Attachment 10 Safety and SOP.pdf

WORK STOPPAGE IN IMMINENT DANGER SITUATIONS

SOP 516-138S-22-005

Bay Pines VA Healthcare System Bay Pines, FL. 33744

Signatory Authority:

Associate Director

Responsible Owner:

Chief, Facilities Management Service

Service Line(s):

Facilities Management Service

Effective Date:

September 1, 2022

Recertification Date:

August 30, 2027

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on work stoppage of "Imminent Danger" as " any conditions where there is reasonable certainty that a danger exists that can be expected to cause death or serious physical harm immediately. This SOP must be followed by all employees and contractors performing duties at BPVAHCS.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with

(1) VHA Handbook 7701.01 Occupational Safety and Health (OSHA) Program Procedures, February 2009

(2) OSHA Standard, 29 CFR 1910, General Industry;

(3) OSHA Standard, 29 CFR 1926, Construction Standards;

(4) 29 U.S. Code 662 SEC 13(A), Imminent Dangers;

(5) Public Law 91-596, Workplace Safety and Health;

(6) Occupational Safety and Health Act of 1970 (OSHA), Section 19, Federal Agency Safety Programs and Responsibilities;

(7) Title 29, Code of Federal Regulations (CFR), Part 1960, Basic Program Elements for Federal Employee OSH Programs and Related Matters

(8) The Joint Commission, EC 01.01.01.

2. PROCEDURES

a. Confirmation of work stoppage.

(1) It shall not be necessary to test or confirm a suspected imminent danger condition before ordering a work stoppage. The testing and confirmation of the

September 1, 2022 SOP 516-138S-22-005 hazard will be completed after the work has been stopped and the workers are no longer exposed to the potential hazard.

(2) When the person who ordered the work stoppage has tested and confirmed that the imminent danger condition has been corrected, he/she shall immediately notify the person or persons with authority to order the resumption of work.

b. Examples of "Imminent Danger" include, but are not limited to; the following conditions/situations.

(1) Workers entering or being in un-sloped/un-shored or inadequately sloped/shored trenches or excavations which may cave in.

(2) High work without fall protection or with inadequate fall protection in place.

(3) Exposure to an electrocution hazard or any other type of stored energy.

(4) Actual or suspected exposure to extremely toxic gases, vapors, fumes, or mists (such as ethylene oxide gas, cyanide gas, etc.), or hazardous solids or liquids (asbestos, strong acids, etc.).

(5) Suspected or confirmed exposure to Heat or Cold Stress.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Director, BPVAHCS. Provides the Safety and Occupational Health Chief the authority to intervene whenever conditions pose an immediate threat to life or health or threatens damage to equipment or buildings.

b. Healthcare System Safety Chief. The healthcare system’s Safety Chief, acting as the Designated Safety and Health Official (DSHO), is responsible for the overall development, implementation, and direction of the Occupational Safety; Fire Protection;

Green Environmental Management Systems; and Industrial Hygiene programs. It is his/her duty to keep the healthcare system Director informed of all Occupational Safety, and Fire Protection health hazards or violations. As Vice-Chairperson of the BPVAHCS Environment of Care Council, the Safety Chief is empowered to correct any unsafe or hazardous conditions immediately. In the event of imminent danger situations, the Safety Chief review and, in cases of conflict, make the final decision on work stoppage and actions to be taken.

c. Service Chiefs and Supervisors. The primary responsibilities of management are the safety and security of individuals, prevention of fires, providing an occupationally safe and healthful workplace, and the protection of property. Supervisory officials at all levels are responsible to:

(1) Determine the presence of physical and environmental hazards and unsafe/unhealthy practices in their work areas through continuous inspections while correcting any under their area of purview.

(2) Report all unsafe/unhealthful conditions and initiate steps to secure correction after making certain that temporary safeguards are set up. Serious incidents or conditions that present immediate jeopardy to the safety or health of occupants are to be reported immediately to the Safety Office at extension 10094.

(3) Train employees in safe work practices and to identify and eliminate hazardous conditions and practices. Special attention should be paid to specialized safety and health training appropriate to the work performed by the employee.

(4) Investigate accidents, prepare required reports, analyze conditions, and institute or recommend measures to preclude repetition of hazardous conditions, or accidents within their area of responsibility.

(5) Ensure safe duty assignments of employees.

(6) Conduct safety meetings with employees on the job emphasizing employee participation.

(7) Ensure that first aid or emergency care treatment is provided to employees for the on-the-job injuries or illnesses, while reporting immediately any serious/lost time cases to the Occupational Safety and Health Chief, extension 10094. Accident reports using the Employee’s Compensation Operations & Management Portal (ECOMP) are required within 24 hours for any employee who is sent to see the Employee Health Physician or Emergency Department for an occupational injury/illness.

d. Employees. Employees will comply with the following:

(1) Follow all safety instructions in the performance of their job and in their movements about the BPVAHCS and all jurisdictional areas under the BPVAHCS while being responsible for their own safety.

(2) Inform any co-workers who they may be instructing of safe practices to be followed.

(3) Inform their supervisors of any condition or practice which they consider may be unsafe, unhealthy, or a fire hazard.

(4) Request instructions from their supervisor before operating any machine or performing any task to which they have been assigned and with which they are not familiar.

(5) Become familiar with safety and fire drill procedures, Hospital Emergency Operations Plan, and job-related safe work practices, etc.

