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STATEMENT OF WORK VA TEXAS VALLEY COASTAL BEND HEALTH CARE SYSTEM (VATVCBHCS) PATHOLOGY AND LABORATORY MEDICINE SERVICE (P&LMS) Patient Queueing System Solution Base + Four INTRODUCTION AND SCOPE OF W... STATEMENT OF WORK VA TEXAS VALLEY COASTAL BEND HEALTH CARE SYSTEM (VATVCBHCS) PATHOLOGY AND LABORATORY MEDICINE SERVICE (P&LMS) Patient Queueing System Solution Base + Four INTRODUCTION AND SCOPE OF WORK: Introduction: VA Texas Valley Coastal Bend Health Care System (VATVCBHCS) Pathology and Laboratory Medicine Service (P&LMS) is requiring a patient queuing system solution that will meet the needs of the operational workflow of the service. P&LMS seeks to provide patients with a smooth customer experience while assisting P&LMS staff with a structured queuing management system tailored to meet the needs of the service. Background: The national contract for the previous queuing system has concluded and the current method of patient check-in via a QR code does not work for the laboratories. VATVCBHCS P&LMS would like to take this opportunity to enhance the current patient check-in/queuing process for both the staff and veterans by seeking a more streamlined and smooth solution. Scope of Work: The contractor will configure and deploy all systems which include all hardware, software, and supporting equipment needed for P&LMS locations below: Harlingen Care Center (HCC) 2601 Veterans Drive Harlingen TX 78550 McAllen Outpatient Clinic (MOPC) 901 E. Hackberry Ave. McAllen TX 78503 Corpus Christi Outpatient Clinic West Point 925 South Padre Island Drive Corpus Christi, TX 78416 Corpus Christi Specialty Outpatient Clinic (CCSC) 205 S. Enterprize Parkway Corpus Christi TX 78405 Laredo Outpatient Clinic (LOPC) 4602 N Bartlett Ave. Laredo TX 78041 Item Description Quantity Clinics Software license including maintenance and upgrades 1 VA Texas Valley Coastal Bend Healthcare System Application remote Support as needed 1 VA Texas Valley Coastal Bend Healthcare System Technical Installation 24 (HCC, CCSC, CCWP, MOPC, & LOPC) Software installation 1 (HCC, CCSC, CCWP, MOPC, & LOPC) Training for Admin Superusers 2 (HCC, CCSC, CCWP, MOPC, & LOPC) Training for Lab Staff 96 (HCC, CCSC, CCWP, MOPC, & LOPC) Project Manager support 16 (HCC, CCSC, CCWP, MOPC, & LOPC) Customer support 27 (HCC, CCSC, CCWP, MOPC, & LOPC) LED display monitors 5 (HCC, CCSC, CCWP, MOPC, & LOPC) Desktop computers 5 (HCC, CCSC, CCWP, MOPC, & LOPC) Hardware support and warranty 5 (HCC, CCSC, CCWP, MOPC, & LOPC) Mounting hardware 5 (HCC, CCSC, CCWP, MOPC, & LOPC) Connection hardware patch cables 5 (HCC, CCSC, CCWP, MOPC, & LOPC) Power supplies, HDMI cables 5 (HCC, CCSC, CCWP, MOPC, & LOPC) Hardware installation 60 (HCC, CCSC, CCWP, MOPC, & LOPC) Travel per diem 5 (HCC, CCSC, CCWP, MOPC, & LOPC) REQUIREMENTS Type of Contract: Firm-Fixed-Price (for configuration and installation of hardware and software components.) General Requirements: The contractor will participate in a project kickoff meeting typically within one (1) month of the contract being awarded that will be scheduled by the Contracting Officer, and follow-on meetings as needed throughout the planning for and installation of the system components. Before the Installation, the contractor will assign a Project Manager (PM) before installation of the hardware, who will work with the VATVCBHCS P&LMS team to address any issue after-hour installation, facility specifics, scheduling, etc.). The PM will also confirm or adjust configuration requirements. Before installation, the PM will confirm solution deployment and coordinate installation with the VATVCBHCS P&LMS team. Installation will last 1-2 days, depending on scheduling. The technician will install and test hardware and software. The installation will be carried out in a manner and during which ti as to minimize disruption to patient care and/or P&LMS workflow. Low patient volume usually occurs during PM hours. The software will be loaded remotely onto local servers. The technician will verify the system is working properly. Training technician will initiate training based on a prearranged schedule and discussed training requirements. During operation, the Project Manager team will continue to work with the local team for two (2) to three (3) weeks after installation to make sure the local team is well-versed and there are no unforeseen issues. The contractor will provide maintenance of the system components to maintain the system in a fully operational status. Period of Performance: Installation of all system components is anticipated to occur within approximately 30 days of the contract award. Maintenance of system software components must be provided during the life of the contract. The period of performance of this contract shall consist of one 12-month base period. At the discretion of the Contracting Officer, the Government may exercise up to four 12-month option periods. REFERENCES: None. SPECIFIC MANDATORY TASKS AND ASSOCIATED DELIVERABLES: Patient Queuing System must be a web platform that connects and maintains interoperability between various web-based applications including Laboratory services that provide interconnectivity to individual CPRS/VistA and other VA-hosted services. The contractor shall provide a patient queuing system solution to include hardware, warranty, software, an annual software license, maintenance, support, and upgrades. The contractor shall deploy a Project Manager to oversee the implementation process. The contractor shall remotely install the required software by collaborating with our local VISN17 OI&T team on this process. The contractor will provide onsite or virtual training to P&LMS staff on the operation of the newly deployed components. The contractor will train service admins as super users. The contractor will provide maintenance and enhancements for software as indicated above. The system will provide an option for queueing by number. The system will provide an order tracking management system for electronic laboratory orders to include active orders, order details, and order progress notes. The system will have the ability to document no-shows and track patients without electronic orders. System must be able to display active orders, order details, and order progress notes in real time. The contractor will provide all upgrades to the equipment hardware and operating system software without additional charge. These enhancements to the contractor equipment shall be delivered to the government site and installed by the vendor within sixty days of their issuance or date of first commercial availability. Any modifications are not to interfere with the operations of the laboratory nor with software systems already in place, including, but not limited to VistA/CPRS and Microsoft Office applications. The contractor must be able to fully install the equipment at all sites and assist with bidirectional connectivity at the time of award to the VA network for full functionality of the system. The contractor system solution must be compatible and successfully interface with the current and future electronic medical record and laboratory information system. The contractor must have an already existing bidirectional BAA at the time of award. The contractor will provide a warranty for all components of the queuing system including repair or replacement of any equipment and/or parts that are not functioning properly. The contractor guarantees all equipment covered in this contract shall be in optimum working condition throughout the lease of the equipment. Contractor must respond to service calls within one hour of notification. All work performed must be accomplished by the manufacturer s instructions. The contract is a full-service contract to include all necessary service calls five (5) days a week between the hours of 8 am to 4:30 pm, Monday through Friday, and 24 hours a day telephone technical assistance, excluding Federal Holidays. The repair services will cover all parts, labor, and travel. The contractor system solution shall capture data for process improvements and gap analysis. All reports/data captures should be in real-time. Data capture should include but not be limited to patients served, waiting times, and turnaround times. Path & Lab service and contractor shall have meetings periodically as agreed upon to work through any challenges that may arise. Contractor must ensure technology/standard is consistent with VA policies and standards, including, but not limited to, VA Handbooks 6102 and 6500; VA Directives 6004, 6513, and 6517; and National Institute of Standards and Technology (NIST) standards, including Federal Information Processing Standards (FIPS). The contractor must ensure sensitive data is properly protected in compliance with all VA regulations. The contractor will furnish a statement in writing to the Contracting Officer at the close out of the contract to include a summary of the contractor s actions and a statement that all requirements of the contract were fulfilled as agreed. A summary evaluation of contract performance based upon the compliance or noncompliance of the contract to include a summary of contractor actions and a statement that all requirements of the contract were fulfilled as agreed. QUALITY ASSURANCE SURVEILLANCE PROGRAM (QASP): The Contracting Officers Representative (COR) will ensure the contractor satisfactorily completes the installation of all system software and that the system is fully functional; the COR will also ensure that the contractor abides by the requirements of the maintenance contract for the software. The COR will ensure the contractor provides the required training to P&LMS staff. SECURITY CONSIDERATIONS: Contractor staff may require access to VATXVCBHCS P&LMS under the escort/supervision of P&LMS staff during the installation of the system. Contract staff will require supervised access to the patient queuing system server for software installation but will not require access to patient information. The patient queuing system server does not contain any patient information. Contractor staff performing any future repair or replacement of software under the maintenance agreement may require access to VATVCBHCS P&LMS under escort/supervision or supervised access to the patient queuing system server; however, will not need access to patient information. The COR and the Contractor will assure that: No other information except what is in this contract will be shared with the contractor in any follow-up communication. None of the information in this contract includes Protected Health Information (PHI) or Individually Identifiable Information (III). NO VA DATA OF ANY TYPE SHALL BE TRANSFERRED FROM THE VA. The vendor will have remote access under VA OI&T supervision to complete necessary repair(s) and preventive maintenance. ALL DATA AND ELECTRONIC MEDIA WILL NOT LEAVE THE VA. All hard drives will not leave the VA. VA Sensitive Information 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. VA INFORMATION CUSTODIAL LANGUAGE a. Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in the 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/subcontractors information systems or media storage systems 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 by 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 follow VA directive requirements. c. Before termination or completion of this contract, the contractor/subcontractor must not destroy information received from VA or gathered/created by the contractor during performing this contract without prior written approval by the VA. Any data destruction done on behalf of the VA by a contractor/subcontractor must be done by 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 by VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship. h. The contractor/subcontractor must store, transport, or transmit VA-sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated. i. The contractor/subcontractor s firewall and Web services security controls, if applicable, shall meet or exceed VA s minimum requirements. VA Configuration Guidelines are available upon request. j. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA s prior written approval. The contractor/subcontractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response. k. Notwithstanding the provision above, the contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, the confidentiality of medical quality assurance records, and/or Title 38 U.S.C. 7332, the confidentiality of certain health records about drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor receives a court order or other requests for the above-mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response. l. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) every year and provide it to the COTR. INFORMATION SYSTEM HOSTING, OPERATION, MAINTENANCE, OR USE a. For information systems that are hosted, operated, maintained, or used on behalf of the 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 COTR and approved by VA Privacy Service before operational approval. All external Internet connections to VA s network involving VA information must be reviewed and approved by VA before 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 before hosting, operation, maintenance, or use of the information system, or systems by or on behalf of the 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 before 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 by 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 the documentation (PIA, System Security Plan, Contingency Plan). The Certification Program Office can guide 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 COTR. 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, backup tapes, etc.) used by the contractors/subcontractors that contain VA information must be returned to the VA for sanitization or destruction or the contractor/subcontractor must self-certify that the media has been disposed of per 6500.1 requirements. This must be completed within 30 days of termination of the contract. h. Bio-Medical devices and other equipment or systems containing media (hard drives, optical disks, etc.) with VA sensitive information must not be returned to the vendor at the end of the lease, for trade-in, or other purposes. The options are: (1) Vendor must accept the system without the drive. (2) VA s initial medical device purchase includes a spare drive which must be installed in place of the original drive at the time of turn-in; or (3) VA must reimburse the company for media at a reasonable open market replacement cost at the time of purchase. (4) Due to the highly specialized and sometimes proprietary hardware and software associated with medical equipment/systems, if the VA can t retain the hard drive, then; (a) 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 (b) Any fixed hard drive on the device must be non-destructively sanitized to the greatest extent possible without negatively impacting system operation. Selective clearing down to the patient data folder level is recommended using VA-approved and validated overwriting technologies/methods/tools. Applicable media sanitization specifications need to be preapproved and described in the purchase order or contract. (c) A statement needs to be signed by the Director (System Owner) that states that the drive could not be removed and that (a) and (b) controls above are in place and completed. The ISO needs to maintain the documentation. 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, 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. 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. Concerning 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 by the executed business associate agreement. d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with the 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 outlined 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. The 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. c. Each risk analysis shall address all relevant information concerning the data breach, including the following: (1) Nature of the event (loss, theft, unauthorized access). (2) Description of the event, including: (a) date of occurrence. (b) data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, and disability code. (3) Number of individuals affected or potentially affected. (4) Names of individuals or groups affected or potentially affected. (5) Ease of logical data access to lost, stolen, or improperly accessed data considering the degree of protection for the data, e.g., unencrypted, plain text. (6) Amount of time the data has been out of VA control. (7) The likelihood that the sensitive personal information will or has been compromised (Made accessible to and usable by unauthorized persons). (8) Known misuse of data containing sensitive personal information, if any. (9) Assessment of the potential harm to the affected individuals. (10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate, and (11) 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. d. 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: (1) Notification. (2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports. (3) Data breach analysis. (4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution. (5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and (6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs. SECURITY CONTROLS COMPLIANCE TESTING Periodically, the 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. TRAINING a. 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: (1) 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. (2) complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training. (3) complete the appropriate VA privacy training and annually complete required privacy training; and (4) 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 role-based information security training required by NIST Special Publication 800-16, Information Technology Security Training Requirements.] b. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each an applicable employee within 1 week of the initiation of the contract and annually thereafter, as required. c. Failure to complete the mandatory annual trainin...