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1 Safety and Commissioning Manual 2010 The Johns Hopkins Hospital (JHH) and Johns Hopkins Bayview Medical Center (JHBMC)...

Safety and Commissioning Manual 2010

The Johns Hopkins Hospital (JHH) and Johns Hopkins Bayview Medical Center (JHBMC) Facilities Department Planning - Design - Project Management – Engineering

TABLE OF CONTENTS COORDINATED LIFE SAFETY ASSURANCE PROGRAM (CLASP) JHH Emergency Management Disaster Codes ....................................................................... 1 JHBMC Emergency Response Codes..................................................................................... 1 JHH Evacuation Plans ............................................................................................................. 2 JHBMC Evacuation Plans ........................................................................................................ 3 JHH Safety Fact Sheet ............................................................................................................ 4 JHBMC Safety Fact Sheet ....................................................................................................... 5 General Policy .......................................................................................................................... 8 Purpose .............................................................................................................................. 8 Features .............................................................................................................................. 8 Policies ................................................................................................................................ 9 Procedures ........................................................................................................................ 11 Life Safety and Other Safety Compromises............................................................................. 14 Interim Life Safety Measures (ILSM) ..................................................................................... 15 Life Safety Criteria Guide.................................................................................................. 17 Project Risk Assessment .................................................................................................. 18 ILSM Decision Table......................................................................................................... 20 Facilities Engineering Supervisor Worksheet Life Safety Compromise/Interim Life Safety Measure Matrix ............................................................................................... 23 Hazard Communication ......................................................................................................... 24 Bloodborne Pathogens .......................................................................................................... 25 Notice of Asbestos Abatement .............................................................................................. 26 CLASP Surveillance................................................................................................................ 27 Procedures ........................................................................................................................ 27 Checklist ........................................................................................................................... 28 Ceiling Permit ......................................................................................................................... 29 Procedures ....................................................................................................................... 29 Form.................................................................................................................................. 30 Infection Control ..................................................................................................................... 31 Training ............................................................................................................................. 31 Section 01110 - Infection Control ................................................................................. - 33 - Policy ................................................................................................................................ 45 Checklist ........................................................................................................................... 47 JHBMC Construction Permit ............................................................................................. 48 JHH Online Outage System .................................................................................................... 49 JHBMC Outage Workflow ...................................................................................................... 79 Safety and Commissioning Manual 2010

Facilities Department Johns Hopkins Health System

Request for Outage................................................................................................................ 81 JHBMC Hot Work Permit ....................................................................................................... 82

Commissioning and Inspection Commissioning And Inspection Procedure ............................................................................ 83 Inspection Request Form ....................................................................................................... 88

Acronym List ASC BCFD BMO CCU CLASP CMSC COMAR CSC CVDL EHS FES HBV HCV HEIC HEPA HIPAA HIPOP HIV HSE HVACR ILSM IPOP JHBMC JHH JHHS JHOPC LOTO LSC MFL MOSH MRI MSDS NESHAP OR OSHA PACU PM PPE WAGD WBS

AdministrativeServicesCenter BalitmoreCityFireDepartment BayviewMedicalOfficeBuilding CriticalCareUnit CoordinatedLifeSafetyAssuranceProgram Children'sMedicalandSurgicalCenter CodeofMarylandRegulations ConstructionSafetyCoordinator CardiovascularDiagnosticLab OfficeofEvironment,HealthandSafety FacilitiesEngineeringSupervisor HepatitisBVirus HepatitisCVirus OfficeofHealthcareEpidemiologyandInfectionControl High‐EfficiencyParticulateAir(filter) HealthInsurancePortabilityandAccountabilityAct HematologyInpatient/Outpatient HumanImmunodeficiencyVirus OfficeofHealth,SafetyandEnvironment HeatingVentilatingAirConditioningRefrigeration InterimLifeSafetyMeasures Inpatient/Outpatient JohnsHopkinsBayviewMedicalCenterCampus JohnsHopkinsHospital JohnsHopkinsHealthSystem OutpatientCenter Lockout/Tagout LifeSafetyCompromise MasonF.LordBuilding MarylandOccupationalSafetyandHealth MagneticResonanceImagingBuilding MaterialSafetyDataSheets NationalEmissionsStandardsforHazardousAirPollutants OperatingRoom OccupationalSafetyandHealthAdministration PostAnesthesiaCareUnit ProjectManager PersonalProtectiveEquipment WasteAnethesiaGasDisposal WorkBreakdownStructure

Safety and Commissioning Manual 2010

Facilities Department Johns Hopkins Health System

JHH Emergency Management Disaster Codes CODE Blue Gold Red Yellow Bio Yellow Chemical Yellow ED

DESCRIPTION Cardiac/Respiratory Arrest Bomb Threat Fire Bioterrorism Chemical Patient influx of up to ten (10) patients from a single event Yellow Hospital Patient influx of more than ten (10) patients from a single event Yellow Radiation Radiation

CALL (410) 955-4444 (410) 955-5585 (410) 955-4444 (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

Safety and Commissioning Manual 2010

DESCRIPTION Cardiac/Respiratory Arrest Bomb Threat Elopement Combative Person Hazardous Material Spill Infant or Child Abduction Security Response Fire Weapon Emergency or Disaster

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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

Facilities Department Johns Hopkins Health System

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 have the authority to evacuate any individual from immediate danger, however wholesale or mass evacuation is performed only on the order of a competent authority (see below). In Health Care Occupancies, upon alarm activation, staff members will implement a “defend-in-place” philosophy and take steps to prepare for possible limited or total evacuation. Specific preparation steps are outlined in the Fire Incident Responsibilities. The decision to evacuate all or part of a unit, floor or building must be made by a competent authority, i.e., Baltimore City Fire Department; representative of the Department of Health, Safety and Environment; senior administrative official of the JHMI; or Security Shift Supervisor. Staff will utilize the Unit Specific Life Safety Plan to assist with any coordination of patients during the event. Areas classified as Business Occupancies are required to evacuate all patients, personnel, and visitors when the fire alarm sounds on these floors, or when ordered to evacuate by a competent authority. “Evacuation” means leaving the building under alarm, which most often can be accomplished by moving horizontally to an adjacent building. Please familiarize yourself with the evacuation plan which follows for your building. Occupants of buildings that are on a high-rise notification system (alarm is activated one floor above and one floor below the affected floor) and are not directly connected to another building until further below (i.e Meyer 9), must have two floors separating you from the floor that is in alarm. Building 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 (Both Wings) MRI Nelson/Harvey Park Pathology Phipps Radiology Rubenstein Smith Weinberg Wilmer Woods

Levels classified as Business Occupancy Entire Building Sub-Basem*nt, Basem*nt, 2, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16 Entire Building Sub-Basem*nt, Basem*nt, 1, 2, 3, 4, 5, 6, 8, 9, 10 Sub-Sub-Basem*nt, Sub-Basem*nt, 1, 2, 3, 4, 6, 8, 9, 10, 11, 12 Sub-Sub-Basem*nt, Sub-Basem*nt, 1, 10, 11, 12, 13 9, 10 Entire Building Entire Building 1, 2, 4, 5, 6, 8 Basem*nt, 1, 4, 5 Sub-Basem*nt, Basem*nt, 1, 2, 3, 5, 6, 7, 8, 9 3, 4, 5, 6, 8 & 9, Sub-Basem*nt, B, 10 None Sub-Basem*nt, 1 SB, 2, 3, 4 Entire Building Entire Building Sub-Basem*nt, 1 Entire Building Basem*nt, 2, 3, 4, 5, 6, 7, 8 L-1, Parking & Storage Portions of L-2, L-3 Sub-Basem*nt, Basem*nt, 1, 2, 5, 6 Entire Building

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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 have 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 A AA Alpha Commons ASC B BMO Francis Scott Key Pavillion John R. Burton Pavilion MFL East MFL West Warehouse

Safety and Commissioning Manual 2010

Levels classified as Business Occupancy 01, 1, 2, 3, 5, 6 02, 01, 1 1, 2, 3, 4 2, 3 01, 1, 2, 3, 4, 5, 6 02, 01, 1, 2, 3 02, 01, 2, 3, 4, 5, 6 02 1, 2, 3, 4, 5, 6 1, 2, 3, 4, 5, 6 1, 2

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Facilities Department Johns Hopkins Health System

JHH Safety Fact Sheet FIRE SAFETY  In case of smoke/fire: 1. Remove patients from danger. 2. Close doors to confine smoke or fire. 3. Pull alarm box. 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 leave. 2. Don’t use elevators. Use the nearest exit.  Keep corridors clear by removing your materials from the corridors.  Doors must never be wedged open unattended.

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 Monument St. and Broadway. 4. Submit reports to the Foreman and the Facilities Project Manger.

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.

OUTAGES  Utility and life safety system 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.

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

PATIENT PRIVACY  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 ID.

CEILING PERMIT  Ceiling access outside a construction site requires a permit from the CSC/FES. HAZARDOUS CHEMICALS  Material Safety Data Sheets (MSDS) describe the hazards of a chemical. MSDS are available from the Health, Safety and Environment.  The Prime Contractor is required to have a chemical list and MSDS on site.  In a spill, contain the area and notify your foreman and/or call (410) 955-4444.

Safety and Commissioning Manual 2010

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.

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Facilities Department Johns Hopkins Health System

JHBMC Safety Fact Sheet FIRE SAFETY  In case of smoke/fire remember RACE: Rescue: Remove patients from danger. Alarm: Pull the alarm. Call (410)-550-0222. Contain: Close doors to confine smoke or fire. Extinguish with a fire extinguisher using PASS: Pull Aim Squeeze Sweep  Evacuate patients if directed.  Don’t use the elevators. Use the nearest exit.  Keep corridors clear by removing your materials from the corridors.  Doors must never be wedged open unattended. NO SMOKING  Smoking is permitted only in designated areas. INFECTION CONTROL Call (410) 550-0515.  Have an on-site pre-construction infection control review.  Submit inspection of infection control measures prior to: 1. Starting construction 2. Changing the class or limit of work 3. Removing infection control measures INJURY  If you are splashed with blood or body fluids or have a needle stick injury, immediately cleanse the area, then from 8 AM to 4:30 PM, M-F, call (410) 550-0477; off hours page (410) 283-1545.  Notify your foreman and get medical attention for any other job related injuries: 1. Go to the Emergency Department or call 911. 2. Submit reports to the Foreman and Facilities Project Manger.

Safety and Commissioning Manual 2010

HAZARDOUS CHEMICALS  Material Safety Data Sheets (MSDS) describe the hazards of a chemical. MSDS are available from the Health, Safety and Environment Department.  The Prime Contractor is required to have a chemical list and MSDS on site.  In a spill, close off the area and notify your foreman and/or call (410) 550-0222. CEILING PERMIT  Ceiling access outside a construction site requires a permit from Facilities. OUTAGES  Utility and life safety system impairments require outage approval.  Electrical, water or structural problems from 8 AM to 4 PM call (410) 550-0477; off hours page (410) 283-1545. PATIENT PRIVACY  Never enter a patient room unescorted.  Do not ask or share patient information.  Avoid situations where patient information is prevalent. SECURITY ISSUES  Call (410) 550-0333.  Always display ID. COMMISSIONING  All work is subject to Facilities’ commissioning.  Comply with commissioning and inspection procedures. GENERAL SAFETY CONTACTS  Report safety concerns to: 1. Your supervisor/foreman. 2. Facilities (PM) or Environment, Health and Safety (EHS) at (410) 550-0228.

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Facilities Department Johns Hopkins Health System

Johns Hopkins Bayview Medical Center Contractor Orientation Detailed Checklist

Facitilies contractors and their employees working at Johns Hopkins Bayview Medical Center (JHBMC) are required to attend an orientation to be trained prior to beginning work. As a condition of continued work at JHBMC, they will be required to adhere to all the hospital’s rules, regulations and policies promoting a safe and secure environment. The following items will be covered during orientation. Facilities / Redevelopment o Parking o Badge o Excavating o Proper attire

o Personal Protective Equipment (PPE): -Ear -Head -Respiratory -Feet -Eyes -Hands o Equipment: -Ladder -Fall Protection -Scaffold -Welding Screens -Guards o Hot Work Permit o Fire Alarm in Drill o Confined Space o MSDS & Hazard Communication o Smoking o Above Ceiling Permit o Exit Area / Building o Notification of any issue - Call Sheet o Radios o Keeping areas clean (Interstitial Space, Above Ceiling and MechanicalRooms)

o Housekeeping o Outages o Communicating with staff/customer o After-hours work o Elevators o Cover on carts o Restrooms o Cafeteria o Cell Phone Safety / Security o Hazardous waste o Blood borne Pathogens (BBP) o Crosswalks o Lockout / Tagout o Fire Extinguishers o Infection Control o Interim Life Safety o Asbestos o Patient Privacy (HIPAA) o Electrical Safety o Medical Emergencies

I have been in-serviced in all areas checked above and agree to abide by JHBMC policies and understand that my failure to do so will result in my removal from the JHBMC premises. Name

Company

Signature

Date

Authorized By:

Dept

Signature

Date

Photo ID issued by JHBMC Security Department on

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

Johns Hopkins Bayview Medical Center Contractor Orientation Detailed Checklist PARKING BADGES EXCAVATING PROPER ATTIRE PPE EQUIPMENT HOT WORK PERMIT DRILLS CONFINED SPACE, MSDS & HAZARD COMMUNICATIONS SMOKING ABOVE CEILING PERMITS EXIT AREA/BUILDING NOTIFICATION OF ISSUES (Call Chain): RADIOS KEEPING AREAS CLEAN (Interstitial Space, Above Ceiling, and Mechanical Rooms) HOUSEKEEPING OUTAGES COMMUNICATING WITH STAFF/CUSTOMERS AFTER HOURS WORK ELEVATORS COVER ON CARTS RESTROOMS CAFETERIA CELL PHONES HAZARDOUS WASTE BLOODBORNE PATHOGENS CROSSWALKS LOCKOUT/TAGOUT FIRE EXTINGUISHERS INFECTION CONTROL INTERIM LIFE SAFETY ASBESTOS PATIENT PRIVACY (HIPAA) ELECTRICAL SAFETY MEDICAL EMERGENCIES

Safety and Commissioning Manual 2010

Designated parking area is located at the gravel lot on Lombard Street. The loading docks are for drop offs and pick ups only. Proper ID is required at all times when onsite. Must notify Superintendent or Project Manager (see call sheet) prior to excavating. Clean presentable work clothing must be worn at all times. Personal Protective Equipment— All workers are required to have and use appropriate PPE. Must be used in conjunction with OSHA standards and manufacturers guidelines. Must be obtained from the Safety Department prior to any hot work. Fire Alarms will be placed in drill by an outage request issued through the Safety Department to the Facilities Department. In accordance with OSHA standards and Bayview’s policy. All chemicals used in a project must have MSDS. Only permitted in designated areas. Must have permit, obtained through the Facilities Department, anytime work requires going above any ceiling or working on any mechanical room, closet, etc. Contractors must be aware of fire evacuation routes for their work areas. Contractors must notify proper personnel listed on attached Call Sheet. All personal entertainment devices are not permitted onsite. All areas must be kept clear from debris and clutter.

Must be maintained on a daily basis or more frequently as needed. Must be coordinated through the Facilities Department 7 days in advance. Refer to Call Sheet when communicating with staff/customers. Contractors must notify appropriate Superintendent or Project Manager to request authorization to work after hours. Designated elevators must be used for projects - keep clear of debris. All carts must be completely covered when transporting debris. Must use designated restroom in project area. Proper behavior is expected at all times. Not to be used in patient care areas or in areas with posted signage. Must be coordinated with the Safety Department. DO NOT handle. Must contact the Safety Department. Must stop at all crosswalks. Do not unload at crosswalks. Coordinate with hospital LOTO policy. Must maintain and have onsite at all times a contractor owned extinguisher Refer to Infection Control Risk Assessment Refer to Interim Life Safety Measures Must contact the Safety Department. Patient confidentiality must be maintained at all times. Equipment must be maintained, do not turn breakers on/off, contact Superintendent or Project Manager. Report immediately to the emergency room or call 911. An incident report is required for all accidents.

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Facilities Department Johns Hopkins Health System

General Policy I.

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.

II. Features A In accordance with the Joint Commission standards, the program is designed to institute and document Interim Life Safety Measures (ILSM) that temporarily compensate for any hazard posed to the existing life safety 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 and infection control 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) or Project Manager (PM) at JHBMC is an integral part of CLASP, providing a primary liaison between the Project Managers (PMs), Facilities Engineering Supervisors (FES), the Johns Hopkins Hospital Office of Health, Safety and Environment (HSE), Johns Hopkins Bayview Medical Center Environment, Health and Safety (EHS), the Johns Hopkins Hospital Office of Healthcare Epidemiology and Infection Control (HEIC) and Johns Hopkins Bayview Medical Center Infection Control. The CSC/PM inspects jobsites for occupational and user safety, and directs changes in practices and procedures pro-actively before emergency measures are necessary. The role of the CSC is assigned to multiple persons at JHH and it is the PM, EHS and Security at JHBMC. In the absence of the primary CSC, one of the alternates assumes the responsibility. The CSC/PM 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 PM or FES.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

E. Implementation of this program is the responsibility of the Facilities Department. PMs/ESMs 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 “Facilities Engineering Supervisor (FES)”. III. Policies A. All contractors and vendors are issued a temporary identification badge to enhance security. I D badges expire yearly on March 31. To obtain an I D badge the applicant must be trained in general Hospital procedures, safety and commissioning. At JHBMC the contactors and vendors must also undergo contractor orientation in accordance with the “JHBMC Contractor Orientation Checklist”. At JHH and JHBMC, a person trained by the CSC or EHS can, in turn, train other people only within their own company. The company must then provide to the CSC a statement on their company letterhead stating the name of the trainer and the names and last four digits of their social security number. B. All marked exits and exit routes must be maintained for access by building occupants and construction personnel throughout the construction/engineering project or repair effort. Any blockage of the exit route or re-routing must be coordinated through the CSC, PM or FES. Before a compromise can be affected at JHH or at JHBMC, written approvals must be obtained in accordance with the CLASP/Outage procedure for that campus. C. At JHH and JHBMC, outages to alarm, detection, suppression systems, or existing utility must be coordinated through the CSC or PM by the PM or FES. 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 with each occurrence. D. At JHH, system outages shall be scheduled for reactivation by the close of each shift. If the outage must be extended beyond the scheduled outage period, the contractor shall notify the PM/FES and the appropriate Engineering service before the system is to be reactivated. The contractor or FES 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 or HSE or at JHBMC, the PM or ESH. E. System outages are subject to review and may require installation of temporary systems. F. The PM in the course of conducting periodic progress meetings shall include “Safety, Infection Control and Outages” as regular agenda items. 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 or compartmentation without following the CLASP/Outage procedures, 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 JHHS projects. Suspension from bidding shall be at the Hospital’s Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

discretion. NOTE: This does not supersede any associated claims resulting from damages. H. Any contractor or employee who is found smoking in the hospital or the construction area shall be removed from the hospital lot permanently. Their identification badge will be turned in. Any contractor or subcontractor who has two or more employees suspended for smoking within a six month period, shall be suspended from bidding on future projects for six months at the discretion of JHHS. I.

The Prime contractor is required to provide and maintain on site an accessible, fully charged, tested and certified 10 lb. ABC fire extinguisher for every 5,000 square feet of project area under construction. Under double surveillance, the area is reduced to 2500 square feet. Contractors must be OSHA trained and certified to use fire extinguishers.

J. The contractor is required to keep the jobsite free of debris and loose combustible materials. All debris is to be removed from the construction area periodically or as directed by the PM and/or project requirements. K. The storage of non-flammable materials in mechanical or electrical equipment rooms or shafts is expressly prohibited unless approved in accordance with the CLASP/Outage procedure. 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 a permit and a review by the CSC and HSE at JHH 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 JHH. 1. Upon notification of the acceptance on the JHH bidders list, the contractor is required to submit a copy of the company's 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 must be received by the CSC before an approved JHH I.D. badge will be issued or renewed. 4. The Prime Contractor is required to post at each project site in a prominent location, an information board. The Project Information Board shall be used for posting: a. Outages b. Emergency telephone numbers c. Evacuation plan d. Infection Control checklist (JHH) or Infection Control Permit (JHBMC) e. Infection Control class f. Surveillance checklist g. Safety Fact Sheet Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

h. i.

Trash route Safety and Commissioning Manual

5. At the preconstruction meeting, the Prime Contractor is required to make available to the PM, a chemical information list and all Material Safety Data Sheets of chemicals that will be used in the course of completing the project. The Prime Contractor is also required to maintain a repository, on the job site, for the Chemical Information Lists and Material Safety Data Sheets for all subcontractors . 6. At the preconstruction meeting, the Prime Contractor is required to present their plan to implement the infection control measures for approval by the PM and CSC. N. When a contractor has violated the CLASP policy, the PM shall immediately notify the contractor, in writing, and take action in accordance with the following: 1. 1st Time - Written notice 2. 2nd Time - Written notice and at the discretion of the Senior Director of Design and Construction, suspension from bidding on projects for the next 60 days. 3. 3rd Time - Written notice and at the discretion of the Senior Director of Design and Construction, suspension from bidding pending meeting with the President of company. The results of this meeting may consider permanent removal from the bidders list. 4. Subsequent to each PM notification of a violation, there must be immediate compliance to the CSC for approval. O. When Facilities determines that 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 Commissions’ Interim Life Safety Measures found later in this policy. IV. Procedures A. The CSC and/or PM shall conduct routine jobsite inspections and report all deficiencies, violations and non-conformance to the contractor, the PM/CSC and the Project Executive. B. The PM will review current or recent deficiencies with the contractor at each construction progress meeting. The contractor(s) shall report measures taken to correct deficiencies and to prevent a recurrence. These actions shall be documented in the progress meeting minutes. C. Any construction, renovation or maintenance work (temporary enclosures, deliveries, etc.) which compromises existing fire safety systems, which may include compartmentation, egress routes or the fire resistive integrity of egress route, or infection control, must be approved in accordance with the CLASP/Outage procedure. D. 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 Facilities Engineering Supervisors at JHBMC. The outage may be rejected on the merit of the timing or JHH’s ability to support the request. Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

For the purposes of all notification requirements the workday is defined as Monday through Friday, except for Hospital holidays. The current day and the first day of the outage is not counted. E. The CSC notifies the Baltimore City 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. The Electrical Supervisor at JHBMC will notify the Baltimore City Fire Department. F. When deemed necessary, the Prime Contractor will submit a work plan to the Project Manager/Engineering Service Manager for review through the outage system. This work plan may require attached documents, such as notices, floor plans, correspondence, etc. After the Project Manager/Facilities Engineering Supervisor, CSC, the Engineering Shops, Client and HSE will examine the work plan and recommend Interim Life Safety Measures for the Prime Contractor to apply. G. At JHH, the contractor doing the work, not an overseeing contractor, 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, the Project Manager arranges the outage confirmation. H. The PM/FES or CSC will routinely inspect the jobsite throughout the period of the outage for compliance. I.

The PM/FES will coordinate necessary notification and training of construction personnel and affected occupants of adjacent areas of the outage.

J.

At the completion of the CLASP/Outage at JHH, the ICS shop , and at JHBMC Facilities, shall verify that all permanent life safety features of the fire alarm system have been restored. Notification of the occupants of adjacent areas, PM/FES, CSC and HSE will be done by ICS through the outage system.

K. 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. L. 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. M. 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 PM/FES for questions. N. 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 Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

planning and timing is essential. The following are elements of double surveillance: 1. Decrease the area per fire extinguisher from 5000 to 2,500 sf. 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. Vigorous housekeeping involving eliminating accumulated combustibles and maintaining egress. 5. Consider using a temporary detection/fire suppression system. 6. Project Manager must submit updated ILSM to the CSC to evaluate building ILSM status. O. 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.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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 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, sovents, painting, roofing 4. Hazardous Materials – Asbestos abatement 5. Confined Space – Manholes, containers, pits, vaults and hard to access or poorly ventilated areas

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

Interim Life Safety Measures (ILSM) The Hospital implements the life safety management plan and performance improvement standards, including all features described in the Joint Commission Elements of Performance for LS.01.02.01. The Hospital also: I.

Maintains current record drawings or documents addressing all structural features of fire protection.

II. Develops a policy for use of interim life safety measures (ILSM) that include written criteria to evaluate various Life Safety Compromises (LSC) deficiencies, the Life Safey 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 a 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 comtribute 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.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

No tif y 1 BC No FD 2 tify Po B 4 sts CFD In ig . sp n C 5 ect sat ond In st ex alte uct 12 all itsd rn fir I tem ail ate ew y ex at 6 nsp Ad ec p.& . its ch. t . d 7 fi & eq In re te ua st ‐f s l 8 all igh tm fire In sm tin on a la cr o g t ‐c eas ke/ eq hly. rm u & on e f d s ire ip s et 9 truc urv re me ec Co tio eil sis nt tio . l n t nt a i , n. ‐s ro sto nce ve b l to fl rag ar ra a e 10 ge m ,e rie A ,h m xc rs 11 dd ouse able ava . A itio ke s& tion d n e , 13 da al pin co fiel C fir fire g& mb dof o de nd ed ‐fig deb us fice fic uc rill ht ris tib s 14 ienc tfi /s h ing rem les r i C es, es ift/ tra ova on co a q i l du nst fet uar ning ct ruc ye te . c ti d r. om on uc pa haz ati rt ar on m ds en & ‐ ta te bu tio mp ild n .ming tr ea ai ni sur ng es .

Life Safety Criteria Guide ILSM‐InterimLifeSafety Measures

LifeSafetyCriteriaGuide ElementsofPerformanceLS.01.02.01

Compartmentation Significantwall/floorpenetration/openingthatis: Smokeratedandabusinessoccupancy. 1or2hr.ratedinabusinessoccupancywithouta smokedetector. Inaninpatientcompartmentwithoutasmoke Egress Obstructing/changingexitsignage x x x x x Narrowing/obstructingexitpath x x x Eliminateexit FireAlarmorSprinklerImpairment x Min.4hr.within24hr.under8hrs.Nohotwork. Min.4hr.within24hr.over8hrs.Nohotwork. x Over24hrs.Nohotwork. x Min.4hr.within24hr.under8hrs.Hotwork. x Businessoccupancy. Min.4hr.within24hr.over8hrs.Hotwork. x Businessoccupancy. Over24hrs.Hotwork.Businessoccupancy. x Min.4hr.within24hr.under8hrs.Hotwork. x Inpatientinsamecompartment. Min.4hr.within24hr.over8hrs.Hotwork. x Inpatientinsamecompartment. Over24hrs.Hotwork.Inpatientinsame x FlammableMaterials HotWorkOutside x Note:Providedocumentationfortheseelementsofperformance.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

Project Risk Assessment ProjectEquipmentOnly___

Location(s)

EvaluationDate ConstructionDates Start Finish

WBS/WorkOrder/CostCenter

ProjectManager

Contractor

DescriptionofWork

Category LifeSafety ‐Egress ‐Compartmentation ‐FireAlarm/Suppression ‐Flammables/Combustibles ‐HotWork InfectionControl ‐RiskLevel/Group# ‐Measures

Evaluation

UtilityCompromises

Noise,Vibration,Odor, Dust Security‐Lockedsites, AfterHourNotification HazardousMaterials‐MSDS, Labels,PPE,ChemicalSpills MedicalEmergencies ‐Bloodbornepathogens ConfinedSpace Miscellaneous ‐CellPhones ‐HIPAA ‐ProperAttire ConstructionManagementPlanElements

ProjectManager_______________________________ILSMCommittee/EHS___________________________ Safety and Commissioning Manual 2010

Facilities De Page 18 Johns Hopkin

ILSM Decision Table

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

LifeSafety InterimLifeSafetyMeasure(ILSM) Compromise(LSC)

Additional(ILSM) forExtendedConditions

AlarmSystems

CompartmentationTraining ConfirmRestoration ControlFlammable/CombustibleMaterials FireExtinguishers FireSafetyTraining FireWatch Lockout/Tagout NotifyFireDepartment NotifySecurity SubmitOutage

ClientCoordination AdditionalFireFightingTraining CLASPSurveillance DoubleSurveillance TemporaryDetection

Compartmentation

CompartmentationTraining ConfirmRestoration ControlFlammable/CombustibleMaterials FireSafetyTraining SubmitOutage

AdditionalFireDrill/Shift/Quarter AdditionalFireFightingTraining CLASPSurveillance DoubleSurveillance TemporaryDetection FireExtinguishers

DetectionSystems

CompartmentationTraining ConfirmRestoration ControlFlammable/CombustibleMaterials FireExtinguishers FireSafetyTraining FireWatch Lockout/Tagout NotifyFireDepartment NotifySecurity SubmitOutage

ClientCoordination AdditionalFireFightingTraining CLASPSurveillance DoubleSurveillance TemporaryDetection

Egress

ClientCoordination CLASPSurveillance ControlFlammable/CombustibleMaterials Detours EgressPlan FireSafetyTraining InspectExitsDaily NotifyFireDepartment NotifySecurity ClientCoordination Signage SubmitOutage

AdditionalFireDrill/Shift/Quarter

Flammables/ Combustibles

CLASPSurveillance CompartmentationTraining ControlFlammable/CombustibleMaterials FireExtinguishers FireSafetyTraining FireWatch SubmitOutage

AdditionalFireDrill/Shift/Quarter AdditionalFireFightingTraining DoubleSurveillance TemporaryDetection

ILSM Decision Table (cont.) Safety and Commissioning Manual 2010

Page 20

Facilities Department Johns Hopkins Health System

LifeSafety Compromise(LSC)

InterimLifeSafetyMeasure(ILSM) Additional(ILSM) forExtendedConditions

HotWork

CLASPSurveillance AdditionalFireFightingTraining CompartmentationTraining DoubleSurveillance ConfirmRestoration TemporaryDetection ControlFlammable/CombustibleMaterials FireExtinguishers FireSafetyTraining FireWatch NotifyFireDepartment Signage SmokeEvacuationPlan SubmitHotWorkPermit SubmitOutage

Storage

MaintainEgress Onlynon‐flammables Signage SubmitOutage

SuppressionSystems

CLASPSurveillance AdditionalFireFightingTraining ClientCoordination DoubleSurveillance CompartmentationTraining TemporaryDetection ConfirmRestoration ControlFlammable/CombustibleMaterials FireExtinguishers FireSafetyTraining FireWatch Lockout/Tagout NotifyFireDepartment StopHotWorkPermits SubmitOutage

UtilityCompromise TemporarySafeguard

AdditionalTemporary SafeguardsforExtended

ChilledWater CondenserWater DomesticWater Electric HeatingWater HVACR NaturalGas NurseCall PneumaticTube EVAC LabAir LabVacuum MedicalAir Nitrogen NitrousOxide Oxygen Steam WAGD Elevator

TemporarySystem

ClientCoordination ConfirmRestoration Lockout/Tagout Signage

ClientCoordination ConfirmRestoration Detours Lockout/Tagout NotifyFireDepartment NotifySecurity Signage

Safety and Commissioning Manual 2010

Page 21

Facilities Department Johns Hopkins Health System

ILSM Decision Table OtherCompromise

TemporarySafeguard

ConfinedSpace

Pre‐approvalMeetingwithSafety

Additional Temporary Safeguardsfor

SubmitConfinedSpacePermitPlan SubmitOutage HazardousMaterials

AirFilters CoverHauledMaterials DustTightBarriers EmployIndustrialHygienist FrequentCleaning NegativeAir Notifications ProtectiveClothing Signage SubmitOutage

InfectionControl

CleanTracks CoverHauledMaterials

AirFilters NegativeAir

DustTightBarriers

ProtectiveClothing

FrequentCleaning InfectionControlInspections StandingWaterDried WalkOffMatsMaintained NoxiousandToxicMaterials MaintainMSDS PersonalProtectiveEquipment ProperLabeling Storage

Onlynon‐flammables Maintainegress Maintainaccesstoswitches, valves,panelboards,cabinets,etc. Postoutageonthedoor.

(cont.)

Safety and Commissioning Manual 2010

Cleanareaafteruse.Acceptanceof thisareaisalineitemofthe projectfinalinspection. SubmitOutage

Page 22

Facilities Department Johns Hopkins Health System

Facilities Engineering Supervisor Worksheet Life Safety Compromise/Interim Life Safety Measure Matrix Date: EmployeeName: WO#: WODescription:

ILSM CLASPSurveillance ClientNotification CompartmentationTraining ConfirmRestoration ControlFlammable/ CombustibleMaterials Detours EgressPlan FireExtinguishers FireSafetyTraining FireWatch InspectExitsDaily Lockout/Tagout NotifyFireDepartment NotifySecurity Signage SmokeEvacuationPlan StopHotWorkPermits SubmitHotWorkPermit SubmitOutage/IncidentReport

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

SubmitOutage/ IncidentReport

X

X

SubmitHotWorkPermit

X

StopHotWorkPermits

X

SmokeEvacuationPlan

X

X

Signage

InspectExitsDaily

FireWatch

FireSafetyTraining

FireExtinguishers

EgressPlan

X

NotifySecurity

X X X X X X X

Detours

ControlFlammable/ CombustibleMaterials

X X X

NotifyFireDepartment

X X

X X X

Lockout/Tagout

X X X X

ConfirmRestoration

ClientNotification X

CompartmentationTraining

AlarmSystems Compartmentation DetectionSystems Egress Flammables/Combustibles HotWork SuppressionSystems

CLASPSurveillance

Check All That Apply LIFESAFETYCOMPROMISE

Building: Floor: Room:

X X X X X X X

SupervisorAction Performroundsatthebeginningofeachshift.CompleteCLASPFireSurveillanceForm,scanto ILSMgrouponBillingsBasem*ntCopier Notifytenantsfirstshift,AdministratoronCall,off‐shifts Noaction AppropriateSupervisorensuresdeficiencyisrepaired RemoveexcessivecombustiblesfoundonFireSurveillanceRounds NotifySafety,allshifts,AdministratoronCall Redirectpatient/publictraffictonearestalternateexit.Altermisleadingexitsigns. Additionalextinguisherrequiredforevery5,000sq.ft.ofwork Noaction Performroundsatthebeginningofeachshift.CompleteCLASPFireSurveillanceForm,scanto ILSMgrouponBillingsBasem*ntCopier CompleteFireSurveillanceForm.ScantoPaul,TheresaandSam. FollowDepartmentalprocedures FaxthisformtoBCFDwithstandardcoversheetlocatedat S:\ILSMInformation\ILSMFaxCoversheet.docx Submissionofoutage/incidentreportwillautosendemail,orcallx5‐5585 Postcomputergeneratedsignsinformingoccupantsofcondition.IncludeFacilitiesnameand phonenumberx5‐5770.PostsignonblueJHMBulletinposterboard. ContactFacilitiesCLASPCoordinator Contactstaff/contractorsthatholdapprovedhotworkpermitstohaltwork FollowDepartmentalprocedures Byendofshift

ILSM(s)havebeenimplementedasof

Date Date

Supervisor Deficiencycorrectedat__________________AM/PM

On

Supervisor

Date Date

SCANTHISDOCUMENTTOTHEILSMGROUPONTHEBILLINGSBAsem*nTCOPIER Safety and Commissioning Manual 2010

Page 23

Facilities Department Johns Hopkins Health System

Hazard Communication

Also called OSHA’s “Employee Right-to Know” law.

States every employee has a right to know every hazard associated with each chemical they work with.

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

Material Safety Data Sheets (MSDS) - are documents that contain all pertinent information about a chemical. All MSDSs are kept in the EB Health, Safety and Environment Office at (410) 955-5918 or the JHBMC Security Office at (410) 550-0333.

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

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

Chemicals Spills should be cleaned up by the users according to the label/MSDS instructions. If the spill is of such a magnitude that the users are unable to contain it, at JHH, call the Centrex emergency number, (410) 955-4444, and at JHBMC, call (410) 550-0222.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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. 2. Dispose of all materials with blood/body fluids into red bags and sharps into sharps containers prior to disposal in red bags. 3. Wear Personal Protective Equipment!! Gloves and eye/face protection (safety glasses, goggles, face shields). 4. Receive the Hepatitis B vaccine 5. Hand washing is still the most effective means to prevent transmission. Steps to follow if you are exposed: 1. Wash the exposed site 2. 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. 3. If recommended, initiate Post-Exposure Prophylaxis (PEP) within 1 - 2 hours after exposure for optimum efficacy. 4. Complete incident report

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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

Notice of Asbestos Abatement Contractors complete this form. At JHH, fax it to (410) 955-5929; at JHBMC, fax it to EHS at (410) 550-3049; AND fax a copy to your Project Manager at (410) 550-3068 or Maintenance supervisor at (410) 550-1096. At Bayview, all documentation related to the testing, removal, transport and certification needs to be sent to the EHS and PM or FES. 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. ____________________ Safety and Commissioning Manual 2010

Contact Name: ______________________________

Page 26

Facilities Department Johns Hopkins Health System

CLASP Surveillance Procedures Purpose 1. Provide a firewatch during off hours. 2. Identify safety compromises. 3. Identify workmanship deficiencies or maintenance related problems. Procedures 1. Each Project Manager (PM) shall, on a periodic or as needed basis, submit to the Construction Safety Coordinator (CSC/FES) the names of those projects that require off-hour surveillance. The CSC/FES 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. 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 form shall represent one completed surveillance visit per site. Each form shall be sent to the CSC/FES 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 shall discuss any deficiencies noted on the surveillance report with the PM. The PM shall report deficiencies to the contractor for correction. Compliance will be noted in progress meeting minutes.

CLASP Surveillance Checklist

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

Category

Lo catio n

P ro ject M anager

Date

Inspecto r

Co ntracto r

Time

Meets Standards Y/N/NA

Description

Life Safety

1 Exits clear and unlocked? 2 Exits & w alkw ays clearly marked and w ell lighted? 3 Fire doors blocked open? 4 Doors in good w orking order? 5 Extinguisher present and accessible? 6 Sprinkler heads blocked? 7 Sprinkler head heat collectors there? 8 Signs of smoking?

Infection Control

Injury

Security

9 Combustible trash or materials minimized? 10 Fire w alls and slabs compromised? 11 Construction barriers smoke tight? 12 Detector heads bagged? 13 Proper signage at construction entrance? 14 Construction entrance locked? 15 Mechanical/electrical rooms locked? 16 Compressed gas cylinders secured? 17 Electric panel covers in place? 18 Barrier dust tight? 19 Negative air sufficient? 20 Interior clean? 21 Walkoff mats present and clean? 22 Standing w ater?

23 Hazardous chemicals labeled & stored Additional Comments

Safety and Commissioning Manual 2010

Page 28

Facilities Department Johns Hopkins Health System

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 firestopping integrity.

Procedures 1. Applicant must obtain and completely fill out top section of the Ceiling Permit. At JHH, attach the location and routing information on the Fire Safety Feature Spacebook plans. At JHH, submit it a minimum 48 hours and at JHBMC 72 hours before to the CSC . 2.

The CSC/ESM reviews the permit application, addresses infection control measures and other concerns. If required, the CSC/ESM, will schedule an inspection date, time and place and put it on the permit. The applicant is required to attend the inspection.

3.

At JHH, the CSC/ESN 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/ESM. At JHBMC, contact the Facilities Call Center at (410) 550-0260.

4.

Contact the CSC/ESM if there are changes to the initial permit and it will then be reissued.

5.

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/ESM.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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

* At JHH Use the Fire Safety Features Option

Safety and Commissioning Manual 2010

Date

Work Order Number

See Ceiling Permit Procedures on the reverse side.

Page 30

Revised 3/10

Facilities Department Johns Hopkins Health System

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.  It’s 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 apergillosis.  It lodges in the lungs or sinuses of the patient.  It is hard to treat and can be fatal. Patients can be protected by preventing the spread of Aspergillus spores outside of the construction site. Project Planning Conducting the risk assessment found in Specification 01110 key to a successful and safe project. All projects must consider:  Temporary containments  Negative air  Access routes  Walkoff mats  Cleaning schedule  HEPA Units Protecting the Worksite Temporary Containments  Separates the clean from the dirty areas.  Provides space that can be put under negative air.  Containments can either be:  existing walls and ceilings  fire retardant plastic  fire retardant plastic and/or drywall with metal studs  Containment construction rules at patient care and fire egress areas:  One shift - Use fire retardant 6 mil poly  More than one shift – Use drywall on metal studs.  Replacing a fire rated partition – Use drywall on metal studs  Internal spaces not applying to anything above – Use fire retardant 6 mil poly Safety and Commissioning Manual 2010

Page 31

Facilities Department Johns Hopkins Health System

Negative Air Pressure  Insures dust in the air moves into the containment.  Can be achieved by blowing air outside with fans and possibly using the building exhaust system.  It must be maintained 24/7.  Negative pressure indicators and alarms ensure maintenance of the negative pressure. Planned Access Routes  Choose routes that least impact patient areas.  Contain, cover and/or clean dusty materials and personnel. Mobile Containment Units  Useful in small isolated locations and activities.  Be careful of dust when entering and exiting the unit. It is best to use HEPA vacuums to remove dust from the unit and your body. Portable HEPA Filtration Units  Units placed just inside and outside the site entrance filters the air effectively.  They can also be used to create negative air as a fan would. HEPA Vacuums  Take dust out of the air as it works.  Use to clean entrance areas.  Must use in a portable containment unit.  Required use for every infection control project. Inspections All infection control measures must be inspected and approved:  Prior to the start of construction  When there is a change in the configuration of the containment or any other change in the practicing of infection control measures.  When a request to reduce or increase the class of infection control rating.  All class 3 and 4 projects will be inspected by Prime Contractor daily using the checklist inserted in this manual. The Owner will also inspect all class 3 and 4 projects daily.  Request the removal of infection control measures by submitting an inspection through the Commissioning and Inspection procedures found later in this manual. The Hospital must be assured of the cleanliness of the site. Personal Health Workers cannot be on site if they have flu, tuberculosis, or any other infectious diseases. If you need help contact in this order:  The Project Manager. At JHH, call (410) 955-5900. At JHBMC, call (410) 550-0286.  CSC. At JHH, call (410) 955-5900. At JHBMC, call (410) 550-0228.  At JHH, the Hospital Epidemiology and Infection Control Department at (410) 955-8384. At JHBMC, the Infection Control Department at (410) 550-0515.

Safety and Commissioning Manual 2010

Page 32

Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

Section 01110 - Infection Control PART 1 - GENERAL RELATED DOCUMENTS Drawings and general provisions of the Contract, including General and Other Conditions and other Division 1 Specifications Sections apply to this section.

SUMMARY This section contains infection control procedures for work performed within all areas of the facility. Related Sections: The following sections contain requirements that relate to this Section: Division 1 Section “Allowances” Division 1 Section “Hospital Procedures” Division 1 Section “Cutting and Patching” Division 1 Section “Construction Facilities” Division 1 Section “Submittals” Division 1 Section “Schedules and Reports” Division 2 Section “Selective Demolition” Division 2 Section “Earthwork”

Products installed and furnished under this Section include, but are not limited to, the following Sections: Division 6 Section “Rough Carpentry” Division 9 Section “Gypsum Board Assemblies” Division 9 Section “Painting” Division 15 Section “System Balancing & Performance Tests” Division 15 Section “Air Distribution”

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

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. TYPE A

Inspection and Non-invasive Activities Includes, but is not limited to:

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

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

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building component or assembly Includes, but is not limited to: ▪ sanding walls for painting or wallcovering

▪ removing floorcoverings, ceiling tiles and casework ▪ new wall construction

▪ minor ductwork or electrical work above ceilings ▪ major cabling activities ▪ any activity that cannot be completed within a single work shift TYPE D

Major demolition and construction projects Includes, but is not limited to:

▪ activities which require consecutive work shifts▪

▪ requires heavy demolition or removal of a complete cabling system ▪ new construction

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

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

DEFINITION OF INFECTION CONTROL RISK AREA/LOCATION JHH: Level of Risk GROUP O

GROUP 1

GROUP 2

GROUP 3

GROUP 4

LOWEST

LOW

MEDIUM

MEDIUM HIGH

HIGHEST

Detached buildings

 Office areas

 Patient care areas not

 Areas not

communicating with patient care

 Emergency Rooms

specified as group 3 or 4

 Radiology

 Laundry

 Post-anesthesia Care

 Cafeteria

units, except Weinberg

 Weinberg building: IPOP, HIPOP, 4 & 5 A, B, C, D, 3A WICU, Radiation therapy basem*nt, 2 Chemo infusion,1,

 Dietary

 Nelson 2 Labor & Delivery

 Materials Management

 Newborn Nurseries

 PT/OT/Speech

 Newborn Intensive Care

 Osler 8

 Admission/Discharge

unit

 Nelson 4,6 & 7

 Pediatrics not specified as

 CMSC 8 E & W

 Echocardiography

group 4

 Intensive Care Units, not

 Pharmacy Admixture

 Laboratories not

specified as group 4

Weinberg OR & PACU, Wilmer

 MRI  Nuclear Medicine

clinical area

 Moore Clinic

 Operating Rooms, GOR,

specified as Group 3

 Microbiology lab

 Public Corridors where

 Virology lab

patients, supplies, and

 Long term/sub-acute

 Sterile Processing

linen pass

units

 CVDL (CMSC 5)

 Pharmacy

 Cardiac Catheterization

 Dialysis

 Outpatient invasive

 Endoscopy  Bronchoscopy areas, including Blalock &

OR, JHOPC OR, Greenspring  C Section Rooms

procedures rooms  Oncology Units

 Anesthesia and Pump areas

Meyerhoff Unit

DEFINITION OF INFECTION CONTROL RISK AREA/LOCATION JHBMC: Level of Risk by Hospital Location Low Risk

Medium Risk

High Risk

Highest Risk

Office areas

Echocardiography

CCU

Burn Unit and Burn Rehab

Areas not

Endoscopy

Emergency Room

Cardiac Cath Lab

patient care areas

Rehab Therapy (except Burn)

A2W (maternal child unit)

Intensive Care Units

Radiology/MRI

Laboratories (specimen)

Medical Units

Respiratory Therapy

Newborn Nursery

Negative pressure isolation rooms

Public corridors where

Outpatient Surgery

Oncology Clinic

patients, patient supplies

Pediatrics

Operating rooms including C-

and linen may be present

Pharmacy

section rooms

Admitting

Post Anesthesia Care Unit

Dialysis Unit

Patient areas not specified

Linen Room

insertion procedures are

communicating with

Nuclear Medicine

Cafeteria

Labor & Delivery

Surgical Units

for high or highest risk

Safety and Commissioning Manual 2010

Central Sterile Supply

Outpatient treatment rooms where performed

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

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 renovation projects. CONSTRUCTION ACTIVITY MATRIX CONSTRUCTION ACTIVITY

TYPE “A”

TYPE “B”

TYPE “C”

TYPE “D”

RISK LEVEL Group 0 Lowest Risk

Class 0

Class 0

Class 0

Class 0

Group I

Class I

Class II

Class II

Class III/IV

Group 2 Medium Risk

Class I

Class II

Class III

Class IV

Group 3 High Risk

Class I

Class III

Class III/IV

Class IV

Group 4 Highest Risk

Class III

Class III/IV

Class III/IV

Class IV

Low Risk

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

INFECTION CONTROL CONSTRUCTION GUIDELINES CLASS 0

 No infection control measures required.

CLASS I

 Execute work by methods to minimize raising dust from construction operations.

CLASS II

 Isolate HVAC system in areas where work is being performed.

 Replace any ceiling tile displaced for visual inspection as soon as possible.  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.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

 Isolate HVAC system in area where work is being done to prevent contamination of the duct CLASS III

system.

 Place dust-mat at entrance and exit of work area and replace or clean when no longer effective.  Maintain negative air pressure within work site utilizing HEPA filtered ventilation units or other methods.

 Complete all construction barriers before construction begins. Request an inspection from the Owner prior to construction.  Maintain barrier integrity.

 Close doors and install project sign.  Wet mop or HEPA vacuum twice per 8-hour period of construction activity or as required in order to minimize tracking.

 Contain construction waste before transport in tightly covered containers  Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

 Barrier material should be wet wiped, HEPA vacuumed or water misted prior to removal.  Establish traffic patterns that minimize exposure to patient care areas.  Quickly dry water spills.

 Wipe casework and horizontal surfaces at completion of project.  Do not remove barriers from work area until completed project is thoroughly cleaned. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction. Barrier material should be wet wiped, HEPA vacuumed or water misted prior to removal.

Request

an inspection from the Owner prior to construction.  Isolate HVAC system in area where work is being done to prevent contamination of duct system. CLASS IV

 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 to minimize tracking.

 Wet mop or HEPA vacuum the construction interior area once per 8-hour shift, minimum.  During demolition, dust producing work or work in the ceiling, disposable shoes and coveralls are to be worn and removed in the anteroom when leaving work area.

 Contain construction waste before transport in tightly covered containers.  Place dust-mat at entrance and exit of work area and replace or clean when no longer effective.  Keep work area broom clean and remove debris daily.

 Wet mop hard surface areas with disinfectant at completion of project. HEPA vacuum carpeted surfaces at completion of project  Maintain barrier integrity.

 Close doors and install project sign.  Establish traffic patterns that minimize exposure to patient care areas.  Quickly dry water spills.  Wipe casework and horizontal surfaces at completion of project.

SUBMITTALS Product data: Portable HEPA filtered air-handling equipment

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

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.

QUALITY 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 insure continuous negative air pressures 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 preconstruction conference and attend all orientation and training sessions as required by the owner.

Part 2 - Products Manufacturers And/Or Suppliers Adhesive Walk-Off Mats:

3 M, 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

Filters:

reinforced, Ventilator Blower Hose Throwaway type fiberglass filters, 1 inch deep, up to 350 fpm rated velocity, 0.04 inch water gauge initial resistance, 72% average arrestance, 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 2000 HC or Model PAS 1000HC equipped air filtration units or equivalent. Provide HEPA filter, primary and secondary filters.

Negative Air Indicator:

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

Molded Plastic Manometer, Dwyer Instruments, Inc., P.O. Box 373, Michigan City, Indiana

46361, (219)

879-8000, www.dwyer-inst.com, model Mark !! Model No. 25 Inclined-vertical

Manometer Portable Work Enclosures:

Kontrol Kube - Fiberlock Technologies, Inc. Or approved equal. Zip-Up Door System:

Protective Products, Inc. or approved equal Mintie Technologies, Inc., www.mintie.com or approved equal

Zip Wall LLC, Cambridge, Mass., or approved equal.

Part 3 - Execution Preparation Contractor will notify the Owner of planned work and obtain approval prior to start of work by submitting an Outage.

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

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. 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.

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

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

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

Install, deck to deck, construction barriers of 3-5/8” metal studs at 16” on center with 5/8” 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 sides.

weather-stripping and closer. Provide an area for mats approximately 24” x 48” both

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. Seal all penetrations at existing perimeter walls and floor slabs. Place isolation barriers at penetration of ceiling envelopes, chases and ceiling spaces to stop movement of air and debris.

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

Prevent birds and insects from gaining access to the hospital and hospital air-intake ducts. Exterior

openings will remain closed when not in use. 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 Delivery and removal of supplies, and equipment may be restricted to a specific period of time when patient/staff activity is minimized. Specific routing will be required. 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

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

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

Ductwork materials will be stored in a clean, dry area to prevent the accumulation of dust in the

ductwork prior to installation.

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

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

Ventilation 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.

Insure 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.

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.

Contractor is responsible for maintaining 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.

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

Housekeeping 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.

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

USE BLEACH IN A WELL-VENTILATED AREA. DO NOT MIX BLEACH WITH OTHER CLEANING CHEMICALS, ESPECIALLY THOSE CONTAINING AMMONIA. POISONOUS VAPORS WILL RESULT.

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

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.

Adhesive walk-off mats should be changed daily, or more frequently as needed, to maintain adhesive surfaces. Mats shall be installed and maintained by the Contractor. 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.

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.

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.

Protective Clothing Disposable shoe covers, head and coveralls are to be worn during demolition and other specified times. Protective clothing shall be provided by the Contractor. Protective clothing will be removed any time the worker leaves the immediate work area. 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. Entering and exiting work area:

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

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 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.

All gypsum and wallboard materials must be installed 1/2” above finish floor materials to illuminate any potential wicking of moisture. Stored Materials: Any material exposed to moisture prior to installation shall be disposed of. Installed Materials: Any material installed, prior to receiving finishes, exposed to moisture shall be removed and disposed of.

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 12” beyond damaged areas as directed by the owner. 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 of water. Strictly follow all manufacturer requirements for use of chlorine based products.

DO NOT rinse with water after application.

Caution chlorine may cause damage to

materials or fade colors, contractor to confirm reactions to chlorine. 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 effected areas. Warrantees: If any recommended cleaning methods would void any warrantees, the material shall be replaced.

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

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

August, 2008

The Johns Hopkins Hospital Standard Specification

Infection Control Section 01110

EMERGENCY SITUATIONS 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. The overall risk to the patient

from both the emergency and Aspergillus 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 Work 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. The Contractor shall vacuum the isolation barrier area with approved HEPA filter equipment. 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.

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.

The Contractor will remove all blockages from the air systems. Owner will examine the HVAC equipment and filters for blockage and/or leakage.

Plumbing Atlerations Exercise caution when handling fluids (i.e. removing plumbing pipes and fixtures) to prevent wetting of building materials and/or contamination of work areas. Cap unused domestic water pipe branches at no more than three pipe diameters from the main line.

END OF SECTION 01110

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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 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 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. 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.

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 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.

Safety and Commissioning Manual 2009

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Facilities Department Johns Hopkins Health System

8.

Prime Contractors with Class 1 and 2 ratings are to comply with specified guidelines. The PM/CSC will inspect on an as needed bases.

9.

If any Class project has a condition that puts the Hospital at extreme risk, the CSC or PM 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.”

Safety and Commissioning Manual 2009

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Facilities Department Johns Hopkins Health System

Infection Control Checklist Instructions: To be completed daily by contractor. Please date, initial and indicated by a check mark that all items noted are being accomplished as outlined in contract documents. Please note start of work, stop and end of demo Class Date & initial

Superintendent Project #

Project Name all all all all all all all all all all IV Exterior Negative Air Barrier Doors Interior Hauled Tracks Mats Signage Clothing cleaned Air Filters Integrity Closed Clean Debris Cleaned Clean Posted Covered daily Clean Ok /secured Covered

Safety and Commissioning Manual 2009

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all No water on floor

rev 3/5/06

Facilities Department Johns Hopkins Health System

INFECTION CONTROL - JHBMC CONSTRUCTION PERMIT

Safety and Commissioning Manual 2009

Page 48

Facilities Department Johns Hopkins Health System

JHH Online Outage System

Revision 2.4 10/2008

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

TABLE OF CONTENTS IntendedAudience...........................................................................................................................52 Purpose............................................................................................................................................52 Figure 1: Online Outage System Workflow.......................................................................................53 UsingtheOnlineOutageSystem.....................................................................................................54 Figure 2: Facilities Intranet Homepage..............................................................................................54 OutagesHome.................................................................................................................................55 Figure 3: Online Outage System Login Screen................................................................................55 Figure 4: Online Outage System Homepage....................................................................................56 Figure 5: Option Sub-menu..................................................................................................................57 Request Outage............................................................................................................................58 Figure 6: Request New Outage...........................................................................................................58 Figure 7: Calendar Pop-up Window....................................................................................................59 Figure 8: Emergency Warning.............................................................................................................60 ModifyOutage.................................................................................................................................61 Figure 9: Outage Selection Criteria....................................................................................................61 Figure 10: Outage Modification Form..................................................................................................62 Figure 11: Link to Outage Information Request and Project Manager Approval..........................63 Figure 12: Outage Information Request..............................................................................................64 Approve Outage............................................................................................................................65 Project Manager Approval...........................................................................................................65 Client Approval..............................................................................................................................65 Figure 13: Client Approval Screen.......................................................................................................66 Shop Approval...............................................................................................................................66 Figure 14: Shop Approval Screen........................................................................................................67 System Restoration.......................................................................................................................68 Figure 15: System Restoration Routine..............................................................................................68 Request Outage Extension..........................................................................................................69 Figure 16: Outage Extensions..............................................................................................................69 Cancel Outage...............................................................................................................................70 Figure 17: Cancel Outage Screen......................................................................................................70 View and Print Outage.................................................................................................................71 Figure 18: View and Print Outage........................................................................................................71 Status Report.................................................................................................................................72 Figure 19: Status Report Selection Criteria........................................................................................72 Figure 20: Status Report......................................................................................................................73 Add/View Attachments.................................................................................................................74 Figure 21: Add/View Attachments Screen..........................................................................................74 Other Options................................................................................................................................75 Print Hot Work Permit...................................................................................................................75 Change Password.........................................................................................................................75 Email Notifications.........................................................................................................................75 Figure 22: Email Notification Matrix.....................................................................................................75 Reporting........................................................................................................................................76 Status Report.................................................................................................................................76 Delinquency Report......................................................................................................................76 Figure 23: Delinquency Report.............................................................................................................76 Contractor PC................................................................................................................................77 Start-up Procedure..................................................................................................................................77 Printing Procedure...................................................................................................................................77 Scanning Procedure................................................................................................................................78 Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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 Safety and Commissioning Manual 2010

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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/FacilitiesV3/ The first page you will see will look like the following:

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

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

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

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

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

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

Figure 5: Option Sub-menu In this example, the contractor has the ability to do the following:  Request New Outage  Modify Outage  Request Outage Extension  Add/View Attachments  Print Hot Work Permit  Cancel Outage  Change Password Each Outage option will be discussed in further detail in the following sections.

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

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

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

icon. This will bring up a pop-up window that looks like the following:

Figure 7: Calendar Pop-up Window In the calendar view, the current day will be highlighted with light grey and any weekend days will be in dark grey. If you wish to move to the previous or next month, you may use the month icon located at the top left and right. Clicking on any day will result in that day being entered as the date on the outage form. Please note that though the times default to 7:30 AM and 3:00 PM, they may be changed. However, you must enter the time in the format HH:MM AM/PM. The 24HR? checkbox can be used to default the start and end times to 12:00 AM and 11:59 PM respectively. Separate outages must be submitted if the outage is both on the weekend and weekday. Click the Weekend Outage checkbox for only the weekend outage. When selecting the Building(s) in the Work Area Information section, please note that it is possible to select more than one building by using the Control key on the keyboard. The same holds true for the Floor(s). The minus sign indicates floors below the 1st or ground floor. The Affected Area section differs from the Work Area section where an 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. Safety and Commissioning Manual 2010

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

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

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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 then being taken directly to the entry from, you are taken to the following screen:

Figure 9: Outage Selection Criteria Since the Outage already exists, it is necessary to select Outage Modify. On this screen, 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 10: 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 11: Link to Outage Information Request and Project Manager Approval Once on the Outage Information Request page, select the participants you want to receive this modification. By default, the From address will be the email address associated with the currently logged-on user. Each party associated with the Outage will be listed under the To field. For each person who is to receive the email, the checkbox must be clicked. If an email should be sent to everyone, the Select All button can be clicked. The Subject is defaulted to “Information Request for Outage#” and then the Outage number. The Body of the email will consists of all current PM/Contractor comments as well as all current Staff Comments. Additional comments can be entered in the corresponding textboxes. These comments will then be saved with the outage. Use the information request procedure to respond to an information request you have received. Click the Send Message button at the bottom of the page.

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

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

Shop Approval After the Project Manager approves the Outage, an Outage Administrator is responsible for assigning the different shops or groups to approve an Outage. Once this is done, each shop will be notified via email that they need to approve the Outage. To perform this action, click on Shop on the Outage homepage and click on Approve Outage. A screen to select the outage will be seen; however, there is a filter already applied that only allows the user to select an Outage for which his or her shop must approve. Using the process described earlier, select the Outage that needs to be approved. Safety and Commissioning Manual 2010

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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 14: Shop Approval Screen Construction Safety Coordinator and Health, Safety and Environment Approval Once all the clients and shops have approved the Outage, it is ready to receive final approval. Both the Construction Safety Coordinator (CSC) and Health, Safety and Environment (HSE) approve the Outage. To approve the Outage, select either the Outage Administrator or Health, Safety and Environment tab on the page and click on the option Modify Outage and choose Yes , and then click Submit at the bottom of the page. The By and Date fields will automatically be populated with the appropriate data. Safety and Commissioning Manual 2010

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

Figure 16: Outage Extensions The important part to notice on an extension is that the original start and end dates are shown in read-only format. The new start date must be greater than or less than the original date in order for the outage to be accepted. Safety and Commissioning Manual 2010

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

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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 18: 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, then click on Status Report. A screenshot of the Status Report Selection criteria can be seen below.

Figure 19: Status Report Selection Criteria

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

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

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

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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 All parties involved with Outage Contractor All parties involved with Outage Email to Outage Administrators Facilities Director

Figure 22: Email Notification Matrix

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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 23: Delinquency Report Safety and Commissioning Manual 2010

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Contractor PC There is a computer located in the Orleans Garage, Level 5, Trailer A Lobby for use by anyone not have ready access to a computer, scanner and printer. 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 deskstop 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. Click OK and the desktop screen should appear. You are not to log off, but sometimes it happens. In this case, follow the step to get to the deskstop screen: 1. Press Ctrl-Alt-Delete. 2. Click OK and the desktop screen should appear. Once you are on the desktop screen: 1. Press Ctrl-Alt-Delete. 2. Click Design and Construction. 3. Click Outages. Printing Procedure 1. 2. 3. 4.

Click Facilities Department icon, unless you are already in the outage system. Click Print Outages. Select desired outage. Click the Print Outage Button.

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Contractor PC (cont.) Scanning Procedure 1. Submit the outage and retain the outage number. 2. Close the outage system by clicking the red X in the upper right hand corner of the first screen. 3. Click the PaperPort icon. 4. The scanner should always be set at WIA-Visioneer9650. 5. Place one sheet at a time into the feeder (top tray). If you have a bound document, use the lower tray (feed bed). 6. Make your selection at the Scan What box. 7. Click the Scan button. 8. Select the paper source. 9. Click Black and White Picture or Text unless it’s a photo. If it is a photo, then choose Color or Gray Scale Picture. 10. Select Scan More Pages or Done from the prompt. 11. Click Preview. 12. Click Adjust Quality of the scanned picture. 13. Adjust Brightness. 14. Click OK. 15. Click Scan. 16. Click Scan More Pages or Done. 17. Click File at the top of the screen above the task bar. 18. Click Save As. 19. At the File Name, type outage and the actual outage number. 20. Click Save. 21. Close PaperPort at the upper right hand corner at the red X. 22. Click Facilities Department. 23. Click Contractor Add/View Attachments. 24. Select outage number. 25. Log in. 26. Click Browse. 27. Click My Paper Port Documents. 28. Click the file with your outage number on it. If you cannot find it, please contact an Outage Administrator. 29. Copy the file name into the File Description box. 30. Click Upload.

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JHBMC Outage Workflow

Figure 12: Outage System Workflow

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JHBMC Request for Outage

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JHBMC Hot Work Permit Environmental Health and Safety Date___________

Project #_____________ Project Name________________

JHBMC Representative: ___________________

Contractor Name: _____________________ Contractor Representative: _______________________ Phone No: _______________ Building: ___________ Floor______ Room (s) _______ Work to Be Done : __________________________________________ ___________________________________________________________________________________________________________ Beginning Date: ___________ Anticipated End Date:_______________

Start time/End time:___________________________

Revised Anticipated End Date: ____________________________________

Approval Initials: _________________

Revised Anticipated End Date: ____________________________________

Approval Initials: _________________

Revised Anticipated End Date: ____________________________________

Approval Initials: _________________

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

PRECAUTIONS

To Be Completed At Work Site

Yes

No

N/A

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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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, July 1, 2003, 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. 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.

4)

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

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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. 5)

The Prime Contractor shall apply for inspections in any of the following ways: JHH Email the attached form to the Front Desk at:: [emailprotected]  FAX the Front Desk at: (410) 502-6924 

JHBMC Email the attached form to the Call Center at: [emailprotected]  FAX the Call Center at: (410) 550-1096 

There is an electronic form for the email and fax submissions. They may be obtained through the Project Manager. A copy is inserted in this manual. On this form the Prime Contractor will need to provide the following information:        

Hospital Project Manager Project title Hospital Project number Prime Contractor on-site contact, phone and/or pager number Desired date and time for the inspection Location of inspection within project site or other if multiple sites Type of inspection and/or test (see item 8) Type(s) of commissioners required:    

Architectural Firestopping Plumbing Medical Gases

   

Fire alarm/Sprinkler HVAC Electrical Other (provide description)

After applying for the inspection request, at JHH, the Front Desk and at JHBMC, the Call Center, will provide the Prime Contractor with a control number (aka: Work Order Number); all effort will be made by the Owner to have this control number available immediately, but if not, instructions will be provided to the Prime Contractor on how to retrieve the control number within four hours. Hard copies of all inspection requests will be maintained at JHH, at Billings Building, Room B-120 and at JHBMC, at Call Center, 5550 Warehouse until the time of the Safety and Commissioning Manual 2010

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inspection. The applicable owner commissioning staff, owner project manager and contractor of the inspection request will then be notified. 6)

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.

7)

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.

8)

The following are various tests and inspections that must be performed on every project. This list does not preclude any inspections or tests being performed that are required by the contract between Owner and Prime Contractor. Similarly, this does not preclude any inspection or test required by statute. Conversely, requirements of a contract or statute do not preclude this list of inspections and tests from being performed. 

DECOMMISSIONING INSPECTIONS. Prior to the start of salvaging and demolition there will be an inspection to select salvaged items, locate termination of services and deem all other items ready for salvage and demolition and identify items to be removed by the vacating tenant.

INFECTION CONTROL INSPECTIONS. Prior to the start and any new phase of construction, the Commissioning Staff must verify that all infection control measures are in place. An inspection is also required at the completion of the project to confirm the cleanliness of the site. Refer to the “Infection Control Policy” in this manual for details.

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

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

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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

FINAL INSPECTIONS. When the Prime Contractor has fully completed all contractual obligations, he will schedule a FINAL INSPECTION to release him from further obligation. The SUBSTANTIAL COMPLETION punch list must be fully completed at this time.

SPECIFIC INSPECTIONS AND TESTS. In addition to the foregoing, the following lists the minimum inspections and tests required for all construction, renovation and major maintenance work

    

  

MECHANICAL SYSTEMS Post demolition/pre-installation Cleaning and flushing of piped systems Cleaning ductwork Sterilization of domestic water piping Pressure testing of:  Domestic water  Sanitary  Storm  Sprinkler  Natural gas  Steam  Chilled water  Condensate  Condenser water  Refrigeration  Medical and laboratory gases  Ductwork Sprinkler operation:  Alarm systems  Drainage facilities  Inspector test Medical gas certification Insulation material and workmanship HVAC operation:  Automatic temperature control  Smoke dampers  M.O.D. dampers  Pumps  Chillers  Cooling Towers  Boilers  Air handling equipment  Training and education

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

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

Safety and Commissioning Manual 2010

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Facilities Department Johns Hopkins Health System

Inspection Request Form Johns Hopkins Hospital

Johns HopkinsBayview Medical Center

FacilitiesFront_Desk @exchange.johnshopkins.edu

BayviewFacilitiesserviceCenter @exchange.johnshopkins.edu

FAX (410) 502-6924

FAX: (410) 550-1096

Hospital Project Manager ________________________________________________________ Project Title ___________________________________________________________________

Hospital Project Number _________________________________________________________

Contractor Contact Name & Phone # _______________________________________________

Contractor Email Address ________________________________________________________

Date, Time ____________________________________________________________________

Location ______________________________________________________________________

Type of Inspection

Commissioners Required

Decommissioning Infection Control Post Demolition Wall Closure Ceiling Closure Substantial Completion Final

Architectural Plumbing Medical Gas HVAC Fire Alarm/Sprinkler Electrical All

Other _____________________________

Other _________________________

Test _______________________________

Safety and Commissioning Manual 2010

Page 88

Facilities Department Johns Hopkins Health System

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