clasp manual 2012 - hopkins medicine

CLASP MANUAL 2012

COORDINATED LIFE SAFETY ASSURANCE PROGRAM

The Johns Hopkins Hospital (JHH) Johns Hopkins Bayview Medical Center (JHBMC)

Howard County General Hospital (HCGH)

Facilities Department Planning - Design - Project Management – Engineering

CLASP Manual 2012 Facilities Department Johns Hopkins Health System

Table of Contents JHH Emergency Management Disaster Codes .........................................1

JHBMC Emergency Response Codes ......................................................1

HCGH Emergency Response Codes ........................................................1 JHH Evacuation Plans ...............................................................................2

JHBMC Evacuation Plans .........................................................................3

HCGH Evacuation Plans ...........................................................................4

JHH Safety Fact Sheet ..............................................................................5

JHBMC Safety Fact Sheet .........................................................................6 HCGH Safety Fact Sheet ..........................................................................7

Contractor Orientation Detailed Checklist .................................................8

General Policy ........................................................................................ 10

Purpose ............................................................................................. 10

Features ............................................................................................ 10

Policies .............................................................................................. 11 Procedures ........................................................................................ 13

Life Safety and Other Safety Compromises ........................................... 17

Interim Life Safety Measures (ILSM) ...................................................... 18

Life Safety Criteria Guide ....................................................................... 20

Project Risk Assessment ........................................................................ 21

Facilities Engineering Supervisor Worksheet ......................................... 26 Hazard Communication .......................................................................... 27

Bloodborne Pathogens ........................................................................... 28

Notice of Asbestos Abatement ............................................................... 29

CLASP Surveillance Procedures ............................................................ 30

CLASP Surveillance Checklist................................................................ 31 Ceiling Permit Procedures ...................................................................... 32

Ceiling Permit Form ................................................................................ 33

Infection Control Training ....................................................................... 34

Section 01 35 33 – Infection Control Procedures ........................ 36

Part 2 - Execution ............................................................................... 43

Infection Control Policy ...................................................................... 48

Infection Control –Construction Permit ............................................. 51 JHH Online Outage System ................................................................... 52

CLASP Manual 2012 Facilities Department Johns Hopkins Health System

JHBMC & HCGH Outage Workflow........................................................ 81

JHBMC Request for Outage ................................................................... 82

JHBMC & HCGH Hot Work Permit ......................................................... 83

Commissioning and Inspection Procedure ............................................. 84

Inspection Request Form ....................................................................... 89

Acronym List

EHS Office of Environment, Health and Safety - JHBMCFES Facilities Engineering Supervisor - JHH & JHBMCHBV Hepatitis B VirusHCV Hepatitis C VirusHEIC Office of Healthcare Epidemiology and Infection Control - JHHHEPA High-Efficiency Particulate Air (filter)HIPAA Health Insurance Portability and Accountability ActHIPOP Hematology Inpatient/OutpatientHIV Human Immunodeficiency VirusHSE Office of Health, Safety and Environment - JHH & HCGHHVACR Heating Ventilating Air Conditioning RefrigerationIC Office of Infection Control - JHBMC & HCGHILSM Interim Life Safety MeasuresIPOP Inpatient/OutpatientJHBMC Johns Hopkins Bayview Medical Center CampusJHH Johns Hopkins HospitalJHHS Johns Hopkins Health SystemJHOPC Outpatient CenterLOTO Lockout/TagoutLSC Life Safety CompromiseMFL Mason F. Lord BuildingMOSH Maryland Occupational Safety and Health MRI Magnetic Resonance Imaging BuildingMSDS Material Safety Data SheetsNESHAP National Emissions Standards for Hazardous Air PollutantsOR Operating RoomOSHA Occupational Safety and Health Administration PACU Post Anesthesia Care UnitPM Project ManagerPOM Plant Opertions Manager - HCGHPPE Personal Protective EquipmentTS Temporary SafeguardsWAGD Waste Anethesia Gas DisposalWBS Work Breakdown Structure

CLASP Manual 2012 Facilities Department Johns Hopkins Health System Page 1

JHH Emergency Management Disaster Codes CODE DESCRIPTION CALL Blue Cardiac/Respiratory Arrest (410) 955-4444 Gold Bomb Threat (410) 955-5585 Red Fire (410) 955-4444 Silver Shooter/Hostage (410) 955-5585 Yellow Bio Bioterrorism (410) 955-4444 Yellow Chemical Chemical (410) 955-4444 Yellow ED Patient influx of up to ten patients from

a single event (410) 955-4444

Yellow Hospital Patient influx of more than ten patients from a single event

(410) 955-4444

Yellow Radiation Radiation (410) 955-4444

JHBMC Emergency Response Codes CODE DESCRIPTION CALL Blue Cardiac/Respiratory Arrest (410) 550-0222 Gold Bomb Threat (410) 550-0333 Gray Elopement (410) 550-0333 Green Combative Person (410) 550-0333 Orange Hazardous Material Spill (410) 550-0222 Pink Infant or Child Abduction (410) 550-0333 Purple Security Response (410) 550-0333 Red Fire (410) 550-0222 Silver Active Shooter/Weapon/Hostage (410) 550-0333 Yellow Emergency or Disaster (410) 550-0222

HCGH Emergency Response Codes

CODE DESCRIPTION CALL Blue Cardiac/Respiratory Arrest 5151* Gold Bomb Threat 5151* Gray Elopement (410) 740-7911 Green Combative Person (410) 740-7911 Orange Hazardous Material Spill 5151* Pink Infant or Child Abduction (410) 740-7911 Purple Security Response (410) 740-7911 Red Fire 5151* Silver Active Shooter/Weapon/Hostage (410) 740-7911 Yellow Emergency or Disaster 5151* Alpha Team Pre-Life threatening Obstetrics 5151* Bravo Team Life threatening Obstetrics 5151* Rapid Response Team Pre-Cardiac/Respiratory Arrest 5151*

*Internal Extension Only


JHH Evacuation Plans

The following evacuation plans are intended to augment the procedures outlined in the Fire Incident Responsibilities categorized by personnel group. All staff has the authority to evacuate any individual from immediate danger, however wholesale or mass evacuation is performed only on the order of a competent authority (see below).

In Health Care Occupancies, upon alarm activation, staff members will implement a “defend-in-place” philosophy and take steps to prepare for possible limited or total evacuation. Specific preparation steps are outlined in the Fire Incident Responsibilities. The decision to evacuate all or part of a unit, floor or building must be made by a competent authority, i.e., Baltimore City Fire Department; representative of the Department of Health, Safety and Environment; senior administrative official of the JHMI; or Security Shift Supervisor. Staff will utilize the Unit Specific Life Safety Plan to assist with any coordination of patients during the event.

Areas classified as Business Occupancies are required to evacuate all patients, personnel, and visitors when the fire alarm sounds on these floors, or when ordered to evacuate by a competent authority. “Evacuation” means leaving the building under alarm, which most often can be accomplished by moving horizontally to an adjacent building. Please familiarize yourself with the evacuation plan which follows for your building. Occupants of buildings that are on a high-rise notification system (alarm is activated one floor above and one floor below the affected floor) and are not directly connected to another building until further below (i.e. Meyer 9), must have two floors separating you from the floor that is in alarm.

Building Levels classified as Business Occupancy Billings Entire Building Blalock Sub-Basement, Basement, 2, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16 Brady Entire Building Carnegie Sub-Basement, Basement, 1, 2, 3, 4, 5, 6, 8, 9, 10 CMSC Hoffberger Wing Sub-Sub-Basement, Sub-Basement, 1, 2, 3, 4, 6, 8, 9, 10, 11, 12 CMSC Patient Wing Sub-Sub-Basement, Sub-Basement, 1, 10, 11, 12, 13 Halsted/Osler 9, 10 Hurd Hall Entire Building JHOPC Broadway Wing Entire Building JHOPC McElderry Wing 1, 2, 4, 5, 6, 8 Marburg* Basement, 1, 4, 5 Maumenee Sub-Basement, Basement, 1, 2, 3, 5, 6, 7, 8, 9 Meyer Lab Wing 3, 4, 5, 6, 8 & 9, Meyer (Both Wings) Sub-Basement, B, 10 MRI None Nelson/Harvey Sub-Basement, 1 Park SB, 2, 3, 4 Pathology Entire Building Phipps Entire Building Radiology Sub-Basement, 1 David M Rubenstein Child Health Entire Building Smith Basement, 2, 3, 4, 5, 6, 7, 8 Weinberg L-1, Parking & Storage Portions of L-2, L-3 Wilmer Sub-Basement, Basement, 1, 2, 5, 6 Woods Entire Building Zayed/Bloomberg B2, B1, 7, 8, 16, 17


JHBMC Evacuation Plans The following evacuation plans are intended to augment the procedures outlined in the Fire Incident Responsibilities categorized by personnel group. All staff has the authority to evacuate any individual from immediate danger, however wholesale or mass evacuation is performed only on the order of a competent authority (see below). In Health Care Occupancies, upon alarm activation, staff members will implement a “defend-in-place” philosophy and take steps to prepare for possible limited or total evacuation. Specific preparation steps are outlined in the Fire Incident Responsibilities. The decision to evacuate all or part of a unit, floor or building must be made by a competent authority, i.e., Baltimore City Fire Department; representative of the Department of Environment, Health, and Safety; senior administrative official of the JHMI; or Security Shift Supervisor. Staff will utilize the Unit Specific Life Safety Plan to assist with any coordination of patients during the event. Areas classified as Business Occupancies are required to evacuate all patients, personnel, and visitors when the fire alarm sounds on these floors, or when ordered to evacuate by a competent authority. “Evacuation” means leaving the building under alarm, which most often can be accomplished by moving horizontally to an adjacent building. Please familiarize yourself with the evacuation plan which follows for your building. Building Levels classified as Business Occupancy 301 Building 1, 2, 3, 4 A 01, 1, 3, 5, 6 AA 02, 01, 1 Alpha Commons 1, 2, 3, 4 ASC 2, 3 BMO 02, 01, 1, 2, 3 Francis Scott Key Pavilion 02, 01, 2, John R. Burton Pavilion 02 MFL East 1, 2, 3, 4, 5, 6 MFL West 1, 2, 3, 4, 5, 6 Warehouse 1, 2


HCGH Evacuation Plans The following evacuation plans are intended to augment the procedures outlined in the Fire Incident Responsibilities categorized by personnel group. All staff has the authority to evacuate any individual from immediate danger, however wholesale or mass evacuation is performed only on the order of a competent authority (see below). In Health Care Occupancies, upon alarm activation, staff members will implement a “defend-in-place” philosophy and take steps to prepare for possible limited or total evacuation. Specific preparation steps are outlined in the Fire Incident Responsibilities. The decision to evacuate all or part of a unit, floor or building must be made by a competent authority, i.e., Howard County Fire and Rescue Department; Incident Commander (Senior Administrator on duty or Nursing Supervisor), Security Control Center, Emergency Department charge nurse, Plant Operations, Administration, Nursing Office and Fire Response Team leader. Staff will utilize the Unit Specific Life Safety Plan to assist with any coordination of patients during the event. Areas classified as Business Occupancies are required to evacuate all patients, personnel, and visitors when the fire alarm sounds on these floors, or when ordered to evacuate by a competent authority. “Evacuation” means leaving the building under alarm, which most often can be accomplished by moving horizontally to an adjacent building. Please familiarize yourself with the evacuation plan which follows for your building.

Zone # Designation Location G-03 Business South Bldg. Building General Stores, Shipping, & Receiving G-04 Industrial Ground floor West bldg., Maintenance & West Plant

G-07 Mixed, Business & Industrial

Ground floor Pavilion

G-06 Assembly South Building - Kitchen and cafeteria

1A-01 Business 1st floor Healthcare and Surgery Center - locker rooms, Sterile Supply, & Receiving

1A-02 Business 1st floor Healthcare and Surgery Center - Breast Health, waiting room, & Infusion Center

2A-01 Business 2nd floor Healthcare and Surgery Center - All 3-01 Industrial Boiler Room 3A-01 Industrial 3rd floor Healthcare and Surgery Center - All 4-01 Industrial Center building tower - above 3I North 4-02 Industrial Center building tower - above 3I South 5-01 Industrial Rooftop mechanical room – Pavilion roof


JHH Safety Fact Sheet FIRE SAFETY • In case of smoke/fire: 1. Remove patients from room on fire. 2. Close doors to confine smoke or fire. 3. Pull the fire alarm at the exit. 4. Call (410) 955-4444. • Upon hearing a building alarm: 1. Evacuate, except on an inpatient unit, where

the fire department, safety or security must direct you to evacuate patients or to leave.

2. Don’t use elevators. Use the nearest exit. • Keep corridors clear by removing your

materials from the corridors and stairwells. • Doors must never be wedged open unattended. NO SMOKING • Smoking is permitted only in designated areas.

Any contractor or employee found smoking outside a designated area shall be removed from the hospital lot permanently.

INFECTION CONTROL • Have an on-site pre-construction infection

control review. • Submit inspection of infection control

measures prior to: 1. Starting construction 2. Changing the class or limit of work 3. Removing infection control measures

CEILING PERMIT Ceiling access outside a construction site

requires a permit from the CSC/FES.

HAZARDOUS CHEMICALS • Material Safety Data Sheets (MSDS) describe

the hazards of a chemical. MSDS are available from the Health, Safety and Environment.

• The Prime Contractor is required to have a chemical list and MSDS on site.

• In a spill, contain the area and notify your foreman and/or call (410) 955-4444.

INJURY If you are splashed with blood or body

fluids or have a needle stick injury, immediately cleanse the area, then call (410) 955-STIX (7849).

• Notify your foreman and get medical attention for any other job related injuries: 1. Call emergency at (410) 955-4444 when

inside JHH. 2. Call 911 when outside of JHH. 3. Go to the Emergency Department at

1800 Orleans St. 4. Submit reports to the Foreman and the

Facilities Project Manager. OUTAGES Utility and life safety impairments require outage system approval. Electrical, water or structural problems

from 8 AM to 4 PM call (410) 955-8300; off-hours page (410) 955-5770.

PATIENT PRIVACY - HIPAA • Never enter a patient room unescorted. • Do not ask or share patient information. • Avoid situations where patient information

is prevalent. SECURITY ISSUES Call (410) 955-5585. Always display your ID. COMMISSIONING • All work, whether through Facilities or

not, is subject to Facilities’ commissioning.

• Comply with commissioning and inspection procedures.

GENERAL SAFETY CONTACTS • Report safety concerns to: 1. Your supervisor/foreman. 2. Facilities Construction Safety

Coordinator (CSC) at (410) 955-5900. 3 Health, Safety and Environment at

(410) 955-5918.


JHBMC Safety Fact Sheet FIRE SAFETY • In case of smoke/fire remember RACE: Rescue: Remove patients from immediate danger. Alarm: Pull the alarm. Call (410)-550-0222. Contain: Close doors to confine smoke or fire. Extinguish: Extinguish and prepare to evacuate patients. PASS: Pull Aim Squeeze Sweep • Evacuate patients if directed. • Don’t use the elevators. Use the nearest exit. • Keep corridors clear by removing your materials

from the corridors. • Doors must never be wedged open unattended. NO SMOKING • Smoking is permitted only in designated areas. INFECTION CONTROL Call (410) 550-0515. • Have an on-site pre-construction infection

control review. • Submit inspection of infection control measures

prior to: 1. Starting construction 2. Changing the class or limit of work 3. Removing infection control measures

INJURY If you are splashed with blood or body fluids or have a needle stick injury, immediately cleanse the area, then from 8 AM to 4:30 PM, M-F, call (410) 550-0477; off hours page (410) 283-1545. Notify your foreman and get medical attention for any other job related injuries: 1. Go to the Emergency Department or call 911. 2. Submit reports to the Foreman and Facilities Project Manager.

HAZARDOUS CHEMICALS • Material Safety Data Sheets (MSDS)

describe the hazards of a chemical. MSDS are available from the Environment, Health and Safety Department.


