1d. Safety and Health During Construction Activities V2.pdf

VA Hospital Hines, IL 60141

Policy Memorandum 578-1.2-138A-076 (R-2)

July 16, 2018

SAFETY AND HEALTH DURING CONSTRUCTION ACTIVITIES

Changes:

• 3 Responsibilities:

Revised Section a. (2) to remove Engineering (Facilities Management) and Engineering

(Projects Management) and to include Engineer (Project Planning Section), Engineering

(Maintenance and Operations), and Engineering (Healthcare Technology Management).

Revised Section a. (3) from "complete at least 10 hours of Construction Safety Training at least every 2 years; ot complete 30 hours of Construction Safety Training" to Hcomplete 30-hour

Construction Safety Training and subsequently completes at least 10 hours of Construction

Safety Training at least every 2 years."

Changed the title of Section c from Chief, Facilities Management Service to Chief, Engineering Service.

Changed the title of Section c from Chief, Biomedical Engineering to Chief, Healthcare

Technology Management.

Correcting Section h. (3) to correctly indicate "CSO(s)" instead of "CSC(s)".

Changed the title of Section i from Facility Safety Program Manager or designee to Safety and

Occupational Health Manager or designee.

Changed the title of Section h from Infection Preventionist to Infection Control Manager or designee.

• 5 References:

Replaced reference VHA Directive 2011-036, Safety and Health During Construction

Activities, dated September 22, 2011 (Data available on Intranet) with VHA Directive 7715, Safety and Health During Construction, dated April 61 2017 (Data available on Intranet)

Replaced reference Interim Life Safety Measures, Policy Memorandum 578-02-001-088(R-2)1 dated October 3, 2011 (Data available on intranet) with Interim Life Safety Measures, Policy

Memorandum 578-02-001-088 (R-3), or more current version (Data available on intranet)

Replaced reference Above Ceiling Entry and Wall Construction Permits 578-07-001-102 (R-2) dated December 27, 2011 (Data available on Intranet) with Above Ceiling Entry and Wall

Construction Permits 578-12-138A-079 (R�3), or more current version (Data available on intranet)

Replaced reference Smoking Policy 578-03-001-038 (R-2) dated February 1, 2012 (Data available on intranet) with Smoking Policy 578-03-001-038 (R-3), or more current version

(Data available on intranet)

Replaced reference Hazard Communication Program 578-03-001-034 (R-1) dated January 13, 2012 (Data Available on intranet) with Hazard Communication Program 578-03-001-034 (R-2), or more current version (Data available on intranet)

• 6 Rescission:

Changed to Policy 578-12-138A-076 (R1) Safety and Health During Construction Activities

• 8 Follow-up Responsibility:

Changed from Facilities Management Service to Engineering Service.

• 9 Attachments:

Created Section 9 and move the attachments list into this section.

• Signature Change

Changed Director's signature from Joan M. Ricard, FACHE, Hospital Director to Steven E.

Braverman, M.D., Hospital Director.

Removed from Previous Policy:

• 3 Responsibilities:

The Construction Safety Committee (Multi-Disciplinary Team), Section m. (2): Conducting preconstruction risk assessments for air quality requirements, infection control, utility requirements; noise, vibration, and other hazards that affect care, treatment, and services.

Using the current American Institute of Architects (AIA) Guidelines, staff must conduct and document in writing preconstruction risk assessments during the design or planning stage of the work (prior to bidding, award, and starting work). Preconstruction risk assessments must focus on eliminating or minimizing the above-mentioned risks during construction and renovation activities. The complexity of the preconstruction risk assessment report is determined by the complexity of the threats posed by the construction project. Assigned VHA staff and Construction Facility Management Resident Engineers (CFM REs) must confirm compliance during the construction phase of the work.

The Construction Safety Committee (Multi-Disciplinary Team), Section m. (5): Participating in all phases of construction work from planning through completion. This includes review and approval of construction plans, contract specifications, and contract submittals related to construction safety and health and any other documents that may assist in the implementation of an effective Construction Safety Program. The Multi-Disciplinary Team must be involved early in the process and continue oversight on a regular basis to avoid costly and disruptive delays.

Education/Training: Engineering Service has already reviewed policy to include in-service training.

Related Forms: see attachments

Key words: safety, health, construction, activities

VA Hospital

Hines, IL 60141

Policy Memorandum 578-12-138A-076 (R-2)

July 16, 2018

SAFETY AND HEALTH DURING CONSTRUCTION ACTIVITIES

1. PURPOSE: To establish policy and procedures to ensure that construction projects will be planned, coordinated and regularly inspected to ensure compliance with applicable fire, infection control, environmental, security, safety, and occupational health regulations and policies.

