Solicitation 75R60221Q00010 BPHC Program Management Resource Compendium.pdf

Title: Bureau of Primary Health Care Program Management Resource Compendium; Solicitation Number 75R60221Q00010; Attachment A – Statement of Work (SOW)

Attachment A Statement of Work (SOW)

Title: Bureau of Primary Health Care Program Management Resource Compendium Date: November 23, 2020

I. Background

The mission of the Bureau of Primary Health Care (BPHC) is to improve the health of the nation’s underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services.

For more than 50 years, the Health Center Program has grown from two health centers to nearly 1,400 health centers and operating approximately 12,000 service delivery sites in every U.S. state and territories. BPHC achieves its mission by administering, managing, monitoring and evaluating all of the Health Center Program activities, including Health Center operational grants, Primary Care Associations (PCAs), National Cooperative Agreements (NCAs), Federally Qualified Health Center (FQHC) Look Alikes (LAL), Health Center Controlled Networks (HCCN), Free Clinics, and the Federal Torts Claims Act (FTCA) Medical Malpractice Insurance program. More than 28 million people rely on a HRSA-funded health centers for affordable, accessible primary health care.

II. Purpose/General Description

The purpose of this requirement is to provide a historical analysis of the Bureau, as well as a historical analysis of the Health Center Program, documenting their evolution, growth, innovations, critical milestones and decision making. This historical analysis will include both an analysis of the Health Center Program and an analysis of the Bureau. These analyses will enable the Bureau to document its evolution and that of the Health Center Program throughout its program management oversight practices and business process history since the beginning. These analyses will capture the key successes, influencing factors, innovations and gaps that improved, or could further improve, the Bureau and its management of the Health Center Program.

These analyses will benefit the 28 million people nationwide who depend on health centers for their health care needs and produce greater efficiencies in Bureau operations, and lead to increased awareness of BPHC and the Health Center Program.

Objectives for this procurement include:

1) A comprehensive analysis documenting BPHCs evolution, in the context of its program management oversight practices of the Health Center Program, Lookalike Programs and Free Clinics. This will include, in addition to the above, management oversight practices, operating model and structure, best practices, lessons learned and previous key program decisions that have impacted the Health Center Program, business processes, succession planning, Bureau reorganizations and the outcomes the Bureau has achieved. This analysis could be in the form of a book or a binder, and shall include a chronological timeline. This analysis is intended for internal agency audiences.

2) A comprehensive analysis documenting the history of the Health Center Program, including the initial health center movement, its evolution, critical milestones, impact and key decision points. This analysis could be in the form of pamphlets, white board, external timeline, web page or other communications vehicle, and is intended for external audiences.

3) Documentation of interviews with influential people and key stakeholders in the history of the Bureau and Health Center Program, including previous leadership, Congressional staff who worked on the program’s authorizing legislation, and other key players and stakeholders in the health center movement (these interviews will inform the analyses above).

III. Period of Performance/Place of Performance

The period of performance shall be for a base period of 12 months plus two 12-month option periods. The estimated start date is March 2021.

The primary place of performance shall be at the contractor’s location. The Government will provide building access via escorting, when required.

Government Furnished

The Government will provide space and building access. The Government will provide appropriate hardware and office productivity software (e.g., SharePoint, word processing, project management, spread sheets, etc.) if required.

IV. Tasks

The contractor shall perform the following tasks during the Base Year, Option Year 1 and Option Year 2:

Task 1: Records Management

Subtask 1.1 - The contractor shall manage and maintain Federal records, including electronic records, ensuing from this contract in accordance with all applicable records management laws and regulations, including but not limited to:

• The Federal Records Act (44 U.S.C. Chapters. 21, 29, 31, 33); 36 CFR §

• 1236.20 What are appropriate recordkeeping systems for electronic records? &

• 1236.22 What are the additional requirements for managing electronic mail records?

(http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5&node=36:3.0.10.2.25);

• NARA Bulletin 2013-02, August 29, 2013, Guidance on a New Approach to Managing

Email Records (https://www.archives.gov/records-mgmt/bulletins/2013/2013-02.html);

and

• NARA Bulletin 2010-05 September 08, 2010, Guidance on Managing Records in Cloud Computing Environments. (http://www.archives.gov/records-mgmt/bulletins/2010/2010- 05.html)

Managing the records includes, maintaining records to retain functionality and integrity throughout the records' full lifecycle including: (1) maintenance of links between records and metadata, and (2) categorization of records to manage retention and disposal, either through transfer of permanent records to NARA or deletion of temporary records in accordance with NARA-approved retention schedules.

Task 2: Records Management Training

Subtask 2.1-The contractor (and/or subcontractor) shall ensure that all employees having access to (1) Federal information or a Federal information system, or (2) personally identifiable information (PII), complete the HRSA Records Management Training before performing work under this contract, and thereafter completing the annual refresher course during the life of the contract. The training can be requested by emailing the records management team at recordsmanagement3@hrsa.gov. The listing of completed training shall be included in the first progress report. Any revisions to this listing as a result of staffing changes shall be submitted with next required progress report.

Task 3: Project Management

The contractor shall:

Subtask 3.1 Single Point of Contact

Provide a single point of contact (POC) for the management of this contract to the Contracting Officer Representative (COR) within five (5) business days from the effective date of contract (EDOC). The POC shall be responsible for ensuring that all tasks and deliverables required are provided in accordance with the contract.

Subtask 3.2 Required Meetings

NOTE: All meetings are intended to occur in person; however, due to COVID-19 restrictions or alternative work schedules, the meetings may also be held virtually.

3.2.1 Kick-off Meeting

Meet with the COR at the Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 or virtually, if decided, within five (5) business days of the EDOC for the kick-off meeting. At the kick-off meeting, the contractor shall provide an agenda, draft master Project Management Plan and timeline, updated roster of key personnel, and proposed communication schedule. After the kick-off meeting, the contractor shall submit meeting minutes in Microsoft Word to the COR via email within three (3) business days.

3.2.2 Status Meetings

• Meet once per month with the COR to discuss the contract performance. These meetings shall occur virtually or in-person at the Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857. These meetings shall include discussion of project updates and critical issues to be resolved.

• send the draft meeting agenda to the COR within one (1) business day prior to the meeting.

• notify the COR within one (1) business day if issues arise that prevent the contractor from attending a meeting.

• submit meeting minutes after each monthly meeting, including any action items and next steps agreed to in the status meeting. This shall be submitted in Microsoft Word to the COR and attendees via email within three (3) business days after the meeting.

3.2.3 Other Meetings (Ad-hoc)

Attend BPHC program meetings to gain a complete understanding of the program being supported, up to twice monthly. The meetings will be held during normal HRSA business hours.

Attendance will either be virtual or on-site at 5600 Fishers Lane, Rockville, Maryland 20857.

Subtask 3.3 Required Reports

3.3.1 Task Area Project Management Plans

3.3.1.1 Develop task area project management plans using Microsoft Word, and email to the COR for review and approval, within 5 business days of the kick-off meeting.

3.3.1.2 Develop and submit to the COR within 30 days from EDOC, separate project management plans for all tasks described herein, outlining specific activities, dependencies, timelines, and milestones to gauge progress.Updated as necessary throughout period of performance.

3.3.2 Monthly Reports

3.3.2.1 Develop and submit to the COR monthly reports that cover all Task Areas for this contract. Reports shall be created using Microsoft Word, Excel or PowerPoint and submitted electronically to the COR no later than the seventh (7) business day of the following calendar month. The monthly report shall include all of the following information. If no new information is available for any item in a given month, the contractor shall list “NA” in the report:

• Summary listing of completed tasks, scheduled tasks, scheduled interviews, submitted deliverables, major events, issues, and staffing updates or contract changes during the reporting period.

Task 4: Conduct Bureau Program Analysis and Health Center Program Analysis (BY)

The following task shall be performed during the Base Period only.

The Contractor shall:

Subtask 4.1 Use historical analysis methods to assess:

4.1.1 BPHC-. This assessment shall encompass chronological timelines, evolution, growth, critical milestones and decision making involved in the Bureau’s history, and includes oral history interviews and research, to capture stakeholder experiences, historical knowledge and viewpoints (Note: A list of individuals to interview will be provided by the COR, which will include current employees, prior employees, staff and former staff of stakeholder organizations, and current and former legislators.

4.1.2 Health Center Program-. This assessment shall encompass chronological timelines, genesis and history of the health center movement and its evolution, critical milestones, impact, and key decision points, and includes oral history interviews and research to capture stakeholder experiences, historical knowledge and viewpoints (Note: A list of individuals to interview will be provided by the COR, which will include current employees, prior employees, staff and former staff of stakeholder organizations, and current and former legislators.

Subtask 4.2- Submit proposed options of analysis for Bureau Health Center Program analyses to be approved by COR. This should include pros and cons of each option, potential challenges associated with each option, and a recommended option for each analysis. The proposed options may include graphical images, audio or visual samples, mockups, or other methods for demonstrating each option. The proposal must also include a recommendation for the medium to be used for each analysis. Draft due 60 days after EDOC and final 75 days from EDOC. COR will approve deliverables within seven (7) business days after receipt.

4.2.1 Provide the draft oral interview questions to be used in Task 5 for approval by the COR. A revised set of oral interview questions to be used in Task 5 and incorporating COR input will be provided to the COR for final approval.

Task 5: Schedule and Conduct Historical Meetings and Interviews (OY1)

The following task shall be performed during Option Period 1 only.

The Contractor shall:

Subtask 5.1: Schedule meetings and interviews with stakeholders adhering to guidance set forth by the COR, to include assessing schedule availability of stakeholders and scheduling of official meeting invites, no less than 14 business days out from proposed interview dates via Microsoft Outlook, upon OMB approval (see Task 6) and in coordination with COR,.

(Historical Interviews for external stakeholders will be scheduled based upon OMB approval-see Task 6).

5.1.1 Prepare communication for meeting and interview invites to be sent via Microsoft Outlook for the above scheduled interviews, three (3) business days prior to scheduled invite to be sent out.

5.1.2 Work in coordination with the COR to schedule logistics 14 business days prior to scheduled meetings and interviews. This shall include conference room scheduling, Adobe Connect or Skype set up if necessary, and conference line access.

5.1.3 Provide to the COR full interview transcripts, audio and video file (Format-high quality .WAV files and/or .mp3 files) from all interviews 60 prior to end of POP.

Task 6: Develop OMB Information Collection Request Clearance Packages and associated Federal Register Notices for Bureau and Health Center Program Analysis Activities (BY, OY1, OY2)

The following tasks shall be performed during the Base Period, Option Period 1, and Option Period 2.

The contractor shall:

Subtask 6.1 -Prepare and submit 60-day and 30-day Federal Register Notices (FRNs) as appropriate and (1) information collection request clearance package in accordance with OMB's clearance process under the Paperwork Reduction Act. The COR will provide the Contractor with the necessary guidance and instructions to produce these documents.

6.1.1 Use applicable forms, provided by the COR, to draft the FRNs and information collection request clearance packages for OMB review. Within 5 business days of

EDOC.

6.1.2 Submit a draft 60-day FRN and draft clearance package to the COR for submission to OMB. Within 45 days of EDOC. The COR will review the draft 60-day FRN and clearance package within 10 business days and the Contractor shall revise the documents accordingly (within 10 business days of receiving the comments.)

6.1.3 Submit a draft 30-day FRN and clearance package incorporating any public comments received by the government to the COR for submission to OMB. Due within 75 days of EDOC. The COR will review the draft 30-day FRN and clearance package within 10 business days and the Contractor shall revise the documents accordingly (within 10 business days of receiving the comments)

• The COR will submit the draft documents to the HRSA Information Collections Clearance Officer for review/approval. Based on this review, the Contractor shall make necessary changes to these documents as requested by the COR (within 5 business days of receiving the comments)

• The government will submit the packages to OMB for review and approval, the Contractor shall answer any questions or make any required revisions as directed by the COR based on OMB’s review within five (5) business days.

Task 7: Planning and Production Pamphlets, white board, external timeline, web page or other Outline and Production of Health Center Program Analysis (OY1)

The following task shall be performed during Option Period 1 only.

The contractor shall:

Subtask 7.1- Outline establishing overarching themes/topics/subthemes for publication to be covered within each chapter or section to be approved by COR.

7.1.1 Provide a recommendation of each layout option proposed, including pros and cons of each option, and the potential challenges associated with each option. These demos may be in the form of graphical images, audio or visual samples, mockups, or other methods of articulating each layout option. Demos must be provided to the COR for approval 30 days prior to end of the performance period. The COR will approve within five (5) business days.

7.1.2 Provide the necessary webpage layouts for final production, upon final approval of webpage outline and layout in task 4.4.2 . The website shall be housed on the HRSA website, following the proper requirements of HRSA Security, Office of Communications and the Office of Information Technology. Final webpage should be published for public use, and the code should be submitted as a final deliverable for approval by the COR, five (5) business days prior to end of contract expiration. Style Guidelines: All web materials must adhere to AP style, along with the HHS exceptions to that guide as seen on HHS’s Web Style Guide page (http://www.hhs.gov/web/policies-and-standards/web-style-guide/index.html)

Task 8: Planning of Book of Bureau of Primary Health Care Analysis (OY2)

The following task shall be performed during Option Period 2 only.

The contractor shall:

Subtask 8.1- Outline establishing overarching themes/topics/subthemes for publication to be covered within each chapter or section to be approved by COR.

http://www.hhs.gov/web/policies-and-standards/web-style-guide/index.html http://www.hhs.gov/web/policies-and-standards/web-style-guide/index.html

Optional Task 9: Planning for printing of book of Bureau of Primary Health Care Analysis

(OY2)

The following task is an optional task that may be exercised up to one time during Option Period 2 only:

Optional Subtask 9.1. Provide the COR Printed five (5) demo draft of proposed option for layout and one (1) electronic copy in PDF format with crop marks , to be sent to the General Printing Office (GPO) for printing, using the final approved layout .

Note: Deliverable shall Display the HRSA Health Center Program logo and adhere to HRSA’s Visual Style Guide found here: https://sharepoint.hrsa.gov/oa/oc/Documents/VisualStyleGuide.pdf

Task 10: OIT Baseline Security Requirements (BY, OY1, OY2)

The following tasks shall be performed during the Base Period, Option Period 1, and Option Period 2.

1) Applicability. The requirements herein apply whether the entire contract or order (hereafter “contract”), or portion thereof, includes either or both of the following:

a. Access (Physical or Logical) to Government Information: A Contractor (and/or any subcontractor) employee will have or will be given the ability to have, routine physical (entry) or logical (electronic) access to government information.

b. Operate a Federal System Containing Information: A Contractor (and/or any subcontractor) will operate a federal system and information technology containing data that supports the HHS mission. In addition to the Federal Acquisition Regulation (FAR) Subpart 2.1 definition of “information technology” (IT), the term as used in this section includes computers, ancillary equipment (including imaging peripherals, input, output, and storage devices necessary for security and surveillance), peripheral equipment designed to be controlled by the central processing unit of a computer, software, firmware and similar procedures, services (including support services), and related resources.

2) Safeguarding Information and Information Systems . In accordance with the

Federal Information Processing Standards Publication (FIPS)199, Standards for Security Categorization of Federal Information and Information Systems, the Contractor (and/or any subcontractor) shall:

a. Protect government information and information systems in order to ensure:

• Confidentiality, which means preserving authorized restrictions on access and disclosure, based on the security terms found in this contract, including means for protecting personal privacy and proprietary information;

• Integrity, which means guarding against improper information modification or destruction, and ensuring information non-repudiation and authenticity; and https://sharepoint.hrsa.gov/oa/oc/Documents/VisualStyleGuide.pdf

• Availability, which means ensuring timely and reliable access to and use of information.

b. Provide security for any Contractor systems, and information contained therein, connected to an HHS network or operated by the Contractor on behalf of HHS regardless of location per FAR clause 52.239-1, Privacy or Security Safeguards. In addition, if new or unanticipated threats or hazards are discovered by either the agency or contractor, or if existing safeguards have ceased to function, the discoverer shall immediately, within one (1) hour or less , bring the situation to the attention of the other party.

c. Adopt and implement the policies, procedures, controls, and standards required by the HHS Information Security Program to ensure the confidentiality, integrity, and availability of government information and government information systems for which the Contractor is responsible under this contract or to which the Contractor may otherwise have access under this contract. Obtain the HHS Information Security Program security requirements, outlined in the HHS Information Security and Privacy Policy (IS2P), by contacting the CO/COR or emailing fisma@hhs.gov.

d. Comply with the Privacy Act requirements and tailor FAR clauses as needed.

3) Information Security Categorization. In accordance with FIPS 199 and National Institute of Standards and Technology (NIST) Special Publication (SP) 800-60, Volume II: Appendices to Guide for Mapping Types of Information and Information Systems to Security Categories, Appendix C, and based on information provided by the ISSO, CISO, or other security representative, the risk level for each Security Objective and the Overall Risk Level, which is the highest watermark of the three factors (Confidentiality, Integrity, and Availability) of the information or information system are the following:

Confidentiality: [X] Low [ ] Moderate [ ] High

Integrity: [X] Low [ ] Moderate [ ] High

Availability: [X] Low [ ] Moderate [ ] High

Overall Risk Level: [X] Low [ ] Moderate [ ] High

Based on information provided by the ISSO, Privacy Office, system/data owner, or other security or privacy representative, it has been determined that this solicitation/contract involves:

[X] No PII [ ] Yes PII

Personally Identifiable Information (PII). Per the Office of Management and Budget (OMB) Circular A-130, “PII is information that can be used to distinguish or trace an http://csrc.nist.gov/publications/nistpubs/800-60-rev1/SP800-60_Vol2-Rev1.pdf http://csrc.nist.gov/publications/nistpubs/800-60-rev1/SP800-60_Vol2-Rev1.pdf http://csrc.nist.gov/publications/nistpubs/800-60-rev1/SP800-60_Vol2-Rev1.pdf individual's identity, either alone or when combined with other information that is linked or linkable to a specific individual.” Examples of PII include, but are not limited to the following: social security number, date and place of birth, mother‘s maiden name, biometric records, etc.

PII Confidentiality Impact Level has been determined to be: [X] Low [ ] Moderate [ ] High

4) Controlled Unclassified Information (CUI). CUI is defined as “information that laws, regulations, or Government-wide policies require to have safeguarding or dissemination controls, excluding classified information.” The Contractor (and/or any subcontractor) must comply with Executive Order 13556, Controlled Unclassified Information, (implemented at 3 CFR, part 2002) when handling CUI. 32 C.F.R.

2002.4(aa) As implemented the term “handling” refers to “…any use of CUI, including but not limited to marking, safeguarding, transporting, disseminating, re-using, and disposing of the information.” 81 Fed. Reg. 63323. All sensitive information that has been identified as CUI by a regulation or statute, handled by this solicitation/contract, shall be:

a. marked appropriately;

b. disclosed to authorized personnel on a Need-To-Know basis;

c. protected in accordance with NIST SP 800-53, Security and Privacy Controls for

Federal Information Systems and Organizations applicable baseline if handled by a Contractor system operated on behalf of the agency, or NIST SP 800-171, Protecting Controlled Unclassified Information in Nonfederal Information Systems and Organizations if handled by internal Contractor system; and

d. Returned to HHS control, destroyed when no longer needed, or held until otherwise directed. Destruction of information and/or data shall be accomplished in accordance with NIST SP 800-88, Guidelines for Media Sanitization.

5) Protection of Sensitive Information. For security purposes, information is or may be sensitive because it requires security to protect its confidentiality, integrity, and/or availability. The Contractor (and/or any subcontractor) shall protect all government information that is or may be sensitive in accordance with OMB Memorandum M-06- 16, Protection of Sensitive Agency Information by securing it with a FIPS 140-2 validated solution.

6) Confidentiality and Nondisclosure of Information. Any information provided to the contractor (and/or any subcontractor) by HHS or collected by the contractor on behalf of HHS shall be used only for the purpose of carrying out the provisions of this contract and shall not be disclosed or made known in any manner to any persons except as may be necessary in the performance of the contract. The Contractor assumes responsibility for protection of the confidentiality of Government records and shall ensure that all work performed by its employees and subcontractors shall be under the supervision of the Contractor. Each Contractor officer or employee or any of its subcontractors to whom any HHS records may be made available or disclosed shall be notified in writing by the Contractor that information disclosed to such officer or employee can be used only for that purpose and to the extent authorized herein.

The confidentiality, integrity, and availability of such information shall be protected in accordance with HHS and HRSA policies. Unauthorized disclosure of information will be subject to the HHS/HRSA sanction policies and/or governed by the following laws and regulations:

a. 18 U.S.C. 641 (Criminal Code: Public Money, Property or Records);

b. 18 U.S.C. 1905 (Criminal Code: Disclosure of Confidential Information); and

c. 44 U.S.C. Chapter 35, Subchapter I (Paperwork Reduction Act).

7) Internet Protocol Version 6 (IPv6). All acquisitions using Internet Protocol shall comply with FAR sections: FAR 7.105(b) (5), FAR 11.002(g), and FAR 12.202(e).

8) Government Websites. All new and existing public-facing government websites must be securely configured with Hypertext Transfer Protocol Secure (HTTPS) using the most recent version of Transport Layer Security (TLS). In addition, HTTPS shall enable HTTP Strict Transport Security (HSTS) to instruct compliant browsers to assume HTTPS at all times to reduce the number of insecure redirects and protect against attacks that attempt to downgrade connections to plain HTTP. For internal-facing websites, the HTTPS is not required, but it is highly recommended.

9) Contract Documentation. The Contractor shall use HRSA-provided templates, policies, forms and other documents to comply with contract deliverables as appropriate.

10) Standard for Encryption. The Contractor (and/or any subcontractor) shall:

a. Comply with the HHS Standard for Encryption of Computing Devices and Information to prevent unauthorized access to government information.

b. Encrypt all sensitive federal data and information (i.e., PII, protected health information [PHI], proprietary information, etc.) in transit (i.e., email, network connections, etc.) and at rest (i.e., servers, storage devices, mobile devices, backup media, etc.) with FIPS 140-2 validated encryption solution.

c. Secure all devices (i.e.: desktops, laptops, mobile devices, etc.) that store and process government information and ensure devices meet HHS and HRSA-specific encryption standard requirements. Maintain a complete and current inventory of all laptop computers, desktop computers, and other mobile devices and portable media that store or process sensitive government information (including PII).

d. Verify that the encryption solutions in use have been validated under the

Cryptographic Module Validation Program to confirm compliance with FIPS 140-2.

The Contractor shall provide a written copy of the validation documentation to the COR prior to the EPLC Design Readiness Review (DRR).

e. Use the Key Management system on the HHS personal identification verification (PIV) card or establish and use a key recovery mechanism to ensure the ability for authorized personnel to encrypt/decrypt information and recover encryption keys.

Encryption keys shall be provided to the COR upon request and at the conclusion of the contract.

11) Contractor Non-Disclosure Agreement (NDA). Each Contractor (and/or any subcontractor) employee having access to non-public government information under this contract shall complete the HRSA non-disclosure agreement, as applicable. A copy of each signed and witnessed NDA shall be submitted to the Contracting Officer (CO) and/or CO Representative (COR) prior to performing any work under this acquisition.

12) Privacy Threshold Analysis (PTA)/Privacy Impact Assessment (PIA) – The

Contractor shall assist the HRSA Senior Official for Privacy (SOP) or designee with conducting a PTA for the information system and/or information handled under this contract to determine whether or not a full PIA needs to be completed.

a. If the results of the PTA show that a full PIA is needed, the Contractor shall assist the

HRSA SOP or designee with completing a PIA for the system or information within 60 days after completion of the PTA and in accordance with HHS policy and OMB M-03-22, Guidance for Implementing the Privacy Provisions of the E-Government Act of 2002.

b. The Contractor shall assist the HRSA SOP or designee in reviewing the PIA at least every three years throughout the system development lifecycle (SDLC)/information lifecycle, or when determined by the agency that a review is required based on a major change to the system, or when new types of PII are collected that introduces new or increased privacy risks, whichever comes first.

1. Training

1) Mandatory Training for All Contractor Staff. All Contractor (and/or any subcontractor) employees assigned to work on this contract shall complete the applicable HHS/HRSA Information Security Awareness, Privacy, and Records Management training (provided upon contract award) before performing any work under this contract.

Thereafter, the employees shall complete HHS/HRSA Information Security Awareness, Privacy, and Records Management training at least annually, during the life of this contract. All provided training shall be compliant with HHS training policies.

http://csrc.nist.gov/publications/fips/fips140-2/fips1402.pdf

2) Role-based Training. All Contractor (and/or any subcontractor) employees with significant security responsibilities (as determined by the program manager) must complete role-based training annually commensurate with their role and responsibilities in accordance with HHS policy and the HHS Role-Based Training (RBT) of Personnel with Significant Security Responsibilities Memorandum.

3) Training Records. The Contractor (and/or any subcontractor) shall maintain training records for all its employees working under this contract in accordance with HHS policy.

The training records shall be provided to the CO and/or COR within 30 days after contract award and annually thereafter or upon request.

2. Rules of Behavior

1) The Contractor (and/or any subcontractor) shall ensure that all employees performing on the contract comply with the HHS Information Technology General Rules of Behavior, the HRSA Information Technology Rules of Behavior (included in the HRSA Information Security and Privacy Awareness Training), and any applicable system-level rules of behavior.

2) All Contractor employees performing on the contract must read and adhere to the Rules of Behavior (ROB) before accessing Department data or other information, systems, and/or networks that store/process government information, initially at the beginning of the contract and at least annually thereafter, which may be done as part of annual HRSA Information Security Awareness Training. If the training is provided by the contractor, the signed ROB must be provided as a separate deliverable.

3. Incident Response

FISMA defines an incident as “an occurrence that (1) actually or imminently jeopardizes, without lawful authority, the integrity, confidentiality, or availability of information or an information system; or (2) constitutes a violation or imminent threat of violation of law, security policies, security procedures, or acceptable use policies. The HHS Policy for IT Security and Privacy Incident Reporting and Response further defines incidents as events involving cybersecurity and privacy threats, such as viruses, malicious user activity, loss of, unauthorized disclosure or destruction of data, and so on.

A privacy breach is a type of incident and is defined by Federal Information Security Modernization Act (FISMA) as the loss of control, compromise, unauthorized disclosure, unauthorized acquisition, or any similar occurrence where (1) a person other than an authorized user accesses or potentially accesses personally identifiable information or (2) an authorized user accesses or potentially accesses personally identifiable information for an other than authorized purpose. The HHS Policy for IT Security and Privacy Incident Reporting and Response further defines a breach as “a suspected or confirmed incident involving PII”.

In the event of a suspected or confirmed incident or breach, the Contractor (and/or any subcontractor), the Contractor (and/or any subcontractor) shall:

1) Protect all sensitive information, including any PII created, stored, or transmitted in the performance of this contract so as to avoid a secondary sensitive information incident with FIPS 140-2 validated encryption.

2) NOT notify affected individuals unless so instructed by the Contracting Officer or designated representative. If so instructed by the Contracting Officer or representative, the Contractor shall send notifications to affected individuals following specific instructions from the HHS Privacy Incident Response Team (PIRT).

3) Report all suspected and confirmed information security and privacy incidents and breaches to the HRSA Security Operations Center (SOC), COR, CO, HRSA SOP (or his or her designee), and other stakeholders, including incidents involving PII, in any medium or form, including paper, oral, or electronic, as soon as possible and without unreasonable delay, no later than one (1) hour, and consistent with the applicable HRSA and HHS policy and procedures, NIST standards and guidelines, as well as US-CERT notification guidelines. The types of information required in an incident report must include at a minimum: company and point of contact information, contract information, impact classifications/threat vector, and the type of information compromised. In addition, the Contractor shall:

a. cooperate and exchange any information, as determined by the Agency, necessary to effectively manage or mitigate a suspected or confirmed breach;

b. not include any sensitive information in the subject or body of any reporting e-mail;

and

c. encrypt sensitive information in attachments to email, media, etc.

4) Comply with OMB M-17-12, Preparing for and Responding to a Breach of Personally Identifiable Information, HHS, and HRSA incident response policies when handling PII breaches.

5) Provide full access and cooperate on all activities as determined by the Government to ensure an effective incident response, including providing all requested images, log files, and event information to facilitate rapid resolution of sensitive information incidents. This may involve disconnecting the system processing, storing, or transmitting the sensitive information from the Internet or other networks or applying additional security controls.

4. Position Sensitivity Designations

All Contractor (and/or any subcontractor) employees must obtain a background investigation commensurate with their position sensitivity designation that complies with Parts 1400 and 731 of Title 5, Code of Federal Regulations (CFR). The following position sensitivity designation levels apply to this solicitation/contract:

The requiring activity representative, in conjunction with Personnel Security, shall use the OPM Position Sensitivity Designation automated tool (https://www.opm.gov/investigations/) to determine the sensitivity designation for background investigations. After making those determinations, include all applicable position sensitivity designations.

The Personnel Security Team (PS-Updates@hrsa.gov) are able to assist with these designations.

Please provide the latest Statement of Work in your correspondence.

5. Homeland Security Presidential Directive (HSPD)-12

The Contractor (and/or any subcontractor) and its employees shall comply with Homeland Security Presidential Directive (HSPD)-12, Policy for a Common Identification Standard for Federal Employees and Contractors; OMB M-05-24; FIPS 201, Personal Identity Verification (PIV) of Federal Employees and Contractors; HHS HSPD-12 policy; and Executive Order 13467, Part 1 §1.2.

Roster. The Contractor (and/or any subcontractor) shall submit a roster by name, position, e-mail address, phone number and responsibility, of all staff working under this acquisition where the Contractor will develop, have the ability to access, or host and/or maintain a government information system(s). The roster shall be submitted to the COR, with a copy to the Contracting Officer, within 14 days of the effective date of this contract. Any revisions to the roster as a result of staffing changes shall be submitted within 14 days of the change. The COR will notify the Contractor of the appropriate level of investigation required for each staff member.

If the employee is filling a new position, the Contractor shall provide a position description and the Government will determine the appropriate suitability level.

6. Contract Initiation and Expiration

1) General Security Requirements . The Contractor (and/or any subcontractor) shall comply with information security and privacy requirements, Enterprise Performance Life Cycle (EPLC) processes, HHS Enterprise Architecture requirements to ensure information is appropriately protected from initiation to expiration of the contract. All information systems development or enhancement tasks supported by the contractor shall follow the HRSA EPLC framework and methodology and in accordance with the HHS Contract Closeout Guide (2012).

2) System Documentation. Contractors (and/or any subcontractors) must follow and adhere to NIST SP 800-64, Security Considerations in the System Development Life Cycle, at a minimum, for system development and provide system documentation at designated intervals (specifically, at the expiration of the contract) within the EPLC that require artifact review and approval.

3) Sanitization of Government Files and Information. As part of contract closeout and at expiration of the contract, the Contractor (and/or any subcontractor) shall provide all https://www.opm.gov/investigations/ mailto:PS-Updates@hrsa.gov required documentation to the CO and/or COR to certify that, at the government’s direction, all electronic and paper records are appropriately disposed of and all devices and media are sanitized in accordance with NIST SP 800-88, Guidelines for Media Sanitization.

4) Notification. The Contractor (and/or any subcontractor) shall notify the CO and/or COR and system ISSO within two weeks before an employee stops working under this contract.

5) Contractor Responsibilities Upon Physical Completion of the Contract. The contractor (and/or any subcontractors) shall return all government information and IT resources (i.e., government information in non-government-owned systems, media, and backup systems) acquired during the term of this contract to the CO and/or COR.

Additionally, the Contractor shall provide a certification that all government information has been properly sanitized and purged from Contractor-owned systems, including backup systems and media used during contract performance, in accordance with HHS and/or HRSA policies.

6) The Contractor (and/or any subcontractor) shall perform and document the actions identified in the HRSA Clearance Form for Separating Employees and Contractors (Form-419) when an employee terminates work under this contract within two (2) weeks days of the employee’s exit from the contract. All documentation shall be made available to the CO and/or COR upon request.

7. Acquisitions Involving Government information Processed on GOCO or COCO Systems

1) Federal Policies. The Contractor (and/or any subcontractor) shall comply with applicable federal laws that include, but are not limited to, the HHS Information Security and Privacy Policy (IS2P), Federal Information Security Modernization Act (FISMA) of 2014, (44 U.S.C. 101); National Institute of Standards and Technology (NIST) Special Publication (SP) 800-53, Security and Privacy Controls for Federal Information Systems and Organizations; Office of Management and Budget (OMB) Circular A-130, Managing Information as a Strategic Resource; and other applicable federal laws, regulations, NIST guidance, and Departmental policies.

2) Security Assessment and Authorization (SA&A). A valid authority to operate (ATO) certifies that the Contractor’s information system meets the contract’s requirements to protect the agency data. If the system under this contract does not have a valid ATO, the Contractor (and/or any subcontractor) shall work with the agency and supply the deliverables required to complete the ATO 30 days prior to the EPLC Operational Readiness Review (ORR). The Contractor shall conduct the SA&A requirements in accordance with HHS IS2P, NIST SP 800-37, Guide for Applying the Risk Management Framework to Federal Information Systems: A Security Life Cycle Approach (latest revision).

For an existing ATO, HRSA must make a determination if the existing ATO provides appropriate safeguards or if an additional ATO is required for the performance of the contract and state as such.

HRSA’s acceptance of the ATO does not alleviate the Contractor’s responsibility to ensure the system security and privacy controls are implemented and operating effectively.

a. SA&A Package Deliverables - The Contractor (and/or any subcontractor) shall provide an SA&A package within 30 days prior to the ORR to the CO and/or COR. The following SA&A deliverables are required to complete the SA&A package:

• System Security Plan (SSP) – Initial draft version due within 30 days of the EPLC

Performance Baseline Review. Final draft due 120 days prior to the Operational Readiness Review. Final version due 30 days prior to the Operational Readiness Review.

The SSP shall comply with the NIST SP 800-18, Guide for Developing Security Plans for Federal Information Systems, the Federal Information Processing Standard (FIPS) 200, Recommended Security Controls for Federal Information Systems, and NIST SP 800-53, Security and Privacy Controls for Federal Information Systems and Organizations applicable baseline requirements, and other applicable NIST guidance as well as HHS and HRSA policies and other guidance. The SSP shall be consistent with and detail the approach to IT security contained in the Contractor’s bid or proposal that resulted in the award of this contract. The SSP shall provide an overview of the system environment and security requirements to protect the information system as well as describe all applicable security controls in place or planned for meeting those requirements. It should provide a structured process for planning adequate, cost-effective security protection for a system. The Contractor shall update the SSP at least annually thereafter.

• Security Assessment Plan/Report (SAP/SAR) – due 30 days prior to the

Operational Readiness Review. The security assessment shall be conducted by HRSA’s Security Assessment Team and be consistent with NIST SP 800-53A, NIST SP 800-30, latest revisions, and HHS and HRSA policies. The assessor will document the assessment results in the SAR.

Thereafter, the Contractor, in coordination with HRSA shall assist in the assessment of the security controls annually and update the SAR at least annually.

• POA&M – due within 7 days after the Security Control Assessment Report is delivered. The POA&M shall be documented consistent with the HHS Standard for Plan of Action and Milestones and HRSA policies. All high-risk weaknesses must be mitigated within 30 days and all moderate weaknesses must be mitigated within 180 days from the date weaknesses are formally identified and documented. HRSA will determine the risk rating of vulnerabilities.

Identified risks stemming from deficiencies related to the security control baseline implementation, assessment, continuous monitoring, vulnerability scanning, and other security reviews and sources, as documented in the SAR, shall be documented and tracked by the Contractor for mitigation in the POA&M document. Depending on the severity of the risks, HRSA may require designated POAM weaknesses to be remediated before an ATO is issued. Thereafter, the POA&M shall be updated at least quarterly.

• Contingency Plan – due within 120 days prior to the Operational Readiness Review.

The Contingency Plan must be developed in accordance with NIST SP 800-34, latest revision, and be consistent with HHS and HRSA policies. The Contractor shall review/update the Contingency Plan at least annually thereafter.

• Contingency Plan Test – due within 60 days of acceptance of the Contingency Plan by the System Owner. Upon acceptance by the System Owner, the Contractor, in coordination with the System Owner, shall test the Contingency Plan and prepare a Contingency Plan Test Report that includes the test results, lessons learned and any action items that need to be addressed. The Contractor shall conduct a Contingency Plan Test at least annually thereafter.

• E-Authentication Questionnaire – The contractor (and/or any subcontractor) shall collaborate with government personnel to ensure that an E-Authentication Threshold Analysis (E-auth TA) is completed to determine if a full E-Authentication Risk Assessment (E-auth RA) is necessary. System documentation developed for a system using E-auth TA/E-auth RA methods shall follow OMB 04-04 and NIST SP 800-63, Rev. 2, Electronic Authentication Guidelines.

Based on the level of assurance determined by the E-Auth, the Contractor (and/or subcontractor) must ensure appropriate authentication to the system, including remote authentication, is in-place in accordance with the assurance level determined by the E-Auth (when required) in accordance with HHS policies.

b. Information Security Continuous Monitoring. Upon the government issuance of an Authority to Operate (ATO), the Contractor (and/or subcontractor)-owned/operated systems that input, store, process, output, and/or transmit government information, shall meet or exceed the information security continuous monitoring (ISCM) requirements in accordance with FISMA and NIST SP 800-137, Information Security Continuous Monitoring (ISCM) for Federal Information Systems and Organizations, and HHS IS2P. The following are the minimum requirements for ISCM:

• Annual Assessment/Review - Assess the system security and privacy controls (or ensure an assessment of the controls is conducted) at least annually to determine the implemented security and privacy controls are operating as intended and producing the desired results. In addition, review all relevant SA&A documentation (SSP, POA&M, Contingency Plan, etc.) and provide updates by specified due date [OpDiv provided].

• Asset Management - Using any available Security Content Automation Protocol

(SCAP)-compliant automated tools for active/passive scans, provide an inventory of all information technology (IT) assets for hardware and software, (computers, servers, routers, databases, operating systems, etc.) that are processing HHS-owned information/data The inventory information is required to be produced within 30 days of the EPLC Performance Baseline Review. Final version due within 30 days prior to the Operational Readiness Review and reviewed and updated on a monthly basis thereafter. IT asset inventory information shall include IP address, machine name, operating system level, security patch level, and SCAP-compliant format information.

The contractor shall maintain a capability to provide an inventory of 100% of its IT assets using SCAP-compliant automated tools.

• Configuration Management - Use available SCAP-compliant automated tools, per NIST IR 7511, for authenticated scans to provide visibility into the security configuration compliance status of all IT assets, (computers, servers, routers, databases, operating systems, application, etc.) that store and process government information. Compliance will be measured using IT assets and standard HHS and government configuration baselines prior to the EPLC Operational Readiness Review. The contractor shall maintain a capability to provide security configuration compliance information for 100% of its IT assets using SCAP-compliant automated tools.

• Vulnerability Management - Use SCAP-compliant automated tools for authenticated scans to scan information system(s) and detect any security vulnerabilities in all assets (computers, servers, routers, Web applications, databases, operating systems, etc.) that store and process government information. Contractors shall actively manage system vulnerabilities using automated tools and technologies where practicable and in accordance with HHS policy. Automated tools shall be compliant with NIST-specified SCAP standards for vulnerability identification and management.