36C25018Q9361-008.pdf

Engineering Section VA Medical Center Standard Operating Procedure Chillicothe, Ohio Number 57 November 26, 2012

COORDINATING UTILITY OUTAGES

1. PURPOSE: To provide a uniform and effective procedure to coordinate utility outages.

2. POLICY: It is the policy of Engineering Section to continually provide all the utilities that are essential to properly operate a modern medical center. When it becomes necessary to temporarily interrupt these essential services, Engineering Section informs concerned parties and coordinates such interruptions within the limits of exigency that exists on a situation by situation basis.

3. RESPONSIBILITY: It is the responsibility of the Chief, Facilities Management Service (FMS) to ensure proper coordination of outages. It is the responsibility of all Engineering Section employees to promptly inform the Chief, FMS through the appropriate chain of command when a utility outage is required or when, in the event of an emergency, the outage has been implemented.

4. PROCEDURES:

a. The Chief, FMS grants approval before any utility outage is implemented except in an emergency situation wherein life, limb, or property may be seriously impaired, seriously damaged, or destroyed by failure to take immediate action to shut down a utility. In the event of such a catastrophic emergency, the Chief, FMS is informed as soon as possible of the outage and other pertinent details that necessitated the outage.

b. Outages, with the exception of emergency outages, are planned, approved, and coordinated with the appropriate personnel as far in advance as is practical.

c. Concerned services/care lines are contacted by telephone in an effort to coordinate the outage. Appendix A, Utility Outage Form is used when the telephone contacts are made. When the telephone contacts are completed and if all services contacted have no objection to any aspect of the planned outage, the outage is scheduled. If appropriate due to the scope of the outage, the secretary sends a station-wide e-mail message informing all employees.

d. Before Appendix A, Utility Outage Form is submitted for approval, the requestor completes all appropriate spaces. The requestor fills in the titles, dates and all spaces above the signature line. In addition, an X is placed in the appropriate spaces indicating which offices or services/care lines are to be contacted. Some offices and services/care lines are permanently marked and are contacted for each utility outage scheduled.

e. The Work Order Clerk makes contacts the services/care lines and areas indicated on the Utility Outage Form to provide details of the scheduled outage. The name of the person receiving the call is noted on the Utility Outage Form. An electronic message is also sent as a secondary means of communicating the outage details.

VHACLLCROCKK

Typewritten Text

EXHIBIT 20

2. Engineering Section SOP No. 57, Coordinating Utility Outages

5. REFERENCES: None.

6. RESCISSION: Standard Operating Procedure Number 57, Coordinating Utility Outages, dated September 6, 2007.

STEVEN BENSON, PE, PS, CHFM

Chief, Facilities Management Service

Dist: Engineering Supervisors (138) Engineering Work Order Clerk (138D)

VAF 10-236 (538)

Engineering Section SOP 57, Appendix A – 01/09/17

Today’s Date: Title of Outage:

Type of Outage:

FIRE ALARM ELEVATORS STREET LIGHTS EMERGENCY GENERATOR ELECTRICITY

HEAT STEAM WATER AIR CONDITIONING SEWAGE

MEDICAL AIR / VACUUM / OXYGEN OTHER ______________________________

Affected Areas/Buildings:

Date(s) of Outage:

Time/Duration of Outage: From a.m. p.m.

To a.m. p.m.

Outage coordinated with: _________________________________________________ (Name of Service Chief/Care Line Manager) Reason for Outage:

Requestor’s Signature 138

E-Mail Notification Sent: ______________________ (Initials/Date)

SERVICE OR CARE LINE

“X” TO

CONTACT BUILDING EXT. NAME OF CONTACT

CALLER

INITIALS

Medical Center Director 1 7002

Associate Director Email 1 7001 CC: Associate Director, AD Secretary

Chief of Staff Email 1 7254 CC: Heather Murphy

AD for Patient Care (Nursing) Email 1 7365 CC: VHACLL Nursing Key Staff VHACLL SPS Patient Care

Nursing Various Email CC: VHACLL Nurse Managers

Human Resources 1 7538

Fiscal 1 7527

Logistics 1 7581 Medical Supply (All med/gas outages) 1 Email CC: VHACLL Medical Supply

