S02 - 4 ILSM.pdf

INTERIM LIFE SAFETY MEASURES

Edward Hines Jr. VA Hospital Hines, IL 60141 Signatory Authority:

Chief of Occupational Safety & Health Responsible Owner:

Fire Inspector

SOP-578-21-21-606

Service Line(s):

Occupational Safety & Health Services Effective Date:

October 20, 2020 Recertification Date:

October 31, 2025

1. PURPOSE AND AUTHORITY

To establish specific procedures for implementing those provisions of the Hospital Fire Safety Management Plan pertaining to the use of interim life safety measures (ILSM).

2. PROCEDURES

a. The eleven interim life safety measures are a series of administrative actions required to temporarily compensate for significant hazards posed by existing Life Safety Code (LSC) deficiencies or construction activities.

b. The ILSM assessment will be completed before any constructions project is initiated.

c. Interim life safety measures will apply to appropriate personnel, including construction workers, will be implemented upon project development, and will be continuously enforced through project completion.

d. A fire watch is implemented on a "case-by-case" basis as determined by the fire watch decision grid. (Attachment E)

3. ASSIGNMENT OF RESPONSIBILITIES

a. The Safety Section is assigned overall responsibility for developing, implementing, enforcing and evaluating the effectiveness of the complete Interim Life Safety Measures Policy.

b. The Safety Section is responsible for:

(1) Evaluating specific LSC deficiencies and construction hazards to determine when and to what extent one or more of the listed ILSMs are applicable,

(2) Maintaining required ILSM records and for conducting required ILSM inspections, testing, training, and monitoring as required,

(3) The day to day enforcement of the ILSM plan, and

(4) For advising the Chief, Engineering, as to the effectiveness of the plan, and recommending plan improvements as necessary.

(5) Provide the appropriate training for all affected personnel if it is determined that

ILSM measures are to be implemented, and

(6) If appropriate based on the ILSM to be implemented, conduct addition fire drills.

c. The Chief, Project/Planning Section Engineering, the Chief, Maintenance and Operations Section Engineering, the Chief, Office of Information and Technology, and all other service/section chiefs who have program responsibility for construction projects and/or activities, including work/projects involving penetrations of walls and/or ceilings are responsible for:

October 20, 2020 SOP 578-21-21-606

(1) Ensuring the accurate preparation and timely submission of the ILSM Construction Project Evaluation Worksheet (Attachment B),

(2) Ensuring that an amended ILSM Construction Project Evaluation Worksheet for the project is promptly submitted to Safety if changes impacting ILSM occur after the construction phase of a project or construction activities begins, and

(3) Ensuring that the members of their respective staffs assigned project coordination duties know and understand the provisions of this plan, and monitor plan compliance within their respective work groups.

d. Police Service is responsible for:

(1) Conducting daily inspections of sites under ILSM during weekends and holidays.

(2) Documenting findings of daily inspections (Attachment D).

4. Other Paragraphs

a. The Chief of a service or section initiating a construction project to be accomplished by a contractor will ensure that requirements for full compliance with all applicable NFPA LSC Codes and Hines Hospital fire and safety policies are communicated to all parties involved.

b. A minimum of two weeks before the start of the construction phase of a project, the chief of the service or section responsible for the project will ensure that an ILSM Construction Project Evaluation Worksheet, describing the project and its potential impact on life safety, is accurately completed and submitted to Safety through the Chief, FMS. After the construction phase of a project begins, the responsible service or section chief will ensure that an amended ILSM Construction Project Evaluation Worksheet for the project is promptly submitted to Safety if changes impacting ILSM occur.

c. Safety staff will review the ILSM Construction Project Evaluation Worksheet submitted for each project, inspect the job site as necessary, obtain additional information as required, and complete an ILSM Occupant Impact Evaluation Worksheet (Attachment C).

d. If it is determined based on the evaluations conducted that ILSMs are not required for a project, Safety personnel will advise the responsible service/section chief accordingly.

e. Should it be determined that one or more ILSMs are required to be used during a given project, Safety personnel will explain the actions necessary to the responsible service/section chief and will ensure implementation of the ILSMs as appropriate.

ILSMs required for a project will be discussed in detail and noted in the minutes of each pre-construction meeting pertaining to that project.

f. When the construction phase of a project with required ILSMs begins, Safety will initiate daily inspection of the site to ensure that ILSMs are in effect, and for compliance with established safety codes and policies. These inspections will continue through project completion. Findings will be documented on the ILSM High Hazard Inspection Report (Attachment D).

g. Police Service will conduct daily inspections on weekends and holidays.

5. DEFINITIONS

None

6. REFERENCES

a. The Joint Commission (TJC), Environment of Care Standards.

b. NFPA Life Safety Code 101

7. REVIEW

This SOP will be reviewed upon change of positions included in SOP, at minimum at recertification, when there are changes to the governing document (for example, national policy or a health care accreditation body mandate), and any regulatory requirement for more frequent review

8. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of October 2025. In the event of contradiction with national policy, the national policy supersedes and controls.

