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STATEMENT OF WORK
Title:
Nurse Staff Scheduling System and Implementation Software
Period of Performance: unknown
Place of Performance: Central Arkansas Veterans Healthcare System
4300 West 7th Street
Little Rock, Arkansas 72205

Contracting Officer's Representative (COR):
Derek Braswell I Email: Derek.Braswell@va.gov
NAICS: 541519
PSC: J065
Type of Contract: Firm-Fixed Price
B.l.l Scope
Introduction
This request seeks to put in a place a contract for one year for a solution to automate scheduling and staffing processes; provide decision support for staff assignments based on the objective and variable data; improve patient care by matching nursing competency to required needs. Contractor software shall provide self-scheduling options to nursing providers and data for outcome measurements. Pull data from Veterans Health Information Systems and Technology Architecture (VistA); VA Time and Attendance System (VATAS),
Decision Support System (DSS); VA Nursing Outcomes Database (VANOD) and Paid Enhancement for VANOD (PEV); Office of Nursing Service (ONS) to create strategic plans based on retrievable and accurate data. The system shall accommodate today's increasing staffing challenges by using 21 st century technology.
This system will accommodate all Central Arkansas Veterans Healthcare Systems facilities and VA staffed CBOCs (Hot Springs, Pine Bluff, Mena, Mountain Home, Searcy, Conway and El Dorado and Russellville).
The system shall automate labor-intensive time-consuming processes that are now manually interfaced with multiple applications that increase efficiencies, data quality, and to support decision making. Staffing schedules are currently created several weeks in advance; however, as a patient population and available resources can change in a matter of hours, it is critical to have access to employee information to be able adjust staffing arrangements to manage the clinical nursing needs of Veterans and to facilitate communication in changing needs within the facility and with the employees. Because nursing care is delivered 24 hours/7 days a week, ability to access and modify scheduling by managers, supervisors, and chiefs in needed.
Resource management not only involves staff planning, but also scores of managerial tasks including adherence to directives limiting hours of work in each time period, regulatory dictates, and special pay and time accounting accordance to defined payment schedules. Nurses functioning as managers must have the flexibility to determine the appropriate level of nurses/nursing staff for patient care needs while considering a constellation of important variables, including the various education scope of practice and experience levels of staff. The number of staffing orientation, the number of temporary staff on the unit, the acuity of patients, anticipated acuity on a particular shift, the physical layout of the unit, the availability of hospital resources, the technology on the unit, and the unit turbulence (such as the number of admissions, discharges and transfers.) Potential use in other Nursing Services areas (Sterile Processing Service) under consideration.
Scope
An integrated system and automated data extraction tools are necessary to effectively assign staffing resources and monitor standards of care. This system will pull from systems that have data stored to avoid duplicate effort and to feed the other downstream data systems.
The primary use of the system will be staffing scheduling, so managers can coordinate schedules, capture data, produce reports, and coordinate work assignments to meet patient care needs. The primary users of the system are nurse managers, supervisors, service chief and secretaries, who will coordinate schedules, capture data, produce reports, and coordinate work assignments.
Tasks or Requirements
Appropriate response to the fluctuations in patient census and acuities by using embedded decision support tools.
Adequate staffing levels based on patient acuity and other care related variables.
Collection of nationally comparable hours per patient day (HPPD) data.
Collection of data to prepare staffing reports, develop strategic plans and improve hiring practices.
Compliance with public law and other regulatory mandates for staffing regulations and monitors.
Ability to consolidate multiple administrative needs in one package (licensure, certifications, emergency notifications, etc.) Generation of predefined and adhoc reports.
Self-scheduling ability (major nursing satisfier).
Accurate accounting of contract/agency nursing utilization. Success factors: production of accurate HPPD data, increase in efficiencies in managing staffing scheduling issues by 50%.
Selection Criteria
Vendor must meet or exceed all requirements as specified below. Price Only.
Deliverables or Deliver Schedule
Specifications
1. Utilizes an HL7 interface with Vista/VATAS that brings in real-time Admit, Discharge, and Transfer information. Utilizes an HR interface that brings in several points of data validation for VANOD including series, position, grade, step, licensure information, EOD, degrees, other schooling, BOC, ALBCC, Occupation Series Code and more. Utilizes the census interface to correlate with budgeting and reporting to databases like VANOD, DSS, NDNQI and more.
Required Functional capabilities:
An automated staffing package is required to provide: Demographic Tracking tools: maintains employee contact/ emergency contact information. Maintains employee-preferred method of communication. Vendor shall provide any software updates and installation as they become available
Staffing Scheduling Tools
Maintain prospective schedules.
Audit Trails for changes to the system
Schedules can be created prospective across 12-month period.
Allow staff to switch shifts amongst peers
Allow staff to make themselves available for overtime and advise of current OT use in comparison to regular clients Manage Position Control
Proficiency System:
Ability to staff and maintain repositories of anecdotal notes for proficiency input, specialty certification tracking, licensure tracking, education (all degrees earned) tracking, skill-based competencies tracking, ACLS/BLS/131.5 tracking, and continuing education tracking. Mandatory tracking, mandatory health information. Tools for staff to self- report professional portfolio.
Rule engines to facilitate scheduling:
Apply regulations hour limits, time off requirements, staffing ratios, etc.) as they apply to individuals being scheduled to work: Apply union requirements stored in the system to create staffing schedules
Use staff preferences to create staffing schedules.
Match competencies to staffing needs. Match nursing staff with patient needs across the system while maintaining balanced patient workloads.
Apply unit preference to competencies, e.g. ICU nurses are ACLS certified.
Apply permanent schedules requests to when generating schedules.
Apply rotating shifts rules when generating schedules. Capabilities to accommodate scheduling changes based on patient census scheduling. Apply patient acuities to staffing needs Track hours per patient day
Generate alternate work schedules
Capability to allow or restrict swapping unit assignments based on competencies.
Capabilities to restrict overtime assignment based on regulations l. Predict staffing needs based on previous trends (e4g. high surgery days)
Provide functionality to maintain disaster preparedness (notifications and callbacks).
Communication Tools:
Creates a personalized web-based dashboard for all stakeholders
Web-based for employee access
Web-based for managers access for staff bidding
Staff bidding on open positions (Staff to staff communication, e.g. to swap shifts)
Exchange shifts between co-workers
Alert applicants for checking status
Produce real time reports for long-term strategy for hiring staff.
Training/implementation:
Vendor to provide on-site training or web-based training as needed on updates/enhancements at each facility to super users on general functionality, staff scheduling for end-users, and management reports for resource analysis.
On-site implementation of the system is required as follows:
Project Definition
Establishing Project Goals
Assigning Project Roles & Workgroups
Define Interfaces
Workload
Define and Document Existing Workflow Processes
Label configuration of job codes and units and leave schedules
Present Projections for Workflow Process
System Configuration
System Administrator Training
Security Configuration
Workload and Unit Budget
Validate Interface Data
User Training
Pilot Unit Training
User Training
System-Wide Project Role Out
Employee Access
Position Tracking
Courses and Consultation
Staffing Methodology Class
Executive Analytics Class Reports Workshop
Data Mining & Scorecards
Set Up Alerts
Government-Furnished Equipment and Government-Furnished Information
Utilizes VA computer workstations, laptops, monitors. Vendor hosted solution utilizes the Amazon Government Cloud. Due to Pll and employee data used by AcuStaf, all data will then be stored on VA servers, behind the VA firewall which can be access through a VPN tunnel.
Security
VISTA/VATAS Interface, access to employee and patient information
Hours of Operation
Normal hours of operation are Monday through Friday from 8:00 am to 4:30pm, excluding holidays
All work must be scheduled in advance with the ISO and IT staff on a mutually agreed upon date and time.
Emergency services required shall be coordinated through the ISO and IT department. Contractor must be available to perform emergency services within 3 hours of notification.
Federal Holidays observed by the VAMC are:
New Years' Day
Labor Day
Martin Luther King Day
Columbus Day
Presidents' Day
Veterans' Day
Memorial Day
Thanksgiving Day
Independence Day
Christmas Day
Objectives:
There is a continued need for an acuity/patient classification system to match the changing care needs of the patients to the appropriate staffing level based on the patient condition and the amount of nursing required to manage the care of each patient.
Hospital based staffing requires a 24-hour coverage a day, 7 days a week. Nursing staff work a variety of shifts that require an hourly rate increase, and contract/agency and travel nurses all have different compensation requirements. Therefore, a Staff Scheduling system needs to accurately correlate and calculate time and cost by work unit, nurse's type and pay variables.
Nurse executives need data to plan for current and future staff needs and costs; this system gives them the tools to help manage their workforce. Multiple standardized reports are needed as well as the ability to create ad hoc reports.
Justification:
To continue to use an integrated system and automated data extraction tools that are necessary to effectively assign staffing resources, monitor standards of care, and pulled from systems that already have the data entered in them to avoid duplicate effort and to feed the other downstream data systems. For example, there is a need for an acuity/patient classification system to match the changing needs of the patients to the appropriate staffing level based on the patient condition and the amount of nursing required to manage the care of each patient.
Hospital based staffing requires 24-hour day coverage, 7 days a week. Nursing hours worked frequently involve a variety of shifts that require an hourly rate increase; in addition, contracts/agency nurses all have different compensation requirements. Therefore, a resource management system needs to accurately correlate and calculate time and cost by work unit, nurse position type, and pay variables. Nurse Executives need data to plan for current and future staffing needs and costs which requires tools to help them manage their workforce. Multiple standardized reports are needed as well as the ability to create adhoc reports.
Benefits:
The need/problem/opportunity: the organization continues to require a realtime dynamic, integrated system to provide comprehensive and systemic accounting of nursing workload and staffing requirements or to provide scheduling to meet federal law and other regulatory requirements.
Successful benefits are: Appropriate response to the fluctuations in patient census and acuities by using embedded decision support tools. Adequate staffing levels based on patient acuity and other care related variables. Collection of nationally comparable hours per patient day (HPPD) data. Collection of data to prepare budget and reports, develop strategic plans, and improve hiring process. Compliance with various regulatory mandates for staffing regulations. Ability to consolidate multiple administrative needs in one package (licensure, certifications, emergency notifications, etc.) Generation of predefined and adhoc reports. Self-scheduling ability (major nursing satisfier). Accurate accounting of contract/ agency nursing utilization. Success factors: production of accurate HPPD data. Increase efficiencies in managing staffing scheduling issues by 50%.
VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE
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 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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
Information systems that are designed or developed for or 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 designations 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.
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.
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.
Applications designed for normal end users shall run in the standard user context without elevated system administration privileges.
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.
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.
The contractor/subcontractor agrees to:
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:
The Systems of Records (SOR); and
The design, development, or operation work that the contractor/subcontractor is to perform;
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
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.
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 a 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.
"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.
"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.
"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.
The vendor 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 vendor anywhere in the Systems, including
Operating Systems and firmware. The vendor shall ensure that Security Fixes shall not negatively impact the Systems.
The vendor shall notify VA 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 days.
When the Security Fixes involve installing third party patches (such as Microsoft OS patches or Adobe Acrobat), the vendor will provide written notice to the VA that the patch has been validated as not affecting the Systems within 10 working days. When the vendor is responsible for operations or maintenance of the Systems, they shall apply the Security Fixes within days.
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
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.
Adequate security controls for collecting, processing, transmitting, and storing of Personally Identifiable Information (Pll), 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 Pll.
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.
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.
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.
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 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.
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.
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 vendor at the end of lease, for trade-in, or other purposes. The options are:
Vendor must accept the system without the drive;
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
VA must reimburse the company for media at a reasonable open market replacement cost at time of purchase.
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;
The equipment vendor 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
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.
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
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.
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.
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.
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
Consistent with the requirements of 38 U.S.C. 55725, 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.
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.
Each risk analysis shall address all relevant information concerning the data breach, including the following:
Nature of the event (loss, theft, unauthorized access);
Description of the event, including:
date of occurrence;
data elements involved, including any Pll, such as full name, social security number, date of birth, home address, account number, disability code;
Number of individuals affected or potentially affected;
Names of individuals or groups affected or potentially affected;
Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text;
Amount of time the data has been out of VA control;
The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons);
Known misuses of data containing sensitive personal information, if any;
Assessment of the potential harm to the affected individuals;
Data breach analysis as outlined in 6500.2 Handbook,
Management of Security and Privacy Incidents, as appropriate; and
Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised.
Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of
$ per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:
Notification;
One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports;
Data breach analysis;
Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution;
One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and
Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs.
8. SECURITY CONTROLS COMPLIANCE TESTING
On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-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.
9. TRAINING
All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:
Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems;
Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training;
Successfully complete the appropriate VA privacy training and annually complete required privacy training; and
Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document e.g., any rolebased information security training required in accordance with NIST Special
Publication 800-16, Information Technology Security Training Requirements.]
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.
Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.

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