clasp manual 2014 - hopkins medicine · 2013. 10. 25. · clasp manual 2014 . coordinated life...

CLASP MANUAL 2014

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

Table of Contents

Emergency Codes

JHH........................................................................... 1 JHBMC………………………………………………..…. 1 HCGH……………………………………………………. 1

Evacuation Plans…………………………………………… 2 JHH………………………………………………………. 2 JHBMC…………………………………………………… 3 HCGH……………………………………………………. 4

Safety Fact Sheet………………………………………….. 5 JHH………………………………………………………. 5 JHBMC…………………………………………………… 6 HCGH………………………………………………….…. 7 Lista de Datos de Seguridad de JHH……………….. 8

General Policy 9 Life Safety and Other Safety Compromises……………... 16 Interim Life Safety Measures (ILSM)………………………. 17 Life Safety Criteria Guide …………………………….……. 19 Project Risk Assessment ………………………………….. 20 Facilities Engineering Supervisor Worksheet …………… 25 F D & C Construction Site PPE Policy……………………. 26 Hazard Communication……………………………………… 27 Bloodborne Pathogens……………………………………… 28 Notice of Asbestos Abatement……………………………. 29 CLASP Surveillance…………………………………………. 30

Procedures ……………………………………………… 30 Checklist ………………………………………………….. 31

Ceiling Permit………………………………………………… 32 Procedures……………………………………………….. 32 Form………………………………………………………. 33

Infection Control……………………………………………... 34 Policy……………………………………………………… 34 Procedures……………………………………………….. 36 Training…………………………………………………… 48 Checklist …………………………………………………. 50 Construction Permit……………………………………… 51

Outages ……………………………………………………… 52 Table of Contents……………………………………….. 53 JHH Online Outage System…………………………….. 54 JHBMC & HCGH Outage Workflow …………………… 79 JHBMC Request for Outage……………………………. 80 JHBMC & HCGH Hot Work Permit…………………….. 81

JHH Contractor PC …………………………………………... 82 Commissioning and Inspection…………………………….. 83

Procedure ………………………………………………. 83 Inspection Request Form………………………………... 88

Acronym List

ASC Administrative Services Center BCFD Baltimore City Fire Department BMO Bayview Medical Office Building CCU Critical Care Unit CLASP Coordinated Life Safety Assurance Program CMSC Children's Medical and Surgical Center COMAR Code of Maryland Regulations CSC Construction Safety Coordinator CVDL Cardiovascular Diagnostic Lab EHS Office of Environment, Health and Safety - JHBMC FES Facilities Engineering Supervisor - JHH & JHBMC HBV Hepatitis B Virus HCV Hepatitis C Virus HEIC Office of Healthcare Epidemiology and Infection Control - JHH HEPA High-Efficiency Particulate Air (filter) HIPAA Health Insurance Portability and Accountability Act HIPOP Hematology Inpatient/Outpatient HIV Human Immunodeficiency Virus HSE Office of Health, Safety and Environment - JHH & HCGH HVACR Heating Ventilating Air Conditioning Refrigeration IC Office of Infection Control - JHBMC & HCGH ILSM Interim Life Safety Measures IPOP Inpatient/Outpatient JHBMC Johns Hopkins Bayview Medical Center Campus JHH Johns Hopkins Hospital JHHS Johns Hopkins Health System JHOPC Outpatient Center LOTO Lockout/Tagout LSC Life Safety Compromise MFL Mason F. Lord Building MOSH Maryland Occupational Safety and Health MRI Magnetic Resonance Imaging Building NESHAP National Emissions Standards for Hazardous Air Pollutants OR Operating Room OSHA Occupational Safety and Health Administration PACU Post Anesthesia Care Unit PM Project Manager POM HCGH - Plant Operations Manager PPE Personal Protective Equipment SDS Safety Data Sheets TS Temporary Safeguards WAGD Waste Anesthesia Gas Disposal WBS Work Breakdown Structure

http://www.thefreedictionary.com/Critical+Care+Unithttp://medical-dictionary.thefreedictionary.com/Hepatitis+B+Virushttp://medical-dictionary.thefreedictionary.com/Hepatitis+B+Virushttp://encyclopedia.thefreedictionary.com/Post+Anesthesia+Care+Unit

CLASP Manual 2014 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 JHHS; 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. You must have two floors separating you from the floor that is in alarm.

Building Levels classified as Business Occupancy Billings Entire Building Blalock Entire Building 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, 5, 6, 7, 8, 9, 10, 11, 12, 13 CMSC Patient Wing Sub-Sub-Basement, Sub-Basement, 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Halsted/Osler 6, 7, 9, 10 Hurd Hall Entire Building JHOPC Broadway Wing Entire Building JHOPC McElderry Wing 1, 2, 4, 5, 6, 7, 8 Marburg* Basement, 1, 4, 5 Maumenee Entire Building Meyer Lab Wing Entire Building Meyer Patient Wing Sub-Basement, B, 1, 2, 10 MRI None Nelson/Harvey Sub-Basement, 1, 2 Park Entire Building 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 Entire Building Woods Entire Building Zayed/Bloomberg B2, B1, 6, 7, 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, 3, 5, 6 AA 02, 1 Alpha Commons 1, 2, 3, 4 ASC 2, 3 BMO 02, 01, 1, 2, 3 Francis Scott Key Pavilion 02, 01, 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. 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.

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.

HAZARDOUS CHEMICALS • Safety Data Sheets (SDS) describe the hazards of

a chemical. SDS are available from the Health, Safety and Environment.

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

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

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.

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.

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. MRI (magnetic resonance imaging) ● You must be screened before entering the room. ● The MRI is always on. 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 • Safety Data Sheets (SDS) describe the

hazards of a chemical. SDS 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.

CEILING PERMIT Ceiling access outside a construction site

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.

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 • Safety Data Sheets (SDS) describe the hazards of a

chemical. SDS are available from the Environment, Health and Safety Department.


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

CEILING PERMIT Ceiling access outside a construction site 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. NO SMOKING • Smoking is permitted only in designated areas. 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.


Lista de Datos de Seguridad de JHH

SEGURIDAD DE INCENDIOS • En caso de humo/incendio: 1. Remover pacientes del cuarto en llamas. 2. Cerrar puertas para confinar el fuego o humo. 3. Hale la alarma que está en la caja. 4. Llame al (410) 955-4444. • Una vez escuchada la alarma del edificio: 1. Evacuar, excepto en la unidad de pacientes

internados, en cual el departamento de bomberos o seguridad deberá indicarle si evacuar los pacientes, o retirarse.

2. No use elevadores. Use la salida más cercana. • Mantenga los pasillos libres, removiendo todos

sus materiales de los pasillos y las gradas o escalones.

• Puertas nunca deberán estar trabadas abiertas y desatendidas.

NO FUMAR • Fumar está permitido solamente en áreas

designadas. Cualquier contratista o empleado que sea encontrado fumando fuera de estas áreas, será removido del hospital permanentemente.

CONTROL DE INFECCIÓN • Mantenga en el sitio un repaso

pre-construcción del control de infección. • Presentar medidas de control de infección

antes de: 1. Empezar la construcción 2. Cambio de tipo o limite de trabajo 3. Remover medidas de control de infección

PERMISO CIELO RASO O TECHO Acceso al cielo raso o techo fuera del sitio de

construcción requiere un permiso de CSC/FES.

QUIMICOS PELIGROSOS • Hojas de Información de Material de Seguridad

(MSDS) describe el peligro de los químicos. MSDS están disponibles del Departamento de Ambiente, Salud y Seguridad.

• Se requiere que el Contratista General tenga una lista de los químicos y MSDS en el sitio.

• En derrame, aísle el área y notifique a su Supervisor y/o llame al (410) 955-4444.

HERIDA • Si usted se rocía con sangre o líquidos de del

cuerpo o tiene una herida causada por un pinchazo de una aguja, inmediatamente limpie el área, y después llame al (410) 955-STIX(7849). • Notifique a su Supervisor y obtenga atención

medica por cualquier otra herida relacionada con el trabajo: 1. Llame a emergencia al (410) 955-4444 cuando

se encuentre adentro de JHH. 2. Llame a 911 cuando se encuentre afuera de

JHH 3. Dirigirse al Departamento de Emergencia en

1800 Orleans Street. 4. Mandar reportes al Supervisor y al Gerente de

las Instalaciones del Proyecto. APAGONES Servicios y deterioramientos que ponen la

seguridad y la vida en peligro requieren la aprobación del sistema de apagón.

Problemas de electricidad, agua o estructurales de 8 AM a 4 pm llamar al (410) 955-8300 después de esas horas llamar (410) 955-5770. PRIVACIDAD DEL PACIENTE • Nunca entrar al cuarto de un paciente sin

compañía o solo. • No preguntar ni compartir información del

paciente • Evitar situaciones donde la información del

paciente es predominante. PROBLEMAS DE SEGURIDAD Llamar al (410) 955-5585. Siempre muestre su identificación. COMISIONANDO • Todo trabajo, sea a través de las Instalaciones o

no está sujeto al Encargado de las Instalaciones. • Cumpla con los procedimientos e inspecciones. CONTACTOS DE SEGURIDAD GENERALES • Reportar preocupaciones de seguridad: 1. Al Supervisor/Jefe 2. Coordinador de Seguridad de las Instalaciones

de la Construcción (410) 955-5900 3. Salud, Seguridad y Ambiente (410) 955-5918


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 with the name of the company’s trainer and the names and last four digits of the trainee(s)’ social security number(s). Once the letter has been received and the flu vaccinations verified, the CSC will 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 an accessible, fully charged, currently tested and certified 10 lb. ABC fire extinguisher for every 5,000 square feet of area under construction. Fire extinguishers must be wall or stand mounted with in full view. One fire extinguisher is to be placed near the entrance to the site. Under double surveillance, the area per extinguishers is 2,500 square feet. Contractors must be OSHA trained and currently 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 e. Infection Control Permit

f. Surveillance checklist g. Safety Fact Sheet h. Trash route i. CLASP 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. At JHH, 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) Each 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

local

fire d

epart

ment.

1 Noti

fy BCF

D. Co

nduct

firew

atch.

2 Post

signs

at alt

ernate

exits.

4 Insp

ect ex

its da

ily.

5 Inst

all te

mp. &

equa

l fire

alarm

& de

tectio

n.

12 In

spect

& test

mon

thly.

6 Add

fire-f

ightin

g equ

ipmen

t.

7 Inst

all sm

oke/f

ire re

sistiv

e barr

iers.

8 Inc

rease

survei

llance

- cons

tructi

on, st

orage

, exca

vatio

n, fie

ld off

ices

9 Con

trol fl

amma

bles &

comb

ustibl

es

- stora

ge, h

ousek

eepin

g & de

bris r

emov

al

10 Ad

dition

al fire

-fighti

ng tra

ining.

11 Ad

d a fir

e drill

/shift/

quart

er.

13 Fir

e safe

ty ed

ucatio

n - b

ldg. d

eficie

ncies,

constr

uction

hazar

ds & t

emp.

measu

res

14 Co

nduc

t com

partm

entat

ion 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 - SDS,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:


F D & C Construction Site PPE Policy (Personal Protective Equipment)

Application 1. Effective as of July 1, 2013

2. All individuals within a construction site regardless of the person’s function

3. All construction sites regardless of its size or task (a room, a portable containment, outside, etc.)

4. Reduction in PPE measures require these restrictions:

A. Only a Senior Director, Director or CSC may deem a reduction in the PPE requirements. B. An announcement will be made when the termination of the use of hard hats, safety glasses

and JHHS Shop safety vests occurs. C. JHHS shops must wear prescribed uniforms of consistent color and markings. D. All other JHHS employees, contractors, inspectors, and visitors must still wear safety vests

with company affiliation. E. No other project wide feature of the PPE Policy will be relaxed.

1. All other safety gear must be worn. 2. Radios and personal entertainment devices remains prohibited.

5. Increase in PPE

A. Tasks exceeding the project-wide precautions must work within a barricade with appropriate PPE.

B. If a task requires additional PPE and proper barricading cannot be established, then the additional PPE must be applied project-wide.

C. Notify your supervisor if there is any uncertainty as to the level of protective measures required.

6. This policy reflects the minimum requirements.

Mandatory 1. Class A Hard Hat

Hard hat must be without cracks, chips or looking dried out.

2. Safety Glasses Safety glasses must be clear enough to see through them without excessive scratches and grime.

3. Safety Vest with company affiliation with letters printed a minimum of 3/8”.

4. Leather Footwear

No soft soles, high heels or open toed shoes. Shoes or boots must be sturdy enough to withstand rough and or uneven surfaces.

5. Long pants

No shorts, capris, dresses or skirts.

6. No loose clothing nor accessories No scarves and wallet chains. Hair longer than shoulder length, non-breakaway lanyards for IDs and ties must be tucked in.

7. Radios, ear buds nor ear phones are not permitted. Cell phones are to be used for business calls only.


Conditional - Special conditions require the appropriate PPE. 1. Ear plugs or headphones

Exposure to loud noise

2. Dust masks Exposure to dusty or high chemically concentrated air

3. Gloves suited to the application

Protection from cuts, bruises chemical irritation, extreme hot or cold, or electrical shock

4. Goggles Eye protection from flying particles (sparks or dust), chemical or biological splash, or other potential damage to the eyes

5. Harness

Fall protection risk

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 —Safety Data Sheets (SDSs) and labels.

Safety Data Sheets (SDS) - are documents that contain all pertinent information about a chemical. All SDSs 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 SDS 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 SDS.

Labels - every container needs to have a label that is written correctly and clearly.

Personal Protective Equipment (PPE) —SDSs 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 C

ateg

ory

Location

Project Manager Date

Inspector

Zone: ____

Contractor Time AM PM

Meets Standards? Y-N-NA Description

Life

Saf

ety

1 Exits clear and unlocked?

2 Exits & walkways clearly marked and well lighted?

3 Fire doors not blocked open?

4 Doors in good working order?

5 Extinguisher present and accessible?

6 Sprinkler heads not blocked?

7 No signs of smoking?

8 Combustible trash or materials minimized?

9 Fire walls and slabs not compromised?

10

Detector heads not bagged?

Secu

rity

11

Proper signage at construction entrance?

12

Construction entrance locked?

13

Mechanical/electrical rooms locked?

Inju

ry 1

4 Compressed gas cylinders secured?

15

Electric panel covers in place?

Infe

ctio

n C

ontr

ol

16 Barrier dust tight?

17 Negative air sufficient?

18 Interior clean?

19

Walkoff mats present and clean?

20 No standing water?

SDS 2

1 Haz. chemicals labeled & stored properly?

Additional Comments

Rev. 10/2013


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 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.”


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

Level 1 Low Risk

Level 2 Medium Risk

Level 3 High Risk

Level 4 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 Proje