Quality Improvement 1 7258

Learning Resources 1 7267

Geriatrics/Extended Care Line 1 7612

Emergency Management 1 6390

Vocational Rehabilitation 3 7342

Nutrition & Food Service 7 7512

Call Center 8 6468

Fee Basis 8 6282

Voluntary Service 9 7420

Quarters 12 – 17 7166

SERVICE OR CARE LINE

“X” TO

CONTACT BUILDING EXT. NAME OF CONTACT

CALLER

INITIALS

Protective Services X 18 7004

Chief Information Officer 18 7189

Primary Care Admin 18 6668

Warehouse 23 7400

SPS (All steam outages) 24 6118

Domiciliary 24 6095/6094

SATP 24 7604

Prosthetics 24 7280

Environmental Management X 25 6383 CC: VHACLL EMS Supervisors

Vocational Rehabilitation 25 7355

Safety Office 26 7699

Recreation Therapy 26 7412

Unit 26AB 26 7309

Unit 26CD – Freedom Harbor 26 6127

Biomedical Engineering 27 Email CC: VHACLL Biomed

Infection Control Nurse 27 7368 CC: Yvonne Jones, Jason Cherry

Medical/Surgical Care Line 27 7717

Specialty Clinic 27 7901 Cardiopulmonary Clinic (All med/gas outages) 27 7730 CC: VHACLL Cardiopulmonary

GI Clinic 27 7919/7987 CC: Angel Reyes, Cathy

Hathaway

EEG Clinic 27 7633

Canteen 28 7573

Social Work 28 6603/7451

MHICM 28 7984

Residential Care 28 7455

Surgery 30 7761

Unit 30 (MICU) 30 7712

Nurse Manager (Special Care) 30 7513

SCU (30A) 30 7708

Telemetry 30 6124

Unit 30CD 30 7680/7681

Respiratory Therapy 30 7695

PCT Clinic 30 7899

Administrative Officers (AODs) X 31 Email CC: VHACLL AOD Dennis Hawk (Outages in Radiology / Dental) 31 6022

Radiology 31 7739

Dental 31 7807

SERVICE OR CARE LINE

“X” TO

CONTACT BUILDING EXT. NAME OF CONTACT

CALLER

INITIALS

Audiology 31 7864

Pharmacy 31 7794

Laboratory 31 7837 CC: VHACLL Laboratory

Mental Health Clinic 31 7872

Primary Care (Teams) 31 7859

Urgent Care (Admissions) 31 7771

Urgent Care (Nursing) 31 7777

PBS Section Supervisors 35 Email CC: VHACLL PBS Section Supervisors

Unit 35A 35 7298

Unit 35B – HBPC 35 7566

Unit 35B – PRRTP 35 Email CC: VHACLL PRRTP

Mental Health Care Line 35 7895

Tool Room 36 7407/7408

210 AB Nurse Manager 210 7636 Dee Copas

210 CD Nurse Manager 210 6106

Sherman Terrace 210 7660/7661

Veterans Homeland 210 6112

211 Nurse Manager 211 7287 Lisa Cooley

Hopewell House 211 7287

Rehabilitative Care Line 211 7638

Library Section 211 7622

CPAC 212 7073

Employee Health 212 7861

Support Services (Mail Room) 212 7590

Release of Info (B212) 212 7709 CC: VHACLL ROI-SCANNING

AFGE 212 7436

Contracting 212 7011/7012

Home Telehealth 212 7362/6222

Patient Business Service 212 7468

Chaplain Service 252 7202

Fire Department X 259 7161

Chillicothe Paints

STADIUM

244 773-7117

Chivaho Federal Credit Union 317 775-3381

ENGINEERING SECTIONS

Interior Design 21 7570/6419

Engineering Supervisors X 21 6172 CC: VHACLL Engineering Supervisors

Boiler Plant X 261 6189 CC: VHACLL Engineering Boiler Plant

Dispatchers (Office Personnel) X 21 6172 CC: T. Hill, J. Skaggs, K. Davis, T. Reynolds, D. Nibert

POLICY MEMORANDUM VA MEDICAL CENTER

NO. 00-16 Chillicothe, Ohio August 11, 2015

PREVENTION OF WORKPLACE HARASSMENT

1. PURPOSE: To advise all employees of their responsibility regarding the prevention of harassment in the workplace, to define and establish procedures for monitoring and evaluation, and to enforce the laws relative to workplace harassment.

