S02 36C25722Q0744 v2.pdf

PAGE 1 OF 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. UEI: EFT:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

549-22-3-352-0295

36C25722Q0744 08-12-2022

Frank Mendoza 972-780-0800 08-18-2022

3:00 PM CDT

36C257 Department of Veterans Affairs NCO 17 North Texas Healthcare System Regional Procurement Office West (RPO-W) 124 E. Hwy 67, Suite 100 Duncanville TX 75137

X

541990

$16.5 Million

N/A

36C257

Department of Veterans Affairs North Texas Healthcare System 4500 S Lancaster Rd

Dallas TX 75116

36C257

NCO 17

Department of Veterans Affairs North Texas Veterans Health Care Center 124 E. Hwy 67, Suite 100 Duncanville TX 75137

This is accomplished through the Tungsten Network located at:

http://www.fsc.va.gov/einvoice.asp This is mandatory and the sole method for submitting invoices.

(877) 353-9791 (512) 460-5540

See CONTINUATION Page

Contractor shall provide Patient Satisfaction Services surveys IAW Statement or Work on page 10.

This acquisition is IAW FAR 12 and FAR 13.5.

Notification to Offerors:

Offerors must complete and return all information designated in Section E prior to the time specified in block 8 of

SF 1449 pg1.

Blocks 30a,30b and 30C on pg. 1 must be completed and signed to be considered for award.

Refer to instructions to Offerors and Evaluation factors on pages 49 and 59 for additional details.

See CONTINUATION Page

X 1

Frank Mendoza Contracting Officer

36C25722Q0744

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 PRICE/COST SCHEDULE

ITEM INFORMATION

B.3 STATEMENT OF WORK (SOW)

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL PRODUCTS

AND COMMERCIAL SERVICES (NOV 2021)

C.2 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.3 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.4 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

C.5 VHA SUPPLEMENTAL CONTRACT REQUIREMENTS FOR COMBATTING COVID-

C.6 VAAR 852.212-70 PROVISIONS AND CLAUSES APPLICABLE TO VA

ACQUISITION OF COMMERCIAL ITEMS (APR 2020)

C.7 VAAR 852.242-71 ADMINISTRATIVE CONTRACTING OFFICER (OCT 2020)

C.8 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (MAY 2022) (JUL 2020) (DEVIATION)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN

D.2 WAGE DETERMINATION DFW

D.3 PAST PERFORMANCE REFERENCES

SECTION E - SOLICITATION PROVISIONS

E.1 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (NOV 2021)

E.2 52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS

AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

E.3 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (OCT 2018)

E.4 52.216-1 TYPE OF CONTRACT (APR 1984)

E.5 52.233-2 SERVICE OF PROTEST (SEP 2006)

E.6 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB

1998)

E.7 52.212-2 EVALUATION—COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES (NOV 2021)

E.8 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL

PRODUCTS AND COMMERCIAL SERVICES (MAY 2022) (JUL 2020) (DEVIATION)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

Phone: ____________________________________

Email: ____________________________________

SAM UEI Number: ____________________________

TAX ID: __________________________________

b. GOVERNMENT:

Frank Mendoza, Contracting Officer Network Contracting Office 17 VHA Regional Procurement Office-West (RPOW) Blng 124 E HWY 67 Suite 100 Duncanville, TX 75137

Phone: 972-780-0801 Email: francisco.mendoza@va.gov

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor shall be electronically reimbursed:

[X} 52.232-33, Payment by Electronic Funds Transfer- System For Award

Management

[ ] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly [ ]

b. Semi-Annually [ ]

c. Other [ x ] Monthly in arrears.

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

mailto:francisco.mendoza@va.gov

5. SECURE FAX: Please review VA Handbook 6500 that requires the following statement on all fax cover sheets be included: This fax is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this fax does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please notify this office immediately at the telephone number listed above.

6. The Contracting Officer will schedule a post award orientation for contract orientation purposes as required by VA Acquisition Manual, Part M842.502-70.

7. ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

B.2 PRICE/COST SCHEDULE

ITEM INFORMATION

ITEM

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

1.00 YR __________________ __________________

A VISN 17 contract: VA North Texas Health Care System (VANTHCS) will develop and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level.

VANTHCS serves over 205,000 enrolled Veterans in 38 counties in North Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Base POP Begin: 09-30-2022 POP End: 09-29-2023 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, and Technical Services PRODUCT/SERVICE CODE: R499 - Support - Professional: Other

A VISN 17 contract: VA South Texas Health Care System will develop and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level. VASTHCS serves over 205,000 enrolled Veterans in 38 counties in SOUTH Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 1 POP Begin: 09-30-2023 POP End: 09-29-2024 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, will develop and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level.

VANTHCS serves over 205,000 enrolled Veterans in 38 counties in North Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 1 POP Begin: 09-30-2023 POP End: 09-29-2024 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level. VASTHCS serves over 205,000 enrolled Veterans in 38 counties in SOUTH Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 1 POP Begin: 09-30-2023 POP End: 09-29-2024 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, will develop and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level.

VANTHCS serves over 205,000 enrolled Veterans in 38 counties in North Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 2 POP Begin: 09-30-2024 POP End: 09-29-2025 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level. VASTHCS serves over 205,000 enrolled Veterans in 38 counties in SOUTH Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 2 POP Begin: 09-30-2024 POP End: 09-29-2025 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, will develop and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level.

VANTHCS serves over 205,000 enrolled Veterans in 38 counties in North Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 3 POP Begin: 09-30-2025 POP End: 09-29-2026 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level. VASTHCS serves over 205,000 enrolled Veterans in 38 counties in SOUTH Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 3 POP Begin: 09-30-2025 POP End: 09-29-2026 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, will develop and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level.

VANTHCS serves over 205,000 enrolled Veterans in 38 counties in North Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs.

Contract Period: Option 4 POP Begin: 09-30-2026 POP End: 09-29-2027 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, and implement a process to provide timely, actionable and accessible patient satisfaction data from the facility/division-level to the unit/clinic-level to prioritize improvement efforts throughout VANTHCS and STVHCS catchment areas. The primary goal is to improve patient satisfaction by having a survey service that provides real-time feedback, identify, root cause of dissatisfaction and offer solutions for progress. The survey service will also provide nursing quality measurement solution, quality indicators and nurse engagement surveys at the unit level. VASTHCS serves over 205,000 enrolled Veterans in 38 counties in SOUTH Texas and 2 counties in Oklahoma. STVHCS serves over 114,193 enrollees across 35 counties in the Southern market of Texas. Health care services are delivered through an integrated system of medical centers, community outpatient or outreach clinics, community living centers, domiciliaries and residential rehabilitation treatment programs. Contract Period: Option 4 POP Begin: 09-30-2026 POP End: 09-29-2027 PRINCIPAL NAICS CODE: 541990 - All Other Professional, Scientific, GRAND TOTAL __________________

B.3 STATEMENT OF WORK (SOW)

PART 1: GENERAL INFORMATION

Introduction: The Department of Veterans Affairs requires non-personnel services contract VISN 17 wide to provide VA North Texas Health Care System (VANTHCS) and South Texas Veterans Health Care System (STVHCS) with systematic surveys of patient experiences. The service will consist of development of inpatient and outpatient satisfaction survey instruments that include customized questions for VANTHCS and STVHCS medical centers and outpatient clinics as well as questions that permit comparison to other VA and non-VA facilities. The primary goal is to improve patient satisfaction by having a service that provides real-time feedback and identifies the root cause of dissatisfaction and offers solutions for progress.

• VA North Texas Health Care Systems – See Attachment A-1 for listings of all facilities

• South Texas Veterans Health Care System – See Attachment A-2 for listings of all facilities

Background: A comprehensive patient satisfaction measurement service is necessary to successfully meet Veteran expectations as measured by VA Performance Measures and Monitors.

Scope: The overall purpose is to develop and acquire a health care consulting service that specializes in the creation, administration, and analysis of patient satisfaction surveys. The primary objective is to increase patient satisfaction at VANTHCS and STVHCS inpatient units and outpatient clinics by providing frontline staff with real-time feedback on patient perceptions that will enable employees to improve their performance and deliver excellent care. The results will be used to gain insight on the opinions of Veterans who use our services. The information will include detailed, comprehensive assessment of patient satisfaction within VANTHC and

STVHCS.

Part 2 Work Requirements

1. Technical Requirements:

• The Contractor should have over 400 million patient engagements annually to include

VA peer groups and non VA health care facilities peer groups

• The Contractor shall have past performance with a minimum of 40 VA facilities

• The Contractor shall provide systematic surveys to key service areas including:

o Customization of survey instrument (from existing vendor surveys and/or Consumer Assessment of Healthcare Providers and Systems (CAHPS) instruments), including a process for survey administration and collection, o An interactive platform for survey response data that does not require local software installation, o A response data analytics and reporting system, o Virtual support/training/coaching

• The Contractor shall be able to benchmark both VA and commercial health care facilities

• The Contractor should be able to provide medical practice reports (i.e. provider-level data) which is critical information for patient experience improvements.

• The Contractors should be able to also provide nursing quality measurement solutions, quality indicators and nurse engagement surveys at the unit level.

• The Contractor shall provide a systematic process based on industry standards to survey patients, family members and Care Givers regarding their healthcare experience.

The Contractor shall propose existing surveys, including the use of(CAHPS)-based tools where applicable or equivalent. Tools Certification needs to be completed within a year.

The Contractor solution shall provide:

o The ability to add VA specific questions.

o The ability to collect, input and report comments (free text) from respondents.

• The Contractor shall provide a project management plan that will include, but is not limited to:

o work breakdown structure, o schedule, o risk management plan, o configuration management plan, o implementation plan, o information security/privacy plan, o training/coaching plan, o quality assurance and control plan, o transition plan, o close-out plan.

• Any solution that is proposed by the contractor must be based on a Commercial Off The Shelf (COTS) platform (or cost effective customized platform) that can be customized for specific needs.

• The platform(s) shall be hosted by the contractor’s server(s).

• Any system maintenance shall be performed outside of business hours.

• Benchmarking capabilities within the healthcare industry

• The contractor shall have the ability to administer surveys in multiple languages.

• On-line and/or in person education sessions/training for staff working with the program and accessing the data and reports.

2. Specific Tasks and Deliverables:

Access to program for online data analysis of VANTHCS and STVHCS. VANTHCS and STVHCS patient data defined queries at the unity, clinic and organizational level.

A survey tool that measures patient satisfaction for the following indices

All indicators of nursing care required by ANCC Magnet recognition program to include courtesy and respect from nurses, careful listening by nurses, response time, pain and education

Front-line staff courtesy and helpfulness Scheduling ease and accuracy Speed of registration process and length of wait Nursing staff (LPN, RN) courtesy Provider courtesy, quality of explanations, amount of face-to-face time with patient Office operations (hours of operations, cleanliness, etc.)

Sensitivity to the patient’s needs (scheduling, privacy concerns, convenience of office hours) Ability to add custom questions to the survey tools for each location

Annual on site data interpretation visits to each facility’s Executive Team Virtual training and support Unlimited customer service phone support during business hours.

Patient comments will be transcribed verbatim and available to VANTHCS and STVHCS via the Contractor on-line portal

Supplying, printing of surveys, cover letters with the logo of the respective medical center with the Director’s electronic signature block, include all first-class postage for those specific services using mail methodology. Digital (email) surveying for valid email addresses.

Supplying postage paid return envelopes for CLC and Inpatient Mental Health hard copies of surveys

The Contractor must use collected data to benchmark using information gathered from other health care institutions that use the same survey instruments. The database used must include information gathered from both commercial and VA hospitals and must allow for inclusion of customized questions for each location.

This service must fulfill the American Nurses Credentialing Center (ANCC) guidelines for survey instruments that allow for hospitals to achieve Magnet Status.

Guidance given on the ANCC website states that hospitals should “choose the highest quality tool that is statistically significant, at the broadest level nationally, with largest cohort to get the greatest comparative value.” Contractors must ensure all survey benchmarking, reporting, and analysis will allow hospital to acquire/maintain Magnet Status. The results will be used to gain insight on the opinions of veterans who use our services. The information will include a detailed, comprehensive assessment of patient satisfaction within VANTHCS and STVHCS.

Assembly of data collected and professional analyses of the data is included in the services. The Contractor will provide access to an online web portal to access patient experience qualitative and quantitative data on demand for each medical center and for the VISN (roll-up of all medical center data). The information will include comprehensive, detailed assessments of our patient’s experiences while they are served at individual medical centers and clinics. The available data will also include a summary for all outpatient clinics and key services included in the contract The on-line web Contractor portal must allow for the creation of customized Ad Hoc reports created by VANTHCS and STVHCS staff using collected data HCS outpatient clinics and services, including the emergency department will be utilizing the service. They require full customization and specialty comparisons, including detailed findings and a full set of data queries available on-line

The Contractor will provide the ability to query on-line data to evaluate satisfaction of services by stop code, patient care unit, site/specialty, survey receipt date, dates of services clinician, and demographics in a timely manner.

3. Schedule for Contract Tasks and Deliverables:

• The Contractor will be expected to contact each patient by the location’s preferred method of delivery. This contact may occur by mail o remail to patients within 3 business days of receipt of the patient information from VANTHCS and STVHCS. The contractor will perform all necessary tasks to provide the quarterly reports within 10 days of the end of each quarter. Scanned surveys can be viewed by VANTHCS and STVHCS staff electronically within 2business days of receipt of the completed survey.

• The contractor shall provide access to the Contractor’s online web portable for on-demand access to data.

4. Method of Evaluating Deliverables:

o VANTHCS and STVHCS medical center staff will evaluate all deliverables and review the resulting data. These reviews will involve validation of the data, viability of the information, and utility of the service in helping improve service to our veterans, as well as the concurrence and/or changes required to proceed with the work as noted in the contractor’s submissions. A Quality Assurance Surveillance Plan (QASP) will be used to assure the success and failure of the vendor for meeting expectations. VANTHCS and STVHCS staff will access the clinic account that checks the number of names/contacts sent from key services, compare to the number of surveys delivered, and analyze data from returned and processed surveys.

o The contractor shall develop and maintain an effective quality control (QC) program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s quality control program is the means by which he assures himself that his work complies with the requirement of the contract and shall be delivered with the contractor’s proposal. After acceptance of the quality control plan the contractor shall receive the Contracting Officer’s acceptance in writing of any proposed change to his QC system.

5. Reserved

6. Post Award Conference/Periodic Progress Meetings:

• Post-Award Kick-Off Meeting shall be scheduled for no later than 10 business days after award. Attendance shall be via telephone and include the CO, COR, and contractor POC and other relevant personnel.

• The Contractor shall attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5.

• The Contracting Officer, Contracting Officers Representative (COR), and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance. At these meetings the Contracting Officer will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced.

Appropriate action shall be taken to resolve outstanding issues.

• These meetings shall be at no additional cost to the government.

7. Facility Information

a) Facility Name: VA North Texas Health Care System 4500 S. Lancaster Road Dallas, Texas 75216

CBOC Locations:

CBOC/Medical Center Name Medical Center/CBOC Address

Dallas VA Medical Center

4500 S. Lancaster Road

Dallas, Texas 75216

Sam Rayburn Medical Center 1201 East 9th Street

Bonham, Texas 75418

Garland VA Medical Center 2300 Marie Curie Boulevard

Garland, Texas 75042

Fort Worth VA Clinic 2201 Southeast Loop 820

Fort Worth, Texas 76119

Denton VA Clinic 2223 Colorado Boulevard

Denton, Texas 76205

Decatur VA Clinic 408 Park West Court

Decatur, Texas 76234

Granbury VA Clinic 1210 Paluxy Medical Circle

Granbury, Texas 76048

Greenville VA Clinic 4006 Wellington Roade, Suite 100

Greenville, Texas 75401

Sherman VA Clinic 1715 Texoma Parkway

Sherman, Texas 75090

Polk Street VA Clinic 4243 South Polk Street

Dallas, Texas 75224

Plano VA Clinic 3804 15th Street

Plano, Texas 75075

Grand Prairie VA Clinic 2737 Sherman Street

Grand Prairie, Texas 75051

Tyler Centennial VA Clinic 428 Centennial Parkway

Tyler, Texas 75703

b) VA North Texas HCS Stop Codes

Primary Stop Code

Primary Stop Code Name Primary

Stop Code

Primary Stop Code Name

104 PULMONARY FUNCTION 321 GI ENDOSCOPY

105 X-RAY 323 PRIMARY CARE/MEDICINE

106 EEG 330 CHEMOTHERAPY PROC.

UNIT-MED.

107 EKG 337 HEPATOLOGY CLINIC

108 LABORATORY 346 ALS CENTER

109 NUCLEAR MEDICINE 348 PRIMARY CARE SHARED

APPT

115 ULTRASOUND 349 SLEEP MEDICINE

116 RESPIRATORY THERAPY 350 GERIPACT

118 HOME TREATMENT SERVICES 372 MOVE! PGM INDIV

121 COMMUNITY RES CARE 401 GENERAL SURGERY

123 NUTRITION/DIETETICS-INDIVIDUAL 403 ENT

124 NUTRITION/DIETETICS-GROUP 404 GYNECOLOGY

Stop Code

Primary Stop Code Name Primary

Stop Code

Primary Stop Code Name

125 SOCIAL WORK SERVICE 406 NEUROSURGERY

130 EMERGENCY DEPT 407 OPHTHALMOLOGY

150 COMPUTERIZED TOMOGRAPHY

(CT) 408 OPTOMETRY

151 MAGNETIC RESONANCE

IMAGING/MRI 409 ORTHOPEDICS

153 INTERVENTIONAL RADIOGRAPHY 410 PLASTIC SURGERY

156 HBPC - PSYCHOLOGIST PODIATRY

160 CLINICAL PHARMACY 413 THORACIC SURGERY

165 BEREAVEMENT COUNSELING 414 UROLOGY CLINIC

166 CHAPLAIN SERVICE - INDIVIDUAL 415 VASCULAR SURGERY

167 CHAPLAIN SERVICE - GROUP 417 PROSTHETICS/ORTHOTICS

170 HBPC - PHYSICIAN 418 AMPUTATION CLINIC

171 HBPC Nursing (RN / LP) 419 ANESTHESIA PRE/POST-OP

CONSULT

172 HBPC PHYSIC EXTND(NP,CNS,PA) 420 PAIN CLINIC

173 HBPC - SOCIAL WORKER 421 VASCULAR LABORATORY

174 HBPC - THERAPIST 427 ANES SPECIAL PROCS IN OR

SUITE

175 HBPC - DIETITIAN 429 PATIENT CARE IN OR

176 HBPC - CLINICAL PHARMACIST 430 CYSTO ROOM IN UROLOGY

CL

177 HBPC - OTHER 434 NON-OR ANESTHESIA

PROCEDURES

180 DENTAL 435 SURGICAL PROCEDURE UNIT

191 COMMUNITY ADHC FOLLOWUP CHIROPRACTIC CARE

197 POLYTRAUMA/TBI IND 507 HUD/VASH GROUP

202 RECREATION THERAPY SERVICE 511 GRANT & PER DIEM INDIV

203 AUDIOLOGY 513 SUBSTANCE USE DISORDER

IND

204 SPEECH-LANGUAGE PATHOLOGY 522 HUD/VASH INDIV

205 PHYSICAL THERAPY 529 HCHV/HCMI INDIV

206 OCCUPATIONAL THERAPY 534 MH INTGRTD CARE IND

209 VIST COORDINATOR 539 MH INTGRTD CARE GRP

210 SPINAL CORD INJURY 552 ICMHR INDIVIDUAL

212 EMG - ELECTROMYOGRAM 555 HOMELESS VT COM EMP SVC

INDIV

250 REHAB SRVCS GROUP 560 SUBSTANCE USE DISORDR

GRP

301 GENERAL INTERNAL MEDICINE 582 PRRC INDIVIDUAL

302 ALLERGY IMMUNOLOGY 583 PRRC GROUP

303 CARDIOLOGY 592 VETERANS JUSTICE

OUTREACH

304 DERMATOLOGY 602 ASSISTED HEMODIALYSIS

305 ENDO./METAB (EXCEPT DIABETES) 669 COMMUNITY CARE CONSULT

306 DIABETES 703 MAMMOGRAM (CAN BE

PRIMARY)

307 GASTROENTEROLOGY 999 OCCUPATIONAL HEALTH

308 HEMATOLOGY

Stop Code

Primary Stop Code Name Primary

Stop Code

Primary Stop Code Name

310 INFECTIOUS DISEASE

312 PULMONARY/CHEST

313 RENAL/NEPHROL(EXCEPT

DIALYSIS)

314 RHEUMATOLOGY/ARTHRITIS

315 NEUROLOGY

316 ONCOLOGY/TUMOR

317 ANTI-COAGULATION CLINIC

318 GERI PROB CONSULT CLINIC

c) Facility Name: South Texas Veterans Health Care System

7400 Merton Minter Boulevard San Antonio, Texas 78229

CBOC Locations:

CBOC Name Medical Center/CBOC Address

Kerrville VA Medical Center 3600 Memorial Boulevard

Kerrville, TX 78028-5768

Balcones Heights VA Clinic 4522 Fredricksburg Road, Suites A-10 and A-88

San Antonio, TX 78201-6521

Data Point VA Clinic 8410 Data Point Drive

San Antonio, TX 78229-3220

Frank M. Tejeda VA Outpatient Clinic 5788 Eckert Road

San Antonio, TX 78240-3900

New Braunfels VA Clinic 705 Landa Street, Suite C

New Braunfels, TX 78130-4170

North Bexar VA Clinic 16019 Nacogdoches Road, Suite 101

San Antonio, TX 78247-1128

North Central Federal VA Clinic 17440 Henderson Pass

San Antonio, TX 78232-1662

San Antonio VA Clinic 4318 Woodcock Drive, Suite 120

San Antonio, TX 78228-1315

San Antonio – Northeast 410 VA Clinic 2391 Northeast Loop 410, Suite 101

San Antonio, TX 78217-5675

San Antonio – Pecan Valley VA Clinic 4243 East Southcross Boulevard, Suite 204

San Antonio, TX 78222-3750

San Antonio – Southwest Military VA Clinic

1714 Southwest Military Drive, Suite 101

San Antonio, TX 78221-1418

Seguin VA Clinic 526 East Court Street

Seguin, TX 78155-5712

Shavano Park VA Clinic 4350 Lockhill-Selma Road, Suite 200

San Antonio, TX 78249-2166

South Bexar County VA Clinic 4610 East Southcross Boulevard, Suite 100

San Antonio, TX 78222-4911

Victoria VA Clinic 1908 North Laurent Street, Suite 150

Victoria, TX 77901-5417

Northwest Health Care Center (*Note

– Pending opening March 2022)

9939 State Hwy 151

San Antonio, TX 78251

d) South Texas VA HCS Stop Codes

Stop Code

Primary Stop Code Name Primary

Stop Code

Primary Stop Code Name

104 PULMONARY FUNCTION 321 GI ENDOSCOPY

105 X-RAY 323 PRIMARY CARE/MEDICINE

Stop Code

Primary Stop Code Name Primary

Stop Code

Primary Stop Code Name

106 EEG 330 CHEMOTHERAPY PROC.

UNIT-MED.

107 EKG 337 HEPATOLOGY CLINIC

108 LABORATORY 346 ALS CENTER

109 NUCLEAR MEDICINE 348 PRIMARY CARE SHARED

APPT

115 ULTRASOUND 349 SLEEP MEDICINE

116 RESPIRATORY THERAPY 350 GERIPACT

118 HOME TREATMENT SERVICES 372 MOVE! PGM INDIV

121 COMMUNITY RES CARE 401 GENERAL SURGERY

123 NUTRITION/DIETETICS-INDIVIDUAL 403 ENT

124 NUTRITION/DIETETICS-GROUP 404 GYNECOLOGY

125 SOCIAL WORK SERVICE 406 NEUROSURGERY

130 EMERGENCY DEPT 407 OPHTHALMOLOGY

150 COMPUTERIZED TOMOGRAPHY

(CT) 408 OPTOMETRY

151 MAGNETIC RESONANCE

IMAGING/MRI 409 ORTHOPEDICS

153 INTERVENTIONAL RADIOGRAPHY 410 PLASTIC SURGERY

156 HBPC - PSYCHOLOGIST PODIATRY

160 CLINICAL PHARMACY 413 THORACIC SURGERY

165 BEREAVEMENT COUNSELING 414 UROLOGY CLINIC

166 CHAPLAIN SERVICE - INDIVIDUAL 415 VASCULAR SURGERY

167 CHAPLAIN SERVICE - GROUP 417 PROSTHETICS/ORTHOTICS

170 HBPC - PHYSICIAN 418 AMPUTATION CLINIC

171 HBPC Nursing (RN / LP) 419 ANESTHESIA PRE/POST-OP

CONSULT

172 HBPC PHYSIC EXTND(NP,CNS,PA) 420 PAIN CLINIC

173 HBPC - SOCIAL WORKER 421 VASCULAR LABORATORY

174 HBPC - THERAPIST 427 ANES SPECIAL PROCS IN OR

SUITE

175 HBPC - DIETITIAN 429 PATIENT CARE IN OR

176 HBPC - CLINICAL PHARMACIST 430 CYSTO ROOM IN UROLOGY

CL

177 HBPC - OTHER 434 NON-OR ANESTHESIA

PROCEDURES

180 DENTAL 435 SURGICAL PROCEDURE UNIT

191 COMMUNITY ADHC FOLLOWUP CHIROPRACTIC CARE

197 POLYTRAUMA/TBI IND 507 HUD/VASH GROUP

202 RECREATION THERAPY SERVICE 511 GRANT & PER DIEM INDIV

203 AUDIOLOGY 513 SUBSTANCE USE DISORDER

IND

204 SPEECH-LANGUAGE PATHOLOGY 522 HUD/VASH INDIV

205 PHYSICAL THERAPY 529 HCHV/HCMI INDIV

206 OCCUPATIONAL THERAPY 534 MH INTGRTD CARE IND

209 VIST COORDINATOR 539 MH INTGRTD CARE GRP

210 SPINAL CORD INJURY 552 ICMHR INDIVIDUAL

212 EMG - ELECTROMYOGRAM 555 HOMELESS VT COM EMP SVC

INDIV

Stop Code

Primary Stop Code Name Primary

Stop Code

Primary Stop Code Name

250 REHAB SRVCS GROUP 560 SUBSTANCE USE DISORDR

GRP

301 GENERAL INTERNAL MEDICINE 582 PRRC INDIVIDUAL

302 ALLERGY IMMUNOLOGY 583 PRRC GROUP

303 CARDIOLOGY 592 VETERANS JUSTICE

OUTREACH

304 DERMATOLOGY 602 ASSISTED HEMODIALYSIS

305 ENDO./METAB (EXCEPT DIABETES) 669 COMMUNITY CARE CONSULT

306 DIABETES 703 MAMMOGRAM (CAN BE

PRIMARY)

307 GASTROENTEROLOGY 999 OCCUPATIONAL HEALTH

308 HEMATOLOGY

310 INFECTIOUS DISEASE

312 PULMONARY/CHEST

313 RENAL/NEPHROL(EXCEPT

DIALYSIS)

314 RHEUMATOLOGY/ARTHRITIS

315 NEUROLOGY

316 ONCOLOGY/TUMOR

317 ANTI-COAGULATION CLINIC

318 GERI PROB CONSULT CLINIC

PART 2: VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY

LANGUAGE FOR INCLUSION INTO CONTRACTS, AS APPROPRIATE

1. GENERAL

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

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

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

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

c. 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.

d. 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.

2. VA INFORMATION CUSTODIAL LANGUAGE

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

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

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

6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

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

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

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

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

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

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

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.

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

a. For information systems that are hosted, operated, maintained, or used on behalf of VA at non-VA facilities, contractors/subcontractors are fully responsible and accountable for ensuring compliance with all HIPAA, Privacy Act, FISMA, NIST, FIPS, and VA security and privacy directives and handbooks. This includes conducting compliant risk assessments, routine vulnerability scanning, system patching and change management procedures, and the completion of an acceptable contingency plan for each system.

The contractor’s security control procedures must be equivalent, to those procedures used to secure VA systems. A Privacy Impact Assessment (PIA) must also be provided to the COR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA’s network involving VA information must be reviewed and approved by VA prior to implementation.

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

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

d. The contractor/subcontractor’s system must adhere to all FISMA, FIPS, and NIST standards related to the annual FISMA security controls assessment and review and update the PIA. Any deficiencies noted during this assessment must be provided to the VA Contracting Officer and the ISO for entry into VA’s POA&M management process.

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

e. The contractor/subcontractor must conduct an annual self-assessment on all systems and outsourced services as required. Both hard copy and electronic copies of the assessment must be provided to the COR. The government reserves the right to conduct such an assessment using government personnel or another contractor/subcontractor.