(6) Review and give support to the BPVAHCS Safety, Fire Protection and Occupational Health Program and ensure that the working environment of the BPVAHCS is as safe as possible.

e. Contractors. All contractors performing work at BPVAHCS will be required to abide by all published rules and regulations in this manual in addition to the VA Manual 7700; OSHA Standards 29 CFR 1910 "General Industry" and 29 CFR 1926 "Construction Standards." Logistics Service and Engineering Service, or other service requesters must review with contractors, the applicable safety regulations that apply to them. The Safety Section and Project Manager/Contracting Officer Representative (COR) will observe and ensure contractor compliance with safety regulations. As stated in the "Statement of Authority," BPVAHCS Safety Chief has the authority to take such actions as are deemed necessary when a hazardous condition/practice exists that could result in personal injury to individual(s) or damage to equipment or buildings.

4. DEFINITIONS

a. Shored. Support or hold up something with props or beams.

b. Sloped. Placed or arranged in a sloping position; inclined.

c. Un-shored. Without shoring.

d. Un-sloped. In a vertical position; not sloping.

5. REFERENCES

a. OSHA Standard, 29 CFR 1910, Occupational Safety & Health Standards.

b. OSHA Standard, 29 CFR 1926, Safety and Health Regulations for Construction.

c. OSHA Standard, 29 U.S. Code 662 SEC 13 (a), Procedures to Counteract Imminent Dangers.

d. OSHA Publication 2014, Recordkeeping and Reporting Guidelines for Federal Agencies.

e. Occupational Safety and Health Act of 1970 (OSHA), Section 19, Federal Agency Safety Programs and Responsibilities.

f. The Joint Commission, EC 01.01.01, inclusive.

g. Public Law 91-596, Workplace Safety and Health.

h. Title 29, Code of Federal Regulations (CFR), Part 1960, Basic Program Elements for Federal Employee OSH Programs and Related Matters.

6. REVIEW

Review will be completed at recertification.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of March 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

SEAN N. TURNER

Associate Director Date Approved:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: The SOP are available at https://dvagov.sharepoint.com/sites/vhabaydocware/sops/SOP/Forms/AllItems.aspx

CONTROL OF HAZARDOUS ENERGY PROGRAM

Lock-Out/Tag-Out Program

SOP 516-138S-22-008

Bay Pines VA Healthcare System Bay Pines, FL. 33744

Signatory Authority:

Associate Director

Responsible Owner:

Chief, Facilities Management Service

Service Line(s):

Facilities Management Service

Effective Date:

May 1, 2022

Recertification Date:

April 30, 2027

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures for maintaining a hazardous energy program, affixing appropriate Lock-out/Tag-out (LOTO) devices to energy isolating devices, and to otherwise restrict machines or equipment from energy sources to prevent injuries. This SOP must be followed by all employees who perform or supervise the lock-out of equipment.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with the Essentials of “Lock-Out/Tag-Out” #16429, Revision 1-2/21/2013, Basics of Lock-Out/Tag- Out, OSHA Standard 29 CFR 1910.147, 29 CFR 1926.20 and CEOSH, General Safety Guidebook, March 2012.

2. PROCEDURES

a. Training.

(1) Will be provided by distance learning on the VA Talent Management System.

“Essentials of Lock-Out/Tag-Out” #16429, Revision 1-2/21/2013, Basics of Lock- Out/Tag-Out from the VHA 30-hour construction safety course, four (4) hours.

(2) Will be conducted on an annual basis for all authorized employees.

(3) Will be conducted when a new employee enters the workforce. The respective supervisor is responsible to ensure that the LOTO training is conducted prior to any LOTO work being performed.

(4) Equipment-specific training will be conducted anytime new equipment or processes require the previous process to change.

(5) Training will be documented by Facility Management Service Shop supervisors and maintained for three years.

b. General Procedures.

May 1, 2022 SOP 516-138S-22-008

(1) Equipment must be locked, tagged and de-energized before performing servicing and/or maintenance.

(2) Only Authorized Employees will be permitted to LOTO equipment for servicing and repair. Those not trained as Authorized Employees will not perform servicing and/or maintenance on machines and equipment.

(3) When LOTO is required, Authorized Employees shall follow machine-specific procedures for multi-source pieces of equipment.

(4) If a machine or piece of equipment is incapable of being locked out, a lock must be incorporated into the LOTO process.

(5) An approved tag must be attached to each lock so that the owner of the lock can be immediately identified.

(6) All employees and personnel, upon observing a machine or piece of equipment that is locked out or tagged out to perform servicing or maintenance, shall not attempt to start, energize, or use that machine or equipment in any way.

(7) If tags must be used alone, they will be attached to the energy isolating devices with non-reusable, self-locking tie straps that must be cut for removal. These devices shall have a minimum unlocking strength of no less than 50 pounds (such as an all environment-tolerant nylon cable tie).

(8) The tags will be filled out in a legible manner to warn employees not to use the machine or equipment.

(9) For tag-out only operations, additional means will be taken to ensure a level of protection equivalent to the use of a lockout device. These include, but are not limited to, removal of an isolating circuit device (such as a fuse), blocking of a controlling switch or panel, opening of an extra disconnecting device, or the removal of a valve handle to reduce the likelihood of inadvertent reapplication of energy. Pulling a fuse shall NEVER be the sole substitute for LOTO.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Service Chiefs and Supervisors.

(1) Ensure the LOTO is utilized as it pertains to their service, as well as tracking service personnel to assure the effectiveness of the program.

(2) Ensure their employees follow the procedures within this policy, conduct the required level and frequency of LOTO training.

(3) Ensure all required documentation is maintained and available within four hours if requested by the Occupational Safety and Health Administration (OSHA).

(4) Ensure that inspections and observations of the energy control procedures used by their employees are conducted on at least 25% of authorized employees every year.

(Appendix C.)

(5) Maintain a current list of employees by name authorized to conduct LOTO procedures and documentation of their annual training.

(6) Maintain a copy of the Hazardous Energy Control Procedure Form (Appendix B) for any procedure that requires LOTO for at least three years after the LOTO work is performed.

(7) Ensure that authorized employees have a written copy of equipment specific LOTO procedure available while working on equipment that requires LOTO.

(8) Ensure that authorized employees know how to locate equipment specific LOTO procedures on the Safety and Emergency Management Home Page.

http://vaww.visn8.portal.va.gov/baypines/assisdir/sem/default.aspx

(9) Ensure corrective action is taken when employees fail to use the appropriate LOTO procedures.

b. Safety and Occupational Health Manager is responsible for the overall maintenance of the program and reviewing services for compliance on an annual basis as required by OSHA. Review of documentation and procedures will occur annually.

c. Employees

(1) Authorized Employees – Perform or supervise the lock-out of the equipment and may only lock-out authorized equipment. VAHCS policy limits authorized employees to the following Engineering Service Employees: Electricians, Plumbers, Maintenance Mechanics, Air Conditioning Operators, Bio-Medical Technicians, Carpenters, Groundskeepers, Project Coordinators/Engineers, CORs and Contracting Officers.

These employees are responsible for:

(a) Following the applicable procedures within this policy and maintaining the required level and frequency of LOTO training.

(b) Ensuring that a written copy of equipment specific LOTO procedure is available while working on equipment that requires LOTO.

(c) Ensuring that any LOTO procedure they perform is documented.

(d) Ensuring that all LOTO procedures are conducted according to OSHA and the Center for Engineering & Occupational Safety and Health (CEOSH) guidelines.

(2) Affected Employees – Operate equipment or work in an area where a lock-out is taking place. While they do not perform the lock-out, they must be notified of the lock-out to safely perform their work.

(3) Other Employees – Are not directly affected by the lock-out but need to recognize when a lock-out is in place. In some cases, the affected employee and the authorized employee may be the same person. An authorized employee, as listed by job title and name, is the only person permitted to perform energy shut-downs and lock-out procedures.

d. Project Coordinators/Engineers, Contracting Officer Representatives (CORs), and Contracting Officers. Ensure that contractors and subcontractors have an effective LOTO program which meets the requirements of OSHA and CEOSH.

Contractors, through project coordinators, will coordinate LOTO procedures with the unit foreman prior to LOTO of all equipment.

4. DEFINITIONS

None.

5. REFERENCES

a. OSHA Standard 29 CFR 1910.147.

b. 29 CFR 1926.20.

c. CEOSH, General Safety Guidebook, March 2012.

d. Essentials of “Lock-Out/Tag-Out” #16429, Revision 1-2/21/2013, Basics of Lock- Out/Tag- Out from the VHA 30-hour construction safety course, four (4) hours. VA Talent Management System.

e. http://vaww.visn8.portal.va.gov/baypines/assisdir/sem/default.aspx.

6. REVIEW

Review will be completed at recertification.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of April 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

Sean N. Turner

Date Approved:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

https://dvagov.sharepoint.com/sites/vhabaydocware

APPENDICES

APPENDIX A

A-1

Date:___________________ Procedure #____________________________

Equipment Name:

Location:

Authorized Employees:

Affected Employees:

Activity That Requires a LO/TO:

The employee(s) performing the work shall use the following procedures when locking or tagging out equipment for maintenance and repair:

The Authorized Employee shall identify all sources of hazardous energies and the method or means to control the hazardous energies.

The Authorized Employee must notify affected employees in the work area that the power will be shut down, the reason for the shutdown, and that the equipment will be locked/tagged out.

Shut down the equipment by the normal stopping procedure. It is strongly encouraged that a “DO NOT OPERATE” tag shall be affixed to the operating controls.

De-energize, secure, and isolate the hazardous energy sources from the equipment, Place locks or tags at the appropriate energy isolating location. When locks are used, they must be affixed in a manner that will hold the energy isolating device in a safe or off position. If tags are used, they must be affixed as closely as possible to the isolation devices so that they are immediately obvious to anyone attempting to restart the equipment.

Safely release all potentially hazardous stored or residual electrical, hydraulic, pneumatic, chemical, spring, gravitational, and/or thermal energy.

Before performing the maintenance on the equipment, verify that the system is isolated. Accomplish this by first establishing that no personnel are exposed and then turning the operating controls to the ON position using the normal operating controls. Return the controls to the OFF position before continuing.

Perform the necessary work.

When work is complete, notify Affected Employee that the work is complete and that the power will be turned on.

Inspect to ensure that the equipment has been properly assembled, that tools have been removed, and that personnel have moved to safe positions. Close any panels or cabinets.

The Authorized Employee(s) shall remove their respective locks/tags and notify Affected Employees that they have been removed.

Energize and test the equipment to verify proper operation.

**Note: Proper Personal Protective Equipment (PPE) must be worn at all times

Energy Source

Magnitude Location of Disconnect

Procedure of LO/TO

Energy Release Method

APPENDIX B

B-1

Periodic Lock-Out/Tag-Out Inspection Record*

Date of Inspection: __________ Equipment: ___________________________

Inspectors (including at least one authorized employee):

Authorized employee(s) performing servicing, repair, or maintenance:

If necessary, specific procedure used by the authorized employee(s):

Yes No

1. Were the affected employees notified before the project started? ______ _____

2. Are the appropriate locks, tags, and attachment devices available? ______ _____

3. Are machine-specific procedures available at the work site? ______ _____

4. Are all sources of energy de-energized, locked, and tagged out? ______ _____

5. Have all exposed employees used locks/tags on all disconnects? ______ _____

6. Was the on/off switch returned to the off position following try-out? ______ _____

7. Has the inspector reviewed and corrected any deficiencies? ______ _____

Comments: ___________________________________________________________

We certify that any problems discovered during this inspection were reviewed with the authorized employees on this job during the inspection process:

Authorized Employee

Inspector

* At least twenty five percent (25%) of all authorized employees must be evaluated using this form for each calendar year. This form must be maintained for three (3) years.

APPENDIX C

C-1

LOCK-OUT/TAG-OUT PROGRAM

INSPECTION FORM

1. Inspection Date: ___________________.

2. Employee Conducting the Lockout/Tagout Procedure: ______________________________.

3. Identity of the Machine or Equipment: ___________________________________________.

4. Circle Type of Procedure: LOCK-OUT / TAG-OUT

5. Were all procedures followed in accordance with the Fire Prevention and Fire Protection Program? _____ Yes _____ No

6. List any deficiencies and corrective action, if applicable.

7. Supervisor’s Name: ____________________________________

HAZARD COMMUNICATION PROGRAM

SOP 516-138-21-006

Bay Pines VA Healthcare System Bay Pines, FL. 33744

Signatory Authority:

Associate Director

Responsible Owner:

Chief, Facility Management Service

Service Line(s):

Facility Management Service

Effective Date:

December 1, 2021

Recertification Date:

December 31, 2026

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on maintaining current service level chemical inventories. This SOP must be followed by all service lines.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with 29 CFR 1910.1200 OSHA Hazard Communication Standards and VA Directive 7700, Handbook 7700.1, February 2009.

2. PROCEDURES

a. Hazard Determination.

(1) Hazardous chemical/material properties may be based on either a health or physical hazard. Many hazardous chemicals/materials and products may consist of several hazardous constituents. Hazardous chemicals/materials should never be mixed unless verified with the manufacturer, and the chemical compatibility reference states that it is safe to do so.

(2) Health hazard means that a hazardous chemical/material has statistical evidence, based on at least one study conducted with established scientific principles that acute or chronic health effects may occur in exposed employees. The term health “hazard” includes hazardous chemicals/materials which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins and neurotoxins agents having an effect on the hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.

(3) Physical hazard means a hazardous chemical/material for which there is scientific valid evidence that it is a combustible liquid, a compressed gas, explosive, flammable or organic peroxide, oxidizer, pyrophoric, unstable (reactive) or water reactive.

b. Safety Data Sheets (SDS).

December 1,2021

SOP 516-138-21-006

(1) Each Service or program shall obtain the most current copy of the specific SDS for each chemical or hazardous material used in the services’ respective areas. A copy of any new or updated SDSs must be sent to the GEMS Program Manager for review.

The SDS from the manufacturer of the chemical or chemical-containing product must be available (an SDS from a different manufacturer is non-compliant).

(2) Locating current copies of SDSs may be accomplished via the following methods:

(a) Contact the manufacturer or distributor of the product and request the most recent SDS, citing the product name, number and manufacturer.

(b) The Department of Veterans Affairs maintains an intranet-based electronic site for common products. This system may be accessed through Healthcare Environment and Facilities Programs (HEFP) website or from the BPVAHCS homepage under “References.”

(c) SDSs may also be available on the internet at sites provided on the container label and from product manufacturers.

(d) See Appendix B for a summary of major elements.

c. Recordkeeping.

(1) BPVAHCS shall maintain its hazardous chemical inventory list for at least 30 years.

(2) Such list will be maintained in accordance with 29 CFR 1910.1020 “Access to Employee Exposure and Medical Records.”

d. CEOSH SDS/Chemical Inventory Database.

(1) It is the responsibility of each Service to upload their chemical inventory to the online HEFP SDS/Chemical Inventory Database.

(a) The GEMS Program Manager will provide access to the Service for purposes up loading and/or changing their listing of chemicals on the online HEFP SDS database.

Updates should be conducted on a regular basis (i.e. whenever chemicals are added/removed from the Service) and the March/September biannual submissions.

3. ASSIGNMENT OF RESPONSIBILITIES

a. The Chief of Safety Office (FMS). Coordinates the development, maintenance, and oversight of the Hazard Communication Program to assure its effectiveness.

b. GEMS Program Manager.

(1) Acts as a consultant in the identification and management of hazardous chemicals/ materials. This is to include the agreed upon locations of SDS Yellow Books to facilitate safe operations and compliance. Primary Care Service, Nursing Service, Lee County Healthcare Center (LCHCC), and Community Based Outpatient Centers (CBOCs) will maintain one (1) SDS Yellow Book per building. The Yellow Book is the standardized binder with the words “Safety Data Sheets” on the cover and side used in the BPVACHS. Some Services may need to maintain several SDS Yellow Books, dependent upon operations and locations, for example, Engineering Service Shops.

Contents for SDS Yellow Book are listed in Paragraph (2) following.

(2) Maintains the Hazard Communication/SDS Base SharePoint which includes the following to be included in each Service SDS Yellow Book:

(a) Semi-annual Service-Specific Inventories (Service responsibility).

(b) SDSs (Service responsibility).

(c) BPVAHCS Memorandum 00-159, Hazard Communication Program.

(d) US Department of Labor (USDOL)/Occupational Safety and Health Administration (OSHA) 29 CFR 1910.1200, Hazard Communication.

(e) Hazard Communication Related Training – Talent Management System (TMS) Courses Available.

(f) Frequently Asked Questions.

(g) Blank Hazardous Chemicals/Materials Inventory Form.

(3) Assures SDSs meet the requirement of 29 CFR 1910.1200.

(4) Monitors the compliance of the Hazard Communication Program by conducting surveys and employee interviews annually. Additionally, SDS Yellow Books and their contents are reviewed weekly during Environment of Care Leadership Readiness Rounds with monitoring results reported to the Environment of Care Committee.

(5) Maintains a master list of Annual Hazardous Chemical/Material Inventories in the SEMS office.

(6) Maintains SDSs for printer toner cartridges in the Medical Warehouse and online at the BPVAHCS Safety Office SharePoint website.

c. Service Chiefs and Chief Nurses.

(1) Maintain a current inventory of hazardous materials being stored or used within their service area.

(2) Ensure printed or electronic copies of SDS for each hazardous chemical within their service are maintained and made readily available to all workers. Hard copies of SDSs shall be maintained in the “Yellow Book,” and must include those items listed above in Paragraph 3.b.(2). All staff is provided access to the SDS search tool which is available on VHA’s Center for Healthcare Environment and Facilities Programs (HEFP) website Safety Data Sheet/Chemical Inventory Service (SDS/CIS), or the BPVAHCS homepage under “References”.

(3) Ensure the inventory is routinely updated (upon acquisition of a new hazardous chemical/ material or manufacturer altered hazardous chemical/material) and electronically submitted to the GEMS Program Manager semiannually, on March 30 and September 30. Inventories, when reviewed, must be signed and dated prior to submission to SEMS. See Appendix A for Hazardous Chemical/Inventory Form.

Exceptions to using the standard format are granted to Research Service, Pharmacy Service, and Pathology and Laboratory Medicine Service. The GEMS Program Manager reports status of the semiannual inventory reviews to the Green Environmental Management Systems (GEMS)/Hazardous Materials Committee and Research Safety Committee.

(4) Ensure the information is always readily and physically available to employees (in their work area), First Responders, Safety, Emergency Room Personnel, and the Employee Occupational Health Clinician. Each affected employee must know the exact physical location of the SDS Yellow Book and associated Hazardous Chemical/Material Inventory/SDSs.

(5) Ensure that a SDS is also obtained from the manufacturer/supplier when initiating Integrated Funds Distribution Control Point Activity Accounting and Procurement (IFCAP) requests or credit card orders for any hazardous chemicals/materials. Upon receipt of a new or a revised SDS, the Service is to inform the users of the new SDS and forward a copy to the GEMS Program Manager for review.

(6) Ensure compliance with Federal Acquisition Regulations (FAR) 23.3 titled, “Hazardous Materials,” which requires a current SDS prior to or upon receipt of ordering a hazardous chemical (or equipment containing a hazardous chemical/material) using credit card or 2237 procurement.

(7) Patient care workplaces within Primary Care Service, Nursing Service, LCHC, and CBOC’s will each maintain one SDS Yellow Book for each building. In addition to service specific hazardous chemicals/materials, Environmental Management Service (EMS) and Sterile Processing Service (SPS), will populate and maintain each SDS Yellow Book with Inventories and SDSs uniquely in use at each respective building.

Therefore, EMS, SPS, and each service will jointly maintain the respective SDS Yellow Book. Each location will be obvious, easily visible, always available, and all staff will know the location. The intent of maintaining one SDS Yellow Book for an entire building is to eliminate multiple locations and simplify the process. Locations include:

(a) Building 100 (C.W. Bill Young Medical Center).

(b) Community Living Center (CLC, C.W. Bill Young Medical Center).

(c) Building 1 (C.W. Bill Young Medical Center).

(d) Domiciliary (C.W. Bill Young Medical Center).

(e) Palm Harbor CBOC.

(f) St. Petersburg CBOC.

(g) Bradenton CBOC.

(h) Sarasota CBOC.

(i) Sebring CBOC.

(j) Port Charlotte CBOC.

(k) Naples CBOC.

(l) LCHCC.

d. Supervisors.

(1) Provide their employees, who handle hazardous chemicals/materials, with initial training, annual refresher training, and training any time a new hazardous substance is introduced into the work area. The following training courses and course numbers are available through VA TMS (NOTE: Item (a) is mandatory for all employees):

(a) Hazard Communication: Hazard Communication: An Employee’s Right to Understand 2.0, NFED 4503951.

(b) Safety Data Sheets (SDS), NFED 3848184.

(c) Globally Harmonized System (GHS)Safety Data Sheet in Laboratory, VA 17057.

(d) Hospital Safety: Hazard Communication/GHS, VA 17048.

(e) The GHS of Classification and Labeling of Chemicals, NFED 2775991.

(f) Hazardous Materials, NFED 11424.

(g) Environment of Care Hazardous Material and Waste Mgmt., VA 8576.

(h) Hazardous Materials Handling and Storage, NFED 12782251

(2) Will verify that all containers of hazardous chemicals received for use within their service are clearly labeled as to the identity of the contents, the manufacture’s name and address and forms of warning are legible.

(3) Ensure that labels on hazardous chemical/material containers are present/intact, and that all incoming product containers procured and distributed are intact, i.e., not broken, punctured or leaking.

(4) Ensure that hazardous chemicals/materials utilized in containers, other than the original, are properly labeled with hazard warning labels to promote safe handling of any chemicals. This requires that all secondary containers are marked with an identifier and hazard warning information and date of transfer to the secondary container.

(5) Ensure hazardous chemicals/materials are stored and segregated properly, and make available to employees appropriate and approved personal protective equipment

(PPE).

(6) Contact the GEMS Program Manager if any hazardous chemical/material is identified as waste (leaking container, damaged, expired, aged, not needed, etc.).

e. Employees.

(1) Attend training sessions and follow established safe working procedures, utilize and properly store/maintain required PPE, and reporting problems through the supervisory chain.

(2) Ensure that hazardous chemicals/materials are stored and segregated properly, and that the appropriate PPE is used.

(3) Know how to access SDS information electronically through the HEFP web site and where the SDS Yellow Book and associated Hazardous Chemical/Material Inventory/SDSs are physically located at their work site.

f. Contracting Officer’s Representatives (COR) and Purchase Card Holders.

(1) Are responsible for receiving and maintaining SDSs for hazardous chemicals/materials used on station by contractors or purchased services. SDSs shall be forwarded to the Safety Office for review and inclusion in the Hazard Communication Program.

(2) Ensure contractors Hazard Communication Program submittal is supplied to the Construction Safety Officer for review prior to authorization for use being issued to the Contractor.

(3) Ensure that contractors receive the site-specific Safety Orientation at the Pre-construction meeting. The BPVAHCS Construction Site Specific Safety Orientation contains information necessary to communicate key information to contracted staff regarding the presence of hazardous regulated materials at our site that their employees may be exposed to as well as information regarding the location of chemical inventories, SDSs, administrative controls, engineering controls or other measures that may be in place to minimize the risk of exposure. Additionally, the training includes necessary information regarding spill reporting protocols.

4. DEFINITIONS: None

5. REFERENCES

a. 29 CFR 1910.1200 OSHA Hazard Communication Standards.

b. Joint Commission Comprehensive Accreditation Manual for Hospitals, (CAMH).

c. VA Directive 7700, Handbook 7700.1.

d. Spill Prevention, Control, and Countermeasures Plan (SPCCP).

e. Applicable statutes of Florida Department of Environmental Protection.

f. Master Agreement between the Department of Veterans Affairs and the American Federation of Government Employees, PVA Pamphlet 05-68, P70450, 2011.

g. VA Directive 0059, VA Chemicals Management and Pollution Prevention, May 2012.

6. REVIEW: Review will be completed at recertification.

7. RECERTIFICATION: This SOP is scheduled for recertification on or before the last working day of December 2026. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Jonathan S. Benoit, Date Approved:

NOTE: Signature remains valid until rescinded via administrative action.

ATTACHMENTS

December 1, 2021 SOP 516-138-21-006

A-1

Hazardous Chemical/Material Inventory

Service:

Unit/Location of Yellow Book: Phone #:

Date of Inventory: Individual Completing Inventory:

Updated:

Signature:

Hazardous Chemical/Material

Manufacturer Storage Location (B- /R- )

Volume of

Container

Typical Number of Container s on Hand

Labeled Correctl y:

Yes/No

SDS Access Verified:

Yes/No

Comments

B-1

SERVICE-LEVEL PROCESS FOR MANAGEMENT OF HAZARD COMMUNICATION

SDS YELLOW BOOK AND EXPOSURE RESPONSE REQUIREMENTS

Service/Section/Unit maintains the SDS Yellow Book and

Hazardous Chemical/Material Inventory and Associated SDSs.

Inventory is updated continually as needed and reported semiannually to

GEMS Program Manager on March/September.

EXPOSURE RESPONSE

Employee or First Responder goes to SDS

Yellow Book

SDS Yellow Book contains:

(a) Semi-annual Service-Specific Inventories

(Service responsibility)

(b) SDSs (Service responsibility)

(c) BPVAHCS Memorandum 516-12-00-159, Hazard Communication Program

(d) USDOL/OSHA 29 CFR 1910.1200, Hazard

Communication.

(e) Hazard Communication Related Training-

TMS Courses Available

(f) Frequently Asked Questions

Suggestion: File your SDSs alphabetically by either product name or chemical name.

Go to Hazardous Chemical/Material Inventory in SDS Yellow Book and locates item.

Go to the SDS within the Service/Section/Unit SDS Yellow Book

Immediately scan for hazard ratings:

(Also, See Appendix C)

C-1

GHS Pictograms and Hazard Classes

▪ Oxidizers

▪ Flammables

▪ Self Reactives

▪ Pyrophorics

▪ Self-Heating

▪ Emits Flammable Gas

▪ Organic Peroxides

▪ Explosives

▪ Self Reactives

▪ Organic Peroxides

▪ Acute toxicity (severe)

▪ Corrosives

▪ Gases Under Pressure

▪ Carcinogen

▪ Respiratory Sensitizer

▪ Reproductive Toxicity

▪ Target Organ Toxicity

▪ Mutagenicity

▪ Aspiration Toxicity

▪ Environmental Toxicity

▪ Irritant

▪ Dermal Sensitizer

▪ Acute toxicity (harmful)

▪ Narcotic Effects

▪ Respiratory Tract

▪ Irritation

C-2

Flammable Liquid Flammable Gas Flammable Aerosol

Flammable solid Self-Reactive Substances

Pyrophorics (Spontaneously Combustible) Self-Heating

Substances

Substances, which in contact with water, emit flammable gases (Dangerous When Wet)

Oxidizing Gases Oxidizing Liquids Oxidizing Solids

Explosive Divisions 1.1, 1.2, 1.3

Explosive Division 1.4 Explosive Division 1.5 Explosive Division 1.6

Compressed Gases Acute Toxicity (Poison): Oral, Dermal, Inhalation

Corrosive

Marine Pollutant Organic Peroxides

CONFINED SPACE PROGRAM

SOP 516-138S-010

Bay Pines, FL. 33744

Signatory Authority:

Healthcare System, Associate Director

Responsible Owner:

Chief, Facility Management Service

Service Line(s):

Facility Management Service

Effective Date:

May 1, 2023

Recertification Date:

May 31, 2028

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on all individuals entering confined spaces adhere to established safety practices and utilize required confined space entry equipment. This SOP must be followed by all employees, visitors, vendors, and contractors that has been granted confined space permission within the Bay Pines VA Healthcare System (BPVAHCS).

b. This SOP sets forth mandatory procedures and processes to ensure compliance with the National Institute of Occupational Safety and Health (NIOSH) Publication #80- 160 and 29 CFR 1910.146.

2. PROCEDURES

a. Workplace Evaluation.

(1) The Healthcare System has identified confined spaces on its campus. Some of these spaces meet the criteria of a permit-required confined space. Appendix B contains a list of confined spaces which are under the control of the facility.

(2) The facility informs exposed employees of the presence of confined spaces by posting danger signs or by any other equally effective means.

(3) When there are changes in the use or configuration of a space that might increase the hazards to the entrants, the facility reevaluates that space and, if necessary, reclassifies it as a confined space.

b. Identification.

(1) Examples of Permit-required confined spaces are underground fuel storage tanks, lift stations, laundry dryers, water storage tanks, all manholes, air handling units, dock levelers and boilers. Boilers are permit required confined spaces if entry into the boilers is completed through a manway/hatchway. Boilers are not permit required confined spaces when the entire end shell of the boiler is removed for entry/work.

May 1, 2023 SOP 516-138S-010

(2) Signage: All permit-required confined space entrances must be properly secured and permanently marked except for manhole covers as follows:

(3) All manholes are considered to be permit-required confined space.

(4) Signs must remain in place until tests and observations indicate entry is safe.

c. Employee Entry. Before an employee enters the space, the internal atmosphere is tested with a calibrated direct-reading instrument for oxygen content, for flammable gases and vapors, and for potential toxic air contaminants, in that order.

d. Acceptable Atmospheric Levels.

(1) The following atmospheric levels must be present (except as discussed at item F) to authorize entry into permit-required confined spaces:

(a) Oxygen content between 19.5% - 23.5%; and note that excessive rusting may be indicative of low oxygen limits;

(b) Flammable gases and vapors below 10% of the lower flammability limit (LFL);

(c) Toxic air contaminants as follows:

1. Carbon monoxide levels below 35 parts per million (ppm); and/or

2. Hydrogen Sulfide levels below 10 ppm.

3. Entry is not authorized when any of the following conditions are present:

a. Any hazardous material over the permissible exposure level (PEL).

b. Airborne dust that obscures vision at 5 feet or less

c. Any other known condition that has the potential to create a hazard.

e. Sampling Device.

D A N G E R

C O N F I N E D S P A C E

E N T R Y BY P E R M I T O N L Y

E N T R Y BY P E R M I T O N L Y

(1) Device requirements.

(a) A calibrated, direct readout device is used which simultaneously tests for the levels of the substances listed in C above, without manual switching.

(b) Device is equipped with audible and visible warning device which indicates when an atmosphere of a confined space has:

1. An oxygen content of less than 19.5% or greater than 23.5%;

2. A combustible gas content of 10% or more of the lower explosive limit;

3. A hydrogen sulfide content of 10ppm or more, or a carbon monoxide content of 35ppm or more.

(2) Calibration.

(a) The device is calibrated per the manufacturer’s recommendation or at least every six months and before each use.

(b) The device is calibrated relative to the oxygen content of ambient air at the time of the sampling. Calibration of the sampling device relative to the oxygen content is to be performed where the 20.9% natural content of oxygen in the air is most likely to occur. This calibration is not to be performed near the opening of a confined space.

(c) Sampling devices are calibrated in accordance with manufacturer specifications before each use.

(d) The battery charge is to be monitored on a periodic basis to ensure that the device is ready to be used when needed. At least two devices are to be constantly plugged in with an A/C adapter.

(3) Use. The MSA Altair 4 Gas Monitor is used to sample the confined space prior to entry. When the entry is through a manhole, a probe is inserted through the pick hole of the cover, or the manhole is pried open on the downwind side to allow just enough room for insertion of the probe or device.

f. Ventilation. If a confined space does not meet the requirements listed under F above, the space is ventilated and is entered only when atmospheric sampling indicates an atmosphere within acceptable limits, as defined in section C. The atmosphere within the space is then continuously tested as necessary to ensure that the continuous forced air ventilation is preventing the accumulation of a hazardous atmosphere.

g. Supplied Air. If the space cannot be brought within the limits specified at section F, the space may be entered if a self-contained positive air positive pressure breathing apparatus is used. A Type C air line respirator with an escape air tank with an adequate supply of air to exit the confined space and a maximum of 300 feet of air line hose may also be used. An approved air purifying respirator may be used in atmospheres which do not have the potential to be immediately dangerous to life or health

h. Control of Hazardous Energy. Prior to entry, the Entry Supervisors are to conduct an evaluation of all potential stored energy sources affecting the confined space. Examples of stored energy include, but are not limited to, piped water, piped steam, electrical components, hydraulically operating equipment, thermal sources, etc.

