POLICIES AND PROCEDURES

FOR BUILDING CONSTRUCTION AND

RELATED WORK

Facilities Project Management Office (PMO)

July 2025

Babak Zare Cross-Out

HARRIS HEALTH SYSTEM

FACILITIES ENGINEERING POLICIES AND PROCEDURES

FOR BUILDING CONSTRUCTION AND RELATED WORK

TABLE OF CONTENTS

1. Contractors Work Guidelines

2. Construction Pre-Demolition Checklist

3. Fire Alarm Event – Analysis Action Plan

4. Hot Work Permit Procedure

5. Fire Watch Log

6. Fire Watch Checklist

7. Damper installation Verification Form

8. Above Ceiling Work & Fire-Smoke Wall Barrier Management

7.1 Above Ceiling Work & Fire-Smoke Barrier Penetrations Permit

9. Request for Utility-Operational System Shutdown

10. Alternative Life Safety Measures

11. Preconstruction Risk Assessment Process

10.1 Pre-Construction Risk Assessment Process Supplemental Information

10.2 Infection Control Risk Assessment

12. Fiber Optic Cabling Protection Procedure

13. Vaccine Preventable Disease Policy

14. On-Boarding Non-Employees Policy

15. Identification/Access Control Badge Policy

16. ID Badge Request Form

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FACILITIES ENGINEERING

DEPARTMENTAL GUIDELINES AND

PROCEDURES

Guideline No: FE.DG.1016 Page Number: 1 of 19

Effective Date: 04/22/2022 Last Review Date: 05/19/2025 Due for Review: 05/19/2028

TITLE: CONTRACTORS WORK GUIDELINES

PURPOSE: To define and outline work guidelines for all contractors and vendors Performing construction and/or maintenance (work) services at Harris

Health System facilities.

PROCEDURE/ GUIDELINE RATIONALE SUMMARY:

All contractors, vendors and their employees or representatives shall comply with the requirements and instructions set forth by the guidelines and procedures.

ELABORATIONS:

I. DEFINITIONS:

A. CONSTRUCTION - the building of something new, this will be handled by Facilities Planning.

B. MAINTENANCE - work that is done regularly to keep a machine, building, or piece of equipment in good condition and working order.

C. REPAIR - to restore something broken or damaged to good condition, and extend life expectancy.

D. RENOVATION - to bring something such as a building back to a former better state by means of repairs, redecoration, or remodeling.

*Construction and major renovations are executed and managed by the Facilities Planning Department.

E. UTILITY SYSTEM - Any system designed to distribute or remove energy, gases, communications, or wastes. The systems include:

• Normal and essential electrical distribution systems and Equipment.

• Piped medical air and medical gas systems.

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• Bulk oxygen storage and delivery equipment.

• HVAC systems.

• Domestic and industrial water systems.

• Sanitary and storm sewer systems.

• Natural gas systems.

• Voice communication systems.

• Data Systems.

• Tube Systems.

• Standby emergency power systems (UPS).

II. SECURITY:

A. Identification Badges

All Contractors and their employees, including sub-contractors, must obtain and wear identification (ID) badges. To obtain badges, the contractor must provide Harris Health System Security Office(s) with a written list of names. Each person requiring a badge shall complete an Identification Access Badge Request and Vendor Non-Employee Onboarding Attestation Form. The Contractor shall comply with all other Harris Health System Policies and Procedures. The contractors and their employees must attend the mandatory Harris Health System Learning and Resource Center Contractor Training prior to the issuance of any badge(s).

1. The Project Managers must submit the written list of names to the Learning and Resource Center within five (5) days.

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2. Unless special permissions are granted, all ID Badges must be returned to the Security Office immediately upon completion of any work or project(s).

3. If Contractor’s employees do not return ID Badges, the Harris Health System shall enforce the restriction of any contractor and/or employee(s) from facility access and future work until all issued ID Badges are accounted.

4. Contractor’s employees who will be working within Harris Health System facilities for more than thirty (30) days shall obtain an ID Badge from the Security Office.

5. Contractor’s employees who will be working at Harris Health System facilities for thirty (30) days or less must obtain temporary visitors badges from the Department of Public Safety

6. All contractors’ employees must sign-in with Facilities Engineering everyday prior to proceeding to the work area(s) and sign-out before leaving the facility. Contractors are to maintain a job site sign-in sheet daily for all personnel and sub-contractors.

7. All contractors’ employees must sign-in with Facilities Engineering everyday prior to proceeding to the work area(s) and sign-out before leaving the facility.

8. Parking for contract workers may be arranged through Harris Health System Department of Public Safety depending on availability and only for those previously authorized to park. Contractors shall not park in any unauthorized locations.

B. Accessing Facility and Secured Areas

Contractors entering Harris Health System facilities must check-in with the Security Office and then proceed to Facilities Engineering to secure all necessary permits and approvals. The Contractor shall pre-arrange access to

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Effective Date: 04/22/2022 Last Review Date: 05/19/2025 Due for Review: 05/19/2028 the Community Health Program through Engineering Department prior to entering any facility.

1. The Contractor must sign-in with Facilities Engineering prior to performing any work.

2. Contractor shall notify Facilities Engineering prior to accessing the roofs.

3. Construction areas or job sites must be secured from unauthorized entry at all times.

4. Harris Health System shall not accept any responsibility for contractor tools that are on the job site and/or unsecured.

5. Contractors shall not leave tools unattended in any area of the Hospital.

6. Theft, misappropriation or damage to Harris Health System equipment due to contractor negligence will result in the responsible party being removed from the job site and Harris Health System shall be reimbursedaccordingly.

7. Health Information Portability and Accountability Act (HIPAA) – The Federal HIPAA regulations establish specific requirements to preserve and protect the confidentiality of patients and their healthcare information. Contractors working within the Harris Health System environment shall be held to the same requirements, and are not allowed access to patient information. Any information obtained while working in the Harris Health System environment is considered personal and confidential

C. Behavior

The Contractor shall enforce strict discipline and order among its employees at all times. The Contractor shall not employ anyone on the work site not skilled in the task assigned. Harris Health System reserves the right to request removal of any individual who does not comply.

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1. Practical jokes, wrestling, throwing material, horseplay, etc. are strictly forbidden on any of Harris Health System premises.

2. Any behavior, which compromises safety within the Harris Health System environment, such as whistling, abusive language or sexual harassment, will result in the removal of that individual from the premises.

3. Lunch breaks and/or other authorized breaks shall be taken in designated areas.

III. SAFETY

All Contractors shall work within the rules and regulations, defined in the current edition of Texas Medical Center Architectural Standards, OSHA and the Harris Health System policies and procedures. The contractor shall be responsible for initiating, maintaining and supervising all safety precautions and programs in connection with the work.

A. On Site Work Injuries

1. Contractors injured while working at a Harris Health System property must report the incident. The contractor must record all information required on an OSHA 300 form for all OSHA recordable injuries, and must maintain an OSHA 301 Log of all recordable injuries.

2. The contractor will report to Harris Health System Project Manager and Safety Specialist a summary of their injury experiences each month. This summary at a minimum shall include the number of first aid injuries, the number of lost time injuries, and the number of fatalities. All but first aid injuries are OSHA recordable.

3. Any incident or injury to a contractor must be reported to the Project Manager immediately. The Contractor shall complete an investigation report within two weeks of the incident and forward it to the Project Manager. The Project Manager will provide the report to the Safety Specialist to enter it into the electronic incident reporting system.

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4. The contractor shall erect and maintain as required all reasonable safe- guards for safety and protection, including posting danger signs and other warnings against hazards promulgating safety regulations and notifying Harris Health System and users of adjacent areas and utilities.

5. The Contractor employees are required to report any unsafe conditions to their immediate supervisor during construction or renovation projects.

6. Personal protective equipment may be deemed necessary and required for some renovation and construction projects. The contractor is required to provide, train where necessary and assure employees utilize proper personal protective equipment.

7. The contractor shall wear approved fall arrest equipment, (contractor provided) and be secured to an approved anchorage point whenever working on roof areas within ten (10) feet of the roof edge.

8. Harris Health System is a “NON-SMOKING” institution. Use of tobacco products, including smoking and electronic cigarettes, is prohibited for all patients, visitors, physicians and staff, (includes contractors) within any Harris Health System facilities and on Harris Health System grounds.

B. Learning and Resource Center Contractor Mandatory Training

ALL contractor personnel shall be required to attend mandatory Harris Health System Learning and Resource Center Contractor Training prior to working at any facility. Contractor must also attend a Departmental Orientation Provided at the Facility which the Contractor will be working per Harris Health Policy No 6.53. Under no circumstances will badges be issued or contractors permitted work in a Harris Health System facility until completion of training. The training shall be arranged by the Project Manager or Facilities Engineering or designee. This training will be a multi-media

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C. Emergency Situations

1. In the event of a FIRE (Code Red), the contractor’s employee should:

• Hospital: Call 713-873-7800 and report CODE RED.

• Clinic or Administrative Facility: call 713-566-6901 and report CODE REDProvide the operator with the fire location (i.e.

building, floor, unit/department, and project name), name of person reporting the incident, company, and if known, what type of fire.

• Initiate the building alarm system by activating the nearest pull station.

• If the fire small (incipient) and it is safe to do so, staff should secure and use a portable fire extinguisher to put out the fire.

2. The Contractor’s employees must be familiar with Harris Health System Emergency Codes and Alerts, and should review Harris Health System Policy 7100 “Emergency Codes, Alerts, and Response”. When any Emergency Code or Alerts are announced overhead, contractor staff should report to their supervisor for further instructions as necessary. Contractors needing to report any of the emergency incidents (as listed below) must call 713-873-7800.

D. Hazardous Materials

The contractor shall be informed by the Project Manager and/or Facilities Engineering or designee of known hazardous materials or conditions that may be encountered during the course of work. Furthermore, the contractor shall be made aware of the Hazardous Materials and Waste Management program and are required to follow Harris Health policy and procedures #7201, #7202, #7204. The Safety Data Sheets (SDS) for chemicals being

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IV. CONSTRUCTION/MAINTENANCE SERVICES

When a Harris Health System facility undergoes construction, renovation, remediation, repairs and/or demolition, a multidisciplinary team shall be established to consider proactive and preventive risk mitigation measures.

The Contractor shall be required to meet with the Project Manager and Facilities Engineering or designee to review the project scope and/or services and determine whether or not measures are required.

During demolition activities, all life safety equipment and systems shall stay remain in place. Contractors are instructed to utilize the Pre-Demolition Checklist issued by the Harris Health PMO construction project managers before any demolition work begins Negligence in adhering to any required Harris Health System policies or procedures may result in a project work stoppage.

A. Preconstruction Risk Assessment (PCRA)

1. Contractors, Project Managers, Facilities Engineering and any party involved in construction, renovation, remediation, repairs and/or demolition at Harris Health System facilities must review and fully adhere to all the requirements of Harris Health System Policy # 7407 Pre-Construction Risk Assessment (PCRA).

2. When a Harris Health System facility undergoes construction, renovation, remediation, repairs and/or demolition, a multidisciplinary team shall be formed to evaluate any new risks created/generated by these activities and develop/implement any necessary risk mitigation measures that minimize their impact on the patient care environment.

3. The Contractor shall be required to be part of this multi-disciplinary team, attend PCRA meetings scheduled by Project Manager or Facilities Engineering, and participate/collaborate in the implementation of any needed risk mitigation measures. Failure and/or

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Effective Date: 04/22/2022 Last Review Date: 05/19/2025 Due for Review: 05/19/2028 negligence in adhering to Harris Health System policies and procedures may result in a work stoppage.

B. Infection Control Permit

All contractors shall adhere to the Harris Health System Infection Control procedures and must obtain an Infection Control Permit when required from the Infection Control Department prior to any construction.

C. False Fire Alarms

False fire alarms are significant incidents in a health care facility and as such are taken seriously.

Contractors working in HHS buildings are required to maintain all Life Safety systems and equipment as part of the project, as outlined in the project drawings and specifications, if applicable.

Any false alarm incident originating in the work area or deemed to be initiated by the contractor or his sub-contractors, will result in the immediate work stoppage of the project in its entirety, with no incurred penalty to Harris Health.

The contractor shall be required to submit a detailed after action report to the building engineer and HHS project manager, with a root cause analysis and details of what actions will be taken to prevent future incidents.

The form to be used will be made available to the contractor by the Project Manager and requires the review and final sign-off from the facility engineer, project manager and/or safety representative before work is allowed to re-commence.

D. Alternate Life Safety Measures (ALSM)

1. Contractors, Project Managers, Facilities Engineering and any party involved in construction, renovation, remediation, repairs and/or demolition at Harris Health System facilities must review and fully adhere to all the requirements of Harris Health System Policy # 7403 Alternate Life Safety Measures (ALSM).

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2. During periods of construction, renovation, remediation, repairs and/or demolition, the level of protection for the occupants must be maintained as hospital patients do not have the ability to self-evacuate in the event of a fire.

3. As sometimes Life Safety Deficiencies may be created by construction activities, Alternate Life Safety Measures (ALSM) must be developed and implemented to ensure that basic life safety principles of the Life Safety Code, though not fully met during this period of construction, are adequately compensated by Alternate Life Safety Measures.

4. The Contractor shall work with the Project Manager and Facilities Engineering, attend ALSM meetings scheduled by Project Manager or Facilities Engineering, and participate/collaborate in the implementation of any ALSMs’.

5. Failure and/or negligence in adhering to Harris Health System procedures may result in a work stoppage.

E. Utility Shutdown/Impairments

1. Harris Health System Project Manager and Facilities Engineering or designee shall be notified at least 14 days prior to any impairment of the utility systems or the fire protection equipment, specifically hydrants, fire pumps, automatic sprinkler systems, smoke detectors, and water supplies.

2. All procedures must be followed and the requests must be submitted on Harris Health System Utility System Shutdown form as stated in procedure # 1035.

