Attachment 05 - SOP 138-02 FMS Safety Plan 2023.pdf

FACILITIES MANAGEMENT SERVICE SAFETY PLAN

SOP 138-02

Sheridan VAHCS Sheridan, WY 82801

Signatory Authority:

Chief, Facilities Management Service

Responsible Owner:

Chief, Facilities Management Service

Service Line(s):

Facilities Management Service (FMS)

Effective Date:

Apr 7, 2023

Recertification Date:

Apr 7, 2028

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures to provide a physical environment free of hazards and manage staff activities to reduce the risk of human injury. This SOP must be followed by all employees who work in Facilities Management Service.

b. There is no governing document.

2. PROCEDURES

a. Safety training. Facilities Management Service (FMS) supervisors will review safety training requirements upon assignment of specific tasks, annually, and as needed. Supervisors will assign additional training via TMS as required. Supervisors are responsible for tracking the safety training of their assigned staff via TMS.

Supervisors are evaluated as part of their performance apprasials for Safety, which will include discussing safety requirements with their staff. All FMS Staff that go onto APU are required to complete MHEOC (Mental Health Environment of Care) training, TMS #1290950. This will be tracked through the Construction Safety Committee. The committee will review compliance twice a year for 95% Training Completed, dates to be reported are January and June.

(1) General safety. General safety training consists of safety classes related to on the job safety hazards. These classes are assigned in TMS by national VA, VHA, FMS or the supervisors. Completion status is documented in TMS and TMS reports are used to monitor completion status.

(2) Specific training. All new employees will be given specific training with respect to their assigned section by their supervisor before beginning work. Refresher training will be assigned when required through TMS. All training will be documented in TMS and completion status is reviewed during the performance rating cycle.

(3) Annually. All employees will complete the annual Fire/Safety refresher, Infection Control Procedure, and attend other training such as respirator, asbestos, etc. as required by work performance.

May 10, 2022 SOP 138-02

(4) Contractor Training. While contractors do not have access to to TMS, the Contracting Officer’s Representative (COR) for the contract will ensure that all contractor staff are trained in this SOP and shall ensure the contractor documents the training of the contractor’s staff. This is documented in the CORs daily project logs and in the contractor’s safety plan submittal. The contractors safety plan submittal will include tool security, and jobsite security as it pertains to patient safety within a hospital environment. This will be reported in the COR’s daily project logs and COR will review Contractor’s daily logs weekly to ensure daily safety training is being conducted before work starts for the specific area the work is being done.

Work Monitoring.

(1) Supervisors are responsible to ensure work accomplished under their direction/control is accomplished using established safety procedures and appropriate personal protective equipment (PPE) is used when required.

(6) All employees are required to observe common sense safety practices.

(7) Facilities Management Service and employees have the responsibility to abate hazardous conditions throughout the Medical Center. Work orders that address safety items need to be monitored and given a high priority.

(8) In all cases where a near miss (accident/injury) occurs, it is the responsibility of the employee to report it to the supervisor. It is then the responsibility of the supervisor to investigate the causes of the near miss and eliminate the hazard, as most near misses eventually become an accident/injury.

b. Protective Equipment

(1) Each employee will be issued personal Protective Equipment as outlined in FMS PPE Policy SOP 138-05.

(2) Items of PPE not listed, such as respirators, will be issued through the Medical Center Safety Office.

c. Asbestos

(1) If asbestos containing material is suspected during the course of work, all work will cease, and the supervisor and the Safety Office will be notified immediately. If asbestos is identified the procedures outlined in Asbestos Management Program, SOP 138-101 will be followed.

d. Trenching, Excavation, Shoring

(1) All trenching, excavation, and shoring activities on the Sheridan VA campus must adhere to OSHA 29 CFR 1926 Subpart P – Excavations (1926.650 – 652). All soils on the Sheridan VA campus are classified as Type C Soils.

e. Tool Control

(1) As one of the primary missions of the Sheridan VAMC is the treatment of patients for a variety of mental health issues, it is vitally important to keep tools and other items, that offer a patient the opportunity for self-harm, under control at all times. All FMS Staff that go onto APU are required to complete MHEOC (Mental Health Environment of Care) training, TMS #1290950. This will be tracked through the Construction Safety Committee. The committee will review compliance twice a year for 95% Training Completed, dates to be reported are January and June.

(2) Tools, extension cords and similar items should not be left out unattended where patients can gain access to them. This includes in the open backs of maintenance vehicles. Tools should be locked in a job box, some other type of toolbox or within a room that can be secured from unauthorized access.

