S02 Final SOW Steam Trap Replacements 5-27-2022.pdf

Statement of Work

Department of Veterans Affairs (VA)

West Haven and Newington Connecticut VA Campuses

Steam Trap Replacement

I. Background

The purpose of this contract is to replace steam traps identified by the 2020 steam trap survey at the West Haven and Newington Connecticut campuses.

II. Scope of Work

The Contractor shall perform the recommended repairs in the section entitled “Recommended Trap Replacements” on the steam trap survey report for each campus, with the following exception. No repairs are required for any radiator components on the sixth floor of building 2 in West Haven. These components are being repaired under a separate renovation contract. The approximate number of components requiring repair or replacement are as follows-

Newington campus: 190 traps, valves, fittings

West Haven Campus: 322 traps, valves, fittings

Types of Traps listed on survey are as follows:

a. Thermostatic

b. Float and Thermostatic

c. Orifice

d. Inverted Bucket

e. Bimetallic

General Requirements

1. Contractor shall provide all parts, materials, and equipment to replace or repair all components for both West Haven and Newington Campuses.

2. All materials furnished and all work installed shall comply with current codes, standards, and recommendations of the Department of Veterans Affairs (DVA), the Joint Commission (JC), the American Society of Mechanical Engineers (ASME), American Society of Testing and Materials (ASTM), National Fire Protection Association (NFPA), the State of Connecticut Building Code, and The National Electric Code (NEC) and the International Plumbing Code.

3. Work shall be accomplished by licensed tradesmen.

4. Unless otherwise specified, installations shall match existing, meaning this shall be a 1 for 1 replacement for all fit and finishes shall be restored, provided the existing components meet current requirements (see paragraph 2 above). If a component to be replaced does not meet the current code requirements, it shall be replaced with a component that does meet current code requirements.

5. All work shall be done between the hours of 7:30am-4:00pm EST, Monday through Friday, with holidays excepted unless other times are prearranged with the Contract Officer’s Representative (COR). When the contractor’s work interferes with Hospital functions (excessive noise, odors, dust etc.) or it cannot be contained within the area of work, the contractor shall schedule said work at other than normal hours and as directed by the COR.

6. Parking is rigidly controlled throughout the Medical Center. Adequate parking is available north of Building 1 in West Haven. Parking of the contractor or employee vehicles in other than this area can result in said vehicle being towed at the owner’s expense, off the Medical Center Grounds.

7. The contractor shall comply with all applicable sections of 29 CFR 1910 and 29 CFR 1926.

a. The contractor should plan for confined space work and supply proper entry watch and air monitors. The contractor shall notify the COR and Safety Manager and coordinate confined space standard operating procedures no less than two business days prior to any planned confines space entry. All confined space entries shall strictly comply with CFR 1926 Subpart AA - Confined Spaces in Construction.

b. The Contractor shall comply with 29 CFR 1910.147 and with the Control of Hazardous Energy

Lockout/Tagout Program of VA Connecticut Health Care System - MCP 138-075. The contractor shall notify the COR, to coordinate Lockout/Tagout standard operating procedures no less than five business days prior to the initial equipment shutdown and tagout.

8. The contractor shall comply with current COVID-19 precautions and procedures being used by VA in

CT.

9. A written safety plan provided by the contractor shall be followed, and Interim Life Safety Measures (ILSM) will be accounted for.

10. Asbestos and lead abatement inspection and documentation, if required, shall be accomplished by the contractor. See appendices A and B for additional requirements.

Debris Removal:

All disposed materials shall be removed from the facilities by the contractor and shall be disposed of in accordance with applicable State Environmental Protection Regulations.

Guarantee:

1. The Contractor shall guarantee all materials, equipment, and workmanship for a period of one year from date acceptance of entire project.

2. During the term of the guarantee, the contractor shall repair or replace all defective material or equipment within 72-hour notice without additional cost to the government.

Special instructions:

The specifications do not detail all existing structure, utilities, or components that may interfere with the contract work required. The contractor shall not obstruct utilities or create conditions that may hinder or interfere with the execution of the contract and will make provision within his bid accordingly.

Interference to Normal Functions:

The contractor may be required to interrupt their work at any time as not to interfere with the function of the facility, including facility repair etc.