3. Upon determining the need for building system impairment, the Contractor shall notify the Project Manager and Facilities Engineering or designee of any pending shutdowns and the contractor must complete the Utility System Shutdown Form. Facilities Engineering with the assistance of the Project Manager shall make all necessary arrangements

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F. Fire Alarm and/or Sprinkler System Shutdowns

1. Harris Health System Project Manager and Facilities Engineering or designee shall be notified at least 14 days prior to any planned impairment to the fire protection equipment, specifically hydrants, fire pumps, automatic sprinkler systems, smoke detectors, fire alarm panel, and water supplies.

2. Contractors must complete and submit th e Harris Health System Facilities Engineering Procedure # 1035 “Request for Utility/Operational System Shutdown” form.

3. When automatic Fire Sprinkler Systems are out of service for more than ten (10) hours in a 24-hr period, Facilities Engineering shall conduct an ALSM analysis, implement a fire watch and notify the local Fire Marshal Office. The option to a Fire Watch is evacuating the building. The 10 hour period is not meant to be continuous but the sum of outages in a 24 hour period.

4. An approved fire watch consists of a designated, trained individual who has no other responsibilities, continuously patrols the entire area affected by the outage looking for signs of fire and potential situations where fire could start, and has the ability to communicate to call the local fire responders in case of fire. This individual cannot leave the impaired area until the fire watch is discontinued or is relieved by another designated, trained individual.

5. Fire Alarm Systems are out of service for more than four (4) hours in a 24-hr period, Facilities Engineering shall conduct an ALSM analysis, implement a fire watch and notify the local Fire Marshal Office. The alternative to a Fire Watch in this situation is to evacuate the building. The 4 hour period is not meant to be continuous but the sum of outages in a 24 hour period.

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6. An approved fire watch consists of a designated, trained individual who has no other responsibilities, continuously patrols the entire area affected by the outage looking for signs of fire and potential situations where fire could start, and has the ability to communicate to call the local fire responders in case of fire. This individual cannot leave the impaired area until the fire watch is discontinued or is relieved by another designated, trained individual.

G. Lock Out/Tag Out

1. If a Lock Out/Tag Out is required necessary to work on a piece of equipment and/or system, it shall be secured by using OSHA’s Lock Out/ Tag Out procedures and Facilities Engineering Policy #1021.

2. The Contractor shall notify and provide Facilities Engineer lock outage schedules, outage times and locations of areas affected by temporarily power disruptions.

H. Hot Work

1. Hot Work Permits shall be required for ALL hot work that involves cutting, burning, welding or an open flame. The Contractor shall adhere to the Facilities Engineering Department Guidelines FE.DG.1020 Hot Work Permit Procedure. Hot work permits shall be obtained from Facilities Engineering prior to the start of any work.

2. Hot Work that requires a permit must have a 10lb fire extinguisher on hand during the entire time of the hot work operation.

3. Hot Work for which a permit has been issued requires a designated fire watch during the entire duration of the hot work and for one (1) hour after all hot work stops. The contractor is responsible for supplying the designated fire watch. This is a designated person with no additional duties other than fire watch.

4. Twenty-four (24) hour prior notification is necessary for all contractor

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5. Hot work permit must be returned same day to receive another.

I. Above The Ceiling Access – Fire/Smoke Barrier Work

1. Contractors shall adhere to all requirements contained in the Harris Health System Policy # 7406 “Above Ceiling Work and Fire/Smoke Wall Penetrations”.

2. All work above the ceiling (plenum) will require a permit.

3. All work on Fire/Smoke barriers (whether is done above or below the ceiling) will require a permit as well.

4. These permits must be obtained from Facilities Engineering prior to the start of any work.

5. Contractors must meet with Facilities Engineering to discuss the scope of work and to make sure all the requirements for the permit are met.

6. The permit must be displayed at all times near job site or on the ladder.

Failure to display the permit will result in the shut-down of all work.

7. A sign-off walk-through inspection will be conducted by Facilities Engineering at the end of the job.

J. Working with Utility Systems (Electrical, Plumbing, HVAC)

The Contractor shall not operate any Harris Health System machinery, equipment or utility systems (HVAC, electrical, automatic sprinkler, etc.)

unless familiar with the facilities operations, has been authorized, and is supervised by Facilities Engineering. Contractor shall provide Ground Fault suppression electrical cords when utilizing existing HHS circuits.

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The Contractor electrical (non-patient) equipment brought into Harris Health System facilities and utilized in patient care areas must be checked-out and certified by the Facilities Engineering for compliance with Harris Health System policy. This shall include proper grounding and system compatibility. The contractor shall initiate said inspections.

1. Contractors conducting electrical repair work or new construction on machinery or building equipment are required to Lock Out and Tag the starting switches and all energy isolation devices, i.e., valves with “DO NOT OPERATE” tags, (including contractor name and date), Facilities Engineering must be informed that the power has temporarily been locked out. All Contractors must follow OSHA and Harris Health System lock out/tag out procedures. Any lock out / tag out actions conducted by the contractor will require prior notification to Facilities Engineering beforeany maintenance / repair procedures are undertaken.

2. The Contractor shall limit electrical interference with Harris Health System electrical equipment and radio telecommunication IV

3. The Contractor must use Safety Related Work Practices for all electrical work as provided in OSHA standards 29 CFR 1910.331-335 and 29 CFR 1926.416 and 417 as applicable.

K. Housekeeping

1. The Contractor shall confine operations to the designated construction work area(s) as permitted by law, ordinances, permits, contract documents and shall not unreasonably encumber the site with any materials, equipment, or unnecessarily disturb other occupants of the facility.

2. The contractor shall at all times keep the premises free from accumulation of waste materials and/or rubbish caused by construction operations. At the completion of the work all waste materials, rubbish materials and tools shall be removed from the project/job site, in addition to construction equipment, machinery and surplus materials.

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Trash/rubbish and combustibles shall be removed daily. All trash and debris bins must be covered when entering/exiting public corridors.

All flammable products shall be returned and stored into an approved flammable storage cabinet prior to project work stoppage at the end of each day.

3. The Contractor shall schedule all necessary material stocking/staging, demolition and trash removal through designated corridors and elevators during non-peak hours as approved by Facilities Engineering and Infection Control during the project kick-off meeting.

4. Littering or poor housekeeping, unsanitary or unsafe conditions, and/or other disruptive procedures in a Harris Health System facility are strictly prohibited. Harris Health System reserves the right to shut-down all work that may be disruptive.

L. Personal Attire for Workforce

All contractors shall observe and comply with Harris Health System standards for dress and personal appearance.

M. Sanitary Facilities for Workforce

The Contractor shall provide their employees suitable sanitary toilet facilities for the entire construction period.

1. The Contractor shall keep all toilet facilities clean and supplied with tissue, disposable towels, soap and waste containers at all times.

2. Contractor employees shall utilize toilet facilities as provided by the contractor and approved by the facility designated representative.

3. Special arrangements will be made for smaller projects, on a case by case basis.

N. Completion of Services and Invoicing

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It is the responsibility of the contractor/vendor to ensure that all invoices are processed accurately and submitted to ensure payment.

1. A Purchase Order must be obtained before any work is initiated at Harris Health System.

2. The purchase order number must be referenced on all service tickets and invoices in order to receive payment. No exceptions will be considered.

3. The Contractor must leave a service ticket at the facility before leaving the premises. If vendors have electronic ticketing, a copy of the service ticket must be emailed to the facility no later than one (1) business day.

4. The vendor must secure signatures from Facilities Engineering management acknowledging services have been completed, inspect and approved.

5. The sign in and out logs in facilities engineering will be utilized to cross reference the times the vendor is on property performing any work. Invoice will not be processed for payment when sign in and out signatures are missing from the logs.

6. Invoices will be returned to vendor if:

• Billing rates per invoice do not agree to the rates per contract or purchase order.

• Invoice was billed as a lump sum when the contract requires billing for time and materials.

• Invoice does not have the signature of an officer of the vendor who is ensuring the accuracy of the invoice.

• The sign in/out logs do not match the labor hours billed.

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• Itemized support for labor and materials (as agreed upon by Harris Health System and contractor) is not attached to invoice when billing for time and materials

• Service tickets are not legible.

7. Service ticket and invoice discrepancies must be resolved prior to forwarding invoices to accounts payable.

8. If any service, scope and/or cost are beyond the contracted approved amount, a justification from the contractor/vendor must be submitted to Facilities Engineering management for approval(s) prior to continuing services. If approved Harris Health System will procure additional funds to the original PO to cover the additional scope/services. Any work performed without Facilities Engineering management approval(s) shall be voided.

9. A copy of the invoice with service ticket and prevailing wage rate compliance forms as stated in the U.S Dept. of Labor form WHD 347, shall be forwarded to the department and original invoice with the correct purchase order mailed to: Harris Health System Accounts Payable Department: P.O. Box 66769 Houston, TX 77266.

REFERENCES/BIBLIOGRAPHY:

• Department of Public Safety Policy #7062

• Hazardous Materials and Waste Management #7201, 7202, 7204

• Alternate Life Safety Measures (ALSM) #7403

• Above Ceiling Work and Fire/Smoke Wall Penetrations #7406

• Pre-Construction Risk Assessment (PCRA) # 7407

• FE.DG.1020 Hot Work Permit Procedure

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• ALSM Risk Assessment Tool # 286029

• Fire Watch Log & Checklist Form # 285192

• Lock Out Tag Out Procedures #1021

• Utility Shutdown Procedures #1035

DEPARTMENTAL - PRIMARY RESPONSIBILITY: Facilities Engineering

REVISION HISTORY:

Effective Date Version # (If Applicable)

Review/ Revision Date (Indicate Reviewed or

Revised) Approved by:

9/2013 1 Original Facilities Engineering 4/22/22 2 Revised Facilities Engineering

Detach, sign, date and return to Facilities Engineering, the following page, certificate of contractor worker guidelines acknowledgement, prior to commencement of contractor activities.

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Harris Health System

Representative:

Department:

CERTIFICATE OF HARRIS HEALTH SYSTEM CONTRACTOR WORK

GUIDELINES ACKNOWLEDGEMENT

I have been presented with Harris Health System Contractor Work Guidelines and attended mandatory training. I have read the guidelines and thoroughly understand its contents:

Representative’s Name (Printed):

Contractor/Company Name:

Address:

Telephone:

Harris Health System Learning and Resource Center Contractor mandatory training. Date class taken:

Signature: Date:

As a representative of the above named Contractor/Company, I hereby certify and acknowledge that I have read, understand and agree to the Harris Health System Contractor Work Guidelines

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CONSTRUCTION SITE

PRE-DEMOLITION CHECKLIST

PROJECT:

LOCATION / AREA OF DEMOLITION:

DATE:

Documentation Requirements Yes No N/A Comments Pre-Demolition Meeting has taken place

• Engineering

• Facilities Planning Project Manager

• IT Manager

• Security Manager

• Infection Prevention

• Contractor

Equipment with Harris Health asset tags have been turned over to the owner.

ICRA Permit has been approved

Pre-Construction Risk Assessment has been completed

Shutdown Request Has Been Submitted / Approved

Survey / photos or video has been documented.

Equipment identified to be turned over to Harris Health has been turned over to the owner

CHECKLIST

Infection Control / Demolition Responsibilities Yes No N/A Comments Infection control and alternate life safety measures are in place

Temporary filter media installed where necessary.

Existing floor & wall penetrations are adequately addressed (Infection Control or fire rating).

Elements / System to demolished have marked and identified

Temporary protection installed for non-demolition areas.

Existing finishes/equipment to remain are clearly identified.

Noise/dust control are in place

Daily clean-up activities have been confirmed and coordinated

Exit routes are adequate and addressed.

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CHECKLIST

Electrical & Low Voltage Scopes Yes No N/A Comments Existing telecom, data cables, conduit, cable tray, and raceways to remain and/or be demolished are clearly identified. Color code items to remain / be removed as necessary. Attach drawing if applicable.

Electrical cables, duct banks, electrical conduit, cable tray, and raceways to remain and be demolished are clearly identified.

Color code items to remain / be removed as necessary.

Attach drawing if applicable.

Existing Security cables and conduit, cable trays, and raceways to remain and/or be demolished are clearly identified. Color code items to remain / be removed as necessary. Attach drawing if applicable.

Security devices and equipment to remain and/or be demolished is clearly identified.

Fire alarm equipment to remain and/or be demolished is clearly identified.

Smoke detectors have been changed to heat detectors if required.

Nurse Call system to remain and/or be demolished is clearly identified.

IT and Telecomm system and equipment to remain and/or be demolished is clearly identified.

Electrical make-safe, lock-out, tag-out is complete if required and verified

All open junction boxes are covered (verify above ceiling).

Any remaining portions of raceway, wiring, and equipment scheduled to remain will be made safe and capped.

Mechanical, Plumbing, and Sprinkler Scopes Yes No N/A Comments Fire suppression, mechanical, and plumbing system(s) scheduled to remain or be removed are clearly identified, including unused piping and utilities.

Color code items to remain / be removed as necessary.

Attach drawing if applicable.

Valve locations for all systems have been identified and are open or closed as required.

BAS/pneumatic control locations have been reviewed and are clearly identified / adequately protected.

Any remaining portions of control wiring, piping, and ductwork scheduled to remain will be capped and/or valved off.

Sprinkler head coverage is properly maintained and protection is in place (Cages to cover and locate shut-off valves).

Dampers for HVAC ductwork are clearly identified and open/closed as required.

Cut/ Cap Make safe is complete and verified (if required).

03/18/2022 Page 3 of 3

FINAL SIGN-OFF

Contractors attest that the above item have been verified

Contractor: Superintendent

Name:

Signature:

Date:

Checklist received and reviewed for completeness by Harris Health System

Harris Health PMO Name:

Signature:

Date:

Harris Health Engineering Name:

Signature:

Title:

Date:

Harris Health IT Name:

Signature:

Title:

Date:

Harris Health Security Name:

Signature:

Title:

Date:

CAP Form 02/05/2014

YES NO YES NO

WHY?

WHY?

WHY?

WHY?

WHY?

CHECK ACT

� Effective, then standardize use � Ineffective, review action or start all over

COMPLETED BY: DATE:

FIRE ALARM EVENT ANALYSIS

AND ACTION PLAN

PLAN DO (Actions implemented to prevent problem from recurring)

Incident Date and Time: Project Name:

Unit/Area/Department: Pavilion/Building/Floor:

FALSE ALARM

Root Cause Analysis (5Y):

Facilities Director or designee

PMO or Pavilion Project Manager

Pavilion Safety Specialist

Approved by: (two signatures required)

What happened?

REAL FIRE EVENT

Signatures Date

COMPANY/DEPARTMENT:

Status & Effectiveness (implemented?

Worked?)

Implementation DateResponsible PersonActions To Be Taken To Prevent RecurrenceRoot Cause (from 5Y analysis above)

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FACILITIES ENGINEERING DEPARTMENT

Guideline No: FE-DG-1020 Page Number: 1 of 5

Effective Date: 10/11/2021

Last Review Date: 09/29/2022 Due For Review: 09/29/2025

TITLE: HOT WORK PERMIT PROCEDURE

PURPOSE: To provide information and direct the appropriate action for managing all Hot Work activities conducted at Harris Health System facilities. The goal of the Hot Work Permit is to minimize or eliminate the risk of fire, smoke, and other products of combustion inherent in Hot Work activities.

GUIDELINES/PROCEDURES STATEMENT:

This procedure shall be applicable to all workforce members performing work at Harris Health System facilities. The Facilities Engineering Department shall maintain a Permit To Work system to control Hot Work operations throughout the facility. Before any work begins, activities must be assessed for the need of a Hot Work Permit. No Hot Work can be conducted without obtaining and posting the required Hot Work Permit.

ELABORATIONS:

I. DEFINITIONS:

A. Hot Work: This includes Work involving burning, welding, or a similar operation that is capable of initiating fires or explosions; any activity involving flame, spark production, or heat; and welding and allied processes including arc welding, oxy–fuel gas welding, open-flame soldering, brazing, thermal spraying, oxygen cutting, and arc cutting.

B. Designated Area: A location dedicated to Hot Work (i.e. welding booth, machine shop, outside grounds, etc.), where the Hot Work activity can be safely conducted, and where there is minimum risk of fire.

C. Hot Work Proximate Area: An area consisting roughly of a circle with a 35 ft.

radius, or by measuring 35 ft. in all directions from the Hot Work location.

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Page Number: 2 of 5

II. RISK ASSESSMENT MATRIX:

Hot Work activities and associated fire hazards shall be avoided when they are not necessary for the job at hand, or when it can be completed using non-hot work or alternative means, that does not compromise quality or safety.

If Hot Work is necessary for the job, first consideration should be given to conducting it in a designated area or outside grounds where the risk of fire can be minimized.

If the Hot Work operation or job cannot be moved to a designated area, combustibles and/or flammables shall be relocated to the outside of the Hot Work Proximate Area.

If combustibles in the Hot Work Proximate Area cannot be moved away, they should be isolated from the Hot Work activity by covering them with fire-resistant barriers (i.e.

welding blankets, curtains, pads, etc.).

If combustibles cannot be covered with fire-resistant blankets, this indicates Hot Work operations cannot be safely conducted and a Permit To Work shall not be issued.

III. REQUIREMENTS:

1. Hot Work Permit To Work shall be issued only to: Hot Work Operators that have been trained by their employers/managers to follow the permit process and requirements, and to implement the required precautions to safely perform the type of Hot Work activity described in the permit.

2. Hot Work Permit To Work shall only be issued only by: Facilities staff authorized to do so, after having been properly trained to: (1) understand this procedure, the permit form, and the permit process, (2) review the Hot Work Permit request, (3) apply the risk assessment matrix, (4) inspect and evaluate the proposed Hot Work location, (5) implement and enforce requirements for the safe conduct of Hot Work, and (6) document all conditions in permit, and (7) properly file permits for future review and inspection.

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Page Number: 3 of 5

3. Prior to issuing the Hot Work permit, a risk assessment shall be conducted by the facilities staff authorized to issue the permit to determine additional safety, security, life safety, or other measures that should be implemented during the period the Hot Work is conducted.

4. The authorized Permit Form to be used shall be the one supplied by Harris Health System Property Insurer: “AXA XL Risk Hot Work Permit Form”.

Completed permit forms should be properly filed for future review and inspection.

5. Hot Work Permits shall expire in 24 hours, and a new permit shall be required if Hot Work operations have not yet been completed after that period.

6. 35 ft. radius area from where the hot work is being conducted shall be clear of combustibles and flammable materials, or protected with suitable fire-resistant covers/barriers.

7. Opening or cracks in walls, floors, ducts, or shafts near the hot work operations should be sealed to prevent sparks from reaching combustible building components. Metal fire resistant guards or approved hot work curtains may serve as an alternative.

8. If hot work is to be done in close proximity to a sprinkler head, the head should be covered by a wet cloth to prevent activation. The cloth must be removed immediately at the conclusion of the hot work.

8. All smoke detectors in the area should be covered or disabled prior to hot work.

The dust covers must be removed immediately or enabled immediately at the conclusion of the hot

10. At least 1 extra fire extinguisher with a rating appropriate for the risk hazards at hand shall be located within the Hot Work Proximate Area (35 feet radius).

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Page Number: 4 of 5

11. Facilities Engineering Department shall inspect the Hot Work location before issuing a Permit To Work and at least once per shift to ensure permit-required precautions are being maintained and adhered to.

12. Facilities Engineering Department shall inspect the area where the Hot Work was conducted at least 1 hour after the work was completed. This final QC check shall be required to close the Hot Work permit.

13. Facilities Engineering Department reserves the right to issue this Permit. Failure to secure a permit, or not to display the permit at the Hot Work location, or failure to return permit, or not returning 1 hour after the work is completed, may deem a person/company unqualified to receive future permits.

IV. FIRE WATCH

1. A Fire Watch shall be continuous (uninterrupted) and shall be in place throughout the time the Hot Work activity is being conducted and shall remain in effect for at least 60 minutes after the hot work has been completed.

2. The Fire Watch should cover an area with at least a 35 ft. radius from where the Hot work activity is being conducted.

3. The individual assigned to the Fire Watch shall be dedicated solely to Fire Watch, shall have no other duties, must continually patrol the area, documenting rounds/patrols at a minimum of once every hour, should be have completed hands-on training in the use/operation of portable fire extinguishers and have one accessible at all times, should know the location of the nearest pull box stations, carry at all times a radio or cell phone to communicate with Facilities Engineering, Security and the fire department to notify them about fires or other emergencies, and must maintain a record of the Fire Watch for inspection by the Authority Having Jurisdiction.

4. Fire Watch rounds should be documented and the forms turned in to Facilities Engineering Department along with Hot Work Permit at completion of work.

Contractors can use their own form or can use the Harris Health System Fire Watch Log & Checklist – DC # 285192.

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Page Number: 5 of 5

FORMS:

AXA XL Risk Hot Work Permit Form

Fire Watch Log & Checklist – DC # 285192

REFERENCES/BIBLIOGRAPHY:

NFPA 51B Standard For Fire Prevention During Welding, Cutting, & Other Hot Work.

29 CFR 1910 OSHA General Industry Subpart Q Welding, Cutting, and Brazing

29 CFR 1926 OSHA Construction Subpart J Welding & Cutting

DEPARTMENT OF PRIMARY RESPONSIBILITY:

Harris Health System Facilities Engineering

REVIEW/REVISION HISTORY:

Effective Date Version #

(If Applicable)

Review/ Revision Date (Indicate Reviewed or

Revised)

Approved by:

10/11/2021 1.0 10/11/2021 Harris Health System Facilities Engineering

09/25/2022 Harris Health System Facilities Engineering

ROUND DATE TIME OBSERVATIONS/ACTIONS

FIRE WATCH START DATE

FIRE WATCH END TIME

FIRE WATCH LOG

CONDUCTED BY

AREA

PROJECT NAME

PROJECT MANAGER

FREQUENCY ENDED/CEASED BY

PAVILION

BUILDING

FLOOR

285192 | 05.21

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# Yes No Observations/Comments/Actions

Are self-closing doors not blocked or wedged and close freely in a fire emergency?

Are flammable and combustible materials are properly stored in approved containers?

Items

FIRE WATCH CHECKLIST

Is the area free of fire and high risk conditions?

Are active sprinkler systems free from sprinkler head obstruction, leakage, closed valves, or decreased pressure?

All remaining operable fire protection equipment is in place and not obstructed?

Are all waste, rags, paint residue, rubbish, and similar combustible items are removed from the building?

Are outside doors closed and secured, and windows, fire doors and fire shutters closed?

Are fire extinguishers in their proper location, undamaged, unobstructed, visible, properly pressurized, sealing bands secured and the pin intact?

Are all unnecessary heat-producing devices turned off in the impairment area?

Is the means of egress free and clear?

Is the space free of potential ignition sources (frayed electrical wires and defective electronic components)?

Are maintenance closets, equipment rooms, and stairwells free of general storage?

285192 | 05.21

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PROJECT MANAGEMENT OFFICE

4800 FOURNACE PLACE, BELLAIRE, TX 77401

harrishealth.org

August 1, 2024

General Contractor Address Line1 Address Line2

To Whom It May Concern:

The purpose of this report is to satisfy the applicable fire, smoke, and/or fire/smoke combination damper device inspection and testing as required by the following standards:

• The City of Houston Fire Department Life Safety Bureau (LSB) Standard 02, Revision 03

• National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives

• NFPA 90A, Standard for the Installation of Air-Conditioning and…