VA250-17-B-0970-025.pdf

LIST OF EXHIBITS

EXHIBIT NO 1 Release Pursuant Clause Form

EXHIBIT NO 2 *Progress Payment

EXHIBIT NO 3 *Contract Progress Report

EXHIBIT NO 4 Electronic Fund Transfer - SF 3881

ACH Vendor/Miscellaneous Payment Enrollment Form

EXHIBIT NO 5 Disclosure of Lobbying Activities Standard Form LLL (for contracts in excess of $100,000.00)

EXHIBIT NO 6 Request for Information (RFI) Form and Instructions

EXHIBIT NO 7 Daily Log

EXHIBIT NO 8 *Transmittal of Shop Drawings, Samples, Test Report, Manufacturer's

Data/Certificates

EXHIBIT NO 9 Policy Memorandum No. 00-14, Medical Center Smoking Policy

EXHIBIT NO 10 Policy Memorandum No. 07-04, Facility Name Badge

EXHIBIT NO 11 Policy Memorandum No. 07-29, Parking and Motor Vehicle Operation

EXHIBIT NO 12 Designated Parking for Contractors and Contractor's Employees

EXHIBIT NO 13 Policy Memorandum No. 138-10, Fire/Smoke Barrier Permits

EXHIBIT NO 14 Electrical Safety, Policy Memorandum 138-15

EXHIBIT NO 15 SOP, Number 11, Fall Protection

EXHIBIT NO 16 SOP Number 20, Confined Space Entry

EXHIBIT NO 17 SOP Number 31, Hot Work Operations

EXHIBIT NO 18 SOP Number 44, Ladder Safety Practices

EXHIBIT NO 19 SOP Number 45, Excavation/Trenching

EXHIBIT NO 20 SOP Number 57, Coordinating Utility Outages

EXHIBIT NO 21 Policy Memorandum No. 00-16, Prevention of Workplace Harassment

EXHIBIT NO 22 Policy Memorandum No. 07-09, Employee Threat Assessment Team (ETAT)

Committee

EXHIBIT NO 23 SOP Number 30, Control of Hazardous Energy (Lockout/Tagout)

EXHIBIT NO 24 SOP Number 12, Construction Project Inspections

EXHIBIT NO 25 Safety and Infection Control Handbook

EXHIBIT NO 26 SOP Number 32, Dig Permits

*Sample is provided for contractor's information. The use of this format is desired by the Department of

Veterans Affairs; however, you may develop your own format, providing that all pertinent information on the sample is incorporated into the form you submit and that the form you use is acceptable to the

Contracting Officer.

ELECTRONIC ACCESS EXHIBITS ARE IN WORD AND ACROBAT READER FORMATS.

VHACLLCROCKK

Typewritten Text

EXHIBIT 9

POLICY MEMORANDUM VA Medical Center NO. 07-04 Chillicothe, Ohio April 27, 2016

FACILITY NAME BADGE

1. PURPOSE: To define policy and procedures for the issuance and control of identification badges at this medical center.

2. POLICY: It is the policy of this medical center that anyone who is employed at, volunteers at, desires to conduct business with or is otherwise a guest of this medical center display an approved form of identification at all times.

3. DEFINITIONS: The following definitions apply to this policy:

a. Employees: Full-time, part-time, temporary and intermittent Department of Veterans Affairs employees or students (paid or not paid) and any other person who is directly paid by this medical center.

b. Non-employees on Official Business: Contractors, vendors, sales representatives, their employees, Fee-Basis Consultants and others seeking to do business with this medical center for the primary purpose of financial gain.

c. Non-employees on personal business: Visitors, inpatients, outpatients and others seeking to further their own particular interests.

d. Volunteers: The unpaid staff of Voluntary Service.

e. Hoptel Guests: Those persons who are utilizing the services of the Hoptel located in Building 29.

4. RESPONSIBILITIES:

a. Department of Veterans Affairs employees:

(1) Are directed, as a part of the new employee orientation, to the Human Resource Manage Service (HRMS) for issuance of a photo Personal Identity Verification (PIV) badge and for vehicle registration.

(2) If an employee notices a person in need of assistance, he/she approaches and offers help to his/her destination, e.g., patient, visitor and others. Should any unidentified person become confrontational, employees do not pursue further inquiry and immediately call VA Police at extension 7004. Employees advise persons required to wear a badge of the policy and call VA Police if the correction is not amicable.

(3) Direct persons who identify themselves as potential contractors, vendors, sales representatives, or others desiring to conduct business with this medical center to the

VHACLLCROCKK

EXHIBIT 10

2. POLICY MEMORANDUM NO. 07-04

office of Logistics Service, Building 1, first floor, room 125. Note: No employee of this medical center may conduct business with any person who has not registered with Logistics Service and who does not have the proper identification badge in his/her possession at the time. Questions are referred to the Logistics Service, Contracting Section, at extensions 7011, 7012 or 7014.

(4) Notify Human Resources Management Service (HRMS) of any name change during his/her employment as soon as possible, but no later than thirty days after the change becomes effective. HRMS will issue a new PIV badge after the employee completes other actions prior to the re-issue. Re-issue for changes of services is not required.

(5) With the exception of VA Police and Fire Fighters in uniform, wearing of the PIV badge by on-duty employees is mandatory at all times. Supervisors may authorize the temporary suspension of the requirement on the work site when an employee is working around equipment and machinery that might pose a safety hazard. Employees on station for off-duty purposes are not required to wear the badge, but must give a reasonable explanation for the visit and cooperate fully to identify themselves when asked. VA Police are contacted for uncooperative employees who are then ordered to fully identify themselves by responding Officers. VA Police accomplish a Police report of any misconduct, if necessary, and forward it to the affected service chief/care line manger for whatever action is deemed appropriate.

(6) Surrender the PIV badge to HRMS as part of the clearance process. Failure to surrender the badge results in a $10 charge against the employee’s final compensation.

b. Logistics Service:

(1) Assigns an employee to complete the orientation, then provides, collects and maintains an approved color-coded temporary visitor’s badge for contractors, vendors, sales representatives or others who desire to conduct business with this medical center.

(2) Provides training to staff on issues related to ethics and other conduct with contractors, vendors, sales representatives and others who desire to conduct business with this medical center.

c. Service chiefs, care line managers and supervisors assure that all employees under their supervision are:

(1) In compliance with the requirements for wearing the PIV badge.

(2) Familiar with the current rules and regulations concerning their business relations with contractors, sales representatives, vendors and others. Guidance and/or training in this area are available from the office of Logistics Service.

3. POLICY MEMORANDUM NO. 07-04

d. Contractors, Vendors, Sales Representatives or others:

(1) Register at the Logistics Service Office located in Building 1, first floor, room 125 and provide name(s) along with other required information for themselves and any additional personnel who are working at or visiting this medical center.

(2) Upon each visit to this medical center, obtain and display any required form of identification that is provided.

(3) Complete any and all ethics, safety or other required training upon the first visit or employment day.

(4) Designate a Contract Superintendent/Manager on any construction/service project, who is responsible for assuring that his/her employee(s) properly display the required identification badges.

e. Volunteers are directed to Voluntary Service, located in Building 9, room 213, to be properly registered. New volunteers are directed to HRMS for issuance of PIV badges in building 1.

f. Protective Services (VA Police):

(1) Conduct a Stop & Question on any suspicious person encountered, or reported and determine if any person stopped should be displaying a PIV or visitor badge.

(2) Provide sequentially numbered and color-coded no picture temporary badges to other services when requested.

(3) Challenge and verify the identity of any person(s) not displaying an approved form of identification badge.

g. Hoptel guests are directed to the Patient Business Service administrative staff (or Administrative Officer of the Day (AOD) during non-administrative hours) in Urgent Care, located in Building 31. The person is registered and issued a room key and an approved temporary badge for the duration of his/her stay.

h. Visitors must provide proof of identity and purpose of visit. Refusal to provide any requested information is basis for denial of entry into this medical center and is immediately reported to the VA Police Operations Center, at extension 7004.

i. Human Resources Management Service: Processes and issues the Personal Identification Verification cards (PIV) required by Homeland Security Presidential Directive 12 (HSPD-12) national standards and Human Resources PIV program standard operating procedure.

4. POLICY MEMORANDUM NO. 07-04

5. PROCEDURES:

a. No photo facility name badge, card or other form of personal identification for employees, contactors, volunteers or affiliates is used for identification purposes other than the PIV card at this medical center. The official nature of any identification badge does not extend beyond this medical center. Its use for any other purpose is the responsibility of the bearer.

(1) Logistics issues an approved color-coded temporary visitor’s badge.

b. Special Security Access Badges (where utilized):

(1) Are NEVER loaned to anyone for any reason.

(2) If lost or stolen the PIV is immediately reported by the user to VA Police, FCIO, and the ISO, as this is our access mechanism for the VA Computer system and in some cases, the future keyless entry system.

a. Pins, stickers or other items may not be placed on or deface the PIV badge. The personnel identification badge must also be worn close to eye level in a manner that the name is legible at all times. Lanyards or retractable devices are authorized with the badge displayed above the waist.

c. Non-paid medical care interns or students working under the supervision of VA medical center personnel may utilize photo identifications from their medical schools.

All stipend paid and without compensation trainees must have a PIV badge issued by the medical center prior to beginning their rotation. If the PIV machine is non-operational, they will be issued a temporary ID by human resources which is tracked and returned when human resources is able to issue a PIV badge. No trainees are permitted to be at the medical center without a facility ID. The use of photo identification from their school is not an acceptable substitute for proper medical center identification.

d. Inpatients, outpatients and visitors are not required to wear an identification badge and their access is limited to public areas of the medical center unless being escorted by an employee. Inpatients also have access to their assigned area(s) on the units. Any failure to provide proper identification and/or purpose of visit is immediately reported to the VA Police Operations Center, at extension 7004.

e. Identification badges are not required for any person or group that is being escorted by an employee of this medical center.

6. REFERENCES: Policy Memorandum No. 05-4, Disciplinary and Adverse Actions

Policy Memorandum No. 122-05, Hoptel-Lodging of Veterans and Family Members MP-5, Part I, Chapter 752, Appendix C (17);

5. POLICY MEMORANDUM NO. 07-04

MP-5, Part I, Chapter 790, Paragraph 11;

Joint Commission Comprehensive Accreditation Manual for Hospitals 2016 IL-2002-013 Under Secretary for Health Information Letter dated August 13, 2002

7. RESCISSION: Policy Memorandum No. 07-04, Employee and Non-Employee Identification, dated September 17, 2015.

8. RESCISSION DATE: April 27, 2019

Keith Sullivan

Keith Sullivan, FACHE Medical Center Director

Distribution: ALL

POLICY MEMORANDUM VA Medical Center NO. 07-29 Chillicothe, Ohio May 31 2016

PARKING AND MOTOR VEHICLE OPERATION

1. PURPOSE: To establish regulations for operating privately-owned motor vehicles on the medical center grounds.

2. POLICY: It is the policy of this medical center to promote safe vehicle control on the roadways, maximize the utilization and benefit of parking facilities, and provide for consistent enforcement of the regulations governing these areas.

3. DEFINITIONS: None

a. VA Police: Ensures all new employees are issued parking registration cards and rearview mirror parking decals identified by sequential numbers to each vehicle operator. Takes enforcement actions when violations of this policy are identified or reported to include issuance of citations, arrests or towing of vehicles.

b. Immediate Supervisors: Takes corrective action when notified that an employee has received enforcement action for any parking violation.

a. Vehicle Registration: All employees parking a privately-owned vehicle on medical center property are required to register that vehicle using VA Form 10-6196, Privately-Owned Motor Vehicle Registration. This includes contractors, volunteers, consultants, etc. These forms are completed at the Police Operations Center, Building 18 lower level, during the in-processing procedure. A parking decal is issued for each vehicle and is displayed on the backside of the rear view mirror or attached to an index card placed on the driver’s side dashboard of the vehicle. Any changes in vehicle such as color, plate number or new vehicle are reported to the Police Operations Center within five workdays. When a vehicle is traded or sold, the employee is responsible for removal and destruction of the decal. Failure to register and display an identification sticker may result in a citation or restriction from use of parking facilities.

b. Traffic Regulations:

(1) All motor vehicle laws of the State of Ohio are observed while operating a vehicle at this medical center.

(2) Parking is allowed in designated areas only. Cars are parked between the marked lines.

EXHIBIT 11

Policy Memorandum No. 07-29

(3) Vehicle ignition keys are removed and the vehicle locked when left unattended in any parking area.

(4) The Department of Veterans Affairs assumes no responsibility for the safety of employees' cars, and any such parking is at the risk of the employee.

(5) In addition to the requirements of the Ohio State Motor Vehicle Code, a

PEDESTRIAN HAS THE RIGHT OF WAY when crossing a highway or street from any point within the geographical limits of the medical center grounds. Vehicles stop for pedestrians in a crosswalk.

c. Parking Allocations:

(1) Reserved parking areas are designated for handicapped, outpatients, physicians, consultants, volunteers, American Federation of Government Employees (AFGE) Union, and Credit Union (short term). Personnel not designated to use these parking spaces use general parking lots.

(2) The ambulance ramp to Building 31 and the two adjacent spaces are reserved for emergency vehicles loading/unloading at Urgent Care.

d. Enforcement:

(1) Courtesy Violation Notice (CVN): This violation notice is merely a reminder to the offender that s/he is in violation of posted rules and regulations governing VA property and the offense is punishable under the law. The yellow copy of the notice is forwarded to the appropriate service chief/care line manager. Service chiefs/care line managers are responsible for making sure their employees are familiar with and comply with parking and motor vehicle regulations, and for counseling employees upon receipt of the second CVN.

(2) Uniform Violation Notice (UVN): This notice is used by the medical center police officer to notify a violator, in writing, that s/he has violated the statutory authority contained in Title 38, United States Code, Section 218(b), 38 Code of Federal Regulations 1.218 and VA Regulations 1.218(b) for traffic, parking, and petty offenses.

Any person receiving a UVN is required to comply with the instructions contained on the ticket at the time of issuance. This notice involves forfeiture of collateral and/or appearance before the District Court Magistrate.

(3) Arrest: The Rule of Court, Southern District of Ohio, dictates the amount of collateral to be posted for a specific offense and those offenses requiring a mandatory appearance before a U.S. Magistrate. However, the Rule of Court does not prohibit the officer from making an arrest and taking the offender directly before a U.S. Magistrate to answer the charge placed against the offender.

2 . Policy Memorandum No. 07-29

(4) Towing: A privately owned vehicle may and will be towed from the medical center grounds when immediate removal is necessary to ensure public safety, or after 96 hours when abandoned. Owners of towed vehicles are liable for charges for towing and storage before the vehicle is released by the towing company.

e. Traffic Accidents: The Chief, Protective Services, or his/her designated Police Officer, investigates and prepares required reports for all motor vehicle accidents on medical center grounds, and may, when authorized, participate in investigations which involve government vehicles off medical center grounds. Neither the Department of Veterans Affairs nor the United States Government assumes responsibility for accidents occurring on the medical center grounds between privately owned motor vehicles. Such accidents are reported to the VA Police as required by law.

6. REFERENCES: DM&S Supplement, MP-1, Part I, Chapter 2, Section B VA Regulation 1.218(b) U.S. District Court, Southern District Rule No. 5.

Title 38, U.S. Code, Section 218(b).

Title 38 Code of Federal Regulations, Section 1.218.

AFGE Master Agreement.

7. RESCISSION: Policy Memorandum No. 07-29, Parking and Motor Vehicle Operation, dated October 15, 2015.

8. COLLABORATED WITH: VHACLL Tops, AFGE

9. RESPONSIBLE OFFICE: 07

10. RESCISSION DATE: May 31 2019

Keith Sullivan Keith Sullivan, FACHE

Distribution: ALL

EXHIBIT6

DESIGNATED PARKING FOR CONTRACTORS

AND CONTRACTORS'S EMPLOYEES

1. All contractors and/or all contractors' employees performing work at this facility are required to park their vehicles in the designated parldng area(s) as shown on the attached drawing.

2. The parking requirements will be strictly adhered to by all contractors and their employees, and will be strictly enfo1·ced by the VA Contracting Officer and/or the VA Contracting Officer's Technical Representative.

3. Failure to observe the required parking, may result in actions such as, but not limited to, parking fines, removal from facility, etc.

EXHIBIT 12

T40T228

T41

121314151617

205206

T233

A

B

A

B

A

B

A B

AB 1

A

B 1A

B

AB 1

A

B

A

B

A

B

A

B

A

B

A

B

A

B

A

B

A

B

A

B

AB 13

AB 6

AB 11

AB 10

B

B

14A 29

A1414

A B 15

A B 17

AB 16

A B 19

A B 18

A

B 31A

AB 31B

A

B

A

B

A

B

B A8B A1B

B A5

B A212

A 1A

B A18

B A9

B A60

A

B

A

B

A

B 28A

A

B 28B

A

B

A

B

A

B 3B

A

B

3A AB 7

AB 29

AB 24

A

B

A B2

A

B

A

B

A B A B

A B

A B

A B

A B

A B

A

B

A B

A B 4

A B3

A B

A B12

A B15

A B9

Ohio State Route 104

H ines Blvd.

Hines Blvd.

Sim s St.

Taft Circle

Dobson Circle

Talbot Road

Botts Road ev

A d n al w o

R

Griffith Circle

NORTH ENTRANCESOUTH ENTRANCE

WEST ENTRANCE

, 201

LOCATION PLAN

A

B

A

B

A

B21

A

B

AB 23

BA24

B

A

N

CONTRACTING OFFICE

BUILDING 212

CONTRACTOR PARKING

CONTRACTOR

OVERFLOW

PARKING

COR OFFICE

BUILDING 21

NOTE: OTHER PARKING MAY BE

AVAILABLE PENDING MEDICAL

CENTER USAGE. CONTACT YOUR

COR FOR REQUST FOR

APPROVAL.

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Line

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Line

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Line

Policy Memorandum VA Medical Center No. 138-10 Chillicothe, OH March 2, 2015

FIRE/SMOKE BARRIER PERMITS

1. PURPOSE: To establish policy and procedures regarding removal of ceiling tile penetrations in ceilings, floors, pipe chases, fire barriers/walls, and smoke barriers/walls for the purpose of maintaining the integrity of the medical center construction as required in National Fire Protection Association (NFPA) 101 to provide for the safety of occupants during fire incidents. Breaches in fire barriers/walls and smoke barriers/walls create the potential for fatal consequences or Veterans, staff, and visitors, should a fire occur.

2. POLICY: Removal of ceiling tile, penetrations made in ceilings, floors, fire walls/barriers and smoke walls/barriers for the purpose of the installation/removal of pipe, conduit, cable, or ductwork or other modifications, including incidental damage, or the removal of such items, are replaced/sealed and documented as repaired upon completion of the work. This policy applies to vertical and horizontal penetrations made by medical center staff, the Chief Information Office and contractors.

Contracting companies are required to comply with the policies, procedures and regulations that apply whenever work is performed. Contracting Officer’s Representatives (COR’s) include the requirements of this policy in the specifications and scope of work for all applicable projects. Repairs are made using assemblies with an Underwriter’s Laboratory (UL) listing or method pre-approved by Facilities Management Service (FMS), Engineering Section.

3. DEFINITIONS:

a. Penetrations are any holes, openings or faults created in a fire barrier/wall or smoke barrier/wall that compromises the integrity or fire rating of the penetrated structure. Drawings indicating the location of rated walls and barriers are available in Appendix A, Fire/Smoke Barrier Building Drawings. Change of use or change of occupancy can affect wall rating requirements. If the current site conditions differ from those shown in the drawings, consult with FMS, Engineering Section and/or your COR.

b. Fire stopping materials are any UL listed materials used to replace or repair any penetrations. Materials used must meet specifications that ensure the original integrity and rating of the penetrated surface are restored. Repairs are marked with a sticker or label at the site of the repair. A sample label is available in Appendix B, Sample Fire/Smoke Barrier Penetration Label. Minimum information required on the label includes:

(1) Date repair/penetration sealed.

(2) Name of technician and company, as applicable.

EXHIBIT 13

2. Policy Memorandum No. 138-10

(3) Contact information, including phone number of technician, of the contractor completing the work.

(4) Project number, if applicable.

(5) Purchase order number, if applicable.

(6) Type of utility or system installed, modified or repaired.

(7) Brand of fire stop material used.

(8) Alpha-alpha numeric fire resistant directory number/UL system number of specific fire stop system used for repairs. Numbers are brand-specific.

c. A fire wall/barrier is a continuous membrane or a membrane with discontinuities created by protected openings with a specified fire protection rating, where such membrane is designed and constructed with a specified fire resistance rating to limit the spread of fire, and also restricts the movement of smoke. Fire walls/barriers are floor ceiling assemblies and walls, including supporting construction. Fire walls/barriers are designed to form fire compartments and are constructed to be continuous from outside wall to outside wall, from one fire wall/barrier to another, or a combination thereof, including continuity through concealed spaces. (NFPA 101)

d. A smoke wall/barrier is a continuous membrane or a membrane with discontinuities created by protected openings, where such membrane is designed and constructed to restrict the movement of smoke. Smoke walls/barriers are designed to form smoke compartments and are constructed to be continuous from outside wall to outside wall, from one smoke wall/barrier to another, or a combination thereof, including continuity through concealed spaces.

(NFPA 101)

e. A fire compartment is a space within a building that is enclosed by fire walls/barriers on all sides, including the top and bottom. (NFPA 101)

f. A smoke compartment is a space within a building that is enclosed by smoke walls/barriers on all sides, including the top and bottom. (NFPA 101)

a. It is the responsibility of Engineering Section to ensure that VA Form 10-410, Fire/Smoke Barrier Permit, is issued and a final inspection is completed. Each issued permit will be assigned an inspection work order number created by the Work Order Clerk. The inspection work order will be closed once the final inspection has been completed and any remaining deficiencies corrected by the initiator of the permit.

3. Policy Memorandum No. 138-10

b. Service chiefs/care line managers are aware of the requirements of this policy and are responsible for ensuring compliance with respect to any equipment/cabling installations that are coordinated by their staff within their assigned building spaces. Following completion of work and repair or sealing of penetrations, initiator of the permit is required to make an inspection to verify work has been satisfactorily completed and then contacts Engineering Section for a final inspection.

c. The Chief, FMS and the Chief Information Officer are responsible for ensuring that their staff or contractors making penetrations into fire walls/barriers or smoke walls/barriers secure penetration permits prior to beginning work, and repair the wall/ceiling/floor in accordance with this policy and the Life Safety Code at completion of the work. Following completion of work and repair or sealing of penetrations, initiator of the permit is required to make an inspection to verify work has been satisfactorily completed and contacts Engineering Section for a final inspection.

d. COR’s are responsible for the following:

(1) Reviewing and approving specific fire stop system submittals, documentation and project-specific engineering judgments/designs.

(2) Ensuring that contractors adhere to this policy during construction, renovation or demolition activities, including pulling electrical or cable lines.

(3) Verifying that holes/penetrations made during construction activities are properly sealed.

e. The Contracting Officer, VISN10 Contracting - Chillicothe, is responsible for ensuring that this policy memorandum is properly inserted in applicable contracts and discussed with the contractor prior to the initiation of project work.

f. Contractors are responsible for:

(1) Before commencing work, submitting documentation and design submittals for project-specific fire stop systems and materials.

(2) Assuring that penetrations made in ceilings, floors, pipe chases, fire walls/barriers, smoke walls/barriers, and other locations are properly sealed and damaged or displaced ceiling tiles are replaced and contacting Engineering Section for a final inspection before leaving the facility, giving as much advance notice as possible, but never less than one full working day.

4. Policy Memorandum No. 138-10

a. Routing of wiring, piping or conduit may require drilling through fire walls/barriers or smoke walls/barriers. When a ceiling, floor, wall, or partition employed as a fire wall/barrier or smoke wall/barrier is compromised for the purpose of installation, repair, or other modification, penetrations are resealed with proper smoke or fire materials. Work, including fire stopping, is inspected by the initiator of the permit and all noted deficiencies corrected before Engineering Section is contacted to make a final inspection.

b. Contracted work, including Chief Information Office projects involving removal of ceiling tile or fire/smoke walls/barriers is approved by Engineering Section prior to installation of equipment, cables, conduit, or ductwork.

c. A penetration permit is secured from Engineering Section and an inspection work order is generated prior to disturbing the integrity of the fire wall/barrier or smoke wall/barrier. The permit is posted and available for inspection at the subject location.

d. Upon completion of work, the initiator of the permit ensures that the penetration is repaired (sealed) and ceiling tiles replaced according to accepted practice utilizing materials, including UL listed through-penetration fire stopping materials, that meet the original fire/smoke wall/barrier construction requirements in order to restore the original design specifications for compartmentalization. Penetrations are affixed with a label on or directly adjacent to the repair indicating:

(2) Name of technician and company, as applicable.

(3) Contact information, including phone number of technician, of the contractor completing the work.

(4) Project number, if applicable.

(5) Purchase order number, if applicable.

(6) Type of utility or system installed, modified or repaired.

(7) Brand of fire stop material used.

(8) Alpha-alpha numeric fire resistant directory number/UL system number of specific fire stop system used for repairs. Numbers are brand specific. A sample label is available in Appendix B, Sample Fire/Smoke Barrier Penetration Label.

e. Upon completion of the final inspection by the initiator of the permit, Engineering Section is notified to make a final inspection. A sample inspection checklist is available in Appendix C, Final Fire/Smoke Barrier Inspection Checklist.

5. Policy Memorandum No. 138-10

f. Penetrations and miscellaneous openings are sealed and protected according to specific manufacturer guidelines applicable to the situation, this policy and NFPA 101.

g. Contracted work uses VA master guide specification 07270, Fire Stopping Systems.

h. A final visual inspection for approval of the repairs performed is requested from

Engineering Section ONLY after the initiator of the permit has made their own final inspection and corrected any deficiencies. Deficiencies found during final inspection by Engineering Section are referred back to the initiator of the permit for correction and reinspection. Following successful final inspection, the inspection work order is closed with comments, as appropriate. The closed work order serves as official document of record.

i. Under no circumstances may any wires, conduits, cables, ducts or other items be suspended from, or come into contact with, fire protection sprinkler lines.

j. Ceiling tiles are replaced immediately upon completion of the work or when workers leave the area.

6. REFERENCES: NFPA 101, Life Safety Code, 2013 VHA Directive 2011-036, Safety and Health During Construction VA Master Guide Specification 07270, Fire Stopping Systems ASTM E2174, Standard Practice for On-Site Inspection of Installed Fire Stops

7. RESCISSION: Policy Memorandum No. 138-10, Fire/Smoke Barrier Permits, dated

October 20, 2011.

8. COLLABORATED WITH: 138, 138S, 07F, 90, 00L, AFGE

9. RESPONSIBLE OFFICE: 138

10. RESCISSION DATE: March 2, 2018

Wendy J. Hepker, FACHE

ATTACHMENTS:

Appendix A: Fire/Smoke Barrier Building Drawings Appendix B: Sample Fire/Smoke Barrier Penetration Label Appendix C: Final Fire/Smoke Barrier Inspection Checklist

Appendix A Policy Memorandum No. 138-10

Fire/Smoke Barrier Building Drawings

Appendix B

Sample Fire/Smoke Barrier Penetration Label

Fire Stop Fire Rated Assembly

Fire Stop Material/Brand: UL System #:

Location/Utility System:

Project #: Purchase Order #:

Installation Information

Company: Technician:

Installation Date: Contact #:

Repenetrated By Date

1.) 1.)

2.) 2.)

3.) 3.)

Penetrations are affixed with a label on or directly adjacent to the repair indicating:

(2) Name of technician and company, as applicable.

(3) Contact information, including phone number of technician, of the contractor completing the work.

(4) Project number, if applicable.

(5) Purchase order number, if applicable.

(6) Type of utility or system installed, modified or repaired.

(7) Brand of fire stop material used.

(8) Alpha-alpha numeric fire resistant directory number/UL system number of specific fire stop system used for repairs. Numbers are brand specific.

Appendix C

Final Fire/Smoke Barrier Inspection Checklist

INSPECTION FORM

Inspection Date: Inspector:

Installer: Project:

Fire Stop Type per Inspection Documents:

Inspected Fire Stops

Location and Inspection Document Reference Deficiency

Repaired Fire Stops

Location and Inspection Form Reference Compliant? Yes. If No, state deficiency.

Fire/Smoke Barrier Permit

Contractor/Department/Service: ___________________________________________

Responsible Party: ______________________________________________________

Location of Penetration(s): ________________________________________________

Purpose: _____________________________________________________________

Prior to issuing a fire/smoke barrier permit, Facilities Management Service, Engineering Section will review the following checklist with the responsible party:

Yes No N/A Did responsible party obtain blueprints from Engineering Service detailing hourly rated walls and identifying the scope of the fire stop work?

Is the manufacturer’s product (fire sealant) application guide containing UL listed fire stop systems available and approved?

Has the responsible party prepared an itemized schedule of fire/smoke barriers to be penetrated?

Materials utilized in repairs:

Fire Stopping __________________________________________________________

Wall board ____________________________________________________________

Other ________________________________________________________________

Approved/Disapproved: _______________________________ Date: _____________ (Approving Official)

After penetrations are sealed, Engineering Section and responsible party will inspect the area to ensure compliance with the required standards.

Inspected By: ________________________________________ Date: ____________

COTR: _____________________________________________ Date: _____________

Note: A copy of this permit must be posted at the work location.

VAF 10-410 (538)

March 2012

VHACLLCROCKK

EXHIBIT 13 (cont.)

POLICY MEMORANDUM VA Medical Center NO. 138-15 Chillicothe, Ohio September 11, 2012

ELECTRICAL SAFETY

1. PURPOSE: To set forth requirements for employees dealing with specific hazards requiring special means of protection to prevent serious injury, impairment, or jeopardy to themselves and patients in the use of electricity and electrical devices.

2. POLICY: It is the policy of this medical center to provide the safest possible environment. Electrical equipment, appliances, and wiring systems are installed, maintained, and used in accordance with the National Electrical Code, VA directives, and other known electrical safety guides.

3. RESPONSIBILITY:

a. Facilities Management Service, Engineering Section, is responsible for the installation and testing of electrical equipment.

b. Each employee is responsible for adherence to regulations contained in this memorandum regarding use of electrical devices and for ensuring that patients under their direct care are properly supervised when using such devices. Employees are responsible for:

(1) Using equipment for the intended purpose only.

(2) Checking equipment before each use.

(3) Removing unsafe or defective equipment from use.

(4) Identifying defective equipment with a Do Not Use tag.

(5) Reporting defective equipment to the supervisor.

4. PROCEDURES:

a. Areas of patient susceptibility to electricity are:

(1) Non-Patient Areas: Administrative areas and areas where patients have little or no direct contact with electrical and electronic equipment.

(2) Patient Areas: Areas where patients have or may have direct contact with non-invasive therapy and/or electrical or electronic monitoring equipment.

(3) Electrically Susceptible Patient Care Areas (ESPCAs): Areas such as operating rooms and special care units that have patients who are or may be subjected to

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2. POLICY MEMORANDUM NO. 138-15

invasive monitoring or therapy using direct pathways to the cardiac musculature.

b. The electrical distribution system is checked annually for deficiencies, such as worn equipment, worn relays, leakage, frayed cables, and loose connections.

Receptacles in the Laboratory are tested for correct polarity, retention force, and Ground Fault Circuit Interrupter (GFCI) function, if provided. Only qualified Engineering Section personnel perform tests, repairs and/or modifications to any electrical equipment or devices.

c. Electrical distribution equipment is cleaned, inspected, tested, and adjusted every three years by a qualified company.

d. Equipment Guidelines:

(1) Prior to the local purchase of any equipment, the requisition is reviewed by Engineering Section to ensure that items such as allowable leakage current and ground lead resistance limits are incorporated into the technical requirements on the requisition.

(2) Upon receipt at the medical center, electrical equipment is inspected by Engineering Section for compliance with manufacturers' specifications and leakage current limits before delivery to the using area. If there are limitations as to use, this is noted on the equipment (restrictions from ESPCAs, anesthetizing location, etc.) before delivery. Information technology equipment is inspected by the Chief Information Office computer technicians for compliance with specifications before delivery to the users.

e. Equipment Testing Program:

(1) Equipment is entered in the VISTA equipment inventory and categorized by Logistics Service.

(2) Engineering Section assesses equipment categories to determine frequency of preventive maintenance and inspections.

(3) Results of the testing program are maintained in Engineering Section.

(4) If equipment is found to be defective, it is tagged and removed from service.

Deficiencies and any actions taken are reported to the person responsible for the operation of the unit inspected.

(5) Personnel in ESPCAs inspect equipment before each use for such hazards as broken or damaged plugs, frayed line cords, abnormal operation, obvious chassis damage, overheating, or tingling sensations. If a hazard is suspected, that equipment is not used unless it is life support equipment, in which case, it is tagged by the using personnel and closely monitored until repaired or replaced.

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(6) Electronic equipment that is loaned to or rented by the medical center for medical care or for evaluation purposes is inspected for compliance with VA standards as well as leakage current and grounding resistance limits prior to its use and, thereafter, at a frequency determined by the area of usage. Engineering Section maintains inspection records.

f. Equipment Restrictions:

(1) Extension cords are not used unless authorized and made available by Engineering Section. A ground fault circuit interrupter protects extension cords used outside, in construction, maintenance, or in wet locations. Engineering Section accomplishes any modifications of the electrical distribution system.

(2) Three-to-two wire adapters are not used. Electrical plugs that do not match outlets are referred to Engineering Section for correction.

(3) Patient-owned, electrical line-operated devices are strictly prohibited from ESPCAs. In other areas of the medical center, written permission in the form of an inspection report signed by the Assistant Chief, Engineering Section, or designee, is obtained prior to their use. When permitted, they are inspected prior to use. Personal equipment resulting in nuisance breaker trips is removed by the owner.

(4) Electrical line-operated equipment used in the patient care vicinity is provided with a three-wire power cord and three-pin grounding hospital-grade plug.

(a) Double insulated appliances are permitted to have two conductor cords and plugs. Line-operated devices with two conductor cords and plugs are not used in psychiatric bedrooms. Receptacles in these areas are the safety type requiring grounding plug for operation.

(b) Electrical line-operated items donated or purchased are inspected by Engineering Section prior to use. The using service/care line personnel visually inspect these items for deficiencies, such as damaged cords, cracked housings, and the presence of an attached electrical safety inspection sticker prior to each use. If discrepancies are discovered, the item is removed from service until repairs are made.

(c) Engineering Section inspects non-Nutrition and Food Services coffee makers and microwave ovens and their location to determine the adequacy of electric circuitry and the safety of the coffee makers or microwave ovens prior to use. A request is submitted to Engineering Section for an inspection of newly procured coffee makers or microwave ovens. Once inspected, personal equipment that is authorized for use is labeled with an inspection sticker. Personal electrical equipment is not utilized without an attached electrical safety inspection sticker.

(5) The use of personally owned devices is discouraged. Personally owned

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devices used by medical center employees are inspected for electrical safety prior to use by contacting extension 6172. Personal equipment resulting in nuisance breaker trips is removed by the owner immediately. Once inspected, personal equipment that is authorized for use is labeled with an electrical safety inspection sticker.

(6) Line-operated devices such as televisions, radios, and electrical razors are prohibited in ESPCAs without written permission of the Assistant Chief, Engineering Section, or designee. This permission is requested by memorandum by the physician in charge of that area. If the physician has authorized such a device, it is mounted at such a distance that it cannot be reached by the patient or by an individual at the patient's bedside. Battery-operated radios are permitted at the patient's bedside with physician's authorization.

(7) Electric beds are prohibited from ESPCAs unless specifically suited for such areas. Electric beds placed in ESPCAs are approved for such use by the Assistant Chief, Engineering Section, or designee.

(8) Bedside lamps in ESPCAs are grounded and permanently affixed in the patient's bedside area.

(9) Line-operated devices used in close proximity to a sink or tub are protected with a ground fault circuit interrupter (GFCI).

(10) Portable space heating devices are prohibited in patient treatment and sleeping areas. Portable space heaters with enclosed elements that limit maximum surface temperatures to 212 degrees Fahrenheit are permitted in non-sleeping, employee-only areas, with the exception of nursing stations. A request for inspection is made by contacting extension 6172 prior to equipment use. Once inspected, personal equipment that is authorized for use is labeled with an electrical safety inspection sticker.

Appliances with open heating elements, including toasters and toaster ovens, are prohibited in any building.

g. Employee Education:

(1) For informational purposes, a copy of High Voltage Systems - Methods, Products, and Code Rules is on file in Building T228 for employees working with this system.

(2) Annual training is conducted for medical center employees in equipment and utility use and safety. Training is documented in the Talent Management System

(TMS).

(3) Personnel in ESPCAs receive instructions in electrical safety as applicable to their situation. This may include the grounding system, isolated power system, and dangers of high frequency current. Instruction is accomplished by scheduling safety

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training classes through TMS.

5. REFERENCES: NFPA 70-1996

NFPA 99-1996, Chapter 3 DM&S Supplemental, MP-3, Chapter 2.22 The Joint Commission Comprehensive Accreditation Manual for Hospitals, 2012

6. RESCISSION: Policy Memorandum No. 138-15, Electrical Safety, dated June 11, 2010.

7. RESCISSION DATE: September 11, 2014

//s//

WENDY J. HEPKER, FACHE

Medical Center Director

Distribution: F 161M3 (10)

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Engineering Section VA Medical Center Standard Operating Procedure Chillicothe, Ohio Number 20 September 13, 2013

CONFINED SPACE ENTRY

1. PURPOSE: To establish guidelines and procedures for working in confined spaces.

2. POLICY: To provide maximum safety protection for employees and contractors who are performing work in confined spaces.

3. RESPONSIBILITIES:

a. The Chief, Facilities Management Service (FMS), is responsible for ensuring projects, maintenance and repairs in confined spaces utilize only authorized entrants under properly executed Confined Space Entry Permits, Attachment A, and ensures permit spaces are identified.

b. The Safety and Occupational Health (OSH) Manager, Industrial Hygienist, or designee, provides technical guidance to affected employees for entry into a confined space. Additional responsibilities include:

(1) Inspecting the confined space prior to entry for compliance to this policy.

(2) Performing atmospheric testing and completing the Confined Space Pre-Entry Checklist, Attachment B.

(3) Providing confined space entry training.

c. The Fire Department provides rescue services and emergency rescue personnel to be utilized as entry attendants for confined spaces that can present special hazards.

Emergency rescue personnel are responsible for completing annual confined space rescue training.

d. The entry supervisor is knowledgeable of the hazards associated with permit required spaces, including information on the mode, signs or symptoms, and consequences of the exposure. Additional responsibilities include:

(1) Determining when responsibility for a permit space entry operation is transferred and, at intervals dictated by the hazards and operations performed within the space, that entry operations remain consistent with terms of the entry permit and that acceptable entry conditions are maintained.

(2) Ensuring that equipment needed for safe entry into any permit required space is available and in proper working order.

(3) Verifying that rescue services are available and that the means for summoning rescue services are operable.

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2. Engineering Section SOP No. 20

(4) Removing unauthorized individuals who enter or attempt to enter the permit space during entry operations.

(5) Verifying, by checking that appropriate entries are made on the permit, that tests specified by the permit are conducted and that procedures and equipment specified by the permit are in place prior to signing and approving the permit and allowing entry to begin.

(6) Terminating the entry and cancelling the permit following task completion.

e. Entry attendants are knowledgeable of permit space hazards, prohibited conditions, the role to remain outside and in communication with entrants, prevention of unauthorized entry, procedures to request rescue and emergency services, and performance of non-entry rescue. The entry attendants’ primary duty is to monitor and protect authorized entrants. Entry attendants are trained on the procedures contained in this policy and are knowledgeable of the hazards associated with permit required spaces, including information on the mode, signs or symptoms, and consequences of the exposure.

f. Authorized entrants are trained on the procedures contained in this policy and are knowledgeable of the hazards associated with permit required spaces, including information on the mode, signs or symptoms, and consequences of the exposure. Additional responsibilities include:

(1) Maintaining proficiency in dealing with the hazards of permit required spaces, proper equipment use, communications systems, acceptable entry and prohibited conditions, immediate evacuation conditions, and safe work task performance.

(2) Alerting the attendant when a prohibited condition is detected or when any warning sign or symptom of exposure to a dangerous situation is recognized.

(3) Exiting the permit space as quickly as possible when:

(a) A prohibited condition is detected.

(b) An order to evacuate is given by the attendant or the entry supervisor.

(c) An evacuation alarm is activated.

(d) Any warning sign or symptom of exposure to a dangerous situation is recognized.

g. Contractors performing work in a confined space at this facility are required to adhere to the requirements of this SOP.

4. DEFINITIONS:

a. Confined Space: An enclosed space that is large enough and so configured that an employee can bodily enter and perform assigned work, has limited or restricted means for entry or exit, and is not designed for continuous employee occupancy. Examples of confined spaces are listed in Attachment C, Confined Spaces, and include storage pits,

3. Engineering Section SOP No. 20 vats, tanks, boilers, ventilation/exhaust ducts, sewers, tunnels, manholes, underground utility vaults or pipelines, and excavations.

b. Permit Required Confined Space:

(1) Contains or has a known potential to contain a hazardous atmosphere.

(2) Contains material with the potential for engulfing of an entrant.

(3) Has internal configurations that could trap or asphyxiate an entrant.

(4) Contains any other recognized serious safety or health hazards.

c. Hazardous Environment/Atmosphere: An atmosphere presenting a potential for death, disablement, injury, or acute illness from one (1) or more of the following causes:

(1) Less than 19.5 percent or more than 23.5 percent oxygen.

(2) A flammable gas or vapor in excess of 10 percent of its lower explosive limit (LEL).

(3) An airborne combustible dust at a concentration that obscures vision at a distance of five (5) feet or less.

(4) An atmospheric concentration that exceeds the listed numerical value of any toxic, corrosive, or asphyxiant substance listed in the Threshold Limit Value (TLV) book by the American Conference of Governmental Industrial Hygienists (ACGIH) or the permissible exposure limit (PEL) that is reasonably expected to be present.

(5) A biological or radiological hazard or one that is otherwise known to present a safety or acute health hazard.

(6) Any condition immediately dangerous to life or health.

d. Entrapment: An area that contains material with the potential to engulf the entrance.

e. Lower Explosive Limit (LEL): The lowest concentration of gas or vapor (percent by volume in air) that will burn or explode if an ignition source is present.

f. Isolation: A process to remove a confined space from service and to completely protected against the inadvertent release of material by the following:

(1) Blanking: The absolute closure of a pipe, line or duct by fastening a solid plate or cap across the pipe, line or duct capable of withstanding the maximum upstream pressure.

(2) Double Block and Bleed: Isolating a confined space from a line, duct or pipe by locking and tagging two (2) closed in-line valves, and locking and tagging open a drain or bleed in the line between the two…