• In a spill, close off the area and notify your foreman and/or call (410) 550-0222.


requires a permit from Facilities. OUTAGES Utility and life safety system impairments require outage approval. Electrical, water or structural problems

call from 7 AM to 5 PM call (410) 550-0260; off hours page (410) 283-0260.

PATIENT PRIVACY - HIPAA • Never enter a patient room unescorted. • Do not ask or share patient information. • Avoid situations where patient information

is prevalent. SECURITY ISSUES Call (410) 550-0333. Always display ID. COMMISSIONING • All work is subject to Facilities’

commissioning. • Comply with commissioning and

inspection procedures. GENERAL SAFETY CONTACTS • Report safety concerns to: 1. Your supervisor/foreman. 2. Facilities (PM) or Environment, Health and Safety (EHS) at (410) 550-0228.


HCGH Safety Fact Sheet FIRE SAFETY • In case of smoke/fire remember RACE: Rescue: Remove patients from immediate danger. Alarm: Pull the alarm. Call 5151. Contain: Close doors to confine smoke or fire. Extinguish: Extinguish and prepare to evacuate patients. PASS: Pull Aim Squeeze Sweep • Evacuate patients if directed. • Don’t use the elevators. Use the nearest exit. • Keep corridors clear by removing your materials

from the corridors. • Doors must never be wedged open unattended. NO SMOKING • Smoking is permitted only in designated areas. INFECTION CONTROL Call (410) 740-7765. • Have an on-site pre-construction infection

control review. • Submit inspection of infection control measures

prior to: 1. Starting construction 2. Changing the class or limit of work 3. Removing infection control measures

INJURY If you are splashed with blood or body fluids or have a needle stick injury, immediately cleanse the area, then from 8 AM to 4:30 PM, M-F, call (410) 740-7838; off hours go to the

Emergency Department or call (410) 740-7777. Notify your foreman and get medical attention for any other job related injuries: 1. Go to the Emergency Department or call 911. 2. Submit reports to the Foreman and Facilities Project Manager.

HAZARDOUS CHEMICALS • Material Safety Data Sheets (MSDS)

describe the hazards of a chemical. MSDS are available from the Environment, Health and Safety Department.


• In a spill, close off the area and notify your foreman and/or call 5151.


requires a permit from Facilities. OUTAGES Utility and life safety system impairments require outage approval. Electrical, water or structural problems

24/7 call (410) 740-7979 PATIENT PRIVACY - HIPPA • Never enter a patient room unescorted. • Do not ask or share patient information. • Avoid situations where patient information

is prevalent. SECURITY ISSUES Call (410) 740-7911 Always display ID. COMMISSIONING • All work is subject to Facilities’

commissioning. • Comply with commissioning and

inspection procedures. GENERAL SAFETY CONTACTS • Report safety concerns to: 1. Your supervisor/foreman. 2. Facilities (PM) or Hospital Operator at 5151


Contractor Orientation Detailed Checklist

Facilities contractors and their employees are required to attend an orientation to be trained prior to beginning work. They will be required to adhere to all the hospital’s rules, regulations and policies promoting a safe and secure environment. The following items will be covered during orientation.

Facilities o Parking o Badge o Excavating o Proper attire o Personal Protective Equipment (PPE): -Ear -Head -Respiratory -Feet -Eyes -Hands

o Equipment: -Ladder -Fall Protection -Scaffold -Welding Screens -Guards

o Hot Work Permit o Fire Alarm in Drill o Confined Space o MSDS & Hazard Communication o Smoking o Ceiling Permit o Exit Area/Building o Notification of any issue - Call Sheet o Radios o Keeping areas clean (Interstitial Space,

Above Ceiling and Mechanical Rooms) o Housekeeping o Outages o Communicating with staff/customer o After-hours work o Elevators o Cover on carts o Restrooms o Cafeteria o Cell Phone

Safety / Security o Hazardous waste o Bloodborne Pathogens (BBP) o Crosswalks o Lock Out/Tag Out o Fire Extinguishers o Infection Control o Interim Life Safety o Asbestos o Patient Privacy (HIPAA) o Electrical Safety o Medical Emergencies


Contractor Orientation Detailed Checklist PARKING Designated parking area is located at the gravel lot on Lombard Street. The

loading docks are for drop-offs and pick-ups only. BADGES Proper ID is required at all times when onsite. EXCAVATING Must notify Superintendent or Project Manager (see call sheet) prior to

excavating. PROPER ATTIRE Clean presentable work clothing must be worn at all times. PPE Personal Protective Equipment— All workers are required to have and use

appropriate PPE. EQUIPMENT Must be used in conjunction with OSHA standards and manufacturers guidelines. HOT WORK PERMIT Must be obtained from the Safety Department prior to any hot work. DRILLS Fire Alarms will be placed in drill by an outage request issued through the Safety

Department to the Facilities Department. CONFINED SPACE, MSDS & HAZARD COMMUNICATIONS

In accordance with OSHA standards and Bayview’s policy. All chemicals used in a project must have MSDS.

SMOKING Only permitted in designated areas. ABOVE CEILING PERMITS Must have permit, obtained through the Facilities Department, anytime work

requires going above any ceiling or working on any mechanical room, closet, etc. EXIT AREA/BUILDING Contractors must be aware of fire evacuation routes for their work areas. NOTIFICATION OF ISSUES (Call Chain):

Contractors must notify proper personnel listed on attached Call Sheet.

RADIOS All personal entertainment devices are not permitted onsite. KEEPING AREAS CLEAN (Interstitial Space, Above Ceiling, and Mechanical Rooms)

All areas must be kept clear from debris and clutter.

HOUSEKEEPING Must be maintained on a daily basis or more frequently as needed. OUTAGES Must be coordinated through the Facilities Department 7 days in advance. COMMUNICATING WITH STAFF/CUSTOMERS

Refer to Call Sheet when communicating with staff/customers.

AFTER HOURS WORK Contractors must notify appropriate Superintendent or Project Manager to request authorization to work after hours.

ELEVATORS Designated elevators must be used for projects - keep clear of debris. COVER ON CARTS All carts must be completely covered when transporting debris. RESTROOMS Must use designated restroom in project area. CAFETERIA Proper behavior is expected at all times. CELL PHONES Not to be used in patient care areas or in areas with posted signage. HAZARDOUS WASTE Must be coordinated with the Safety Department. BLOODBORNE PATHOGENS DO NOT handle. Must contact the Safety Department. CROSSWALKS Must stop at all crosswalks. Do not unload at crosswalks. LOCKOUT/TAGOUT Coordinate with hospital LOTO policy. FIRE EXTINGUISHERS Must maintain and have onsite at all times a contractor owned extinguisher INFECTION CONTROL Refer to Infection Control Risk Assessment INTERIM LIFE SAFETY Refer to Interim Life Safety Measures ASBESTOS Must contact the Safety Department. PATIENT PRIVACY (HIPAA) Patient confidentiality must be maintained at all times. ELECTRICAL SAFETY Equipment must be maintained, do not turn breakers on/off, contact

Superintendent or Project Manager. MEDICAL EMERGENCIES Report immediately to the emergency room or call 911. An incident report is

required for all accidents.


General Policy

Purpose The purpose of the CLASP is to ensure construction, renovation and maintenance activities within the Johns Hopkins Health System (JHHS) is conducted in a manner that minimize safety hazards to the patients, visitors, staff and construction forces.

Features A. In accordance with the Joint Commission standards, the program is designed to institute and

document Interim Life Safety Measures (ILSM) and Temporary Safeguards (TS) that temporarily compensate for any hazard posed to the existing life safety systems, utilities and other systems by construction, repair or renovation efforts.

B. The program is a series of actions and procedures to ensure the safety of the occupants of the construction and adjacent work areas, when compromises are imposed upon the fire alarm, smoke detection, suppression systems, egress, compartmentation, infection control, and utility features. Infection control has its own set of procedures, notifications and monitoring, explained in a later section.

C. The program is intended to ensure contractors and in-house work forces comply with the Occupational Safety and Health Administration (OSHA), Maryland Occupational Safety and Health (MOSH), all Johns Hopkins Health System (JHHS) safety policies, standards and other authorities having jurisdiction.

D. The Construction Safety Coordinator (CSC) is an integral part of the CLASP. The CSC provides the primary liaison between plant operations or facilities, project management, safety and infection control. The CSC inspects jobsites for occupational and user safety, and directs changes in practices and procedures pro-actively before emergency measures are necessary. In the absence of the primary CSC, the role of the CSC is assigned to multiple competent persons, which includes the CSC liaisons [Facilities Engineering Supervisors (FES), Plant Operations Managers (POM), Project Managers (PM), Security, Office of Health, Safety and Environment (HES), Office of Environment, Health and Safety (EHS), Office of Healthcare Epidemiology and Infection Control (HEIC) and Infection Control (IC). The Acronym List in the Table of Contents identifies which liaison is at each campus.

The CSC is charged with supporting construction, renovation and maintenance projects with appropriate safety measures and programs to permit the temporary disruption of egress, alarm, suppression and detection systems, while minimizing risks to life safety. The CSC may not direct a contractor or engineering employee to stop work or leave a jobsite unless extreme hazards to life safety are imminent. Any such stop-work order must be reported immediately to the project or maintenance manager.

E. Implementation of CLASP is the responsibility of the Facilities Department. PM, FES and POM or their designees are directly accountable for compliance with this program. All portions of this program are applicable to construction projects performed by outside contractors. Only certain portions are applicable to maintenance activities. Those portions applicable to maintenance activities will contain specific references to the FES or POM.


Policies

A. All contractors and vendors are issued a temporary identification badge to enhance security. I. D. badges expire annually. To obtain or renew an I D badge, the applicant must be trained annually in general Hospital procedures, safety and commissioning and have submitted documentation of a current flu shot beginning with the 2012/2013 flu season.

Compliance with CLASP training requirements is based on an honor system. A person trained by the CSC can, in turn, train other people within their own company. The company must then provide to the CSC a statement on their letterhead including the name of the company trainer along with the names and last four digits of the trainee’(s) social security number(s). Once the letter has been received and the flu shots verified, the CSC will then issue JHMI ID Request Forms that allows the trainees to obtain a badge from the badging office. The applicant must also present a picture ID to the badging office to process their badge.

B. All marked exits and exit routes must be maintained for egress by building occupants and construction personnel throughout the construction/engineering project/repair effort. Any blockage of the exit route or re-routing must be coordinated through the CSC. Before a compromise can be affected, written approvals must be obtained in accordance with the CLASP/Outage system.

C. Outages to fire alarm, detection, suppression system, or existing utility must be coordinated through the CSC. Before a compromise can be affected, written approvals must be obtained in accordance with the CLASP/Outage procedure. Lock Out/Tag-Out procedures will be incorporated.

D. System outages shall be scheduled for re-activation by the close of each shift. If the outage must extend beyond the scheduled period, the contractor shall notify the CSC and the appropriate Engineering service before the system is to be re-activated. The contractor or FES/POM is responsible to remain on site and provide surveillance until the system has been fully reactivated. Additional training and notification procedures may be put into place as recommended by the CSC.

E. System outages are subject to review and may require installation of temporary systems.

F. The PM shall include “Safety, Infection Control and Outages” as regular agenda items in periodic progress meetings. Documentation of safety related issues shall be written in the minutes of all held progress meetings.

G Any contractor who proceeds with work that compromises existing fire safety systems, alarm, detection and suppression systems, egress routes, utilities, compartmentation or infection control conditions without following the CLASP/Outage procedures shall upon their first offense receive a written warning. Upon their second offense within one calendar year, they shall be suspended from bidding on future JHHS projects. Suspension from bidding shall be at the Hospital’s discretion. NOTE: This does not supersede any associated claims resulting from damages.

H. Any contractor or employee who is found smoking in the hospital or the construction area shall be removed from the hospital lot permanently. Their identification badge will be turned in. Any contractor or subcontractor, who has two or more employees suspended for smoking


within a six month period, shall be suspended from bidding on future projects for six months at the discretion of JHHS.

I. The Prime contractor is required to provide and maintain on site an accessible, fully charged, tested and certified 10 lb. ABC fire extinguisher for every 5,000 square feet of project area under construction. Under double surveillance, the area is reduced to 2,500 square feet. Contractors must be OSHA trained and certified to use fire extinguishers.

J. The contractor is required to keep the jobsite free of debris and loose combustible materials. All debris is to be removed from the construction area periodically or as directed by the PM and/or project requirements.

K. The storage of non-flammable materials in mechanical or electrical equipment rooms or shafts is expressly prohibited unless approved in accordance with the CLASP/Outage procedure at JHH. Any contractor who violates this procedure shall upon their first offense, receive a written warning, upon their second offense in one calendar year, they shall be suspended from bidding on future JHH projects for a period of six months. Suspension from bidding shall be at the JHHS option.

L. The Prime Contractor is required to follow all state and federal regulations regarding work in Confined Spaces”. All “Confined Space” activities shall require the request for an outage and a permit and a review by the CSC and HSE at JHH or HCGH or CSC and EHS at JHBMC prior to the start of the work.

M. The Prime Contractor is responsible for the overall Occupational Safety and Health Program on the project. This responsibility cannot be delegated to subcontractors, suppliers, other persons or JHHS.

1. Upon notification of the acceptance on the JHHS bidders list, the contractor is required to submit a copy of the company's site specific safety program to the CSC.

2. Each contractor shall immediately upon receipt, furnish copies of all citations from regulatory agencies to the CSC, where these citations were issued as a result of working at JHH.

3. Prior to the start of work, each contractor is required to attend the Annual Safety and Commissioning Training. Documentation of that training and of flu shots must be received by the CSC before an approved JHH I.D. badge will be issued or renewed.

4. The Prime Contractor is required to post at each project site in a prominent location, an information board. The Project Information Board shall be used for posting:

a. Outages b. Emergency telephone numbers c. Evacuation plan d. Infection Control checklist (JHH) or Infection Control Permit (JHBMC) e. Infection Control class f. Surveillance checklist g. Safety Fact Sheet h. Trash route i. Safety and Commissioning Manual


5. At the pre-construction meeting, the Prime Contractor is required to make available to the PM, a chemical information list and all Material Safety Data Sheets of chemicals that will be used in the course of completing the project. The Prime Contractor is also required to maintain a repository, on the job site, for the Chemical Information Lists and Material Safety Data Sheets for all subcontractors.

6. At the pre-construction meeting, the Prime Contractor is required to present their plan to implement the infection control measures for approval by the PM and CSC.

N. When a contractor has violated the CLASP policy, the PM shall immediately notify the contractor, in writing, and take action in accordance with the following:

1. 1st Time - Written notice

2. 2nd Time - Written notice and at the discretion of the Senior Director of Design and Construction, suspension from bidding on projects for the next 60 days.

3. 3rd Time - Written notice and at the discretion of the Senior Director of Design and Construction, suspension from bidding pending meeting with the President of company. The results of this meeting may consider permanent removal from the bidders list.

4. Subsequent to each PM notification of a violation, there must be immediate compliance and a request for approval from the CSC.

O. When a building or area is adversely affected by fire safety deficiencies or any combination of fire safety deficiencies and active construction, that building shall be put into Interim Life Safety Status. Measures shall be instituted throughout each building or area in Interim Life Safety Status in accordance with the Joint Commission’s Interim Life Safety Measures found later in this policy.

Procedures A. The CSC shall conduct routine jobsite inspections and report all deficiencies, violations and

non-conformance to the contractor, the PM/CSC and the Project Executive.

B. The PM will review current or recent deficiencies with the contractor at each construction progress meeting. The contractor(s) shall report measures taken to correct deficiencies and to prevent a recurrence. These actions shall be documented in the progress meeting minutes.

C. Any construction, renovation or maintenance work (temporary enclosures, deliveries, etc.)

which compromises existing fire safety systems, which may include compartmentation, egress routes or the fire resistive integrity of egress route, or infection control, must be approved in accordance with the CLASP/Outage procedure.


D. The contractor/engineering service must submit the CLASP/Outage requests to the

CSC/FES/POM in accordance with the following advance notice requirements: 1. Seven (7) workdays (do not count the submission day or the first day of the outage) for

all routine outage categories below:

a. Alarm systems b. Asbestos - Non-NESHAP c. Compartmentation d. Detection systems e. Egress f. Flammable materials g. Noxious materials i. Hazardous materials j. Storage k. Chilled water

l. Condenser water m. Domestic water n. Electric o. Elevator p. Heating water q. HVACR r. Natural gas s. Nurse call t. Pneumatic tube

2. Twelve (12) workdays (do not count the submission day or the first day of the outage)

for all non-routine outage categories below:

a. Asbestos - NESHAP b. Fire suppression c. EVAC – blower scavenging

system d. Lab air e. Lab vacuum f. Medical air

g. Medical vacuum h. Nitrogen i. Nitrous oxide j. Oxygen k. Steam l. WAGD – waste anesthesia gas

disposal (vacuum pumps)

3. Outage extensions must be submitted no later than 24 hours before the start of the last day of the original outage.

E. It is the responsibility of the CSC/FES/POM to submit, to the CSC, the outage requests

with sufficient detailed information. The outage shall be submitted to the CSC in accordance with the following advance notice requirements:

1. Five (5) workdays (do not count the submission day or the first day of the outage) for all routine outage categories below:

a. Alarm systems b. Asbestos - Non-NESHAP c. Compartmentation d. Detection systems e. Egress f. Flammable materials g. Noxious materials i. Hazardous materials j. Storage k. Chilled water

l. Condenser water m. Domestic water n. Electric o. Elevator p. Heating water q. HVACR r. Natural gas s. Nurse call t. Pneumatic tube


2. Ten (10) workdays (do not count the submission day or the first day of the outage) for

all non-routine outage categories below:

a. Asbestos - NESHAP b. Fire suppression c. EVAC – blower scavenging system d. Lab air e. Lab vacuum f. Medical air g. Medical vacuum

h. Nitrogen i. Nitrous oxide j. Oxygen k. Steam l. WAGD – waste anesthesia gas

disposal (vacuum pumps)

F. Outage requests submitted in a timeframe less than stated above must be treated as an emergency requiring approval of the Senior Director of Engineering Services at JHH or the FES at JHBMC and POM at HCGH. The outage may be rejected on the merit of the timing or the Hospital’s ability to support the request. For the purposes of all notification requirements, the workday is defined as Monday through Friday, except for Hospital holidays. The submission day and the first day of the outage are not counted. G. The CSC notifies the local fire department in advance on all fire suppression, smoke detector and other fire alarm impairments. The CSC shall not allow work to proceed that does not honor the advance notice requirements. H. When deemed necessary, the Prime Contractor will submit a work plan to the CSC/FES/POM for review through the outage system. This work plan may require attached documents, such as notices, floor plans, correspondence, etc. Afterwards, the CSC will examine the work plan and recommend ILSM and/or TS for the Prime Contractor to apply. I. The contractor doing the work not an overseeing contractor requiring the impairment of the fire alarm/sprinkler system must sign-in each day of the outage prior to the beginning of the shift. The sign-in board is outside the lobby of Engineering Services at Billings B-120. The outage number must be filled in to be valid. If the contractor is late in signing in, the contractor must pursue the fire alarm mechanic by asking the Front Desk to radio the fire alarm mechanic. At JHBMC and HCGH, the PM arranges the outage confirmation. J. The CSC will routinely inspect the jobsite throughout the period of the outage for compliance. K. The CSC/FES/POM will coordinate necessary notification and training of construction personnel and affected occupants of adjacent areas of the outage. L. At the completion of the CLASP/Outage at JHH, the ICS shop, at JHBMC, Facilities, and at HCGH the POM shall verify that all permanent life safety features of the fire alarm system have been restored. Notification to the occupants of adjacent areas will be done at JHH, by the ICS shop, at JHBMC, by the FES, and at HCGH, by the POM.


M. Any work that commences without following all the proper CLASP procedures will be stopped immediately. Said work will not be allowed to continue until all proper outage procedures have been followed. Additionally, all such outages shall be noted as such on the outage delinquency report. N. Engineering personnel shall conduct surveillance of construction areas designated by the CSC during off-hour shifts. This procedure shall be done in accordance with the CLASP Surveillance Procedure. O. Construction and renovation project areas shall be secured to prevent staff patients or visitors from entering. Each Prime Contractor will be issued keys for all their projects. The door must be locked when the site is unoccupied and signage identifying the area as unsafe with a contact number of the CSC/FES/POM for questions. P. Double surveillance is an ILSM that addresses higher fire risks, such as extending the impairment of the sprinkler system beyond one shift. Minimizing this risk in project planning and timing is essential. The following are elements of double surveillance: 1. Decrease the area per fire extinguisher from 5000 sq. ft. to 2,500 sq. ft. 2 Conduct a fire watch of one hour after cessation of any hot work. 3. Manage a fire watch at least once per shift when work is not being done. 4. Maintain vigorous housekeeping, involving eliminating accumulated combustibles and maintaining egress. 5. Consider using a temporary detection/fire suppression system. 6. The Project Manager must submit updated Risk Assessment to the CSC to evaluate building ILSM status. Q. The storage of non-flammable materials in mechanical or electrical equipment rooms or shafts is expressly prohibited unless approved in accordance with the CLASP/Outage, which carries the following requirements: 1. Store only non-flammable items, not wood/ or cardboard. 2. Maintain egress. 3. Maintain access to valves, switches, panel boards, IDF cabinets, etc. 4. Post outage on the door. 5. Clean area after use. 6. Acceptance of this area is a line item of the project the final inspection.


Life Safety and Other Safety Compromises

The following explanation will aid Project Management and Engineering in determining when a situation is considered reportable under CLASP. A CLASP-related situation would be a construction, renovation or maintenance activity that the Life Safety System, Utility or Other Safety System is impaired. A Life Safety System refers to any appliance, device, method, means, person and/or procedure which has been put into place and/or is depended upon to eliminate or minimize exposure to death or injury in case of a fire. Below are examples of Life Safety Compromises: 1. Egress Routes – Corridor width reduction, exit elimination, fire lane obstruction, traffic detour, redirection of corridor traffic, egress to the corridor impaired 2. Detection Systems – Activity setting off a smoke or heat detector 3. Flammable Materials – Painting with flammable paints, storage of flammable materials outside of approved cabinet or room, storage or use of flammable compressed gas cylinders. 4. Fire Suppression Systems – Sprinkler or Halon, permanent extinguisher removal or relocation. 5. Compartmentation – Floor or wall demolition or penetration, fire door removal/relocation. 6. Alarm Systems – Fire Department disconnection, device changes of the fire alarm system 7. Hot Work – Welding, soldering, heat gun use, temporary heating arrangements A CLASP-related situation could also be cause by other conditions. Below are examples of other safety compromises: 1. Infection Control – Isolate dust producing activity from patients 2. Utilities – Outages of services for building functioning (electric, elevators, medical gases) 3. Noxious and Toxic Materials – Applying adhesives, solvents, painting, roofing 4. Hazardous Materials – Asbestos abatement

5. Confined Space – Manholes, containers, pits, vaults and hard to access or poorly ventilated areas


Interim Life Safety Measures (ILSM) The Hospital implements the life safety management plan and performance improvement standards, including all features described in the Joint Commission Elements of Performance for LS.01.02.01. The Hospital also: I. Maintains current record drawings or documents addressing all structural features of fire protection. II. Develops a policy for use of interim life safety measures (ILSM) that include written criteria to evaluate various Life Safety Compromises (LSC) deficiencies, the Life Safety Criteria Guide, and construction hazards for determining when and to what extent they are applicable. The ILSM consist of one or more of the following actions: 1. The hospital notifies the fire department and initiates a fire watch when a fire alarm or

fire suppression system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented.

2. The hospital posts signage identifying the location of alternative exits to everyone

affected. 3. The hospital has a written interim life safety measure (ILSM) policy that covers

situations when the Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.

4. Inspect exits in affected areas on a daily basis. 5. Provide temporary but equivalent fire alarm and detection systems for use when a fire

system is impaired. 6. Provide additional fire-fighting equipment. 7. Use temporary construction partitions that are smoke tight and make of noncombustible

or limited-combustible material that will not contribute to the development or spread of fire.

8. Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. 9. Enforce storage, housekeeping and debris removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level. 10. Provide additional training to those who work in the hospital on the use of fire-fighting equipment.


11. Conduct one additional fire drill per shift per quarter. 12. Inspect and test temporary systems monthly. 13. Conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. 14. Train those who work in the hospital to compensate for impaired structural or compartmental fire safety features. III. Implement, document and enforce appropriate interim life safety measures (ILSM) as determined by the organization.


Life Safety Criteria Guide

Notify BCFD

1 Notify BCFD. C

onduct fire

watch.

2 Post signs a

t alte

rnate exits.

4 Inspect e

xits d

aily.

5 Insta

ll temp. &

equal fire alarm

& detection.

12 Inspect &

test m

onthly.

6 Add fire-fig

hting equipment.

7 Insta

ll smoke/fir

e resis

tive barrie

rs.

8 Increase su

rveillance

- constr

uction

, storag

e, exca

vatio

n, fie

ld office

s

9 Control fl

ammables & co

mbustibles

- storag

e, hou

sekeeping &

debris

removal

10 Additional fi

re-fightin

g training.

11 Add a fire drill

/shift/quarte

r.

13 Fire sa

fety education - b

ldg. d

eficie

ncies,

constr

uction

hazar

ds & te

mp. measu

res

14 Conduct compartm

entation tra

ining.

ILSM - Interim Life Safety Measures Life Safety Criteria Guide Elements of Performance LS.01.02.01

CompartmentationSignificant wall/floor penetration/opening that is:

Smoke rated and a business occupancy. x x x x x1 or 2 hr. rated in a business occupancy without a smoke detector.

x x x x x x x

In an inpatient compartment without a smoke x x x x x x x xEgress

Obstructing/changing exit signage x x x xNarrowing/obstructing exit path x x x x x x xEliminate exit x x x x x x x

Fire Alarm or Sprinkler ImpairmentMin. 4 hr. within 24 hr. under 8 hrs. No hot work. x x x x x xMin. 4 hr. within 24 hr. over 8 hrs. No hot work. x x x x x x xOver 24 hrs. No hot work. x x x x x x xMin. 4 hr. within 24 hr. under 8 hrs. Hot work. Business occupancy.

x x x x x x x

Min. 4 hr. within 24 hr. over 8 hrs. Hot work. Business occupancy.

x x x x x x x

Over 24 hrs. Hot work. Business occupancy. x x x x x x xMin. 4 hr. within 24 hr. under 8 hrs. Hot work. Inpatient in same compartment.

x x x x x x x

Min. 4 hr. within 24 hr. over 8 hrs. Hot work. Inpatient in same compartment.

x x x x x x x

Over 24 hrs. Hot work. Inpatient in same x x x x x x x xFlammable Materials x x x x x xHot Work Outside x x x x x x x x xNote: Provide documentation for these elements of performance.


Project Risk Assessment Evaluation Date

From

To

WBS/Work Order/Cost Center Project Manager Contractor

CategoryLife Safety- Egress- Compartmentation- Fire Alarm/Suppression- Flammables/Combustibles- Hot WorkInfection Control- Risk Level/Group # - Measures

Utility Compromises

Security - Locked sites,After Hour NotificationHazardous Materials - MSDS,Labels, PPE, Chemical Spil lsMedical Emergencies - Bloodborne pathogensConfined Space

Miscellaneous- Cell Phones- HIPAA- Proper Attire

Construction Dates

Construction Management Plan Elements

Project Manager ______________________________ Risk Assessment Committee ___________________________

Noise, Vibration, Odor, Dust

Project Equipment Only Location(s)

Evaluation

Description of Work


Project Risk Assessment Project Manager: Assessment Date: Project:

WBS # Life Safety Compromise (LSC) Interim Life Safety Measure (ILSM)

Additional (ILSM) for Extended Conditions

Comments

Alarm Systems Compartmentation Training Client Coordination Confirm Restoration Additional Fire Fighting Training

Control Flammable/Combustible Materials CLASP Surveillance Fire Extinguishers Double Surveillance Fire Safety Training Temporary Detection Fire Watch Lock out/Tag out Notify Fire Department Notify Security Submit Outage Compartmentation Compartmentation Training Additional Fire Drill/Shift/Quarter Confirm Restoration Additional Fire Fighting Training Control Flammable/Combustible Materials CLASP Surveillance Fire Safety Training Double Surveillance Submit Outage Temporary Detection Fire Extinguishers Detection Systems Compartmentation Training Client Coordination Confirm Restoration Additional Fire Fighting Training Control Flammable/Combustible Materials CLASP Surveillance Fire Extinguishers Double Surveillance Fire Safety Training Temporary Detection Fire Watch Lock out/Tag out Notify Fire Department Notify Security Submit Outage Egress Client Coordination Additional Fire Drill/Shift/Quarter CLASP Surveillance Control Flammable/Combustible Materials Detours Egress Plan Fire Safety Training Inspects Exits Daily Notify Fire Department Notify Security Client Coordination


Project Risk Assessment Life Safety Compromise (LSC) Interim Life Safety Measure (ILSM)

Additional (ILSM) For Extended Conditions

Comments

Flammables/Combustibles CLASP Surveillance Additional Fire Drill/Shift/Quarter Compartmentation Training Additional Fire Fighting Training Control Flammable/Combustible

Materials Double Surveillance

Fire Extinguishers Temporary Detection Fire Safety Training Fire Watch Submit Outage Hot Work CLASP Surveillance Additional Fire Fighting Training Compartmentation Training Double Surveillance Confirm Restoration Temporary Detection Control Flammable/Combustible

Materials

Fire Extinguishers Fire Safety Training Fire Watch Notify Fire Department Signage Smoke Evacuation Plan Submit Hot Work Permit Submit Outage Storage Only non-flammables Maintain access to switches, valves Post outage on the door. Clean area after use. Acceptance of this

area is a line item of the project final inspection.

Submit Outage Suppression Systems CLASP Surveillance Additional Fire Fighting Training Client Coordination Double Surveillance Compartmentation Training Temporary Detection Confirm Restoration Control Flammable/Combustible

Materials

Fire Extinguishers Fire Safety Training Fire Watch Lock out/Tag out Notify Fire Department Stop Hot Work Permits Submit Outage


Project Risk Assessment Other Compromises (OT) Comments

Utilities Chilled Water EVAC Condenser Water Lab Air Domestic Water Lab Vacuum Electric Medical Air Heating Water Nitrogen HVACR Nitrous Oxide Natural Gas Oxygen Nurse Call Steam Pneumatic Tube WAGD Temporary Safeguard (TS) for Utility Compromises

Additional (TS) For Extended Conditions

Comments

Client Coordination Temporary System Confirm Restoration Lock out/Tag out Signage Other Compromises (OT) Temporary Safeguard (TS)


Comments

Confined Space Pre-approval Meeting with Safety Submit Confined Space Permit Plan Submit Outage Elevator Client Coordination Confirm Restoration Detours Lock out/Tag out Notify Fire Department Notify Security Signage Hazardous Materials Air Filters Cover Hauled Materials Dust Tight Barriers Employ Industrial Hygienist Frequent Cleaning Negative Air Notifications Protective Clothing Signage Submit Outage


Project Risk Assessment Other Compromises (OT) Temporary Safeguard


Comments

Infection Control Clean Tracks Air Filters Cover Hauled Materials Negative Air Dust Tight Barriers Protective Clothing Frequent Cleaning Infection Control Inspections Standing Water Dried Walk Off Mats Maintained Noxious/Toxic Materials Maintain MSDS Personal Protective Equipment Proper Labeling


Facilities Engineering Supervisor Worksheet Life Safety Compromise/Interim Life Safety Measure Matrix

Date:Employee Name:

WO#:WO Description:

Check All

That Apply LIFE SAFETY COMPROMISE CL

ASP

Sur

veill

ance

Clie

nt N

otif

icat

ion

Com

part

men

tati

on T

rain

ing

Conf

irm

Res

tora

tion

Cont

rol F

lam

mab

le/

Com

bust

ible

Mat

eria

ls

Det

ours

Egre

ss P

lan

Fire

Ext

ingu

ishe

rs

Fire

Saf

ety

Trai

ning

Fire

Wat

ch

Insp

ect E

xits

Dai

ly

Lock

out/

Tago

ut

Not

ify

Fire

Dep

artm

ent

Not

ify

Secu

rity

Sign

age

Smok

e Ev

acua

tion

Pla

n

Stop

Hot

Wor

k Pe

rmit

s

Subm

it H

ot W

ork

Perm

it

Subm

it O

utag

e/In

cide

nt R

epor

t

Alarm Systems X X X X X X X X X XCompartmentation X X X X X XDetection Systems X X X X X X X X X XEgress X X X X X X X X X X XFlammables/Combustibles X X X X X X XHot Work X X X X X X X X X X X XSuppression Systems X X X X X X X X X X

ILSM

CLASP Surveil lance

Client NotificationCompartmentation TrainingConfirm RestorationControl Flammable/Combustible MaterialsDetoursEgress PlanFire ExtinguishersFire Safety Training

Fire Watch

Inspect Exits DailyLockout/Tagout

Notify Fire Department

Notify Security

Signage

Smoke Evacuation PlanStop Hot Work PermitsSubmit Hot Work PermitSubmit Outage/Incident Report

Date

Deficiency corrected at __________________ AM/PM On Date

Date

SCAN THIS DOCUMENT TO THE ILSM GROUP ON THE BILLINGS BASEMENT COPIER

Contact Facil ities CLASP CoordinatorContact staff/contractors that hold approved hot work permits to halt workFollow Departmental procedures

Supervisor

ILSM(s) have been implemented as of Date

Supervisor

By end of shift

Post computer generated signs informing occupants of condition. Include Facil ities name and phone number x5-5770. Post sign on blue JHM Bulletin poster board.

Perform rounds at the beginning of each shift. Complete CLASP Fire Surveil lance Form, scan to ILSM group on Bil l ings Basement Copier

Notify tenants first shift, Administrator on Call, off-shiftsNo actionAppropriate Supervisor ensures deficiency is repaired

Remove excessive combustibles found on Fire Surveil lance Rounds

Notify Safety, all shifts, Administrator on CallRedirect patient/public traffic to nearest alternate exit. Alter misleading exit signs.Additional extinguisher required for every 5,000 sq. ft. of workNo action

Complete Fire Surveil lance Form. Scan to Paul, Theresa and Sam.

Submission of outage/incident report will auto send email, or call x5-5585

Follow Departmental procedures

Perform rounds at the beginning of each shift. Complete CLASP Fire Surveil lance Form, scan to ILSM group on Bil l ings Basement Copier

Fax this form to BCFD with standard coversheet located at S:\ILSM Information\ILSM Fax Coversheet.docx

Supervisor Action

Building:Floor:

Room:


Hazard Communication

Also called OSHA’s “Employee Right-to Know” law. States every employee has a right to know every hazard associated with each chemical they work with.

This is communicated in two ways — Material Safety Data Sheets (MSDSs) and labels.

Material Safety Data Sheets (MSDS) - are documents that contain all pertinent information about a chemical. All MSDSs are kept in the Health, Safety and Environment Office at (410) 955-5918 or the JHBMC Security Office at (410) 550-0333. At HCGH, all MSDS are available online through the employee portal, or call “MSDS online®” on the toll-free hotline 1-800-362-7416 for Fax back service of the MSDS. Labels - every container needs to have a label that is written correctly and clearly.

Personal Protective Equipment (PPE) — MSDSs and labels explain which type of PPE should be worn when handling that particular chemical.

Chemicals Spills should be cleaned up by the users according to the label/MSDS

instructions. If the spill is of such a magnitude that the users are unable to contain it, at JHH, call the Centrex emergency number, (410) 955-4444; at JHBMC, call

(410) 550-0222; and at HCGH, call 5151.


Bloodborne Pathogens

Bloodborne pathogens are microorganisms such as viruses or bacteria that are carried in blood, internal body fluids and unfixed tissue that can cause disease in humans. Three Most Common Bloodborne Pathogens: 1. HIV — Human Immunodeficiency Virus. Small but real hazard. Attacks the T4 cells which defend the body against infection. There is no cure or vaccine but an exposed person can be placed on Post Exposure Prophylaxis (PEP) within one to two hours of exposure. 2. HBV —Hepatitis B Virus. Attacks the liver. Currently 1.25 million people in the US are infected. There is a vaccine offered free of charge. 3. HCV —Hepatitis C Virus. Attacks the liver. Currently 4 million people in the US are infected. There is no vaccine. Routes of Exposure 1. Parenteral—through the skin via punctures and open wounds. 2. Mucous membranes-splash to the eyes, nose, and/or mouth. 3. Sexually 4. Prenatal 5. But not through casual contact!!! Prevention 1. Standard Precautions: consider all body fluids/blood to be infectious. Dispose of all materials with blood/body fluids into red bags and sharps into sharps containers prior to disposal in red bags. 2. Wear Personal Protective Equipment!! Gloves and eye/face protection (safety glasses, goggles, face shields). 3. Receive the Hepatitis B vaccine 4. Hand washing is still the most effective means to prevent transmission. Steps to follow if you are exposed: 1. Wash the exposed site 2. At JHH, call (410) 955-STIX (7849) 24 hour hotline. At JHBMC, call (410) 550-0477, M-F, 8 AM - 4:30 PM and page (410) 283-1545 after hours. At HCGH, call Occupational Health at (410) 740-7838, M-F, 7:30 AM to 4 PM, the Emergency Department after hours at (410) 740-7777. 3. If recommended, initiate Post-Exposure Prophylaxis (PEP) within 1 - 2 hours after exposure for optimum efficacy. 4. Complete incident report


Johns Hopkins Health System At JHH - Health, Safety and Environment

At JHBMC - Environment, Health and Safety At HCGH – Facilities Engineering

Notice of Asbestos Abatement

Contractors complete this form. At JHH, fax it to (410) 955-5929; at JHBMC, fax it to EHS at (410) 550-3049; AND fax a copy to your Project Manager at (410) 550-3068 or Maintenance supervisor at (410) 550-1096. At Bayview, all documentation related to the testing, removal, transport and certification needs to be sent to the EHS and PM or FES. At HCGH fax a copy to Facilities Engineering at (410) 740-7578. Facility: ___________________________ Site/Building Name: __________________________________ Address/Floor: _________________________________________________________________________ Site Description/Location: ________________________________________________________________ Describe the amount to be abated, procedures to be used, scheduled start and end date and time. If due to Operations & Maintenance of equipment or an emergency repair, describe the reasons(s) this abatement meets O&M protocols and/or the emergency. If an emergency situation exists, at JHH, HSE or at JHBMC, EHS must be notified immediately. Start Date: _______________________________ Completion Date: ______________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

PROJECT TYPE: ____NESHAP ____NON-NESHAP

I certify that all work will comply with all applicable Federal, State and Local regulations and the JHHS asbestos guidelines. The Industrial Hygiene services will be performed by __________________________________________ This form must be sent, with appropriate documentation, at least 10 working days prior to the start of the project or within 24 hours of an emergency project. NESHAP projects require the Contractor to post “Notice of Asbestos Project” signs complying with COMAR 26.11.21 at least 3 working days before the project starts. __________________________________________________________________________________ Signature of Owner/Contractor Date Contractor Name, Address, Phone: _________________________________________________________ _____________________________________________________________________________________ MD License No.: ____________________ Contact Name: ____________________________________


CLASP Surveillance Procedures

Purpose

1. Provide a firewatch during off hours. 2. Identify safety compromises. 3. Identify workmanship deficiencies or maintenance related problems.

Procedures

1. Each PM shall, on a periodic or as needed basis, submit to the CSC/FES/POM the names of those

projects that require off-hour surveillance. The CSC/FES/POM shall compile and submit a list of those projects to Engineering. Also be done on a weekly basis. Engineering, upon receipt of the list, shall forward the list to the appropriate personnel for execution.

2. Emergency additions to the list may be made by the PMs at any time. However, they must be

coordinated through the CSC/FES/POM. Engineering shall be responsible for providing surveillance for any emergency additions.

3. Surveillance shall be done on the 2nd and/or 3rd shift unless otherwise indicated on the list. Each

survey shall be documented on the CLASP Engineering Surveillance Form. One completed the form shall represent one completed surveillance visit per site. Each form shall be sent to the CSC/FES/POM by the beginning of the next first shift.

4. We maintain double surveillance when a site has extraordinary fire safety risks, such as a disabled

fire detection or sprinkler system. There will be an inspection on each unoccupied shift. 5. The CSC/FES/POM shall discuss any deficiencies noted on the surveillance report with the PM.

The PM shall report deficiencies to the contractor for correction. Compliance will be noted in progress meeting minutes.


CLASP Surveillance Checklist Location Project Manager Date

Inspector Contractor Time

Meets Standards

1 Exits clear and unlocked?

2 Exits & w alkw ays clearly marked and w ell lighted?

3 Fire doors blocked open?

4 Doors in good w orking order?

5 Extinguisher present and accessible?

6 Sprinkler heads blocked?

7 Sprinkler head heat collectors there?

8 Signs of smoking?

9 Combustible trash or materials minimized?

10 Fire w alls and slabs compromised?

11 Construction barriers smoke tight?

12 Detector heads bagged?

13 Proper signage at construction entrance?

14 Construction entrance locked?

15 Mechanical/electrical rooms locked?

16 Compressed gas cylinders secured?

17 Electric panel covers in place?

18 Barrier dust tight?

19 Negative air suff icient?

20 Interior clean?

21 Walkoff mats present and clean?

22 Standing w ater?

23 Hazardous chemicals labeled & stored

Infe

ctio

n Co

ntro

lIn

jury

Secu

rity

Life

Saf

ety

Additional Comments

Cate

gory

Y/N/NA Description


Ceiling Permit Procedures Purpose 1. Confirm the work meets Industry and Hospital standards. 2. Insure proper safety and infection control measures are taken. 3. Maintain fire stopping integrity. Procedures

1. The ceiling permit is not used inside work sites that have established for temporary construction barriers. Only use ceiling permits outside these barriers, or for projects that don’t have established construction barriers.

2. Applicant must obtain and completely fill out top section of the Ceiling Permit. At JHH

and JHBMC, attach the location and routing information on the Fire Safety Feature Spacebook plans. At JHH, submit it a minimum 48 hours to the CSC and at JHBMC and HGCH 72 hours before to the CSC/FES/POM.

3. The CSC/FES/POM reviews the permit application, addresses infection control measures

and other concerns. If required, the CSC/FES/POM, will schedule an inspection date, time and place and put it on the permit. The applicant is required to attend the inspection.

4. At JHH, the CSC sends the approved permit application to the Front Desk, who attaches a

work order number to it and issues it to the applicant, commissioners, impacted staff and the CSC. At JHBMC, contact the Facilities Call Center at (410) 550-0260. At HCGH contact POM at (410) 740-7942.

5. Contact the CSC/FES/POM if there are changes to the initial permit and it will then be re-

issued.

6. As mentioned in the permit application, the permit must be visible when in the Ceiling Space. If it isn’t, work will have to cease until proper arrangements are made through the CSC/FES/POM.


Ceiling Permit Form

CEILING PERMIT JOHNS HOPKINS HEALTH SYSTEM Staff/Project Manager Entrant/Contractor

Cost Center Spacebook Plan Attached? * Yes __ No __

POLICY VIOLATIONS- Accessing a CEILING SPACE without a valid Ceiling Permit.- Performing work outside the scope of the permit.- Providing false information on the permit or to the permit issuer.- Allowing another company to work under the permit.- Not complying with the CLASP Policy.

Entrant/Contractor's Signature Date

FOR STAFF USE ONLY. DO NOT WRITE BELOW THIS LINE

___ Portable Enclosure ___ Frequent Mopping ___ Plastic Tent ___ Frequent Vacuuming ___ Drywall Partition ___ Bunny Suits ___ Sticky Mat ___ Gowns ___ Carpet Mat ___ Footies ___ Negative Air ___ Bonnets ___ HEPA Fan ___ Terminal Cleaning ___ HEPA Vac ___ Other: see comments

Name

Phone

Email

Start Date End Date

Name

Phone

EmailBuildings Floors

The white copy of the form is your permit and must be displayed at all times in the CEILING SPACE.

I have read and understand the CEILING PERMIT POLICY and agree to comply fully.

NOTICE TO ALL WORKING UNDER THIS PERMIT TO READ THE FOLLOWING CAREFULLY

Ceiling spaces and utility closets are CEILING SPACE and are restricted to authorized personnel. Access is a privilege and may be denied for those not complying with the CLASP Policy, which applies to all staff, as well as, vendors and contractor personnel.

Approved By Date Work Order Number

Corridors/Rooms

Comments

Inspection Date/Time NA

Inspection Location NA

Date ReceivedInfection Control Measures Required? Yes __ No __

Work to Be Performed □ Off Hours?


Infection Control Training Overview Dust and debris caused by construction work can harm hospital patients. The vast majority of the harm is caused by a genus of various fungi and common molds called Aspergillus By taking a few simple, practical measures, you can reduce or eliminate the problem. Aspergillus What is it? Aspergillus is a common fungus found in abundance in nature. Its spores are too small to be seen by the eye. Where is it found? Aspergillus is found outside, in dirt, in dust, in rotting leaves and in the dust that is in walls

and ceilings. Aspergillus found inside is the threat to patients. • It can cause disease in immune suppressed patients and patients with lung conditions. It causes a disease called Aspergillosis. It lodges in the lungs or sinuses of the patient. It is hard to treat and can be fatal. Patients can be protected by preventing the spread of Aspergillus spores outside of the construction site. Project Planning Conducting the risk assessment found in Specification 01110 key to a successful and safe project. All projects must consider: Temporary containments Negative air Access routes Walkoff mats Cleaning schedule HEPA Units Protecting the Worksite Temporary Containments Separates the clean from the dirty areas. Provides space that can be put under negative air. Containments can either be: existing walls and ceilings fire retardant plastic fire retardant plastic and/or drywall with metal studs Containment construction rules at patient care and fire egress areas: One shift - Use fire retardant 6 mil poly More than one shift – Use drywall on metal studs. Replacing a fire rated partition – Use drywall on metal studs Internal spaces not applying to anything above – Use fire retardant 6 mil poly


Negative Air Pressure

Insures dust in the air moves into the containment. Can be achieved by blowing air outside with fans and possibly using the building

exhaust system. It must be maintained 24/7. Negative pressure indicators and alarms ensure maintenance of the negative pressure.

Planned Access Routes Choose routes that least impact patient areas. Contain, cover and/or clean dusty materials and personnel.

Mobile Containment Units Useful in small isolated locations and activities. Be careful of dust when entering and exiting the unit. It is best to use HEPA vacuums to remove dust from the unit and your body.

Portable HEPA Filtration Units Units placed just inside and outside the site entrance filters the air effectively. They can also be used to create negative air as a fan would.

HEPA Vacuums Take dust out of the air as it works. Use to clean entrance areas. Must use in a portable containment unit. Required use for every infection control project.

Inspections All infection control measures must be inspected and approved: Prior to the start of construction When there is a change in the configuration of the containment or any other change in the practicing of infection control measures. When a request to reduce or increase the class of infection control rating. All class 3 and 4 projects will be inspected by Prime Contractor daily using the checklist inserted in this manual. The Owner will also inspect all class 3 and 4 projects daily. Request the removal of infection control measures by submitting an inspection through the

Commissioning and Inspection procedures found later in this manual. The Hospital must be assured of the cleanliness of the site.

Personal Health Workers cannot be on site if they have flu, tuberculosis, or any other infectious diseases. Starting November, 2012 it will be required for all to have a flu shot to get your badge and access to work on site. If you need help, contact someone in this order: The Project Manager at JHH, call (410) 955-5900; at JHBMC, call (410) 550-0286 & at HCGH, call (410)740-7948. The CSC at JHH, call (410) 955-5900; at JHBMC, call (410) 550-0228 & at HCGH, call (410)740-7979 At JHH, the Hospital Epidemiology and Infection Control Department at (410) 955-8384; at JHBMC, the Infection Control Department at (410) 550-0515 & at HCGH, call the Infection Control Department at (410) 740-7765.


Section 01 35 33 – Infection Control Procedures

Part 1 - General 1.1 RELATED DOCUMENTS

A. All of the Contract Documents, as listed on the Table of Contents and including General and Supplementary Conditions and Division 1, General Requirements, shall be included in, and made part of, this Section.

1.2 SUMMARY

A. This Section contains infection control procedures for Work, performed within all areas of the facility.

B. Related Sections: The following Sections contain requirements that relate to this Section:

1. Section 01 11 00 “Summary of work.” 2. Section 01 21 00 “Allowances.” 3. Section 01 31 00 “Project Management and Coordination.” 4. Section 01 32 00 “Construction Progress Documentation.” 5. Section 01 33 00 Section “Submittal Procedures.” 6. Section 01 35 13.19 Section “Special Project Procedures for Healthcare

Facilities.” 7. Section 01 50 00 “Temporary Facilities and Controls.” 8. Section 01 73 00 “Execution” for procedural requirements for cutting and

patching necessary for the installation or performance of other components of the Work.

9. Section 02 41 19 “Selective Demolition.” 10. Section 02 82.13 “Asbestos Abatement.” 11. Section 31 20 00 “Earth Moving.”

C. Products installed and furnished under this Section include, but are not limited to the following Sections:

1. Section 06 10 53 “Miscellaneous Rough Carpentry.”

2. Section 09 29 00 “Gypsum Board.”

3. Section 09 91 23 “Interior Painting.”

4. Section 23 31 00.”Sheet Metal Work and Accessories.”

1.3 PROJECT CLASSIFICATION

A. Step One

Construction Activity Type comes from the table below. Construction Activity Type is defined by the amount of dust that is generated, the duration of the activity, and the involvement with HVAC systems.


B. Step Two

Select Infection Control Risk Group from the table below. Infection Control Risk Groups are based on project location and occupancy. As in outpatient areas, day-treatment only areas, etc., work should be done after hours since these areas have limited times when patients are seen.

DEFINITION OF INFECTION CONTROL RISK AREA/LOCATION

Level of Risk by Hospital Location

Low Risk Medium Risk High Risk Highest Risk • Office areas not communi-cating with patient care areas

• Admitting • Cafeteria • Echocardiography • Endoscopy • Nuclear Medicine • Patient areas not specified for high or highest risk • Public corridors where patients, patient supplies and linen are • Radiology/MRI • Rehab Therapy (except Burn) • Respiratory Therapy

• CCU • Emergency Room • Labor & Delivery • Maternal Child Unit • Laboratories (specimen) • Newborn Nursery • Outpatient Surgery • Pediatrics • Pharmacy • Post Anesthesia Care Unit • Surgical Units • Linen Room

• Burn Unit and Burn Rehab • Cardiac Cath Lab • Central Sterile Supply • Intensive Care Units • Medical Units • Negative pressure isolation rooms • Oncology Clinic • ORs including c-section rooms • Dialysis Unit • Outpatient treatment rooms where insertion procedures are performed

C. Step Three

Using the Construction Activity Type and the Infection Control Risk Group selected from the tables above, use the matrix below to determine Construction Classification. Construction Classification determines the procedures to be followed during construction and removal projects.

TYPE A Inspection and Non-invasive Activities Includes, but is not limited to: ▪ removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet ▪ painting (but not sanding) ▪ wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

TYPE B Small scale, short duration activities which create minimal dust Includes, but is not limited to: ▪ installing telephone or computer cabling ▪ access chase spaces ▪ cutting walls or ceilings where dust migration can be controlled

TYPE C Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building component or assembly Includes, but is not limited to: ▪ sanding walls for painting or wallcovering ▪ removing floorcoverings, ceiling tiles and casework ▪ new wall construction ▪ minor ductwork or electrical work above ceilings ▪ major cabling activities ▪ any activity that cannot be completed within a single work shift

TYPE D Major demolition and construction projects Includes, but is not limited to: ▪ activities which require consecutive work shifts▪ ▪ requires heavy demolition or removal of a complete cabling system ▪ new construction


IC Matrix - Class of Precautions: Construction Project by Patient Risk

Construction Project Type Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III/IV IV

HIGHEST Risk Group II III/IV III/IV IV

Note: Infection Control approval will be required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are necessary

D. Step Four

Implement the appropriate Infection Control Construction Guideline based on the Project classification selected from the Construction Activity Matrix listed above in Step Three. Infection Control Construction Guidelines are procedures to control release of airborne contaminants resulting from construction, demolition, or renovation activities.


INFECTION CONTROL CONSTRUCTION GUIDELINES CLASS 0 • No infection control measures required. CLASS I • Execute work by methods to minimize raising dust from construction operations.

• Replace any ceiling tile displaced for visual inspection as soon as possible. CLASS II • Isolate HVAC system in areas where work is being performed.

• Provide active means to prevent airborne dust from dispersing into atmosphere. • Seal unused doors with tape. • Maintain barrier integrity. • Close doors and install project sign. • Contain construction waste before transport in tightly covered containers. • Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area daily. • Place dust mat at entrance and exit of work area and replace or clean when no longer effective. • Establish traffic patterns that minimize exposure to patient care areas. • Quickly dry water spills. • Wipe casework and horizontal surfaces at completion of project.

CLASS III • Isolate HVAC system in area where work is being done to prevent contamination of the duct system. • Place dust-mat at entrance and exit of work area and replace or clean when no longer effective. • Maintain negative air pressure within work site utilizing HEPA filtered ventilation units or other methods. • Complete all construction barriers before construction begins. Request an inspection from the Owner prior to construction. • Maintain barrier integrity. • Close doors and install project sign. • Wet mop or HEPA vacuum twice per 8-hour period of construction activity for as required in order minimizing tracking. • Contain construction waste before transport in tightly covered containers. • Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction. • Barrier material should be wet wiped, HEPA vacuumed or water misted prior to removal. • Establish traffic patterns that minimize exposure to patient care areas. • Quickly dry water spills. • Wipe casework and horizontal surfaces at completion of project. • Do not remove barriers from work area until completed project is thoroughly cleaned. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction. • Barrier material should be wet wiped, HEPA vacuumed or water misted prior to removal. Request an inspection form the Owner prior to construction.

CLASS IV • Isolate HVAC System in area where work is being done prevent contamination of duct system. • Complete all construction barriers before construction begins. Request an inspection from the Owner prior to construction. • Maintain negative air pressure within work site utilizing HEPA filtered ventilation units or other methods to maintain negative pressure. • Seal holes, pipes, conduits, and punctures to prevent dust migration. • Construct anteroom and require all personnel to pass through this room. Wet mop or HEPA vacuum the anteroom twice per 8-hour period of construction activity or as required in order minimizing tracking. • Wet mop or HEPA vacuum the construction interior area once per 8-hour shift, minimum. • During demolition, dust producing work or work in the ceiling, disposable shoes and coveralls are to be worn and removed in the anteroom when leaving work area. • Contain construction waste before transport in tightly covered containers. • Place dust-mat at entrance and exit of work area and replace or clean when no longer effective. • Keep work area broom clean and remove debris daily. • Wet mop hard surface areas with disinfectant at completion of project. HEPA vacuum carpeted surfaces at completion of project. • Maintain barrier integrity. • Close doors and install project sign. •Establish traffic patterns that minimize exposure to patient care areas. • Quickly dry water spills. • Wipe casework and horizontal surfaces at completion of project.


HC

GH

D

esc

rip

tion

of

R

equ

ire

d In

fec

tio

n C

ont

rol

Pr ec au

tio

n s by

Cla ss

During Construction Project Upon Completion of Project C

LAS

S I • Execute work by methods to minimize raising dust

from construction operations. • Immediately replace a ceiling tile displaced for visual

inspection

• Clean work area upon completion of task.

CLA

SS

II

• Provide active means to prevent airborne dust from dispersing into atmosphere.

• Water mist work surfaces to control dust while cutting. • Seal unused doors with duct tape. • Block off and seal air vents. • Place dust mat at entrance and exit of work area • Remove or isolate HVAC system in areas where work

is being performed.

• Wipe work surfaces with disinfectant. • Contain construction waste before transport in

tightly covered containers. • Wet mop and/or vacuum with HEPA filtered

vacuum before leaving work area. • Remove isolation of HVAC system in areas

where work is being performed.

CLA

SS

III

• Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

• Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

• Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

• Contain construction waste before transport in tightly covered containers.

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

• Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Department.

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

• Vacuum work area with HEPA filtered vacuums. • Wet mop area with disinfectant. • Remove isolation of HVAC system in areas


CLA

SS

IV

• Isolate HVAC system in area where work is being done to prevent contamination of duct system.

• Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

• Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

• Seal holes, pipes, conduits, and punctures. • Construct anteroom and require all personnel to pass

through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave work site.

• All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area. *

• Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Dept.

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

• Contain construction waste before transport in tightly covered containers.

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

• Vacuum work area with HEPA filtered vacuums. • Wet mop area with disinfectant. • Remove isolation of HVAC system in areas


HCGH Continuing Steps

E. Step 5.

Identify the areas surrounding the project area, assessing potential impact

Unit Below Unit Above Lateral Lateral Behind Front


F. Step 6.

Identify specific site of activity e.g., patient rooms, medication room, etc. See above.

G. Step 7.

Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.

H. Step 8. Identify containment measures, using prior assessment. What types of barriers?

(E.g., solid wall barriers); Will HEPA filtration be required?

I. Step 9.

Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)

J. Step 10.

Work hours: Can or will the work be done during non-patient care hours?

K. Step 11.

Do plans allow for adequate number of isolation/negative airflow rooms? N/A

L. Step 12.

Do the plans allow for the required number & type of hand washing sinks? Yes

M. Step 13.

Does the infection control staff agree with the minimum number of sinks for this project? (Verify against AIA Guidelines for types and area)

N. Step 14.

Does the infection control staff agree with the plans relative to clean and soiled utility rooms? N/A

O. Step 15.

Plan to discuss the following containment issues with the project team. E.g., traffic flow, housekeeping, debris removal (how and when)

Appendix: Identify and communicate the responsibility for project monitoring that includes infection control concerns and risks. The ICRA may be modified throughout the project. Revisions must be communicated to the Project Manager.

*Worksite garb: Contractor personnel clothing should be free of loose soil and debris before leaving the construction area. If protective apparel is not worn, a HEPA-filtered vacuum should be used to remove dust from clothing before leaving the barricade. Personal protective equipment (e.g., face shields, gloves, respirators) are worn as appropriate. Contractors entering invasive procedure areas should be provided with disposable jump suits and head and shoe coverings. Protective clothing should be removed before exiting the work area. Tools and equipment should be damp wiped before entry and exit from the work areas.


1.4 SUBMITTALS Product Data: Portable HEPA filtered air-handling equipment. Schedule: Submit schedule indicating proposed sequence of operations for erection of construction site barriers and control measures to the Owner for review prior to start of Work. Shop Drawings: For all control measures required. Show all containment assembly areas, methods, exhaust locations, and equipment. 1.5 QUALTIY ASSURANCE General: All phases of barrier erection, removal, or alteration may be monitored by the Owner by use of smoke tests, Baulin Tube device, and/or negative pressure alarm devices to ensure continuous negative air pressure occurring within the Work area. Reports: Owner will provide a “Check List” sheet, which outlines work requirements. Contractor will review this document and enter the date started and completed. Maintain a current, up-to-date report for review by the Owner. When project is completed, provide completed copy to the Owner. Retain original in project file and turn over with as-built drawings. Installer Qualifications: Engage an experienced installer to perform work of this Section. Pre-Construction Conference: Before starting installation of control devices, conduct a pre-construction conference and attend all orientation and training sessions as required by the Owner. 1.6 PRODUCTS MANUFACTURERS AND/OR SUPPLIERS Adhesive Walk-Off Mats: 3M, St. Paul, MN 55144 or approved equal. Provide minimum size mats of 24 inches x 36 inches Exhaust Hoses: Federal Hose Mtg. Co., Painsville, OH 44077 or approved equal. Heavy duty flexible steel reinforced, Ventilator Blower Hose. Filters: Throwaway type fiberglass filters, 1 inch deep, up to 350 fpm rated velocity, 0.04 inch water gauge initial resistance, 72% average resistance, and classified as UL900 Class 2. Fine Filtration Portable Vacuums: Nilfisk of America, Inc., Malvern, PA or approved equal. HEPA-Filtered Ventilation Units: HPA Aire, Model PAS 2000 HC or Model PAS 1000 HC equipped air filtration units or equivalent. Provide HEPA filter, primary and secondary filters. Negative Air Indicator: Molded Plastic Manometer, Dwyer Instruments, Inc., P.O. Box 373, Michigan City, Indiana 46361, (219) 879-8000, www.dwyer-inst.com, model Mark II, Model No. 25 Inclined-vertical Manometer. Portable Work Enclosures: Kontrol Kube - Fiberlock Technologies, Inc. or approved equal Zip-Up Door System: Protective Products, Inc. or approved equal. Mintie Technologies, Inc., www.mintie.com, or approved equal. Zip Wall LLC, Cambridge, Mass., or approved equal;

http://www.dwyer-inst.com/

http://www.mintie.com/


Part 2 - Execution

2.1 PREPARATION

A. Contractor will notify the Owner of planned work and obtain approval prior to start of work by submitting an Outage.

2.2 ISOLATION

A. Install highly visible signage, with barricades when warranted, indicating area is closed to all but authorized construction personnel.

B. Construction activities causing disturbances of existing dust, or creating new dust, will be conducted in tight enclosures that cut off flow of particles into adjacent areas.

C. Where possible, utilize building walls and doors for containment. All doors, except construction access doors, should be closed and sealed with duct tape to prevent dust and debris from escaping.

D. Seal all HVAC supply, return, and sometimes the exhaust grilles, registers, and ductwork to ensure that room air is not being circulated from the construction area to the Hospital ventilation system. The Contractor is only permitted to close or open supply, return, or exhaust dampers, as directed by the Owner. The commissioning authority will accept temporary capping of, and subsequent removal of, capping. As construction progresses, ensure that exhaust air ductwork remain closed and sealed or properly filtered (see ventilation).

E. Construction, demolition, or reconstruction not capable or containment utilizing, existing building walls and doors, will use one of the following methods of isolation:

1. Airtight plastic barriers extending from floor to floor above, or ceiling tiles if not removed. Plastic barrier seams will be sealed with duct tape to prevent dust and debris from escaping. It should be fire retardant polyethylene sheet plastic goods (antistatic as warranted), 6 mil minimum thickness, with minimum width of 5 cm (2 inch) heavy duty cloth duct tape, sealing all junctions and seams. Provide all necessary support and bracing to prevent collapse or failure of barrier systems.

2. Portable dust containment units with polyethylene puffed tight against floor and ceiling.

3. Install, deck to deck, construction barriers of 3- 5/8 inch metal studs at 16 inches on center with 5/8 inch type X fire code gypsum board on both sides. All seams shall be taped and finished. Paint side of partition exposed to public view. Install vinyl cove base to match existing. Entry door shall be hollow metal pre-hung type with integral full perimeter smoke weather-stripping and closer. Provide an area for mats approximately 24 inches by 48 inches both sides.

4. Contractor shall advise the Owner of any work to be performed outside of any areas protected by barriers. All necessary containment requirements will remain in effect for work in areas outside of barriers.

5. Seal all penetrations at existing perimeter walls and floor slabs.

6. Place isolation barriers at penetration of ceiling envelopes, chases, and ceiling spaces to stop movement of air and debris.

7. Erect dust barriers at egress routes allowing for emergency egress.


8. Provide anteroom or double entrance openings that allow workers to remove protective clothing or vacuum off existing clothing. Provide a zip-up door entry system or triple batted polyethylene sheet plastic goods, 6 mil minimum thickness, entryway with weighted bottom. Seal top attachment point with at least two overlapping layers of 5 cm wide heavy-duty cloth duct tape for each side of entry.

9. When openings are made into existing ceilings, a portable dust containment or plastic enclosure will be used, sealing off openings, and fitted tightly from ceiling to floor. Any ceiling access panels opened for investigation beyond the sealed areas will be replaced immediately when unattended.

10. Prevent birds and insects from gaining access to the hospital and hospital air-intake ducts. Exterior openings will remain closed when not in use.

11. Upon completion of barrier, cease all operations and contact the Owner so that a proper inspection can occur by submitting an inspection request per the “Commissioning and Inspection Procedure.”

2.3 EQUIPMENT AND SUPPLIES

A. Delivery and removal of supplies and equipment may be restricted to a specific period time when patient/staff activity is minimized. Specific routing will be required.

B. Any material which is prepackaged, boxed, or otherwise contained in such a manner as to prevent contamination to the surrounding areas is not required to be covered as specified by this Section.

C. Construction materials such as drywall will be stored in clean, dry areas to prevent the growth of bacteria and fungi.

D. Ductwork materials will be stored in a clean, dry area to prevent the accumulation of dust in the ductwork prior to installation

E. All construction debris shall be placed in rigid containers with integral covers, or covered with polyethylene film sheeting, 6 mil minimum thickness, and sealed with 5 cm width heavy duty cloth duct tape, before removal from the construction area. Containers are to be wiped down with a bleach-solution-treated damp cloth prior to removal from the construction area.

2.4 INTERNAL TRAFFIC FLOW

A. All construction traffic within the building shall follow routes as designated by the Owner and shall be strictly enforced.

B. Direct pedestrian traffic from construction areas away from patient-care areas to limit opening and closing of doors (or other barriers) that may cause duct dispersion, entry of contaminated air, or tracking of dust to patient areas.

2.5 VENTILATION

A. When negative air pressure is required, the first method of choice is to exhaust to the outside atmosphere. The Contractor will provide exhaust fans or HEPA filtered ventilation units to maintain the negative air pressure within the construction area. Provide redundant exhaust fans or HEPA filtered ventilation units, whenever possible. Exhaust fans or HEPA filtered ventilation units will run continuously. Ensure that exhausted air does not circulate back into other areas of the building by locating vents away from all intakes and sealing windows and openings adjacent to the construction. Units shall provide a minimum of 6 air changes per hour.


B. The secondary method of choice to maintain negative air pressure is by using the hospital’s exhaust system that is properly filtered by a filter box. The Contractor will provide a filter box, approved by the Owner, to connect to the exhaust system. If not properly filtered, the Contractor will be responsible for cleaning the ductwork. The return air system will not be used to obtain negative air pressure without the approval of the Owner.

C. Contractor is responsible for maintain equipment and replacement of HEPA and other filters. Filters will be changed on a regular basis. Change filters daily during demolition and drywall sanding and a minimum of twice a week during other times.

D. System shall maintain a minimum of 0.01 to 0.02 inches or greater of negative pressure inside the containment area. The Contractor will furnish and install the Baulin-tube device to monitor. Negative air pressure will be continuously monitored by the Owner.

E. Maintain airflow from clean area through the anteroom and into the work area

2.6 HOUSEKEEPING

A. Dust generation shall be reduced as much as possible. Prevent airborne dust from developing. Use of bleach solution sprays is acceptable, provided that no accumulation of standing water or material saturation is permitted. Lightly mist concealed areas with an aerosolized bleach solution to minimize dust generation.

B. Use bleach in a well-ventilated area. Do not mix bleach with other cleaning chemicals, especially those containing ammonia. Poisonous vapors will result.

C. Walk-off mats will be used at exits and entrances to the work area. Adhesive walk-off mats should be placed at all doors exiting the construction area and carpeted walk-off mats should be placed at all doors entering into a construction area.

D. Carpeted walk-off dust mats will be vacuumed at least twice per 8-hour shift and at the end of the workday. Any dust tracked outside of the construction area shall be vacuumed or damp-mopped immediately. Vacuum cleaners shall be outfitted with HEPA filters.

E. Adhesive walk-off mats should be changed daily, or more frequently as needed, to maintain adhesive surfaces.

F. Mats shall be installed and maintained by the Contractor.

G. From the start of construction until the drywall has been primed, the work area shall be bleach-solution-treated damp-mopped clean a minimum of once per eight hour shift, at equal intervals or as directed by the Owner, whichever is more frequent. Vacuum cleaners will be outfitted with HEPA filters. Class III and IV areas also require HEPA filtered vacuuming at the same intervals as listed above. After the drywall has been primed, the damp mopping and vacuuming operations shall be performed on an as-needed basis as recommended by the Owner.

H. All construction debris is to be removed a minimum of one time per eight-hour shift, at equal intervals, or as recommended by the Owner, whichever is more frequent in accordance with all requirements previously noted.

I. The Contractor shall record all information pertaining to cleaning on a log. This log shall be posted on the inside of the construction barrier entry door and kept current by the Contractor. Information required, but not limited to, will be the name of the person cleaning the area, changing the mats, changing the filters, and recording the date and time-of-day the work was performed.


2.7 PROTECTIVE CLOTHING

A. Disposable shoe covers, head covers, and coveralls are to be worn during demolition and other specified times.

B. Protective clothing shall be provided by the Contractor.

C. Protective clothing will be removed any time the worker leaves the immediate work area.

D. Used coveralls, head covers, and shoe covers will be placed in a sealed plastic bag, prior to removal from the work area, for disposal by the Contractor.

E. Entering and Exiting Work Area: During demolition and anytime existing surfaces are to be disturbed, as directed by the Owner, workers may enter the area at the beginning of their respective work shift in normal work attire. Once in the construction area, all workers must wear disposable, coverall jumpsuits made of a non-woven fabric over and completely covering their work clothing. The coverall shall be worn at any time that the worker is within the perimeter of the barrier work site, and shall be taken off as the worker leaves the work site enclosure.

2.8 PRECAUTIONARY AND REMEDIAL WORK

A. The Contractor is responsible to protect all construction materials (stored or in-place) from exposure to moisture or accidental leaks and water intrusion. Ensure that moisture is not trapped in enclosed spaces such as under metal stud channels or encapsulated by finishes such as saturated slabs.

B. All gypsum and wallboard materials must be installed 1/2 inch above finish floor materials to eliminate any potential wicking of moisture.

C. Stored Materials: Any material exposed to moisture prior to installation shall be disposed of.

D. Installed Materials: Any material installed, prior to receiving finishes, exposed to moisture shall be removed and disposed of.

E. Finished Materials; Any material damaged by moisture after finishing shall have all damaged portions removed and disposed of. Damaged materials shall be defined as any material showing a moisture content of 60% or more, 24 hours after the exposure, as measured by a surface moisture detection device such as the Tramex Moisture Encounter non-invasive moisture meter. Contractor shall remove damaged material to at least 1/2 inch beyond damaged areas as directed by the Owner.

F. Non-Absorbent (Hard) Materials: Any hard material exposed to moisture shall be thoroughly scrubbed with a mild detergent followed by a rinse of surface using a solution of 1/4 to 1/2 cup of bleach per gallon water. Strictly follow all manufacturer requirements for use of chlorine based products. Do not rinse with water after application.

1. Caution: Chlorine may cause damage to materials or fade colors; contractor to confirm reactions to chlorine.

2. If reactions are determined to be possible, the Contractor shall utilize the mild detergent method of cleaning.

G. Furnishings, Fabrics, or Finish Materials: Any furnishing, fabrics, or finishes exposed to moisture shall be examined by the Owner. If the Owner determines the products to be damaged, the Contractor shall remove and replace all damaged products. If the Owner determines that the products can be cleaned and remain in place, the Contractor shall steam clean (provided this method is approved by the manufacturer) and completely dry all affected areas.


H. Warranties: If any recommended cleaning methods would void any warranties, the material shall be replaced.

I. Contractor shall employ dehumidifiers to dry the affected areas immediately. After the area has been completely dried the Contractor may continue work.

2.9 EMERGENCY SITUATIONS

A. Notify the Owner immediately if an emergency situation should occur. All work in the area shall be stopped immediately and work may not begin again until authorized by the Owner. The overall risk to the patient from both the emergency and Apergillus must be considered. Prior to taking corrective action the patient should be removed from the area. However, if the patient cannot be removed from the area, the patient must be isolated from the work in accordance with the requirements.

2.10 COMPLETION OF THE WORK

A. The isolation barrier and filtered negative airflow equipment shall be disconnected and removed only after approval by the Owner. Upon approval, remove the isolation barrier and other equipment. All debris resulting from the demolition of the isolation barrier shall be removed in accordance with these specifications.

B. The Contractor shall vacuum the isolation barrier area with approved HEPA filter equipment.

C. The Contractor will vacuum and clean all surfaces in the completed construction area, rendering them free of dust prior to the removal of isolation barriers.

D. Barrier materials should be removed carefully to minimize spreading of dirt and debris associated with construction. Barrier materials should be wet wiped, HEPA vacuumed, or water misted prior to removal. Barriers should be discarded as construction debris.

E. The Contractor will remove all blockages from the air systems.

F. Owner will examine the HVAC equipment and filters for blockage and/or leakage.

2.11 PLUMBING ALTERATIONS

A. Exercise caution when handling fluids (i.e. removing plumbing pipes and fixtures) to prevent wetting of building materials and/or contamination of work areas.

B. Cap unused domestic water pipe branches at no more than three pipe diameters from the main line.

END OF SECTION 01 35 33


Infection Control Policy Intent

The intent of this policy is to minimize nosocomial, hospital-acquired infections in patients that may arise as a result of exposure to organisms released into the environment during construction activities. Controlling dispersal of air- and/or water-borne infectious agents is critical. These agents may be concealed within the building components or imported from the outside. Therefore, all construction activities shall be defined and managed in a way that the occupants’ exposure to dust, moisture and their accompanying hazards is minimized. Procedures 1. Adhere to the requirements in JHHS Standard the Infection Control Specification 01110. 2. The PM must include infection control requirements in every project. The Prime Contractor

will propose the means and methods to satisfy the infection control requirements for approval by the PM / CSC / POM prior to the start of the project.

3. The Prime Contractor will set up all the infection control measures prior to starting

construction. A. The site must have the Hospital’s checklist and class rating posted. B. The CSC may elect to have a baseline particle count taken. C. The Prime Contractor must request the inspection through the inspection system

procedures in the Commissioning and Inspection section of this manual. D. The PM / CSC / POM must approve the infection control measures. 4. The Prime Contractor will request an inspection for intermediate changes to the infection

control measures which must be approved by the PM / CSC / POM. These changes may include changing the classification, modification of the physical area of the site or some other measure.

5. The Prime Contractor will request an inspection for the removal of the infection control

measures, which must be approved by the PM / CSC / POM. 6. The Prime Contractor will inspect his Class 3 and 4 sites daily and post his findings on the

Hospital provided checklist. 7. The PM / CSC / POM will inspect all Class 3 and 4 sites daily. Findings will be

communicated to the Prime Contractor, PM and project management staff. Deficiencies are to be corrected immediately and reported in the project progress meeting minutes.

8. Prime Contractors with Class 1 and 2 ratings are to comply with specified guidelines. The PM /

CSC / POM will inspect on an as needed bases.


9. If any Class project has a condition that puts the Hospital at extreme risk, the CSC or PM or POM will stop work, allowing only corrective measures to proceed. The CSC will notify the PM and upper management immediately. If corrections cannot be made immediately, the Prime Contractor must arrange with the CSC to inspect the site prior to resuming work.

10. The Prime Contractor must notify the PM when a project works off hours or hours that are

different from the start of the project. The PM must notify the CSC so the inspection rounds can be adjusted accordingly.

11. Infection control related issues shall be included in the minutes of progress meetings in the

agenda item “Safety, Infection Control and Outages.”


Infection Control Checklist Instructions: To be completed daily by contractor. Superintendent

Please date, initial and indicated by a check mark that all items notedare being accomplished as outlined in contract documents. Project #Please note start of work, stop and end of demo

Project Name Class all all all all all all all all all all IV all rev 3/5/06

Date & initial

Exterior cleaned

daily

Negative Air

Air Filters Clean

Barrier Integrity

Ok

Doors Closed

/secured

Interior Clean

Hauled Debris

Covered

Tracks Cleaned

Mats Clean

Signage Posted

Clothing Covered

No water on floor


INFECTION CONTROL –Construction Permit

Infection Control Construction Permit Permit No: Location of Construction: Project Start Date:

Project Coordinator:

Estimated Duration:

Contractor Performing Work:

Permit Expiration Date:

Supervisor: Telephone: YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration,

moderate to high levels GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities Requiring consecutive work shifts

GROUP 4: Highest Risk

CLASS I 1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace any ceiling tile displaced for visual inspection.

3. Minor Demolition for Remodeling

CLASS II 1. Provides active means to prevent air-borne dust from dispersing into atmosphere

2. Water mist work surfaces to control dust while cutting. 3. Seal unused doors with duct tape. 4. Block off and seal air vents. 5. Wipe surfaces with disinfectant.

6. Contain construction waste before transport in tightly covered containers.

7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

8. Place dust mat at entrance and exit of work area. 9. Remove or isolate HVAC system in areas where work

is being performed. CLASS III

1. Obtain infection control permit before construction begins. 2. Isolate HVAC system in area where work is being done to

prevent contamination of the duct system. 3. Complete all critical barriers or implement control cube

method before construction begins.

6. Vacuum work with HEPA filtered vacuums. 7. Wet mop with disinfectant 8. Remove barrier materials carefully to minimize

spreading of dirt and debris associated with construction.

9. Contain construction waste before transport in Date 4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units. 5. Do not remove barriers from work area until complete

project is thoroughly cleaned by EVS. Services Dept.

tightly covered containers. 10. Cover transport receptacles or carts. Tape covering. 11. Remove or isolate HVAC system in areas where work

is being performed/ Initial

CLASS IV

1. Obtain infection control permit before construction begins. 2. Isolate HVAC system in area where work is being done to

prevent contamination of duct system. 3. Complete all critical barriers or implement control cube

method before construction begins. 4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units. 5. Seal holes, pipes, conduits, and punctures appropriately. 6. Construct anteroom and require all personnel to pass

through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

7. All personnel entering work site are required to wear shoe covers

8. Do not remove barriers from work area until completed project is thoroughly cleaned by the Environmental Service Dept.

9. Vacuum work area with HEPA filtered vacuums. 10. Wet mop with disinfectant. 11. Remove barrier materials carefully to minimize

spreading of dirt and debris associated with construction.

12. Contain construction waste before transport in tightly covered containers.

13. Cover transport receptacles or carts. Tape covering. 14. Remove or isolate HVAC system in areas where work

is being performed.

Date

Initial

Additional Requirements: See attached Infection Control Risk Assessment Contractor Signature:

_______ Exceptions/Additions to this permit Date Initials are noted by attached memoranda

Permit Request By: Permit Authorized By:

Signature: Date:


JHH Online Outage System

Revision 2.5 2/2011


TABLE OF CONTENTS

Intended Audience ..................................................................................................................................... 54 Purpose ...................................................................................................................................................... 54

Figure 1: Online Outage System Workflow ......................................................................................... 55 Using the Online Outage System .............................................................................................................. 56

Figure 2: Facilities Intranet Homepage ............................................................................................... 56 Outages Home ........................................................................................................................................... 57

Figure 3: Online Outage System Login Screen ................................................................................... 57 Figure 4: Online Outage System Homepage ...................................................................................... 58 Figure 5: Option Sub-menu ................................................................................................................. 59

Request Outage ......................................................................................................................................... 60 Figure 6: Request New Outage ........................................................................................................... 60 Figure 7: Calendar Pop-up Window .................................................................................................... 61 Figure 8: Emergency Warning ............................................................................................................. 62

Modify Outage............................................................................................................................................ 63 Figure 9: Outage Selection Criteria ..................................................................................................... 63 Figure 10: Outage Modification Form ................................................................................................... 64 Figure 11: Link to Outage Information Request and Project Manager Approval ................................. 65 Figure 12: Outage Information Request ............................................................................................... 66

Approve Outage ......................................................................................................................................... 67 Project Manager Approval ......................................................................................................................... 67 Client Approval........................................................................................................................................... 67

Figure 13: Client Approval Screen ....................................................................................................... 68 Shop Approval ........................................................................................................................................... 68

Figure 14: Shop Approval Screen ........................................................................................................ 69 System Restoration ................................................................................................................................... 70

Figure 15: System Restoration Routine ............................................................................................... 70 Request Outage Extension ........................................................................................................................ 71

Figure 16: Outage Extensions .............................................................................................................. 71 Cancel Outage ........................................................................................................................................... 72

Figure 17: Cancel Outage Screen ....................................................................................................... 72 View and Print Outage ............................................................................................................................... 73

Figure 18: View and Print Outage ........................................................................................................ 73 Status Report ............................................................................................................................................. 74

Figure 19: Status Report Selection Criteria .......................................................................................... 74 Figure 20: Status Report ..................................................................................................................... 75

Add/View Attachments ............................................................................................................................... 76 Figure 21: Add/View Attachments Screen ........................................................................................... 76

Other Options............................................................................................................................................. 77 Print Hot Work Permit ................................................................................................................................ 77 Change Password ..................................................................................................................................... 77 Email Notifications ..................................................................................................................................... 77

Figure 22: Email Notification Matrix ...................................................................................................... 77 Figure 23: Hot Work Pemit ................................................................................................................... 78

Reporting ................................................................................................................................................... 79 Status Report ............................................................................................................................................. 79 Delinquency Report ................................................................................................................................... 79

Figure 24: Delinquency Report ............................................................................................................. 79 JHH Contractor PC .................................................................................................................................... 80

Start-up Procedure ................................................................................................................................ 80 Scanning Procedure .............................................................................................................................. 80


Intended Audience This documentation is intended for users of the Facilities Online Outage System. Users include not only The Johns Hopkins Hospital and Health System staff, but outside contractors and vendors.

Purpose The Online Outage System is developed to better process outages that ensure the safety of patients, staff, visitors, and contractors. The Online Outage System will act as a central repository for all outage information past, present, and future. This web-based application will be accessible from anywhere, allowing participants to create, approve, and check the status from off-campus.


Online Outage System Workflow

Figure 1: Online Outage System Workflow


Using the Online Outage System The Online Outage System is built within the Facilities Department Intranet. To access the Facilities Intranet, you may browse to the following address: http://facilities.jhmi.edu/FacilitiesV4/ The first page you will see will look like the following:

Figure 2: Facilities Intranet Homepage Next select the option for Design and Construction, which will take you to the Design and Construction applications. To access the Online Outage System, you will then choose the option for Outages.


Outages Home The first screen you will see when you enter the Online Outage System is a login screen:

Figure 3: Online Outage System Login Screen The Outage Administrators will be responsible for creating accounts and assigning the appropriate rights to that account. First you must register into the Online Outage System. Contact Outage Administrators. They will assign your user login and password. The Outage Administrators will provide you with any help you may need with the Online Outage System.


After a successful login, you will be forwarded to the following screen, which will be referred to as the Outage Homepage:

Figure 4: Online Outage System Homepage The menu is broken down by the different types of personnel using that particular action on the Outage. Each group has different rights to the system. The All Users menu offers the following items that are of common use:

• View/Print Outages • Status Report


Moving the mouse over any group exposes a sub-menu of options. The following figure is an example of moving the mouse over the Contractors group.

Figure 5: Option Sub-menu In this example, the contractor has the ability to do the following:

• Request New Outage • Modify Outage • Request Outage Extension • Add/View Attachments • Print Hot Work Permit • Cancel Outage • Change Password

Each Outage option will be discussed in further detail in the following sections.


Request Outage Contractors and Project Managers have the ability to create, or initiate an Outage. To do this, select the option Request New Outage. The request page looks like the following:

Figure 6: Request New Outage There is a large amount of information that is collected when creating an Outage. Besides pages being password protected, each account also has specific rights to which fields it may enter data; therefore, some fields may be present under one account, whereas it may not be under another. For example, an account for a contractor would not have the ability to select the different groups necessary to approve an outage, where an account with escalated privileges would. The system will assign an Outage Number to the new Outage. The Project Number field must be selected from either the Capital Projects drop-down list or from the Other Cost Centers drop-down list, which also includes University numbers. If the particular project or cost center is not in the drop-down, please contact an Outage Administrator.


In the Contact Information section, you must select a Project Manager from the drop-down list. The PM’s phone and email address will automatically be populated. Please fill in as much information as you can in regards the contractor, sub, and foreman when entering the Contact Information. The red asterisks (*) indicate required information to submit the outage. The next section involves the clients that only the project managers have. See the details later under Project Manager Approval. The next section is the Outage Date and Time Information. You may manually type in the beginning and end date of the Outage, or you may use the calendar feature to select a date. To use the calendar, click on the icon. This will bring up a pop-up window that looks like the following:

Figure 7: Calendar Pop-up Window In the calendar view, the current day will be highlighted with light grey and any weekend days will be in dark grey. If you wish to move to the previous or next month, you may use the month icon located at the top left and right. Clicking on any day will result in that day being entered as the date on the outage form. Please note that though the times default to 7:30 AM and 3:00 PM, they may be changed. However, you must enter the time in the format HH:MM AM/PM. The 24HR? checkbox can be used to default the start and end times to 12:00 AM and 11:59 PM respectively. Separate outages must be submitted if the outage is both on the weekend and weekday. Click the Weekend Outage checkbox for only the weekend outage. When selecting the Building(s) in the Work Area Information section, please note that it is possible to select more than one building by using the Control key on the keyboard. The same holds true for the Floor(s). The minus sign indicates floors below the 1st or ground floor. The Affected Area section differs from the Work Area section where impairment on a building system may affect a much larger area than the work area. If the affected area is uncertain select the Required Shop Investigation for the staff to confirm.


Include all clarifications and questions in the Contractor/Project Manager Comments box. This information is critical for others to understand the scope of the outage. After all fields have been entered, click the Submit Outage button at the bottom of the page. If the dates chosen have the potential to cause an emergency outage, a warning will be displayed as shown in the following figure:

Figure 8: Emergency Warning If Yes is chosen, the outage will continue to the project manager. If No is chosen, you are given the opportunity to change the dates. Then click the Submit Outage button again.


Modify Outage A Contractor can only submit a modification up to the time the Project Manager approves it. The Outage Modification screen is similar to that of the Request Outage screen. The first difference you will encounter is when you click on the option Modify Outage, rather Tha being taken directly to the entry from, you are taken to the following screen:

Figure 9: Outage Selection Criteria Since the Outage already exists, it is necessary to select Outage Modify. On this screen, non-cancelled and incomplete Outages are loaded into the drop-down box that says Select an Outage. If the Outage Number is unknown, the filters may be used to reduce the number of Outages that are loaded into this drop-down box. The Select an Outage drop-down box will now only contain Outages that meet the criteria selected. It is possible to use one or all four filter criteria, which are a Building, Project Manager, Project Number, or Date.


After an Outage is selected, a form that looks like the Request Outage form will be seen, but the fields will already be populated. An example can be seen here:

Figure 10: Outage Modification Form


After all modifications have been made, click the link Click Here to the Outage Information Request page shown below.

Figure 11: Link to Outage Information Request and Project Manager Approval Once on the Outage Information Request page, select the participants you want to receive this modification. By default, the From address will be the email address associated with the currently logged-on user. Each party associated with the Outage will be listed under the To field. For each person who is to receive the email, the checkbox must be clicked. If an email should be sent to everyone, the Select All button can be clicked. The Subject is defaulted to “Information Request for Outage#” and then the Outage number. The Body of the email will consists of all current PM/Contractor comments as well as all current Staff Comments. Additional comments can be entered in the corresponding textboxes. These comments will then be saved with the outage. Use the information request procedure to respond to an information request you have received. Click the Send Message button at the bottom of the page.

Request for

Click here to print a hot work permit.


Figure 12: Outage Information Request You will automatically return to the Outage Modification Form where you click on the Update Outage button at the bottom of the page. The Reset Form button located at the bottom of the page can be used to reset the form back to the state where it began, that is, before any modifications were made. Please note that this will reset the whole form, not just one field.


Approve Outage There are a few different levels of approval when dealing with Outages. The first is the Project Manager approval. This approval occurs after the Outage is created by the Contractor. Another type of approval is the Shop approval. Each shop assigned to an Outage is responsible for approving the Outage. Clients must also approve the Outage before it can begin. Lastly, there are approvals from Health, Safety, and Environment, as well as approval from the Construction Safety Coordinator. Approvers may find they do not have enough information to approve the Outage. Therefore they would use the information request page to gather that information. This topic is discussed around the Figures 11 and 12.

Project Manager Approval After the Contractor submits the Outage, the Project Manager (PM) will be notified by email. It is then the responsibility of the PM to review the information entered by the Contractor and approve the Outage. The PM will choose the option Approve and Modify Outage located under the Project Manager heading on the Outage homepage. This is shown in Figure 11. The PM Approved By field will be automatically populated with the name of the user who is currently logged in. The date will also be automatically populated with today’s date and time. To approve the Outage, select Yes and then click Update Outage button at the bottom of the page. If the selected dates will cause the outage to become and emergency, a warning is displayed at the bottom of the form as shown in Figure 8. If Yes is chosen, the emergency outage routine will be trigger, which begins with an email to the Director of Engineering to approve the Outage. Only after this explicit approval occurs, will the Outage approval process be able to continue. If No is chosen, you are given the opportunity to change the dates. Client Approval The Project Manager must fill out the Client portion, which is located in the Contact Information section of the Request New Outage or Modify Outage pages. First, select the Client’s role in the right part of the section. If the Clients are to approve, be copied, click the Add/Modify Clients link on the left portion of the section. On this new page, click the Add New Client button. Press the Outage Clients drop-down list to select the clients. Now, click the Add button and the clients will appear in a list. Click the Delete button if you want to delete any of the selected Clients. If the Client doesn’t appear in the drop-down list, then click the Close button and use the information request link and put the missing Client’s name, phone, and email address in the Comment Box and select the Outage Administrators to receive, register, and add these clients to the Outage. Coinciding with the Shop Approval is the Client Approval. In order to approve the Outage as a client, click on the Approval Outage link found under the Clients heading on the homepage. After logging in, a list of available Outages for that particular client will be available in a drop down list.


After selecting the appropriate Outage, the following screen will be seen:

Figure 13: Client Approval Screen To approve the Outage, simply click the checkbox and then press the Submit button.

Shop Approval

After the Project Manager approves the Outage, an Outage Administrator is responsible for assigning the different shops or groups to approve an Outage. Once this is done, each shop will be notified via email that they need to approve the Outage. To perform this action, click on Shop on the Outage homepage and click on Approve Outage. A screen to select the outage will be seen; however, there is a filter already applied that only allows the user to select an Outage for which his or her shop must approve. Using the process described earlier, select the Outage that needs to be approved.


The next screen will display in a read-only format the information that has been entered about the Outage. The user will, however, have the ability to modify a few fields such as Affected Areas, Interim Life Safety Measures, and Staff Comments. The actual approval of the Outage occurs at the bottom of this screen. The name of the currently logged-on user will automatically populate the Approved By field. Also, the date will also automatically be populated. It is the responsibility of the user to check either Yes or ask for information in the staff comments box. Choosing Yes will approve this particular shop’s portion of the Outage. A screenshot of the approval can be seen below.

Figure 14: Shop Approval Screen

Construction Safety Coordinator and Health, Safety and Environment Approval Once all the clients and shops have approved the Outage, it is ready to receive final approval. Both the Construction Safety Coordinator (CSC) and Health, Safety and Environment (HSE) approve the Outage. To approve the Outage, select either the Outage Administrator or Health, Safety and Environment tab on the page and click on the option Modify Outage and choose Yes , and then click Submit at the bottom of the page. The By and Date fields will automatically be populated with the appropriate data.


System Restoration If the Outage impairs a Fire Suppression System or Fire Alarm System, then these systems must be restored after the Outage is completed. This happens through the Restoration option, which can be found under the Shops heading on the Outage homepage. As with most options, clicking on this option will display the Outage Selection Criteria screen. Once the user selects an Outage, information for that Outage will be displayed. At the bottom of the screen, there is a location where the user can choose if all systems have been restored. This can be seen below.

Figure 15: System Restoration Routine To show that all systems have been restored, select Yes, and then click Submit.


Request Outage Extension It is sometimes necessary to request an extension for an Outage if it is running behind, or if unforeseen problems arise, also to start an Outage earlier than originally approved. Only Outages that are 24 hours or more away from expiring may be extended through this process. The 24 hour period is counted from the start time of the last day. If the Outage is within 24 hours or less away from expiring, then a new Outage must be submitted through the regular process. For those Outages that are eligible to be extended, click the Request Outage Extension link on the Outage homepage. This will pull up a screen similar to the modify Outage screen. Fields will be pre-filled with the information from the original Outage. The difference with this option is when the extension is submitted, a new Outage number is assigned and the Outage is put into the Workflow to be approved.

Figure 16: Outage Extensions The important part to notice on an extension is that the original start and end dates are shown in read-only format. The new start date must be greater than or less than the original date in order for the outage to be accepted.


Cancel Outage If an Outage has been entered in error, or if there is no longer a need for an entered Outage, then it can be canceled. To perform this action, select the option Cancel Outage from the Outage homepage. After selecting an Outage from the Outage Selection Criteria screen, the user will see the following:

Figure 17: Cancel Outage Screen This screen asks the user to confirm cancellation of the Outage. If Yes is chosen, the Outage will be marked cancelled and all parties associated with the Outage up to the point it is cancelled will be notified that it was cancelled. Always put why it is cancelled in comment box provided.


View and Print Outage Viewing and Printing Outages are options available to any user with an account. To view an Outage, select the option All Users, then View/Print Outage on the Outage homepage. After selecting an Outage from the drop-down box, a read-only copy of the outage will be displayed.

Figure 18: View and Print Outage

Click here to print a Hot Work Permit from the Outage Modification screen

Click here to print a Hot Work Permit.


Status Report The Status Report is used to look at the status of all current, cancelled and expired outages. Select All Users from the Outage Home Page, and then click on Status Report. A screenshot of the Status Report Selection criteria can be seen below.

Figure 19: Status Report Selection Criteria


To find the status of a specific outage you can enter its outage number or use the series of filters to refine the list of outage(s) desired. Click the Filter button and view the following:

Figure 20: Status Report The report shows which groups have approved the Outage and which have not. The Status Report may also be sorted by any heading that is underlined such as Date Submitted or Start Date.


Add/View Attachments Attachments can be any electronic document that supports the Outage. In order to add or view an attachment, click on the Add/View Attachments link on the Outage homepage after selecting the category (Contractor, Project Manager, Client, Shops, etc.) desired. Next, select the Outage that you would like to attach documents to. You will then be taken to the following screen:

Figure 21: Add/View Attachments Screen To add an attachment, click on the Browse button. You will see a list of files on your local computer. Select the file that you wish and click Open. Next, enter a description of the file you are uploading in the File Description textbox. Lastly, click the Upload button. This will actually save the file on the server. After attachments have been uploaded, people will then be able to view them. To view attachments that have already been associated with an Outage, click on any link under the Available Attachments heading in the Outage page. This will bring display the attached file.


Other Options Print Hot Work Permit Hot Work Permits are only required by some Outages, so if one is necessary, click on the option Print Hot Work Permit on the Outage homepage. Hot Work Permits can also be printed from the Outage Modification on Figure 11 or View and Print Outage Figure 18. Change Password Each user has the ability to change his or her password by clicking the link Change Password. The new password must be entered and confirmed in the textboxes, then click Change Password.

Email Notifications System generated emails are at the heart of the Online Outage System workflow. Emails are used to notify the next person or persons in the workflow that the Outage is awaiting approval. The following table describes actions that trigger emails to be sent, and also who they are sent to:

Action Email Recipient(s) Outage created by Contractor Project Manager selected by Contractor when Outage is

created Project Manager approval Outage Administrator(s) Shops and Clients assigned Each shop and client that is been assigned to the Outage All Shops and Clients approved Outage Administrator (CSC) and Health, Safety, and

Environment (HSE) Final Approval (CSC and HSE) All parties involved with Outage System Restored CSC and HSE Outage Cancelled All parties involved with Outage Outage Information Request by PM Contractor Outage Rejected by CSC All parties involved with Outage Outage Information Request by Group Email to Outage Administrators Emergency Facilities Director

Figure 22: Email Notification Matrix


THE JOHNS HOPKINS INSTITUTIONS

HEALTH, SAFETY AND ENVIRONMENT

EXTENSION 5-5918

CUTTING-WELDING HOT WORK PERMIT

IMPORTANT: PRECAUTIONS ON REVERSE SIDE MUST BE FOLLOWED

Date: 4/8/2010

Building: Meyer

Floor: 005

This permit expires: 4/30/2010

If fire occurs, PULL FIRE ALARM BOX AND DIAL 5-4444.

Approved by: Paul Matuska on 3/31/2010

DANGER PREVENT FIRES

DO NOT CUT, WELD, OR USE OTHER OPEN-FLAME OR SPARK-PRODUCING EQUIPMENT UNTIL THE FOLLOWING PRECAUTIONS HAVE BEEN TAKEN. Check each item.

1. The Project location has been examined.

A. Sprinklers, where provided, are in operation and will not be taken out of service until this work has been completed.

B. B. There is no flammable lint, dust, vapors, or liquids; or tanks or equipment which previously contained such materials.

C. This work will be confined to the area or equipment specified in the permit.

2. The following safeguards have been provided:

A. Floors and surroundings have been swept clean and wet down.

B. Ample portable extinguishing equipment – hand hose, extinguishers, water pails, etc.

3. If the work involves cutting, welding, or other spark-producing equipment, the following additional safeguards have been provided:

A. All combustibles have been located 40 ft. from the operation and the remainder protected with metal guards or flame proofed covers (not ordinary tarpaulins).

B. All floor and wall openings within 40 ft. of the operations have been covered tightly.

C. Responsible individuals have been assigned to watch for dangerous sparks in area, as well as in floors above and below.

4. Flame or spark-producing equipment to be used has been inspected and found in good repair

5. Arrangements have been made for a patrol of the area, including floors above and below, during any lunch or rest period and for at least one hour after work has been completed.

Figure 23: Hot Work Permit


Reporting There are a couple reports built into the Online Outage System: Status Report and Delinquencies Report.

Status Report The Status Report is discussed earlier in the Outage Modification section.

Delinquency Report The purpose of the Delinquencies Report is to show which Project Managers and Contractors have submitted their Outages with enough lead time. A sample of the Delinquencies Report can be seen in the next figure. The Delinquencies Report is only available to Outage Administrators and is, therefore, password protected. Note for this example the numbers in the “Proceeded Without Approval” column is not accurate.

Figure 24: Delinquency Report


JHH Contractor PC There is a computer, scanner and printer located in the Orleans Garage, Level 5, Trailer A lobby for use. The following are instructions on using the PC. If you have questions or comments, please call any of the three Outage Administrators, which have their phone numbers posted near the computer.

Start-up Procedure The computer is to remain on at all times, but sometimes it gets turned off. In this case, follow the steps to get to the desktop screen:

1. Hit the space bar and wait a minute. The screen saver may be working and the computer isn’t really off. If it doesn’t respond continue to the next step.

2. Press the power button on the front of the computer. 3. Press Ctrl-Alt-Delete. 4. Click OK and the desktop screen should appear.

Once you are on the desktop screen: 1. Click the Internet Explorer icon. 2. Click Design and Construction. 3. Click Outages. 4. Click Facilities Intranet Login. 5. Enter your User Name and Password.

Scanning Procedure 1. Click the red and green OT icon in the lower right corner of the desktop. 2. Place paper into the top tray, face up and click Auto Feed. If you have a bound

document, use the lower tray and click Flatbed. 3. In the Visioneer 9650 box in the lower right hand corner, click Func: F1. 4. Click the Scan All or Scan button. 5. Click Text Document for most applications. 6. Click Scan More Pages or Done at the prompt. 7. Click OK. 8. Enter the outage system doing steps in the Once you are on the desktop screen: above. 9. The scanned file is placed in the PDF Documents folder located on the desktop. 10. Click Contractors. 11. Click Add/View Attachments. 12. Click the outage number. 13. Click Add/View Attachments. 14. Click the Browse Button. 15. Click PDF Documents. 16. Click your specific scanned file name. 17. Click Open. 18. In the File Description box fill in the description of the file. 19. Click Upload.


JHBMC & HCGH Outage Workflow


JHBMC Request for Outage


JHBMC & HCGH Hot Work Permit Environmental Health and Safety

Date___________ Project #_____________ Project Name________________ JHBMC Representative: ___________________ Contractor Name: _____________________ Contractor Representative: _______________________ Phone No: _______________ Building: ___________ Floor______ Room (s) _______ Work to Be Done : __________________________________________ ___________________________________________________________________________________________________________ Beginning Date: ___________ Anticipated End Date: _______________ Start time/End time: ___________________________ Revised Anticipated End Date: ____________________________________ Approval Initials: _________________ Revised Anticipated End Date: ____________________________________ Approval Initials: _________________

Revised Anticipated End Date: ____________________________________ Approval Initials: _________________ Note: Before approving any welding, brazing, cutting, soldering, grinding, or other activities which produce sparks or use flame, the following provisions must be agreed to in accordance of NFPA 51B.

PRECAUTIONSTo Be Completed At Work Site Cutting and welding equipment in good repair Welding Screens in place where necessary Gas Cylinders Secured to prevent from being upset/damaged Within 35 Ft of Work Combustibles relocated away from work site Floors swept clean of combustibles Remaining combustibles protected with fire resistant covers, guards, etc. All wall and floor openings covered Work on Walls or Ceilings Construction is noncombustible and w/o combustible cover Combustibles moved from opposite side of wall Work on Enclosed Equipment (tanks, containers, ducts, dust collectors, etc.) Equipment cleaned of all combustibles Containers purged of flammable vapors Fire Watch To be provided during & 30 minutes after operation To be provided on floors above & below as needed Supplied with CO2 extinguisher Trained in use of equipment & sounding fire alarm Fire System in Drill

Yes No N/A ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Comments: PERMIT APPROVED BY:


Commissioning and Inspection Procedure All construction, renovation and major maintenance work performed on the Hospital Lot and at all other locations, including utility distribution systems, that are the responsibility of Johns Hopkins Health System Facilities Department, shall be commissioned and inspected by technical staff to ensure design, code and system performance compliance of the work being performed. This requirement shall be included in all contracts for such work regardless of which institutional entity is issuing the agreement. The Johns Hopkins Health System Standard Specification, December 2, 2012, includes the following provision concerning commissioning and inspection:

OWNER’S COMMISSIONING “Any test, inspection or similar service to be performed as provided in the Contract Documents, may be, at the Owner’s option, performed by the Owner’s operations and commissioning personnel in addition to any required third party or jurisdictional participation. Cooperate with the Owner’s operations and commissioning personnel in the performance of these inspections, tests, and similar services. Provide reasonable auxiliary services as requested, including but not limited to access to the Work, and incidental labor and facilities necessary to facilitate inspections and tests.

The Contractor shall adhere to the Owner’s published Commissioning and Inspection Procedures that are current at the time of bids for the Project.

If specific elements of the Work have failed their initial and one remedial inspection or test, then the Contractor shall be responsible for the Owner’s costs for further inspections or tests and will be deducted from payments owed the Contractor.”

All contractors shall follow the process provided below and as modified for specific projects: 1) Prime Contractor will be responsible for the management and scheduling of required commissioning and

inspections. Requests to the JHH Facilities Department for commissioning and inspection services will only be honored when received from the Prime Contractor.

2) Each trade contractor (including the Prime Contractor when self-performing work) shall be present for

their respective inspection. Though not required, it is in the Prime Contractor’s own interest to be present for all inspections.

3) Owner inspections will be conducted between the hours of 8:30 AM and 2:30 PM, Monday through

Friday, and will require a forty-eight (48) hour notice period excluding the period between 3:30 PM Friday through 7:30 AM Monday and Hospital holidays. Inspections that must be performed off hours, on weekends or holidays will require a two (2) week notice period.

4) The notice period for inspections that require an outage or that is associated with an outage, will be the

same period as required for the outage as provided in the owner’s CLASP/Outage Program or (2) weeks, whichever is the longer period.


5) If the owner does not provide the inspection service within the time frames stated in these procedures,

provided that the prime contractor is in compliance with these procedures, the work requested for inspection can proceed as if the inspection service had been performed, and the prime contractor shall immediately notify the owner’s Project Manager of actions taken.

At the Owner’s sole discretion, he may elect to inspect such un-inspected work although the procedural time frames have expired. The Owner shall exercise this election no more than forty-eight (48) actual hours (without limitation) after the expiration of the time frame for the original inspection request. The prime contractor shall provide assistance to the owner necessary to perform such inspections including any demolition and restoration.

Upon such inspection, should the work be found in compliance, the Owner shall compensate the prime contractor, in accordance with the terms of the contract between the parties, for documented additional costs and time extension incurred by the prime contractor directly resulting from the delayed inspection. In contrast, should the work be found out of compliance, the Prime Contractor shall bear all costs and there will be no time extension and the process for re-inspection shall be followed.

6) The Prime Contractor shall apply for inspections by using the form at the end of this section. The

applicable commissioning staff, project manager and contractor of the inspection request will then be notified.

7) Inspections and tests will be conducted and the results will be given directly to the contractor

representative within 4 hours, with a copy forwarded to the owner’s project manager. Copies of acceptable test results shall be included with applicable operation and maintenance manuals to be provided in accordance with the contract between Owner and Prime Contractor.

8) When an inspection or test fails, corrections shall be made and re-inspected. This will require a new request for inspection. The scope of re-inspection or retesting shall apply only to those types that failed. When an inspection or test is determined by the Owner’s commissioning staff to be unacceptable and the prime contractor objects, citing that it is not within his contractual obligations, prior to commencing corrections, the Prime Contractor shall notify the Owner’s Project Manager of this objection in accordance with provisions provided in the contract documents. Resolution and direction will be provided under the terms of the contract between the parties. Otherwise, the findings of the Owner’s commissioning staff are final and the Prime Contractor will make timely corrections.


9) The following are various tests and inspections that must be performed on every project. This list does

not preclude any inspections or tests being performed that are required by the contract between Owner and Prime Contractor. Similarly, this does not preclude any inspection or test required by statute. Conversely, requirements of a contract or statute do not preclude this list of inspections and tests from being performed. DECOMMISSIONING INSPECTIONS. Prior to the start of salvaging and demolition there will be

an inspection to select salvaged items, locate termination of services and deem all other items ready for salvage and demolition and identify items to be removed by the vacating tenant.

INFECTION CONTROL INSPECTIONS. Prior to the start and any new phase of construction, the

Commissioning Staff must verify that all infection control measures are in place. An inspection is also required at the completion of the project to confirm the cleanliness of the site. Refer to the “Infection Control Policy” in this manual for details.

POST DEMOLITION INSPECTIONS. This is initiated when the Prime Contractor has uncovered

all concealed areas and completed removal of all utilities. Commissioners, Project Managers and Designers are invited to address hidden conditions, allow the Owner’s engineering forces to repair landlord conditions outside the scope of the project and verify the completion of the demolition. The Commissioning staff will include items outside the scope of the Prime Contractor’s scope of work. The Owner’s Project Manager will identify out of scope items and transmit the inspection report to the Prime Contractor, the Engineering Senior Director and the Commissioning Administrator. The Owner’s Project Manager must specify the time period available for the Owner’s forces to correct deficiencies.

CLOSE-IN INSPECTIONS. Prior to the concealment of any element of construction, a close-in

inspection will be required. The Prime Contractor must identify all trades affected by the proposed concealment. Any testing or any element requiring an outage that needs to be performed prior to a Close-in Inspection shall have been successfully tested and/or inspected prior to making a request for Close-in Inspection. The Commissioners must be satisfied with the condition of the work before permission to close-in can occur. A designated Commissioner will give the final approval for all Commissioners.

SUBSTANTIAL COMPLETION INSPECTIONS. Prior to any occupancy or any use of any element

of the work, the Prime Contractor shall request a SUBSTANTIAL COMPLETION INSPECTION citing all commissioning trades that have, or should have, participated during the performance of the work. This is the punch list and inspection provisions that may be required in the contract between the parties.

FINAL INSPECTIONS. When the Prime Contractor has fully completed all contractual obligations,

he will schedule a FINAL INSPECTION to release him from further obligation. The SUBSTANTIAL COMPLETION punch list must be fully completed at this time.

SPECIFIC INSPECTIONS AND TESTS. In addition to the foregoing, the following lists the

minimum inspections and tests required for all construction, renovation and major maintenance work


MECHANICAL SYSTEMS Post demolition/pre-installation Cleaning and flushing of piped systems Cleaning ductwork Sterilization of domestic water piping Pressure testing of:

Domestic water Sanitary Storm Sprinkler Natural gas Steam Chilled water Condensate Condenser water Refrigeration Medical and laboratory gases Ductwork

Sprinkler operation: Alarm systems Drainage facilities Inspector test

Medical gas certification Insulation material and workmanship HVAC operation:

Automatic temperature control Smoke dampers M.O.D. dampers Pumps Chillers Cooling Towers Boilers Air handling equipment Training and education


ELECTRICAL SYSTEMS Low Voltage Systems

Test and demonstrate fire alarm systems Test and demonstrate nurse call systems Test speaker systems Demonstrate security systems Test communication cable Demonstrate intercom and paging systems Test and demonstrate variable frequency controllers Test and/or demonstrate specialty systems

Service voltage systems Test medium voltage switchgear Test and demonstrate transfer switches Test and demonstrate enclosed controllers Test and demonstrate motor control centers Test and certify isolated grounding Inspect wiring devices Test receptacles Test medium voltage transformers Test and demonstrate generators Conduct feeder megger reports Inspect branch circuits Demonstrate lights and lighting systems Test and/or demonstrate specialty systems


Inspection Request Form

JHH or JHBMC HGCH FacilitiesFront_Desk@

exchange.johnshopkins.edu Project Manager

FAX (410) 502-6924 Hospital Project Manager __________________________________________________________ Project Title _____________________________________________________________________ Hospital Project Number ___________________________________________________________ Contractor Contact Name & Phone # _________________________________________________ Contractor Email Address __________________________________________________________ Date, Time ______________________________________________________________________ Location ________________________________________________________________________ Type of Inspection Commissioners Required

Decommissioning Landscaping Elevator/Pneumatic Tube Infection Control Architectural Fire Alarm/Sprinkler/Clock Post Demolition Carpentry/Architectural Specialties Plumbing/Med Gases Wall Closure Firestopping HVAC Ceiling Closure Roofing ATC Substantial Completion Doors Electrical Final Automatic Roll-up/Revolving Doors Communication/Security Other (provide description) Glazing Other (provide description) Test ________________ Painting

Comments/Description: