Attachment G - ILSM Checklist Permit.pdf

HSP 003S-04

Attachment A

VA LONG BEACH HEALTHCARE SYSTEM

INTERIM LIFE SAFETY MEASURE (ILSM) ASSESSMENT CHECKLIST

WHAT (brief description of deficiency): __ WHERE (areas affected):

Building(s) #: Floor(s): Room(s)#:

FIX (corrective action planned):

WORK (description to be performed): _ _ PERMITS (in conjunction with): Hot work Above the Ceiling & Penetration Energized Work Permit N/A TIMELINE Implementation Date/Time: Completion Date/Time:

Deficient Life Safety Conditions (as a result of any construction / rehabilitation) YES NO N/A If YES, implement ILSM & applicable PROVISIONS

A Existing EXITS are obstructed. 3, 5, 9, 10, 12, 13, 14

B Emergency responders’ access is limited or impaired. 3,4, 5, 9, 12, 14

C Disruption of FIRE ALARM SYSTEM is greater than 4 hours in a 24-hour period. 2, 4, 5, 6, 7, 9, 13, 14, 15

D Disruption of FIRE SUPPRESSION SYSTEM is greater than 10 hours in a 24-hour period. 1, 2, 6, 7, 9, 10, 12, 13, 14,15

E Temporary construction partitions are erected. 8, 9, 10, 12, 13, 14

F Fire and smoke compartments will not remain intact. 9, 10, 12

G Demolition in construction area that generates major amounts of debris 7, 8, 9, 10, 12

H Doors locked against egress. 3, 4, 8, 9, 11, 12

I Fire exit stairs discharge improperly. 3, 7, 8, 10, 13

J Greater than 150 feet travel distance to an approved exit. 8, 9, 13

K Lack of two remote exits. 7, 8, 9, 10, 12

L Nonconforming building construction material. 6, 8, 9, 10, 11, 13,15

M Improperly protected vertical openings 8, 9, 12

N Penetrations in fire/smoke barriers. 7, 8, 9, 10, 11

O Corridor walls do not extend to the structure 8, 9, 11, 12

P Major renovation of an occupied floor. 3, 4, 5, 6, 8, 9, 11, 12,15

Q Replacing or repairing fire alarm system (out-of-service). 3, 4, 7, 8, 9, 11

R Replacing or repairing sprinkler system (out-of-service) 2, 5, 6, 7, 9, 10, 13,15

S Significantly modifying smoke or barrier walls. 5, 8, 9, 11, 12

T Blocking off an approved exit 3, 4, 5, 9, 12, 13

U Disconnecting alarm devices 4, 5, 7, 8

V Other (specify):

PROVISIONS: To put in place, to effectively COMPENSATE Life Safety Deficiency that cannot be immediately corrected.

1. Ensure the Chief of OSEMS provides notification to LB Fire Department (or other emergency response group, e.g., VA Police), when a fire alarm (FA) or fire suppression (FS) system is out of service more than 4 hours (FA) or 10 hours (FS), in a 24-hour period: in an occupied building (notification is documented).

2. Initiate a fire watch when: a fire alarm system is out of service for more than 4 hours, w/in a 24-hour period, or a fire suppression system is out of service more than 10 hours in a 24-hour period in an occupied building. Utilize Attachment – B (VALBMC Fire Watch Action Log), to document Fire watch / times.

3. Ensure access and post signage identifying the location of alternative exits to everyone affected.

4. Ensure alternate access for emergency services.

5. Inspect exits in affected areas on a daily basis.

6. A temporary but equivalent fire alarm and detection systems shall be provided when a fire system is impaired. Ensure fire alarm and detection systems are in good working order.

7. Provide additional firefighting equipment. Write type and location of firefighting equipment:

8. Ensure temporary construction partitions are smoke tight or made of noncombustible or limited-combustible materials that will not contribute to the development and spread of fire.

9. Smoking is NOT allowed at VALBMC. Increase surveillance of: buildings, grounds, & equipment storage; w/ extra attention to construction areas, excavations, & temp field offices.

10. Enforce storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

11. Provide additional training to those who work in the hospital on the use of firefighting equipment.

12. Conduct one additional fire drill (tour of duty) per quarter.

13. Conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.

14. Train those who work in the affected areas and construction personnel to compensate for impaired structural or compartmental fire safety features.

15. Inspects and tests temporary systems monthly. Document completion dates of tests.

Signatures of Persons Implementing (sign/date):

1.Initiator/COR: 2. General Contractor Competent Person:

3. Project Section/Unit Supervisor: 4. Chief/M&O

5. APPROVED by (Chief of ENGINEERING): Date:

6. FINAL APPROVAL (Chief of OSEMS): Date:

HSP 003S-04

Revised January 2020