2. POLICY:

a. To protect patients, staff, visitors, and contractors from safety and health hazards associated with construction activities, this policy is established for the Edward Hines Jr. VA Hospital (Hines VA) and for all property where construction is undertaken. This policy requires that strategies be established to control the hazards inherent in conducting construction or maintenance operations in areas that are occupied by patients, visitors. or healthcare staff. These strategies include the assignment of appropriate responsibility at all levels of the organization, establishing and maintaining the necessary expertise to manage an effective construction health and safety program, applying technical guidance and best practices to assist in managing the program, and providing a

Construction Safety Committee to oversee and enforce the application of this policy.

b. Construction activities shall be defined to include delegated minor or non-recurring maintenance projects performed by contractors, station-level projects performed by contractors, and station Maintenance and Operations (M&O) personnel. Construction shall also include non-delegated projects including majors. Hines VA shall coordinate those construction impacts with the project's

Project Engineer/Contracting Officers Representative (COR) through Hines VA single point of contact. This definition also applies to Enhanced Use and Lease (EUL) projects related to structures for which Hines VA maintains management responsibility or authority.

c. The intention of this Construction Safety Program is to reduce the potential for injury and illness to VA patients, employees, and visitors that might result from unsafe construction activities; to increase the level of construction safety expertise of VA employees; to decrease the potential for serious Occupational Safety and Health Administration (OSHA) violations; to provide a guideline for addressing safety-related construction issues; and to reduce the potential for property and liability exposures due to construction-related activities.

d. Proper application of this program will reduce the potential for liability, which could result from construction accidents, life safety deficiencies, or infection control failures.

3. RESPONSIBILITY:

a. VA Hospital Director:

(1) Establishing and monitoring an effective facility Construction Safety Program.

(2) Establishing a Multi-Disciplinary Team (Construction Safety Committee) with representatives from the following program areas:

• Infection Control

• Patient Safety

• Occupational Safety and Health

• Police

• Engineering (Project Planning Section)

• Engineering (Maintenance and Operations)

• Engineering (Healthcare Technology Management)

• Green Environmental Management System (GEMS)

• Emergency Planning Coordinator

• Local Union Safety Representatives (from affected bargaining units)

• Contracting

• Employee Occupational Health

(3) Ensuring that appropriate staff receives training in construction safety. All members of the

Multi-Disciplinary Team complete 30-hour Construction Safety Training and subsequently completes at least 10 hours of Construction Safety Training at least every 2 years.

(4) Ensuring that the Construction Safety Committee actively engages in:

(a) Protecting patients, visitors, and employees from traumatic injury, toxic environmental exposures, and occupational and facility-associated infections.

b. Associate Director:

(1) Completing responsibilities delegated from the Hospital, as appropriate, for oversight of these policies.

c. Chief, Engineering Service:

(1) Working with contractor and VHA facility staff to coordinate and monitor an effective

Construction Safety Program for projects under their direction.

(2) Completing OSHA's 30-hour Construction Safety Training and subsequently completes at least 10 hours of Construction Safety Training at least every 2 years.

(3) Supporting the periodic inspections of construction sites.

(4) Ensuring contractors comply with VA safety and health policies and procedures and contract requirements.

(5) Serving on the facility Construction Safety Committee/subcommittee to ensure contracts meet the committee's requirements.

(6) Supporting the Construction Safety Officer, Facility Safety Manager, Contracting Officer, and engineering staff in implementing the Construction Safety Program.

d. Chief, Project Planning Section:

(1) Working through safety and health staff, CORs, maintenance staff, contractors, and the

Construction Safety Committee to plan, coordinate and monitor the Construction Safety Program for all projects at the facility.

(2) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

(3) Participating in monthly construction rounds of construction sites to ensure compliance with safety elements of the construction contract and performance of the program.

(4) Serving on the facility Construction Safety Committee to ensure contract requirements meet the committee's approval.

(5) Supporting the Competent Person (CP), Safety Officer, Infection Control Practitioner, Contracting Officer (CO), and engineering staff in implementation of the Construction

Safety Program.

(6) Working with contracting staff to ensure competent staff is assigned as CORs to oversee work.

e. Chief, Maintenance and Operations Section:

(1) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10

(2) Participate in construction rounds of in-house construction sites to ensure compliance with safety elements of the construction contract and performance of the program.

(3) Ensure that in-house work forces have necessary training and competency for tasks being performed.

f. Chief, Healthcare Technology Management:

(1) Ensuring that all construction accomplished in support of major equipment ihstall-ations (as a part of the equipment purchase) comply with the site Construction Safety Program policy and procedures.

g. Contracting Officer (CO) and Contracting Officer's Representative (COR):

(1) Completing at least at least 10 hours of Construction Safety Training and completing

OSHA's 30-Hour Construction Safety training. Subsequently, complete at least 10 hours of construction safety training every 2 years.

(2) Ensuring that all solicitations and contracts include the Federal Acquisition Regulation

(FAR) clause found in FAR 52.236-13.

(3) Designating, in writing, the Construction Safety Officer(s) (CSO) to serve as the Safety

Officer for VHA contracts.

(4) Adding paragraph (f) found in FAR 52.236-13 to the basic clause if the contract will involve work of a long duration or hazardous nature, or performance on a government facility that on the advice of CSO or COR involves hazardous materials or operations that might endanger the safety of the public or government personnel or property.

(5) Ensuring that all solicitations and contracts specify that on-site general and sub-contractor's construction workers have completed at least 10 hours of Construction Safety training or the OSHA 30-hour Construction Safety training, and other relevant competency training, as determined by the CSO with input from the Multi-Disciplinary Team. The determination for other relevant competency training is based on the project hazards and complexity, Federal, and State regulations and VA requirements,

(6) Ensuring that all projects require contractor certification verjfying completion of required training.

