Attachment 04 Butler VA HCS MCP.pdf

PROJECT DESIGN AND REVIEW

MCP EC-17

Butler VA Health Care System Butler, PA 16001

Signatory Authority:

Butler VA Health Care System Director

Responsible Owner:

Chief, Facility Manager

Rescinded Document:

See paragraph 7.

Effective Date:

September 29, 2023

Recertification Date:

September 29, 2028

1. POLICY

To establish policy and procedures for the design and review of construction projects to ensure compliance with all applicable code requirements.

2. JUSTIFICATION

It is the policy of this facility to design projects that comply with VA Construction Standards, VA Barrier-Free Design Handbook, Life Safety Code, Uniform Plumbing Code, VA HVAC Design Criteria, Uniform Building Code, and current guidelines for design and construction published by the Facility Guidelines Institute (FGI).

Compliance to codes is documented at the 100 percent design review.

3. RESPONSIBILITIES

a. VA Medical Facility Director. The VA medical facility Director is responsible for ensuring overall VA medical facility compliance with this policy, and appropriate corrective action is taken if non-compliance is identified.

b. Representative (COR). is responsible for certifying that each project complies with appropriate codes.

c. Project Manager(s): along with infection control and pest control are responsible for performing construction site inspections, as appropriate. Construction site inspection sheets are documented for each visit certifying compliance or non-compliance.

d. The Project Manager: is the COR and responsible for completing and addressing issues identified in the Pre-Construction/Safety Assessment, APPENDIX C.

e. The Facility Manager: is the COR when or if the assigned COR or Project Manager is not able to perform the required duties.

4. OTHER PARAGRAPHS

a. All designs for new construction will include accessibility to parking lots. All buildings will have at least one entrance/exit that is accessible to the handicapped. This

September 29, 2023 MCP EC-17 includes, but is not limited to, handicap ramps, automatic doors or doors with appropriate hardware to render them accessible to the handicapped, Braille signage, tactile warning strips as appropriate, and handrails as appropriate.

b. Handicap accessibility will also be provided to all public areas, amenities, and elevators.

c. An Infection Control Risk Assessment (ICRA) is required for every renovation and new construction project. The ICRA is performed by a multidisciplinary team with expertise in infectious disease, facility design, construction, ventilation, epidemiology, and environmental specialties. The team will provide documentation of the risk assessment(s) during initial planning and in subsequent construction phases. Based on the ICRA, an Infection Control Construction Permit is issued for each project. See APPENDIX A.

d. All construction workers including in-house employees and subcontractors shall follow the infection control procedures as identified in the permit.

e. Infection control will participate in pre-construction meetings and complete regular construction site walk-through inspections as necessary.

f. Pest control employee(s) are involved in any phase of the construction process where infestation may present a problem. Pest control will conduct walk-through inspections as necessary.

g. Project Manager, Infection Control Specialist, Environmental Protection Specialist, and Pest Control assigned to the administration of construction projects will ensure compliance with this policy and all applicable codes. A Construction Site Inspection Sheet is utilized to document conformance. (See APPENDIX B).

h. Project Manager will ensure that project drawings and specifications are submitted to the VISN Safety and Fire Protection Engineer for review and comment in accordance with VHA Directive 2005-007.

i. Planning and Construction Phase

(1) Infection Control Specialist, Safety Officer, and Environmental Protection Specialist will participate in preconstruction meetings both for in-house work and outside contracted construction. The Sterile Processing Service (SPS) Supervisor is a stakeholder and participates in all design and construction meetings where medical equipment is used or re-processed or where supplies are to be stored. Pest Control is involved in that the extent of the project involves pest control concerns.

(2) Infection Control Specialist is involved in the planning phases for all renovation and new construction projects specific to the following major components (schematic design):

(a) Number and placement of isolation rooms

(b) Air handling systems; use of adjunctive measures such as ultraviolet germicidal irradiation (UVGI)

(c) Number and placement of hand-washing facilities

(d) Staff and patient traffic patterns for the duration of the project

(e) Relocation decisions regarding patient care areas, storage areas, etc.

(f) Water supply and plumbing

(g) Construction waste containment, transport, and disposal

(h) Selection and installation of medical equipment as it relates to infection control

(i) Selection of finishes and surfaces that can be effectively cleaned

(j) Accommodation of personal protective equipment (accessibility, security, sanitation, etc.)

(k) Storage of moveable modular equipment

j. Operational Phase

(1) Medical Waste

(a) Hospital staff shall remove any medical waste, including sharps containers, from areas to be renovated or constructed PRIOR to the start of the project.

(b) Infection Control Specialist and Environmental Protection Specialist are notified immediately if unexpected medical waste is encountered.

(c) Barrier Walls: Construction or renovation sites must be separated from patient-care areas and other critical areas by barriers that keep the dirt and dust inside the worksite.

(d) The integrity of the barrier walls must assure a complete seal of the construction area from adjacent areas.

(e) Rigid construction or fire-rated plastic sheeting (4 to 6 mil thickness) is used depending on the location of the project, adjacent uses, and duration of the project.

(f) Walls are dustproof with airtight seals maintained at the full perimeter of the walls as well as all penetrations.

k. Traffic Control

(1) Designated entry and exit procedures are defined (in conjunction with any necessary Interim Life Safety Measures) for each construction project where applicable.

(2) All egress pathways are free of debris.

(3) Unauthorized personnel will not be allowed to enter the construction zone.

(4) Only designated elevators are used for construction activities during scheduled times.

l. Cleaning

(1) The construction zone and adjacent entry areas are maintained in a clean and sanitary manner by the contractors and are swept and damp mopped daily or more frequently as needed to minimize dust generation.

(2) Facilities Management will ensure completion of routine cleaning of adjacent areas by the contractor. Terminal cleaning of the construction zone prior to the opening of the newly renovated or constructed area is coordinated with Environmental Management Services. Specific responsibilities are defined in the construction contracts.

m. Personnel Requirements

(1) Clothing is free of loose soil and debris upon exiting the construction zone.

(2) Contractor will provide personal protective equipment, including face shields, gloves, and N95 respirators to be utilized as appropriate for the task at hand. Personnel entering sterile/invasive procedure areas are provided with a disposable jump suit, head covering and shoe coverings which must be removed prior to exiting the work area.

(a) Tools and equipment must be damp-wiped prior to entry and exit from sterile and invasive procedure areas.

(b) Tools and equipment soiled with blood and body fluids are cleaned with an approved germicide.

(c) Contractors will receive infection control training as it relates to construction at the pre-construction meeting.

n. Environmental Monitoring - Infection Control Specialist, in conjunction with Facilities Management and Environmental Protection Specialist will plan for environmental monitoring as appropriate for the project.

o. Interim Life Safety Measure Monitoring - Project Manager/COR will complete a daily inspection of the construction site to meet the interim life safety requirements.

(See MCM SC-23, Interim Life Safety Measures, APPENDIX C).

p. Completion Phase

(1) After completion of construction, ventilation will meet specifications as mandated by regulatory bodies.

(2) The area is thoroughly cleaned and disinfected before being placed into service.

(3) Water supply lines are flushed before placing newly renovated or constructed areas into service. Infection Control Specialist is notified prior to the flushing.

q. Compliance Monitoring - The Project Manager, with the support of the Safety Officer, Infection Control Specialist, Environmental Protection Specialist, and the contractor (or designee), will conduct compliance monitoring as necessary. The following parameters are monitored:

(1) Air handling system

(2) Integrity of barrier walls

(3) Dress code

(4) Environmental control

(5) Noise

(6) Traffic control

(7) Personal protective equipment; and

(8) Water supply.

5. DEFINITIONS

None

6. REFERENCES

VHA Directive 2005-007, Fire Code Reviews of Delegated Construction Projects

NFPA 101, Life Safety Code (current edition).

The Joint Commission Comprehensive Accreditation Manual, Environment of Care Standards (current edition)

Facility Guidelines Institute, Guidelines for Design and Construction, 2018

Medical Center Memorandum SC-23, Interim Life Safety Measures, dated May 1, 2023

7. RESCISSION

Medical Center Memorandum SC-17 dated September 30, 2019.

8. REVIEW

This policy will be reviewed, at minimum at recertification and including when there are changes to the governing document.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of July 2028.

This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

Sharon Coyle, MSN, RN, MBA Butler VA Medical Center Executive Director

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

DISTRIBUTION: MCPs are available at: Medical Center Policies, SOPs and Charters - Home (sharepoint.com)

APPENDIX A

INFECTION CONTROL RISK ASSESSMENT

MATRIX OF PRECAUTIONS FOR CONSTRUCTION & RENOVATION

Step One:

Using the following table, identify the Type of Construction Project Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet painting (but not sanding) wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection

TYPE B

Small scale, short duration activities which create minimal dust installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling where dust migration can be controlled

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not limited to:

sanding of walls for painting or wall covering removal of floor coverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities any activity which cannot be completed within a single work shift

TYPE D

Major demolition and construction projects activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction

STEP 1:____________________________________________________

Step Two:

Using the following table, identify the Patient Risk Groups that are affected.

If more than one risk group is affected, select the higher risk group:

Low Risk Medium Risk High Risk Highest Risk

Office areas

Physical Therapy

Radiology/MRI Respiratory

Therapy

Laboratories (specimen)

Outpatient Pharmacy

Central Sterile Supply Nursing Unit Negative pressure isolation rooms

STEP 2_____________________________________________________

Step Three: Match the Patient Risk Group (Low, Medium, High, Highest) with the planned Construction Project Type (A, B, C, D) on the following matrix, to find the Class of Precautions (I, II, III or IV) or level of infection control activities required.

Class I-IV or Color-Coded Precautions are delineated on the following page.

IC Matrix - Class of Precautions: Construction Project by Patient Risk

Construction Project Type

Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III/IV IV

HIGHEST Risk Group II III/IV III/IV IV

Note: Infection Control approval is required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are necessary.

STEP 3_____________________________________________________

DESCRIPTION OF REQUIRED INFECTION CONTROL PRECAUTIONS BY CLASS

During Construction Project Upon Completion of Project

C L

A S

I

1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace a ceiling tile displaced for visual inspection.

None

C L

A S

S I

I

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area.

6. Remove or isolate HVAC system in areas where work is being performed.

7. Wipe work surfaces with disinfectant.

8. Contain construction waste before transport in tightly covered containers.

9. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

10. Remove isolation of HVAC system in areas where work is being performed.

None

L A

S S

I

II

1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e.

sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Contain construction waste before transport in tightly covered containers.

5. Cover transport receptacles or carts.

Tape covering unless solid lid.

1. Do not remove barriers from work area until completed project is

Department and Infection Control Department and thoroughly cleaned by

Department.

2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with disinfectant.

5. Remove isolation of HVAC system in areas where work is being performed.

C L

A S

S I

V

1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e.

sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Seal holes, pipes, conduits, and punctures appropriately.

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.

7. Do not remove barriers from work area until completed project is inspected by the

Control Department and thoroughly

Services Department.

1. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

2. Contain construction waste before transport in tightly covered containers.

3. Cover transport receptacles or carts.

Tape covering unless solid lid.

4. Vacuum work area with HEPA filtered vacuums.

5. Wet mop area with disinfectant.

6. Remove isolation of HVAC system in areas where work is being performed.

Step 4. Identify the areas surrounding the project area, assessing potential impact

Unit Below Unit Above Lateral Lateral Behind Front

Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

Step 5. Identify specific site of activity (eg, patient rooms, medication room, etc.).

Step 6. Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.

Step 7. Identify containment measures, using prior assessment. What types of barriers? (eg, solids wall barriers); Is HEPA filtration required?

(Note: Renovation/construction area is isolated from the occupied areas during construction and are negative with respect to surrounding areas)

Step 8. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (eg, wall, ceiling, roof)

Step 9. Work hours: Can or will the work be done during non-patient care hours?

Step 10. Do plans allow for adequate number of isolation/negative airflow rooms?

Step 11. Do the plans allow for the required number & type of hand washing sinks?

Step 12. Does the infection control staff agree with the minimum number of sinks for this project?

(Verify against AIA Guidelines for types and area)

Step 13. Does the infection control staff agree with the plans relative to clean and soiled utility rooms?

Step 14. Plan to discuss the following containment issues with the project team

(eg, traffic flow, housekeeping, debris removal (how and when)).

Appendix: Identify and communicate the responsibility for project monitoring that includes infection control concerns and risks. The ICRA may be modified throughout the project. Revisions must be communicated to the Project Manager.

Infection Control Construction Permit Permit No:

Location of Construction: Project Start Date:

Project Coordinator Estimated Duration:

Contractor Performing Work Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration, moderate to high levels GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities Requiring consecutive work shifts

GROUP 4: Highest Risk

CLASS I 1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace any ceiling tile displaced for visual inspection.

3. Minor Demolition for Remodeling

CLASS II 1. Provide active means to prevent air-borne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Wipe surfaces with disinfectant.

6. Contain construction waste before transport in tightly covered containers.

7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

8. Place dust mat at entrance and exit of work area.

9. Remove or isolate HVAC system in areas where work is being performed.

CLASS III

Date

Initial

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of the duct system.

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

5. Do not remove barriers from work area until complete project is thoroughly cleaned by Env. Services Dept.

tightly covered containers.

6. Vacuum work with HEPA filtered vacuums.

7. Wet mop with disinfectant.

8. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

9. Contain construction waste before transporting

10. Cover transport receptacles or carts. Tape covering.

11. Remove or isolate HVAC system in areas where work is being performed.

CLASS IV

Date

Initial

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

5. Seal holes, pipes, conduits, and punctures appropriately.

6. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

7. All personnel entering work site are required to wear shoe covers.

8. Do not remove barriers from work area until completed project is thoroughly cleaned by the Environmental Service Dept.

9. Vacuum work area with HEPA filtered vacuums.

10. Wet mop with disinfectant.

11. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

12. Contain construction waste before transport in tightly covered containers.

13. Cover transport receptacles or carts. Tape covering.

14. Remove or isolate HVAC system in areas where is being done.

Additional Requirements:

Date Initials ___________ Exceptions/Additions to this permit Date

Initials are noted by attached memoranda

Permit Request By: Permit Authorized By

Date: Date:

July 17, 2023 MCP EC-17

APPENDIX B

DAILY INSPECTION LOG OF INTERIM LIFE SAFETY MEASURES

Project Title:__________________ Project #:____________Project Coord:__________

Instructions: One log sheet maybe used for one full week with dates entered at top of yes in the box next to the item. If the area is not in compliance with life safety measures provide comments and actions to abate the situation.

