Final PWS Fire Extinguisher Services.docx

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H312--Fire Extinguisher Maintenance, Inspection, and Testing Services
Solicitation number
36C24825Q0110
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This Performance Work Statement (PWS) outlines requirements for maintenance, inspection, and testing services of portable fire extinguishers at James A. Haley Veterans' Hospital (JAHVH) in Tampa, FL and Brooksville CBOC in Brooksville, FL. The contractor must provide all labor, materials, equipment, and tools to conduct monthly inspections of approximately 800 extinguishers, annual maintenance of approximately 1,120 extinguishers, and scheduled hydrostatic testing/6-year maintenance as specified in detailed quantity tables spanning 2025-2029.

The PWS requires contractors to follow NFPA 10 standards, maintain proper certification, provide monthly and annual inspection reports, update inventory sheets and tags, and conduct work during normal business hours (8:00 AM - 4:00 PM Monday-Friday, with special arrangements for operating rooms). Key deliverables include inspection reports, maintenance records, service tickets, and itemized bills. The contractor must obtain PIV cards for secure area access and replace up to 5 unserviceable ABC fire extinguishers annually at no additional charge. A kickoff meeting is required within one week of Notice to Proceed. The associated solicitation (36C24825Q0110) is a Service-Disabled Veteran Owned Small Business (SDVOSB) set-aside under NAICS 561990 with quotes due December 11, 2024, at 15:00 EST for a base period plus four option years starting January 1, 2025.

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PERFORMANCE WORK STATEMENT

MAINTENANCE, INSPECTION AND TESTING OF

PORTABLE FIRE EXTINGUISHERS

A. GENERAL INFORMATION

Title of Service:

Maintenance, Inspection, and Testing of Portable Fire extinguishers Places of Performance:

1. James A. Haley Veterans’ Hospital (JAHVH), 13000 Bruce B. Downs Blvd., Tampa, FL 33612.

2. Brooksville CBOC, 14540 Cortez Boulevard, Brooksville, FL 34613.

Scope of Work: The contractor shall provide all resources necessary (labor, materials, equipment, tools, carts, and other items) to accomplish the tasks described in this Performance Work Statement (PWS), except as may otherwise be specified. The vendor must ensure all service technicians that clean, maintain, test, and inspect equipment at any listed location be competent, certified, and licensed to perform the services in accordance with the manufacturers ‘established operating standards, applicable to NFPA 10 code requirements in a manner that will ensure serviceability and prevent deterioration in value or effectiveness. Monthly inspections shall be accomplished for all extinguishers located throughout the JAHVH campus within the month due. Annual inspection and equipment maintenance shall be accomplished for all extinguishers located throughout the JAHVH and Brooksville campuses within the calendar year they are due. Requests for clarification or additional information concerning scope or specifications shall be directed to the JAHVH Safety COR or COR Alternate.

The scope of work for this project includes the following elements:

1. Conduct six-year maintenance for portable fire extinguishers

2. Conduct hydrostatic testing for portable fire extinguishers

3. Conduct maintenance per NFPA 10 chapters 7 and 8

4. Conduct maintenance per specific manufacturers specifications based on model (Co2, Sodium bicarbonate, Water, Water Mist, Class K)

5. Conduct Monthly Inspections per NFPA 10

6. Maintenance staff to be certified to conduct work

7. Transport of and return of VHA property or replacement with like fire extinguisher

8. Update monthly inspection tags, serial numbers, maintenance dates, locations, and other necessary information in VA Inventory Sheets to reflect status. All handwriting must be legible on documentation and inspection tags.

9. Provide proof with stamp or tags that work was completed

10. Possess and furnish written proof of a fire extinguisher manufacturer factory service certification and/or National Association of Fire Equipment Distributors Portable Fire Extinguisher Technician certification relevant to the type of work performed.

11. All extinguishers placed in use must be clean and neat in appearance where the public or patients have visibility.

Types of fire extinguishers including approximate quantities requiring annual inspection, testing and maintenance are provided below.

Hydrostatic Testing

Quantity Next Due

Item #
Size
Type
FY 2025
FY 2026
FY 2027
FY 2028
FY 2029
1
2.5 lb.
ABC
3
0
12
12
0
2
2.5 lb.
BC
0
0
1
0
0
3
5 lb.
H-Tron
0
0
0
0
16
4
5 lb.
ABC
4
11
11
2
21
5
10 lb.
ABC
205
17
53
8
27
6
20 lb.
PKP
0
0
0
0
0
7
50 lb.
PKP Wheel
0
0
0
1
0
8
2.5 gal.
Water
0
1
0
2
4
9
2.5 gal.
W-Mist
1
3
0
2
0
10
6 ltr.
K
1
0
3
3
5
11
5 lb.
CO2
2
8
11
26
40
12
10 lb.
CO2
56
2
3
1
29
13
20 lb.
CO2
0
3
0
0
0

6 Year Maintenance/Recharge

Quantity Next Due

Item #
Size
Type
2025
2026
2027
2028
2029
14
2.5 lb.
ABC
0
1
0
1
0
15
2.5 lb.
BC
5
0
0
0
0
16
5 lb.
H-Tron
0
0
0
0
1
17
5 lb.
ABC
27
11
14
10
1
18
10 lb.
ABC
52
89
71
36
1
19
20 lb.
PKP
0
0
0
2
0
20
50 lb.
PKP
0
0
0
0
0
21
Annual Maintenance
1120
22
Monthly Inspections
9600

NOTE: Campus Totals include all buildings on campus except Building 2 which is under construction. Monthly inspections totals are less than annual inspection totals due to extinguishers in storage that do not require monthly inspections.

B. HOURS OF OPERATION AND SCHEDULING

The contractor shall provide complete inspection and maintenance services for the JAHVH during normal hours of operation Monday through Friday 08:00-16:00. Fire Extinguisher Inspections in the operating rooms must be inspected during abnormal business hours before 07:00 or after 17:00 and must be arranged with the Safety COR. The contractor is not to perform work on weekends or the following observed holidays:

· New Year’s DayJanuary 1
· Martin Luther King’s Birthday3rd Monday in January
· President’s Day3rd Monday in February
· Memorial DayLast Monday in May
· JuneteenthJune 19th
· Independence DayJuly 4th
· Labor Day1st Monday in September
· Columbus Day2nd Monday in October
· Veteran’s DayNovember 11
· Thanksgiving DayLast Thursday in November
· Christmas DayDecember 25

C. CONTRACT AWARD MEETING

The contractor shall not commence performance on the tasks in this PWS until the CO has conducted a kickoff meeting or has advised the contractor that a kickoff meeting is waived. Contractors are encouraged to visit the participating facilities to fully inform themselves of the character and conditions under which the services are to be performed. Failure to do so shall in no way relieve the successful offeror from the necessity of furnishing the services as specified in this solicitation without additional cost to the Government.

D. PERFORMANCE REQUIREMENTS

1. All work is to be completed between the hours of 8:00 AM and 4:30 PM, Monday through Friday unless otherwise specified or agreed upon.

2. Monthly fire extinguisher inspections shall be conducted no later than the 25th of the month. If additional work dates are required to complete the monthly inspections, they shall be scheduled with the JAHVA COR or designated Safety Staff.

3. The invoice must include the building(s) inspected, work performed, number and types of fire extinguishers or suppression systems inspected, dates work performed, testing interval, discrepancies noted, inspectors’ identification, edition of NFPA 10 exercised, components inspected, and maintenance performed.

4. There are to be daily start and end briefings so that it may be known what is expected to be completed that day and what has been completed and if fire extinguishers were not able to be located.

5. Once all work has been completed, a final briefing will be conducted to advise if there were any issues/discrepancies or deficiencies noted with the work that was performed.

E. SAFETY REQUIREMENTS

1. Obtain GOV PIV Cards for all contractors providing services to allow for entry to secure areas without escort by Safety Office.

2. Remove carts and equipment from corridor during fire alarms.

3. Ensure carts, equipment and tools are staged along the wall to prevent obstruction of corridors or hindering daily activities.

F. ASSOCIATED DELIVERABLES

1. Task One: Within one week of receiving the Notice to Proceed, the contractor will conduct a kickoff meeting for all pertinent contractor and VHA personnel. The meeting will be in the form of a limited in person (no more than two people), teleconference, or webinar. The meeting will discuss the overall project scope, schedule, and expectations.

In preparation for the work to be performed, the contractor can request any data related to the type, size, and number of extinguishers needing to be serviced on a yearly basis.

2. Task Two: Certification of Contractors that will conduct maintenance for the following facilities:

a) James A Haley VA Hospital (JAHVH), 13000 Bruce B. Downs Blvd., Tampa, FL 33612.

b) Brooksville CBOC, 14540 Cortez Boulevard, Brooksville, FL 34613.

Deliverable Two: The contractor will provide current certifications for contractor staff conducting the maintenance on the portable fire extinguishers prior to conducting monthly or annual services.

3. Task Three: Identify all portable fire extinguishers by VA inventory sheets and physical locations and prepare an inspection report that reflects the inventory sheet. The Inventory report shall be legible and contain for each extinguisher the inspection date, pass, or fail status, comments, edition of NFPA code maintenance was performed, and any changes. The Inspection Report is to be completed during the first 30 days after contract award to reflect VA inventory sheets. Contractor shall provide monthly inspection reports as an electronic file and one hard copy.

Deliverable Three: Contractor will provide an inspection report to include the first month inspection details to facility Safety COR within 30 days of award. Any additional information or adjustments the Safety COR deems necessary for the report shall be provided for the following monthly report. The inspection report will be used for all monthly and annual services for JAHVH.

4. Task Four: Contractor will follow NFPA 10 – Chapters 7 and 8 for inspection maintenance and recharging requirements.

Deliverable Four: Keep each record and provide a copy of each record to the Safety COR for the hydrostatic test until it is replaced by a new record, or the extinguisher is no longer in use. The record must be legible and have the date of test, test pressure, serial number of the extinguisher (or other unique identifier), the person or company doing the test, and the certification of testing.

5. Task Five: Annual Maintenance of Portable Fire Extinguishers (approximately 1180 total). Each individual fire extinguisher must have annual maintenance performed to include new tags (annual and monthly tags). Notify Safety of any unserviceable fire extinguishers before replacement. Annual maintenance of any unserviceable fire extinguishers, up to a total of 5 per year for class ABC, will be replaced immediately on a point-to-point basis at no additional charge to the government. The annual maintenance shall include, at a minimum, the following items:

a) Location in designated place

b) No obstruction to access or visibility

c) Operating instructions on nameplate are legible and facing outward

d) Safety seals and tamper indicators are not broken, not missing, and indicate current year

e) Fullness determined by weighing or “hefting”

f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle

g) Pressure gauge reading or indicator in the operable range or position

h) Tag replacement with prior year’s tags deliverable to the Safety department

i) Survey any extinguishers that are due for routine maintenance and testing per NFPA 10 Standards Deliverable Five: Upon completion of Task Five, the vendor’s Service Technician shall provide to the Safety Manager (or designee), within 30 days of service completion, a completed service ticket that is legible, which includes the following information:

a) Purchase order number

b) Number of fire extinguishers inspected by location

c) List of unserviceable extinguishers replaced or due for service (i.e., 6-year maintenance, hydrostatic testing, etc.)

6. Task Six: The contractor will provide an itemized bill for each maintenance cycle.

Deliverable Six: The bill should include work completed, labor, and a list of fire extinguishers sent back to the JAHVH by type, size, and amount of each. Supplying all equipment, materials, and labor to accomplish the task. Examples are:

a) Supplying all required safety equipment

b) Service Technician is to provide a service visit report in accordance with NFPA, and Joint Commission documentation requirements.

c) Protecting veterans, visitors, and staff while working at James A. Haley VAMC.

d) Notifying the COR if any portable fire extinguishers are not serviced or located within 24 hours.

e) Boots, foot rings and attachments

f) Annual and monthly service tags/labels, tamper seals, collars, and static conductivity labels.

James A Haley VAMC may need to service more extinguishers than identified, in the attached list. The Facility retains the right to borrow against an upcoming year, but not to exceed contract limits, in order to maintain equipment to Life Safety Standards which could affect the life safety of the facility.

G. SCHEDULE FOR DELIVERABLES

1. The contractor shall complete the deliverables as indicated in Task One thru Task Six.

2. If for any reason any deliverable cannot be delivered within the scheduled time frame, the contractor is required to explain why in writing to the CO, including a firm commitment of when the work shall be completed. This notice to the CO shall cite the reasons for the delay and the impact on the overall service. The CO will then review the facts and issue a response in accordance with applicable regulations.

H. CHANGES TO PERFORMANCE WORK STATEMENT

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

I. TRAINING AND RECORD MAINTENANCE

The vendor must ensure all Service Technicians inspecting equipment listed in the PWS at JAHVH be licensed to perform fire extinguisher inspections. The contractor will provide all professional certifications and copy of training certificates/certification to the COR within 3 days of contract award for all contractor personnel performing work under this contract.

J. COMPLIANCE

The contractor shall be fully responsible for compliance with all VA, Local, State, and Federal occupational safety laws, rules, and regulations. The contractor shall follow life and safety codes and take necessary actions to avoid conditions that may be hazardous to the health and safety of hospital personnel and patients. The contractor is responsible for meeting all applicable OSHA and VA guidelines for safe working procedures. All work for the duration of the contract shall be performed by licensed technicians.

It is agreed that:

1. The preliminary and final deliverables, and all associated working papers, application source code, and other material deemed relevant by VA which have been generated by the contractor in the performance of this task order, are the exclusive property of the U.S. Government and shall be submitted to the CO at the conclusion of the task order.

2. The CO will be the sole authorized official to release, verbally or in writing, any data, draft deliverables, final deliverables, or any other written or printed materials pertaining to this task order. No information shall be released by the contractor. Any request for information relating to this task order, presented to the contractor, shall be submitted to the CO for response.

3. Press releases, marketing material, or any other printed or electronic documentation related to this service, shall not be publicized without the written approval of the CO.

K. QUALITY ASSURANCE SURVEILANCE PLAN

The contractor shall be evaluated in accordance with the following QASP.

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

1. What shall be monitored.

1. How monitoring shall take place.

1. Who shall conduct the monitoring.

How monitoring efforts and results shall be documented.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance. This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities:

Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the Department of Veteran Affairs (VA) in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Jennifer Eakes Alternate COR: James Watson

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a) Certified Fire Protection Engineer -

b) Other Contractor Personnel –

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets, or does not meet these standards.

The Performance Requirements are listed below. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

ID
Performance Standard
Quality Standard
Method of Surveillance
Incentives
1
Contractor Qualifications
Contracted employees performing the inspection and maintenance services for portable fire extinguishers and be certified to perform inspections. Certification by an organization acceptable to the authority having jurisdiction (AHJ); or registration, license, or certification by the state; and IAW NFPA 10 and 96, to maintain, service, and recharge all portable extinguishers.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required certifications and documentation.
· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

2
Startup/ Transition Phase.
The Contractor must provide all start up services necessary to provide seamless inspection and maintenance services for all portable fire extinguishers campus wide. Submission and review of all required building documentation to provide seamless inspection and maintenance services without failures in providing services to our customers.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

3
Staffing and ability to communicate with CO, COR, and responsible parties.
Contractor must staff and provide communication methods to ensure services are adequately provided to JAHVH. Staff to the levels of the staffing plan. Quality of staffing, staffing attendance, and methods of communication are within the requirements of the contract and ensure adequate response to all Contract requirements. Changes to the staffing plan must be approved prior by the CO or designee.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

4
Tours
Tours must be conducted and documented in accordance with Contract requirements. All tours must be conducted and documented as required and will reflect actual conditions. Adjustments will be made as needed. Logs and check sheets must be adequate to track operating hours.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

5
Monthly Inspections
All in use fire extinguishers are to be inspected each month with legible documentation to reflect the Month, Day & Year with initials of the inspector. Replace the monthly tags when they are full and deliver completed tags to the Safety COR or alternate. Obtain GOV PIV to allow inspection without Safety Office Escorts.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

6
Annual Inspections
The contractor shall inspect IAW NFPA 10 and if necessary, replace deficient extinguisher. Replace tamper tag, replace inspection card, and punch the required areas IAW NFPA 10. Complete inspection report and communicate any discrepancies to the Safety COR upon completion of tour hours. Obtain GOV PIV to allow inspection without Safety Office Escorts.

The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

7
5-, 6-, and 12-Year Maintenance
The contractor shall perform overhaul maintenance, repair, and recharging IAW using the manufacture’s recommendations for each type of extinguisher and NFPA 10 and 96. Each 5, 6, and 12-year maintenance shall be recorded legibly on an inspection document tag or plate, which shall be affixed on the exterior of the extinguisher shell. Obtain GOV PIV to allow maintenance without Safety Office Escorts.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

8
Extinguisher Replacement
Contractor shall use extinguishers in storage for replacement of ones in service if they do not pass inspection. Contractor must update the inspection report to reflect the change of extinguishers, documentation must be legible. If sufficient quantities of stored extinguishers are not available for replacements due to maintenance and recharge/repair services, the contractor shall provide (free of charge) a replacement extinguisher until above mentioned is completed and original extinguisher is placed back in service.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

9
Fire Extinguisher Disposals
Contractor must report any extinguishers for disposal and report the serial numbers to the Safety COR.
The Government will evaluate performance based on tenant satisfaction, surveys, tenant interviews, service request or other required documentation.

· Incentives: Favorable contactor performance evaluation

· Disincentive: Unfavorable contractor performance evaluation

Repeated violation may result in termination of services

5. Incentives/Disincentives The Government shall use favorable contractor performance evaluations as incentives. Incentives/Disincentives shall be based on exceeding, meeting, or not meeting performance standards.

6. Procedures/Methods of QA Surveillance

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a) Direct Observation. Direct observation can be performed periodically or through 100% surveillance.

b) Reported complaints. Any complaint data is reviewed by the CO/COR and any validated complaints against a contractor will be further investigated.

7. Ratings Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

Positive Outcome: No more than 1incident of not meeting the performance standard during the period of performance.

Neutral Outcome: No more than 3 incidents of not meeting the performance standard during the period of performance.

Negative Outcome: More than 3 incidents of not meeting the performance standard during the period of performance.

8. Documenting Performance

a) Acceptable Performance The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b) Unacceptable Performance When unacceptable performance occurs, the COR shall inform the Contracting Officer (CO). This shall normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in their respective file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the CO. The CO will in turn review and submit to the contractor’s program manager for corrective action.

The contractor shall acknowledge receipt of the CDR in writing. The CDR shall specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR shall also state how long after receipt the contractor must present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability. Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. FREQUENCY OF MEASUREMENT

a) Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b) Frequency of Performance Assessment Meetings.

The COR shall conduct a performance assessment meeting with the contractor if negative trends are identified, otherwise an annual performance assessment report will be completed and uploaded into the Contractor Performance Assessment Reporting System (CPARS).

L. WITH NO SENSITIVE DATA BUT REQUIRES TRAINING

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE

1. VA INFORMATION CUSTODIAL LANGUAGE:

a) 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.

b) 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.

c) 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.

d) 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.

2. 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.

3. LIQUIDATED DAMAGES FOR DATA BREACH:

a) Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract. However, it is the policy of VA to forgo collection of liquidated damages in the event the contractor provides payment of actual damages in an amount determined to be adequate by the agency.

b) The contractor/subcontractor shall provide notice to VA of a “security incident” as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

4. SECURITY CONTROLS COMPLIANCE TESTING:

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all 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.

5. TRAINING:

a) All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete VA Privacy and Information Security Awareness and Rules of Behavior Training before being granted access to VA information and its systems.

(1) Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Rules of Behavior before being granted access to VA information and its systems.

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

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

The Certification and Accreditation (C&A) requirements do not apply, and a Security Accreditation Package is not required for this SOW.

All Contractor, Pharmaceutical Company Representative (PCR), and Healthcare Industry Representatives (HIR) will coordinate with Contracting Officer Representative for instructions, so they are in compliance with James A. Haley Veterans’ Hospital policies listed on the JAHMC Document Management Center share point site:

HPM NO. 90-25; HEALTHCARE VENDOR ACCESS AND COMPETENCY

HPM NO. 132-04; SECURITY MANAGEMENT PROGRAM

HPM NO. 13205; HOSPITAL IDENTIFICATION PROGRAM

HPM NO. 11-91; PHARMACEUTICAL COMPANY REPRESENTATIVES

HIR are required to report to MSDU (Room GC-003), immediately after entering the facility. HIR will be required to sign into the monitoring system and print a badge for proper identification. The Healthcare Industry Representatives for Nutrition and Food Services, Office of Information and Technology, and Social Work Services are in included in this policy; vendors (HIR) for Pharmacy Services are to follow (HPM 11-91) policy. HIR must be sponsored by a physician, a Service Chief, or their designee, for a specified date and a specified case. HIR are not permitted in patient care areas or clinics unless a prior appointment has been made.

Pharmaceutical Company Representative (PCR) refers to anyone acting on behalf of a pharmaceutical company or its business partners for the purpose of promoting the use of items managed under the VA formulary process. These items primarily include drugs, but to a lesser extent also include any medical supplies, nutritional supplements, and similar commodities managed under the VA formulary process.

Sign-In: PCRs may visit VA Medical care facilities no earlier than 8:00 a.m. and stay no later than 3:30 p.m., Monday through Friday, unless they receive prior approval from both the Chief of the Service that they will be visiting and the Chief of Pharmacy. Representatives visiting the JAHVH must sign in at the Pharmacy Administrative Office (Located in Trailer 78) and wear a visitor’s badge as well as their company’s personal name badge while in the hospital.

Vendors: Reference Hospital Memorandum Policy Number 90-25 Healthcare Vendor Access and Competency.

Contractors and/or project managers: Will be issued a PIV/ID badge in accordance with the facility PIV Policy. Contactors will contact their assigned VA Contracting Officer Representative (COR) for coordination.

Contract Personnel/Sub-Contractors: Contractors are responsible for the daily accountability and identification of all personnel assigned to their respective contract including sub-contractors. Contractors will identify personnel using the following procedures as appropriate.

Construction Project contract personnel will report to the contractor for issuance of a temporary self-adhesive identification badge. This badge will be issued daily and must include the following information: Company name, project number, date, and name of individual. Contractor will maintain a daily log of all personnel.

Contract personnel not involved in an actual construction project will report to police dispatch for issuance of a numbered badge. A driver’s license or photo ID will be required each day upon entering the facility, in exchange for the badge, and will be given back once the badge is returned to police dispatch. The contractor will provide Police Service with a list of names for all sub-contract personnel requiring access to the facility. It is the responsibility of the contractor to update the list as necessary.

NPR OPC; CBOCs and Off-site Lease facilities with VA Police staffing: As above with check-in with VA Police.

Off-site Lease facilities w/o VA Police staffing: Coordinate with COR, Administrative Officer, or Service Point of Contact.

M. NARA Records Management Language for Contract

1. Contractor Requirements

a) 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. Ch’s. 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.

b) 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.

c) In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created while 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.

d) James A Haley Veterans’ Hospital and Clinics 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 James A. Haley Veterans’ Hospital and Clinics 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, Contractor must report to James A. Haley Veterans’ Hospital and Clinics. The agency must report promptly to NARA in accordance with 36 CFR 1230.

e) The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records, or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract vehicle]. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to James A. Haley Veterans’ Hospital and Clinics 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 Contracting Officer or address prescribed in the [contract vehicle]. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

f) The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and James A. Haley Veterans’ Hospital and Clinics guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

g) The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with James A. Haley Veterans’ Hospital and Clinics policy.

h) The Contractor shall not create or maintain any records containing any non-public James A. Haley Veterans’ Hospital and Clinics information that are not specifically tied to or authorized by the contract.

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

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

k) Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take VHA-provided records management training, Talent Management System (TMS) Item #4192704, Records Management for Everyone. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

[Note: To the extent an agency requires contractors to complete records management training, the agency must provide the training to the contractor.]

2. Flow down of requirements to Subcontractors

a) The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this [contract vehicle], and require written subcontractor acknowledgment of same.

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

N. VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY

1. GENERAL Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

a) A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

b) All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

c) Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness.

d) Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor.

e) The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor’s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

3. VA INFORMATION CUSTODIAL LANGUAGE

a) Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

b) VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor’s information systems or media storage systems, in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct onsite inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

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

d) The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations, and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations, and policies in this contract.

e) The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

f) If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient…

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