(7) Ensuring submittals for contract construction or renovation work to include the names, qualifications, and training dates for the contractor CP designated to administer the site-specific safety program, as well as the CP for other activities as required by OSHA regulation (such as scaffolds, cranes, excavations, etc.).

(8) Serving on the facility Construction Safety Committee or subcommittee to ensure contracts meet the Committee's requirements.

(9) Supporting the CSO, Facility Safety Manager, and appropriate staff in implementing the construction safety program and enforcement of the contracts.

(10) Ensuring that if contracted construction worker(s) have been determined to be at risk for transmission of tuberculosis (TB) based upon the TB section of the Infection Control Risk

Assessment (to be completed by COR and approved by Infection Control prior to Contract

Award), the contractor must provide written certification that all contract employees assigned to the work site have had a pre-placement tuberculin screening within 90 days prior to assignment to the workslte and been found to·be with negative screening reactions.

This can be the CDC two-step skin testing or a Food and Drug Administration (FDA)-approved blood test. Contract employees manifesting positive screening reactions to the tuberculin must be examined per current CDC guidelines prior to working on VHA property.

Subsequently, if the employee is found without evidence of active (infectious) pulmonary

TB, a statement documenting examination by a physician must be on file with the employer

(construction contractor) noting that the employee with a positive tuberculin screening test is without evidence of active (infectious) pulmonary TB. If the employee is found with evidence of active (infectious) pulmonary TB, the employee would require treatment with a subsequent statement as outlined in subparagraph 4q(11)(c) before being allowed to return to work on VHA property.

(11) Evaluating and considering past safety records of prospective contractors in awarding contracts. At a minimum, ensuring that all solicitations and contracts specify that contractors must not have more than three serious, one repeat, or one willful OSHA violation(s) in the past 3 years, or any significant environmental penalties, when contract selection is applicable at the station level.

(12) Ensuring that prior to the commencement of all projects that the contractor receive a copy of the HINES VAH Contractor Safety Disciplinary Procedures (Attachment F).

(13) The COR shall ensure proper notification to the CO ff unsafe action by the contractor occurs by submitting to both the Contractor and the Contracting Officer (Attachment G)

Hines VAH COR Letter of Concern for Safety Non-Compliance, in accordance with

(Attachment F) HINES VAH Contractor Safety Disciplinary Procedures.

h. Construction Safety Officer(s) (CSOs):

(1) Submitting project reviews of all construction projects, to include at a minimum the Infection

Control Risk Assessment, Pre-Construction Risk Assessment (Attachment A), and National

Environmental Protection Act Evaluation (Attachment B).

(2) Providing oversight of contract construction safety.

(3) Being knowledgeable in the general inspection of typical work sites during construction and renovation performed by contract staff and in the review of contractor safety program submittals. Note: CSO(s) do not take the place of the contractor's CP nor act on their behalf. The CSO(s) determines if the contractor is meeting VA standards and contractual requirements for safety and OSHA compliance. When these standards and contract requirements are not being met, the VA Contracting Officer's Representative (COR), CO, and CSO must take immediate action to prevent injury, exposure, noncompliance, and/or property damage.

(4) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10

(5) Ensuring that the specific safety requirements for construction operations are implemented during facility projects.

(6) Serving as a member of the Multi-Disciplinary Team.

(7) Conducting periodic inspections of VHA construction sites to ensure compliance with safety elements of the established program(s); at minimum, weekly inspections are required.

(8) Monitoring and inspecting construction and renovation work sites periodically to ensure compliance with safety elements of established program(s) as noted in Attachment H, titled

OSHA Required Competent Person Inspections.

(9) Maintaining competence in the general inspection of work sites during construction, renovation, and maintenance, falls under the purview of this policy.

(10) Approving corrective actions.

(11) Stopping unsafe work or activities that are non-compliant with the contract or OSHA and notifying the CO immediately.

(12) Maintaining communication with the contractor CP on questions of safety,

(13) As applicable if a Crane lift is required to complete aspects of the project then the Hines

VA Hospital Planned Critical Lift Plan & Crane Permit (Attachment J) is required to be completed and approved by a member of the Safety Section prior to the Crane being allowed on campus. Once the Crane is onsite the HINES VAH Onsite Inspection Checklist for Mobile Cranes (Attachment I) shall be completed by the Construction Safety Officer prior to commencement of work.

i. Safety and Occupational Health Manager or designee:

(1) Completing OSHA's 30-hour Construction Safety Training and subsequently complete at least 10 hours of Construction Safety Training at least every 2 years.

(2) Ensuring that VHA policy for the Construction Safety Program is implemented within the medical center.

(3) Chairing the Construction Safety Committee.

(4) Ensuring that necessary and relevant Interim Life Safety Measures (ILSMs) are established and implemented. Conducts required additional training for compliance with identified

ILSMs.

(5) Rendering technical advice and assistance as required in connection with life safety and fire protection issues during construction, project design, and development.

(6) Overseeing compliance with OSHA and other relevant construction safety regulations,

(7) Confirming that VAMC staff receives training required by this memorandum.

(8) Ensuring that the Construction Safety Program includes appropriate periodic construction site hazard surveillance.

J. Infection Control Manager or designee:

(1) Advising and/or providing recommendations on exposure mftfgatfon and the prevention of facility associated infections in patients, staff, and visitors.

(2) Coordinating with the manager of each construction project (in�house and contract) to conduct an Infection Control Risk Assessment (ICRA) during the planning and/or design stage of the work. ICRAs must be documented in writing and focus on eliminating or minimizing the risk of infection during construction and renovation activities.

(3) Monitoring infection prevention protocols during construction activities as indicated in ICRA for that project.

k. GEMS Coordinator:

(1) Providing guidance on EPA regulations and environmental issues, as those regulations and issues directly and immediately relate to the safety during the design stage.

(2) Monitoring contractor compliance with contract specifications on EPA regulations, Attachment B - NEPA Assessment) as those regulations directly and immediately relate to the construction project, including environmental compliance, pollution prevention

(Attachment 0- GEMS Awareness Competent Person Training), waste management

(Attachment E - Construction Project Waste Minimization Report), and permitting.

(3) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10

I. Emergency Planning Coordinator:

(1) Providing guidance on OSHA regulations as they apply to emergency planning, response and operations in construction (i.e.29 CFR 1926.35 and 29 CFR 1926.65).

(2) Monitoring contractor performance to contracted specifications on OSHA Regulations as they appear to emergency planning, response, and operations related to construction operations.

m. The Construction Safety Committee (Multi-Disciplinary Team):

(1) Determining the scope and depth of safety, infection control, emergency management, and security interventions appropriate for all construction work. The team may develop threshold criteria for each level of intervention. For instance, after review, some projects may require only Construction Safety Officer surveillance to ensure employee safety and

OSHA compliance, while other projects will require all disciplines to be involved.

(2) Verifying that an Infection Control Risk Assessment (ICRA) was completed prior to construction occurring thereby mitigating the risk of transmission of Mycobacterium

Tuberculosis (TB) to contracted construction workers. The completed ICRA though reviewed by the Infection Control Manager per project is based upon rnany variables such as the construction site location, duration of construction activity, patient population, as well as the Hines VAH Annual Tb Risk Assessment, and the Center for Disease Control (CDC) defined risk as outlined in the "CDC Guidelines for Preventing the Transmission of

Mycobacterium Tuberculosis in Health-Care Setting, 2005.11

(3) Ensuring ILSMs are assessed and implemented on all construction work in accordance with TJC Standards. ILSMs are required when Life Safety Code deficiencies or construction activities pose significant hazards as determined by the assessment. Each medical facility must have a local policy addressing ILSM as required by TJC.

(4) Ensuring that the Construction Safety Program includes periodic construction site hazard surveillance activities with appropriate membership, scope, and frequency for each project as determined by the Construction Safety Committee. The frequency and location of the hazard surveillance activities shall be defined and adhered to, which will include an agreed schedule for construction safety rounds and appropriate follow up enforcement of the corresponding corrective actions. Hazard Surveillance activities must be documented

(date1 time, members of the inspection team, deficiencies, types of corrective action, and time and date of correction). Note: Correction of hazards found during hazard surveillance activities must be tracked to completion by the Construction Safety Committee, with action by the appropriate COR/CSO/CP.

(5) Ensuring all contractors entering VHA properties comply with the security management program. As a minimum, contractors must notify and obtain permission from the VA Police, be identified by project and employer, and be restricted from unauthorized access.

(6) Evaluating the effectiveness of the Construction Safety Program in an annual report to the facility Safety Committee and/or Environment of Care Committee or equivalent committee.

(7) Requiring the contractor CP to implement and maintain an effective Safety Program that identifies and controls hazards that may cause injury or illness to VA patients, staff, visitors, and contractor employees.

(8) Requiring the contractor CP to implement and maintain an effective Safety Program that identifies and makes available their sub-contractors CP qualifications/certifications to the

COR for all generally determined high risk construction activities as defined in 29 CFR

1926.

(9) Ensuring that documentation of the team's inspections is provided to the Network Safety and Health Staff as requested.

n. Police and Security:

(1) Ensuring that all contractors entering VAMC property comply with the Security

Management Program. At a minimum, contractors must notify and obtain permission of the

VAMC Police, be identified by project and employer, and be restricted from unauthorized access.

(2) Conducting periodic surveillance of site security and the integrity of barriers for trenches and other hazards.

4. INTERVENTION AND ENFORCEMENT:

a. All the individuals with defined actions in this directive will intervene whenever conditions of construction activities immediately threaten life or health or threaten to damage equipment or buildings. Intervention and enforcement of this policy and the associated regulatory requirements are as follows:

(1) Staff. All staff will identify hazardous conditions in need of intervention and further develop a culture of safety. CPs and all facility management will take prompt corrective measures to include immediate abatement of hazards, stopping of work, hazard awareness training, administrative controls, etc.

(2) Contractors. The Construction Safety Officer or CO shall notify the contractor orally, with written confirmation, and request immediate initiation of corrective action of hazards identified. After receiving the notice, the Contractor shall immediately take corrective action. If the Contractor fails or refuses to promptly take corrective action, the CO may issue an order stopping all or part of the work until satisfactory corrective action has been taken. Upon a repeat offense of the same or substantially similar hazard, the Construction

Safety Officer or CO should inform OSHA or other authorities (i.e., federal, state, or local officials) of the instances where the contractor has been notified to take immediate action to correct serious or imminent dangers. The Construction Safety Officer, with assistance from the Multi-Disciplinary Team, is responsible for making the Contractor and CO formally aware of hazards in need of correction. The CO is responsible for enforcement of the contract.

5. REFERENCES:

VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017 (Data available on internet)

Interim Life Safety Measures, Policy Memorandum 578-02-001-088 (R-3), or more current version (Data available on intranet)

Above Ceiling Entry and Wall Construction Permits 578-12-138A-079 (R-3), or more current version (Data available on intranet)

Smoking Policy 578-03-001-038 (R-3), or more current version (Data available on intranet)

Cutting, Welding, and other Hot work 578-03-001-089 (R-2) dated July 5, 2013 (Data available on

Hazard Communication Program 578-03-001-034 (R-2), or more current version (Data available on intranet)

Confined Space Program 578-12-138S-047 dated May 2, 2012 (Data available on intranet)

Asbestos Management Program 578-03-001-046 (R-1) dated January 30, 2012 (Data available on

ISO 14001/Environmental Management System (Data available on internet)

OSHA 1926, Construction Standards. www.osha.gov (Data available on internet)

CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Setting, 2005 (Data available on internet)

29 CFR 1926 (Data available on internet)

6. RESCISSION: Policy 578-12-138A-076 (R1) Safety and Health During Construction Activities

7. RECERTIFICATION: This policy will be recertified three years from effective date.

8. FOLLOW-UP RESPONSIBILITY: Engineering Service (138), Chief, Project Planning.

9. ATTACHMENTS:

A Pre-construction/Safety Risk Assessment

B National Environmental Protection Act Assessment

C Construction Safety Checklist

D GEMS Awareness Competent Person Training E Construction Project Waste Minimization Report

F Hines VAH Contractor Safety Disciplinary Procedure

G Hines VAH COR Letter of Concern for Safety Non-Compliance

OSHA Required Competent Person Inspections

Crane Operation and Minimum Criteria On-Site Inspection Checklist

Hines VA Hospital Planned Critical Lift Plan & Crane Permit

Steven E. Braverman, M.D Hospital Director

Distribution: Hines Internet Website and Service Chiefs / Service Line Managers via Email http://www.osha.gov/

VHA Pre-Construction Risk Assessment (PCRA)

VHA PCRA-1.1 (May 21, 2024) Page 1 of 5

PCRA Introductory Information and Instructions

Use this template as a baseline for performing facility Pre-Construction Risk Assessments (PCRA) for Construction, Renovation, and Maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity type(s) and safety risk to determine the level of precautions needed to prevent impact related to Construction, Renovation and Maintenance on patients, employees, and contractors.

Ensure that the activity statement of work and any drawings available are used for the PCRA assessment and included in the project file with the completed PCRA.

Communication and coordination of all types of activity with affected areas are to be included among the control measures. The development of communication and coordination plans must begin during the activity planning phase.

Facilities may customize this template to incorporate site-specific information and requirements.

NOTE: This VHA PCRA template pertains specifically to non-infection-related safety for Construction, Renovation, and Maintenance activities. It must be used in conjunction with the VHA Infection Control Risk Assessment (ICRA) for the activity, if required, which specifically addresses infection risks outside the scope of this PCRA.

PERMIT: See the last page of this document for a fillable permit form to be used for posting at the activity site.

Activity Location:

Activity Name, Number, and/or Brief Description:

Table 1 - Construction, Renovation, and/or Maintenance Activity Type and Control Measures

NOTE: If any of the bulleted criteria in a higher activity type pertains to the work that will be done (even if the other criteria are in a lower type), use the higher activity type for the VHA PCRA.

Controls defined in Table 1 for the activity must be in place before the activity begins and maintained until work is completed and the area is activated. Control measures for each activity must also include the control measures in the preceding row(s).

As the activity progresses, a full re-evaluation of remaining activity type and risk is required prior to changing the level of control measures.

Activity Type determined from Table 1:

Activity Type and Description Control Measures

Inspection/upkeep generally defined as follows:

• Work can be completed in a single shift, not to exceed 10 hours.

• Patients, employees and/or visitors may be in the area depending on the activity.

• Work that does not create dust or debris.

• Work that does not create vapors or fumes.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection that will not impair fire safety systems and are limited to 1 tile per 50 square feet with limited

1. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

2. Site visits of construction area are required weekly by member of multi-disciplinary team.

Site visits will be documented on standard checklist.

3. Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor and approved where a contact is in place. For internal work the

VHA PCRA-1.1 (May 21, 2024) Page 2 of 5 exposure time (not to exceed an hour for each tile) within the shift.

• Minor interior updates (e.g., replacing floor or ceiling tiles, carpentry work to include hanging signage, and painting with hand tools) that do not create vibration or noise.

• Limited building system maintenance that does not require Lock Out Tag Out (LOTO) such as plumbing on potable systems limited to faucet replacement, steam trap replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

shop involved must work with Safety to ensure proper precautions are in place.

4. Must address identified hazards and controls that will be implemented to ensure minimal impact to patients, employees, contractors and facility.

5. Communication and coordination plan for all affected areas

Small scale Construction, Renovation and general maintenance/repair work, generally defined as follows:

• Prolonged work that may take longer than a single shift but not exceeding six months.

• Patients and employees are not to be in the area until activity is completed.

• Work that creates some noise and vibration due to power tool use.

