00S-214.pdf
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- Solicitation number
- 36C25224Q0512
About this file
This document is a Standard Operating Procedure (SOP) that outlines the procedures for evaluating and determining when Interim Life Safety Measures (ILSM) are necessary for significant existing Life Safety Code (LSC) deficiencies and conditions due to construction at the Clement J. Zablocki VA Medical Center in Milwaukee, WI.
The SOP establishes the process for Facility Management, Occupational Safety & Health, and Office of Quality Management & Safety employees to identify Life Safety deficiencies and implement ILSM. It details the responsibilities of various roles, including the Contracting Officer's Representative, Occupational Safety & Health Specialist, Safety Officer, and Facility Management Projects Supervisor. The SOP includes two appendices that provide evaluation checklists for determining appropriate ILSM for construction/maintenance projects and existing LSC deficiencies.
The related federal contract opportunity is for fire barrier maintenance, inspection, and repair services at the Clement J. Zablocki Medical Center. The contractor will be required to inspect and repair rated wall assemblies in Buildings 111 and 144, with an approximate combined square footage of 922,455. The work is to begin within 90 days of the contract award.
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INTERIM LIFE SAFETY MEASURES
(ILSMs)
SOP MCM 00S-214
Clement J. Zablocki VA Medical Center Milwaukee, WI 53295
Signatory Authority:
Medical Center Director
Responsible Owner:
Industrial Hygiene/Safety Manager
Service Lines:
Occupational Safety & Health (OSH), Facility Management (FM), Office of Quality Management & Safety (OQMS)
Effective Date:
November 2, 2020
Recertification Date:
November 30, 2025
1. PURPOSE AND AUTHORITY
A. The purpose of this standard operating procedure (SOP) is to outline procedures for evaluating and determining when, and to what extent, Interim Life Safety Measures (ILSM) are necessary for significant existing Life Safety Code (LSC) deficiencies and conditions due to construction. This SOP establishes the process for Facility Management (FM), Occupational Safety & Health (OSH), and Office of Quality Management & Safety (OQMS) employees who identify Life Safety deficiencies.
B. The need for ILSM will be addressed during project development and evaluated throughout the construction or maintenance process. ILSM will apply to all construction workers as well as any medical center personnel within the construction areas or in any adjacent areas affected by the construction.
C. ILSM will also be addressed when significant existing LSC deficiencies (as identified in Appendix B) are identified. LSC deficiencies that would be scored as a “4” (indirect impact) by The Joint Commission under the Life Safety Standards would not be considered significant.
D. ILSM are intended to provide compensating measures when the requirements of the LSC cannot be met. All ILSM actions will be documented. Deficiencies that are not significant may be evaluated as a group and summarized in the Environment of Care Council (EOCC) minutes.
E. This SOP sets forth mandatory procedures and processes to ensure compliance with the most recent versions of NFPA 101, the Life Safety Code, and to comply with The Joint Commission (TJC) Life Safety standards LS.01.02.01, EPs 1-15.
2. PROCEDURES
November 2, 2020 SOP MCM 00S-214
A. Prior to the start of any construction or maintenance project, and continually through the duration of the project, the Occupational Safety & Health Specialist (OSHS) will evaluate the need for ILSM. The OSHS will complete an ILSM evaluation and submit it to the Safety Officer for approval.
B. The OSHS will complete an ILSM evaluation for significant existing LSC deficiencies and submit it to the Safety Officer for approval.
C. To complete an ILSM evaluation, use either Appendix A (for construction or maintenance) or Appendix B (for existing Life Safety Code deficiencies).
1) Using the Evaluation Table, determine what impacts in Column B will be created by the work.
2) For each impact, note the marked columns. Each column header has a recommended action to take to mitigate the hazard. On the Evaluation Sheet, circle Yes, No, or NA for each possible mitigation activity.
3) Determine which mitigating actions will be taken, detail them in the
Description, and get the Safety Officer’s review and signature.
4) Finally, create the ILSM flyer and provide both the completed Evaluation and the ILSM announcement sheet to the project manager.
D. Once ILSM for construction are implemented, the project will be inspected daily by the construction contractor, with the findings recorded in the daily log. Weekly verification of ILSM will be performed by the COR or designee, and the OSHS.
Any identified problems with the implementation of the ILSM will be abated as soon as possible.
E. All necessary documentation will be maintained in the FM construction project files (ILSM for Construction or Maintenance) or Safety Office (ILSM for Significant Existing LSC Deficiencies) to reflect compliance with these procedures.
3. ASSIGNMENT OF RESPONSIBILITIES
A. For construction activities:
1) The Contracting Officer’s Representative (COR) is responsible for:
a. Communicating and coordinating potential construction project impacts to life safety with OSH.
b. Implementation, enforcement, and documentation of ILSM.
2) The Occupational Safety & Health Specialist (OSHS) is responsible for:
a. Evaluating projects concerning ILSM.
b. Developing procedures for the implementation, enforcement, and documentation of the ILSM.
c. Reevaluations and extensions of ILSM throughout the project.
3) The Safety Officer is responsible for:
a. Reviewing and approving initial ILSM evaluations to ensure compliance with applicable regulations.
b. Communicating and coordinating with the Chief Engineer any issues related to the implementation, documentation, and enforcement of ILSM.
4) The FM Projects Supervisor is responsible for:
a. Ensuring all construction projects are evaluated for ILSM.
b. Resolving any issues related to the implementation, documentation, and enforcement of ILSM.
B. For significant existing LSC deficiencies:
1) The OSHS is responsible for:
a. Evaluating the deficiency concerning ILSM.
b. Developing procedures for the implementation, enforcement, and documentation of the ILSM.
c. Reevaluations and extensions of ILSM until correction of the deficiency.
2) The Safety Officer is responsible for:
a. Ensuring all significant existing LSC deficiencies are evaluated for
ILSM.
b. Coordinating resource allocation for ILSM implementation, enforcement, and documentation.
c. Providing status reports of ILSM to the Life Safety Code Deficiency Oversight Group (LSCDOG).
d. Reviewing and approving the initial ILSM evaluations to ensure compliance with applicable regulations.
4. DEFINITIONS
None.
5. REFERENCES
A. Joint Commission Life Safety Standards LS.01.02.01, EPs 1-15
B. NFPA 101 Life Safety Code, 2018 or most recent edition
6. REVIEW
This SOP must be reviewed, at minimum, at recertification.
7. RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of November 2025. In the event of contradiction with national policy, the national policy supersedes and controls.
8. SIGNATORY AUTHORITY
Daniel S. Zomchek, Ph.D., FACHE Clement J. Zablocki VA Medical Center Director
NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: SOPs are available at:
https://dvagov.sharepoint.com/sites/VHAMIW/PolicyManual/default.aspx https://dvagov.sharepoint.com/sites/VHAMIW/PolicyManual/default.aspx
Appendix A
Interim Life Safety Measures (ILSM) Construction or Maintenance EvaluationTable
Interim Life Safety Measures (ILSM) for Evaluation
A B C D E F G H I J K L M
Deficiencies or Conditions as a
Result of Construction or Maintenance
N o ti fy
F ir e D e p a rt m e n t a n d V
A P o li c e
P o s t fi re w a tc h s t s ig n a g e i d e n ti fy in g a lt e rn a te e x it s in s ta ll a d d it io n a l e x it s ig n a g
R lo c a te c a rt s a n d e q u ip m e n t o u t o f a re a
In s p e c t m e a n s o f e g re s s d a il y ta ll t e m p o ra ry f ir e d e te c ti o n e q u ip m e n t ti e d i n to b u il id n g f ir e a la rm s y s te m a n d p rf o rm c e rt if ic a ti o n t e s t fo ll o w e d b m n th ly t e s ti ro v id e a d d it io n a l p o rt a b le f ir x ti n g u is h e rs a n d t ra in in
C n s tr u c t te m p o ra ry f ir e b a rr ie rs n s tr u c t te m p o ra ry s m o k e b a rr ie n d u c t a d d it io n a l h a z a rd s u rv e il la n d u c e c o m b u s ti b le m a te ri a ls i n s tr u c ti o n a n d u c t o n e a d d it io n a l fi re d ri ll p e r s h if t p e r q u a rt e r
(s it u a ti o n d e p e n d e t) v id e a d d it io n a l s ta ff t ra in in g w a re n e s s a n d c o m p e n s a ti n g f o r d im in is h e d l if e s a fe ty f e a tu
Sprinkler system impairment > 10 hrs X X X X X
Sprinkler system removal X X X X X X
Fire alarm system impairment > 8 hrs X X X X
Fire alarm system removal X X X
Fire hydrant out of service X X X
Exit closed for construction X X X X X
Reduced corridor or exit access width/height X X X X
Excessive travel distance to an exit X X X X X X
Excessive common path of travel X X X X X X
Dead-end corridor X X X X
Impeded access for emergency responders X X X X
Smoke barrier or partition compromised X X X X
Fire barrier compromised X X X X X
Ceiling system removal in sprinklered area X X X
Hot work (welding, cutting, brazing) X X X X X
INTERIM LIFE SAFETY MEASURES (ILSM) EVALUATION SHEET
For Conditions as a Result of Construction or Maintenance
Project No: Date:
Project Title:
The following ILSM will be evaluated individually and initiated as needed to compensate for conditions due to construction. ILSM implementation will be documented on Signature Page.
A. Is notification of the Milwaukee Fire Department and VA Police required?
Yes No N/A
B. Is a fire watch required?
C. Is additional egress signage required?
D. Is relocation of permitted wheeled equipment required?
E. Is daily inspection of means of egress required?
F. Is temporary fire detection equipment, including monthly testing, required?
G. Are additional portable fire extinguishers and training on their use required?
H. Are temporary fire barriers required?
I. Are temporary smoke barriers required?
J. Is additional hazard surveillance required?
K. Is reduction of combustibles required?
For Conditions as a Result of Construction or Maintenance
L. Is an additional fire drill per shift per quarter required?
M. Is additional staff training on awareness and compensating for diminished life safety features required?
Description of Interim Life Safety Measures (ILSM) Used
Based on the responses to the evaluation questions, provide a description of the ILSM that will be implemented during the project to compensate for the deficiency or condition. Attach additional sheets if necessary.
Signatures required as indicated below. Completed form will be maintained in the project file.
Occupational Safety & Health Specialist: __________________________________ Date: _____________
Reviewers:
1. Safety Officer: _______________________________ Date: _____________
Appendix B
Interim Life Safety Measures (ILSM) LSC EvaluationTable
Interim Life Safety Measures (ILSM) for Evaluation
A B C D E F G H I J K
Existing Significant Life Safety Code Deficiencies
N o ti fy
F ir e D e p a rt m e n t a n d V
A P o li s t fi re w a tc h s t s ig n a g e i d e n ti fy in g a lt e rn a te e x it s in s ta ll d it io n a l e x it s ig n a lo c a te c a rt s a n d e q u ip m e n t o u t o f a p e c t m e a n s o f e g re s s d a il ta ll t e m p o ra ry f ir e d e te c ti o n e q u ip m e n t ti to b u il id n g f ir e a la rm s y s te m a n d p e rf rm rt if ic a ti o n t e s t
P ro v id e a d d it io n a l p o rt a b le f ir e e x ti n g u is h d t ra in n d u c t a d d it io n a l h a z a rd s u rv e il la n d u c e c o m b u s ti b le m a te ri a ls i n c o n s tr u c ti n d u c t o n e a d d it io n a l fi re d ri ll p e r s h if t p e r q u a rt e r
(s it u a ti o n d e p e n d e t) v id e a d d it io n a l s ta ff t ra in in g o n a w a re n e d c o m p e n s a ti n g f o r d im in is h e d l if e s a fe ty fe tu
Noncompliant fire barrier X X X X
Noncompliant smoke barrier X X X X
Improperly protected vertical openings X X X
Fire or smoke damper inoperational X X
Hazardous area not properly protected X X X X
Excessive common path of travel X X X X X
Excessive dead end corridor X X X X X
Excessive travel distance to an approved exit X X X X X
Lack of two remote exits X X X X X
Noncompliant locking arrangement X X X X X
Fire alarm system out of service X X X X X X
Fire protection system out of service X X X X X X X X
For Significant Existing Life Safety Code Deficiencies
Date: ___________
Unique Identifier:
Deficiency:
The following ILSM will be evaluated individually and interim measures initiated as needed to compensate for significant existing Life Safety Code (LSC) deficiencies as identified on the previous page. Where a deficiency is not listed, all questions below should be addressed.
A. Is notification of the Milwaukee Fire Department and VA Police required?
B. Is a fire watch required?
C. Is additional egress signage required?
D. Is relocation of permitted wheeled equipment required?
E. Is daily inspection of means of egress required?
F. Is temporary fire detection equipment, including monthly testing, required?
G. Are additional portable fire extinguishers and training on their use required?
H. Is additional hazard surveillance required?
I. Is reduction of combustibles required?
J. Is an additional fire drill per shift per quarter required?
K. Is additional staff training on awareness and compensating for diminished life safety features required?
Description of Interim Life Safety Measures (ILSM) Used
Based on the responses to the evaluation questions, provide a description of the ILSM that will be implemented until the deficiency is corrected. Attach additional sheets if necessary.
Signatures required as indicated below. Completed form will be maintained in the Safety Office.
Occupational Safety & Health Specialist: __________________________________ Date: _____________
Reviewers:
1. Safety Officer: ________________________________ Date: _____________
| 2020-11-02T16:07:51-0600 | |
| DANIEL S. ZOMCHEK 226924 |
File details come from the government source that posted it. Updated .