9. SIGNATORY AUTHORITY

Afif Marouf, M.D., M.P.H.

Chief of Occupational Safety & Health Date Approved:

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

DISTRIBUTION: Hines Intranet Website and Service Chiefs/Service Line Managers via E-mail SOPs are available at http://vaww.hines.med.va.gov/hines/Policy/files.asp http://vaww.hines.med.va.gov/hines/Policy/files.asp

Attachment A

1. Ensuring free and unobstructed exits. Personnel in affected areas receive additional training when alternative exits are designated. Buildings or areas under construction must always maintain escape routes for construction workers. Means of exiting construction areas are inspected daily.

2. Ensuring free and unobstructed access to emergency services and for fire, police, and other emergency forces.

3. Ensuring fire alarm, detection, and suppression systems are in good working order. A temporary but equivalent system shall be provided when any fire system is impaired. Temporary systems must be inspected and tested monthly.

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

5. Providing additional firefighting equipment and training personnel in its use.

6. Prohibiting smoking, according to the Joint Commission Environment of Care standards, throughout all buildings on the station as well as in and adjacent to construction areas.

7. Developing and enforcing storage, housekeeping, and debris removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

8. Conducting a minimum of two fire drills per shift per quarter.

9. Increasing hazard surveillance of buildings, grounds, and equipment with special attention to excavations, construction areas, construction storage, and field offices.

10. Training personnel to compensate for impaired structural or compartmentalization features of fire safety.

11. Conducting organization-wide safety education programs to promote awareness of Life

Safety Code deficiencies, construction hazards, and Interim Life Safety Measures.

Attachment B

EDWARD HINES JR. VA HOSPITAL

Engineering Service

CONSTRUCTION PROJECT EVALUATION WORKSHEET

PROJECT TITLE/NUMBER: 578-26-006 Repair Building 1 Steam and Condensate Risers

- Phase 2

BUILDING/ROOM NUMBER: Building # 1

SERVICE/SECTION RESPONSIBLE: Engineering Service/Project Planning

EFFECTS ON LIFE SAFETY

Provide a brief description of the project and any effects it is likely to have on life safety. Examples include closing of an exit; use or storage of flammable materials on-site; installation of a dust barrier; blocking streets, driveways or access roads; impairment of fire detection and/or suppression systems; and removal of doors.

The overall scope of this project is to replace the steam/condensate risers and connect them to radiators in the rooms selected and to steam/condensate lines in the tunnels on the east and west sides of Building 1. The steam/condensate lines should then be insulated by the contractor. The contractor shall furnish labor, material, equipment and supervision to do the work described above.

LAWRENCE DOYLE DOYLE

Digitally signed by LAWRENCE

SPECIFIC SAFETY CONCERNS

Will any of the work to be performed during this project as currently planned compromise or impair the use of the critical elements of fire protection listed below?

1. FIRE ALARM SYSTEMS: YES ☐ NO ☒

If YES is checked above, provide additional details, including number of devices affected and length of time systems will be impaired, on a separate sheet. See above Safety Plan

2. AUTOMATIC FIRE SPRINKLER SYSTEMS: YES ☐ NO ☒

If YES is checked above, provide additional information including the size and occupancy of the area affected, and the anticipated duration of the impairment.

3. EXITS (STAIRWELLS, CORRIDORS & DOORS): YES ☐ NO ☒

If YES is checked above, provide additional information including the type, number, and location of exits, which will be obstructed, and the anticipated duration of the impairment.

Exit to the stairs will be closed temporarily. Appropriate signs will be posted to direct the people to nearest alternate exits.

4. ACCESS TO EMERGENCY VEHICLES & PERSONNEL: YES ☐ NO ☒

If YES is checked above, provide additional information including location of blockage, how access will be obstructed, and the anticipated duration of the impairment.

5. INTEGRITY OF SMOKE &/OR FIRE COMPARTMENTS: YES ☐ NO ☒

If YES is checked above, provide additional information including size, location, number, and purpose of penetrations, which will be made.

MARK JHELO

MANALILI

Digitally signed by MARK JHELO

MANALILI

Date: 2025.10.21 08:32:26 -05'00'

Person responsible for construction projects

And/or activities, including work/projects

Service/Section Chief

Attachment C

OCCUPANT IMPACT EVALUATION WORKSHEET

DESCRIPTION OF LSC DEFICIENCY OR CONSTRUCTION PROJECT:

SIGNAGE

1. Will the above described LSC deficiency or construction project hinder the occupants in the immediate area from effectively implementing RESCUE?

YES ☐ NO ☐

If YES is checked above, will the condition described exist for more than one working day?

YES ☐ NO ☐

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants of the compromise of safety and directing a higher level of awareness of fire hazards.

