Performance Work Statement.pdf

Readjustment Counseling Service (RCS) in North-East Nevada

Performance Work Statement

INTRODUCTION

Readjustment Counseling Service (RCS) consists of 300 Vet Centers, organized into 5

Districts. Vet Centers provide a broad range of readjustment counseling, outreach, and referral services to eligible Veterans, Active-Duty Service Members (ADSMs), and their families, including eligible Coast Guard, National Guard and Reserve members.

BACKGROUND

RCS service mission is to provide readjustment counseling to assist eligible individuals resolve war and other trauma related psychosocial and socioeconomic difficulties and to support eligible individuals with their readjustment back into their home communities.

Vet Centers provide readjustment counseling through individual, group, and family counseling formats. As specified below, referral for contract readjustment counseling will be limited to the provision of individual, group and family readjustment counseling to eligible individuals. Individuals eligible for readjustment counseling currently include

Veterans, Service Members, including National Guard and Reserve personnel, and U.S.

Coast Guard members whose military duties involved exposure to traumatic stressors, either within or in support of areas of hostilities, or in response to domestic crises, national or state, or coast guard members engaged in drug interdiction operations. All such duty assignments have the potential for interfering with a successful readjustment to civilian or continuing military life. In addition, the family members of all eligible individuals are eligible to participate in family readjustment counseling as indicated for the readjustment of the eligible individual.

PERFORMANCE OBJECTIVES AND STANDARDS

1. SCOPE OF WORK

The contractor shall furnish readjustment counseling services to eligible individuals and family members referred by the Vet Center COR or by other designated professional counseling staff members of the Vet Center. Readjustment counseling, for purposes of this contract, is counseling provided by social workers and psychologists, or other qualified counselors such as licensed marriage and family therapists (LMFT) or licensed professional mental health counselors (LPMHC).

Contractors will provide readjustment-counseling services to eligible veterans referred by the Vet Center COR in accordance with the requirements of VA Form 10-5565b, the

RCS Contract Services Authorization. Readjustment counseling can be provided individually, in groups and/or within the context of a family meeting. In whatever approved format, readjustment counseling is directed at social, psychological or behavioral difficulties related to post-military readjustment to community or continued military life.

The contractor will provide all eligible individuals the following services as clinically indicated:

a) Group counseling

b) Individual, couple, and family readjustment counseling

c) Substance abuse assistance

d) Other supportive counseling services for socioeconomic readjustment problems such as employment and career counseling as part of readjustment counseling

(which does not include job placement services).

e) Any other psychosocial or healthcare needs that go beyond the scope of the contract will be coordinated for appropriate referral through the COR.

The contractors shall maintain counseling records for recording all delivered services provided to Vet Center referred clients inclusive of the psychosocial assessment, military history, service plans, risk assessments, Warwick, Crisis Reports and ongoing client visits.

All assigned contractor staff shall be required to undergo a background investigation and compete initial and annual Privacy and Security training in accordance with VA

Handbook 6500.6 prior to the contractor’s employment. Work cannot begin until favorable background investigations are complete.

The contractor shall identify staff and provide licenses for all staff that are providing counseling services to the Contracting Officer’s Representative (COR) for evaluation:

a. The contractor shall provide verification of professional credentials of each staff through documentation of all Federal or State professional license(s) and/or certification(s) applicable to the provision of readjustment counseling services

b. The contractor shall provide official verification of educational credentials will be obtained from the academic institution awarding a professional degree to the contractor and designated staff.

c. Prior to the contractor’s start of providing services to client, the contractor’s staff need to complete the following training:

1. TMS 10176 (VA Privacy and Information Security Awareness and Rules of Behavior) At onset of contract and annually.

2. TMS 10203 (Privacy and HIPAA Training) At onset of contract and annually.

3. Sign the Rules of Behavior.

d. Contractor will provide all required documentation of professional credentials to the Contracting Officer at the time of the award.

