STATEMENT OF WORK - Triennial Electrical Testing.docx

STATEMENT OF WORK

Triennial Inspection and Testing of the Electrical Power Distribution System

1. GENERAL:

a. This solicitation is for triennial inspection and testing of electrical breakers and the electrical power distribution system at the Iowa City VA Healthcare System located in Iowa City, Iowa. The Contractor shall have a minimum of five (5) years of specialized continuous experience in testing, inspection, cleaning, adjusting, and appraising electrical distribution systems and apparatuses to ensure their reliable operations in healthcare, industrial, educational, and commercial facilities.

b. All work performed shall be fully documented by the Contractor. Testing shall be performed in compliance with manufacturers’ recommendations and applicable NEMA, NEC, NFPA, ASTM, ASA, and VA standards. All outages shall be scheduled and approved in writing in at least two weeks in advance. Outages will be scheduled only at night and on weekends.

c. A complete list of distribution system equipment and apparatus to be inspected, cleaned, tested, and adjusted is found in “Attachment B” of this specification.

2. MAINTENANCE AND TESTING REQUIREMENTS:

a. In addition to complying with the general codes referenced in 1. B., the contractor shall pay special attention to compliance with VHA Directive 1028 and see Attachment C and NFPA 70B.

b. Switchgear Equipment, Medium Voltage Circuit Breakers, and Protective Relays:

i. Record switchgear, breaker, and device nameplate information and compare with facility’s one-line diagram, when available. Identify and record discrepancies.

ii. Inspect all electrical equipment, including each breaker, and report damaged, or malfunctioning equipment, loose connections or material or any contamination that must be corrected. Clean where appropriate.

iii. Check equipment for level, security to foundation, and operation of doors. Report any unfavorable environmental conditions such as excessive moisture.

iv. Visually inspect the equipment ground and record the number and size of ground bus and straps, Report deficiencies, and clean where appropriate.

v. Inspect the insulation system on the primary bus and assemblies. Test insulation on each bus, phase-to-phase, and phase-to-ground with suitable megohmmeter. Record values, report deficiencies, and clean where appropriate.

vi. Draw or rack each breaker from its cell. Remove arc chutes, clean, inspect, and adjust all contracts as necessary. Measure and record contact resistance in micro-ohms and clean all insulating surfaces. Megger and record phase-to-phase and phase-to-ground. Lubricate as necessary.

vii. Electrically close and trip each breaker with control switch. Manually close and trip each breaker. Trip each breaker with each of its protective devices. Tighten all connections. Record any discrepancies.

viii. Remove each relay from its case. Clean, inspect, and tighten all connection. Apply three multiples of relay tap current to each relay to verify manufacturers’ time current characteristics. Test each relay for instantaneous pickup. Test all ground fault relays for proper calibration and operation. Report deficiencies and adjust where appropriate.

c. Primary Disconnects

i. De-energize entire substation, clean all insulating surfaces, and clean and dress all contacts.

ii. Measure contact resistance in micro-ohms, Megger each phase-to-ground. Record any discrepancies.

iii. Clean and inspect cubicle, tighten all untapped connections, and lubricate as necessary.

d. Transformer

i. Record transformer nameplate information and compare with the facility’s one-line diagram, when available. Record discrepancies.

ii. Inspect transformer and accessories and report damage, loose connections ore material, shipping blocks, or contaminations that must be corrected. Clean where appropriate, inspect for leaks and tighten all untapped connections. Clean insulating surfaces.

iii. Sample all insulating liquids and test dielectric and water content.

e. Low Voltage Circuit Breakers

i. Record switchgear, breaker, and device nameplate information and compare with the facility’s one-line diagram, when available. Record discrepancies. NOTE: Work includes all service equipment and power distribution panel boards but not branch-circuit panel boards that are used on the various floors in the buildings.

ii. Inspect equipment and each breaker and report damage, loose connections or material, or contamination that must be corrected. Clean where appropriate.

iii. Check equipment for level, security to foundations, and operation of doors. Report any unfavorable environmental conditions such as excessive moisture or conducting dust that must be corrected. Clean where appropriate.

iv. Visually inspect the equipment ground an record the number and size of ground bus and straps. Report deficiencies.

v. Inspect the insulation system on the primary bus and assemblies. Test insulation on each bus, phase-to-phase, and phase-to-ground with suitable megohmmeter. Record values, report deficiencies and clean where appropriate.

vi. Clean and inspect each breaker. Megger phase-to-phase, phase-to-ground, and measure contact resistance in micro-ohms. Test each series over current trip device for pickup at 200% and 300% of its rating for instantaneous pickup. Clean and dress all contact surfaces and lubricate as necessary.

f. Generators

i. Record nameplate data including manufacturer, age, and capacity. List fuel type, kW load under load conditions, number of hours of fuel tank capacity, and number of hours of accumulated run time.

ii. Test run the generators in loaded condition. Record the transfer time and evaluated the reliability of the emergency power system.

g. Batteries

i. Provide and replace batteries inside each micro-logic, size ½ AA 3.6 volts – Schneider Electric part number 33593. Approximately 85 batteries.

3. REPORTS:

a. Provide two copies of data, testing, and inspection results to the Maintenance and Operations (M&O) Engineer of all devices tested as required by the scope. Report shall be securely bound and in an 8 ½ x 11 format. Provide one electronic copy (CD) of the report as either a PDF file or Word document.

b. At a minimum, the report shall include the following:

i. Summary of project

ii. Description of equipment tested

iii. Description of tests

iv. Test Data

v. Analysis and recommendations

c. Test data records shall include the following minimum requirements:

i. Identification of the testing organization

ii. Equipment identification

iii. Humidity, temperature, and other conditions that may affect the results of the tests/calibrations

iv. Date of inspections, tests, maintenance and/or calibrations

v. Identification of the testing technician

vi. Indication of inspections, tests, maintenance and/or calibration to be performed and recorded

vii. Indication of expected results when calibrations are to be performed

viii. Indication of “as-found” and “as-left” results, as applicable

ix. Sufficient spaces to allow all results and comments to be indicated

4. ELECTRICAL GROUNDING SYSTEM TESTING CRITERIA

a. Grounding Testing Procedures

i. This section describes grounding system testing procedures.

ii. These tests should be performed when the site ground system can be safely disconnected from the power company neutral wire.

b. Overview

i. Testing will be performed using one of the three methods which are described as follows:

1. Three-Point / Fall of Potential Testing This method is the most widely accepted. However, performing the test may require access to areas that may be beyond the site property lines. When testing a grounding electrode system consisting of a multi-bonded/ multi-grounding electrode system, the distance required for testing is directly related to the effective diagonal distance of the buried grounding electrode system.

2. Clamp-on Ohmmeter This method shall be used when access to necessary space needed for the Three-point/Fall of Potential test is not available. However, the clamp-on Ohmmeter test can only be performed after AC utilities have been connected to the site and various feed conductors are accessible.

3. Combined Soil Resistivity Testing with Clamp-on Ohmmeter Testing This method shall only be used in special cases where three-point/fall of potential testing or clamp-on ohmmeter testing cannot directly provide a suitable evaluation. The data obtained from soil resistivity testing and clamp-on ohmmeter testing is then used by an engineering firm specializing in grounding electrode system design to make determinations regarding the grounding electrode system.

c. Limitations to Performance Testing

i. The following conditions must be met in order to perform grounding electrode system testing:

1. Three-point/fall of potential testing is possible only if the following conditions can be met:

A. Sufficient land area must be available to perform a three point/ fall-of-potential test. The reference probe may likely need to be inserted into soil that is beyond the site property line. Testing using a clamp-on ohmmeter may be an option in these cases.

B. The grounding electrode system must be able to be isolated from the power company grounded conductor (may be a neutral wire).

b. If these conditions cannot be met, an added supplemental grounding electrode system can be installed. This supplemental grounding electrode system could be installed and tested prior to its connection to the existing system. This supplemental system should be installed in such a manner as to allow an easy disconnect point for future testing.

d. Three Point / Fall of Potential Test Procedure The three point/fall of potential test is the most widely accepted and recommended test method. This procedure is described in detail in ANSI/IEEE STD 81.2.

In the three point/fall of potential test, two test rods are driven into the soil. These rods are placed in a straight line from an electrode in the grounding electrode system to be tested (referred to here as connection 'X'). One of the test rods (referred to here as rod 'Z') is placed at a known distance from the 'X' connection. The other test rod (referred to here as rod 'Y') is placed at various distances between the 'x' connection and rod 'Z', a potential difference (voltage drop) will exist between the 'x' connection and rod Y. The fall of potential tester measures the voltage drop between the 'X' connection and rod 'Y', and converts the measurement to a resistance reading using Ohm's Law (R=E/I). In this manner, the resistance at any point between 'x' connection and rod 'z' can be measured. The multiple readings obtained during this test are entered and plotted as data points on a graph. From the graph, the resistance of the grounding electrode system can be determined.

This test requires disconnection of the site grounding electrode system from the power company grounded conductor, and the disconnection of all other grounds that may be connected to the site grounding system, such as telecommunications system grounds. This is required in order to allow testing that is limited only to the site grounding electrode system. Attempting to perform measurements while the site remains connected to the extensive ground/neutral system of the power company and telecommunications utilities artificially enhances the grounding electrode system reading, resulting in measurement error.

e. Clamp-On Ohmmeter Testing Procedure The clamp-on ohmmeter test can be performed on both single grounding electrode and multi-grounding electrode systems. However, the test can only be accurately performed on a site supplied by commercial power.

NOTE: if the electrical service provided by the power company does not contain a neutral wire that is bonded to the extensive power company ground system (such as a three-phase delta service), the clamp-on ohmmeter will not give an accurate reading. In these cases, this is because the neutral wire is locally derived at the transformer and is not part of the extensive power company grounding system; therefore, it cannot provide an effective low resistance return path.

The clamp-on ohmmeter works on the basis of injecting a known voltage into the grounding electrode system in order to create a current flow whose value is a function of the grounding electrode system resistance. The test current flows from the grounding electrode system through the earth, returning to the grounding electrode system via the power company's multi-grounded neutral wire. The meter then measures this current and converts the measurement to a resistance reading using Ohm's Law (R=E/I). As such, the meter displays a resistance of the grounding electrode system in ohms. Since the power company's grounding system is so extensive, the meter considers it to be of negligible value and disregards its effect on the reading.

This test requires disconnection of the site utility power. This is required in order to allow testing that is limited only to site grounding system. Attempting to perform measurements while the site remains connected to the utility's extensive grounding/neutral system artificially enhances ground readings that result in measurement error.

f. Combined Soil Resistivity Testing with Clamp-On Ohmmeter

Providing site soil resistivity readings along with clamp-on ohmmeter readings is at times the only method available for grounding electrode system resistance verification.

This test can be performed in the energized state where the grounding connections are accessible. Once the external grounding electrode system has been verified, the internal system can then be tested.

This test will verify only the conductivity to the main ground buss of the commercial power system. This test will not confirm the status to the exterior grounding electrode system or fall of potential.

The internal system should be visually inspected and made free of defects prior to testing. Never disconnect any part of the grounding system while in operation. Once visual inspection has been made, a digital low resistance measurement will be made between all bolted/compressed connections and between bolted/compressed connections to enclosures. All bolted connections should be torque to NETA specifications, then retested with a digital low resistance meter. These readings should be documented in a format so that connectivity and conductivity of the grounding electrode system can be demonstrated.

External grounding electrode system test procedures are performed in the de-energized state.

Internal grounding electrode system test procedures can be performed in the de-energized or energized state.

g. Additional Requirements - VHA Directive 1028 is tailored to include:

The current VHA Directive 1028 grounding testing requirement is, "Inspect and tighten ground connections. Test ground resistance for the entire facility grounding system."

We require that the following criteria be added to VHA Directive 1028:

i. Perform visual inspection for bonding conductor and equipment grounding conductor condition, continuity, and termination. Correct any defects.

ii. Perform soil resistivity tests in several locations (if fall-of-potential test method is to be used).

iii. After visual inspection and correction of defects is complete, use a digital low resistance meter to measure resistance between all bolted/compressed connections and between bolted/compressed connections to enclosures. All bolted connections will be torqued to NETA specifications, then retested. These readings shall be documented in a format so that connectivity and conductivity can be calculated as to the effectiveness of the grounding electrode system through-out the systems.

iv. Ground resistance tests shall be performed using fall-of-potential method or calibrated clamp-on ground resistance tester.

ATTACHMENT B

16U - Space - No Breaker

SEL-351

MEZZ Breaker Location

ATTACHMENT C

Department of Veterans Affairs VHA DIRECTIVE 1028 Veterans Health Administration Transmittal Sheet Washington, DC 20420 February 24, 2020

ELECTRICAL POWER DISTRIBUTION SYSTEMS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive establishes policy regarding the installation, operation, testing, and maintenance of Electrical Power Distribution Systems at VA medical facilities and affiliate sites. \

2. SUMMARY OF MAJOR CHANGES: Major changes include updates to references (Paragraph 11) and responsibilities (Paragraph 5).

3. RELATED ISSUES: VHA Directive 7701, Comprehensive Occupational Safety and Health Program, dated May 5, 2017.

4. RESPONSIBLE OFFICE: The Office of Capital Asset Management, Engineering and Support (OCAMES) (10NA5E), is responsible for the content of this directive. Questions can be submitted to the Healthcare Environment and Facilities Program Share at: https://vaww.vhs.vaco.portal.va.gov/sites/DUSHOM/10NA/10NA5/HealthcareEngineering/waiver/Pages/Waiver%20Requests.aspx. Note: This is an internal VA Web site that is not available to the public.

5. RESCISSIONS: VHA Directive 1028, Electrical Power Distribution System, dated July 25, 2014, is rescinded.

6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of February 2025. This VA directive will continue to serve as national VHA policy until it is recertified or rescinded.

BY THE DIRECTION OF THE

UNDER SECRETARY FOR HEALTH

/s/ Renee Oshinski Deputy Under Secretary for Health for Operations and Management

DISTRIBUTION: Emailed to the VHA Publications Distribution List on February 27, 2020.

February 24, 2020 VHA DIRECTIVE 1028

CONTENTS

FACILITY ELECTRIC POWER SYSTEMS

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. APPLICABILITY OF THIS DIRECTIVE

7. SAFETY

8. IMPLEMENTATION

9. TRAINING

10. RECORDS MANAGEMENT

11. REFERENCES

February 24, 2020 VHA DIRECTIVE 1028

FACILITY ELECTRICAL POWER SYSTEMS

1. PURPOSE

This Veterans Health Administration (VHA) directive provides policy regarding the installation, operation, testing, and maintenance of Facility Electrical Power Systems at Department of Veterans Affairs (VA) medical facilities. AUTHORITY: Executive Order 12196, dated February 26, 1980; Title 38 United States Code (U.S.C.) 7301(b); 40 U.S.C. 3312.

2. BACKGROUND

a. VHA and The Joint Commission have adopted the National Fire Protection Association (NFPA) codes and standards including the National Electrical Code (NFPA 70), Recommended Practice for Electrical Equipment Maintenance (NFPA 70B), Standard for Electrical Safety in the Workplace (NFPA 70E), Health Care Facilities Code (NFPA 99), Life Safety Code (NFPA 101) and Standard for Emergency and Standby Power Systems (NFPA 110) as the basis for the requirements of the design, installation, operation, testing, and maintenance of the Electrical Power System at VA medical facilities and affiliate sites. NOTE: VHA adopts national codes and standards upon issuance; in some cases, The Joint Commission may be using older editions of such standards which may cause discrepancies.

b. The Joint Commission’s Environment of Care (EC) standards require written Utility Management Plans. The Utility Management Plans must ensure reliability, control risks, reduce failures, and train users and operators of the Facility Electrical Power System. Non-compliance with this directive could lead to accreditation issues with The Joint Commission, impact patient care and increase the risk of harm to patients in critical care areas such as the Intensive Care Unit and Operating Rooms.

c. Working on energized electrical equipment is inherently dangerous to patients, staff, visitors, and VA property. Such actions, if unplanned or poorly executed, can result in disruption of operations, injuries, loss of life and loss of property. Occupational Safety and Health Requirements (OSHA) Title 29 Code of Federal Regulations (CFR) Part 1910 Subpart J, The Control of Hazardous Energy (lockout/tagout) (1910.147); Part 1910 Subpart February 24, 2020 VHA DIRECTIVE 1028

S, Electrical (1910.301-1910.399); and Safety and Health Regulations for Construction Part 1926 Subpart K, Electrical (1926.400-1926.449) apply to work on this equipment.

3. DEFINITIONS

a. Electric Power Production and Distribution Network. The Electric Power Production and Distribution Network consists of power production, distribution, and utilization equipment and facilities, such as electric utility systems that deliver electric power to the connected loads, that are external to and not controlled by an interactive system.

b. Emergency Power Supply. The Emergency Power Supply (EPS) is the source of electric power of the required capacity and quality for an emergency power supply system (EPSS).

c. Emergency Power Supply System. The Emergency Power Supply System (EPSS) as defined in NFPA 110 is a complete functioning EPS system coupled to a system of conductors, disconnecting means and overcurrent protective devices, transfer switches, and all control, supervisory, and support devices up to and including the load terminals of the transfer equipment needed for the system to operate as a safe and reliable source of electric power. Within health care facilities, the EPSS may be part of the Essential Electrical System (EES) (when serving loads allowed to be on the EES) or may be part of a standby power system when serving non-health care related loads.

d. Essential Electrical System. The Essential Electrical System (EES) as defined in NFPA 99, Health Care Facilities Code, is a system comprised of alternate sources of power and all connected distribution systems and ancillary equipment, designed to ensure continuity of electrical power to designated areas and functions of a health care facility during disruption of normal power sources, and also to minimize disruption within the internal wiring system.

e. Facility Electrical Power Systems. The Facility Electrical Power System includes the Premises Wiring and the portion of the Electrical Power Production and Distribution Network (both as defined in NFPA 70) owned by VHA.

February 24, 2020 VHA DIRECTIVE 1028

f. Mission Critical VA Medical Facilities. Mission critical VA medical facilities are those VA medical facilities and affiliate sites that are required to continue operation during a natural or manmade extreme event or a national emergency. NOTE: Refer to Physical Security Design Manual (PSDM), latest edition, for the definition and list of Mission Critical facility types. The PSDM is available on the CFM Technical Information Library (TIL): https://www.cfm.va.gov/til/criteria.asp.

g. Premises Wiring. Premises Wiring consists of interior and exterior wiring, including power, lighting, control, and signal circuit wiring together with all their associated hardware, fittings, and wiring devices, both permanently and temporarily installed. This includes (a) wiring from the service point or power source to the outlets or (b) wiring from and including the power source to the outlets where there is no service point. Such wiring does not include wiring internal to appliances, luminaires, motors, controllers, motor control centers, and similar equipment.

h. Qualified Persons. Qualified persons, as defined in NFPA 70, Article 100, are those that have demonstrated skills and knowledge related to the construction and operation of electrical equipment and installations and received safety training to identify the hazards and reduce the associated risk. Training must be classroom, on-the-job or a combination of the two. The type and extent of training must be proportionate to the risk to the employee.

i. Utility Management Plan. The Utility Management Plan is a written plan which includes processes for selection, maintenance, and training that are designed to promote safe and effective use of utility systems while minimizing risks to patients and staff. The Utility Systems Management Plan applies to hospital functions at each designated VA medical facility subject to inspection by The Joint Commission.

j. Wet Procedure Location. Wet Procedure Locations are the areas in a patient care space where a procedure is performed that is normally subject to wet conditions while patients are present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff.

February 24, 2020 VHA DIRECTIVE 1028

4. POLICY

It is VHA policy that the Facility Electrical Power System must operate in a safe, reliable, and efficient manner, recognizing its importance and potential danger; and in compliance with The Joint Commission, OSHA, and NFPA electrical standards.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall compliance with this directive.

b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary of Health for Operations and Management is the Authority Having Jurisdiction (AHJ) as it pertains to this directive and is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Ensuring that each VISN Director has the resources required to support the execution of this directive in all the VA medical facilities within the VISN.

(3) Confirming that each VISN has and utilizes on an ongoing basis a means for ensuring the terms of this directive are fulfilled in all the VA medical facilities of the VISN. The annual survey of compliance, Annual Workplace Evaluations (AWE) and Joint Commissions can comprise the basis for ensuring compliance.

(4) Approving variances or equivalencies to this directive. For example, approval of an alternative simulation if the utility connection cannot be opened during a test of the EES. See paragraph 8.j(4)(b).

February 24, 2020 VHA DIRECTIVE 1028

c. Office of Capital Asset Management Engineering and Support Director. The Office of Capital Asset Management Engineering and Support (OCAMES) Director is responsible for:

(1) Providing technical subject matter expertise regarding this directive, VA criteria, and related national codes and standards.

(2) Responding to questions from the field regarding technical issues and conducting site assessments related to this directive when requested or when otherwise determined to be required.

(3) Reviewing requests for deviations or variances from this directive, VA criteria, and national codes and standards and making recommendations to the Deputy Under Secretary for Health for Operations and Management to approve or not approve such requests.

(4) Reporting on results of annual survey of compliance with this directive as requested by VA leadership.

d. Veterans Integrated Service Network Director. The VISN Director is responsible for:

NOTE: For the purpose of this directive as it applies to non-medical facilities within VHA, the National Consolidated Mail Out Pharmacy (CMOP) Director or equal position is considered equivalent to the VISN Director and therefore responsible for the following:

(1) Ensuring the installation, operation, testing, and maintenance of Facility Electrical Power Systems meet or exceed The Joint Commission, NFPA, and other applicable requirements.

(2) Confirming that all work on the Facility Electrical Power Systems complies with OSHA and NFPA standards.

(3) Reviewing and providing concurrence or non-concurrence on VA medical facility requests for deviation from this directive, VA criteria, or national standards February 24, 2020 VHA DIRECTIVE 1028 and codes. Requests approved by the VISN Director must be submitted to the Deputy Under Secretary for Health for Operations and Management or designee for approval as the AHJ.

(4) Ensuring that appropriate resources are provided to each VA medical facility in order to ensure compliance with this directive. To ensure each VA medical facility in the VISN is in compliance with this directive, the VISN Director:

(a) Delegates review and interpretation of Facility Electrical Power System documentation to a qualified member of the VISN staff, including tracking of status reports regarding the installation, operation, testing, and maintenance of Facility Electrical Power Systems within the network.

(b) Ensuring each VA medical facility within each VISN completes a status verification survey once a year on or before May 1 using the survey tool found on the VHA Center for Engineering and Occupational Safety and Health (CEOSH) Web site electrical page under VA Policy and Guidance at: http://vaww.ceosh.med.va.gov/01HE/Pages/ST_electrical_distribution.shtml#VAPolicy_ Guidance.

NOTE: This is an internal VA Web site that is not available to the public.

e. Veterans Integrated Service Network Staff. VISN staff designated by the VISN Director are responsible for reviewing and interpreting electrical power system documentation, including tracking of status reports regarding the installation, operation, testing, and maintenance of Facility Electrical Power Systems within the network. Such staff should review any requests for deviation from this and other standards on behalf of, and make recommendations to, the VISN Director.

f. VA Medical Facility Director. The VA medical facility Director is accountable to the respective regional or national Director (e.g., VISN or CMOP Director). The VA medical facility Director is responsible for:

February 24, 2020 VHA DIRECTIVE 1028

NOTE: For the purpose of this directive as it applies to non-medical facilities within VHA, positions equivalent to the VA medical facility Director at affiliate sites are responsible for the following:

(1) Ensuring that the design, installation, operation, testing, and maintenance of Facility Electrical Power Systems meet or exceed The Joint Commission, NFPA, VA and other applicable requirements, and that all work on this system complies with OSHA, NFPA, and VA standards.

(2) Reviewing and providing concurrence or non-concurrence on deviations from VA and national standards requested by VA medical facility staff (typically requested by Engineering or Facilities Management). Approved deviation requests must be forwarded to the VISN Director for further review and concurrence.

(3) Approving a Utility Systems Management Plan developed by Engineering or other appropriate office which meets, or exceeds The Joint Commission, OSHA, and NFPA requirements and is approved by the VA medical facility Director or designee. See paragraph 8.k.(1).

(4) Approving exceptions for when electrical equipment that typically must be secured can remain unsecured.

(5) Allocating the appropriate resources (funds, training, equipment and qualified personnel) to achieve compliance.

(6) Authorizing only qualified staff at the VA medical facility and qualified electrical contract professionals to execute any design, installation, operation, testing, and maintenance of the Facility Electrical Power System in accordance with The Joint Commission and NFPA requirements and that all work on these systems is compliant with OSHA standards.

February 24, 2020 VHA DIRECTIVE 1028

(7) Approving a management system, developed and implemented by Engineering and Safety staff, to ensure that work on energized equipment does not take place without the VA medical facility Director’s prior knowledge and written approval; ensuring this information is disseminated to VA medical facility Service Line Chiefs

(8) Ensuring that electrical hazards (including arc flash and shock) are analyzed and identified per NFPA and OSHA requirements (see paragraph 7 for additional information on analysis requirements).

(9) Ensuring that appropriate actions are taken to correct deficiencies found in the Facility Electrical Power System.

(10) Overseeing the development and implementation of written procedures which prepare the VA medical facility for a planned electrical outage and ensuring that such procedures are communicated and disseminated to Service Line Chiefs.

(11) Ensuring a testing plan for Ground Fault Circuit Interrupters (GFCI) by which each GFCI is in place. Where there are not enough staff to keep up with the volume of GFCI that need to be tested, the VA medical facility Director may approve testing at less frequent intervals in this circumstance. (See paragraph 8.j.(7).)

(12) Certifying the survey which is a report of status indicating VA medical facilities are in compliance with the required maintenance and testing of the Facility Electrical Power System. See http://vaww.ceosh.med.va.gov/01HE/Pages/ST_electrical_distribution.shtml#VAPolicy_ Guidance. NOTE: This is an internal VA Web site that is not available to the public.

(13) Delegating, in writing, authority for the VA medical facility Chief Engineer to approve an energized electrical work plan for non-patient care Branch Circuits (see paragraph 8.h.(5)(b)).

February 24, 2020 VHA DIRECTIVE 1028

(14) Ensuring that transformers and other electrical equipment, including all related components, are inspected, tested, and maintained every 36 months. (See paragraph 8.j.(5-6).)

g. VA Medical Facility Chief Engineer. The VA medical facility Chief Engineer is responsible for:

(1) Ensuring the design, installation, operation, testing, and maintenance of Facility Electrical Power Systems meets or exceeds The Joint Commission, NFPA, VA and other applicable requirements and that all work on this system complies with OSHA, NFPA, and VA standards, as delegated from the VA medical facility Director. Ensures information related to electrical system maintenance, testing and operation is communicated to Service Line Chiefs.

(2) Developing concurrence/non-concurrence documentation for any deviations from VA and national standards. This includes obtaining VA medical facility Director concurrence/non-concurrence for such deviance/variation requests, ensuring approved deviance requests are forwarded to the VISN for further review and concurrence and notifying OCAMES of pending deviance/variation requests.

(3) Approving an energized electrical work plan for Branch Circuits when delegated from the VA medical facility Director or CMOP Director (see paragraph 8.h.(5)(a) for work plan information), and completing a risk assessment that indicates energized electrical work will not affect patient care and the work qualifies for one of the three NFPA 70E/OSHA exceptions (see paragraph 8.h.(3)(a-c) for exception information).

(4) Assigning a person as overwatch when energized work is being performed.

(5) Conducting a risk assessment when a planned electrical outage cannot be accomplished to determine if the work qualifies as meeting one of the three exceptions in NFPA 70E and OSHA which allow energized work (see paragraph 8.h.(3)(a-c) for additional information on the exceptions).

February 24, 2020 VHA DIRECTIVE 1028

(6) Certifying the annual survey which is a report of status indicating that the VA medical facility is in compliance with this directive. The survey can be found here: http://vaww.ceosh.med.va.gov/01HE/Pages/ST_electrical_distribution.shtml#VAPolicyGuidance. NOTE: This is an internal VA Web site that is not available to the public.

h. Service Line Chiefs. Service Line Chiefs located at the VA medical facility or other affiliate sites are responsible for:

(1) Communicating regularly with the VA medical facility Director in order to receive the plans and any additional information pertaining to planned electrical outages and planned work on electrical equipment.

(2) Working closely with the VA medical facility Chief Engineer to ensure information related to electrical system maintenance, testing and operation is communicated.

i. VA Medical Facility Engineering Staff. Engineering staff located at the VA medical facility or affiliate sites are responsible for:

(1) Designing, installing, operating, testing, and maintaining of Facility Electrical Power Systems to meet or exceed The Joint Commission, NFPA, VA and other applicable requirements and to perform all work on this system so as to comply with OSHA, NFPA, and VA standards.

(2) Developing and conducting a peer review of a specific energized work plan before initiating work. (See paragraph 8.h.(4)(c).)

(3) Developing a Utility Systems Management Plan which meets or exceeds The Joint Commission, OSHA, and NFPA requirements.

February 24, 2020 VHA DIRECTIVE 1028

6. APPLICABILITY OF THIS DIRECTIVE

a. The Facility Electrical Power System includes the Premises Wiring and that portion of the Electrical Power Production and Distribution Network (both as defined in NFPA 70) owned by VHA. This directive applies:

(1) To work on all VA medical facilities and affiliate sites owned, operated, or maintained by VHA.

(2) To work performed by any type of funding to include, but not be limited to, major construction, minor construction, non-recurring maintenance (NRM), Clinical Specific Initiatives (CSI), energy projects (e.g., Energy Savings Performance Contract (ESPCs), Research-funded, Office of Information and Technology projects, donated VA medical facilities (i.e., Fisher Houses, Public-Private Partnerships) and general maintenance, repair and replacement funded by VA medical facilities funds (i.e., applies regardless of funding source).

(3) To all facets of work on the Facility Electrical Power System to include, but not limited to, design, installation, construction, testing, and maintenance.

(4) To all work, including that performed by VA contractors as well as that performed by VA in-house (hired labor) personnel.

b. This directive does not apply to those leased VA medical facilities in which the installation, construction, testing, and maintenance of the Facility Electrical Power System is completely the responsibility of the lessor. Leased VA medical facilities must at a minimum comply with all local, State, and national codes and standards subject to review and oversight by VA personnel.

c. This directive does not apply to the equipment plugged into the Facility Electrical System. Such equipment is covered by other standards, for example, the use of Relocatable Power Taps in accordance with NFPA 99, Health Care Facilities Code, Chapter 10.2.

February 24, 2020 VHA DIRECTIVE 1028

7. SAFETY

The VA medical facility or affiliate site analyses and identifies electrical hazards, arc flash, and shock. The analysis, identification, and notification include the following:

a. Shock Hazard Analysis. The shock hazard analysis determines the voltage(s) to which personnel will be exposed, the boundary requirements, and the personal protective equipment (PPE) necessary to minimize the possibility of electrical shock to personnel.

b. Arc Flash Hazard Analysis. An arc flash hazard analysis determines the arc flash protection boundary and the PPE required for employee protection with within the arc flash protection boundary.

NOTE: Regularly updating the preceding analyses, labeling and reports to ensure accuracy and reflect current VA medical facility conditions, including additions, upgrades and other changes that occurred following completion of the previous analyses. Arc Flash risk assessment must be reviewed at least every 5 years and updated as changes mandate.