• Selective demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements that may o disturb asbestos, lead or silica o create the potential for falling objects o create vibration and/or noise in excess of 80 dB(A) in surrounding areas.

o cause penetrations in fire or smoke barrier

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing that requires utility outages or work on the steam system that may require:

o LOTO o The use of compressed gas cylinders

• Electrical work such as installation of conduit and wire for lighting, receptacles and switches for an area, the installation of conduit and wire for new devices such as terminal units, fans etc. Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that require LOTO.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit, a single device and the installation of ductwork, diffusers, and terminal units for an area that may require:

o Work on ladders o Rigging, hoisting or lifting of equipment or materials overhead

• Modification of existing fire alarm and suppression systems requiring system outages and ILSMs or obstruction of exits and or impact on corridors.

• Architectural, structural, or any other work that may cause vapors or fumes such as:

o Roofing work o Flooring work o Painting or other large-scale use of such substances.

All control measures in the row above and the following:

1. Hazard communication chemical inventory required to be provided by the contractor and approved.

2. Where construction, Renovation and maintenance are done in an accredited facility, and ILSM assessment is required to be done and ILSMs put into place in accordance with TJC LS.01.02.01 and the local facility policy including Fire watch if necessary. Staff is trained and the ILSM is verified regularly

3. Hot Work or burn permits in place and staff trained

4. LOTO procedures in place and staff trained on their use

5. Site visits will be reviewed using the criteria in standardized guide.

6. Daily inspections of the site are to be conducted by the General Contractor or shop supervisor and documented on their daily log.

Large-scale construction, renovation, or maintenance generally defined as follows:

• Work exceeding 6 months in duration.

• Patients and employees are not to be in the area until activity is completed.

All control measures in the two rows above and the following Activity Hazard Analyses and Control Plans (check all that apply):

1. Excavation safety plan in place ☐

2. Dust control plan in place ☐

VHA PCRA-1.1 (May 21, 2024) Page 3 of 5

• Excavation or heavy equipment use taking place o Dig safe required utility location o Trench safety o Dust control plan o Equipment exhaust, Noise, Vibration

• Confined space entry required (permit required or not)

• Requires crane work o General crane work o Lift over buildings

• Includes elevated work o Roof work, fall protection o Window work, scaffolding and fall protection o Odor control

• Welding, cutting or use of torches requiring burn permits

• Demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and HVAC that may o require asbestos, lead or silica abatement o create the potential for falling objects o create vibration and/or noise in excess of 90 dB(A) in surrounding areas.

o cause breaches to fire or smoke barrier

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work that requires transport of significant materials through building and up elevators i.e., weight limits of floors and elevators

• Plumbing work requiring LOTO and system shutdown and startup such as the installation of:

o new medical gas systems, o steam/heating hot water, condensate systems, o Potable water and sanitary drainage, multiple sinks, showers and toilets including associated plumbing.

• Electrical work such as installation of electrical feeders, distribution panels, conduit and wire for lighting, receptacles and switches for an area, the installation of conduit and wire for new devices such as terminal units, fans etc. requiring LOTO and system isolation.

• Installation of fire alarm and suppression systems requiring outages of those systems and ILSMs or closure of exits/corridors

• Mechanical work such as the installation of air handling equipment, associated ductwork, diffusers, heat exchangers, terminal units and controls requiring lifting and support of equipment and systems.

3. Pollution prevention plan in place ☐

4. Dig safe paperwork in place ☐

5. Crane lift plan in place ☐

a. Crane placement

b. Crane swing

c. Crane load evaluation

6. Fall protection plan in place and staff trained ☐

7. Confined entry plan in place and staff trained ☐

Table 2. Affected Adjacent Area Assessment

In addition to the minimum precautions noted above for the Activity Type, it is critical that the activity be coordinated with the areas adjacent to the activity to ensure operations in those areas are not disrupted or impacted. List the adjacent areas in Table 2 below and develop activity-specific coordination plans and associated communication plans with each area to address activity work that could impact or disrupt the operation of the areas, in general as follows:

• If adjacent area is vacant (e.g., work outside, construction of new building, etc.):

o Coordination is typically not necessary other than potentially traffic flow and pedestrian access.

VHA PCRA-1.1 (May 21, 2024) Page 4 of 5

• If adjacent area is non-continuously occupied (e.g., areas where outpatient care is provided, employee health, etc.):

o Develop a list of activities that will potentially impact or disrupt the operation of the area (e.g., work involving noise, vibration or exit obstruction) and meet with POC to coordinate execution of work in a way that mitigates the impact (e.g., conduct work after hours).

• If adjacent area is occupied continuously (e.g., areas where inpatient care is provided, residential areas such as Community Living Centers, etc.):

o Develop a list of activities that will potentially impact or disrupt the operation of the area (e.g., work involving noise, vibration or exit obstruction) and meet with POC to coordinate execution of work in a way that mitigates the impact (e.g., move affected party temporarily).

Area Service(s)/Type(s) of Area(s)

(e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc)*

Point of Contact

(POC)

POC Contact Information

Construction plan communicated to POC?

Activity Area**

Area Above

Area Below

Adjacent Area 1

Adjacent Area 2

Adjacent Area 3

Adjacent Area 4

* There may be more than one Service/type of area for each row. List all. The information entered on this table must be used in the ICRA if required.