2. PERIOD OF PERFORMANCE:

Base Year: (7/1/25 to 6/30/26)

Option Year 1: (7/1/26 to 6/30/27)

Option Year 2: (7/1/27 to 6/30/28)

The length of time in which counseling services are provided to individual veterans under this contract will be as authorized by Readjustment Counseling Service Vet

Center COR. In any case, if readjustment counseling beyond the one-year period of the contract is indicated, and if the contract is not renewed, the contract provider is responsible to make appropriate referral to another counseling resource, in consultation with the original VA referrer to ensure no break in services. VCD need to demonstrate a need for continued service with contractor, beyond two years, in doing so, Deliverables and Quality assurance plan must exceed a 95% threshold for continued service beyond two years. Deliverables, record management must exceed 95% threshold for continued services beyond two years.

All clinical indicators must be evident for service to continue beyond two years. A nexus between military history treatment must be clearly documented for continued service beyond 2 years.

3. CONTRACT TYPE: USUAL AND CUSTOMARY FEE.

Contracts will only be entered into by VA which are based on a rate schedule (amount charged by provider for each client visit) which falls within the range of usual and customary fees for the specific geographical area in which services are provided. The contracting officer in consultation with the contracting officer’s Representative (COR) is responsible for determining the usual and customary fee, through communication with the State, County, or District for (a) American Psychological Association for

Psychologists; (b) Association of Social Workers, for Psychiatric Social Workers;

American Counseling Association for LMHPCs; and American Association of Marriage and Family Therapists FOR LMFTs. In instances where conflicting data is provided, the

COR must consult with the local VAMC Chief of Psychiatry, Psychology, or Social Work

Service to determine the usual and customary fees for services provided by a mental health worker other than those from the three professional disciplines listed above.

4. PLACE OF PERFORMANCE:

Service providers submitting offers in response to this request for proposals must be physically located in North-East Nevada. VA will only make referrals to providers under this contract for circumstances where VA or other government facilities are not capable of furnishing needed services or cannot do so economically because of geographical distances.

5. SPECIFIC TASK/REQUIREMENTS:

The contractor shall provide, at a minimum, all tasks and deliverables described within this document.

1. PROJECT MANAGEMENT

The contractor shall manage its staff to include training VA policy and procedures. The

COR in collaboration with the Associate District Director for counseling and the

Associate District Director for Administration shall provide the contractor with a high level of explanation of the services offered and protocol for invoicing. The contractor shall provide routine clinical supervision to all staff that are providing services through the contract.

The contractor shall designate a Project Manager (PM) who shall provide oversight of all contracted work. The PM shall be available during regular business hours (7:30 a.m.-

4:30 p.m. (Mon-Fri) and shall return all calls and emails within 24 hours. However, for emergency situations, the PM is required to respond within a 2-hour period. The PM shall attend the kick-off meeting in person or virtually via telephone or TEAMS to discuss the project approach, schedules, milestones, and provide the contractor points of contact (POCs).

Deliverables:

1. PROJECT MANAGEMENT:

a. KICK-OFF MEETING

The contractor shall attend a kick-off meeting five (5) business days after order award date. This meeting will preferably be a face-to-face meeting at the contractor’s location but may be conducted via telephone or TEAMS if necessary. The meeting will consist of the contractor specifying their methods and staff necessary to complete the task. The meeting will also consist of the review of the Contract for Fee polices and guidelines.

b. MONTHLY STATUS REPORTS

The contractor shall submit monthly status reports unless otherwise specified on the TO

(Task Order). The contractor shall report on any barriers to completing the task and will make every effort to ensure that issues raised by the local vet center are addressed.

The monthly report should include the name of each client, VIF number, total number of sessions, type of session (i.e., individual, group, family or referral services) referral date, start date and closing date relevant to completing the work. Documented visits that are within the approved number and length of visits are billable.

