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aSTATEMENT OF WORK for Legal Representation for Commitment of Mentally Ill Patients (Short-Term) At the Mountain Home VAMC GENERAL INFORMATION Scope of Work: To provide Legal Representation on behalfo... aSTATEMENT OF WORK for Legal Representation for Commitment of Mentally Ill Patients (Short-Term) At the Mountain Home VAMC GENERAL INFORMATION Scope of Work: To provide Legal Representation on behalfofthe James H. Quillen Veterans Affairs Medical Center (VAMC) for all short term Involuntary Mental Health Commitment Hearings held at the Washington County Circuit Court located at 108 W. Jackson Blvd, Jonesborough, TN 37659. The James H. Quillen provides a process known as Involuntary Commitment. Involuntary commitment is the use of legal means to commit a person to a mental hospital or psychiatric ward against their will or over their protests. A State of Tennessee form MH 5535 "Certificate of Need for Emergency Admission" must be completed by two VA physicians, or one Qualified Mental Health professional and one VA physician, one VA physician and one clinical psychologist, or one VA physician and one resident physician (all must be licensed in Tennessee). A copy of each Certificate of Need is to be presented to General Sessions Court by the end of the first workday after commitment is requested as well as sent to Attorney Representing the James H. Quillen VAMC. 2. Performance Period: 10/01/2022 - 09/30/2023 3. Tme of Contract: Firm-Fixed-Price CONTRACT AWARD MEETING The contractor shall not commence performance on the tasks in this SOW until the CO has conducted a kick off meeting, or has advised the contractor that a kick off meeting is waived. GENERAL REQUIREMENTS Provide Legal Representation for the James H. Quillen VAMC on commitment hearings of mentally ill patients (short-term). This includes all Involuntary Commitment Cases and Judicial Commitment Hearings. SPECIFIC MANDATORY TASKS AND ASSOCIATED DELIVERABLES Description of Tasks and Associated Deliverables: The attorney will provide Legal Representation for the James H. Quillen VAMC on commitment hearings of mentally ill patients (short-term). This includes all Involuntary Commitment Cases and Judicial Commitment Hearings. Review of electronic correspondence from psychiatric team at hospital regarding involuntary admission. Review of certificates of need. Prepare Notice of Admission to file with Court. Communicate with clerk or judge's assistant regarding need to present ex parte Order. Court appearance to present the ex parte Order I Order to Hold for the judge·s approval and entry by Court. Prepare electronic correspondence to psychiatric team regarding entered Order and upcoming hearing. Exchange of electronic correspondence with psychiatric team at hospital regarding dismissal. Prepare Notice to file with the Court. Prepare Order of Dismissal. Prepare correspondence to Judge regarding the proposed Order. OR Obtain updated certificates of need to be filed prior to probable cause hearing. Prepare for hearing. Court appearance for probable cause hearing. Prepare correspondence to client regarding hearing outcome and action to occur. The final report/deliverables mentioned above shall accompany the Contractor's invoice. The invoice, or attachment to the invoice, must show details as to the charges being billed, i.e., dates and times of work and description of work activity. Payment will not be authorized without appropriate detail of charges and/or without final report/deliverables. Any charges or expenses beyond those identified on the purchase order will be disallowed unless prior authorization was provided by the VA contracting officer. CHANGES TO STATEMENT OF WORK Any changes to this SOW shall be authorized and approved only through written correspondence from the CO. A copy of each change will be kept in a project folder along with all other products of the project. Costs incurred by the contractor through the actions of parties other than the CO shall be borne by the contractor. CONTRACT ADMINISTRATION: The contractor shall designate a primary and alternate point of contact by name and phone number who will function as liaison with the Contracting Officer Technical Representative on day-to-day operations, and will be available from 8:00 am to 4:30pm (Eastern Standard Time), Monday through Friday, excluding Federal Holidays. 2. Day to day communication between both contract parties occur between the VA COTR and the contractor's primary or alternate contact. Problems unresolved at this level will be referred to the VA contracting officer and the contractor's designated corporate officer. Contractor is to respond to any complaint or call by management in a timely fashion. I. CONTRACTOR EXPERIENCE AND LICENSE REQUIREMENTS: The contractor shall have competent, documented experience in Involuntary Mental Health Commitment proceedings and hearings. The contractor and associates who provide legal representation, must hold a current State Attorney License to practice law in the State of Tennessee. CONFIDENTIALITY AND NONDISCLOSURE It is agreed that: The preliminary and final deliverables, and all associated working papers, application source code, and other material deemed relevant by VA which have been generated by the contractor in the performance of this task order, are the exclusive property of the U.S. Government and shall be submitted to the CO at the conclusion of the task order. The CO will be the sole authorized otftcial to release, verbally or in writing. any data, draft deliverables, final deliverables, or any other written or printed materials pertaining to this task order. No information shall be released by the contractor. Any request for infonnation relating to this task order, presented to the contractor, shall be submitted to the CO for response. Press releases, marketing material, or any other printed or electronic documentation related to this project, shall not be publicized without the written approval of the CO. Privacy/Security Training: All Contractor employees under this contract are required to complete the VA's on-line Information Security Awareness Training Course and the Privacy Awareness Training Course annually.. This training can be accessed on line through the VA Talent Management System found at http://www.ees-leaming.net/ or https://www.tms.va.gov. ls required via printed certification of completion and must be provided to the CO/COR. The Contracting Officer or COR will provide the details required for obtaini11g the VHA Privacy Policy Training. Each contractor must read and sign the VA National Rules of Behavior prior to gaining access to VA infonnation and/or information systems. Contractors must initial and date each page of the copy of the VA National Rules of Behavior, they must also provide the information requested on the last page, sign and date it. These requirements will be maintained in a contractor employee file by the CO/COR for each contractor employee working on contract. SYSTEM OF RECORDS: The Veterans Administration's system of records to which the Contractor personnel shall have access to in order to maintain patient medical records is described annually in the Federal Register. Contractor personnel who obtain access to hardware or media which stores drug or alcohol abuse, AIDS, or sickle cell anemia treatment records or medical quality assurance records protected by code 38 U.S.C. 7332 or 38 U.S. C. 5705, as defined by the Department of Veterans Affairs, shall have access only to those records absolutely necessary to perform their contractual duty for which access was obtained. Violation of these statutory provisions by the Contractor or Contractor employee as stated in agency regulations may involve imposition of criminal penalties. This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal statute 38 USC§ 7332 (42 CFR Part 2) prohibits you from making any further disclosure of it, without the specific written authorization of the person to whom it pertains, or as otherwise permitted by such regulations. CONTRACTOR PERSONNEL SECURITY REQUIREMENTS: All contractor employees who require access to the Department of Veterans Affairs' computer systems shall be the subject of a background investigation and must receive a favorable adjudication from the VA Office of Security and Law Enforcement prior to contract performance. This requirement is applicable to subcontractor personnel requiring the same access. The C&A requirements do not apply, and that a Security Accreditation Package is not required. I. Position Sensitivity- The position sensitivity has been designated as [Low Risk]. Background Investigation - The level of background investigation commensurate with the required level of access is [N/A]. Contractor Resnonsibilities The contractor shall prcscreen all personnel requiring access to the computer systems to ensure they maintain a U.S. citizenship, and arc able to read, write, speak and understand the English language. The contractor shall submit or have their employees submit the required forms (SF 86 or SF 85P, SF 85P-S, FD 258, Contractor Fingerprint Chart, VA Form 0710, Authority for Release oflnformation Form, and Optional Forms 306 and 612) to the VA Office of Security and Law Enforcement within 30 days ofreceipt. The contractor, when notified of an unfavorable determination by the Government, shall withdraw the affected employee from working under the contract. Failure to comply with contractor personnel security requirements may result in termination of the contract for default. Government Resnonsibilities The VA Office of Security and Law Enforcement will provide the necessary forms to the contractor, or to the contractor's employees, after receiving a list of names and addresses. Upon receipt, the VA Otlice of Security and Law Enforcement will review completed forms for accuracy, and forward the forms to the office of Personnel Management (OPM) to conduct background investigations. The VA Office of Security and Law Enforcement will notify the CO, and contractor, of adjudication results received from 0MB. Upon being notified about a favorable determination, the CO may issue a notice to proceed to the contractor. VHA HANDBOOK 6500.6, APPENDIX B: VA ACQUISITION REGULATION SOLICITATION PROVISION AND CONTRACT CLAUSE: NOTE: This clause will undergo official rule making by the Otlice of Acquisitions and Logistics. The below language will be submitted for public review through the Federal Register. The final wording of the clause may be changed from what is outlined below hased on public review and comment. Once approved, the final language in the clause can be obtained from the Office of Acquisitions and Logistics Programs and Policy. I. SUBPART 839.2- INFORMATION AND INFORMATION TECHNOLOGY SECURITY REQUIREMENTS 839.201 Contract clause for Information and Information Technology Security: 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 fonnat (e.g., paper, microfiche, electronic or magnetic portable media). In solicitations and contracts where VA Sensitive Information or Information Technology will be accessed or utilized, the CO shall insert the clause found at 852.273-75, Security Requirements for Unclassified Information Technology Resources. 2. 852.273-75-SECURITY REQUIREMENTS FOR UNCLASSIFIED INFORMATION TECHNOLOGY RESOURCES (INTERIM- OCTOBER 2008) As prescribed in 839.20 I, insert the following clause: 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. VHA HANDBOOK 6500.6, APPENDIX C: VA INFORMATION AND INl.,ORMATION SYSTEM SECURITY/PRIVACY LANGUAGE FOR INCLUSION INTO CONTRACTS, AS APPROPRIATE I.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 infonnation system security. ACCESS TOVA 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 (NlSP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while perfonning work on contracts, programs, bids, or research and development efforts. The Department of Vcterans Affairs docs not have a Memorandum of Agreement with Defense Security Service (DSS). Vcrification 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 arc 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. c. 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. VA INFORMATION CUSTODIAL LANGUAGE 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- l 4(d) ( l ). 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 Saniti=ation. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Oflicer 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 infonnation confidentiality and security laws, regulations and policies become applicable to the VA infonnation 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 infom1ation 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. IfVA 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 1600.0 I, 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 COTR. 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 COTR, and approved by the VA Privacy Service in accordance with Directive 6507, VA Privacy Impact Assessment. The contractor/subcontractor shall certify to the COTR that applications are fully functional lnd 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, /nfbrmativn Security Program and VA Handbook 6500.5, Incorporating Security and Privacy in System Development L{fecycle. 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 3 I, 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; (2) 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 (3) 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 otlicers 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. (l) "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 photot:,>raph. "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 rernediated 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 IO 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 rcmediated 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 1:,>rantcd with approval of the contracting officer and the VA Assistant Secretary for Office of Information and Technology. 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 COTR 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 involvt..'Ci, 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 infonnalion that the contractor/subcontractor considers relevant. With respect to unsecured protected health infomrntion, 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 lo, the incident. LIQUIDATED DAMAGES FOR DATA BREACH Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal infonnation. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPJ 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 PII, such as full name, social security number, date of birth, home address, account number. disability code; Number of individuals affected or potentially atlected; 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 ofV A 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; ( I 0) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy /11cide11ts, as appropriate; and (11) Whether credit protection services may assist record subjects in avoidin...