(3) There are special procedures for tool control on the Acute Psych Unit (APU). Due to the high self-harm/suicide risk on the APU, the following procedures will be followed for work on that unit.

(a) Prior to work on the APU the Maintenance Supervisor will conduct a safety brief with the workers “Just In Time Training”, discussing the importance of tool control while on the APU.

(b) Even if work is being accomplished in an area that can be secured from patient access, workers need to minimize the tools that are out and take tools with them when they leave. Any tools that need to remain overnight or unattended need to be in locked tool box before leaving the room. If work is being done in a public area of the APU (a public area is definded as any area with APU that patients are able to access on their own, without being escorted/let in by staff), then the two-person rule shall be used, to the maximum extent possible, one person to do the work and one to monitor the area to ensure that patients do not access tools or materials. Two person rule applies to the public areas such as common spaces, hallways, patient rooms and bathrooms. One person to complete the work and one person to monitor tools while in those spaces.

APU staff may be asked to perform the monitoring function in such cases as night and weekend emergency calls, where only a single FMS staff member is available. These same rules shall apply to contractors working on APU.

(c) In no case shall tools be left out overnight behind a locked door. All tools need to be secured in a locked tool box behind the locked door or removed from the unit overnight.

(d) Workers shall not assume that a door will automatically lock behind them and shall always double check that a room door actually locks behind them. To the maximum extent practicable the workers shall have a second person double check that the door is in fact locked, before leaving the unit.

f. Other

(1) Off Work Safety. Safety does not stop when leaving the worksite. Good safety practices become a habit if practiced off-duty as well as on-duty.

(2) When cleaning up broken glass, do not handle it directly. Use a broom and dustpan to pick it up and dispose of it in trash.

(3) Special procedures for the battery charging room on the old linen dock requires charging to take place under the hood with the fan running. All battery charging will be accomplished in a well-vented area.

g. Injury/Accident

(1) In the event of an accident involving injury to yourself or a fellow employee, report the situation to your supervisor as soon as you can. If you believe the situation requires immediate attention, call a “Code Blue” by dialing 5555 if you are inside a building connected to the Tram, if not dial 911 and report the situation as outlined in MCP 111-07 Emergency Health Care Services.

(2) If you observe a spill of a dangerous substance such as mercury or pesticide, do not attempt to clean it up. Call your supervisor and the Safety Office immediately and try to keep visitors and patients out of the area.

h. Facilities Management Service Safety Sub-Committee

(1) Facilities Management Service safety issues will be discussed at the monthly service meeting. Items of concern will be addressed and reported at the following months meeting.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Supervisors are responsible for tracking the safety training of their assigned staff.

b. The COR for the contract will ensure that all contractor staff are trained in this SOP and shall ensure the contractor documents the training of the contractor’s staff.

4. DEFINITIONS

a. None.

5. REFERENCES

a. OSHA 29 CFR 1926, Subpart P – Excavations (1926.650-652)

b. SOP 140-11, Personal Protective Equipment, dated December 14, 2016

c. MCP 140-10, Respiratory Protection Equipment, dated October 15, 2020.

https://www.osha.gov/laws-regs/regulations/standardnumber/1926/1926SubpartP https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FSafety%20%28140%29%2FSOP%20140%2D11%20PERSONAL%20PROTECTIVE%20EQUIPMENT%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FSafety%20%28140%29 https://dvagov.sharepoint.com/sites/VHASHE/MCMs/Safety%20(140)/MCP%20140-10%20Respiratory%20Protection%20Equipment.pdf

d. SOP 140-05, Waste Management, dated December 10, 2021.

e. MCP 140-23, Confined Space, dated May 1, 2022.

f. MCP 111-07, Emergency HealthCare Services, dated September 28, 2016,

g. SOP 138-04, FMS Disaster Plan, May 10, 2022

h. SOP 138-05, Personal protective Equipment Policy, dated May 10, 2022.

i. SOP 138-16, Electrical Safety, dated May 10, 2022.

j. SOP 138-101, Asbestos Management Policy, dated May 10, 2022.

k. Facility Safety, Occupational Health and Fire Protection Plan

l. Medical Center Infection Control Manual

m. Medical Center Disaster Plan.

6. REVIEW

Frequency of required review, at minimum at recertification, when there are changes to the governing document, national policy or a health care accreditation body mandate, and any regulatory requirement for more frequent review.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of Apr 2028.

In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

X Stephen Petzold

Signed by: Stephen C. Petzold 1391921

Stephen Petzold Chief, Facilities Management Service Date Approved: Apr, 07 2023

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

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