S02 - Attachment A - PWS.docx

COMBINED SYNOPSIS/SOLICITATION 36C24821Q0652

Performance Work Statement I. Introduction

The Department of Veterans Affairs, Bay Pines VA Health Care System (BPVAHCS) has a requirement for a transitional housing facility. It would provide 1 to 20 beds per day/365 days per year to serve chronically homeless veterans with substance use and/or mental illness diagnosis. The intent of this Performance Work Statement (PWS) is for VA medical centers to engage community provider(s) to offer homeless Veterans services through a “Safe Haven" model of residential care.

II. Background

To meet the challenge of ending Veteran homelessness, the U.S. Department of Veterans Affairs (VA) launched a comprehensive, evidence-based, outcome-driven strategy consistent with Opening Doors: Federal Strategic Plan to Prevent and End Homelessness. The VA transformation effort has resulted in several new service models for Veterans who are homeless or at risk that promote a more person-centered approach to rapidly connect Veterans in need to permanent housing, healthcare, and other supports designed to end homelessness and promote greater community reintegration and improved quality of life. One important development has been the implementation of Safe Havens within the VA.

A Safe Haven is a 24-hour/7-days-a-week community-based early recovery model of supportive housing. Safe Havens serve hard-to-reach homeless individuals with severe mental illness and/or substance use problems who are living on the street and have been unable or unwilling to participate in traditional treatment and supportive services. This model, consistent with principles of Housing First, does not require sobriety or full compliance with treatment for admission or continued stay in the program. Many individuals experiencing homelessness cannot be fully compliant with traditional program demands and consequently have repeated failures in these programs, resulting in chronic homelessness. Safe Havens attempt to reverse that trend by continuously engaging residents using state-of-the art, evidence-based therapies.

The Safe Haven model provides a housing environment that is safe, sanitary, flexible, and stable. The small facilities, typically with 25 beds or fewer, provide a low-demand, non-intrusive setting designed to re-establish trust and re-engage residents in treatment services and permanent housing options. In fact, research indicates that low-demand housing programs are more effective than traditional programs in reducing hospitalizations and have similar outcomes regarding substance use and participation in mental health programs.

III. Terms of Contract:

The government anticipates awarding a Firm-Fixed Requirements contract with 5 years ordering period of performance.

Ordering Period 1: May 1, 2021 through April 30, 2022 Ordering Period 2: May 1, 2022 through April 30, 2023 Ordering Period 3: May 1, 2023 through April 30, 2024 Ordering Period 4: May 1, 2024 through April 30, 2025 Ordering Period 5: May 1, 2025 through April 30, 2026

IV. Location of Performance

Work shall be performed at the contractor's facilities. Government furnished workspace will not be provided for this effort.

V. Scope of Work

1. The Safe Haven contractor shall offer 24-hour staffed transitional residence to include a semi-private or private room with bath access, communal dining with three meals/day and healthy snacks, and laundry facilities on site.

2. The Safe Haven contractor shall target the population of hard-to-reach, chronically homeless Veterans with mental illness and/or substance use problems who require a low-demand environment.

3. The Safe Haven contractors shall offer a low-demand environment with a minimum set of rules designed to re-establish trust in the chronically homeless and engage the Veteran in needed treatment services. Low- demand environments emphasize safety and usually operate with guidelines designed to encourage a gradual engagement in treatment at the Veteran’s pace. These guidelines include:

a. Acceptance of treatment shall not be a condition of admission or continued stay.

b. Abstinence from alcohol or drugs shall not be a condition of treatment or continued stay.

c. Unless a clear breach of safety, infractions of rules shall be used as opportunities for engagement.

4. The Safe Haven contractor has policies and procedures to identify how intoxicated or impaired participants will be identified and managed in this program, with a focus on safety and adherence to the low-demand environment.

a. The program ensures that staff are educated on this policy and procedure.

5. Outreach shall be conducted by the Safe Haven contractor and VA homeless outreach staff. All admissions shall have concurrence of VA. If a Veteran arrives at the facility during weekends or at night, the Safe Haven provider may accept the Veteran; however, VA staff have right of approval/disapproval for payment. The Safe Haven Contractor shall conduct screenings and process admissions a minimum of five business days per week, excluding federal or other agency-recognized holidays.

6. The Safe Haven contractor staff shall develop a highly individualized treatment plan with each Veteran consistent with low-demand program goals. Individualized treatment plans will reflect a recovery orientation that includes the Veteran’s identification of his/her strengths, needs, abilities and preferences as well as the definition of treatment goals and steps to achievement. The plan will include time parameters and measurable objectives along with expected dates for review and revision.

7. The Safe Haven contractor will provide residents with opportunities for immediate learning and/or development of responsible living with a goal of achieving a more adaptable level of psychosocial functioning, utilizing a recovery/low demand model of care. This will include improving social skills, personal relationships, health, and personal hygiene maintenance.

8. The Safe Haven contractor will establish procedures for the safe storage of each Veteran’s medications, supervised access as prescribed, and reconciliation of all prescribed and over the counter medications. Additionally, the Safe Haven contractor will provide a safety check with each Veteran on each shift and will inquire as to the comfort level of the Veteran when any change in behavior is noted.

9. Utilizing VA Liaison staff, treatment planning discussions, and information on available programs/services in the area, the Safe Haven contractor shall encourage its Veteran residents to work towards transitional or permanent housing within six months of admission. All extensions beyond six months will require approval of VA.

10. The Safe Haven contractor will maintain records necessary to determine bed days of care so that monthly invoices submitted to VA for payment are accurate and timely. The contractor will provide the VA with a bed roster daily, Monday-Friday (to exclude weekends). The contractor may be reimbursed for up to 7 bed days of care per month, when the Veteran is absent from the facility due to therapeutic or medical reasons. Other absences in excess of 48 hours will not be reimbursable. Approval by the VA will depend on documentation and justification for the absence. This would be determined on a case by case basis. In the event of a Veteran’s death, the contractor will notify the VA within one hour, and the contractor will safeguard and secure the Veteran’s personal effects.

11. Documentation required by the Safe Haven contractor:

a. Essential identifying data relevant to the Veteran, including verification of Veteran status, family status, employment history, education and marketable skills, history of the Veteran’s homelessness, and other appropriate assessments.

b. Data relevant to the Veteran’s admission and anticipated length of stay.

c. A treatment plan will be completed within 14 days of admission. Treatment Plan should identify a Veteran’s Strengths, Needs, Abilities, and Preferences (SNAP), including barriers, needs beyond scope of program, and referrals made for additional services. Goals should be developed with active participation from the Veteran and expressed in the words of the Veteran served. Goals should include a plan for more stable housing, which may include a VA residential program. Objectives should be Specific, Measurable, Attainable, Realistic, Timely, and reasonably expected to be accomplished within 6 months. Interventions should identify who is responsible for implementation, frequency/duration of intervention, and techniques/methods/services used. Treatment Plans should include identification of support systems including family/social/community (or reason for lack thereof).

d. A Transition Plan (TP) will be completed between days 30 and 60 of program admission to allow for the Veteran to become established in the program and for a comprehensive TP to be developed. The TP is developed with the Veteran served, family (if applicable), and Treatment Plan team members to ensure seamless transition when the Veteran transfers to another level of care, another program, and/or prepares for planned discharge. The TP should identify:

i. Current progress in his/her own recovery or move towards well-being (including securing stable housing)

ii. Gains achieved during program participation

iii. Veteran’s need for support systems or other types of services that will assist in continuing his/her recovery, well-being, or community integration

iv. Information on the continuity of the Veteran’s medication(s) when applicable

v. Referral information such as contact name, telephone number, location, hours, days of services when applicable

vi. Communication of information on options and resources available if symptoms recur

vii. Any additional services needed

e. Monthly Treatment Plan updates to measure progress toward treatment goals. Updates should explicitly outline progress on goals and any changes to goals or objectives that might be required as a result.

f. Final summaries on each Veteran who leaves the program within 3 business days of discharge, which must include a description of changes realized during the Veteran’s stay in the residential program, reason for leaving, future plan, aftercare plan, and specific follow up information.

g. Language reflecting the quality of the discharge should read “Planned” or “Unplanned”.

h. VA staff will provide input into treatment planning process when onsite at the Safe Haven Program.

i. Other documentation and/or data reporting as requested or required by VA based on changing or subsequent local, VISN or National Contracted Residential Services program requirements. This reporting may be daily, weekly, monthly, or quarterly in duration and will follow format as required by the VA.

j. Documentation and/or reporting as requested by the Homeless Management Information System (HMIS).

12. The Contractor shall be responsible for compliance with following VA policies and procedures regarding incident reporting. A staff member who becomes aware of the occurrence of an event should report it through a formal mechanism so that the event can be officially recorded, learned from to make future improvements and preventative measures, and tracked through resolution. This includes the reporting of all close call/near miss events as part of this reporting process.

a. Reportable events shall be defined as serious incidents and non-critical adverse events involving disturbances and assaults, patient safety related events, suicidal behavior, or other adverse occurrences directly associated with care or services provided. Reportable events may result from acts of commission or omission. All reportable events require reporting and review; however, the level of review and required timeframe of reporting is determined by the type of adverse event.

b. Definitions

i. Disturbance: A person using a loud, inappropriate voice and/or inappropriately confronting another person(s) but not verbally or physically threatening another person(s). The perpetrator’s behavior is disruptive to the environment. Perpetrators may be a patient, visitor, volunteer, staff member, or other person on the property.

ii. Verbal Threat: When a person uses inappropriate language in a threatening way, stating that he/she will cause harm to another.

iii. Physical Assault: When a perpetrator physically touches, in a manner to cause harm, another person or when touch results in harm to another.

iv. Sexual Assault: Any type of sexual contact or attempted sexual contact that occurs without the explicit consent of the recipient of the unwanted sexual activity. Sexual assaults may involve psychological coercion, physical force, or victims who cannot consent due to mental illness or other factors. Falling under this definition are sexual activities such as, but not limited, to, forced sexual intercourse, sodomy, oral penetration, or penetration using an object, molestation, fondling, and attempted rape. Victims of sexual assault can be male or female. Please note: this does not include cases involving only indecent exposure, exhibitionism, or sexual harassment. Sexual assaults require additional timely reporting (within 2 hours) in accordance with Appendix B.

v. Suicidal Behavior: Any behavior of a suicidal nature with or without physical injury, short of death, including the full range of known or reported attempts.

vi. Patient Safety Related Events: Actual events and close call/near miss events such as patient falls, medication management events, at-risk missing patient events/missing patient events, device and equipment failures/events, unintended clinical consequences, including unexpected death, and any events where patient safety was or could have been compromised.

vii. At-Risk Patient: A patient who is determined to be At-Risk for harm due to having been identified as a suicide risk, recent hospitalization, is a danger to self or others, requires ongoing medical intervention (i.e. PEG tube, oxygen, dialysis), frailty, physical impairment, lack of cognitive ability to make relevant decisions, mental impairment or the potential for mental impairment.

viii. Serious incidents shall be defined as (1) sentinel events as defined by The Joint Commission, which are unexpected occurrences involving death or serious physical or psychological injury or risk thereof; (2) fire; (3) police/drug raid; (4) abduction of a Veteran; (5) homicide involving a Veteran; (6) suicide or suicide attempt; (7) alleged sexual assault of a Veteran, to include rape; (8) media events involving inquiries about VA; (9) evacuation or relocation of residents.

ix. Non-Critical Adverse events shall be defined as (1) medication errors, including missing narcotic medication and excluding the withholding of medication when a Veteran is under the influence of alcohol or illicit substances; (2) acts of violence or abuse involving individuals at the facility; (3) significant clinical incidents/outcomes negatively affecting a group/cohort of Veterans; (4) all other adverse events, close calls, or intentionally unsafe acts not otherwise specified.

c. Procedures for Serious Incidents

i. At the time of a serious incident, the staff at the contract facility will take immediate action to ensure the safety of the patient(s). If an incident has the potential to place other patients, employees, or visitors at risk, staff at the contract facility must act immediately to contain the situation and safeguard those at risk.

ii. Serious incidents shall be verbally reported by phone to the VA Liaison or representative as soon as possible, no later than one hour from the time of the contract staff learning of the incident. Receipt of a voicemail will not be an acceptable substitution for the verbal notification requirement.

iii. Serious incidents occurring after normal business hours shall be reported to the Administrator on Duty (AOD) by phone at (727) 410-7925 as soon as possible, no later than one hour from the time of the contract staff learning of the incident.

iv. A written incident report shall be filed as soon as possible on the same calendar day of the required verbal notification, either by fax or encrypted email. The filing of an incident report to the VA shall not preclude the contract facility from reporting incidents appropriately to law enforcement, regulatory agencies, nor following its internal reporting procedures. Incident reports will include the following: name(s) of the individuals involved, date/time of incident, description of incident, corrective action initiated (if warranted), report number and contact information of any law enforcement involvement with the incident.

d. Procedures for At-risk Missing Patient events

i. If a patient has been missing and all efforts to locate him/her have been exhausted, a missing person’s report will be made by the contracted facility to local law enforcement no later than 24 hours following the patient being identified as missing. The contracted facility will continue daily efforts to locate the patient.

ii. Filing of missing person’s report shall be reported by phone from the contracted facility staff to the VA Liaison on the date of the event. Events occurring after normal business hours shall be reported by the following business day no later than 10:00am.

e. Procedures for non-critical Adverse Events

i. Non-critical Adverse Events shall be reported by phone to the VA Liaison or representative on the date of the event.

ii. Non-critical Adverse Events occurring after normal business hours shall be reported by the following business day no later than 10:00 am.

iii. The filing of an incident report to the VA shall not preclude the contract facility from reporting incidents appropriately to law enforcement, regulatory agencies, nor following its internal reporting procedures. Incident reports will include the following: name(s) of the individuals involved, date/time of incident, description of incident, corrective action initiated (if warranted), report number and contact information of any law enforcement involvement with the incident.

iv. For any non-critical adverse event involving an absent patient it is expected that the contracting facility make efforts to locate the patient on a daily basis.

13. Payment:

a. Per Diem will be paid for the day of admission or the day of discharge from the program, but not for both.

b. If a Veteran is admitted to and discharged on the same calendar day, payment will be made for one day.

c. Income will not be required for admission; however, contract providers may charge the Veteran up to 30% of income for program fees. Fees collected (up to $2000.00) shall be used to cover the Veteran’s expenses to transition to permanent housing; such as rent, deposits, furniture, and other costs related to setting up a household. Income shall not be a condition of admission.

d. Payments made under the terms of the contract will constitute the total cost of residential care. The Contractor agrees that no additional charges will be billed to the beneficiary or his/her family, either by the residential treatment setting or any third-party furnishing services or supplies required for such care. Veterans will not be billed for treatment services.

e. Payment for the Residential Care Program will be made on a monthly basis for services rendered. Should a Veteran referred be absent in an unauthorized manner, payment for services for that Veteran may be continued for a period of 2 days, provided there is an active outreach attempt on the part of the Residential Care Program staff to return the Veteran to the Residential Care Program and a strong likelihood that the Veteran will return. Veteran absences from the Residential Care Program in excess of 48 hours will not be reimbursable, except with the prior approval of the VA Liaison, Homeless Program Coordinator, or designee.

f. Admission, discharges, and unauthorized absences should be reported to the VA Liaison or designee by the close of business on the day of the event. If the event occurs overnight, the VA Liaison or designee should be notified the following morning. If the event occurs on a weekend, notification shall take place by 10:00 am Monday morning.

g. Monthly invoices and any necessary justification documents shall be received no later than the fifteenth calendar day of the subsequent month.

14. The Safe Haven contractor will provide three meals per day with healthy snacks, to include weekends.

a. Contractor will provide/post a weekly menu, which represents a nutritionally adequate diet.

b. Contractor will demonstrate the ability to meet special dietary needs.

c. Contractor will ensure that all food service personnel observe safe sanitation practices as outlined by the Federal Drug Administration (FDA) Food Code.

d. Contractor will ensure that refrigeration, dry storage, and food preparation areas are monitored and maintained in a sanitary condition as outlined by the FDA Food Code.

15. The Safe Haven contractor shall ensure facility meets all applicable life/safety codes and other standards/compliance requirements as determined by VA. These include:

a. Adherence to Standards of the Life Safety Code (National Fire Protection Association (NFPA) #101)

b. Possession of applicable City, State and Federal licenses for residential settings providing substance use treatment and mental health treatment;

c. Acquisition of liability insurance;

d. Adherence to the Privacy Act: The notification and contract clauses entitled “Privacy Act Notification” as specified in Federal Acquisition Regulation (FAR) 52.224-1 and 52.224-2 is included with this contract.

16. The Safe Haven contractor shall allow VA staff to inspect the facility and/or review Veteran participant treatment protocols at any time determined necessary by VA.

17. The Safe Haven contractor shall be responsible for maintaining compliance with VA performance metrics, including but not limited to Exits to Permanent Housing and Negative Program Exits.

18. The Safe Haven contractor will be responsible for the development and implementation of a Corrective Action Plan when accomplishments vary for any of the Goals, Objectives, or Performance Metrics as stated in the contract.

19. The Safe Haven contractor shall ensure that transportation is available for Veterans to attend medical appointments, search for transitional or permanent housing, and address other care needs such as access to spiritual care and community based abstinence meetings. Transportation may include public conveyances such as buses. To ensure timely transport for Veterans to medical appointments, the contractor’s facility shall be within 15 miles of the C.W. Bill Young VA Medical Center and situated within reasonable walking distance to the local bus routes. Transportation for the Veterans enrolled to be provided by the Safe Haven contractor.

20. A maximum of twenty (20) Veterans are expected to be served in the Safe Haven setting. The independent cost estimate indicates that costs associated with these services will exist for each of the following: room with bath facilities; on site laundry facilities; daily meals with communal dining; 24/7 staff experienced with substance use dependence and mental illness; secure facility with controlled access; communal sitting/group area with TV, recreational materials for diversionary activities; medication storage and oversight; and shared computer access for Veteran residents.

21. The contracting facility will be staffed by a core team of individuals with substance use and mental health treatment experience that typically includes occupations such as counselors, social workers, licensed practical nurses and health techs. Additional supportive services from registered nurses, pharmacy technicians and administrative staff are expected as needed.

22. 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. The contractor or subcontractor must notify the Contracting Officer immediately when an employee 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.

23. VA Information Custodial Language:

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

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

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

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

24. Security Incident Investigation:

a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

b. To the extent known by the contractor/subcontractor, the contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

25. Liquidated Damages for Data Breach:

a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

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

26. Security Controls Compliance Testing: On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-day’s notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time.

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

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

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

i. Contractors must complete training courses “VA Privacy and Information Security Awareness and Rules of Behavior” and “HIPAA and Privacy Training” on an annual basis in the VA Talent Management System (TMS).

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

28. RECORDS MANAGEMENT OBLIGATIONS

a. Applicability: This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

b. Definitions

i. “Federal record” as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

ii. The term Federal record:

1. includes Bay Pines VA Healthcare System records.

2. does not include personal materials.

3. applies to records created, received, or maintained by Contractors pursuant to their Bay Pines VA Healthcare System contract.

4. may include deliverables and documentation associated with deliverables.

c. Requirements

i. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

ii. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

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

iv. Bay Pines VA Healthcare System and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of Bay Pines VA Healthcare System or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to Bay Pines VA Healthcare System. The agency must report promptly to NARA in accordance with 36 CFR 1230.

v. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the contract. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to Bay Pines VA Healthcare System control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the contract. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

vi. The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and Bay Pines VA Healthcare System guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

vii. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with Bay Pines VA Healthcare System policy.

viii. The Contractor shall not create or maintain any records containing any non-public Bay Pines VA Healthcare System information that are not specifically tied to or authorized by the contract.

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

x. The Bay Pines VA Healthcare System owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which Bay Pines VA Healthcare System shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

xi. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take [Agency]-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

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

d. Flowdown of requirements to subcontractors

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

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

29. Evaluation Criteria elements are:

a. Past Performance, including CPARS and QASP data.

b. Satisfaction of all life/safety code requirements

c. Competitive price.

d. Staffing by a core team of individuals with substance use and mental health treatment experience, including occupations such as counselors, social workers, licensed practical nurses and health techs. Additional supportive services from registered nurses, pharmacy technicians and administrative staff are expected as needed.

VI. Location of Performance

Work shall be performed at the contractor's facilities. Government furnished workspace will not be provided for this effort.

Performance and Quality Standards

The government will periodically evaluate the contractor’s performance using Quality Assurance Surveillance Plan (QASP)

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE

VA INFORMATION CUSTODIAL LANGUAGE:

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

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

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

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

SECURITY INCIDENT INVESTIGATION:

a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

b. To the extent known by the contractor/subcontractor, the contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

LIQUIDATED DAMAGES FOR DATA BREACH:

a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

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

SECURITY CONTROLS COMPLIANCE TESTING :

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-day’s notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time.

TRAINING:

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

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

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

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