S02 - Exhibit 6. Construction Safety Procedure.pdf

CONSTRUCTION SAFETY PROCEDURE

MCP 001S-01-28

Jesse Brown VA Medical Center Chicago, IL 60612

Signatory Authority:

Ricky A. Ament, FACHE, Director

Responsible Owner:

Occupational Safety and Health Service

Rescinded Document:

MCP 003S-05-25, dated December 31, Effective Date:

July 10, 2023

Recertification Date:

July 2023

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

This policy was created for compliance with VHA Directive 7715, Safety and Health During Construction.

3. RESPONSIBILITIES

a. VA Medical Facility Director. The VA medical center Director will establish resourcing and monitoring of the VA medical facility's construction safety and health program using a Construction Safety Committee (CSC) and appointing a member of the VA medical facility Executive Leadership Team (ELT) as the chair and the VA medical facility Safety Manager as co-chair. NOTE: The VA medical facility CSC must be a multi-disciplinary team composed of representatives from the following

July 10, 2023 MCP 001S-01-28 program areas: Infection Prevention and Control, Patient Safety, SOH, Healthcare Engineering as well as Construction Safety Officers (CS0s). Contracting, Green Environmental Management System, VA Police, Emergency Planning, Safe Patient Handling and Mobility, Pharmacy, Sterile Processing, Employee Occupational Health;

other program areas that may be affected by a construction project may be asked to participate on an ad hoc basis as deemed appropriate by the VA medical facility CSC chair. Local unions are notified of meetings and may choose to attend.

b.Facility's Safety Officer and Safety Staff. 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.Facility Safety Officer. 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 Safety and Health Leadership Council (SHLC).

(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-hour);

(b) Designated 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. Construction Safety Officer (CSO). The CSO is responsible for project submittal reviews of all construction projects and:

(1) Identifying work site risks.

(2) Collecting deficiency information.

(3) Documenting and disseminating actions and results.

(4) Providing 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) Determining 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) Requiring 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) Ensuring that the specific safety requirements for construction operations are implemented during facility projects.

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

(c) Conducting 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). The 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. The Environment Management Services is responsible for providing terminal cleaning to all construction areas prior to releasing areas back to services.

g. Patient Safety. 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.

h. Projects Section Supervisor and In-House Construction Supervisor.

Projects Section Supervisor and In-House Construction Supervisor are 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. The 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. The Chief of Biomedical Engineering is responsible for 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. The Contracting Officer Representative/Project Engineers are responsible for:

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

(2)Completing the required Project Risk Assessment (PRA) in Appendix C, and following the PRA Completion Flow Chart in Appendix F.

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

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

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

(6) Assessing 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 C if plastic is to be used.

(7) Conducting and documenting 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) Providing 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) Complying 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) Performing 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) Requesting Hot Work Permits directly from the Jesse Brown VA Medical Center Engineering.

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

(5) Adhering 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 D). 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) Providing and maintaining 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. Multi-disciplinary Team. 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) Reviewing 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. GEMS Coordinator. 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.

o. Emergency Manager. The Emergency Manager is responsible for:

(1) Providing guidance on OSHA regulations as they apply to emergency planning, response, and operations in construction (Le., 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. Construction Lead Person. 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. Police and Security Officers. 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 and 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. OTHER PARAGRAPHS

PROCEDURE

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

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

c. If ILSM'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 C. A copy of Appendix C 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 or Construction Safety 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 iAuditor 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 C must be completed and signed by the Medical Center Director. The COR/Project Engineer must contact the Facility Safety Officer requesting a reactivation inspection. The Facility Safety Officer will contact the Project Reactivation Team (PRT) and schedule the reactivation inspection. If the Mental Health Ward (7 E/VV 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.

(16) Project Reactivation Team (PRT)

a. Area Nurse Manager or Service/Sect. Chief

b. Patient Safety Manager

c. Chief, Occupational Safety & Health Service

d. Chief, Environmental Management Service

e. Chief, Engineering Service

f. Infection Prevention and Control

g. Medical Center Director

h. Any other Service as directed by Leadership

July 10, 2023 MCP 0015-01-28

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 003S-05-25, dated December 31, 2020.

