MCM 140-02 CONSTRUCTION SAFETY-2019.pdf

MCM 140-02, Page 1

Medical Center Memorandum VA Health Care System No. 140-02 Sheridan, WY February 20, 2019

CONSTRUCTION SAFETY

1. SUMMARY: Medical Center Memorandum (MCM) 140-02 dated January 7, 2016, is rescinded. This update reflects minor changes in references and policy.

2. PURPOSE: To establish policy and procedures to ensure that construction projects will be planned, coordinated, and regularly inspected to ensure compliance with applicable fire, infection control, environmental, security, safety and occupational health regulations and policies.

3. POLICY:

A. This policy is established for the Sheridan VA Health Care System (SVAHCS) in order to protect patients, staff, visitors, and contractors from safety and health hazards associated with construction activities. This policy requires that strategies be established to control the hazards inherent in conducting construction or maintenance operations in areas that are occupied by patients, visitors or health care staff. These strategies include the assignment of appropriate responsibility at all levels of the organization, establishing and maintaining the necessary expertise to manage an effective construction health and safety program, applying technical guidance and best practices to assist in managing the program, and providing a construction safety multi-disciplinary team to oversee and enforce the application of this policy.

B. Construction activities shall be defined to include delegated minor or non-recurring maintenance projects performed by contractors or purchase and hire personnel, as well as station-level projects performed by contractors, purchase and hire personnel or station maintenance personnel. Construction shall also include non-delegated projects including majors. SVAHCS shall coordinate those construction impacts with the project’s Contracting Officer Representative (COR) through a SVAHCS single point of contact. This definition also applies to enhanced-use and lease projects related to structures for which SVAHCS maintains management responsibility or authority.

C. The intention of this construction safety program is to reduce the potential for injury and illness to VA patients, employees and visitors that might result from unsafe construction activities; to increase the level of construction safety expertise of VA employees; to decrease the potential for serious Occupational Safety and Health Administration (OSHA) violations; to provide a guideline for addressing safety-related construction issues; and to reduce the potential for property and liability exposures due to construction-related activities.

MCM 140-02, Page 2

D. Proper application of this program will reduce the potential for liability, which could result from construction accidents, life safety deficiencies or infection control failures.

4. RESPONSIBILITY:

A. SVAHCS Director:

(1) Establish and monitor an effective facility construction safety program.

(2) Establish a multidisciplinary team (Construction Safety Committee) with representatives from the following program areas:

(a) Infection Control

(b) Patient Safety

(c) Occupational Safety

(d) Police

(e) FMS (Engineering, Maintenance)

(f) Green Environmental Management Systems (GEMS)

(g) Local Union Safety Representatives

(h) Employee Health

(3) Ensure appropriate staff receives training in construction safety.

(4) Ensure Competent Persons (CPs) are designated who have the necessary training, experience and authority to carry out their responsibilities with respect to safety and health during construction activities. Note: OSHA Title 29 Code of Federal regulations (CFR) 1926.32(f) states “competent person means one who is capable of identifying existing and predictable hazards in the surroundings and working conditions which are unsanitary, hazardous or dangerous to employees, and who has the authorization to take prompt corrective measures to eliminate them.” Qualified VA staff must be appointed to serve as CP for construction work performed by VA employees. The name and qualifications of the CP must be identified in writing and noted in the minutes of the facility safety committee (or equivalent body) responsible for the safety management functions as defined under The Joint Commission Environment of Care Standards.

(5) Ensure the Construction Safety Committee functions to:

(a) Protect patients, visitors, and employees from injury, illness, as well as occupational and nosocomial infections related to construction activities.

MCM 140-02, Page 3

(b) Oversee compliance with OSHA and state construction safety regulations.

(c) Oversee compliance with Environmental Protection Agency

(EPA) and state environmental regulations.

(d) Oversee compliance with Federal Acquisition Regulation

(FAR) and VA Acquisition Regulation (VAAR) in addressing the contractor’s construction safety program.

(e) Respond to, investigate and report violations of these policies to upper management.

(6) Develop and implement a written facility policy addressing the responsibilities of the Construction Safety Committee.

(7) Ensure that the following VA staff complete OSHA’s 30-hour construction safety training and, as a refresher, subsequently complete at least 10 hours of construction safety related training every 2 years:

(a) VHA Chief Engineers, Contracting Officer’s Technical

Representative (COTR) Project Engineers, and Project Lead Persons;

(b) Construction Safety Officers (CSO) and facility Safety

Program Managers; and

(c) Other members of the multi-disciplinary team, as appropriate.

(8) Ensure that construction contracts awarded specify that on-site general and sub-contractor’s construction workers have completed the OSHA 10-hour construction worker course, the 30-hour construction safety course, or other relevant competency training, as determined by the VA CP with input from the Construction Safety Committee. The determination for training is based on the project hazards and complexity, state and federal regulations and VA requirements.

B. Associate Director: Has delegated responsibility from the SVAHCS

Director, as appropriate, for oversight of these policies.

C. Chief, Facilities Management Service:

(1) Has delegated responsibility from the Associate Director, as appropriate, for oversight of these policies.

MCM 140-02, Page 4

(2) Ensures policies are addressed by all sections of engineering having oversight of construction.

D. Supervisory Engineer:

(1) Chairs Construction Safety Committee.

(2) Works through safety and health staff, CORs, maintenance staff, contractors and the Construction Safety Committee to plan, coordinate and monitor the construction safety program for all projects at the facility.

(3) Participates in OSHA’s 30-hour construction safety training and refresher courses.

(4) Participates in periodic inspections of construction sites to ensure compliance with safety elements of the construction contract and performance of the program.

(5) Supports the CPs, Safety Officer, Infection Control Nurse, Contracting Officer and engineering staff in implementing the construction safety program.

(6) Works with contracting staff to ensure competent staff are assigned as CORs to oversee work.

E. Maintenance Supervisor:

(1) Participates in OSHA’s 30-hour construction safety training and

(2) Participates in periodic inspections of in-house construction sites to ensure compliance with safety elements of the construction contract and performance of the program.

(3) Ensures in-house workforces have necessary training and competency for tasks being performed.

F. Biomedical Technicians: Ensures all construction accomplished in support of major equipment installations (as a part of the equipment purchase) are in compliance with this policy and these procedures.

G. Contracting Officer:

(1) Participation in OSHA’s 30-hour construction safety training and

MCM 140-02, Page 5

(2) Ensures safety elements of this policy are included in each construction contract.

(3) Evaluates past safety records of prospective contractors and considers this information in the contract award process.

(4) Supports the CP, Safety Officer, Resident Engineer, and appropriate staff in implementing the construction safety program.

(5) Works with the Projects Engineer to assign competent CORs as necessary.

H. Contracting Officer’s Representative (COR):

(1) Participates in OSHA’s 30-hour construction safety training program and refresher courses.

(2) Is trained and designated as a CP for the purposes of this policy.

(3) As the team member most familiar with the technical aspects of his/her designated project, inspects his/her projects on a daily basis to identify and document deficiencies in the work including safety and infection control, and acts to correct deficiencies on the spot whenever possible.

(4) Reports all deficiencies to the multi-disciplinary team whether corrected or not.

(5) Consults with other members of the team, as appropriate, to assure that all deficiencies are handled properly.

(6) Consults with members of the team during design or planning to establish the risks to be addressed and the degree of protection appropriate to the situation.

(7) Monitors compliance with relevant safety and health requirements by the contractor in the field.

I. VA Competent Person:

(1) Reviews project design submissions to assure project compliance with these policies.

(2) Monitors and inspects construction and renovation work sites weekly to assure compliance with these policies.

MCM 140-02, Page 6

(3) Maintains competence in the general inspection of work sites during construction, renovation and maintenance, which fall under the purview of this policy.

(4) Maintains higher level of competency when serving as CP for VA staff performing activities requiring CPs, such as fall protection, scaffolds and trenching. Note: The VA CP does not take the place of the contractor’s competent person nor acts on their behalf. The VA CP determines if the contractor is meeting VA standards and contractual requirements for safety and OSHA compliance. When these standards and contract requirements are not being met, the VA Contracting Officer’s Technical Representative (COR) and/or CP must take immediate action to prevent injury, non-compliance, and/or property damage.

(5) Participates in OSHA’s 30-hour construction safety training and

(6) Ensures that the specific safety requirements for construction operations are implemented and continuously observed during the course of all projects subject to this policy.

(7) Participates in the facility multidisciplinary team established for construction safety.

(8) Conducts periodic inspections of construction sites to ensure compliance with safety elements of the construction contract using the attached Job Safety Check Sheet.

(9) Approves corrective actions.

(10) Stops unsafe work or activities not complying with the contract or

OSHA and notifies the Contracting Officer immediately.

(11) Communicates mainly with the contractor’s CP on questions of safety.

J. Safety Manager:

(1) Participates in OSHA’s 30-hour construction safety training and

(2) Maintains oversight of the construction safety program to ensure implementation of VHA policy throughout SVAHCS.

(3) Participates in the construction safety committee and serves as subject matter expert for construction issues as appropriate.

MCM 140-02, Page 7

(4) Ensures necessary and relevant Interim Life Safety Measures ISLMs are established and implemented. Conducts required additional training for compliance with identified ILSMs.

(5) Renders technical advice and assistance as required regarding life safety and fire protection issues during construction and project design and development.

(6) Oversees compliance with OSHA and other relevant construction safety regulations.

(7) Ensures SVAHCS staff is trained as required by this memorandum.

(8) Ensures the construction safety program includes appropriate periodic construction site hazard surveillance.

(9) Stops unsafe work or activities not complying with the contract or

OSHA policy and notifies the Contracting Officer/COR immediately.

K. Infection Control Nurse:

(1) Advises and/or provides recommendations on exposure mitigation and the prevention of facility associated infections in patients, staff, and visitors.

(2) Coordinates with the manager of each construction project (in-house and contract) to conduct an Infection Control Risk Assessment (ICRA) during the planning and/or design stage of the work. ICRAs must be documented in writing and focus on eliminating, or minimizing, the risk of infection during construction and renovation activities.

(3) Monitors infection control during construction activities as indicated in ICRA for that project.

L. GEMS Coordinator:

(1) Provides guidance on environmental issues during design stage.

(2) Monitors contractor conformance to contract specifications, including environmental compliance and pollution prevention.

M. Construction Safety Committee (Multi-Disciplinary Team):

(1) Meets monthly when construction projects are on going and files reports to the facility Environment of Care Committee.

MCM 140-02, Page 8

(2) Determines the scope and depth of safety, infection control, environmental and security procedures appropriate for all construction work.

(3) Develops threshold criteria for each level of intervention. For example, after review, some projects may require only VA CP surveillance to ensure employee safety and OSHA compliance, while other projects will require all disciplines to be involved.

(4) Ensures submittals for contract construction or renovation work include the names, qualifications, and training dates for the contractors’ CPs designated to administer the site-specific safety program, as well as the CPs for other activities as required by OSHA regulation (such as scaffolds, cranes, excavations, etc.).

(5) Conducts Infection Control Risk Assessments (ICRA) using the attached ICRA Matrix. Using current AIA Guidelines, the staff must conduct and document ICRA for all construction projects during the design or planning stage of the work. ICRAs must be documented in writing and focus on eliminating or minimizing the risk of infection during construction and renovation activities. The complexity of the ICRA report is determined by the complexity of the threats posed by the construction project. Assigned VA staff, including resident engineers or project managers for major construction, must maintain compliance during the construction phase of the work.

(6) Identifies Interim Life Safety Measures (ILSMs). Facility safety and engineering staff must ensure that ILSMs are implemented on all construction work in accordance with The Joint Commission Environment of Care Standards.

ILSMs are required when construction activities pose significant temporary Life Safety Code deficiencies or hazards. Implementing ILSMs is the responsibility of the local medical facility and construction contractors in accordance with VA Master Specification 01010, General Requirements.

(7) Participates in all phases of construction work from planning through completion. This includes review and approval of the construction plans, contract specifications, and contract submittals related to construction safety and health and any other documents that may assist in the implementation of an effective construction safety program. The Construction Safety Committee must be involved early in the process and continue oversight on a regular basis to avoid costly and disruptive delays.

(8) Ensures the construction safety program includes periodic construction site hazard surveillance activities with appropriate membership, scope, and frequency for each project as determined by the CP, the ILSMs and ICRA reports. Hazard surveillance activities must be documented as to date, time, membership of the inspection team, deficiencies, type of corrective action, MCM 140-02, Page 9 and time and date of correction. Ensures corrective actions are tracked to completion.

(9) Implements procedures to ensure general contractors exercise their responsibility for ensuring subcontractors comply with this safety and health policy, and all other related contract requirements.

(10) Ensures all contractors entering VA property comply with the security management program. As a minimum, contractors must notify and obtain permission of the VA Police, be identified by project and employer, and be restricted from unauthorized access.

(11) Requires the contractors’ CPs to implement and maintain effective safety programs that identify and control hazards that may cause injury or illness to VA patients, staff, visitors, and contractor employees.

(12) Evaluates the effectiveness of the construction safety program in an annual report to the facility Safety Committee.

N. VA Police:

(1) Ensures all contractors entering SVAHCS property comply with the security management program.

(2) Conducts periodic surveillance of site security and the integrity of barriers for trenches and other hazards.

5. REFERENCES:

A. NFPA Codes and Standards, available at:

http://vaww.ceosh.med.va.gov/01CS/Pages/ASSE_Membership_Warning.shtml

B. APIC Infection Control Tool Kit Series: Construction and Renovation, available from the Association of Professional Infection Control Practitioners and Epidemiologists (APIC).

C. Guidelines for Design and Construction of Hospital and Health Care

Facilities, 2014, Facilities Guidelines Institute.

D. Guidelines on Assessment and Remediation of Fungi in Indoor

Environments, New York City Department of Health, Bureau of Environmental and Occupational Disease Epidemiology, at http://www.nyc.gov/html/doh/html/environmental/moldrpt1.shtml.

E. Infection Control During Construction, Third Edition, Wayne Hansen, November 2011.

http://vaww.ceosh.med.va.gov/01CS/Pages/ASSE_Membership_Warning.shtml http://www.nyc.gov/html/doh/html/environmental/moldrpt1.shtml

MCM 140-02, Page 10

F. OSHA Regulations for Construction Safety, 29 CFR 1926, available at:

http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=STANDARDS&p _toc_level=1&p_keyvalue=Construction.

G. U.S. Environmental Protection Agency Regulations, available at:

http://www.epa.gov/lawsregs/bizsector/construction.html.

H. Current Standards from The Joint Commission available at:

http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx.

I. VA Directive 7700, Occupational Safety and Health.

https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=428&FType=2.

J. VHA Directive 7701, Comprehensive Occupational Safety and Health

Program. https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5397

K. VHA Directive 7715, Safety and Health During Construction.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5380

L. VA Master Specification 01010, General Requirements.

6. RESPONSIBLE OFFICIAL: Occupational Safety and Health Manager.

Pamela S. Crowell, MPA SVAHCS Director

Attachment 1: Job Safety Check Sheet Attachment 2: Infection Control Risk Assessment Attachment 3: Infection Control Construction Permit http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=STANDARDS&p_toc_level=1&p_keyvalue=Construction http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=STANDARDS&p_toc_level=1&p_keyvalue=Construction http://www.epa.gov/lawsregs/bizsector/construction.html http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=428&FType=2 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5397 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5380 file://///vhashefpc21/Common/MCM%20Attachments/Safety%20Office/MCM%20140-02,%20Attachment%201,%20SVAHCS%20Job%20Safety%20Check%20Sheet.doc file://///vhashefpc21/Common/MCM%20Attachments/Safety%20Office/MCM%20140-02,%20Attachment%202,%20SVAHCS%20Infection%20Control%20Risk%20Assessment.doc file://///vhashefpc21/Common/MCM%20Attachments/Safety%20Office/MCM%20140-02,%20Attachment%203,%20SVAHCS%20Infection%20Control%20Construction%20Permit.doc