Dates

AREAS INSPECTED COMMENTS/

ACTIONS

Means of egress is clear in construction areas.

Access for the fire department & emergency services is clear.

Buildings are accessible to fire department apparatus and personnel

Roadways are maintained within 20 feet of all buildings.

Fire detection and sprinkler systems are functional.

Construction partitions are maintained.

Good housekeeping practices are used in the construction area. Flammables and combustible fire load is being kept to a minimum.

Buildings, grounds and equipment are being maintained in a safe manner (pay special attention to excavations, construction areas, and construction storage or field offices).

Smoking regulations are being followed.

Area found to be secured.

Signature of COTR/Project Coordinator Date

APPENDIX C

PRE-CONSTRUCTIONS/RENOVATION SAFETY RISK ASSESSMENT

Project:

Date of Risk Assessment:

Safety Risk Assessment:

Guidelines Y/N Risk Areas to be Impacted

Control Activities Needed

Will there be any compromise to the quality of building Air?

-Patient care areas?

-Non-Patient care area?

-Public access areas?

Will there be any compromise to the building ventilation?

-Public access areas?

Are there any anticipated utility disruptions?

-Communication/Telephone

-Electrical

-Generator

-Temperature

-HVAC

-Medical Gases

-Natural Gas

-Vacuum

-Sewer / Sanitary

-Water

Guidelines Y/N Risk Areas to be

Impacted Control Activities Needed

-Other

-Non-Patient care area?

-Communication/Telephone

-Electrical

-Generator

-Temperature

-HVAC

-Medical Gases

-Natural Gas

-Vacuum

-Sewer / Sanitary

-Other

-Public access areas?

-Communication/Telephone

-Electrical

-Generator

-Temperature

-HVAC

-Medical Gases

-Natural Gas

-Vacuum

-Sewer / Sanitary

-Other

Will there be any unusually loud or high-pitched noise levels?

Guidelines Y/N Risk Areas to be

Impacted Control Activities Needed

-Patient care areas?

-Non-Patient care area?

-Public access areas?

Will vibration levels be excessive for hospital machinery to operate properly?

-Public access areas?

Does the construction present any conflicts with the emergency disaster management program?

-Public access areas?

Will the construction compromise the security of the hospital?

-Public access areas?

Will project be short duration, small scale, minimal dust?

-Public access areas?

Will there be work that generates moderate to high levels of dust?

Key: No Risk 0 Limited Risk 3 High Risk - 5

Assessment Performed by: Review By:

Project Manager/COTR Infection Control

Project Designer Safety Officer

Facility Manager

Environmental Specialist

Guidelines Y/N Risk Areas to be Impacted

Control Activities Needed

Will there be major demolition or new construction?

-Public access areas?

Are there hazardous material concerns?

-Non-Patient care areas?

ELECTRICAL SAFE WORK PRACTICES

MCP EC-27

Butler VA Health Care System Butler, PA 16001

Signatory Authority:

Butler VA Health Care System Director

Responsible Owner:

Chief, Facilities Management

Rescinded Document:

see paragraph 7.

Effective Date:

May 15, 2023

Recertification Date:

May 15, 2028

1. POLICY

This medical center policy MCP-EC-27 Electrical Safe Work Practices establishes electrical safe work practices standards and requirements for employees facing a risk of electric shock. The purpose of this program is to protect all employees, contractors, and visitors from injury due to electrical hazards that cannot be completely controlled by design or using lockout/tagout. This program is written to comply with the regulations set forth by OSHA in 29 CFR 1910, Subpart S, National Fire Protection Association (NFPA) 70E, and VHA Directive 1028, Electrical Power Distribution. This program applies to all employees and contractors working on, near, or with premises wiring. Furthermore, this program forbids all employees and contractors from conducting live electrical work except during emergency situations as determined by the Director. These situations will be approved using an Energized Electrical Work Permit. The only exceptions to this are those outlined in VHA Directive 1028, Electrical Power Distribution and NFPA 70E, section 130.1[B][3].

2. JUSTIFICATION

This policy exists to meet the following:

a. Veterans Health Administration (VHA) Directive 1028, Electrical Power Distribution Systems, dated February 24, 2020

b. OSHA 29 Code of Federal Regulations [CFR] 1910.331-335

c. National Fire Protection Association (NFPA) 70E

3. RESPONSIBILITIES

a. The Chief of Facility Management and Engineering Services is responsible for the following:

(1) Developing and publishing the written Electrical Safe Work Practices Program.

