Statement of Work SOW SAVAHCS Mobile MRI CT Trailer Lease.docx

STATEMENT OF WORK

Radiology Services

The Southern Arizona VA Healthcare System is requesting a contractor to provide mobile Magnetic Resonance Imaging (MRI) and Mobile Computed Tomography (CT) equipment.

BASICS

B1. Requirements:

The contractor will provide a mobile, handicap-accessible, magnetic resonance imager One Mobile Siemens Aera 1.5T MRI & One Mobile Siemens Flash 256 Slice CT.

B2. Authority:

This procurement is executed under:

1.1 The Enhanced Sharing Authority, Public Law 104-262, Title 38 U.S.C. 8153 [The Government, under this authority reserves the right to sell excess capacity.];

1.2 The procedures described in FAR Subpart 12.6 and Part 13, as updated through FAC and as supplemented with information included in this solicitation;

1.3 VHA Handbook 1105.05, Magnetic Resonance Imaging Safety;

1.4 Title 38 United States Code 7301 (b); and

1.5 Title 38 Code of Federal Regulations 17.38.

1. Specifications (Mobile MRI & Mobile CT):

1.1 General Requirements (mobile MRI/CT):

a. The MRI and CT units will be available for patient exams seven (7) days per week, excluding Federal Holidays, i.e. New Year’s Day, Martin Luther King, Jr’s. Birthday, Presidents’ Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving, Christmas and any other days specifically declared by the President of the United States to be national holidays.

b. The equipment is to be used for federal government contract work only.

c. Contractor will be solely responsible for all driver-staffing issues related to the mobile MRI and mobile CT.

d. Contractor will perform arrival, set-up, take-down, and departure of mobile MRI and mobile CT at contract end.

e. Contractor will provide a mobile MRI and mobile CT that operate full days (6AM-9PM M-Sun).

f. Mobile MRI Unit Must Comply with VA Directive 1105.05 to have a separate Zone II changing and screening room on the mobile.

g. The modular trailer for MRI will be at a minimum 12 feet and 50 feet to accommodate physical separation of Zone II and Zone III inside the unit.

h. Covered walkway from facility building to mobile unit will be supplied by contractor.

i. Equipment operating systems must be supportable Windows 10 or higher

1.2 Mobile Equipment:

a. The Contractor shall be responsible for all maintenance, upgrades, updates, and servicing of Contractor owned equipment during the contract period.

b. All responsibilities will be scheduled and coordinated to be performed after business hours with the COR.

c. The unit will be equipped with a hydraulic lift to accommodate a wheelchair or to accommodate a stretcher and the person transporting the patient.

1.3 Utilities and Government Furnished Materials provided by the VA:

a. Fiber reinforced concrete pad

b. Power outlet located approximately 25 feet from the pad. Power requirements 480 volts, 3 phase, 150 amps, 112 kVA Russel Stohl connector

c. Water for mobile units, and sewer drain.

d. Two (2) telephone line terminals located near the 480v power outlet

e. One computer terminal with VA Radiology PACS network access

f. Telephone instruments for the mobile unit

g. Restroom facilities within a reasonable walking distance if not available in unit

h. Please review images provided with site location and connections.

i. All supplies, including basic consumables and linens, required to perform the MRI examinations, contrast material and supplies.

Emergency crash cart with special oxygen tanks and regulators One MRI safe stretcher One MRI safe wheelchair will be provided by the VA All cleaning supplies All PPE required by COVID 19- Masks, hand sanitized, Digital Temperature gauge.

1.4 Supplies:

a. The Contractor will be responsible for providing all necessary cryogen.

2. Special Requirements:

2.1 Resources:

a. The resources specified in this contract may be changed only by written modification by the assigned VISN ___VA Contracting Officer.

b. The MRI services to be performed by the Contractor will be under the direction of the Chief, Radiology Service, VA. The resulting contract is a non-personnel services contract under which the personnel rendering services are not subject, either by the contract terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees.

2.2 Term of Contract:

a. The contract is effective for one (1) year base period and four (4) 12-month option period with an expected award date that is to be ________TBD.

b. Funds for option period will be subject to the availability of funds. Service will not be performed by the Contractor after the ending date of this contract, until the Contracting Officer authorizes such services in writing.

2.3 Study Quality:

The Contractor will provide the VA a study-quality standard that reflects the quality of the studies the provider is prepared to ensure will be maintained throughout the duration of the contract. Examples of most, if not all, study types to be performed will be included in the study-quality standard and maintained on the MRI and CT hard drive systems. All protocols will be entered and tested with applications specialist supplied by contractor. Reading radiologists will confirm protocols, and request modifications as necessary.

2.4 Quality Control:

The Contractor will have a documented quality assurance program and provide a copy of quality assurance documents with the proposal. The program will comply with all relevant TJC and HIPPA standards. The Contractor will have readily available several phantoms that can be used to determine MRI parameters. Phantom studies will be conducted as needed to test and ensure study quality.

2.5 Site Maintenance:

The VA will be responsible for maintenance of a concrete pad appropriate for support and location of the mobile units. The VA will be responsible for maintenance of connectivity ports appropriate for linking the mobile units to power, computer network, and local-access phone/modem/fax as needed. The telephone technology will include one line dedicated for direct access to the code emergency response line in the VA Clinic. The emergency phone line must be a dedicated sole use line. The VA will be responsible for connectivity from within the VA Clinic to connectivity ports located outside the VA Clinic facility at the site of the pad. The Contractor will be responsible for connectivity from within the mobile units to the connectivity ports of the VA Clinic.

One phone line will have access to long distance for reporting concerns issues to the contractor 24/7/365 service line.

2.6 Pre-operation Contractor/ Tests of Mobile Units:

The Contractor and VA personnel will conduct tests of the mobile units when they are first located. The tests will be performed to ensure the units are working properly, to insure all needed/desired connectivity’s are functioning properly, and to ensure functionality is such that the conditions of this contract are met prior to the date of award. All MRI and CT protocols will be entered with support from the contractor’s applications specialist and tested with images sent to reading radiologists for confirmation.

2.7 Service Contracts:

The Contractor will, throughout the period of the contract, a service person, parts with for the mobile units. This will include service on the MRI and CT, and on any peripherals required to ensure connectivity to the VA Radiology Service PACS. No routine maintenance will be scheduled or performed such that it conflicts with the imaging schedules of the mobile MRI or CT. No maintenance will be scheduled or performed during scheduled scanning hours except to address emergency failures of the mobile units. Service response time to emergency failures should be within two hours.

2.8 Medical Records:

Clinical and/or other medical records, including images in DICOM form, of VA beneficiaries treated by the Contractor will be forwarded to the VA and shall remain the property of the US Government. The VA will own solely the data/images of the examinations and studies performed on the mobile unit.

2.9 Insurance:

The Contractor will provide proof of liability and workers’ compensation, a certificate of insurance providing evidence of liability coverage including the name of the insurance carrier, limits of liability and type of coverage (Ref: VAAR 852.237-7, Indemnification and Medical Liability Insurance).Standard requirement for $200,000 per person and $500,000 per occurrence for bodily injury and $20,000 per occurrence for property damage as well.

2.10 Medical Emergencies:

The Contractor will provide to the VA written emergency plans addressing emergencies such as patient codes, personal injury, fire, and disruptive behavior. All emergency response teams at the VA will be trained in MRI safety. Lead technologist will conduct the training, to emphasize the critical safety issues with the MRI Magnet.

2.11 Regulatory Adherence:

The Contractor is responsible for adhering to all relevant regulations regarding patient care, medical practice, use of contrast agents, use of radiopharmaceuticals, MRI and CT technology. Examples of relevant regulations are those of NHPP, OSHA, TJC, NRC, VHA, and various other federal agencies.

2.12 Quality and Contract Monitoring:

a. The Contractor will be monitored through a variety of mechanisms appropriate to VA regulations and policies.

b. The Contracting Officers Representative (COR) () will be responsible for monitoring the quality of services provided under this contract.

2.14 Past Performance:

a. The Contractor must provide past performance information to establish their established ability to provide this service.

3. Payment:

3.1 The VA agrees to reimburse the Contractor on a unit basis for resources furnished at the price listed in the schedule of this contract.

3.2 The Contractor will be paid monthly, in arrears, upon receipt of a properly prepared invoice. The invoice shall include at a minimum: invoice number, invoice amount, Contract’s name and address, contract number, purchase order number and period of performance. The Contractor will provide backup document to COR for verification of amount invoiced. Backup document shall include invoice number, Contractor’s name and address, the contract number, purchase order number, date of exam, Veteran Patient ID, type of exam, invoice amount and any additional cases. Invoices will be reconciled with VA record prior to disbursement of payments.

3.3 The Contractor shall submit all invoices to the following address:

FSC VA (667)

PO BOX 149971

Austin, TX 78714-8971

4. Administration of Contract:

The Contractor shall contact the Contracting Officer on all matters pertaining to the administration of this contract. Only the Contracting Officer is authorized to make changes that will affect the price, quantity, quality, or delivery terms of this contract.

5. Conflict of Interest:

The Contractor shall not employ any person who is an employee of the United States Government if the employment of that person would create a conflict of interest.

6. Contract Monitoring Procedures:

6.1 At the time of contract award, the Contracting Officer will appoint a Contracting Officer Representative (COR) to assist with the contract monitoring requirements. The COR will monitor such items as quality of service, timeliness of performance, customer service, cost control business relations. In accordance with FAR 1.601 (a) “Contracts may be entered into and signed on behalf of the Government only by contracting officers.” A COR is not authorized to modify the stated terms of the contract, including extending the length of the contract period. Quality of service will be monitored through a continuous review of requested studies vs. performed studies, the appropriateness of images produced and morbidity and mortality figures. These factors will be rated by a consensus of radiologists interpreting the MRI and CT studies and through a radiologist.

6.2 Timeliness of performance will be measured through systems’ uptime. A Cost control will be monitored through a comparison of hours worked and the type and number of studies completed per day. Appropriate regulatory and accrediting standards will apply, and all adverse events will be reported in accordance with medical center and other applicable guidelines.

6.3 The delegated COR will notify the Contracting Officer of any non-compliance immediately upon his/her gaining knowledge of any such situation or incident. Initial communication of such may be communicated by telephone. After such communication, the COR will provide a written statement to the Contracting Officer along with any supporting documentation regarding the performance failure noticed.

6.4 Upon receipt of a proper invoice, the COR shall certify that the services identified have been performed within 48 hours. Once certification has been made, the invoice will be forward through the proper billing channels and payment shall be made to the Contractor.

6.5 Both parties shall jointly conduct a review of Contractor’s performance to evaluate if services being provided are in accordance with the contract terms and if payments and billings are being properly handled. This review shall include but is not limited to analysis of all billings, payments, costs, administrative issues, patient satisfaction, quality of care and other related documentation that identifies services have been received. Any concerns need to be brought to the Contractor/COR’s attention at the time noted rather than an agreement reached prior to the expiration of services provided and consideration being received are satisfactory.

6.6 Upon conclusion of the initial contract period and all option periods, and in coordination with the Contracting Officer, the using service shall provide a statement to the Contracting Officer providing a summary of Contractor’s actions and a statement that all requirements of the contract were fulfilled as agreed. This information shall be forwarded by the COR to the Contracting Officer at least 90 days prior to the end of base period and each option period if option periods are included. A CPAR will be completed for each annual period of performance.

7. Locations and Period of Performance:

7.1 The VA , including the Radiology Service is located at: 3601 S. 6th Avenue, Tucson, AZ 85723

7.2 The mobile MRI and mobile CT are to be sited at: 3601 S. 6th Avenue, Tucson, AZ 85723 Coordination of exact location shall be conducted with the VA’s point of Contact immediately after award. Please review images provided with site location and connections.

7.

7.1.

7.2.

7.3. Period of Performance (POP):

7.4. Hours of Operation:

The contractor will provide the service during the hours of operation Monday – Friday, 7:00 AM – 5:00 PM and is subject to change depending on the Governments need. Weekends may be added through contract modification if funds permit. Unless otherwise specified the Government observes the following holidays:

Any other date specifically declared by the President of The United States to be a national holiday will also be observed.

INFORMATION SECURITY:

a. IT access: All Contractor personnel accessing Veterans Health Information and Technology architecture (VISTA, etc.) system will be required to sign and abide by all VA security policies and applicable confidentiality statues and the privacy act.

b. Patient confidentiality: Contractor to maintain the confidentiality of patient records in accordance with the Privacy Act. HIPAA and all VHA Privacy regulations.

c. Security requirements: Contractor shall insure the confidentiality of all patient and employee information and are subject to the completion of all mandatory training specified by the VHA.

d. Employee Background Checks: Contractor(s) are required to have background investigations initiated; to include fingerprints, PRIOR to start of contract. Contractor(s) will have completed VA Information Security and Privacy along with Rules of Behavior from the following link https://www.ees-learning.net/librix/loginhtml.asp?v=librix prior to start of contract and will compete on an annual basis, before the expiration of previous training. The contractor, when notified of an unfavorable determination by the Government, shall withdraw the employee from consideration from working under the contract.

ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS:

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

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

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

d. Custom software development and outsourced operations must be 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.

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

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

i. Due to the threat of data breach, compromise or loss of information that resides on either VA-owned or contractor-owned systems, and to comply with Federal laws and regulations, VA has developed an Information and Information Technology Security clause to be used when VA sensitive information is accessed, used, stored, generated, transmitted, or exchanged by and between VA and a contractor, subcontractor or a third party in any format (e.g., paper, microfiche, electronic or magnetic portable media).

j. The contractor and their personnel shall be subject to the same Federal laws, regulations, standards and VA policies as VA personnel, regarding information and information system security. These include but are not limited to Federal Information Security Management Act (FISMA), Appendix III of OMB Circular A-130, and guidance and standards, available from the Department of Commerce’s National Institute of Standards and Technology (NIST). This also includes the use of common security configurations available from NIST’s Web site at: http://checklists.nist.gov/. To ensure appropriate security controls are in place, contractors must follow the procedures set forth in “VA Information and Information System Security/Privacy Requirements for IT Contracts” located at the following Web site: http://www.iprm.oit.va.gov/ (852.273-75, Security Requirements for Unclassified Information Technology Resources).

k. The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract.

VA INFORMATIONAL CUSTODIAL TERMS:

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

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

c. Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA contracting officer within 30 days of termination of the contract.

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

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

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

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

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

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

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 the security controls required for government furnished equipment (GFE) must be utilized in approved 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 enclave 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 or any person acting on behalf of 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.

SECURITY INCIDENT INVESTIGATION:

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

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

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

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

LIQUIDATED DAMAGES FOR DATA BREACH:

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

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

SECURITY CONTROLS COMPLIANCE TESTING:

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

(End of Statement of Work)