2. RECORDS MANAGEMENT:

Contractors will maintain counseling records for recording all delivered procedures provided to Vet Center referred clients inclusive of the psychosocial assessment, military history, service plans and ongoing client visits. Counseling Records are considered the property of the VA and will be maintained according to RCS record standards, adhere to Privacy Act and HIPAA and that are accurate, complete and in compliance with professional standards and RCS records standards for clinical record keeping. Any request for records would be submitted to the COR for consideration of release.

Deliverables:

a. COMPREHENSIVE PSYCHOSOCIAL ASSESSMENT

The contractor will complete the psychosocial assessment in accordance with VHA and

RCS policy and guidelines.

The contract providers will complete an initial comprehensive psychosocial assessment that reflect the psychosocial problem areas and provisions of readjustment counseling.

The contractor will complete the psychosocial assessment within 5 sessions. A suicide risk assessment is completed on the first visit.

Subsequent psychosocial assessments are not to be repetitious copies of the original, but rather should build on and clinically amend the original contingent upon case movement and newly emerged readjustment problems.

b. SERVICE PLAN

The contractor will complete the service plan in accordance with VHA and RCS policy and guidelines.

The contract providers will complete an initial service plan that reflects the psychosocial problem areas and planned provisions of readjustment counseling.

The contractor will complete the first service plan within 5 sessions of the 1st visit, and develop a new service plan every 180 days thereafter.

Subsequent service plans are not to be repetitious copies of the original, but rather should build on and clinically amend the original contingent upon case movement and newly emerged readjustment problems.

The contractors are to ensure their readjustment counseling service plans clearly reflect the findings of the psychosocial assessment concurred on by the eligible individual and include all applicable readjustment counseling interventions that will be employed

(individual, group, and family) and expected outcomes.

The service plan will reflect the configuration of PSFAs introduced by the individual during the intake interviews and subsequent counseling visits. Each plan also reflects the full composite of readjustment counseling modalities being provided (e.g., individual, group, and family counseling).

c. PROGRESS NOTES

A progress note contains the substantive counseling content that occurred during a face-to-face interview or counseling visit held at the contracting site. It must accurately record the relevant aspects of the visit with the eligible individual and address agreed-upon interventions and expected outcomes. All visit progress notes must be signed and dated by the counselor as well as indicate the visit type (individual, group, family).

Progress notes document the substance of contractor visits and must be entered by the contractor’s staff into the individual record within two working days from date of the visit.

Individual records contain two types of notes: visit progress notes and non-visit progress notes. Progress notes will include the time and date the note was entered. Contractor must use an addendum to make any subsequent changes and corrections to a progress note. The original text of the progress note is integral to the eligible individual’s official record and must not be altered or destroyed.

Use of the Description Assessment Plan format. The Description, Assessment, and

Plan (DAP) format will be utilized for recording all visit and non-visit progress notes used to document substantive readjustment counseling services provided and significant counseling supportive activities such as case staffing, consultation and/or supervision.

(1) Description. Describes the counselor’s subjective and objective observations regarding the visit’s substantive case content.

(2) Assessment. Describes the counselor’s estimation as to the individual’s current case progress related to the psychosocial assessment and service plan.

(3) Plan. Describes the counselor’s plan for therapeutically alleviating the eligible individual's readjustment problems. The plan should reflect and build upon previous progress notes and be forward looking to the next scheduled appointment.

The contractor will complete and document in the counseling record by the contractor for all telephone interventions of substantive direct service content with eligible individuals.

The contractor will complete the progress notes (whether the individual showed or no showed) within two business days for every in-center visit and will document the eligible individuals service need(s) based on the psychosocial assessment and military history, therapeutic goals and interventions as reflected in the service plans, and the type of readjustment counseling visit: individual, group, family.

Required visit information will include:

(1) PSFAs problem code(s) that describe the focus of the readjustment counseling provided during the visit.

(2) Type of counseling intervention (individual, group, family).

(3) Family member(s) who participated in the family counseling session,

d. NON-VISIT PROGRESS NOTES:

Contractor staff must enter non-visit progress notes into the counseling record for the following:

(1) Routine appointment scheduling,

(2) Case Assignments. The note will specify the Contractor (or designee) making the case assignment, the assigned Contractor provider, and the provider’s professional qualifications vis-à-vis the readjustment needs of the eligible individual (and, as appropriate, their family).

(3) Case Transfers. This note is completed by the originating Contractor provider and should explain the reason for the case transfer and document the means used to communicate to the eligible individual the reason for the transfer.

(4) Case Staffing and Supervision. Client case staffing and consultation require a non-visit progress note written in DAP format indicating the participants, counseling issues discussed, and recommendations for continuing readjustment counseling.

(5) Follow-up Contact for Missed Appointments. It is the responsibility of the contractor counselor to make every effort to contact and re-engage any eligible individual who fails to show for a scheduled appointment, to assess their current psychosocial situation and the reason for missing the appointment

a. Follow-up for eligible individuals assessed at low risk is attempted by telephone or other electronic means no later than 24 hours (one workday) after the scheduled appointment. If the eligible individual is not contacted, the counselor will follow-up as professionally indicated.

b. In the case of a missed appointment for an eligible individual who has been assessed as intermediate to high-risk, follow-up telephone calls should be made within (1) hour of the scheduled appointment, and periodically thereafter until the individual has been re-contacted, and/or until some responsible party has been contacted who can reliably confirm their status.

e. CRISIS REPORTING

The contractor will report all client crisis events, for severe and unrelenting suicidal ideation, attempts and completions, are required according to the timelines specified below to the COR.

f. RISK ASSESSMENT

RCS divides suicide risk into two interrelated categories: Acute and Chronic. The variables used to differentiate acute from chronic risk are similar in both circumstances, but their symptoms are unique in persistence and intensity. The core variables to consider when assigning acute and chronic levels of risk should include risk indicators such as intensity of suicidal ideation and intent, environmental risk factors such as psychosocial instability, personal warning signs such as emotional distress or behavioral acting out, and protective factors such as environmental support or coping skills that are available to the individual to maintain safety, either independently or with external assistance.

(a) Acute Risk. Acute suicide risk refers to an estimation of risk in the next few hours to days and one’s ability to independently maintain safety during that timeframe. Factors to consider in making this determination include: presence and nature of recent suicidal ideation or behavior, environmental and psychosocial stressors, and any other factors that might have resulted in acutely elevated risk in the past. Additionally, protective factors, such as reasons for living, should be considered.

(b) Chronic Risk. Chronic risk refers to an estimation of risk over a longer period of time (days to weeks and beyond). In making a determination about the level of chronic risk, one considers the presence of persistent suicidal ideation, chronic mental health conditions and psychosocial stressors, previous suicide attempts, and maladaptive coping skills. These factors are considered in the context of long-term protective factors, such as strong social support and ability to utilize coping skills.

The contractor is required to complete a Risk Assessment on the first counseling encounter, and to complete additional Risk Assessments on subsequent visits contingent upon the counselor’s judgment, especially focusing on documenting changes in risk. The risk assessments will be conducted via a face-to-face interview whenever possible and will incorporate collateral information as deemed appropriate by the contractor.

The contractor will develop a Safety Plan in conjunction with the individual that identifies the specific stressors and plans for maintaining safety if they the individual is assessed to be from intermediate to high risk. The Safety Plan will be developed in direct interaction with the individual and will specifically identify the safety/coping strategies identified by the individual. A copy of the completed Safety Plan will be provided to the individual and the original retained in the counseling record.

g. CLOSING CONTRACTOR COUNSELING RECORDS

When all the interventions included in the service plan have been completed, or when an eligible individual abandons readjustment counseling (as evidenced by the documentation of a reasonable sequence of unsuccessful attempts by contractor staff to re-engage the eligible individual by telephone and follow-up letters) the responsible contractor counselor is to close the case, documenting the basis for the closure and all the steps justifying this action.

1. The contractor will provide documentation and enter a non-visit progress note in their counseling record. This note must specifically include the readjustment counseling case summary, inclusive of the presenting readjustment problem(s), the configuration of PSFAs problem codes addressed, the general course of readjustment counseling via the planned interventions and expected outcomes, any referrals made, case consultations, the reasons for closing the case, and the counselor’s assessment regarding the eligible individual’s need for further readjustment counseling.

2. When a contract provider has completed all required services for a referred client, the case will be closed.

3. Contractors whose contract has expired or been terminated will bring all assigned clients to an appropriate clinical termination.

3. QUALITY REVIEW OF COUNSELING SERVICES:

Oversight monitoring of RCS contract operations will consist of onsite assessment of the contract provider’s operations in implementation of the contract provisions, and annual oversight of the COR’s operational activities in management of the contract program(s) assigned to their jurisdiction. VA policy governing the required activities of assigned CORs is stated in VHAPM Part 801.603-70, COR SOP, Revision 08, May 7, 2021. COR basic responsibilities are outlined in Attachment D of this policy, ‘COR Delegation Memo’. Attachment D also identifies the COR’s application of the QASP for quality assurance. The protocol for the quarterly COR report for contractor performance evaluation and the protocol for fiscal management are provided in Attachment F and G respectively.

a. QUAILTY REVIEW OF SERVICES

1. Operational management is the primary responsibility of the Vet Center COR for verifying eligibility, authorizing readjustment counseling services, tracking contract caseload activity, and monitoring fiscal operations for all contract providers under their jurisdiction. The COR’s ongoing management responsibilities are appropriately conducted in coordination with the VA

Contracting Officer, the contract provider, the RCS DDD and/or designated

ADD/C and/or ADD/A.

2. Due to the sensitivity of the readjustment counseling service mission, the COR will also be responsible for conducting onsite quality visits to the contract provider’s location to assess its adequacy for readjustment counseling services, interview staff providers assigned to the Vet Center contract, and review the contract provider’s caseload inclusive of a chart review of 10% contract provider’s active clients. The initial on-site visit will be made immediately following award of contract, followed by a second onsite visit after the first full year of operation, and thereafter following an alternating schedule of onsite and remote every other year. RCS retains the right to review records and conduct site visits as deemed appropriate by the government. The contract document will clearly articulate the COR’s authority for conducting onsite evaluations of the contract provider’s service delivery and billing procedures.

3. As designated by the RCS DDD having responsibility for district contract operations, annual oversight reviews of Vet Centers with contract counseling will be conducted by the ADD/C in coordination with the ADD/A for assistance with fiscal and other administrative matters. As logistically feasible, the annual CFF oversight visits will be conducted in conjunction with the annual Vet Center clinical site visit with participation of the ADD/C and ADD/A contingent upon their respective domains of expertise. ADD/C and ADD/A level oversight will take into consideration the assessment of the COR’s management of all aspects of Vet

Center contract program management including all administrative and counseling service operations. ADD/C and ADD/A contract program site visits will be completed online and housed in the RCS National Service Support (NSS) data repository, where they are subject to review by the responsible RCS DDD and the RCS Deputy Chief Officer (DCO) having national responsibility for readjustment counseling oversight.

4. On-site visits to the contract provider’s location by the ADD/C and/or the ADD/A may also be authorized as needed to respond to any administrative or clinical concerns or problems that develop during the term of the contract. These reviews may be conducted for the purposes of ensuring quality service delivery to eligible individuals, effective utilization of federal funds, and/or for addressing any procedural difficulties arising from the relationship of the contract provider with relevant VA staff.

5. In conjunction with the annual scheduling of the clinical oversight visits, ADD/C and ADD/A CFF annual oversight may be conducted on an alternating on-site and remote schedule, where every CFF program will receive an onsite assessment at least every other year, or biannually.

6. All site visits by the ADD/C and/or ADD/A will be conducted in compliance with

RCS national policy standards and reported via CFF Site Visit Protocols developed and approved by the RCS national clinical team directly responsive to the RCS DCO. Completed reports will be used to document deficiencies and/or irregularities noted along with recommendations and timeliness for corrective action.

8. DELIVERABLES

All deliverables shall be submitted to the Contracting Officer Representative (COR), in accordance with each individual task order. Unless otherwise stipulated, written deliverables shall be phrased in plain English. Statistical and other technical terminology shall not be used without providing a glossary of terms.

SOW

Section

Deliverable Description Estimated Qty Due Date

7.1 Project Management

7.1 a Kick-Off Meeting 1 5 business dates after award

7.1 c Weekly Status Report 1 per week Every 1ST Monday of the month by COB

7.2 Records Management

7.2 a Comprehensive Psychosocial Assessment

1 Due within 5 days after 1st visit or as clinically indicated per section 7.2 a

7.2 b Service Plan 1 per 180 days Due within 5 days after 1st visit and every 180 days thereafter

7.2 c Progress Notes 1 per session Due within 48 hours of session.

7.2 d Non-Visit Progress Notes: As clinically indicated per section 7.2 d

As clinically indicated per section 7.2 d

7.2 e Crisis Reporting As clinically indicated per section 7.2 e

As clinically indicated per section 7.2 e

7.2 f Risk Assessment 1st visit of each client then as clinically indicated per section

7.2 f

Due on 1st visit of each client then as clinically indicated per section 7.2 f

7.2 g Closing Contractor Counseling Records

1 per client Due upon termination of services

7.3 Quality Review of Counseling

Services

7.3 a Quality Review of Services 1 Annually

9. GOVERNMENT FURNISHED INFORMATION/PROPERTY:

Each Vet Center will identify and provide the records/documents for quality review. The local Vet Center and RCS National Service Support (NSS) office will provide the contractor with guidance to identify the indexing values for all document types. The contractor shall provide a windows compatible laptop for individual use.

10. KEY PERSONNEL: ANY OF THE FOLLOWING PERSONNEL:

Professional Qualifications of Contract Providers: Prospective contract service providers will be required to identify all staff providing counseling services under this contract according to the 4 licensed counseling professions referenced above, psychologist, social worker, mental health counselor, marriage and family therapist, and to verify the professional credentials of each through documentation of all Federal or State professional license(s) and/or certification(s) applicable to the provision of readjustment counseling services. In addition, official verification of educational credentials will be obtained from the academic institution awarding a professional degree to the contractor and designated staff. All required documentation of professional credentials will be provided to the Contracting Officer at the time of the award.

1) Psychologist:

Minimum Education: PsyD/ PHD

Minimum Experience: 3 Years Counseling experience.

2) Social Worker:

Minimum Education: MSW degree

3) Marriage and Family Therapist:

Minimum Education: MA/MS degree

4) Licensed Professional Mental Health Counselor:

Minimum Education: MA/MS/EdD degree

11. Substitution of Personnel

All the contractors requests for approval of substitutions hereunder shall be submitted in writing to the COR and the Contracting Officer at least sixty (60) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the

Contracting Officer necessary to approve or disapprove the proposed substitution. New personnel shall not commence work until all necessary security requirements have been fulfilled and resumes provided and accepted. The COR and the Contracting Officer will evaluate such requests and promptly notify the contractor of approval or disapproval in writing.

The contractor shall be responsible for managing and overseeing the activities of all contractors’ personnel, as well as subcontractor efforts used in performance of this effort. The contractor’s management responsibilities shall include all activities necessary to ensure the accomplishment of timely and effective support, performed in accordance with the requirements contained herein.

12. Quality Assurance Surveillance Plan (QASP)

The Government shall evaluate the contractor's performance in accordance with the

Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the government must do to ensure the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rates.

The contractor’s performance on this task order will be reported on an annual basis to the Contractor Performance Assessment Reporting System (CPARS). Poor performance may result in issuance of a Discrepancy Report (CDR), as outlined in

Section 5.2 of the IDIQ contract. The CO and COR will make use of information from

CDRs, as well as any additional knowledge and information available to them with respect to the contractor’s performance, to complete the CPARS. The Government will not pay for services that do not conform or do not meet performance standards or have not been properly rendered. the contractor will be given an opportunity to correct non-conforming services at no cost to the Government if the services are non-conforming or the contract requirement is unacceptable.

Deliverable or Requirement

Performance Standard

Surveillance Method

Outcome

Kick off Meeting 100% of the Kickoff Meeting and RCS Policies and guidelines for services shall be provided.

The deliverables and services shall meet the requirements as outlined in Section 7 of the SOW.

Deliverables shall be free of grammatical and typographical errors 95% of the time

100% Inspection.

The COR will review each Deliverable for quality/timeliness according to criteria established.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Monthly status reports (7.1)

Status reports will provide monthly reports on the implementation of counseling services. The monthly report should include the name of each client, VIF number, total number of sessions, type of session (i.e., individual, group, family or referral services) referral date, start date and closing date relevant to completing the work.

100% Inspection.

The COR will review each Deliverable for quality/timeliness according to criteria established.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Comprehensive Psychosocial Assessment (7.2)

The psychosocial assessment will show a clinically significant connection between the individual’s pre-military social history, military history, and post-military levels of functioning.

100% Inspection.

The COR will review each Deliverable for quality/timeliness according to criteria established.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Service Plan (7.2)

Service Plans will be completed by the 5th session, identify the full scope of readjustment problems discussed, the planned readjustment counseling interventions, and will be updated every 180 days to document clinical growth.

100% Inspection.

The COR will review each Deliverable for quality/timeliness according to criteria established.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Progress Notes (7.2)

Progress Notes should be written in DAP format and entered within 48 hours of counseling session.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Non-Visit Progress Notes (7.2)

Non-Visit Progress notes are entered for case assignments, case transfers, case staffing and supervision, case consultation and case coordination with external providers.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered

Crisis Reporting (7.2)

Counselors will inform the COR by close of business on the day of notification.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Risk Assessment (7.2)

All individuals will be assessed for suicide on the first visit. Risk assessments will be recorded as Low, Intermediate or High, in two interrelated categories, Chronic and Acute.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Closing Contractor Counseling Records (7.2)

Progress notes documenting successful completion of all service plan interventions, or non-visit progress notes documenting appropriate, but unsuccessful attempts to reengage an eligible individual.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered to be within scope of this SOW.

Quality review of Counseling Services (7.3)

Review of CFF Site Visit Protocols completed by the RCS ADD/C, and two reports completed by the Vet Center COR: (1) the QASP and (2) the COR Contractor Performance Evaluation Reports: Attachment E, VHAPM Part 801.603-70

COR SOP.

100% Inspection.

The COR will review each Deliverable for quality/timeliness according to criteria established.

Contractor shall re-work products found to be unacceptable or not meeting the intent of the task and the re-work considered

IT CONTRACT SECURITY VA INFORMATION AND INFORMATION SYSTEM

SECURITY/PRIVACY

1. GENERAL

Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and

Handbooks as VA and VA personnel regarding information and information system security.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

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

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

Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

c. Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of

Veterans Affairs does not have a Memorandum of Agreement with Defense Security

Service (DSS). Verification of a Security Clearance must be processed through the

Special Security Officer located in the Planning and National Security Service within the

Office of Operations, Security, and Preparedness.

d. Custom software development and outsourced operations must be located in the

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

e. The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor's employment. The Contracting

Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

3. VA INFORMATION CUSTODIAL LANGUAGE

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

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

c. Prior to termination or completion of this contract, contractor/ subcontractor must not destroy information received from VA, or gathered/ created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its

Handbook 6300.1 Records Management Procedures, applicable VA Records Control

Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

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

Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract.

e. The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement and will not preserve electronic information to be stored on contractor/subcontractor electronic storage media for restoration in any case. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

f. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

g. If a VHA contract is terminated for cause, the associated BAA must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship.

h. The contractor/subcontractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated.

i. The contractor/subcontractor's firewall and Web services security controls, if applicable, shall meet or exceed VA's minimum requirements. VA Configuration

Guidelines are available upon request.

j. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA's prior written approval. The contractor/subcontractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response.

k. Notwithstanding the provision above, the contractor/subcontractor shall not release

VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor is in receipt of a court order or other requests for the above-mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response.

l. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security

Control Assessment (CSCA) on a yearly basis and provide it to the COR.

4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT

a. Information systems that are designed or developed for or on behalf of VA at non-

VA facilities shall comply with all VA directives developed in accordance with FISMA, HIPAA, NIST, and related VA security and privacy control requirements for Federal information systems. This includes standards for the protection of electronic PHI, outlined in 45 C.F.R. Part 164, Subpart C, information and system security categorization level designations in accordance with FIPS 199 and FIPS 200 with implementation of all baseline security controls commensurate with the FIPS 199 system security categorization (reference Appendix D of VA Handbook 6500, VA

Information Security Program). During the development cycle a Privacy Impact

Assessment (PIA) must be completed, provided to the COR, and approved by the VA

Privacy Service in accordance with Directive 6507, VA Privacy Impact Assessment.

b. The contractor/subcontractor shall certify to the COR that applications are fully functional and operate correctly as intended on systems using the VA Federal Desktop

Core Configuration (FDCC), and the common security configuration guidelines provided by NIST or the VA. This includes Internet Explorer 7 configured to operate on Windows

XP and Vista (in Protected Mode on Vista) and future versions, as required.

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

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

e. The security controls must be designed, developed, approved by VA, and implemented in accordance with the provisions of VA security system development life cycle as outlined in NIST Special Publication 800-37, Guide for Applying the Risk

Management Framework to Federal Information Systems, VA Handbook 6500, Information Security Program and VA Handbook 6500.5, Incorporating Security and

Privacy in System Development Lifecycle.

f. The contractor/subcontractor is required to design, develop, or operate a System of

Records Notice (SOR) on individuals to accomplish an agency function subject to the

Privacy Act of 1974, (as amended), Public Law 93-579, December 31, 1974 (5 U.S.C.

552a) and applicable agency regulations. Violation of the Privacy Act may involve the imposition of criminal and civil penalties.

g. The contractor/subcontractor agrees to:

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

(a) Comply with the RCS Systems of Records (SOR) for all relevant actions to include client recording, referrals, bulling, etc.

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

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

and

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

h. In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a

SOR on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a SOR on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a SOR on individuals to accomplish an agency function, the contractor/subcontractor is considered to be an employee of the agency.

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

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

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

i. The vendor shall ensure the security of all procured or developed systems and technologies, including their subcomponents (hereinafter referred to as "Systems"), throughout the life of this contract and any extension, warranty, or maintenance periods.

This includes, but is not limited to workarounds, patches, hotfixes, upgrades, and any physical components (hereafter referred to as Security Fixes) which may be necessary to fix all security vulnerabilities published or known to the vendor anywhere in the

Systems, including Operating Systems and firmware. The vendor shall ensure that

Security Fixes shall not negatively impact the Systems.

j. The vendor shall notify VA within 24 hours of the discovery or disclosure of successful exploits of the vulnerability which can compromise the security of the

Systems (including the confidentiality or integrity of its data and operations, or the availability of the system). Such issues shall be remediated as quickly as is practical, but in no event longer than days.

k. When the Security Fixes…