Lock-Out/Tag-Out procedures have been developed for stored energy sources at the facility, and the prescribed procedures are to be conducted to ensure the safety of the entrants.

i. Entry Procedures.

(1) The following are general entry requirements. Space specific procedures/permits have been created and can be found in Appendix B. The signed, authorized permit will be posted at the confined space entry, and a copy to be provided to the Office of Safety & Emergency Management.

(2) The duration of any permit may not exceed the time required to complete the assigned task or job identified on the permit. Since conditions may change in the confined space due to the work being conducted, any task exceeding one shift or one day is recommended to have a permit issued each day.

(3) Performing entry into or work in a Permit-required Space

(a) Confined Space Entry Permit Guidelines.

1. The process begins by obtaining a confined space entry permit by contacting the Office of Safety & Emergency Management.

2. Contact the Seminole Fire Department, Communications Center, and BPVAHCS Emergency Department prior to entry.

3. All employees who have a function in the process must be listed in the permit and the entry supervisor must sign the permit.

4. The completed entry permit must be posted near the location of all entries.

5. The permit is valid until the job is completed or the work crews or shifts change. A new work crew must complete their own permit before entering the confined space.

6. All equipment used for the confined space entry must be inspected prior to the entry to ensure that it is in working order.

7. The completed permits are to be forwarded to the Office of Safety and Emergency Management where they are retained on file for a minimum of three years.

8. As part of the process, a pre-entry briefing should be held to ensure that all employees participating are knowledgeable about the entire procedure and the conditions that are present at the time of entry.

9. If there are multiple employers working in a confined space, they must coordinate their efforts and exchange information so that the work of one does not create a hazard for another.

(b) Working in a Confined Space.

1. The atmosphere within the authorized entrant’s immediate area is continuously monitored for oxygen, hydrogen sulfide, carbon monoxide, and combustible gas.

2. Signals from the monitoring device will immediately indicate when the atmosphere is not within the air quality limits specified in section f.

3. While in the confined space, if the air quality fall outside any of the air quality limits specified in section f, the authorized entrant is to immediately exit the confined space.

4. Ventilation is not used in lieu of monitoring devices. An employee may not enter the space until forced ventilation has eliminated any hazardous atmosphere. When forced air ventilation is used, it is so directed as to ventilate the immediate areas where an authorized entrant is or will be present within the space and will continue until all entrants have left the confined space. The air supply for forced air ventilation is from a clean source and may not increase the hazards in the confined space. Note: in a combustible atmosphere, static discharge from forced ventilation could become an ignition source.

5. No employee may enter a confined space without at least one attendant stationed at the entrance of the confined space. The attendant must be in place for the duration of the entry.

6. When the entry into a confined space is by means of a top opening (manhole) which is more than 5 feet deep, a mechanical retrieval device must be available for rescue attempts prior to entry.

7. While in a confined space, the attendant has voice or other means of communication with the entrant.

8. An authorized entrant entering vertically into a confined space wears a full body harness secured to a retrieval line.

(c) Work Involving Multiple Employee(s). When working with another employee(s) where more than one employee performs confined space entry, the BPVAHCS:

1. Apprises the other employee of the elements, including the hazards identified and each employee’s experience working in the space, that makes the space in question a confined space and;

2. Coordinates entry operations with the other employee when personnel from both departments/sections are working together in or near confined spaces.

j. Rescue.

(1) Non-entry rescue is to be used at BPVAHCS. Participants are not to perform entry rescue.

(2) Confined Space Rescue Service is provided by contract with the City of Seminole Fire Department.

(3) The Entry Supervisor, or designee, will notify the Seminole Fire Department

(727) 588-4761 on the day of, and prior to, entry into a permit-required confined space for the purpose of putting the fire department rescue team on alert.

(4) The non-entry rescue procedure is provided on the permit for each space.

k. Training.

(1) Training Content. Affected employees are trained and equipped to recognize, understand, and control the hazards that may be encountered in confined spaces. This training includes:

(a) Training on the entry procedure established by the Program.

(b) Training on the implementation and use of required respiratory protection as well as the training requirements in the BPVAHCS Respiratory Protection Program.

(c) The duties of their assigned job – Authorized entrant, attendant and/or entry supervisor.

(d) The contents of this Program.

(2) Training Requirements/Schedule.

(a) The training is conducted in a manner which establishes employee proficiency in the duties required by this Program and will introduce new or revised procedures, as necessary, for compliance with this Program. Documented training is maintained in the employee’s file, training record, or contract packet if a vendor/contractor.

(b) Training is provided:

1. Before an employee is first assigned duties covered by this program.

2. Before there is a change in assigned duties covered by this program.

3. Whenever there is a change in confined space operations that presents a hazard about which an employee has not been previously trained.

(c) BPVAHCS shall certify that the training required by paragraphs (g)(1) through (g)(3) of 29 CFR 1910.146 has been accomplished for each employee that is assigned any responsibilities under the confined space program. The certification shall contain each employee’s name, the signatures or initials of the trainers, and the dates of training. The certification shall be available for inspection by employees and their authorized representatives.