2. POLICY: It is the policy of this medical center that no employee is subjected to harassment, a form of employment discrimination that violates Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act (ADEA) of 1967 and the Americans with Disabilities Act (ADA) of 1990. All employees are entitled to a work environment in which they feel free to raise concerns and are confident that those concerns will be addressed. Unwelcome harassing conduct is not tolerated and immediate, appropriate action is taken when management becomes aware of allegations.

3. DEFINITIONS:

a. Harassment is unwelcome conduct that is based on race, color, sex (including sexual orientation), religion, national origin, disability, and/or age.

Harassment becomes unlawful when:

(1) Enduring the offensive conduct becomes a condition of continued employment; or

(2) Employment decisions are based on whether the employee accepts or rejects such conduct; or

(3) The conduct is severe or pervasive enough to create a work environment that a reasonable person would consider intimidating, hostile, or abusive. Anti-discrimination laws also prohibit harassment against individuals in retaliation for filing a discrimination charge, testifying, or participating in any way in an investigation, proceeding, or lawsuit under these laws; or opposing employment practices that they reasonably believe discriminate against individuals, in violation of these laws.

b. Petty slights, annoyances, and isolated incidents (unless extremely serious) do not rise to the level of illegality. To be unlawful, the conduct must create a work environment that would be intimidating, hostile, or offensive to reasonable people.

EXHIBIT 21

2. Policy Memorandum No. 00-16

c. Offensive conduct may include, but is not limited to, offensive jokes, slurs, epithets or name calling, physical assaults or threats, intimidation, ridicule or mockery, insults or put-downs, offensive objects or pictures, and interference with work performance.

d. Harassment can occur in a variety of circumstances, including, but not limited to, the following:

(1) The harasser can be the victim's supervisor, a supervisor in another area, an agent of the employer, a co-worker, or a non-employee.

(2) The victim does not have to be the person harassed, but can be anyone affected by the offensive conduct.

(3) Unlawful harassment may occur without economic injury to, or discharge of, the victim.

4. RESPONSIBILITIES:

a. Employees are encouraged to inform the harasser directly that the conduct is unwelcome and must stop. Employees also report harassment to management at an early stage to prevent its escalation.

b. The VA recognizes that the question of whether a particular action or incident is a purely personal, social relationship without a discriminatory employment effect requires a factual determination based on all facts in each case. When investigating allegations of harassment, management looks at the entire record, including the nature of the conduct, and the context in which the alleged incidents occurred. A determination of whether harassment is severe or pervasive enough to be illegal is made on a case-by-case basis.

5. PROCEDURES:

Persons believing they have been subjected to harassment discuss concerns with their immediate supervisor, service chief/care line manager, the Equal Employment Opportunity (EEO) Program Manager, an Office of Resolution Management (ORM) EEO counselor, or their union representative. All information disclosed during the discussion is held in the strictest confidence and is only disclosed on a need-to-know basis in order to investigate and resolve the matter. Reprisal against one who engages in protected activity is not tolerated, and this medical center supports the rights of all employees to exercise their rights under the civil rights statutes.

Complaints of harassment may also be brought to the attention of an EEO Counselor within 45 calendar days of the date of occurrence of the event or alleged

3. Policy Memorandum No. 00-16 acts. Procedures for initiating and processing individual complaints of harassment may be discussed with an ORM EEO Counselor or the EEO Program Manager.

6. REFERENCES: Section 703 of Title VII of the Civil Rights Act of 1964; 29 CFR, Chapter XIV; VA Handbook 5977.

7. RESCISSION: Policy No. 00-16, Prevention of Workplace Harassment, December 14, 2014.

8. COLLABORATED WITH: OOE

9. RESPONSIBLE OFFICE: OOE

10. RECISSION DATE: August 11, 2018

//s// Wendy J. Hepker, FACHE Medical Center Director

Distribution: F

POLICY MEMORANDUM VA Medical Center NO. 07-09 Chillicothe, Ohio June 1 2016

EMPLOYEE THREAT ASSESSMENT TEAM (ETAT)

COMMITEE

1. PURPOSE: To establish a proactive policy for the prevention of workplace violence involving employees, visitors, volunteers and contractors at this medical center.

2. POLICY:

a. It is the policy of this medical center to promote a safe environment for employees, patients, visitors, and volunteers. The medical center is committed to working with its employees to maintain a work environment free from violence, threats of violence, harassment, intimidation, and other disruptive behavior. While this kind of conduct is not pervasive at this medical center, no medical center is immune. Every medical center is affected by disruptive behavior at one time or another.

b. Violence, threats, harassment, intimidation, and other disruptive behavior in the workplace are not tolerated. Reports of incidents are taken seriously and are dealt with appropriately. Such behavior can include oral or written statements, gestures, or expressions that communicate a direct or indirect threat of physical harm. Individuals who commit such acts may be removed from the premises and may be subject to disciplinary action, criminal penalties, or both.

3. DEFINITIONS: As used in this policy, violence is defined as unwanted or hostile physical contact, threats, coercion, or harassment.

a. Physical attack is unwanted or hostile physical contact, such as hitting, fighting, pushing, shoving or the throwing of objects.

b. Threat is the expression of a present or future intent to cause physical or mental harm. An expression constitutes a threat without regard to whether the party communicating it has the present ability to do harm, and without regard to whether the expression is contingent, conditional, or future.

c. Harassment is behavior or communication designed or intended to intimidate, menace or frighten another person.

d. Property damage is behavior or acts that contribute to the destruction or damage of private or government property.

e. Employee Threat Assessment Team (ETAT) is a medical center-level interdisciplinary team whose primary charge is using evidence-based and data-driven practices for addressing the risk of violence posed by generated behavior(s) that are disruptive or that undermine a culture of safety.

EXHIBIT 22

POLICY MEMORANDUM NO. 07-09

2.

f. Employee-generated disruptive behaviors which undermine(s) a culture of safety can be committed by VHA employees, contractors, volunteers, academic affiliates, locum tenens and any other personnel whose responsibilities bring them into a VHA facility.

4. RESPONSIBILITIES:

a. The Medical Center Director is responsible for:

(1) Providing and maintaining policy and procedures to assure that employees, patients, visitors, volunteers and all other categories of personnel are provided a safe and healthful work environment.

(2) Implementing a system to notify law enforcement agencies when violations of the policy are committed.

(3) Ensuring that employee-generated disruptive behavior(s) is addressed through administrative processes.

(4) Ensuring that high-risk areas within the medical center are designated based upon the Workplace Behavioral Risk Assessment (WBRA) conducted by medical center staff.

b. Disruptive Behavior Committee (DBC) is responsible for:

c. The Employee Threat Assessment Team (ETAT) is composed of designated representatives from AFGE, the Occupational Safety and Health Manager, Protective Services, Human Resources Management Service, Equal Employment Opportunity (EEO), Rehabilitation Medicine and Services Care Line, Psychologist and the Code Orange Team Coordinator. The ETAT Committee is responsible for:

(1) Acting in an advisory capacity to supervisors assessing workplace violence complaints or other significant incidents.

(2) Activating or notifying the ETAT Committee when any member becomes aware of, or receives reports of violence or threats of violence. An email group is organized and maintained by the chairperson under VHACLL ETAT.

(3) Identifying trends, developing strategies, and performing workplace analyses as defined by the Occupational Safety and Health Administration (OSHA) in order to review and eliminate risks associated with violent behavior at the medical center.

(4) Reviewing the policy for appropriate revisions and making an annual report by June 30 each year on the status of the ETAT Program to the appropriate supervisory personnel regarding incidents referred.

3.

(5) Performing risk assessments and making recommendations to supervisory staff in reference to referred or reported incidents.

d. Supervisory responsibilities:

(1) Enforce VA safety rules, regulations, and standards, including those concerning violent behavior.

(2) Investigate injuries or illnesses that occur to employees under their supervision, and preclude recurrence of similar injuries. If a patient(s) is/are involved, an electronic Patient Event Report (ePER) the incident is completed. The ePER is available on the Chillicothe VAMC home page. If a visitor or volunteer is involved, notify the Occupational Safety and Health Manager.

(3) Assure that employees or volunteers who are verbally or physically assaulted, who witness violent behavior in the workplace, or who have demonstrated warning signs associated with potential violent behavior are offered employee assistance, counseling and professional support, as appropriate.

(4) Initiate disciplinary actions, as appropriate, against employees or volunteers who assault patients, volunteers, visitors or other employees.

e. Employee and Volunteer responsibilities:

(1) Follow safe work practices (those that minimize the potential for violent behavior).

(2) Immediately report work-related injuries as a result of workplace violence to supervisory personnel.

(3) Complete the Workplace Incident Form, VAF 10-84 (538), available at the Police Operations Center, lower level, Building 18, or electronically through the VA Chillicothe Intranet website. Provide one copy to the appropriate level of supervision, one copy to the VA Police and one copy to the Chairperson, or designee of the ETAT Committee, immediately after an incident of workplace violence occurs.

(4) Attend mandatory training related to violent behavior prevention.

f. Human Resources Management Service responsibilities:

(1) Assist, when appropriate, investigations of claims of violence raised by employees and others.

(2) Advise managers on how to address and resolve concerns in their areas.

(3) Refer reported potential workplace violence situations to VA Police, appropriate

4.

level of supervision, and the Chairperson of the ETAT Committee.

g. The Chief Protective Services is responsible for:

(1) Assisting with educational efforts to ensure that a procedure is in place to provide training to employees and volunteers on violent behavior prevention. The training includes customer service training that addresses methods to recognize potential violent behavior, appropriate responses, methods to obtain assistance, and procedures to summon VA Police. Warning signs, response procedures, prevention techniques and defensive techniques are addressed in this training.

(2) Reviewing the medical center’s ETAT Program annually to assure that the program is current and addresses the medical center’s need. Conducts quarterly meetings, as needed, and forwards the meeting minutes to the Environment of Care Committee.

(3) Reviewing incident investigation reports, conducting incident investigations, if deemed appropriate, and identifying corrective actions to preclude incidents of violence at the medical center.

(4) Assuring that reported incidents of violence involving patients, employees, volunteers, or visitors (either as the victim or perpetrator) are appropriately referred.

(5) Developing recommendations and assuring implementation of corrective action(s) intended to preclude recurrence of violent behavior incidents involving employees (in coordination with the requirements of this program).

(6) Identifying trends and developing strategies to reduce or eliminate risks associated with violent behavior at this medical center. This includes developing a standardized database for gathering and reporting data of violent incidents.

(7) Providing training on workplace violence prevention matters for supervisors and employees, when requested.

h. The Crisis Intervention/Code Orange Response Team: This clinical team responds to emergency requests for help and provides employees with assistance in managing violent behavior. The team provides verbal and physical intervention, as needed, to ensure the safety of persons (patients, volunteers, visitors and employees).

Community Based Outpatient Clinic (CBOC) staff contact appropriate community law enforcement agencies for emergency response. CBOC staffs also inform medical center staff of this contact with a written summary report.

i. Police: The Chief, Protective Services ensures a Prevention of Violence in the Workplace briefing is provided to new employees. A yearly briefing to incumbent employees is recommended when requested by medical center service chiefs/care line managers and documented as continuing in-service training.

5.

5. PROCEDURES:

a. Acts of violence perpetrated by patients are referred to the attending physician, treatment team and VA Police for evaluation and appropriate action. The DBC will evaluate cases involving patients referred to the committee from facility staff. While the patients may or may not be reported to law enforcement authorities, clinical personnel determine the reason(s) for the assault and implement corrective action.

b. Requests for review by the ETAT Committee can be initiated by a multitude of sources.

c. Any employee who has concerns regarding personal situations that may affect his or her workplace safety (e.g., restraining orders, domestic violence, or stalking) may consult with the VA Police Operations Officer and/or the ETAT Chairperson.

d. Any supervisor or manager who receives a complaint of violence, threats or harassment, or who has reason to suspect that these acts or behaviors are occurring, involving employees, volunteers, and/or patients, investigates the complaint and contacts the VA Police and/or the ETAT Committee for assistance.

e. Training and education are provided so staff members are aware of potential security hazards and how to protect themselves and co-workers through established policies and procedures. Employees receive general awareness training annually.

Awareness training is a mandatory segment of new employee orientation.

6. REFERENCES: Policy Memorandum No. 00-02, Patient Safety Improvement Program

VHA directive 2012-026, “Sexual Assaults and other Defined Public Safety Incidents in Veterans Health Administration (VHA) Facilities, dated September, 27, 2012.

7. RESCISSION: Policy Memorandum No. 07-9, Employee Threat Assessment Team (ETAT) Committee, dated August 19, 2015.

8. COLLABORATED WITH: VHACLL Tops, AFGE

9. RESPONSIBLE OFFICE: 07

10. RESCISSION DATE: June 1 2019

Keith Sullivan Keith Sullivan, FACHE Medical Center Director

Distribution: ALL

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