** List the area(s) in which the construction/renovation/maintenance activity will occur.

Infection Control Risk Assessment (ICRA)

Consult with Infection Prevention and Control regarding the assessment of potential patient infection risks associated with the activity and the need for control measures. For example, activities such as a boiler plant project and/or facility steam shutdown, if properly planned, should have minimal to no patient infection risk impacts and likely do not require an ICRA. See VHA Directive 7715 and the VHA ICRA Template for more information.

Is an ICRA required for the Activity? Yes ☐ No ☐

VHA PCRA-1.1 (May 21, 2024)

Pre-Construction Risk Assessment (PCRA) Permit

This page must be posted at the entrance to the project area, or other designated area

Unique permit number:

Location and brief description of construction/renovation/maintenance

Project manager Project start date

Contact phone number Completion date

Contractor or lead shop Permit expiration date

Activity Type Inspection/Upkeep, Small-scale, or Large-scale)

Activity Type Control measures to be in place for the duration of the activity (Check the box for the Activity Type to indicate the Control Measures)

Inspection/Upkeep

1. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

2. Site visits of construction area are required weekly by member of multi-disciplinary team. Site visits will be documented on standard checklist.

3. Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor and approved.

4. Must address identified hazards and controls that will be implemented to ensure minimal impact patients, employees, contractors and facility.

5. Communication and coordination plan for all affected areas

Small-scale

All control measures in the row above and the following:

1. Hazard communication chemical inventory required to be provided by the contractor and approved.

2. ILSMs in place and staff trained on situation

3. Hot Work or burn permits in place and staff trained

4. LOTO procedures in place and staff trained on their use

5. Site visits will be reviewed using the criteria in standardized guide.

6. Daily inspections of the site are to be conducted by the General Contractor and documented on their daily log.

Large-scale

All control measures in both rows above and the following Activity Hazard Analyses and Control Plans as applicable (check all that apply):

1. Excavation safety plan in place ☐

2. Dust control plan in place ☐

3. Pollution prevention plan in place ☐

4. Dig safe paperwork in place ☐

5. Crane lift plan in place ☐

a. Crane placement

b. Crane swing

c. Crane load evaluation

6. Fall protection plan in place and staff trained ☐

7. Confined entry plan in place and staff trained ☐

*The location of all Activity Hazard Analyses and Control Plans (excavation, dust, pollution, etc.) as applicable shall be identified on this permit and shall be made available to all workers on the job.

Additional requirements:

Is an Infection Control Risk Assessment (ICRA) required for the Activity? Yes ☐ No ☐

Infection Prevention and Control signature:

Date:

Project Manager signature Date

Safety Officer signature Date

Chair, Construction Safety Committee signature

Date

Pol.icy Memorandwn 578-12-138A-076 (R-2)

Hazardous

NEPA Assessment Attachment B

Project: Location: Date:

Project#:

Type of Project:

r Operation and Maintenance Activities r Repairs/Renovation Project r New Construction Project r Lease r Other

Project Scope:

Level of NEPA Analysis:

r Categorical Exclusion (CATEX) r Environmental Assessment Needed (EA) r Environmental Impact Statement Needed

Other Environmental Permits/Analysis Needed:

EIS

DETERMINATION

r I find the proposed project qualifies as a CATEGORICAL EXCLUSION with no extraordinary

X .x Prolect Enal,...11::!oer

VA Categorical Exclusion List

Found in 38 CFR Part 26.6(b)(1)

1. Repair, replacement, and new installation of primary or secondary electrical distribution systems;

2. Repair, replacement, and new installation of components such as windows, doors, roofs;

and site elements such as sidewalks, patios, fences, retaining walls, curbs, water distribution lines, and sewer lines which involve work totally within VA property boundaries.�

3. Routine VA grounds and facility maintenance activities;

4. Procurement activities for goods and services for routing facility operations maintenance and support;

5. Interior construction or renovation;

6. New construction of 75,000 gross square feet or less;

7. Development of 20 acres of land or less within an existing cemetery, or development on acquired land of five acres or less;

8. Actions which involve support or ancillary appurtenances for normal operation;

9. Leases, lfcenses, permits, and easements;

10. Reduction in force resulting from workload adjustments, reduced personnel or funding levels, skill imbalances or other similar causes;

11. VA policies, actions and studies which do not significantly affect the quality of the human environment;

12. Preparation of regulations, directives, manuals or other guidance that implement, but do not substantially change, the regulations, directives, manuals, or other guidance of higher organizational levels or another Federal agency; and

13. Actions, activities, or programs that do not require expenditure of Federal funds.

Extraordinary Circumstances List

Found in 38 CFR Part 26.6(b)(1)

1. Greater scope or size than normally experienced for a particular categorical exclusion

2. Actions in highly populated or congested areas

3. Potential for degradation, although slight. or existing poor environmental conditions

4. Use of unproven technology

5. Potential presence of an endangered species, archeological remains, or other protected resources

6. Potential presence of hazardous or toxic substances

Attachment C

VHA Construction Site Safety Review Checklist

Project: Date: Time:

Contractor:----------- COR

Inspection Team-'--: _

Safety & Health General OK NC NIA Concrete Operations OK NC N/A

1. Safety Program / Injury Illness Protection Plan

50. Cement/Silica dust exposures

2. Orientation/Code of Safe

Practices/Badges

51. Cutting

Sawing/Grinding Controls

3. Toolbox Meetings/Pre-Job Safety

52. PPE utilized by Crew

4. Postings (OSHA) (Project lnfo/POC)

53. Wall or Structure

Supported

5. Emergency Numbers/First Aid 54. Pumps/equipment set-up/ cond.

6. Toilets/ Hand Wash/Drinking

Water

Ladders

Environment 55. Ladder Conditions

7. Ventilation, incl neg. air/ HEPA / Manometer

56. 3' Above Landing

8. Illumination 57. Braced & Tied

9. Integrity of Dust Control and containment

58. A-Frame Step Ladder

Set Up

10. Openings Guarded/Covered-

Marked

59. Correct Height

11. Stairs/Walkways Guarded & Accessible

60. Proper Use

12, Rebars Capped Scaffolds/Shoring

(Interior/Exterior)

13. Equipment/Material Storage 61. Current certified installation doc

14. Traffic/Public Safety 62. Planks/toe boards

15. 1 or 2 hr. fire separation based upon ILSM

63. Railed Properly

16. Construction Warning Signs Posted

64. Tied to Structure

17. Housekeeping 65. Ladder Access

18. Emergency Exits - Clear I Unlocked

66. Daily Inspections

19. ILSM in place- Exits

Blocked/Locked

67. Users trained/Competent person

Electrical Safety 68. Fallinq Object

Protection

20. Cords, Plugs Conditions, Sun::ie Protectors

Excavations/Trench

21. GFI Boxes & Grounding 69.Daily Inspections/Competent Person

22. Overhead Lines protected/marked/spotter

70.Shored/sloped > 5' or soil cond.

23. Lock out Tag Out 71. Spoil Piles at least 2' from edqe

24. Power/Generator/breaker panels secured

72. Underground Line located/potholed

Personal Protection (PPE) 73. Barricades/protective measures

25. Hard Hats 74. Ladder every 25' & after 4'deep

26. Eye & Face Protection Vehicle/Equipment

Operations

27. Ear Protection 75. Seat Belts by Operators

28. Gloves/Clothing 76. Back Up Alarms - all

Equipment

29. Footwear 77. Reflective qarments/PPE

30. Respiratory (DusUCanister

Masks)

78. Personal cars in designated areas

Site Security 79. Forklift operators trained

31. Fencinq 80. Flagmen/Traffic Control

32. Security Scissors/Zoom Booms/Lift

Trucks

33. Entrance/Exit 81. Controls Operative

Hand/ Power/Powder Actuated

Tools

82. Safety Chains in Place

34. Guards attached/functional 83. Harness & Lanyards

(JLG's)

35. Grounded Properly 84. Operator Certification

36. Working Properly 85. Visual Inspection

37. Trained or Certified

Operators/PPE

86. Fluid Levels (Oil, Water)

Fire Protection 87. Brakes/Lights/Back up

Alarm(s)

38. Fire Extinguishers checked/accessible

88. Gauges - Operative

39, Alarm/Detection System in Place

89. Scheduled Maintenance

40. Smoking (No Smoking) Welding & Cutting

41. Hot Work Permits 90. Approved Hot Work

Policy Memorandwn 578-12-l 38A-076 (R-2) approved/current Permit

42. Flammable/Combustible Material

91. Cylinders - Use & Seqreqation

Fall Protection 92. Torches, Horses, Gauqes, PPE, etc.

43. Use of Fall Protection above 6'

93. Weld Cables, Holders & Grounds

44. Floor openings/holes securely covered

94. Fire Protection (Task Work)

45. Perimeter/Interior Shaft Guardrails

Personnel Hoists & Cranes

46. Falling material/objects 95. Inspections &

Maintenance

47. Trained on Use - Competent Person

96. Crane Set Up & Swing Protection

48. Handrails for stairs 4 or more steps

97. Rigging & Loads Secured

49. Fall Protection Equipment in place/Inspected.

98. Certified Operator

Legend: OK= Condition of non-compliance was not identified; NC= Needs Correction;

NIA = Not Applicable

Policy Memorandum 578-I2-138A-076 (R-2)

Section I - Non-Compliance Issues Associated with Project

Section &

Line

Number

Deficiency

Observed &

Where

Corrective Actions

Needed

Due

How Corrective Actions Were Completed

Corrected

Tracking for CSC: Identify non-compliance item noted, where & what was observed, corrective actions needed, Date Corrective

Action due, and when and how non-compliance was addressed completed.

Content of the above checklist is advisory and should be modified to satisfy the circumstances of the specific contract or work activity.

Any modification of the checklist requires the consent of the safety and engineering staff.

All Contractor personnel and Subcontractor employees are responsible to conduct work activities in a safe and healthful manner for their health and well-being as well VHA personnel. The purpose of this Site Safety Review is to increase the Contractor/Subcontractors awareness of the need for safe work habits and a positive attitude toward loss prevention and control. Below columns marked with "NC" answers require the Contractor/Subcontractors implementation of corrective action plans. Additional comments/actions will be described on additional pages to supplement this report.

Policy Memorandtun 578-12-138A-076 (R-2)

Attachment D

GEMS Awareness Training for…