May 15, 2023 MCP EC-27

(2) Ensuring department-wide electrical safety standard operating procedures (SOPs) are developed and implemented for all employees under Facilities direct supervision.

b. The Safety Manager is responsible for the following:

(1) Assisting the Chief of Facility Management and Engineering Services with Electrical Safe Work Practices Program reviews and audits of SOPs, and training records.

(2) Upon request, assisting supervisors in coordinating training for relevant employees.

(3) Evaluating arc flash and shock hazard assessments to determine the proper types of Personal Protective Equipment (PPE) for relevant locations.

c. The Maintenance Supervisor has the following responsibilities:

(1) Compiling a list of qualified persons based on electrical training certifications, competencies, and individual observations and performance evaluations.

(2) Coordinating electrical safety training for all qualified personnel working on or near live electrical circuits and equipment in accordance with section 5.0 of this program.

(3) Coordinate arc flash and shock hazard assessments/surveys to evaluate electrical power distribution systems installations, changes in equipment, and for periodic updates, to ensure proper labeling and ratings are in place to determine the proper types of Personal Protective Equipment (PPE) and procedures are available for work plan development.

(4) Along with other supervisors (such as IT, in some cases), coordinate electrical safety training for new and reassigned personnel who may be exposed to electrical hazards, and maintains training records of these sessions.

d. Supervisors are responsible for the following:

(1) Ensure all qualified or affected employees under their direction have received the level of electrical safety training necessary to safely perform their job.

(2) Requiring employees to follow the safe work practices outlined below in section V, Work Practices, when performing work in your area of supervision.

(3) Along with the Maintenance Supervisor, coordinate electrical safety training for new and reassigned personnel who may be exposed to electrical hazards, and maintains training records of these training sessions.

(4) Develop standard operating procedures for the specific tasks within the department that require electrical work by employees under their direct supervision.

(5) Perform the PPE risk analyses, update when new risks are identified, and review annually.

(6) Conduct pre-job planning and develop written job-specific procedures to be followed by qualified employees performing electrical work.

(7) Supervisor must conduct a pre-job briefing, prior to starting a job that involves working on or near exposed energized components, with all workers involved.

(a)The briefing must include all applicable hazards, methods to control hazards, work procedures, special precautions, energy source controls, and PPE required.

(b) Review NFPA 70E Table 130.7(C)(15)(a) and Table 130.7(C)(16) for task Hazard/Risk Category, PPE and Insulated tool requirements prior to start of work.

(c) In general, only one job briefing must be conducted for tasks that are similar in nature and hazards. If further tasks are required that exhibit additional or greater hazards, another job briefing will be required prior to the start of work.

(d) Job briefing information and attendees can be documented using the Energized Electrical Work Permit in the space provided.

e. Employees are responsible for attending and participating in scheduled training sessions and following safe work practices, including completion of electrical safety inspections.

f. Logistics/Purchasing Agents are responsible for ensuring that electrical safety equipment, such as insulating gloves and mats, meets applicable American Society for Testing and Materials (ASTM) and American National Standard Institute (ANSI) testing requirements prior to ordering.

g. VA Medical Facility Director. The VA medical facility Director is responsible for ensuring overall VA medical facility compliance with this policy, and appropriate corrective action is taken if non-compliance is identified.

4. WORK PRACTICES

a. The Veterans Health Administration (VHA) established Directive 1028, Electrical Power Distribution Systems, requires facilities to develop and implement a management system to prevent unapproved work on energized electrical equipment.

(1) Three high priorities were identified that must be followed in order, when work is performed on electrical circuits:

(a) First, disconnect the electrical circuit and perform lockout/tagout. VHA Directive 1028 states, "electrical work is executed with all proximate energized circuits de-energized."

(b) Second, schedule a system shutdown to accommodate safe electrical maintenance. VHA Directive 1028 also states that, "It is the intent of this directive to make planned electrical system shutdowns for maintenance/repair the standard operating procedure, not the exception."

(c) Third, as a last resort, when a planned outage cannot be accomplished, the following are mandatory for working on energized circuits:

1. An energized circuit work permit must be obtained before conducting live electrical work. All energized electrical work permits must have the prior knowledge and approval of the facility Director.

2. Before initiating work, a specific work plan is developed, and a peer review of the plan is documented.

3. Evaluate the current arc flash hazard and shock hazard analyses conducted in accordance with NFPA 70E and the Institute of Electrical and Electronic Engineers (IEEE) 1584, Guide for Performing Arc Flash Hazard Calculations, and update the arc flash hazard and shock hazard study, prior to proceeding, if the review identifies a change in equipment, operating processes, or procedures as determined by the qualified person and the Chief of Engineering.

(d) Full and proper arc-rated personal protective equipment (PPE) must be available and used by qualified employees working on or near energized circuits.

(3) Before proceeding, please recognize that only qualified persons, as defined in 29 CFR 1910.399, may handle, adjust, repair, or replace electrical components or equipment.

b. PPE

(1) Protective equipment will be maintained in a safe, reliable condition and visually inspected prior to each use. Rubber-insulating gloves must be tested by ASTM method D 1048-93 before first issue and every 6 months thereafter or replaced. Rubber-insulating blankets must be tested by ASTM method D 120-87 before first issue and every 12 months thereafter in accordance with NFPA 70E. Hot sticks must be tested before first issue and every 24 months thereafter or replaced.

(2) Employees working in areas with potential electrical hazards will use PPE appropriate for the body parts to be protected and for the hazard to be encountered.

Always refer to the most recent edition of the Fault Current Study and Flash Hazard Analysis for details.

(3) Protective equipment subject to damage during use will have the insulating material protected by a material such as leather to prevent insulation damage.

(4) Wear appropriate PPE for the hazards encountered and use rubber insulated (and tested) blankets or other insulation to prevent contact with live electrical circuits.

Switchboard matting is also available for use. Use eye, face, and bodily protection when the possibility of electrical arcs, flashes, or explosions is present. Electrical PPE includes insulated gloves, flame-retardant aprons, face shields, goggles, electrical hazard rated footwear, fire rated coveralls/clothing and insulated hard hats.

(5) Whenever possible, stand on switchboard matting and avoid touching grounded objects.

c. De-energized parts:

(1) Current-carrying parts and equipment shall be disconnected from all sources of hazardous energy (including stored energy in capacitors, accumulators, springs, etc.)

before an employee works on or near them. Working with energized equipment is only permitted when de-energizing introduces additional/increased hazards or is infeasible due to equipment design or operational limitations (deactivating alarm systems, removing lighting from critical areas). In these cases, work will only be permitted after the Director approves an Energized Electrical Work Permit, unless otherwise specified in VHA Directive 1028, Electrical Power Distribution Systems or NFPA 70E, section 130.1[B][3].

(2) Follow lockout/tagout procedures to disconnect equipment from power sources before performing maintenance or repairs. Interlocks, selector switches, push buttons and the like will not be used as a substitute for formal lockout/tagout procedures.

(3) If a circuit can only be tagged out, use one additional measure to ensure the same level of protection as a locked-out condition. Examples include physically blocking a control switch, removing a fuse, or opening a second isolating switch.

(4) Conductors that have been de-energized, but not locked/tagged out, shall be treated as energized, and appropriate safety-related work practices shall be used.

d. Energized Parts

(1) If exposed parts are not de-energized, safety-related work practices appropriate for the conditions and conductor voltage shall be used.

(2) Only qualified persons are permitted to work on, or near, exposed live electrical components, including machine electrical control panels and components. Exception: for the purposes of confirming circuit activity during routine workplace inspections, the Safety Officer and Facilities Manager are permitted to use low voltage AC or DC testing devices.

(3) Live electrical work will only be permitted after the Director approves an Energized Electrical Work Permit, unless otherwise specified in VHA Directive 1028, Electrical Power Distribution Systems or NFPA 70E, section 130.1[B][3]. As a rule, live electrical work for VA employees will not be approved for hazard risk levels greater than two.

(4) Perform live work in conjunction with a second qualified person possessing equivalent PPE for the task at hand.

(5) Treat all circuits as though they are live unless proven otherwise with a multi-meter.

(6) When normally enclosed live parts are exposed for maintenance or repair, the parts shall be guarded to protect unqualified persons from contact with the live parts.

(7) Use non-conductive ladders (not metal ladders) when working on or near live electrical equipment.

(8) Employees may not enter spaces containing exposed energized parts unless illumination is provided to enable safe work. Persons may not perform tasks near exposed energized parts with a lack of illumination or an obstruction that hinders the observation of work. Employees shall not reach blindly into areas that may contain energized parts.

(9) Wear appropriate PPE for the hazards encountered and use rubber insulated (and tested) blankets or other insulation to prevent contact with live electrical circuits. Note that switchboard matting is also available for use. Use eye, face, and bodily protection when the possibility of electrical arcs, flashes, or explosions is present. Electrical PPE includes insulated gloves, flame-retardant aprons, face shields, goggles, electrical hazard rated footwear, fire rated coveralls/clothing, and insulated hard hats.

(10) Handle all conductive materials and equipment in a manner that prevents them from contacting energized conductors or circuit parts.

(11) If long conductive objects (such as metal ducts or pipes) must be handled, techniques such as the use of insulation and guarding will be employed to minimize the hazard.

(12) Do not wear rings, bracelets, watch bands, or other jewelry or conductive items while working on electrical equipment.

(13) Use tools insulated for the circuit voltage whenever working on or around electrical circuits. The insulating material of tools and equipment shall be protected if it is subject to damage during use.

(14) Whenever possible, stand on switchboard matting and avoid touching grounded objects.

(15) Before working on high-voltage equipment that has been energized and then de-energized, ground the equipment to ensure that no residual voltage remains as a potential shock hazard.

(16.) Interlock switches may be bypassed by qualified persons only when necessary for troubleshooting, and then only temporarily. The interlock must be restored to normal at the end of troubleshooting.

(17) Housekeeping duties shall not be performed close enough for contact with live parts to occur. Electrically conductive cleaning materials, including steel wool, metalized cloth, silicon carbide, and conductive liquid solutions will not be used near energized parts.

e. Cord-and-Plug Equipment: This section applies to the use of cord-and-plug-connected equipment, including flexible cord sets such as extension cords.

(1) Inspection.

(a) Portable cord-and-plug-connected equipment and flexible cord sets (extension cords) shall be visually inspected for external defects before use. Defects include loose parts, deformed and missing pins, damage to the outer jacket or insulation, and possible internal damage from a pinched or crushed outer jacket.

(b) When defects or evidence of damage are detected that might expose employees to injury, the defective/damaged item shall be removed from service.

(2) General Handling.

(a) Portable equipment shall not be handled in a manner that will cause damage.

(b) Flexible electric cords connected to equipment shall not be used for raising or lowering equipment.

(c) Flexible cords may not be fastened with staples or otherwise hung in a manner that could damage the outer jacket or insulation.

(d) Portable electrical hand tools shall be unplugged when not in use.

(e) Flexible cords used with grounding-type equipment must contain a grounding conductor.

(f) Equipment with frayed cords or three-wire cord ends with the grounding prong removed will not be used.

(g) Attachment plugs and receptacles may not be connected/altered in a manner that prevents proper continuity of the ground at the point where plugs are attached to receptacles.

(h) Plugs and receptacles may not be altered to allow the grounding pole to be inserted into current connector slots.

(i) Adapters that interrupt the continuity of the equipment grounding connection may not be used.

(j) Use a Ground Fault Circuit Interrupter (GFCI) with temporary wiring or in wet or moist locations.

(k) Maintain a 36” clearance around electrical control panels and circuit breaker panels at all times. Clearance must be maintained for all sides of the panel that may require access (to replace fuses, etc.). Keep electrical panel doors closed.

(l) Do not use temporary wiring for permanent installations or locations.

(3) Conductive Work Locations

(a) All portable electric equipment and flexible cords used in highly conductive areas shall be approved for use in such locations. This includes areas with water, other conductive liquids (such as oil), or extremely moist atmospheres.

(b) Use a GFCI with temporary wiring or in wet or moist locations

(c) Employees shall not plug, unplug, or otherwise handle flexible cords and portable equipment with wet hands.

(d) Insulated protective equipment must be used to handle energized plug and receptacle connections if they are wet or might provide a conducting path to employees' hands.

(e) Locking-type connectors shall be properly secured over connections in wet or moist atmospheres.

f. Electric Power and Lighting Circuits.

(1) Only load-rated switches, circuit breakers, or other devices specifically designed as a disconnecting means may be used for opening, reversing, or closing circuits under load conditions. Cable connectors, fuses, terminal lugs, and cable splice connections not of the load-break type may not be used for opening, reversing, or closing circuits under load conditions, except in an emergency.

(2) Repetitive manual closing of circuit breakers or re-energizing of circuits through multiple replaced fuses is prohibited.

(3) Once a circuit is de-energized by a circuit protective device (such as a fuse or circuit breaker), it must be determined that the equipment can be safely energized before the circuit is manually reset.

(4) When the design of the circuit and the overcurrent device involved indicate that the circuit tripped due to an overload rather than a fault, no examination of the circuit or connected equipment is needed before re-energizing the circuit.

(5) Overcurrent protection devices may not be modified, even on a temporary basis, beyond normal system design.

g. Test Equipment and Instruments

(1) Test equipment and their accessories shall be rated for the circuits and equipment to which they will be connected and shall be designed for the environment in which they will be used.

(2) Only qualified persons are permitted to perform testing work on exposed electric circuits or equipment, unless otherwise designated in section V, paragraph C, above.

(3) All test equipment and associated test leads, cables, power cords, and probes shall be visually inspected by the employee for external defects and damage before the equipment is used.

(4) If defective or damaged items are discovered that might expose an employee to injury, the items shall be removed from service.

h. Occasional Use of Flammable or Ignitable Materials: Where flammable materials are occasionally present, electrical equipment capable of igniting the flammable materials will not be used unless appropriate measures are taken to prevent hazardous conditions from developing. Flammable materials include, but are not limited to:

flammable gases, vapors, or liquids; combustible dust; and ignitable fibers or flyings.

i. Alerting Techniques.

(1) The following alerting techniques shall be used when necessary to warn and protect employees from electrical shock hazards, burns, or failure of electric equipment parts:

(a) Safety signs, safety symbols, or accident prevention tags will be used where necessary to warn employees about electrical hazards. These devices will meet the requirements of OSHA 29 CFR 1910.145, Specifications for Accident Prevention Signs and Tags.

(b) Barricades shall be used in conjunction with safety signs where necessary to prevent/limit access to areas exposing employees to uninsulated energized conductors.

Conductive barricades will not be used if they could cause an electrical hazard.

(c) An attendant shall be stationed as needed to warn and protect employees if signs and barricades do not provide enough protection.

j. Minimum Approach Distances

(1) Unqualified persons will maintain a minimum clearance of 11 feet from:

(a) Overhead lines carrying more than 480 volts.

(b) Conductors leading to the incoming side of switch gears and transformers.

(2) This distance shall be measured from the conductor to the person or nearest conductive object with which the employee has contact, including a man lift or scissor lift.

(3) Qualified persons will adhere to “approach” distances set forth in the table below, whether working from the ground or in an elevated position.

APPROACH DISTANCES FOR QUALIFIED PERSONS EXPOSED TO

ALTERNATING CURRENT

Voltage Range (phase to phase) Minimum Approach Distance 300V and less Avoid contact

Over 300V, not over 750V 1 ft. 0 in.

Over 750V, not over 2kV 1 ft. 6 in.

Over 2kV, not over 15 kV 2 ft. 0 in.

Over 15kV, not over 37kV 3 ft. 0 in.

Over 37kV, not over 87.5kV 3 ft. 6 in.

Over 87.5kV, not over 121kV 4 ft. 0 in.

Over 121kV, not over 140kV 4 ft. 6 in.

k. Training:

a. All-qualified persons will be trained in the requirements of 29 CFR 1910 Subpart S, NFPA 70E, and the safe work practices outlined in this procedure.

(1) Every employee working at Butler VA Health Care System facilities who face the risk of electric shock from working on or near energized or de-energized electrical sources will receive training in electrical related safety work practices pertaining to the individual's job assignment. The goal of the electrical safety training program is to ensure that all employees understand the hazards associated with electric energy and that they can perform the necessary steps to protect themselves, their coworkers, and visitors.

(2) Training shall be presented before the employee is assigned duties on or near electrical systems, or whenever supervisors determine that an employee doesn’t have the necessary knowledge or skills to work safely near electrical systems. Exception: For NFPA 70E gaps, a supervisor may simply restrict a new or transferred employee from conducting live electrical work until appropriate training is received. Presenting safe work practice and Subpart S training will allow these employees to perform electrical work in a de-energized state.

(3) All non-qualified employees shall be instructed that they are not allowed to approach unguarded electrical workspaces or perform work on electrical components.

Work on electrical components includes accessing electrical enclosures or resetting of electrical breakers.

(4) In addition to the basic training elements, "qualified" employees will be trained in the skills and techniques necessary to identify exposed live parts, determine nominal voltages, and clearance distances and corresponding voltages. Such persons shall also be able to perform job safety planning, assess associated risk, and select proper control methods and PPE. This Electrical Safety Policy shall be reviewed with all qualified employees to include supervisors who are required to work on or near electrical components.

(5) All personnel that perform electrical work on Butler VA facility distribution systems or equipment or perform tasks with exposure to electrical hazards must complete the appropriate training as required by OSHA and the NFPA.

(a) Specific items to be reviewed with qualified employees include:

1. The meaning of Electrically Safe Work Conditions;

2. Working with energized components and systems;

3. Flash protection boundaries;

4. Arc flash hazard assessments;

5. The Electrical Safety Matrix;

6. Shock hazard approach boundaries;

7. Shock hazard assessments;

8. Selection, inspection, and testing of personal protective equipment and tools; and

9. Lockout/Tagout

a. Lockout and tagging of conductors and parts of electrical equipment.

b. Safe procedures for de-energizing circuits and equipment.

c. Application of locks and tags.

d. Verification that the equipment has been de-energized.

e. Procedures for reenergizing the circuits or equipment.

f. Other electrically related information which is necessary or employee safety.

(6) This facility will document that each employee has received the required training. This documentation will be made when the employee demonstrates proficiency in the work practices involved and will be maintained for the duration of the employee’s employment.

(7) The employee training documentation will contain the date(s) of training, the instructor(s) name, a copy of the written material presented, and the names of the employee(s) to whom the training was given.

5. DEFINITIONS

a. Accumulator: A storage unit that holds a charge of hydraulic pressure to be released at specific times during an operation. Accumulators represent a potential source of lethal energy and must be rendered safe during lockout/tagout scenarios by safely releasing stored pressure.

b. Ampacity: A current-carrying capacity of electric conductors expressed in amperes.

c. Approach Boundaries (Shock Protection Boundaries):

(1) Limited: An approach limit at a distance from an…