P11 - MCP 003S-05-025 Construction Safety Procedure.pdf

December 31, 2020 MCP 003S-05-25

CONSTRUCTION SAFETY PROCEDURE

MCP 003S-05-25

Jesse Brown VA Medical Center Chicago, IL 60612

Signatory Authority:

Rick Ament, FACHE Jesse Brown VA Medical Center Director

Rescinded Document:

MCP 001S-01-21, dated April 2018

Effective Date:

December 31, 2020

Responsible Owner: Recertification Date:

Occupational Safety and Health Service (003S) December 31, 2025

1. POLICY

Construction activities at the Jesse Brown VA Medical Center and associated outpatient clinics present potentially hazardous working conditions for VA patients, volunteers, employees and contractors. These conditions can result in serious personal injuries and extensive property damage. This policy is established to ensure monitoring and compliance with all established Occupational Safety and Health Administration (OSHA), The Joint Commission (TJC), VA and other applicable safety regulations and procedures.

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 and Operations (M&O) personnel. Construction shall also include nondelegated projects including majors, and Jesse Brown VAMC shall coordinate those construction impacts with the project's Engineer through a single point of contact. This definition also applies to enhanced use and lease projects related to structures for which Jesse Brown VAMC maintains management responsibility or authority.

2. JUSTIFICATION

Policy created for compliance with VHA Directive 7715 Safety and Health During Construction.

3. RESPONSIBILITIES

a. Medical Center Director will establish and monitor an effective facility construction safety program using a construction safety committee chaired by a member of management, or designee, composed of a multi-disciplinary team with representatives from the following program areas: Infection Prevention and Control (IP&C), Patient Safety, Occupational Safety and Health, VA Police, Engineering, Project Management, Green Environmental Management System (GEMS), Emergency

Planning, Local Union Representatives, Employee Occupational Health, Construction Safety Officer (CSO) and Contracting.

b. The Facility's Safety Officer and Safety Staff will provide policy guidance and training materials to all employees on the proper procedures associated with risk assessment, policy implementation, and required documentation associated with construction safety.

c. The Facility Safety Officer is responsible for ensuring that the multi-disciplinary team oversees:

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

(2) Compliance with Federal and State Environmental Protection Agency (EPA) and OSHA regulations.

(3) Compliance with Federal and State (EPA) and Veterans Affairs Acquisition Regulation (VAAR) in addressing a contractor's construction safety program.

(4) Ensuring that regular inspections of construction areas are conducted by Project Engineers.

(5) Conducting at least a weekly inspection of construction areas and maintaining appropriate documentation. These inspections will be scheduled through the AMES/MERS work order system.

(6) Each inspection shall have consistent documentation of inspection results through written meeting minutes to include findings, follow-up actions to resolve unsafe conditions and tracking of actions to completion for all required elements.

(7) Ensuring that contractor personnel are offered a safety orientation briefing and safety contact information sheet prior to commencing work on the project. At a minimum, this includes ensuring that the Contracting Officer's Representative (COR)/Project Engineers issue Appendix A, Contract Worker's Safety Information Sheet, to all construction contract workers.

(8) Instructing Contractor Personnel to take immediate corrective action when unsafe practices are observed.

(9) Monitoring hot work permits and retaining completed hot work permit documentation for the duration of the project (Appendix B).

(10) Evaluating the effectiveness of the construction safety program in a bi- monthly report to the Environment of Care Committee (EOCC).

(11) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of construction safety training at least every 2 years.

(12) Ensuring that the following staff complete OSHA's 30-hour or 10-hour Construction Safety training and, as a refresher, subsequently complete at least 10 hours of construction safety related training every 2 years:

(a) Chief Engineers, COR/Project Engineers and Project Lead Persons (OSHA's 30-hr);

(b) All members of the multi-disciplinary team (OSHA's 10-hour); and

(c) CSO and facility safety staff and program managers (OSHA's 30-hour).

d. CSO is responsible for project submittal reviews of all construction projects and:

(1) Identifies work site risks.

(2) Collecting deficiency information.

(3) Documents and disseminates actions and results.

(4) Provides oversight of contract construction safety for being knowledgeable in the general inspection of typical work sites during construction and renovation performed by contracted staff.

NOTE: CSO(s) do not take the place of the contractor's Competent Person (CP) or act on their behalf.

(5) Determines if the contractor is meeting VA standards and contractual requirements for safety and OSHA compliance (Acting as the Safety Officer in accordance with VAAR (836.236-87). When these standards and contract requirements are not being met, the VA COR or CO, in coordination with the CSO must take immediate action to prevent injury, exposure, noncompliance, or property damage.

(6) Requires the contractor CP to implement and maintain an effective safety program that identifies and controls hazards that may cause injury or illness to VA patients, visitors, staff and contractor employees; this includes:

(a) Ensures that the specific safety requirements for construction operations are implemented during facility projects.

(b) Participates as part of the multi-disciplinary team established for the construction safety committee.

(c) Conducts periodic inspections of construction sites to ensure compliance with safety elements of the established program(s), at minimum weekly inspections are required.

(d) Completing OSHA's 30-hour construction safety training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

NOTE: COR/Project Engineers or assigned Resident Engineers are the Safety Officers for Office of Construction & Facilities Management (CFM) managed construction sites and any associated inspections. Be aware that TJC requires protection of all who enter VHA properties, and as such RE construction sites factor into accreditation.

e. Infection Prevention and Control (IP&C) is responsible for:

(1) Facilitating the approval of Infection Control Construction Permit (Appendix C) when the Infection control risk assessment requires it.

(2) Providing technical advice on Infection Control strategies to the COR/Project Engineer or Safety Officer when unusual or difficult infection control issues arise on constructions projects.

(3) Reviewing Project Risks Assessment for the transmission of Mycobacterium Tuberculosis (TB) based upon the construction site location, patient population, hospital layout, and the Center for Disease Control (CDC) defined risk.

(4) Shall verify documentation of Infection Control findings and tracking of corrective actions in the Construction Safety Committee (CSC) meeting minutes.

(5) Advising and/or providing recommendations on exposure mitigation and the prevention of facility associated infections in patients, visitors and staff.

(6) Coordinating 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.

(7) Monitoring infection prevention protocols during construction activities as indicated in ICRA for that project.

(8) Completing OSHA's 10-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

f. Environmental Management Services is responsible for:

(1) Provide terminal cleaning to all construction areas prior to releasing areas back to services.

g. Patient Safety is responsible for:

(1) Providing technical advice on patient safety strategies to the COR/Project Engineer or Safety Officer when patient safety issues arise on constructions projects.

(2) Completing OSHA's 10-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

h. Projects Section Supervisor is responsible for:

(1) Working with safety and health staff, CORs, maintenance staff, contractors, and the Construction Safety Committee (CSC) to plan, coordinate, and monitor the Construction Safety Program for all projects at the facility.

(2) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

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

(4) Serving on the facility CSC to ensure contract requirements meet the committee's approval.

(5) Supporting the Competent Person, Safety Officer, Infection Preventionist, Contracting Officer, Patient Safety Specialist and engineering staff in implementation of the Construction Safety Program.

(6) Working with contracting staff to ensure competent staff is assigned as CORs to oversee work.

i. Chief of Operations and Maintenance is responsible for:

(1) Completing OSHA's 30-hour construction safety training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

(2) Participating in periodic inspections of in-house construction sites to ensure compliance with safety elements of the construction contract and performance of the program. At minimum weekly inspections are required.

(3) Ensuring that in-house work forces have necessary training and competency for tasks being performed.

j. Chief of Biomedical Engineering is responsible for:

(1) Ensuring that all construction accomplished in support of major equipment installations as a part of the equipment purchase are in compliance with the facility Construction Safety Program policy and procedures.

k. Contracting Officer Representative/Project Engineers are responsiblefor:

(1) Will invite the multi-disciplinary team, which will include at a minimum: Safety, HazMat/GEMS, Infection Control, VA Police, and a representative from the using service/resident service to the pre-construction meeting.

(2) Will complete the required Project Risk Assessment (PRA) in Appendix D

(3) Will coordinate necessary Interim Life Safety Measures (ILSM) with the Safety Officer if identified in the Project Risk Assessment.

(4) Will conduct infection control risk assessments prior to construction with the Safety Officer and Infection Prevention and Control Section.

(5) Will seek approval of Infection Control Construction Permits from Infection Prevention and Control Section on all areas required by completed risk assessment.

(6) Will assess the use of plastic barriers for infection control on a case-by-case basis and ensure that contractors' follow the appropriate specifications listed in Appendix D if plastic is to be used.

(7) Will conduct and document a daily walkthrough of assigned construction areas to ensure contract and OSHA compliance and will notify the CSO and/or Contracting Officer (CO) when a safety violation is observed.

(8) Will provide a monthly submission of construction site safety inspection dates, and general results in the Project Tracking Report entered in the VHA Support Service Center database for each construction project.

(9) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

I. Construction Contractor or VA Personnel involved in Construction Operations is responsible for:

(1) Shall comply with the facility security management program. As a minimum, contractors must notify and obtain permission of the VA Police, be identified by project and employer and restricted from unauthorized access.

(2) Will perform construction operations in a safe manner according to all established safety regulations and infection prevention & control requirements as stated in his/her contract and/or description of work.

(3) Shall request Hot Work Permits directly from the Jesse Brown VA Medical Center Engineering.

(4) Shall adhere to all Jesse Brown GEMS program guidelines referring to the management of construction waste and purchases as well.

(5) Shall adhere to all provisions of Jesse Brown VAMC Memorandum "Above Ceiling Work Permit Procedure" for all work above installed ceilings. The COR/Project Engineer shall provide a copy of this procedure and a training briefing to all affected parties.

(6) Where applicable, shall request and provide the COR/Project Engineer with a completed Fire/Smoke Wall Penetration Permit prior to making penetrations through fire-rated walls (Appendix E). After penetrations are sealed, Engineering Services, Facility Safety Staff, the COR/Project Engineer, and the contractor's responsible person shall inspect the area to ensure compliance with the required standards.

(7) Shall provide and maintain an adequate number of job-site fire extinguishers. Maintenance includes a monthly inspection, documented on a tag in day/month/year format with the initials of the inspector.

m. The multi-disciplinary team is responsible for:

(1) Determining the scope and depth of safety, infection control, emergency management, and security responsibilities as appropriate for all construction work.

(2) Confirming compliance with applicable regulations, standards, and policies during the construction phase of the work.

(3) Reviewing the construction project risk assessment to assess all hazards that affect healthcare, treatment, and services.

(a) Staff must conduct and document in construction project risk assessments during the design or planning stage of the construction project and/ or renovation.

(b) Project risk assessments need to be conducted prior to bidding, award, and starting work.

(c) Project risk assessments must focus on eliminating, or minimizing, the aforementioned risks during construction and renovation activities.

(4) Review the construction project risk assessment for the transmission of TB to the contracted construction workers based upon the construction site location, patient population, hospital layout, and the defined risk as outlined in the "CDC Guidelines for preventing the transmission of Mycobacterium Tuberculosis in healthcare setting.

(5) Ensuing ILSM assessments are implemented on all construction work according to The Joint Commission standards. ILSM's are required when Life Safety Code deficiencies or construction activities pose significant hazards as determined by the assessment.

(6) Participating in all phases of construction work from planning through completion. This includes review and approval of construction plans, contract specifications, 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 multidisciplinary team must be involved early in the process and continue oversight on a regular basis.

(7) Ensuring the construction safety program includes periodic construction site hazard surveillance activities with appropriate membership, scope and frequency for each project as determined by the CSO and the project risk assessment. Weekly surveillance activities are required with reports or checklists submitted to the CSO.

In some cases, daily inspections may be required by the CSO [e.g., construction activities capable of a High-Severity Serious-Construction (HSCS) accident.

(8) Acting as members of the Construction Safety Committee or subcommittee and meeting at least monthly.

(9) Ensuring that documentation of the team's inspections is provided to the CO or COR/Project Engineer, and the VISN Safety and Health Staff, as requested.

n. The GEMS Coordinator is responsible for:

(1) Providing guidance on EPA regulations and environmental issues; as those regulations and issues directly and immediately relate to safety during the design stage.

(2) Monitoring contractor compliance with contract specifications on EPA regulations; as those regulations, directly and immediately relate to the construction project, including environmental compliance, pollution prevention, waste management, and permitting.

(3) Completing the VHA or OSHA 10-hour Construction Safety Course and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

o. The Emergency Manager is responsible for:

(1) Providing guidance on OSHA regulations as they apply to emergency planning, response, and operations in construction (i.e. 29 CFR 1926.35 and

29 CFR 1926.65).

(2) Monitoring contractor performance to contracted specifications on OSHA Regulations as they apply to emergency planning, response, and operations related to construction operations.

p. The Construction Lead Person (Engineering Supervisors, VHA Forepersons, Contractor's Superintendent, Contractor's Forepersons, and other assigned lead persons) is responsible for:

(1) Administering the site-specific construction safety program as the OSHA deemed CP.

NOTE: Inspections by CPs are required in accordance 29 CFR Part 1926.

(2) Acting as the CP for other activities as required by OSHA regulations;

including, but not limited to scaffolds, cranes, and excavations.

q. The Police and Security Officers are responsible for:

(1) Ensuring all contractors entering JBVAMC comply with the Security Management Program. As a minimum, contractors must notify and obtain permission from the VA Police, be identified by project and employer, and be restricted from unauthorized areas.

(2) Providing consultation to the CSO, COR/Project Engineer, or other responsible staff in periodic surveillance of site security and the integrity of barriers to the construction site.

(3) Will conduct off tour surveillance (fire watches) of construction sites under ILSM, and document findings.

Intervention an,d Enforcement:

a. All individuals with defined actions in this directive will intervene, whenever conditions, as a result of construction activities, immediately threaten life or health or threaten to damage equipment or buildings. Intervention and enforcement of this

Directive and the associated regulatory requirements are as follows:

b. Staff: All staff will identify hazardous conditions in need of intervention and further develop a culture of safety. CPS and all facility management will take prompt corrective measures to include immediate abatement of hazards, stopping of work, hazard awareness training, administrative controls, etc.

c. Contractors: CSO or CO shall notify the contractor orally, with written confirmation, and request immediate initiation of corrective action of hazards identified. After receiving the notice, the Contractor shall immediately take corrective action. If the contractor fails or refuses to promptly take corrective action, the CO may issue an order stopping all or part of the work until satisfactory corrective action has been taken (FAR 52.236-13). Upon a repeat offense of the same or substantially similar hazard, the CO should inform OSHA or other authorities (i.e., federal, state, or local officials) of the instances where the contractor has been notified to take immediate action to correct serious or imminent dangers (FAR 36.513). The Construction Safety Officer, with assistance from the multidisciplinary team, is responsible for making the contractor and CO formally aware of hazards in need of correction. The CO is responsible for enforcement of the contract.

Note: Following these enforcement procedures will limit VHA 's regulatory and civil liability while supporting TJC accreditation requirements.

4. PROCEDURE

a. Project Engineers/COR's shall complete the Project Risk Assessment (PRA) form attached in Appendix D of this policy for all project.

b. Conduct a National Environmental Policy Act (NEPA) analysis per Jesse Brown VA Memorandum.

c. If I LSM's are required, those shall be coordinated with the Safety Officer.

d. With the assistance of the CSO, Project Engineers/COR's shall conduct an Infection Control Risk Assessment prior to the beginning of each project Utilizing Appendix D. A copy of Appendix D shall be provided to the Facility Safety Manager who will review the PRA and forward it to Infection Prevention & Control Section prior to commencing work on any project.

e. If the results of the Project Risk Assessment dictate that an Infection Control Construction Permit (Appendix C) is required, the COR/Project Engineer shall request one from the Infection Prevention & Control Section which is good for one year from the date it was issued. The COR/Project Engineer shall ensure that all VA construction contractor personnel adhere to the infection control precautions stipulated in the permit. An infection control construction permit is always required for all class three and above projects.

f. Once the project has commenced, responsible engineering personnel will continually survey VA construction contractor operations to make certain all required safety precautions are being taken to prevent accidents.

g. COR/Project Engineers shall conduct a daily, documented walk through of their project sites to ensure that contract provisions are being followed, applicable ILSM remain intact, and for other safety-related issues. Documentation of these daily walk through will be kept electronically in the EOC database.

h. Safety office personnel shall conduct at minimally a weekly documented inspection of all project sites.

i. All personnel conducting inspections shall become familiar with the most frequent safety and health hazards described below:

(1) Poor housekeeping, including refuse and non-salvageable materials not removed from the work areas at regular intervals; cords, hoses, and lagging scattered on the floor, resulting in tripping hazards; slipping and falling hazards from oil, grease, or water; and unsafe stacking of wood, metal, parts, and other materials.

(2) Ineffective guards (e.g., inadequate rails and toe boards) around open stairwells and on overhead storage areas.

(3) Pulleys, gears and "point of operation" of equipment (such as horizontal or vertical band saws, shears, punch presses, and press brakes) unguarded or inadequately guarded.

(4) Unsafe ladders (e.g., with broken rungs or split rails) in use and ladders not properly secured.

(5) A lack of minimum respirator programs or adequate ventilation for certain operations (e.g., welding and spray painting) in confined spaces.

(6) Resins, paints, oils, and solvents handled without proper Personal Protective Equipment (PPE).

(7) Electrical hazards such as ground pins cut from power tools, ungrounded extension cords and electrical equipment, and frayed, damaged, and misused flexible cords.

(8) Unsecured and improper storage of compressed gas (acetylene-oxygen) cylinders.

(9) Fire hazards caused by improper storage and use of flammable and combustible materials (e.g., solvents, paint, gasoline, acetylene, and wood) and the presence of various ignition sources (e.g., welding, burning, and soldering).

(10) Unsafe work practices, which could result in burns from hot work operations such as welding, burning, and soldering.

(11) Improper lifting and materials handling.

(12) Delayed maintenance and repair of machinery resulting in breakdowns which could cause injuries.

(13) The Facility Safety Officer will also conduct prompt investigations of accidents involving constructions contractors so that immediate corrective action can be taken to enforce existing safety regulations or implement new safety techniques.

(14) Any violation of safety procedures/regulations shall be immediately referred to the Construction Safety. Corrective action shall be coordinated with the COR/Project Engineers.

(15) Upon completion of the project the Reactivation form Appendix D must be completed and signed by the Medical Center Director. If the Mental Health Ward (7 EAN in the Bed Tower or Emergency Department rooms1470A or 1470B are part of the project prior to reactivation the Mental Health Environment of Care (MHEOC) inspection team must be notified.

5. DEFINITIONS

None

6. REFERENCES

a. VAR 852.236.87 Safety and Health Accident Prevention

b. FAR52.236.7 Permits and Responsibilities

c. FAR 52.236.12 Accident Prevention

d. 29 CFR 1926 General Construction Standards (OSHA)

e. 29 CFR 1910 General Industry Standards

f. VHA Directive 7715 Safety and Health During Construction

g. VA Construction Safety Guidebook

h. VHA Directive 7701, Comprehensive Occupational Safety and Health Program

i. Joint Commission Standards: EC 02.06.05; current ed. LS 01.02.01; current ed.

7. RESCISSION

MCP 001S-01-21, dated April 2018.

8. REVIEW

The MCP is scheduled for review at minimum every three years, at the time of recertification.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of December 31, 2025. 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 on controls.

10. SIGN ORY AUTHORITY

R A. Am nt, FACHE Jesse Brown VA Medical Center Director Date Approved:

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

DISTRIBUTION: MCPs are available at:

https://dvagov.sharepoint.com/sites/chi/mcm/default.aspx

APPENDIX A

Contract Worker's Safety Information

Contract Reference Number and Location(s):

The Jesse Brown VA Medical Center is a full service medical center with inpatients, outpatients, and staff who can be affected by what you do while working here. Many of these patients may have health problems that make them more susceptible to materials used in or generated by your work.

In the event of a fire, remember RACE. Rescue persons in immediate danger, pull the fire Alarm and Contain the fire by closing any doors. If it is safe to do so, and you have been trained, try to Extinguish the fire with a portable fire extinguisher. If you do not hear the alarm sound, call 9-1-1 to report the location. Know the location of the fire alarm and extinguisher in your work area.

Keep all dust and odors within the construction or maintenance site. All Safety Data Sheets (SDS) for materials used on the construction site must be posted. Provide SDS to the Contracting Officer's Representative (COR). SDS for materials already present in the area may be obtained through the Industrial Hygiene Office, extension 57000.

Asbestos: Contact the COR/Project Engineer to verify that your work will not disturb any asbestos containing materials (ACM).

Above-Ceiling Work: Permits are required for all above-ceiling work in accordance with local procedures.

Ceiling tiles cannot be moved or displaced without proper containment and personal protective equipment. Wall penetrations cannot be made without proper documentation, containment, and personal protective equipment. An itemized log of all penetrations of fire and smoke-rated partitions is required to be submitted to the Safety Office as they occur, along with your plan for abatement. Refer to Policy Memorandum 138-33-14 or current addition "Above Ceiling Work Permit Procedure" for additional details.

Hazardous Waste: Jesse Brown VA Medical Center indicates waste that is hazardous with different colored bags:

• RED for infectious or bio-hazardous waste.

• YELLOW for radioactive waste.

• CLEAR for general waste.

• Signs on containers also indicate whether the contents are bio-hazardous, radioactive or cytotoxic.

• Do Not Touch the Contents of Any of These Containers.

Hazardous Spills: Locate the Safety Data Sheet (SDS) and contact Engineering Service at extension 56173 (from any house phone) for assistance.

Utility Shutdown. You must notify your supervisor and the COR/Project Engineer:

• Prior to lock out/tag out of any utility system.

• If a utility failure occurs.

• Prior to restoring a system.

APPENDIX A

Injuries: The Emergency Department, located on the first floor of the Damen Pavilion, will evaluate all injuries which require immediate attention. Dial 9-1-1 in the event of an emergency from any in-house phone.

Identification: All contract personnel are required to wear VA-issued identification at any time they are working in the facility. Contractor identification is issued at the Bed Tower entrance. Contact your

COR/Project Engineer or Police Service at x56505 from any house phone with any questions.

Smoking: Smoking is not allowed in any building and only in designated outdoor areas.

Patient Care Areas: Before entering a patient care room, receive permission and instructions from the nurse in charge. Respect the privacy of all patients. Remember, the patients at the Jesse Brown VA Medical Center are veterans who have served to protect our country.

Your Project Manager (COR) is Cell Phone:

The Safety Officer is ext. Cell Phone:

VA Police can be reached at 9-1-1 from any in-house phone in the event of an emergency.

Employee Name/Signature Date:

This completed form is to be returned to the COR/Project Engineer.

Compliance with safety rules outlined in this form is mandatory. Thank y

APPENDIX B

PERMIT NUMBER

HOT WORK PERMIT FOR CUTTING, AND WELDING WITH PORTABLE GAS OR ARC EQUIPMENT

SHOP REQUESTING PERMIT: Date

Building: Department Floor

Work to be done

ATTENTION

Before approving any cutting and welding permit, the fire safety supervisor/appointee shall inspect the work area and confirm that precautions have been taken to prevent fire in accordance with NFPA 51B.

PRECAUTIONS

Sprinklers in service Cutting and welding equipment in good repair.

WITHIN 35 FT. OF WORK

Floor swept clean of combustibles.

Combustible floors wet down, covered with damp sand, metal, or metal shield.

All walls and floor openings covered.

Covers suspended beneath work collect sparks.

WORK ON WALLS OR CEILINGS

Construction noncombustible and without combustible covering.

Combustibles moved away from opposite side of wall.

WORK ON ENCLOSED EQUIPMENT (Tank, containers, ducts, dust collectors, etc.)

Equipment cleaned of all combustibles Containers purged of flammable vapors.

FIRE WATCH

To be provided during and 30 minutes after operation.

Supplied with extinguisher and small hose.

Trained in use of equipment and in sounding fife alarm.

The location where this work is to be done has been examined and necessary precautions taken.

*Supervisor Signature: Date

Time Started Completed

Permission is granted for work. Yes, No Permit Expires:

*Safety Department Signature: Date

FINAL CHECK-UP

Work area and all adjacent area to which sparks, and heat might have spread (including floors above and below also on opposite side of walls) were inspected 30 minutes after work was completed and were found fire safe.

* Supervisor or Fire Watcher Signature Date

RETURN A COPY OF THE COMPLETED FORM BACK TO THE SAFETY OFFICE

APPENDIX C

Jesse Brown VA Medical Center IR Infection Control Construction Permit

Project 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 more than one work shift for completion.

GROUP 3: High Risk

TYPE D: Major duration and construction activities. Requires consecutive work shifts.

GROUP 4: Highest Risk

CLASS

l

1.

2.

3.

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

Immediately replace any ceiling tile displaced for visual inspection.

Minor Demolition for Remodeling.

1. Provides active means to prevent air-borne dust 6. Contain construction waste before transport in from dispersing into atmosphere. tightly covered containers.

2. Water mist work surfaces to control dust while 7. Wet mop and/or vacuum with HEPA filtered cutting. . vacuum before leaving work area.

II

3. Seal unused doors with duct tape. 8. Place dust mat at entrance and exit of work area.

4. Block off and seal air vents. 9. Remove or isolate HVAC system in areas where

5. Wipe surfaces with disinfectant, work is being performed.

1. Obtain infection control permit before 6. Vacuum work with HEPA filtered vacuums.

construction begins. 7. Wet mop with disinfectant.

2. Isolate HVAC system in areas where work is being 8. Remove barrier materials carefully to minimize done to prevent contamination of the duct system. spreading of dirt and debris associated with

3. Complete all critical barriers or implement construction.

Ill control cube method before construction begins. 9. Contain construction waste before transport in

4. Maintain negative air pressure within work site tightly covered containers.

utilizing HEPA equipped air filtration units. 10. Cover transport receptacles or carts. Tape

5. Do not remove barriers from work area until covering.

complete project is thoroughly cleaned by 11. Remove or isolate HVAC system in areas where

Environmental Services Department. work is being performed.

Date:

Note: COR/Project Engineer Initials here are required for a Class III Permit.

Initials signify understanding of infection control precautions to be taken during Class III Construction Initials:

Activities, and that contractors will be briefed on these precautions prior to beginning construction.

APPENDIX C

CLASS

IV

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in areas 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 Environmental Services Department.

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 transport in tightly covered containers.

10. Cover transport receptacles or carts. Tape covering.

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

Note: COR/Project Engineer Initials here are required for a Class IV Permit.

Initials signify understanding of infection control precautions to be taken during Class IV Construction Activities, and that contractors will be briefed on these precautions prior to beginning construction. Initials:

Additional Requirements from Infection Prevention and Control:

Are attached memoranda authorizing additions/exceptions to this permit attached by Infection Control?

YES NO

Initials of Infection Preventionist authorizing changes:

Permit Requested By: Permit Authorized By:

Date: Date:

APPENDIX D

PROJECT RISK ASSESSMENT (SAFETY, INFECTION CONTROL &

ILSM)

Project Title: Project or Work Order Number:

Location: Coordinator:

Start Date: Phone Number:

Type of Project: Description of project:

r Operation and Maintenance Activities r Repairs/Renovation Project r New Construction Project r Lease r Other

Other Environmental Permits/Analysis Needed:

Level of NEPA Analysis:

E Categorical Exclusion (CATEX) r Environmental Assessment Needed (EA) r Environmental Impact Statement Needed (EIS)

PROJECT IMPACTS -

Would the proposed activity involve or generate any of the following?

Source Yes No Source Yes No Source Yes No

Air Emissions Including GHG's r f Liquid Effluent r

RCRA or CERCLA Sites

Asbestos

Petroleum Storage r

Wetlands r

Excess Noise

Solid Waste r F Permit Modification

Utility Modification r rHazardous Waste •r r Chemical Use/Storage r Soil Disturbances r i Biological Resources

Aesthetics r

Water Treatment Treatment

Radioactive Waste

Water/Well Use

Water Flow Modification

1 Mixed Waste I I Other:

i

DETERMINATION

A'

I find the proposed project qualifies as a CATEGORICAL EXCLUSION with no extraordinary circumstances.

Specify which CATEX:

r I find that the proposed project MAY have a significant effect on the environment; therefore, an ENVIRONMENTAL ASSESSMENT will be prepared.

E EIS

X X X Project Engineer GEMS Coordinator Engineering Chief

Project Title: Project or Work Order Number:

Location: Coordinator:

Start Date: Phone Number:

Description of project:

CONSTRUCTION ACTIVITIES

The following projects do not require completion of the Project Risk Assessment form:

1. Painting and installation of new wallpaper in business offices and non-patient areas.

2. Painting in a patient room, if closed for painting and less than 3 square feet of wall area is to be patched and painted Contractor shall replace the air filter for the room's air conditioning unit upon completion of painting.

3. Installation of a soap dispenser/needle box/paper towel holder in a patient room

4. Repair of a window blind.

5. Ceiling tile replacement for areas less than ten (10) 2' x 2' tiles, if not in business offices and non-patient areas.

6. Ceiling tile replacement for areas less than five (5) 2' x 2' tiles in a patient area, if patient is out of the immediate area and clean up can be accomplished before patient returns.

7. Minimal repair of Nurse Call System/TV/Bed/Telephone.

8. Checking or replacing of electric outlet.

9. Replacing a light bulb.

10. Unstopping sink/commode with no water on floor.

11. Unstopping commode when water on floor requires maintenance to have Housekeeping clean area immediately.

12. Repair of a medical gas outlet. (Front Body)

13. Taking air balance measurement readings.

14. Checking air conditioning unit/system.

15. Intermediate jobs that create a moderate amount of dust inside the room with negative air pressure maintained in the room via use of HEPA-equipped unit with minimum 10 ACH, and all air discharged outside. The HEPA unit must continue running 2 hours after completion of job and Housekeeping must clean room before the HEPA unit is removed from room. All work and use of HEPA unit must be documented and copies forwarded to Infection Prevention and Control and Safety.

NOTE: All duct vents to be sealed off during work!

,..j, Off Tour Construction Necessary?

Permit Required Confined Space (PCRS) Entry Necessary?

Cutting, Burning, or Welding Necessary?

Lead or Other Hazardous Abatement Necessary?

Legionella Assessment: Will potable water system(s) be affected in any way?

Does this Project involve a Mental Health Unit (Bed Tower 7E/VV or ED rooms 1470A or 1470B)?

If yes has the Mental Health EOC Team been notified?

Lock-Out/Tag-Out of the following systems will be necessary:

Domestic Water

Electrical Systems

HVAC Systems

Medical Gases

Steam Systems

Security Alarms The following departments will be involved in this project:

Infection Control

Construction

Paint Shop

Engineering

Biomed

Safety

Patient Safety

Carpenter

IRM

Other

Project Title: Project or Work Order Number:

List other:

Asbestos removal Asbestos Assessment:

N Conducted by wall or ceiling penetration visual inspection?

N Conducted via access panel visual inspection?

. Conducted by review of facility diagrams and/or prior removal paperwork?

need? YES NO

Involve Infection Prevention & Control Section in planning before construction begins

Negative-pressure containment and ventilation shall be used during any dust-producing activity. When exhausting to and exhaust

Remove indoor space, HEPA filtration must be used. Unused doors shall be sealed with tape. Existing air supply ducts shall be sealed. HEPA vacuum all surfaces at least once per shift and then prior to completion.

containment only after approval of VA COR.

"Sticky" dust mats and carpeting remnants shall be maintained at all construction area entrances & exits to control dust.

Contractors shall thoroughly sweep & mop construction & entrance/exit areas at least daily.

All trash shall be removed from the building at least every shift using tightly covered containers.

Project coordinator and contractor safety manager (designated competent person) to check site daily & log in project folder.

Appropriate safety and project signage shall be posted.

All doors into the work area are smoke-tight, self-closing and self-locking (where required).

Temporary (solid) partitions separating construction from public areas shall be smoke-tight. Only remove after approval of VA. A temporary plastic sheeting enclosure is required to contain dust while removing temporary walls.

Firefighting equipment shall be in place & accessible. Inspection tags shall remain attached and current.

Ceiling tiles shall be replaced as soon as possible to prevent impairment of sprinklers.

All power equipment shall be UL listed and properly grounded, extension cords protected, and plugged into GFCI receptacle.

Flammable & combustible liquids/gases/solids shall be used properly and stored in fire-safe containers and cabinets.

No smoking policy shall be enforced.

Smoke detectors disconnected to prevent dust from activating the fire alarm (typically only occurs during demolition).

Replace with heat detectors.

Trailers, sheds, and dumpsters shall be no closer than10 feet of buildings.

Gang boxes and tool carts shall be secured at all times when not in use.

If water systems were affected, conduct system flushing and testing.

If HVAC, air exchanges or ventilation systems were affected, conduct system balancing and testing.

Upon completion, HEPA vacuum all horizontal surfaces, and then wipe all surfaces with disinfectant, and then damp-mop floors. Then notify EMS for terminal cleaning.

This project will require Interim Life Safety Measures if any of the following are checked YES YES NO

Approved exits/means of egress passages will be obstructed

Emergency access ways will be obstructed

Fire alarm/detection/suppression system(s) will be impaired longer than 4 hours

Smoke barrier or vertical shaft will be compromised

Removal of any corridor or more than 5% of a room's ceiling tiles

Floors or ceilings will be penetrated during construction

Significant renovation of an occupied floor

Project Title: Project or Work Order Number:

Are ILSM measures required for this project? YES NO

CONTRACTOR BRIEFINGS & TRAINING N/A INITIALS

Ensuring free and unobstructed access to emergency department/services and for emergency forces.

Ensuring fire alarm, detection, and suppression systems are not impaired; a temporary but equivalent system shall be provided when any fire system is impaired.

Contractor will schedule work to minimize how long the systems are impaired and shall notify safety section prior to system being impaired.

Ensuring temporary construction partitions are smoke tight and built of noncombustible or limited combustible materials which will not contribute to the development or spread of fire.

Providing additional fire-fighting equipment and use training for personnel.

Developing and enforcing storage, housekeeping, and debris removal practices which reduce the potential (flammable or combustible) fire load of the work area to the lowest possible level.

INFECTION CONTROL MEASURES ARE IN PLACE I/C STAFF HAS VERIFIED CONTRACTOR

BRIEFINGS & TRAINING

N/A INITIALS

Met with VA services/sections surrounding construction area to inform them of impacts and precautions to be taken, and to inform them in basic I.C. requirements (see attached) NOTE: address in design & planning phase

Met with the contractor project manager, construction crews, and subcontractors to inform them of precautions to be taken, and to educate them in basic I.C. requirements. NOTE: address in design & planning phase

Informed the contractor that barriers are not to be removed from work area until completed project is inspected by the Safety and Infection Control Departments, and thoroughly cleaned by Environmental Management Service.

ILSM'S ARE IN PLACE SAFETY STAFF HAS VERIFIED NOTIFICATIONS & TRAINING N/A INITIALS

VA Police have been notified of responsibility to conduct a fire watch at least once per shift during non-business hours whenever any portion of the fire alarm, detection, or suppression systems are impaired for more than four hours within a twenty-four-hour period.

If exits are obstructed, then personnel in building were trained on alternate routes and exits.

Construction areas will have designated and marked exits, maps delineating new exit pathways are in place.

Staff in the affected area(s) will conduct 2 fire drills within every three-month period.

TB RISK ASSESSMENT YES NO

Is there a risk based upon construction site location, patient population, hospital layout, and the defined risk as outlined in the "CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Setting, (IF SO, SEE COMMENTS BELOW):

Ensure that VHA-required content regarding TB is included in every contract.

Contractor shall provide written certification that all contract employees assigned to the work site have had a pre-placement tuberculin within 90 days prior to assignment to the worksite and been found have negative TB screening reactions. Contractors shall be required documentation of negative TB screening reactions for any additional workers who are added after the 90-day requirement before they allowed to work on the work site.

Review the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings (MMWR 54-RR17) and select the risk category. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm) screening to show will be

Project Title: Project or Work Order Number:

INFECTION CONTROL RISK ASSESSMENT

This Project will require Infection Control Measures if any of the following are checked "Yes" YES NO

TYPE A — Inspection and Non-Invasive Activities

TYPE B -- Small scale, short duration activities which create minimal dust, fumes/odors, noise, or vibration

TYPE C -- Will generate a moderate amount of dust, fumes/odors, noise, or vibration

TYPE D -- Major demolition and construction projects.

I. LOW Risk Area (affects one or more of the following areas):

Office Areas/Shops Equip Storerooms

Locker Rooms Boiler/Chiller Plants

Mechanical Equip Rooms Other:

Non-Public Access Areas

Medical Inpatient Units Psychiatric Inpatient Endoscopy

Outpatient Clinics Physical Therapy Cardiology

Respiratory Therapy Radiology/MRI/CT Echocardiograph

Canteen, Kitchen Areas Nuclear Medicine

III. HIGH Risk Area (affects one or more of the following areas):

Post-Anesthesia Care Unit Outpatient Surgery

Emergency Room Pharmacy

CCU's

SCM —

Laboratories

Surgical Units

11111111r f Ar' ea 7aK-OfS-one.or more the following areas): , Operating Rooms Oncology Surgical Inpatient Area

_ Sterile Supply Endoscopy ICU's

Surgical Recovery Unit Cardiac Catheter Lab lmmunocompromised patient areas or negative pressure Isolation Rooms

USING THE FOLLOWING TABLE, IDENTIFY THE

PROJECT CLASS

B D

LOW Risk Area I

111/ly

MODERATE Risk Area I II III

HIGH Risk Risk Area I II III/IV ; IV

HIGHEST Risk Area ll III/IV III/IV :. IV

Project Classification (I, II, III, or IV)

ALL CLASS III AND IV PROJECTS REQUIRE AN INFECTION CONTROL PERMIT

MEASURES DURING CLASS I, & ll PROJECTS

See: Listing of Measures to be Taken for All Projects Classifications (page 3)

MEASURES DURING CLASS III & IV PROJECTS MEASURES UPON COMPLETION

Above measures PLUS:

• Do not remove barriers from work area until completed project is inspected by the Resident Engineer, Project Manager, and Facility Safety Manager/Officer or Contracting Officer Representative.

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

• Complete all critical barriers i.e. sheet rock, 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,

• Maintain negative air pressure, 0.01 inches of water gauge, within work site utilizing HEPA equipped air filtration units and continuously monitored with a digital display, recording and alarm instrument, which must be calibrated on installation, maintained with periodic calibration and monitored by the contractor.

• Cover transport receptacles or carts. Tape covering unless solid lid.

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

• If exiting to a patient care area, 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 site.

• Walk-off mats are recommended to minimize tracking of heavy dirt and dust from construction areas. Shoe covers may be considered in certain areas.

Pro ect Title: Project or Work Order Number:

Will the project involve the deployment of a crane to deliver equipment over occupied facilities?

Must submit a Lift Safety Plan to the Safety Office for approval a minimum of 3 weeks prior to the arrival of the crane on JBVAMC property. The Lift Safety Plan will include the following information: crane specifications, crane inspection list, and crane staff training record/certification. Contractors shall maintain and present the following items prior to crane start (items can be kept in crane cab):

crane certifications, crane registration, fire extinguisher, and crane operating and safety manual.

The following must be completed prior to any construction activities:

• Construct separation walls prior to project start.

• Fire protection…