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					Northern Arizona VA Health Care System         HCS MEMORANDUM NO. 138-FM-30
Prescott, AZ

August 2008

                         INTERIM LIFE SAFETY MEASURES

1.    INTRODUCTION: To establish Interim Life Safety Measures (ILSM) to
temporarily compensate for hazards posed by existing Life Safety Code deficiencies or
construction activities.

2.    POLICY:

       a.      ILSM shall be implemented in all healthcare areas that are under
construction or are adjacent to construction areas and throughout patient care buildings
with existing Life Safety Code deficiencies.

      b.    ILSM shall apply to all NAVAHCS personnel and all construction
personnel working on the NAVAHCS grounds.

      c.    ILSM relative to construction areas shall be implemented upon project
development, and shall be continuously enforced through project completion.

      d.     ILSM requiring the working on live electrical parts must be approved and
signed by the Director before work is to proceed.

      e.     Master work on the oxygen system and work which requires the oxygen
system to be shut down will require ILSM signed by the Director.

3.    DEFINITIONS:

       a.     Interim Life Safety Measures (ILSM) - a series of 11 administrative actions
required to temporarily compensate for the significant hazards posed by existing Life
Safety Code deficiencies or construction activities.

      b.      Resident Engineer (RE) - an Engineer assigned, by Veterans Affairs
Central Office, and responsible for a major construction project at the NAVAHCS.

        c.    Contracting Officer's Technical Representative (COTR) - A member of the
Facilities Management Projects Section assigned to oversee a local construction
project.

4.   PROCEDURES: Prior to the start of any construction project, the Safety
Manager or Supervisory Project Engineer will evaluate and document the need for
                                       Health Care System Memorandum No. 138-FM-30

Interim Life Safety Measures in accordance with the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) (Attachment 1). The official will complete an
Interim Life Safety Measures Evaluation Sheet (Attachment 2) and present it to the
Construction Safety Workgroup for review and concurrence prior to submitting it to the
Facilities Manager, or designee, for approval. The Construction Safety Workgroup will
review the evaluation during their risk assessment safety review of the project prior to
start of work. The evaluation sheet will include a list of all Interim Life Safety measures,
which are deemed appropriate to be included as a result of the project. The list will also
include regulatory procedures, which will be incorporated to ensure compliance. All
necessary documentation will be maintained to reflect compliance with this procedure.

5.     RESPONSIBILITIES:

       a.     Facilities Manager

             (1) Is designated the Health Care System Safety and Fire Protection
Officer.

             (2) Is empowered to intervene when any hazardous condition is
discovered and shall cause said hazard to be eliminated and in cases where there is an
immediate threat to life or health will cause a cease and desist order to be issued to the
person(s) responsible for and/or engaged in the deficient operation.

       b.     Safety Manager:

             (1) Is empowered to intervene when any hazardous condition is
discovered and shall cause said hazard to be eliminated and in cases where there is an
immediate threat to life or health will cause a cease and desist order to be issued to the
person(s) responsible for/and or engaged in the deficient operation.

               (2) Shall assure the implementation of inspections to assure that ILSM as
outlined in Attachment “1” are complied with relative to construction sites.

               (3) Provides training to supervisors and employees, where applicable
relative to ILSM.

              (4) Shall provide Pre-Construction (PreCon) Safety information for
contractors outlining ILSM as appropriate to the upcoming project.

       c.     Resident Engineer (RE) or Contracting Officers Technical Representative
(COTR): The RE or COTR shall be responsible to see that ILSM are adhered to, so as
to temporarily compensate for the hazards posed by construction activities. The RE




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                                     Health Care System Memorandum No. 138-FM-30

and/or COTR shall assure that all ILSM as outlined in Attachment 1 are continually
enforced through completion of the project.

      d.     Supervisors: Shall assure that employees adhere to guidelines for ILSM
and that employees attend training provided relative to those ILSM.

       e.      Employees: Shall attend applicable training on and adhere to ILSM as
outlined in Attachment 1.

6.     REFERENCES:

      a. Environment of Care Standards (ILSM): JC

      b. Life Safety Code: NFPA 101 (Latest edition).

7.     RESCISSION: Health Care System Memorandum No. 13-30, dated April 2002.

8.     REVIEW AND REISSUE DATE: August 2012

9.     FOLLOW-UP RESPONSIBILITY: Safety Manager (FM 138S)


       /s/

Susan A. Angell, MSW, Ph.D.
Director

Attachments (2)

Dist: B and W




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                                      Health Care System Memorandum No. 138-FM-30
                                                                  ATTACHMENT 1

 INTERIM LIFE SAFETY MEASURES (ILSM) IN BUILDINGS WITH EXISTING LIFE
           SAFETY CODE DEFICIENCIES AND BUILDINGS UNDER
                     CONSTRUCTION/RENOVATION

The NAVAHCS Safety Manager shall assure that the following Interim Life Safety
Measures (ILSM) are implemented in all patient care buildings with existing Life Safety
Code deficiencies.

The Resident Engineer (RE) or Contracting Officers Technical Representative (COTR)
shall assure that Interim Life Safety Measures outlined below are developed and
implemented at construction sites, under his/her control, at NAVAHCS.

1.      Ensure that all exits are free and unobstructed. Ensure that personnel receive
training if and when alternate exists are designated. Exits must be maintained free,
clear and unobstructed for construction personnel at all times.

2.   Ensure free and unobstructed access to emergency department/services and for
emergency responders.

3.     Ensure that no fire alarm, detection or suppression system is impaired. On those
rare occasions when a system must be impaired, a temporary and equivalent system
shall be provided and shall be tested and inspected monthly.

4.    Temporary construction partitions shall be smoke tight and shall be built of non-
combustible materials. Such temporary construction partitions shall be inspected
weekly to ensure compliance.

5.     NAVAHCS is designated as a “No Smoking” facility. The NAVAHCS Smoking
Policy shall be strictly adhered to. Smoking is prohibited in or adjacent to construction
areas, and inside all buildings. Smoking is permitted in designated smoking areas only.

6.      Coordinate with Facilities Manager to assure housekeeping and to assure debris
removal is conducted in a timely fashion so as to reduce the flammable and combustible
fire/fuel load to the lowest level necessary for daily operations. RE/COTR shall
coordinate with the contractor as appropriate.

7.      Where applicable, the minimum number of Fire Drills shall be two Fire Drills per
shift per quarter in each patient occupied building with existing Life Safety Code
deficiencies and/or each patient occupied building undergoing construction or
renovation.




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                                       Health Care System Memorandum No. 138-FM-30
                                                                   ATTACHMENT 1

8.      Increase hazard surveillance by conducting at least one additional fire/safety
inspection in each patient occupied building with existing Life Safety Code deficiencies
as identified above. To assure compliance with these ILSM, there will be at least one
fire/safety inspection conducted on each ward in each affected building per quarter.
RE/COTR shall coordinate inspections in construction areas with the contractor as
appropriate.

9.     All patient wards in buildings with existing Life Safety Code deficiencies will be
equipped with a minimum of one additional 5 lb. ABC Fire Extinguisher at the nurses
station and at least one 5 lb. ABC Fire Extinguisher in the Fire Extinguisher
cabinet/closet on the ward.

10.    Personnel shall be given special training whenever structural or compartment
features of fire safety are compromised.

11.    Conduct an organization wide safety education program to ensure awareness of
any Life Safety Code deficiencies, construction hazards and ILSM.

APPLICATION:

BUILDINGS WITH EXISTING LIFE SAFETY CODE DEFICIENCIES: Where
applicable, these ILSM shall remain in effect in all patient care buildings with existing
Life Safety Code (LSC) deficiencies and until such time as those existing LSC
deficiencies have been corrected or equivalencies have been officially granted.

OCCUPIED BUILDINGS UNDER CONSTRUCTION: These ILSM shall remain in effect
in all buildings under construction/renovation (and occupied by NAVAHCS) until such
time as the construction/renovation project has been completed.




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                                      Health Care System Memorandum No. 138-FM-30
                                                                  ATTACHMENT 2

             INTERIM LIFE SAFETY MEASURES EVALUATION SHEET


Project/Deficiency: _______________________________________________
Date: _____________________

PROJECT EVALUATION
Review each of the following categories and indicate whether each item is
applicable to the project/Life Safety code deficiency by checking the appropriate
response.
A yes answer may indicate that Interim Life Safety Measures are required.

A. EXITS
1. Does the project/deficiency have the potential of affecting   YES   NO   N/A
an exit or other components of the means of egress?
2. Will affected exit be used by other than contractor           YES   NO   N/A
personnel?

B. EMERGENCY ACCESS
1. Does the project/deficiency have the potential of             YES   NO   N/A
obstructing access to emergency departments, services or
vehicles?
2. Does the project/deficiency have the potential of             YES   NO   N/A
obstructing access of emergency responders to the
construction area?

C. FIRE PROTECTION
1. Does the project/deficiency have the potential of impairing YES     NO   N/A
existing fire alarm, fire detection, or fire suppression
systems?
2. Will temporary fire protection systems be required as part YES      NO   N/A
of the project/deficiency?

D. TEMPORARY PARTITIONS
Will construction involve the use of temporary partitions?       YES   NO   N/A




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                                       Health Care System Memorandum No. 138-FM-30
                                                                   ATTACHMENT 2

E. ADDITIONAL FIRE FIGHTING EQUIPMENT and TRAINING
1. Does the area affected by the project/deficiency warrant     YES   NO   N/A
placement of additional fire protection equipment?
2. Will additional fire safety training be required of affected YES   NO   N/A
personnel?

F. SMOKING POLICY
Will variance to the existing Medical Center smoking Policy     YES   NO   N/A
be permitted:
NOTE: VAMC PRESCOTT is a NO SMOKING FACILITY

G. COMBUSTIBLE FUEL LOAD LEVELS
1. Does the project/deficiency involve the storage of           YES   NO   N/A
flammable or combustible materials?
2. Does the project/deficiency have the potential of creating   YES   NO   N/A
flammable or combustible debris?

H. FIRE DRILLS
Does the project/deficiency warrant additional fire drills?     YES   NO   N/A


I. HAZARD SURVEILLANCE
Does the project/deficiency present added hazards, such as:     YES   NO   N/A
excavations; construction storage; or field offices, which
warrant increased hazard surveillance?

J. ADDITIONAL PERSONNEL TRAINING
1. Does the project/deficiency have the potential to affect     YES   NO   N/A
structural features of the fire safety system?
2. Does the project/deficiency have the potential to affect     YES   NO   N/A
compartmentation features of the fire safety systems?

K. FACILITY-WIDE TRAINING
Does the project/deficiency present Life Safety Code            YES   NO   N/A
deficiencies or construction hazards, which warrant facility-
wide education of personnel concerning these Interim Life
Safety Measures?




                                            Health Care System Memorandum 138-FM-30


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                                                                     ATTACHMENT 2


L. FIRE/SMOKE BARRIERS
1. Will the project cause penetrations to be made in          Yes    NO     N/A
Fire/Smoke Barriers?
2. Will fire/smoke barriers be temporarily sealed with        YES    NO     N/A
intumescent fillers on both sides of the barrier?
3. Will these temporary intumescent fillers adequately        YES    NO     N/A
compensate for the penetrations made in the fire/smoke
barriers?


PART II: INTERIM LIFE SAFETY MEASURES

Provide a description of all items indicated as applicable in Part I. Explain Interim
Life Safety Measures/procedures, which will be incorporated into the project.




Safety Manager                                Facilities Manager
ILSM Evaluator                                Safety and Fire Protection Officer




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