In the event of an emergency, contractor services may be stopped and rescheduled at no additional cost to the Government.

Period of Performance Contract period shall commence upon date of Award Notification and shall be completed within 240 calendar days.

1. Contractor shall treat all deliverables under the contract as the property of the U.S.

Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.

2. Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records.

3. 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 by the Freedom of Information Act.

4. Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.

5. The Government Agency owns the rights to all data/records produced as part of this contract.

6. The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractor must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data.

7. Contractor agrees to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974. These policies include the preservation of all records created or received regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.].

8. No disposition of documents will be allowed without the prior written consent of the

Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation.

Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules.

9. 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, this contract. The Contractor (and any sub-contractor) is required to abide by Government and Agency guidance for protecting sensitive and proprietary information.

Location of Facilities:

West Haven VAMC Newington

950 Campbell Ave 555 Willard Ave

West Haven, CT 06516 Newington, CT 06111

APPENDIX A

ENVIRONMENTAL ASSESSMENT – SCOPE OF WORK

SECTION I

1.1 GENERAL:

A. This Scope of Work (SOW) is applicable to renovation and/or remodeling projects that may contain asbestos, lead, mold, and other potentially hazardous or regulated substances in which the VA Industrial Hygienist (VPIH) is hired by the A-E. In this document, the term A-E may also refer to as a contractor.

B. These special instructions cover the A-E and VPIH services for the Design Development and the

Construction Documents stages of the VA process and the construction period services of a project. The VPIH hired by the A-E is not only required to have the experience and expertise of all aspects of hazard analysis and abatement but also have experience working as a member of a A-E design team.

C. The assessment and inspection portion of the services shall be completed by VPIH personnel who are licensed by the State of Connecticut Department of Public Health as asbestos inspectors for those performing asbestos inspection or assessment. VPIH personnel who perform lead paint inspection or assessment shall be licensed by the State of Connecticut Department of Public Health as a Lead Inspector or Lead Risk Assessor. VPIH personnel who perform microbial inspection or assessment shall show proof of expertise through experience and training in microbial and mold remediation inspection and assessment techniques.

D. The design documents shall be produced using VA Master Specifications by the VPIH with personnel who are licensed by the State of Connecticut Department of Public Health as an Asbestos Project Designer, Lead Project Planner/Designer, have expertise, experience, and training in microbial and mold remediation techniques, and are reviewed and approved by a Certified Industrial Hygienist (CIH) accredited by the American Board of Industrial Hygiene

(ABIH).

E. A-E shall be responsible for providing all design documents related to demolition, phasing and other related documents for the project, (as determined by VA if proposed abatement impacts the specific construction project). The VPIH working for the A-E shall design and produce all hazard analysis and abatement contract documents and fully coordinate these drawings with A- E firm contract documents. Work requirements are listed in SECTION 2.2 for the VPIH.

F. The A-E will employ an independent industrial hygienist (VPIH) consultant and/or use its own qualified personnel to perform various services on behalf of the VA. The VPIH will perform the necessary monitoring, inspection, testing, and other support services to ensure that VA patients, employees, and visitors will not be adversely affected by abatement work, and that abatement work proceeds in accordance with specifications, that the abated areas or abated buildings have been successfully decontaminated. The work of the VPIH consultant in no way relieves the Contractor from their responsibility to perform the work in accordance with contract/specification requirements, to perform continuous inspection, monitoring and testing for the safety of their employees, and to perform other such services as specified. The cost of the VPIH and their services will be borne by the VA except for any repeat of final inspection and testing during monitoring services that may be required due to unsatisfactory initial results, as specified. The VPIH during asbestos abatement oversight shall be licensed by the State of

Connecticut Department of Public Health as an Asbestos Project Monitor with project oversight by a Certified Industrial Hygienist (CIH) accredited by the American Board of Industrial Hygiene

(ABIH).

SECTION 2

2.1 Project Scope of Work (SOW)

The VPIH shall perform an environmental assessment of the proposed work areas, and areas adjacent to, directly above and below work areas that will be impacted by the project and any other areas not indicated in this section determined by the A-E that may be impacted during the project. Areas that could be impacted by this project should be carefully inspected including walls, floors, shafts and above ceiling and the precise location and quantity of all hazardous materials including but not limited to asbestos, lead, polychlorinated biphenyls, and mold should be provided. The COR will provide access to all the historical records available for the areas impacted by the project before the beginning of the inspection.

2.2 VPIH Services Scope of Work:

1. All areas that may be impacted by this project (as described in General AE Scope of Work section) shall require environmental assessment for the presence of asbestos-containing materials, lead-based paint, silica, and other environmental hazards (e.g., PCB, mercury, refrigerant, polychlorinated biphenyls, etc.).

In addition, any areas located adjacent to, above, and below these rooms will require assessment if planned project activities impact these areas. This determination of these additional locations should be made prior to initiating field portion of the environmental assessment.

VPIH Services will include:

2. Asbestos Inspection:

a. A State of Connecticut licensed Asbestos Inspector will conduct an asbestos inspection in each impacted area to meet the requirements of EPA NESHAP/AHERA inspection and State of Connecticut regulations.

b. The inspector will collect bulk samples of suspect materials using approved EPA protocol for analysis by polarized light microscopy (PLM) method in a NVLAP accredited laboratory.

c. The inspector will check above ceiling spaces, including the existing HVAC system and all access hatches leading to above ceiling equipment for presence of suspect asbestos-containing materials and/or debris that might have become dislodged from above equipment.

d. The inspector may be required to perform selective demolition to expose concealed potential asbestos containing materials in the following areas, if impacted by the project: below existing flooring, inside wall cavities and chases, and inside ceiling chases.

3. Lead Inspection:

a. A state licensed Lead Inspector/Risk Assessor will test suspect surfaces and building components that may be impacted by the project for lead-based paint or lead-containing materials.

b. An X-ray Fluorescence Analyzer (XRF) will be used to identify the presence of lead or lead-based paint on/in building components prior to project activities.

c. Representative composite TCLP (Toxicity Characteristic Leaching Procedure) lead sample(s) may be collected as necessary to determine if demolition debris is either classified as hazardous waste or solid waste, depending on lead content and/or leachable lead content.

d. Ceiling spaces shall be included in the scope for inspection for the presence of lead-based paint or lead-containing components.

4. Mold Assessment: An inspector shall conduct a visual assessment of existing conditions for any visible mold and water damaged building materials in each area that will be impacted by this project.

5. Other Hazardous or Regulated Materials Assessment: During above inspections, also record any other hazardous or regulated materials noticed in the impacted areas and their conditions, such as mercury-containing equipment or items, refrigerant in any AHU, PCB-containing materials or equipment or items, etc.

6. VPIH Project Monitoring: During any asbestos abatement activities, provide VPIH monitoring services as specified in VA Master Specifications.

7. Written Reports:

a. A written report will be generated to summarize work activities and detail the findings of each inspection.

b. The asbestos inspection report will include quantities and locations of asbestos-containing materials identified, sample location diagrams, photographs of each homogenous area and any damaged materials as documentation of present conditions, sample log and results, as well as the completed laboratory analysis.

c. The lead inspection report will include locations and components of lead-based paint, a sample location diagram, sample log and results, as well as any laboratory analysis.

d. Two (2) hard copies and one electronic copy of the final report shall be provided, with electronic copy in PDF format. All data tables must be provided in Microsoft Excel format.

All sample locations must be identified on a print and marked in the field.

8. Abatement Specifications:

a. A State licensed Project Designer will review all inspection results and visit the site if regulated or hazardous materials have been identified in the impacted area.

b. Develop a written specification in accordance with the VA Master Spec for abatement of all asbestos-containing materials to be impacted by the renovation work and lead compliance during abatement and renovation for each area that requires asbestos and/or lead abatement.

c. The specification shall include the quantity and location of asbestos-containing materials to be removed and CAD drawings shown containment locations.

d. The materials for constructing the containments shall be outlined as well as methods of asbestos removal and disposal requirements, engineering controls during abatement.

e. Regulatory requirements specific to the site and final clearance criteria shall be detailed.

f. The specification will also provide appropriate guidance related to the lead compliance and disposal of lead-contaminated demolition debris, and other regulated or hazardous materials identified in the project impacted areas.

9. Final payment for design services will not be made until all project documents are received during the design phase and final payment will not be made until project close-out documentation including, but not limited to, VPIH site logs, monitoring results, and waste manifests is received after the completion of VPIH construction period services.

END OF APPENDIX

APPENDIX B

INFECTION PREVENTION MEASURES

A. Implement the requirements of VA Medical Center’s Infection Control Risk Assessment (ICRA) team.

ICRA Group may monitor dust, in the vicinity of the construction work, and require the Contractor to take corrective action immediately if the safe levels are exceeded.

B. Establish and maintain a dust control program as part of the contractor’s infection preventive measures in accordance with the guidelines provided by ICRA Group as specified here. Prior to start of work, prepare a plan detailing project-specific dust protection measures, including periodic status reports, and submit to the COR and Facility ICRA team for review for compliance with contract requirements in accordance with Section 01340, SAMPLES AND SHOP DRAWINGS.

1. All personnel involved in the construction or renovation activity shall be educated and trained in infection prevention measures established by the medical center.

C. Medical Center Infection Control personnel shall monitor for airborne disease (e.g., aspergillosis) as appropriate during construction. A baseline of conditions may be established by the medical center prior to the start of work and periodically during the construction stage to determine impact of construction activities on indoor air quality. In addition:

1. The COR and VAMC Infection Control personnel shall review pressure differential monitoring documentation to verify that pressure differentials in the construction zone and in the patient-care rooms are appropriate for their settings. The requirement for negative air pressure in the construction zone shall depend on the location and type of activity. Upon notification by the COR, the contractor shall implement corrective measures to restore proper pressure differentials as needed.

2. In case of any problem, the COR, along with assistance from the contractor, shall conduct an environmental assessment to find and eliminate the source.

D. In general, following preventive measures shall be adopted during construction to keep down dust and prevent mold.

1. Dampen debris to keep down dust and provide temporary construction partitions in existing structures where directed by Resident Engineer. Blank off ducts and diffusers to prevent circulation of dust into occupied areas during construction.

2. Analyze each site during design to determine the effects of blocking HVAC ducts and their impact on existing air handling systems that must remain operational before initiating a dust control program. The method of capping ducts shall be dust tight and withstand airflow.

3. Construct anteroom to maintain negative airflow from clean area through anteroom and into work area where required.

4. High risk patient care areas may require additional measures like air locks, special signage, smoke, and negative pressure alarms.

5. Identify these areas clearly on the drawings and work with Medical Center personnel to achieve desired level of isolation suited to the scope of risk involved.

6. Do not perform dust- producing tasks within occupied areas without the approval of the Project Manager. For construction in any areas that will remain jointly occupied by the medical Center and Contractor’s workers, the Contractor shall:

a. Provide dust proof fire-rated temporary drywall construction barriers to completely separate construction from the operational areas of the hospital in order to contain dirt debris and dust. Barriers shall be sealed and made presentable on hospital occupied side.

Install a self-closing rated door in a metal frame, commensurate with the partition, to allow worker access. Maintain negative air at all times. A fire-retardant polystyrene, 6-mil thick or greater plastic barrier meeting local fire codes may be used where dust control is the only hazard, and an agreement is reached with the Resident Engineer and Medical Center.

b. HEPA filtration is required where the exhaust dust may reenter the breathing zone.

Contractor shall verify that construction exhaust to exterior is not reintroduced to the medical center through intake vents or building openings. Install HEPA (High Efficiency Particulate Accumulator) filter vacuum system rated at 95% capture of 0.3 microns including pollen, mold spores and dust particles. Insure continuous negative air pressures occurring within the work area. HEPA filters should have ASHRAE 85 or other pre-filter to extend the useful life of the HEPA. Provide both primary and secondary filtrations units. Exhaust hoses shall be heavy duty, flexible steel reinforced and exhausted so that dust is not reintroduced to the medical center.

c. Adhesive Walk-off/Carpet Walk-off Mats, minimum 24” x 36”, shall be used at all interior transitions from the construction area to occupy medical center area. These mats shall be changed as often as required to maintain clean work areas directly outside construction area at all times.

d. Vacuum and wet mop all transition areas from construction to the occupied medical center at the end of each workday. Vacuum shall utilize HEPA filtration. Maintain surrounding area frequently. Remove debris as they are created. Transport these outside the construction area in containers with tightly fitting lids.

e. The contractor shall not haul debris through patient-care areas without prior approval of the COR and the CO. When, approved, debris shall be hauled in enclosed dust proof containers or wrapped in plastic and sealed with duct tape. No sharp objects should be allowed to cut through the plastic. Wipe down the exterior of the containers with a damp rag to remove dust. All equipment, tools, material, etc. transported through occupied areas shall be made free from dust and moisture by vacuuming and wipe down.

f. Using a HEPA vacuum, clean inside the barrier and vacuum ceiling tile prior to replacement. Any ceiling access panels opened for investigation beyond sealed areas shall be sealed immediately when unattended.

g. There shall be no standing water during construction. This includes water in equipment drip pans and open containers within the construction areas. All accidental spills must be cleaned up and dried within 12 hours. Remove and dispose of porous materials that remain damp for more than 72 hours.

h. At completion, remove construction barriers and ceiling protection carefully, outside of normal work hours. Vacuum and clean all surfaces free of dust after the removal.

E. Final Cleanup:

1. Upon completion of project, or as work progresses, remove all construction debris from above ceiling, vertical shafts and utility chases that have been part of the construction.

2. Perform HEPA vacuum cleaning of all surfaces in the construction area. This includes walls, ceilings, cabinets, furniture (built-in or free standing), partitions, flooring, etc.

1. All new air ducts shall be cleaned prior to final inspection. SPEC WRITER NOTE: On small projects developed at Medical Center, COR may tag items to be removed and stored, instead of noting such items on drawings or in specifications.

APPENDIX C

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

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

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

3. VA INFORMATION CUSTODIAL LANGUAGE

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

b. VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor’s information systems or media storage systems in order to ensure

VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct 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, 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. VA Configuration Guidelines are available upon request.

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

k. Notwithstanding the provision above, the contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor is in receipt of a court order or other requests for the above-mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response.

l. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COR.

4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT

a. Information systems that are designed or developed for on behalf of VA at non-VA facilities shall comply with all VA directives developed in accordance with FISMA, HIPAA, NIST, and related VA security and privacy control requirements for Federal information systems. This includes standards for the protection of electronic PHI, outlined in 45 C.F.R. Part 164, Subpart C, information and system security categorization level designation in accordance with FIPS 199 and FIPS 200 with implementation of all baseline security controls commensurate with the FIPS 199 system security categorization (reference Appendix D of VA Handbook 6500, VA Information Security Program). During the development cycle a Privacy Impact Assessment (PIA) must be completed, provided to the COR, and approved by the VA Privacy Service in accordance with Directive 6507, VA Privacy Impact Assessment.

b. The contractor/subcontractor shall certify to the COR that applications are fully functional and operate correctly as intended on systems using the VA Federal Desktop Core Configuration (FDCC), and the common security configuration guidelines provided by NIST or the VA. This includes Internet Explorer 7 configured to operate on Windows XP and Vista (in Protected Mode on Vista) and future versions, as required.

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

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

e. The security controls must be designed, developed, approved by VA, and implemented in accordance with the provisions of VA security system development life cycle as outlined in NIST Special Publication 800-37, Guide for Applying the Risk Management Framework to Federal Information Systems, VA Handbook 6500, Information Security Program and VA Handbook 6500.5, Incorporating Security and Privacy in System Development Lifecycle.

f. The contractor/subcontractor is required to design, develop, or operate a System of Records Notice (SOR) on individuals to accomplish an agency function subject to the Privacy Act of 1974, (as amended), Public Law 93-579, December 31, 1974 (5 U.S.C. 552a) and applicable agency regulations. Violation of the Privacy Act may involve the imposition of criminal and civil penalties.

g. The contractor/subcontractor agrees to:

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

a. The Systems of Records (SOR); and

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

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

and

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

h. In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a SOR on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of SOR on individuals to accomplish an agency function. For purposes of the ACT, when the contract is for the operation of a SOR on individuals to accomplish an agency function, the contractor/subcontractor is considered to be an employee of the agency.

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

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

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

i. The A-E shall ensure the security of all procured or developed systems and technologies, including their subcomponents (hereinafter referred to as “Systems”), throughout the life of this contract and any extension, warranty, or maintenance periods. This includes, but is not limited to workarounds, patches, hotfixes, upgrades, and any physical components (hereafter referred to as Security Fixes) which may be necessary to fix all security vulnerabilities published or known to the A-E anywhere in the Systems including Operating Systems and firmware. The A-E shall ensure that Security Fixes shall not negatively impact the Systems.

j. The A-E shall notify the COR within 24 hours of the discovery or disclosure of successful exploits of the vulnerability which can compromise the security of the Systems (including the confidentiality or integrity of its data and operations, or the availability of the system).

Such issues shall be remediated as quickly as is practical, but in no event longer than 7 calendar days.

k. When the Security Fixes involve installing third party patches (such as Microsoft OS patches or Adobe Acrobat), the A-E will provide written notice to the VA that the patch has been validated as not affecting the System within 10 working days. When the A-E is responsible for operations or maintenance of the Systems, they shall apply the Security Fixes within 7 calendar days.

l. All other vulnerabilities shall be remediated as specified in this paragraph in a timely manner based on risk, but within 60 days of discovery or disclosure. Exceptions to this paragraph (e.g., for the convenience of VA) shall only be granted with approval of the contracting officer and the VA Assistant Secretary for Office of Information and Technology.

5. 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. The contractor/subcontractor must take appropriate and timely action (this can be specified in the contract) to correct or mitigate any weaknesses discovered during such testing, generally at no additional cost.

f. VA prohibits the installation and use of personally owned or contractor/subcontractor-owned equipment or software on VA’s network. If non-VA owned equipment must be used to fulfill the requirements of a contract, it must be stated in the service agreement, SOW, or contract. All of the security controls required for government furnished equipment (GFE) must be utilized in approved or other equipment (OE) and must be funded by the owner of the equipment. All remote systems must be equipped with, and use, a VA-approved antivirus (AV) software and a personal (host-based or enclaved based) firewall that is configured with a VA-approved configuration. Software must be kept current, including all critical updates and patches.

Owners of approved OE are responsible for providing and maintaining the anti-viral software and the firewall on the non-VA owned OE.

g. All electronic storage media used on non-VA leased or non-VA owned IT equipment that is used to store, process, or access VA information must be handled in adherence with VA Handbook 6500.1, Electronic Media Sanitization upon: (i) completion or termination of the contract or (ii) disposal or return of the IT equipment by the contractor/subcontractor, whichever is earlier.

Media (hard drives, optical disks, CDs, back-up tapes, etc.) used by the contractors/subcontractors that contain VA information must be returned to the VA for sanitization or destruction or the contractor/subcontractor must self-certify that the media has been disposed of per 6500.1 requirements. This must be completed within 30 days of termination of the contract.

h. Bio-Medical devices and other equipment or systems containing media (hard drives, optical disks, etc.) with VA sensitive information must not be returned to the A-E at the end of lease, for trade-in, or other purposes. The options are:

(1) A-E must accept the system without the drive;

(2) VA’s initial medical device purchase includes a spare drive which must be installed in place of the original drive at time of turn-in; or

(3) VA must reimburse the company for media at a reasonable open market replacement cost at time of purchase

(4) Due to the highly specialized and sometimes proprietary hardware and software associated with medical equipment/systems, if it is not possible for the VA to retain the hard drive, then;

(a) The equipment A-E must have an existing BAA if the device being traded in has sensitive information stored on it and hard drive(s) from the system are being returned physically intact; and

(b) Any fixed hard drive on the device must be non-destructively sanitized to the greatest extent possible without negatively impacting system operation. Selective clearing down to patient data folder level is recommended using VA approved and validated overwriting technologies/methods/tools. Applicable media sanitization specifications need to be pre-approved and described in the purchase order or contract.

(c) A statement needs to be signed by the Director (System Owner) that states that the drive could not be removed and that (a) and (b) controls above are in place and completed. The ISO needs to maintain the documentation.

6. SECURITY INCIDENT INVESTIGATION

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

7. 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 actual liquidated damages in the event of a data breach or privacy incident involving any SPI the…