8. REVIEW

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

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of July 2028. 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.

MCP 001S-01-28 July 10, 2023

10. SIGN AUTHORITY

Ric t, F Jesse Brown VA Medical Center Director Date Approved:

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

DISTRIBUTION: MOPS 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 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.

A-1

APPENDIX A

• If a utility failure occurs.

• Prior to restoring a system.

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 you.

A-2

APPENDIX B

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

EQUIPMENT

PERMIT NUMBER

SHOP REQUESTING PERMIT: Date

Building: Department Floor

Work to be done

A I I ENTION

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

Sprinlders 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 fire 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

Project Title: Project or Work Order Number: MCP 001S-01-28 Appendix C

PROJECT RISK ASSESSMENT (SAFETY, INFECTION CONTROL & ILSM)

US Department Project Title:

of Veterans Affairs: Categorical Exclusion from NEPA Requirement Project or Work Order No:

for EA or EIS

Location:

Project Manager/COR:

Start Date:

Coordinator Phone Number:

Address or intersection:

Description of project:

City, State:

ZIP:

County:

Type(s) of project:

00perations/ maintenance 0 Repairs/renovation 0 New Construction 0 Lease 0 Grant 0 Other (describe)

Specify applicable categorical exclusion(s) (38 CFR 26.6(b)(1)):

0 Electrical 0 Support/appurtenances for normal 0 Components or site elements within VA operations property line 0 Leases, licenses, permits, and easements 0 Routine maintenance 0 Reduction in force 0 Procurement for routing facility 0 Policies, actions, studies with no significant 0 Interior construction/renovation environmental effect 0 New construction 575,000 GSF 0 Regulations/guidance implement

0 Cemetery development <20 acres existing requirements from higher VA levels or other property; development 5.5 acres new land agencies 0 No expenditure of federal funds

Review for extraordinary circumstances (38 CFR 26(b)(3)) - Check each box to confirm review and item is not applicable:

0 N/A: Greater scope or size than normally 0 N/A: Use of unproven technology experienced for a particular categorical exclusion 0 N/A: Potential presence of an endangered species, 0 N/A: Actions in highly populated or congested areas archaeological remains, or other protected resources 0 N/A: Potential for degradation, although slight, or existing 0 N/A: Potential presence of hazardous or toxic poor environmental conditions substances List other potentially significant environmental effects reviewed, if any:

Indicate (check out) whether the proposed activity would involve or generate any of the following:

0 Air emissions including GHGs 0 Water flow modification 0 Mixed waste 0 Aesthetics 0 Asbestos 0 Liquid effluent 0 Radioactive Waste 0 Water/well use 0 Excess Noise 0 Petroleum storage 0 RCRA or CERCLA site 0 Historic property 0 Utility Modification 0 Solid Waste 0 Wetlands 0 Other (describe):

0 Soil disturbance 0 Hazardous waste 0 Permit modification 0 Water treatment 0 Biological resource 0 Chemical use/storage

Determination 0 The proposed project qualifies as a categorical exclusion (specified above) with no extraordinary circumstances.

0 The proposed project may have a significant effect on the environment. Therefore, an environmental assessment will be prepared.

0 Environmental impact statement.

Reviewed by COR

Signature

Title

Approved by GEMS Coordinator

Signature

Title

C-1

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.

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 are to be sealed off during work!

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In. STEP #1 lir ili FOR THE FOLLOWING QUESTIONS, TAKE THE ACTION IN THE ASSOCIATED 'NO' OR 'YES' COLUMNS TO DETERMINE IF ILSM IS REQUIRED

NO YES

A. Will this work restrict EGRESS from the affected space? PROCEED TO STEP B ILSM REQUIRED B. Is the equipment, component, etc., part of a building LIFE SAFETY system? ILSM NOT REQUIRED PROCEED TO STEP C C. Is the activity in a PATIENT CARE AREA or will it affect a PATIENT CARE AREA? ILSM NOT REQUIRED ILSM REQUIRED D. Removal of any corridor or more than 5% of a room's ceiling tiles? ILSM NOT REQUIRED ILSM REQUIRED E. Floors or ceilings will be penetrated during construction? ILSM NOT REQUIRED ILSM REQUIRED F. Significant renovation of an occupied floor? ILSM NOT REQUIRED ILSM REQUIRED lir

STEP #2

Today's Date Building Project Loc.

Start Date Est Comp. Date Project Mgr.

Project /WO Number Project Name Specific Deficiency and Location

STEP #3

USE THE CRITERIA BELOW TO DETERMINE THE APPROPRIATE INTERIM LIFE SAFETY (ILSM) FOR CONSTRUCTION, MAINTENANCE, REPAIR, OR INSPECTION ACTIVITIES

Unless otherwise noted below, these requirements apply to impairments of a duration extending beyond the current shift (greater than 8 hours)

IL

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IL

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ILS

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IL

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Check all that apply.

Any impairment of a required egress less than 4 hours X

X

Any impairment of a required egress greater than 4 hours X X

XXXXXXXXX

Fire detection ALARM system impairment greater than 8 hours *** X

XXXXXXX

Fire SUPPRESSION system impairment greater than 8 hours

XXXXXXX

Problem with a single fire or smoke door hardware

Fire or smoke barriers with unprotected penetrations

Missing or incomplete fire or smoke barriers

Missing or impaired NFPA 101 required fire or smoke dampers

Hazardous use areas not properly separated from corridors

Accumulation of combustibles end/or materials X

X X

Temporary construction doors not latching or missing hardware

Activity involving ignition sources (welding, torching) X

Major utility failure or outage affecting a life safety system greater than 4 hours

XXX

XXX

XXXXX

Multiple LS impairments within the same fire or smoke zone X

X XXXXXXXX

**Requires review by Construction Safety Subcommittee Members prior to ILSM commencement.

*** The following functions shall be actuated and considered as part of a complete fire alarm system: Release of hold-open devices for doors or other opening protectives, Stairwell or elevator shaft pressurization, Smoke management or smoke control systems, unlocking of doors, Elevator recall and shutdown, and HVAC shutdown, STEP #4

Ilk INTERIM LIFE SAFETY IMPLEMENTATION MEASURES Mil ___Illa

ILSM 1 Inspect'exits in affected areas on a daily basis and resolve problems immediately.

ILSM 2 Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

ILSM 3 Provide additional firefighting equipment as needed.

ILSM 4 Use temporary construction partitions that are smoke-tight or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.

ILSM 5 Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

ILSM 6 Enforce storage, housekeeping, and debris-removal practices that reduce the buildings flammable and combustible fire load to the lowest feasible level.

ILSM 7 Provide additional training on use of firefighting equipment, impaired structural or fire safety features, temporary measures implemented, construction hazards, and building deficiencies. (NOTE: ILSM7 requires VEHS notification. Additional staff training is required for project duration exceeding 8 hours.)

ILSM 8 Conducts one additional fire drill per shift per quarter as called for by policy, best practice, or at the discretion of the VUMC Safety Officer.

ILSM 9 Inspect and test ILSM systems monthly or once per project if the duration is less than one month.

ILSM 10 Notify the local fire department and internal responders of the ILSM steps in place using the Interim Life Safety Measures form as required.

ILSM 11 Notify the occupants in the area of the deficiency and the ILSM steps in place using the Interim Life Safety Measures form as required.

ILSM 12 Install signage identifying the location of alternate exits to everyone affected.

ILSM 13 Refer to MCP 001S-39-28 "Fire Watch Policy" (The Fire Watch Policy may require a time limit less than 8 hours.)

ILSM 14 Blocked egress paths are never left unattended.

Name of Person(s) Completing this Assessment Date the assessment was completed

OSH Staff Reviewing this Assessment Date the review was completed

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ILSM ALERT

Situation: Effective immediately

Interim Life Safety Measures are in effect for the until cancelled. This alert is due to Background: Contracted personnel will be:

Assessment:

(Work to be done)

However, handheld fire extinguishers are located throughout the floor. The rest of are protected by a fully functional fire system including sprinklers.

Requirements: All personnel MUST be on high alert for signs of fire.

A review of emergency response, evacuation procedures, and handheld fire extinguishers locations MUST be completed by all hands.

JBVAMC Police will increase patrols of the during off-shift hours.

You are required to pass this information to all staff members, patients in the and anyone who may on occasion be in this building.

Any questions should be addressed by calling extension 56985.

Mr. Paul L. King Safety and Occupational Health Manager

Jesse Brown VA Medical Center

Project Title: Project or Work Order Number: MCP 001S-01-28

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CONTRACTOR BRIEFINGS & TRAINING

INITIALS

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

0 N/A

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 firefighting equipment and use training for personnel. 0 N/A

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

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.

ILSMs ARE IN PLACE SAFETY STAFF HAS VERIFIED NOTIFICATIONS & TRAINING

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. 0 N/A

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

TB RISK ASSESSMENT

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): LI YES 0 NO 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 screening within 90 days prior to assignment to the worksite and been found have negative TB screening reactions. Contractors shall be required to show documentation of negative TB screening reactions for any additional workers who are added after the 90-day requirement before they will be 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.qov/mmwr/preview/mmwrhtml/rr5417a1.htm)

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Inspection/upkeep generally defined as follows:

• Work can be completed in a single shift, not to exceed 10 hours.

• Patients, employees and/or visitors may be in the area depending on the activity.

• Work that does not create dust or debris.

• Work that does not create vapors or fumes.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection that will not impair fire safety systems and are limited to 1 tile per 50 square feet with limited exposure time (not to exceed an hour for each tile) within the shift.

• Minor interior updates (e.g., replacing floor or ceiling tiles, carpentry work to include hanging signage, and painting with hand tools) that do not create vibration or noise.

Limited building system maintenance that does not require Lock Out Tag Out (LOTO) such as plumbing on potable systems limited to faucet replacement, steam trap replacement etc. and electrical work such as replacement of bulbs, rece tacles, or switches.

Small scale Construction, Renovation, and q_eneral maintenance/repair work, generally defined as follows:

• Prolonged work that may take longer than a single shift but not exceeding six months.

Pre-Construction Risk Assessment (PCRA)

This form provides minimum requirements for categorizing activity type(s) and safety risk to determine the level of precautions needed to prevent impact related to Construction, Renovation and Maintenance on patients, employees, and contractors.

Ensure that the activity statement of work and any drawings available are used for the PCRA assessment and included in the project file with the completed PCRA.

Communication and coordination of all types of activity with affected areas are to be included among the control measures. The development of communication and coordination plans must begin during the activity planning phase.

Table 1 - Construction, Renovation, and/or Maintenance Activity Type and Control Measures

NOTE: If any of the bulleted criteria in a higher activity type pertains to the work that will be done (even if the other criteria are in a lower type), use the higher activity type for the VHA PCRA.

Controls defined in Table 1 for the activity must be in place before the activity begins and maintained until work is completed and the area is activated. Control measures for each activity must also include the control measures in the preceding row(s).

As the activity progresses, a full re-evaluation of remaining activity type and risk is required prior to changing the level of control measures.

Activity Type determined from Table 1:

Activity Type and Description Control Measures

1. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

2. Site visits of construction area are required weekly by member of multi-disciplinary team. Site visits will be documented on standard checklist.

3. Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor and approved where a contact is in place.

For internal work the shop involved must work with Safety to ensure proper precautions are in place.

4. Must address identified hazards and controls that will be implemented to ensure minimal impact to patients, employees, contractors, and facility.

5. Communication and coordination plan for all affected areas

All control measures in the row above and the following:

1. Hazard communication chemical inventory required to be provided by the contractor and approved.

2. Where construction, Renovation and maintenance are done in an accredited facility, and ILSM assessment is

Project Title: Project or Work Order Number: MCP 001S-01-28

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• Patients and employees are not to be in the area until activity is completed.

• Work that creates some noise and vibration due to power tool use.

• Selective demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements that may o disturb asbestos, lead or silica o create the potential for falling objects o create vibration…