SIGNS POSTED BY: DATE:

2. Will the above described LSC deficiency or construction project hinder the occupants in the immediate area from effectively activating a pull station fire ALARM?

YES ☐ NO ☐

If YES is checked above after question 2, will the condition described exist for more than one working day?

YES ☐ NO ☐

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants that the fire alarm pull station is out of service and instructing the occupants to call the Hines Police Department by telephone at extension 22323 to report a fire.

3. Will the above described LSC deficiency or construction project hinder the ability of the occupants in the immediate area to CONFINE a fire?

If YES is checked above, will the condition described exist for more than one working day?

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants of the condition and listing alternative actions to be taken until the condition is remediated.

4. Will the above described LSC deficiency or construction project reduce or hinder the ability of the occupants in the immediate area or the community Fire Department to EXTINGUISH a fire?

YES ☐ NO ☐

If YES is checked above, will the condition described exist for more than one working day?

YES ☐ NO ☐

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants of the condition and listing alternative actions to be taken until the condition is remediated. Additionally, the community Fire Department will develop a contingency firefighting tactical plan for the area. In the case of construction projects, that contingency plan must be approved and in place prior to permitting any work to start at the job site.

5. Will the above described LSC deficiency or construction project hinder the occupants’ ability to EVACUATE the building or area?

If YES is checked above, will the condition described exist for more than one working day?

If the condition will exist for more than one working day, signage must be prepared and posted advising the occupants of the condition and describing alternate routes of egress.

TRAINING

6. Does the ILSM signage pertaining to RESCUE provide enough information and instruction to ensure proper occupant response during an emergency incident?

YES ☐ NO ☐

If the signage is determined to be inadequate to ensure proper occupant response, Safety will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

TRAINING CONDUCTED BY: DATE:

7. Does the ILSM signage pertaining to ALARM provide enough information and instruction to ensure proper occupant response during an emergency incident?

YES ☐ NO ☐

If the signage is determined to be inadequate to ensure proper occupant response, Safety will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

8. Does the ILSM signage pertaining to CONFINE provide enough information and instruction to ensure proper occupant response during an emergency?

YES ☐ NO ☐

If the signage is determined to be inadequate to ensure proper occupant response, Safety will provide the personnel affected with additional instruction and training as necessary.

9. Does the ILSM signage pertaining to EVACUATE provide enough information and instruction to ensure proper occupant response during an emergency?

YES ☐ NO ☐

If the signage is determined to be inadequate to ensure proper occupant response, Project/Planning will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

FIRE DRILLS

10. Will the above described LSC deficiency or construction project necessitate altering staff response to RESCUE, ALARM, CONFINEMENT, EXTINGUISHMENT and/or

EVACUATION?

YES ☐ NO ☐

If YES is checked above, will condition exist for more than sixty days?

YES ☐ NO ☐

If staff response to Rescue, Alarm, Confinement, Extinguishment and/or Evacuation will be altered for more than sixty days, the Safety Section will increase the frequency of scheduled fire drills in the area affected to two per shift per quarter.

ADDITIONAL FIRE DRILLS SCHEDULED BY: DATE:

INSPECTION

If evaluation indicates that one or more ILSMs must be used for this deficiency or project, daily inspection of the site by Safety personnel will be required. Each inspection must be documented on the ILSM High Hazard Inspection Report.

INSPECTION REQUIRED: YES ☐ NO ☐

INSPECTION SCHEDULED BY: DATE:

EVALUATION COMPLETED BY:

SIGNATURE OF SAFETY STAFF DATE

Attachment D

HIGH HAZARD INSPECTION REPORT

LOCATION:

DESCRIPTION OF DEFICIENCY OR PROJECT:

ILSMs REQUIRED:

YES NO

1. Is the ability of the occupants to perform rescue impaired?

2. Is the ability of the occupants to activate an alarm impaired?

3. Is the ability of the occupants to confine a fire impaired?

4. Is the ability of the occupants to extinguish a fire impaired?

5. Is the ability of the occupant to perform evacuation impaired?

6. Is access to emergency vehicles/personnel impaired?

7. Is the automatic fire sprinkler system in operation?

8. Are the smoke detectors operating?

9. Are flammable or combustible materials stored in the area?

10. Is the area clear of storage, trash, waste and debris?

REMARKS/CORRECTION ACTION REQUIRED:

SIGNATURE OF INSPECTOR DATE

Attachment E

Fire Watch Decision Grid

Service Situation Fire Watch

Required?

ILSM Evaluation

Required?

A. Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours

Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area.

B. Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours the entire area is fully operational

Rationale: During a controlled event, the organization would be managing the deficiency. The area would be continually monitored, and ILSM should be implemented as per policy

C. Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours

• Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system)

X

Rationale: During a controlled event, the organization would be managing the deficiency. The area would be continually monitored, and ILSM would be implemented as per policy.

X

• Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure)