VA property, systems, equipment, records, or information resulting from negligence, improper procedures, unauthorized access, failure to follow contract requirements, or failure to comply with VA direction.

g. Stop work authority: the COR, co, chief engineer, VA police, safety, or other designated VA authority may stop work at any time when conditions are determined to be unsafe, non-compliant, disruptive to patient care, or a risk to VA personnel, patients, visitors, property, information, or facility operations.

25.1 Information Security, Privacy, and Access Control

The contractor shall comply with all applicable Department of Veterans Affairs

(VA), VA Southern Nevada healthcare system (VASNHS), and VISN 21 privacy, security, access control, badging, and information protection requirements while performing work at the medical center. The contractor shall protect patient, employee, visitor, facility, utility, and operational information from unauthorized access, use, disclosure, loss, or compromise.

a. Contractor personnel shall not access, use, disclose, photograph, copy, transmit, store, or discuss VA sensitive information unless specifically authorized by the contracting officer (co), contracting officer representative (COR), or authorized

VA official. VA sensitive information includes, but is not limited to, protected health information (phi), personally identifiable information (pii), employee information, patient care information, facility security information, utility infrastructure information, emergency power system information, and any other information that could affect patient privacy, employee privacy, facility safety, or medical center operations.

b. Contractor personnel shall comply with all applicable federal privacy requirements, including the health insurance portability and accountability act

(HIPPA), the privacy act, VA privacy policies, and local VASNHS procedures.

Unauthorized disclosure of patients, employees, or VA-sensitive information is strictly prohibited.

c. Contractor personnel shall remain within assigned and approved work areas only. Contractor personnel shall not enter clinical areas, administrative offices, patient care areas, information technology areas, restricted spaces, utility spaces, or any other non-work-related areas unless access is specifically authorized and coordinated through the COR or designated VA representative.

d. Contractor personnel shall not roam the medical center, loiter in unauthorized areas, or access areas outside the approved scope of work. movement through the facility shall be limited to approved routes necessary to perform the contracted work.

e. Contractor personnel shall always wear VA-issued identification badges above the waist and visible while on VA property. Contractor personnel shall comply with all VA police, badging office, and local facility access control requirements.

badges shall be returned at the completion of work or upon request by the VA.

f. Contractor personnel shall be always escorted unless unescorted access has been specifically authorized by the VA. Contractor personnel shall not bypass security controls, prop doors open, allow tailgating, share badges, or permit unauthorized individuals to access VA spaces.

g. Contractor personnel shall not connect personal devices, laptops, removable media, diagnostic tools, or contractor-owned equipment to VA information systems, networks, or communication infrastructure unless specifically authorized in writing by the VA.

h. Contractor personnel shall not photograph, record, audio record, or otherwise capture images of VA patients, employees, computer screens, documents, protected areas, security features, utility infrastructure, or facility operations unless specifically authorized by the co or cor.

i. Any actual or suspected privacy breach, security incident, unauthorized access, loss of information, lost badge, suspicious activity, or incidental exposure to

PHI/Protected Health Record, or VA-sensitive information shall be reported immediately to the COR and VA police. The contractor shall cooperate fully with any VA inquiry, investigation, or corrective action related to fully with any VA inquiry, investigation, or corrective action related to privacy, security, or access control.

j. failure to comply with these requirements may result in removal of contractor personnel from VA property, denial or revocation of access, contract remedies, termination for default, and any other action available to the government.

27.2 Records Management and Data Protection

The contractor shall comply with all applicable VA records management, privacy, and data protection requirements for records, reports, test data, field service reports, communications, photographs, notes, electronic files, and deliverables created, collected, received, or maintained under this contract.

a. All documentation, reports, test results, photographs, notes, logs, correspondence, data, and deliverables generated under this contract are the property of the department of Veterans affairs and shall be provided to the COR or designated VA representative for official records retention and compliance reporting.

b. The contractor shall protect all records from unauthorized access, disclosure, alteration, loss, or destruction. This includes any information related to patients, employees, visitors, medical center operations, utility systems, emergency power systems, facility infrastructure, security conditions, and contract performance.

c. Contractor personnel shall not copy, photograph, scan, transmit, remove, retain, reuse, or distribute VA information, including phi, pii, employee information, facility-sensitive information, utility infrastructure information, or test data, unless specifically authorized by the co or cor.

d. Any records maintained by the contractor during performance shall be always secured. physical records shall not be left unattended in public or unsecured areas.

Electronic records shall be protected from unauthorized access and shall not be stored on personal devices or non-approved systems unless specifically authorized by the VA.

e. Electronic transmission of records shall be performed only through secure, VA-approved methods or as otherwise directed by the cor. The contractor shall not transmit VA-sensitive information through unsecured email, personal email accounts, text message, personal cloud storage, or other non-approved platforms.

f. upon completion of the contract, completion of the work, or upon request by the

VA, the contractor shall provide all records and deliverables to the COR and shall not retain copies unless expressly authorized in writing by the co or cor.

g. The contractor shall immediately notify the COR of any lost, missing, compromised, or improperly disclosed record or data file. Failure to protect records or sensitive information may result in removal from the facility, contract remedies, termination, and any other action available to the government.

27.3 Security requirements for unclassified information technology security resources

a. The contractor and their personnel shall be subject to the same federal laws, regulations, standards and VA polices as VA personnel, regarding information and information system security. These include but are not limited to federal information security management act (fisma), appendix iii of omb circular a-130, and guidance and standards, available from the department of commerce’s national institute of standards and technology (nist). This also includes the use of common security configuration available from nist’s web site at: http://checklists.nist.gov.

b. To ensure that appropriate security controls are in place, contractors must follow the procedures set forth in “VA information and information system security/privacy requirements for it contractors” located at the following site:

http://www.iprm.oit.va.gov.

c. these provisions shall apply to all contracts in which VA sensitive information is stored, generated, transmitted, or exchanged by VA, a contractor, subcontractor or a third-party, or on behalf of any of these entities regardless of format or whether it resides on a VA system or contractor/subcontractor’s electronic information system(s) operating for or on the VA behalf.

27.4 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 is 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.

e. The contractor or subcontractor must notify the COR immediately when

An employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor’s employer. The COR must http://checklists.nist.gov/ http://www.iprm.oit.va.gov/ also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

27.5 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 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 contractors 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 COR 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. in accordance with 45 cfr 164.502(e), the privacy rule includes exceptions to the business associate standard. This requirement meets the exception and does not require a business associate agreement for covered entity to disclose protected healthcare information to the contractor for treatment.

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. The records created in accordance with this contract belong to the vasnhs and should be returned to the vasnhs and/or destroyed in accordance with vha rcs 10-1.

destruction should only occur with advance notice and guidance from the records management officer at the vasnhs. records shall be safeguarded in accordance with the privacy act, health insurance portability and accountability act (hipaa) and the vasnhs release of information unit. Patient medical information is considered privileged and shall not be disclosed or revealed in any way without prior written permission from the va chief, health information management section.

The contractor shall only release medical information obtained during the course of this contract to those VA staff members involved in the necessary management and treatment of that individual patient. patient list and name of patients are considered privileged information and shall not be disclosed or revealed in any way for use outside the contractor without prior written permission from the referring VA chief of staff. veterans requesting copies of medical information generated by the contractor will be referred to the vasnhs release of information unit.

l. 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 vasnhs release of information unit for response.

m. 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 vasnhs release of information unit for response.

n. 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

6500.1requirements. This must be completed within 30 days of termination of the

The c&a requirements do not apply, and a security accreditation package is not required.

ensure that a contractor security control assessment (csca) is completed within 30 days of contract approval and yearly on the renewal date of the contract.

ensure that the csca is sent to the iso and the ocs certification program office for review to ensure that appropriate security controls are being implemented in service contracts.

ensure a copy of the csca is maintained in the security management and reporting tool (smart) database. cor will provide a copy of the completed csca to iso for uploading into smart database.

Health insurance portability and accountability act (hipaa):

contractors shall take reasonable measures to ensure patient privacy and confidentiality. The contractor agrees to take all reasonable precautions to safeguard patient information from unauthorized access or modification, in both electronic and hard-copy formats. this includes not only electronic security measures such as “strong” user passwords on computer systems, but also physical barriers to prevent unauthorized use of computer work-stations; that hard copy patient files are in secured lockable areas, that files are in lockable cabinets, that the cabinets can in fact be locked, i.e., keys are available, and the locking mechanisms work properly. This precaution also includes the proper transfer of patient information via electronic means, such as faxing or system transmission systems.

that only the minimum necessary patient information is used to provide appropriate service to the correct patient.

that the undersigned understands that all parties are bound by the requirements of the “health insurance portability and accountability act of 1996” which provide guidance on the protection of patient privacy and confidentiality. This act states that all government agencies, and those bodies with whom they contract, must follow the directives of the act.

27.6 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.

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 considering 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 sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons).

(8) known misuses of data containing sensitive personal information, if any.

(9) assessment of the potential harm to the affected individuals.

(10) data breach analysis as outlined in 6500.2 handbook, management of security and privacy incidents, as appropriate; and

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

d. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of

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

(1) notification.

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

(3) data breach analysis.

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

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

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

Security controls compliance testing

On a periodic basis, VA, including the office of inspector general, reserves the right to evaluate any or all the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. with 10 working-days’ 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.

Training

Contractor/subcontractor employees requiring access to VA information shall complete privacy training annually as required for covered entities under the hipaa.

The COR shall ensure employees complete training within 1 week of the initiation of the contract and annually thereafter, as required.

failure to complete the mandatory annual training 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.

1. Records management language

Contractor shall comply with all applicable records management laws and regulations, as well as national archives and records administration (nara) records policies, including but not limited to the federal records act (44 u.s.c. chapters. 21, 29, 31, 33), nara regulations at 36 cfr chapter xii subchapter b, and those policies associated with the safeguarding of records covered by the privacy act of 1974 (5 u.s.c. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

In accordance with 36 cfr 1222.32, all data created for government use and delivered to, or falling under the legal control of, the government are federal records subject to the provisions of 44 u.s.c. chapters 21, 29, 31, and 33, the freedom of information act (foia) (5 u.s.c. 552), as amended, and the privacy act of

1974 (5 u.s.c. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

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

The VA southern Nevada healthcare system (vasnhs) and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. records may not be removed from the legal custody of vasnhs or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the head of the contracting activity. willful and unlawful destruction, damage or alienation of federal records is subject to the fines and penalties imposed by 18 u.s.c. 2701.

In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, the contractor must report to vasnhs. the agency must report promptly to nara in accordance with 36 cfr 1230.

The contractor shall immediately notify the appropriate contracting officer (co) upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. disclosure of non-public information is limited to authorized personnel with need-to-know as described in the contract documents. the contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The contractor shall not remove material from government facilities or systems, or facilities or systems operated or maintained on the government’s behalf, without the express written permission of the head of the contracting activity. When information, data, documentary material, records and/or equipment are no longer required, it shall be returned to vasnhs control, or the contractor must hold it until otherwise directed. items returned to the government shall be hand carried, mailed, emailed, or securely electronically transmitted to the co or address prescribed in the contract documents. destruction of records is expressly prohibited unless in accordance with paragraph (4).

the contractor is required to obtain the co's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts.