Saint Clare S Health System

SAINT CLARE’S HEALTH SYSTEM

POLICY STATEMENT:

It is the policy of Saint Clare’s Health Services to provide a safe work environmentfor all hospitalemployees, patients and guests at all times. One way to accomplish this is by meeting all the requirements of the NFPA 101 – 2000 Life Safety Code. It will be Saint Clare’s Health System policy to require all personnel who do work in a ceiling area to obtain a “Ceiling Work Permit” so that their work can be examined to assure all penetrations and other “compromises” have been sealed in all corridor, smoke barrier and fire walls.

GENERAL:

Maintenance and Engineeringwill establishthe procedure forobtaining Ceiling Work Permits and for inspectingall completed work.

CONTRACTOR NOTIFICATION:

To assure that contractors are aware of the requirement to obtain a Ceiling Work Permit if they will be working in a ceiling, the following three pronged approach will be taken:

1)The Saint Clare’s Purchasing Dept. will send a cover letter and copy of this policy to all contractors on their vendor list.

2)The Managers/Directors of IT, Security, Facility Development and Engineering & Maintenance will be instructed to reference the requirement to obtain a Ceiling Work Permit on bid documents.

3)The Purchasing Dept. will add a note to all purchase orders given to contractors reminding them of the requirement to obtain a Ceiling Work Permit.

PROCEDURE:

A)The Ceiling Work Permit Program will be administered by the hospital Engineering and Maintenance Dept. To obtain a Ceiling Work Permit the contractor must submit to the hospital Engineering and Maintenance Dept.:

1)Completed “Restricted Space Access Permit” form

2)Redline diagram on a hospital floor plan showing diagrammatic location and written description of work to be done. This redlined floor plan will be initialed by E&M prior to work and after completion.

3)Manufacturer’s spec sheet and MSDS for sealant product to be used – must be an approved sealant.

B)Blanks of the Permit application and blank floor plans can be obtained from two sources:

1)Facility Development at The Barns

2)Engineering and Maintenance at the hospital where work is to be performed

C).Upon submission, and subsequent approval of these documents all the contractor’s workers will be given a Ceiling Contractor Badge. The badge is to be worn by all workers and returned to Engineering and Maintenance at the conclusion of the job.

D).The Engineering & Maintenance Dept.(E&M) will be notified in advance by the contract issuing department Director of any such ceiling work that will be contracted. A schedule of work shall also be provided to E&M of each specific campus where work is to be performed.

E).No work in a ceiling area will be permitted without a Ceiling Contractor Badge.

F).At the conclusion of work the Engineering and Maintenance Dept. will inspect all penetrations. If thework is over a long period of time the inspections will occur periodically as work is being done. Final

payment to the contractor is to be withheld until the final inspection at the conclusion of all work. If all penetrations have been sealed the final payment can be issued to the contractor.

G)The final “as built” redline drawings will be submitted to Facilities Development who will be responsible for viewing the completed documents and incorporating them into the Master electronic drawing file.

.

ORIGINATORS:O.ROBLING

CONTENT REVIEW:6//06

ENGINEERING & MAINT.CEILING WORK PERMIT