CLASP MANUAL 2015 - Facilities Department

Transcription

CLASP MANUAL 2015
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
JHH………………………………………………. 2
JHBMC…………………………………………… 3
HCGH……………………………………………. 4
Safety Fact Sheet
JHH………………………………………………. 5
Lista de Datos de Seguridad de JHH………… 6
JHBMC…………………………………………... 7
HCGH……………………………………………. 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…………………………… 28
HSE Hazard Communication Program………...... 29
Bloodborne Pathogens……………………………. 39
Notice of Asbestos Abatement………………….... 40
CLASP Surveillance……………………………….. 41
Ceiling Permit………………………………………. 43
Infection Control……………………………………. 45
JHH & JHBMC Online Outage System rev 2.7…. 63
Table of Contents……………………………… 64
HCGH
Outage Workflow ……………………………. 90
Request for Outage……………………………. 91
Hot Work Permit……………………………….. 92
JHH Contractor PC ………………………………... 93
JH Spacebook System Tutorial…………………... 94
Commissioning and Inspection…………………... 97
Acronym List
ASC
BCFD
BMO
CCU
CLASP
CMSC
COMAR
CSC
CVDL
EHS
FES
HBV
HCV
HEIC
HEPA
HIPAA
HIPOP
HIV
HSE
HVACR
IC
ILSM
IPOP
JHBMC
JHH
JHHS
JHOPC
LOTO
LSC
MFL
MOSH
MRI
NESHAP
OR
OSHA
PACU
PM
POM
PPE
SDS
TS
WAGD
WBS
Administrative Services Center
Baltimore City Fire Department
Bayview Medical Office Building
Critical Care Unit
Coordinated Life Safety Assurance Program
Children's Medical and Surgical Center
Code of Maryland Regulations
Construction Safety Coordinator
Cardiovascular Diagnostic Lab
Office of Environment, Health and Safety - JHBMC
Facilities Engineering Supervisor - JHH & JHBMC
Hepatitis B Virus
Hepatitis C Virus
Office of Healthcare Epidemiology and Infection Control - JHH
High-Efficiency Particulate Air (filter)
Health Insurance Portability and Accountability Act
Hematology Inpatient/Outpatient
Human Immunodeficiency Virus
Office of Health, Safety and Environment - JHH & HCGH
Heating Ventilating Air Conditioning Refrigeration
Office of Infection Control - JHBMC & HCGH
Interim Life Safety Measures
Inpatient/Outpatient
Johns Hopkins Bayview Medical Center Campus
Johns Hopkins Hospital
Johns Hopkins Health System
Outpatient Center
Lockout/Tagout
Life Safety Compromise
Mason F. Lord Building
Maryland Occupational Safety and Health
Magnetic Resonance Imaging Building
National Emissions Standards for Hazardous Air Pollutants
Operating Room
Occupational Safety and Health Administration
Post Anesthesia Care Unit
Project Manager
HCGH - Plant Operations Manager
Personal Protective Equipment
Safety Data Sheets
Temporary Safeguards
Waste Anesthesia Gas Disposal
Work Breakdown Structure
JHH Emergency Management Disaster Codes
CODE
Blue
Gold
Red
Silver
Yellow Bio
Yellow Chemical
Yellow ED
DESCRIPTION
Cardiac/Respiratory Arrest
Bomb Threat
Fire
Shooter/Hostage
Bioterrorism
Chemical
Patient influx of up to ten patients
from a single event
Patient influx of more than ten
patients from a single event
Radiation
Yellow Hospital
Yellow Radiation
CALL
(410) 955-4444
(410) 955-5585
(410) 955-4444
(410) 955-5585
(410) 955-4444
(410) 955-4444
(410) 955-4444
(410) 955-4444
(410) 955-4444
JHBMC Emergency Response Codes
CODE
Blue
Gold
Gray
Green
Orange
Pink
Purple
Red
Silver
Yellow
DESCRIPTION
Bomb Threat
Elopement
Combative Person
Hazardous Material Spill
Infant or Child Abduction
Security Response
Fire
Active Shooter/Weapon/Hostage
Emergency or Disaster
CALL
(410) 550-0222
(410) 550-0333
(410) 550-0333
(410) 550-0333
(410) 550-0222
(410) 550-0333
(410) 550-0333
(410) 550-0222
(410) 550-0333
(410) 550-0222
HCGH Emergency Response Codes
CODE
Blue
Gold
Gray
Green
Orange
Pink
Purple
Red
Silver
Yellow
Alpha Team
Bravo Team
Rapid Response Team
DESCRIPTION
Bomb Threat
Elopement
Combative Person
Hazardous Material Spill
Infant or Child Abduction
Security Response
Fire
Active Shooter/Weapon/Hostage
Emergency or Disaster
Pre-Life threatening Obstetrics
Life threatening Obstetrics
Pre-Cardiac/Respiratory Arrest
CALL
5151*
5151*
(410) 740-7911
(410) 740-7911
5151*
(410) 740-7911
(410) 740-7911
5151*
(410) 740-7911
5151*
5151*
5151*
5151*
*Internal Extension Only
CLASP Manual 2015
Page 1
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
Billings
Blalock
Brady
Carnegie
CMSC Hoffberger Wing
CMSC Patient Wing
Halsted/Osler
Hurd Hall
JHOPC Broadway Wing
JHOPC McElderry Wing
Marburg*
Maumenee
Meyer Lab Wing
Meyer Patient Wing
MRI
Nelson/Harvey
North Energy Plant
Park
Pathology
Phipps
Radiology
David M Rubenstein Child Health
Smith
South Energy Plant
Weinberg
Wilmer
Woods
Zayed/Bloomberg
CLASP Manual 2015
Levels classified as Business Occupancy
Entire Building
Entire Building
Entire Building
Sub-Basement, Basement, 1, 2, 3, 4, 5, 6, 8, 9, 10
Sub-Sub-Basement, Sub-Basement, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13
Sub-Sub-Basement, Sub-Basement, 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
6, 7, 9, 10
Entire Building
Entire Building
1, 2, 4, 5, 6, 7, 8
Basement, 1, 4, 5
Entire Building
Entire Building
Sub-Basement, B, 1, 2, 10
None
Sub-Basement, 1, 2
Entire Building
Entire Building
Entire Building
Entire Building
Sub-Basement, 1
Entire Building
Basement, 2, 3, 4, 5, 6, 7, 8
Entire Building
L-1, Parking & Storage Portions of L-2, L-3
Entire Building
Entire Building
B2, B1, 6, 7, 16, 17
Page 2
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
301 Building
A
AA
Alpha Commons
ASC
BMO
Francis Scott Key Pavilion
John R. Burton Pavilion
MFL East
MFL West
Warehouse
CLASP Manual 2015
Levels classified as Business Occupancy
1, 2, 3, 4
01, 3, 5, 6
02, 1
1, 2, 3, 4
2, 3
02, 01, 1, 2, 3
02, 01,
02
1, 2, 3, 4, 5, 6
1, 2, 3, 4, 5, 6
1, 2
Page 3
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 #
G-03
G-04
G-06
Designation
Business
Industrial
Mixed,
Business &
Industrial
Assembly
1A-01
Business
1 floor Healthcare and Surgery Center - locker rooms, Sterile
Supply, & Receiving
1A-02
Business
1 floor Healthcare and Surgery Center - Breast Health, waiting room,
& Infusion Center
2A-01
3-01
Business
Industrial
2 floor Healthcare and Surgery Center - All
Boiler Room
3A-01
4-01
4-02
5-01
Industrial
Industrial
Industrial
Industrial
3 floor Healthcare and Surgery Center - All
Center building tower - above 3I North
Center building tower - above 3I South
Rooftop mechanical room – Pavilion roof
G-07
Location
South Bldg. Building General Stores, Shipping, & Receiving
Ground floor West bldg., Maintenance & West Plant
Ground floor Pavilion
South Building - Kitchen and cafeteria
st
st
nd
CLASP Manual 2015
rd
Page 4
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.
CLASP Manual 2015
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.
Page 5
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.
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.
QUIMICOS PELIGROSOS
• Hojas de Información de Material de Seguridad
(MSDS) describe el peligro de los químicos.
CONTACTOS DE SEGURIDAD GENERALES
MSDS están disponibles del Departamento de
• Reportar preocupaciones de seguridad:
Ambiente, Salud y Seguridad.
1. Al Supervisor/Jefe
• Se requiere que el Contratista General tenga una
2. Coordinador de Seguridad de las Instalaciones
lista de los químicos y MSDS en el sitio.
de la Construcción (410) 955-5900
• En derrame, aísle el área y notifique a su
3. Salud, Seguridad y Ambiente (410) 955-5918
Supervisor y/o llame al (410) 955-4444.
CLASP Manual 2015
Page 6
JHBMC Safety Fact Sheet
FIRE SAFETY
HAZARDOUS CHEMICALS
• Safety Data Sheets (SDS) describe the
• In case of smoke/fire remember RACE:
hazards of a chemical. SDS are available
Rescue: Remove patients from immediate
from the Environment, Health and Safety
danger.
Department.
Alarm:
Pull the alarm. Call (410)-550-0222.
Contain: Close doors to confine smoke or fire.
Extinguish: Extinguish and prepare to evacuate
• In a spill, close off the area and notify your
patients. PASS: Pull
foreman and/or call (410) 550-0222.
Aim
CEILING PERMIT
Squeeze
 Ceiling access outside a construction site
Sweep
requires a permit from Facilities.
• Evacuate patients if directed.
• Don’t use the elevators. Use the nearest exit.
OUTAGES
• Keep corridors clear by removing your materials
 Utility and life safety system impairments
from the corridors.
require outage approval.
 Electrical, water or structural problems
call from 7 AM to 5 PM call (410) 550NO SMOKING
0260; off hours page (410) 283-0260.
INFECTION CONTROL
 Call (410) 550-0515.
• Have an on-site pre-construction infection control
review.
• Submit inspection of infection control measures
prior to:
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.
CLASP Manual 2015
PATIENT PRIVACY - HIPAA
• 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.
2. Facilities (PM) or Environment, Health
and Safety (EHS) at (410) 550-0228.
Page 7
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.
INFECTION CONTROL
 Call (410) 740-7765.
• Have an on-site pre-construction infection
control review.
• Submit inspection of infection control
measures prior to:
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.
CLASP Manual 2015
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
• Avoid situations where patient information is
prevalent.
NO SMOKING
SECURITY ISSUES
 Call (410) 740-7911
 Always display ID.
COMMISSIONING
• All work is subject to Facilities’ commissioning.
• Comply with commissioning and inspection
procedures.
2. Facilities (PM) or Hospital Operator at 5151.
Page 8
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.
CLASP Manual 2015
Page 9
Policies
A. All contractors and vendors are required to have a temporary identification badge to enhance
security. I. D. badges expire annually on November 30.. 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 during the flu season.
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 company letterhead stating the
name of the company’s trainer and the names and last four digits of the trainee(s)’ social
security number(s). Once this letter has been received along with flu vaccination
confirmations, the CSC will issue the JHMI ID Request Forms allowing 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.
Those renewing their ID must surrender their present one. They still can obtain an ID, but
pay a penalty. Security only allows 10 business days after paying for a new ID to return the
original one for a refund.
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.
CLASP Manual 2015
Page 10
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.
b.
c.
d.
e.
Outages
Emergency telephone numbers
Evacuation plan
Infection Control checklist
Infection Control Permit
CLASP Manual 2015
Page 11
f.
g.
h.
i.
Surveillance checklist
Safety Fact Sheet
Trash route
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 Safety Data Sheets 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 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. The
PM will always invite the CSC to this meeting.
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.
CLASP Manual 2015
Page 12
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.
b.
c.
d.
e.
f.
g.
i.
j.
k.
2.
l.
m.
n.
o.
p.
q.
r.
s.
t.
Condenser water
Domestic water
Electric
Elevator
Heating water
HVACR
Natural gas
Nurse call
Pneumatic tube
Twelve (12) workdays (do not count the submission day or the first day of the outage)
for all non-routine outage categories below:
a.
b.
c.
d.
e.
f.
3.
Alarm systems
Asbestos - Non-NESHAP
Compartmentation
Detection systems
Egress
Flammable materials
Noxious materials
Hazardous materials
Storage
Chilled water
Asbestos - NESHAP
Fire suppression
EVAC – blower scavenging
system
Lab air
Lab vacuum
Medical air
g.
h.
i.
j.
k.
l.
Medical vacuum
Nitrogen
Nitrous oxide
Oxygen
Steam
WAGD – waste anesthesia gas
disposal (vacuum pumps)
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.
b.
c.
d.
e.
f.
g.
i.
j.
k.
Alarm systems
Asbestos - Non-NESHAP
Compartmentation
Detection systems
Egress
Flammable materials
Noxious materials
Hazardous materials
Storage
Chilled water
CLASP Manual 2015
Page 13
l.
m.
n.
o.
p.
q.
r.
s.
t.
Condenser water
Domestic water
Electric
Elevator
Heating water
HVACR
Natural gas
Nurse call
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.
b.
c.
d.
e.
f.
g.
Asbestos - NESHAP
Fire suppression
EVAC - blower scavenging system
Lab air
Lab vacuum
Medical air
Medical vacuum
h.
i.
j.
k.
l.
Nitrogen
Nitrous oxide
Oxygen
Steam
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.
CLASP Manual 2015
Page 14
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.
CLASP Manual 2015
Page 15
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
CLASP Manual 2015
Page 16
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.
CLASP Manual 2015
Page 17
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.
CLASP Manual 2015
Page 18
ILSM - Interim Life Safety Measures
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Compartmentation
Significant wall/floor penetration/opening that is:
Smoke rated and a business occupancy.
1 or 2 hr. rated in a business occupancy without a
smoke detector.
In an inpatient compartment without a smoke
Egress
Obstructing/changing exit signage
Narrowing/obstructing exit path
Eliminate exit
Fire Alarm or Sprinkler Impairment
Min. 4 hr. within 24 hr. under 8 hrs. No hot work.
Min. 4 hr. within 24 hr. over 8 hrs. No hot work.
Over 24 hrs. No hot work.
Min. 4 hr. within 24 hr. under 8 hrs. Hot work.
Business occupancy.
Min. 4 hr. within 24 hr. over 8 hrs. Hot work.
Business occupancy.
Over 24 hrs. Hot work. Business occupancy.
Min. 4 hr. within 24 hr. under 8 hrs. Hot work.
Inpatient in same compartment.
Min. 4 hr. within 24 hr. over 8 hrs. Hot work.
Inpatient in same compartment.
Over 24 hrs. Hot work. Inpatient in same
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
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x
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x
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x
x
x
x
x
x
x
x
x
x
x
x
x
x
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x
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x
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x
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x
x
x
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x
x
x
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x
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x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Flammable Materials
Hot Work Outside
x
Note: Provide documentation for these elements of performance.
CLASP Manual 2015
x
x
x
Page 19
x
x
x
Project Risk Assessment
Project
Equipment Only
Evaluation Date
Location(s)
Construction Dates
From
To
WBS/Work Order/Cost Center
Project Manager
Contractor
Description of Work
Category
Life Safety
- Egress
- Compartmentation
- Fire Alarm/Suppression
- Flammables/Combustibles
- Hot Work
Infection Control
- Risk Level/Group #
- Measures
Evaluation
Utility Compromises
Noise, Vibration, Odor,
Dust
Security - Locked sites,
After Hour Notification
Hazardous Materials - SDS,
Labels, PPE, Chemical Spills
Medical Emergencies
- Bloodborne pathogens
Confined Space
Miscellaneous
- Cell Phones
- HIPAA
- Proper Attire
Construction Management Plan Elements
Project Manager ______________________________ Risk Assessment Committee ___________________________
CLASP Manual 2015
Page 20
Project Manager:
Assessment Date:
Life Safety Compromise (LSC)
Interim Life Safety Measure (ILSM)
Additional (ILSM)
for Extended Conditions
Alarm Systems
Compartmentation Training
Confirm Restoration
Client Coordination
Additional Fire Fighting Training
Control Flammable/Combustible Materials
Fire Extinguishers
Fire Safety Training
Fire Watch
Lock out/Tag out
Notify Fire Department
Notify Security
Submit Outage
Compartmentation
Confirm Restoration
Submit Outage
Detection Systems
Confirm Restoration
Fire Extinguishers
Fire Watch
Lock out/Tag out
Notify Security
Submit Outage
Egress
Client Coordination
CLASP Surveillance
Detours
Egress Plan
Inspects Exits Daily
Notify Security
Client Coordination
CLASP Manual 2015
Project:
WBS #
Comments
CLASP Surveillance
Double Surveillance
Temporary Detection
Additional Fire Drill/Shift/Quarter
CLASP Surveillance
Double Surveillance
Temporary Detection
Fire Extinguishers
Client Coordination
CLASP Surveillance
Double Surveillance
Temporary Detection
Page 21
Life Safety Compromise (LSC)
Interim Life Safety Measure (ILSM)
Flammables/Combustibles
CLASP Surveillance
Control Flammable/Combustible
Materials
Fire Extinguishers
Fire Watch
Submit Outage
Hot Work
CLASP Surveillance
Confirm Restoration
Materials
Fire Extinguishers
Fire Watch
Signage
Smoke Evacuation Plan
Submit Hot Work Permit
Submit Outage
Additional (ILSM)
For Extended Conditions
Comments
Double Surveillance
Temporary Detection
Double Surveillance
Temporary Detection
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
Client Coordination
Confirm Restoration
Materials
Fire Extinguishers
Fire Watch
Lock out/Tag out
Stop Hot Work Permits
Submit Outage
CLASP Manual 2015
Double Surveillance
Temporary Detection
Page 22
Other Compromises (OT)
Utilities
Chilled Water
Condenser Water
Domestic Water
Electric
Heating Water
HVACR
Natural Gas
Nurse Call
Pneumatic Tube
Temporary Safeguard (TS)
for Utility Compromises
Client Coordination
Confirm Restoration
Lock out/Tag out
Signage
Temporary Safeguard (TS)
Comments
EVAC
Lab Air
Lab Vacuum
Medical Air
Nitrogen
Nitrous Oxide
Oxygen
Steam
WAGD
Additional (TS)
Comments
Temporary System
Additional (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 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
CLASP Manual 2015
Page 23
Temporary Safeguard
Infection Control
Clean Tracks
Cover Hauled Materials
Dust Tight Barriers
Frequent Cleaning
Infection Control Inspections
Standing Water Dried
Walk Off Mats Maintained
Additional (TS)
Comments
Air Filters
Negative Air
Protective Clothing
Noxious/Toxic Materials
Maintain MSDS
Personal Protective Equipment
Proper Labeling
CLASP Manual 2015
Page 24
Facilities Engineering Supervisor Worksheet
Life Safety Compromise/Interim Life Safety Measure Matrix
Date:
Employee Name:
WO#:
WO Description:
ILSM
CLASP Surveillance
Client Notification
Confirm Restoration
Control Flammable/
Combustible Materials
Detours
Egress Plan
Fire Extinguishers
Fire Watch
Inspect Exits Daily
Lockout/Tagout
Notify Security
Signage
Submit Outage/Incident Report
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Submit Outage/
Incident Report
X
X
X
X
X
X
Signage
Inspect Exits Daily
Fire Watch
Fire Extinguishers
Egress Plan
X
Notify Security
X
X
X
X
X
X
X
Detours
Control Flammable/
Combustible Materials
X
X
X
X
X
X
X
X
Lockout/Tagout
X
X
X
X
Confirm Restoration
X
Client Notification
LIFE SAFETY COMPROMISE
Alarm Systems
Compartmentation
Detection Systems
Egress
Flammables/Combustibles
Hot Work
Suppression Systems
CLASP Surveillance
Check
All
That
Apply
Building:
Floor:
Room:
X
X
X
X
X
X
X
Supervisor Action
Perform rounds at the beginning of each shift. Complete CLASP Fire Surveillance Form, scan to
ILSM group on Billings Basement Copier
Notify tenants first shift, Administrator on Call, off-shifts
No action
Appropriate Supervisor ensures deficiency is repaired
Remove excessive combustibles found on Fire Surveillance Rounds
Notify Safety, all shifts, Administrator on Call
Redirect patient/public traffic to nearest alternate exit. Alter misleading exit signs.
Additional extinguisher required for every 5,000 sq. ft. of work
No action
Perform rounds at the beginning of each shift. Complete CLASP Fire Surveillance Form, scan to
ILSM group on Billings Basement Copier
Complete Fire Surveillance Form. Scan to Paul, Theresa and Sam.
Follow Departmental procedures
Fax this form to BCFD with standard coversheet located at
S:\ILSM Information\ILSM Fax Coversheet.docx
Submission of outage/incident report will auto send email, or call x5-5585
Post computer generated signs informing occupants of condition. Include Facilities name and
phone number x5-5770. Post sign on blue JHM Bulletin poster board.
Contact Facilities CLASP Coordinator
Contact staff/contractors that hold approved hot work permits to halt work
Follow Departmental procedures
By end of shift
ILSM(s) have been implemented as of
Date
Supervisor
Deficiency corrected at __________________ AM/PM
On
Supervisor
Date
Date
Date
SCAN THIS DOCUMENT TO THE ILSM GROUP ON THE BILLINGS BASEMENT COPIER
CLASP Manual 2015
Page 25
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.
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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
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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.
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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
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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) 732-8393 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.: ____________________
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Contact Name: ____________________________________
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CLASP Surveillance Procedures
Purpose
1.
2.
3.
Provide a firewatch during off hours.
Identify safety compromises.
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.
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CLASP Surveillance Checklist
SDS
Infection Control
Injury
Security
Life Safety
Category
Location
Inspector
Project Manager
Date
Contractor
Time
Zone: ____
Meets Standards?
Y-N-NA
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?
11
Proper signage at
construction entrance?
12
Construction entrance
locked?
13
Mechanical/electrical
rooms locked?
14
Compressed gas
cylinders secured?
15
Electric panel covers in
place?
16
Barrier dust tight?
17
Negative air sufficient?
18
Interior clean?
19
Walkoff mats present and
clean?
20
No standing water?
21
Haz. chemicals labeled &
stored properly?
AM
PM
Description
Additional Comments
Rev. 10/2013
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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.
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Ceiling Permit Form
CEILING PERMIT
JOHNS HOPKINS HEALTH SYSTEM
Staff/Project Manager
Cost Center
Spacebook Plan
Attached? *
Yes __ No __
Entrant/Contractor
Name
Name
Start Date
End Date
Phone
Phone
Buildings
Floors
Email
Email
Corridors/Rooms
□ Off Hours?
Work to Be Performed
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.
The white copy of the form is your permit and must be displayed at all times in the CEILING SPACE.
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
I have read and understand the CEILING PERMIT
POLICY and agree to comply fully.
Date
FOR STAFF USE ONLY. DO NOT WRITE BELOW THIS LINE
Date Received
Infection Control Measures Required? Yes __ No __
Inspection Date/Time
 NA
Inspection Location
 NA
___
___
___
___
___
___
___
___
Portable Enclosure
Plastic Tent
Drywall Partition
Sticky Mat
Carpet Mat
Negative Air
HEPA Fan
HEPA Vac
___
___
___
___
___
___
___
___
Frequent Mopping
Frequent Vacuuming
Bunny Suits
Gowns
Footies
Bonnets
Terminal Cleaning
Other: see comments
Comments
Approved By
Date
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Work Order Number
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.
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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.”
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Section 01 35 33 – Infection Control Procedures
Part 1 - General
1.1
A.
1.2
RELATED DOCUMENTS
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.
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:
C.
1.3
A.
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.”
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.”
PROJECT CLASSIFICATION
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.
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B.
Step Two
TYPE A
TYPE B
TYPE C
TYPE D
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.
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
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
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
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
• Office
areas not
communicating
with
patient
care
areas
C.
Level 2
Medium Risk
• 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
Level 3
High Risk
• CCU
• Emergency Room
• Labor & Delivery
• Maternal Child Unit
• Laboratories (specimen)
• Newborn Nursery
• Outpatient Surgery
• Pediatrics
• Pharmacy
• Post Anesthesia Care Unit
• Surgical Units
• Linen Room
Level 4
Highest Risk
• 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
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.
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IC Matrix - Class of Precautions: Construction Project by Patient Risk
Construction Project Type
Patient Risk Group
TYPE A
TYPE B
TYPE C
TYPE D
Level 1
LOW
Risk Group
I
II
II
III/IV
Level 2
MEDIUM
Risk Group
I
II
III
IV
Level 3
HIGH
Risk Group
I
II
III/IV
IV
Level 4
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.
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INFECTION CONTROL CONSTRUCTION GUIDELINES
CLASS I
CLASS II
CLASS III
CLASS
IV
• Execute work by methods to minimize raising dust from construction operations.
• Replace any ceiling tile displaced for visual inspection as soon as possible.
• 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.
• 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.
• Wet mop or HEPA vacuum twice per 8-hour period of construction activity for as required in
order minimizing tracking.
• 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.
• 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.
• 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.
• 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.
•Establish traffic patterns that minimize exposure to patient care areas.
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During Construction Project
Upon Completion of Project
CLASS 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.
CLASS 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.
CLASS 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.
CLASS IV
HCGH DESCRIPTION OF REQUIRED INFECTION CONTROL PRECAUTIONS BY CLASS
• 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
• 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
construction.
• Contain construction waste before transport in
• Cover transport receptacles or carts. Tape
covering unless solid lid
• Vacuum work area with HEPA filtered vacuums.
• Wet mop area with disinfectant.
HCGH Continuing Steps
E.
Step 5.
Identify the areas surrounding the project area, assessing potential impact
F.
Step 6.
Identify specific site of activity e.g., patient rooms, medication room, etc. See
above.
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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.
CLASP Manual 2015
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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. The CSC must be
invited to attend this meeting.
1.6
PRODUCTS
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.
HEPA-Filter Drill Attachment: Milwaukee M12tm Hammervactm Universal Dust Extractor Kit 2306-22 at:
http://www.milwaukeetool.com/power-tools/cordless/2306-22.
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.
Negative Air Indicator: Lamiflow Airflow Monitor models LN-102, Lamiflow Air Systems, Inc., 3286
Balsamridge, Cincinnati, OH 45239, (800) 554-6221 www.lamiflowtech.com
Portable Work Enclosures: Kontrol Kube - Fiberlock Technologies, Inc. or approved equal
Zip-Up Door System: Protective Products, Inc. or approved equal.
Portable Work Enclosures: Mintie Technologies, Inc., www.mintie.com, or approved equal.
CLASP Manual 2015
Page 53
Portable Work Enclosures: Zip Wall LLC, Cambridge, Mass., or approved equal;
Part 2 - Execution
PREPARATION
2.1
A.
Contractor will notify the Owner of planned work and obtain approval prior to start of
work by submitting an Outage.
ISOLATION
2.2
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.
CLASP Manual 2015
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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 airintake 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.”
EQUIPMENT AND SUPPLIES
2.3
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.
INTERNAL TRAFFIC FLOW
2.4
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.
VENTILATION
2.5
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.
CLASP Manual 2015
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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
HOUSEKEEPING
2.6
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 walkoff 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.
CLASP Manual 2015
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PROTECTIVE CLOTHING
2.7
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.
PRECAUTIONARY AND REMEDIAL WORK
2.8
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:
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.
G.
Any material exposed to moisture prior to installation shall be
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.
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.
CLASP Manual 2015
Page 57
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.
EMERGENCY SITUATIONS
2.9
A.
2.10
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.
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
CLASP Manual 2015
Page 58
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
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
CLASP Manual 2015
Page 59
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 polyNegative
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.
CLASP Manual 2015
Page 60
Infection Control Checklist
Instructions: To be com pleted daily by contractor.
Please date, initial and indicated by a check m ark that all item s noted
are being accom plished as outlined in contract docum ents.
Please note start of work, stop and end of dem o
Superintendent
Project #
Project Nam e
Class
all
all
all
all
all
all
all
all
all
all
IV
all
all
No
Date & initial Exterior Negative
Air
Barrier Doors Interior Hauled Tracks M ats Signage Clothing Full
Cleaned
Air
Filters Integrity Closed & Clean Debris Cleaned Clean Posted Covered PPE Standing
Daily
Clean
Ok
Secured
Covere
Worn Water
CLASP Manual 2015
Page 61
rev 10/14
.INFECTION CONTROL –Construction Permit
Infection Control Construction Permit
Location of Construction:
Permit No:
Project Start Date:
Project Coordinator:
Estimated Duration:
Contractor Performing Work:
Permit Expiration Date:
Supervisor:
Telephone:
YES
NO
CLASS I
CONSTRUCTION ACTIVITY
INFECTION CONTROL RISK GROUP
GROUP 1: Low Risk
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
1.
1.
2.
3.
4.
5.
CLASS III
NO
TYPE B: Small scale, short duration,
moderate to high levels
2.
CLASS II
YES
TYPE A: Inspection, non-invasive activity
1.
2.
3.
Date
4.
Initial
5.
CLASS IV
1.
2.
3.
Date
4.
Initial
5.
6.
Execute work by methods to minimize raising dust from
construction operations.
Immediately replace any ceiling tile displaced for visual
inspection.
3.
Minor Demolition for Remodeling
Provides active means to prevent air-borne 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.
Wipe surfaces with disinfectant.
6.
Contain construction waste before transport in tightly
covered containers.
Wet mop and/or vacuum with HEPA filtered vacuum
before leaving work area.
Place dust mat at entrance and exit of work area.
Remove or isolate HVAC system in areas where work
is being performed.
Obtain infection control permit before construction begins.
Isolate HVAC system in area where work is being done to
prevent contamination of the duct system.
Complete all critical barriers or implement control cube
method before construction begins.
6.
7.
8.
Maintain negative air pressure within work site utilizing
Do not remove barriers from work area until complete
project is thoroughly cleaned by EVS. Services Dept.
Obtain infection control permit before construction begins.
Isolate HVAC system in area where work is being done to
prevent contamination of duct system.
Complete all critical barriers or implement control cube
method before construction begins.
Maintain negative air pressure within work site utilizing
Seal holes, pipes, conduits, and punctures appropriately.
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.
8.
9.
Vacuum work with HEPA filtered vacuums.
Wet mop with disinfectant
Remove barrier materials carefully to minimize
construction.
9. Contain construction waste before transport in
10. Cover transport receptacles or carts. Tape covering.
11. Remove or isolate HVAC system in areas where work
is being performed/
7.
8.
9.
10.
11.
12.
13.
14.
All personnel entering work site are required to wear
shoe covers
Do not remove barriers from work area until completed
project is thoroughly cleaned by the Environmental
Service Dept.
Vacuum work area with HEPA filtered vacuums.
Wet mop with disinfectant.
Remove barrier materials carefully to minimize
construction.
Contain construction waste before transport in tightly
covered containers.
Cover transport receptacles or carts. Tape covering.
Remove or isolate HVAC system in areas where work
is being performed.
Additional Requirements: See attached Infection Control Risk Assessment
Contractor Signature:
_______
Date Initials
Exceptions/Additions to this permit
are noted by attached memoranda
Permit Request By:
Permit Authorized By:
Signature:
Date:
CLASP Manual 2015
Page 62
JHH and JHBMC Online Outage System
Revision 2.7
CLASP Manual 2015
Page 63
Table of Contents
Intended Audience………………………………………………………………….... 65
Purpose………………………………………………………………………………. 65
Figure 1: Online Outage System Workflow……………………………………… 66
Using the Online Outage System……………………………………………………. 67
Figure 2: Facilities Intranet Homepage………………………………………... …. 67
Figure 3: Homepage Outage Selection………………………………………… … 67
Figure 4: Outage System Login Choice………………………………………....... 68
Figure 5: Outage System Login Screen………………………………………... …. 68
Figure 6: Outage System Hompage…………………………………………….…. 69
Figure 7: Option Sub-menu……………………………………………………. …. 69
Request Outage………………………………………………………………………. 70
Figure 8: Request New Outage…..……………………………………………..…. 70
Figure 9: Calendar Pop-up Window…………………………………………… …. 71
Figure 10: Emergency Warning………………………………………………… 72
Modify Outage…………………………...…………………………………………... 73
Figure 11: Outage Selection Criteria……………………………………………. 73
Figure 12: Outage Modification Form………………………………………….. 74
Figure 13: Link to Outage Information Request & Project Manager Approval.. 75
Figure 14: Outage Information Request………………………………………… 76
Approve Outage……………………………………………………………………… 77
Project Manager Approval…………………………………………………………… 77
Client Approval.……………………………………………………………………... 77
Figure 15: Client Approval Screen……………………………………………… 78
Shop Approval..……………………………………………………………………… 78
Figure 16: Shop Approval Screen………………………………………………. 78
System Restoration…………………………………………………………………... 80
Figure 17: System Restoration Routine………………………………………… 80
Request Outage Extension…………………………………………………………… 81
Figure 18: Outage Extension……………………………………………………. 81
Cancel Outage……………………………………………………………………….. 82
Figure 19: Cancel Outage Screen…….…………………………………………. 82
View & Print Outage…………………………………………………………………..83
Figure 20: View & Print Outage……..…………………………………………. 83
Status Report………………………………………………………………………….. 84
Figure 21: Status Report Selection Criteria……………………………………...84
Figure 22: Status Report……………...…………………………………………. 85
Add/View Attachments……………………………………………………………….. 86
Figure 23: Add/View Attachments Screen……………………………………… 86
Other Options…………………………….…………………………………………… 87
Print Hot Work Permit..………………….………………………………………….... 87
Change Password...……………………….…………………………………………... 87
Email Notifications……………………….………………………………………….. 87
Figure 24: Email Notification Matrix..………………………………………….. 87
Figure 25: Hot Work Permit…………………………………………………….. 88
Reporting…...…………………………….…………………………………………... 89
Status Report…………………….…………………………………………………… 89
Delinquency Report…………………….……………………………………………. 89
Figure 26: Delinquency Report…………………………………………………. 89
CLASP Manual 2015
Page 64
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.
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Online Outage System Workflow
Figure 1: Online Outage System Workflow
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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 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.
Figure 3: Homepage Outage Selection
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You will then see this login screen.
Please choose one of the Options to Login
Figure 4: Outage System Login Choice
You now see this screen.
Figure 5: 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:
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Figure 6: 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
Figure 7: Option Sub-menu
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.
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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
• Information Request
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 8: Request New Outage
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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 9: 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.
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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 10: 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.
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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 11: Outage Selection Criteria
Since the Outage already exists, it is necessary to select Outage Modify. On this screen, noncancelled 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.
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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 12: Outage Modification Form
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After all modifications have been made, click the link Click Here to the Outage Information
Request page shown below.
Click here to print a
hot work permit.
Figure 13: 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.
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Figure 14: 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.
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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.
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After selecting the appropriate Outage, the following screen will be seen:
Figure 15: 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.
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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 16: 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.
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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 17: System Restoration Routine
To show that all systems have been restored, select Yes, and then click Submit.
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Request Outage Extension
It is sometimes necessary to request an outage extension if it is running behind or ahead of the
original approved dates. Dates are the only change that can be made. Different locations, times, etc
require a new outage request. 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 18: 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.
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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 19: 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.
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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.
Click here to print
a Hot Work Permit
from the Outage
Modification screen
Click here to print a Hot
Work Permit.
Figure 20: View and Print Outage
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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 21: Status Report Selection Criteria
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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 22: 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.
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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 23: 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.
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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
Outage created by Contractor
Project Manager approval
Shops and Clients assigned
All Shops and Clients approved
Final Approval (CSC and HSE)
System Restored
Outage Cancelled
Outage Information Request by PM
Outage Rejected by CSC
Outage Information Request by Group
Emergency
Email Recipient(s)
Project Manager selected by Contractor when Outage is
created
Outage Administrator(s)
Each shop and client that is been assigned to the Outage
Outage Administrator (CSC) and Health, Safety, and
Environment (HSE)
All parties involved with Outage
CSC and HSE
Contractor
Email to Outage Administrators
Facilities Director
Figure 24: Email Notification Matrix
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THE JOHNS HOPKINS INSTITUTIONS
HEALTH, SAFETY AND ENVIRONMENT
EXTENSION 5-5918
CUTTING-WELDING HOT WORK PERMIT
DANGER
PREVENT FIRES
DO NOT CUT, WELD, OR USE OTHER OPENFLAME 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.
Date : 10/14/2013
Building : Zayed Bloomberg
B. There is no flammable lint, dust, vapors, or
liquids; or tanks or equipment which previously
contained such materials.
Floor : 006
This permit expires : 11/27/2013
If fire occurs, PULL FIRE ALARM BOX AND DIAL
5-4444.
C. This work will be confined to the area or
equipment specified in the permit.
Approved by : Paul Matuska on 10/16/2013
A. Floors and surroundings have been swept clean
and wet down.
2. The following safeguards have been provided:
B. Ample portable extinguishing equipment – hand
hose, extinguishers, water pails, etc.
3. If the work involves cutting, welding, or other sparkproducing 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 hours after
work has been completed.
Figure 25: Hot Work Permit
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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 26: Delinquency Report
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HCGH Outage Workflow
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HCGH Request for Outage
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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: _________________
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.
PRECAUTIONS
Yes No N/A
To 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
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Comments:
PERMIT APPROVED BY:
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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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Click the red and green OT icon in the lower right corner of the desktop.
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.
In the Visioneer 9650 box in the lower right hand corner, click Func: F1.
Click the Scan All or Scan button.
Click Text Document for most applications.
Click Scan More Pages or Done at the prompt.
Click OK.
Enter the outage system doing steps in the Once you are on the desktop screen: above.
The scanned file is placed in the PDF Documents folder located on the desktop.
Click Contractors.
Click Add/View Attachments.
Click the outage number.
Click Add/View Attachments.
Click the Browse Button.
Click PDF Documents.
Click your specific scanned file name.
Click Open.
In the File Description box fill in the description of the file.
Click Upload.
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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.
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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 fortyeight (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.
CLASP Manual 2015
Page 98

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
CLASP Manual 2015
Page 99









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
CLASP Manual 2015
Page 100


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
CLASP Manual 2015
Page 101
Inspection Request Form
JHH or JHBMC
Billings B120
HGCH
Project Manager
Major/Complex Project
Around $100 million
Constructware
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









Decommissioning
Infection Control
Post Demolition
Wall Closure
Ceiling Closure
Substantial Completion
Final
Other (provide description)
Test ________________
Commissioners Required









Landscaping
Architectural
Carpentry/Architectural Specialties
Firestopping
Roofing
Doors
Automatic Roll-up/Revolving Doors
Glazing
Painting








Elevator/Pneumatic Tube
Fire Alarm/Sprinkler/Clock
Plumbing/Med Gases
HVAC
ATC
Electrical
Communication/Security
Other (provide description)

Comments/Description:
CLASP Manual 2015
Page 102

CLASP MANUAL 2015 - Facilities Department

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