Amendment_3.pdf

Except as provided herein, all terms and conditions of the document referenced in item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. Name and Title of Signer (Type or Print) 16A. Name and title of Contracting Officer (Type or Print)

15B. Contractor/Offeror 15C. Date Signed 16B. United States of America

(Signature of Contracting Officer)

16C. Date Signed

(Signature of person authorized to sign)

NSN 7540-01-152-8070 30-105 STANDARD FORM 30 (REV. 10-83)

PREVIOUS EDITIONS UNUSABLE Prescribed by GSA FAR (48 CFR) 53.243

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. Contract ID Code Page of Pages

1 2 2

2. Amendment/Modification No. 3. Effective Date 4. Requisition/Purchase Req. No. 5. Project No. (if applicable)

AMENDMENT 0003 August 4, 2016 TBD

6. Issued By Code 7. Administered By (If other than Item 6) Code SEE BLOCK 6 Indian Health Service - DES 701 Fifth Avenue, Suite 1600 MS/24 Seattle, WA 98104

8. Name and Address of Contractor (No., Street, County, and Zip Code) (X) 9A. Amendment of Solicitation No.

X

16-102-SOL-00005

9B. Date (See Item 11)

July 28, 2016 10A. Modification of Contract/Order No.

10B. Date (See Item 13)

Code Facility Code

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in item 14. The hour and date specified for receipt of Offers is extended X is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDG-

MENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT

IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. Accounting and Appropriation Data (if required)

1. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACT/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

(x) A. This change order is issued pursuant to: (Specify authority) The changes set forth in item 14 are made in the Contract Order No. in item 10A.

B. The above numbered Contract/Order is modified to reflect the administrative changes (such as changes in paying office, appropriation date, etc.)

Set fourth item 14, pursuant to the authority of FAR 43.103 (b)

C. This supplemental agreement is entered into pursuant to authority of:

D. Other (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. Description of Amendment/Modification (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

SUMMARY OF CHANGES:

The purpose of this amendment is to:

1. Clarify the site visit date and time; and

2. Incorporate Infection Control Risk Assessment (ICRA) documents attached to this amendment into the solicitation and resulting contract; and

3. Answer pre-proposal inquiries.

(END SUMMARY OF CHANGES)

16-102-SOL-00005, Amendment 0003

1. Site Visit:

To clarify, the site visit for this requirement will be held at 0900 (9:00 AM), site local time, on August 9, 2016 as specified in the solicitation’s Section L.6.

2. ICRA

The attached ICRA documents are hereby incorporated into the solicitation and resulting contract.

3. Responses to PPI:

Question No. 6

Product Substitution

QUESTION: Vendor requests product substitution with the following:

- Flex FB 80 PVC roof membrane

Please consider the following product for the Gallup Indian Medical Center project.

Answer: Offerors are directed to price the specification as currently written. Substitution requests will be entertained after contract award. Reference solicitation Section I.1, 52.236-5 Material and Workmanship.

All other terms, conditions, and requirements remain unchanged.

Gallup Service Unit

Policy & Procedure Statement

Subject: Interim Life Safety Measures Policy

Organizational Level: GSU.HR.SAF.00c

I. Purpose:

To provide a level of life safety comparable to that described by the Life Safety Code

(LSC) when necessary to temporarily compensate for LSC deficiencies, system failures, or construction activities. The purpose of the interim life safety measures (ILSMs) is to protect patients, visitors, and staff from any additional safety risks.

II. Policy:

It is the policy of the Gallup Service Unit (GSU) to implement ILSMs when appropriate and necessary in accordance with The Joint Commission Life Safety Standards.

III. Procedure:

The facility will implement those relevant interim life safety measures identified below anytime that life safety is jeopardized. The ILSMs will be implemented during construction or renovation that reduces or negatively impacts on life safety, or while a system is inoperative which lowers the required level of safety. Interim life safety measures may also be implemented in the event existing conditions pose hazards that violate the National Fire Protection Agency (NFPA) 101-2000 Life Safety Code. The implementation of ILSM will be continuously enforced throughout the duration of the project, system failure, or prior to the correction of the existing condition.

A. Application:

The ILSM will apply to all personnel in the facility including construction workers on the job, physicians, nurses, other staff, and contractors; whether temporary or permanent employees or volunteers.

B. Frequency and Duration:

The ILSMs will be implemented throughout the duration of the project, system failure, or existence of the diminished life safety feature. Frequencies of inspection, testing, monitoring, evaluation, and training will be determined on a case-by-case basis and will be determined prior to when the measures are implemented.

C. Documentation:

The following attached forms will document the implementation of the ILSMs

1. NAIHS Interim Life Safety Measures Condition Project Evaluation Form

(ATTACHMENT A) - used to evaluate each situation to determine if ILSM are necessary and develop a written plan for each project or situation that requires ILSM.

2. NAIHS Interim Life Safety Measures Inspection/Compliance Form

(ATTACHMENT B) - a documentation form and checklist that validates and documents inspections and compliance of each project or situation requiring ILSM implementation according to established and required frequencies.

3. NAIHS Training Log (ATTACHMENT C) - used to document all required training as a result of ILSM implementation.

D. Responsibilities:

The responsibility for ensuring that projects, conditions, renovations, or other situations are evaluated to determine whether ILSM are necessary belongs to the

Safety Officer (SO) and Facility Manager (FM). Other responsibilities associated with inspection, monitoring, and training may be delegated by the SO and FM and specified in the written plan for each ILSM. It is the responsibility of each individual (employee, volunteer, contractor, permanent or temporary) to comply with the ILSM.

E. Interim Life Safety Measures Defined:

1. ILSMs consist of the following actions:

a. Inspection of exits in the affected areas on a daily basis. This inspection will be conducted by a staff member designated by the

Safety Officer or Facilities Management Director, such as heating plant operator or security personell. The daily inspection will be documented. Inspection will be done to ensure exits provide free and unobstructed egress.

b. Personnel in the affected areas shall receive training if alternative exits must be designated. Buildings or area under construction must maintain escape facilities for construction workers at all times. Means of egress in construction areas must be inspected daily.

c. Ensuring free and unobstructed access to emergency departments/services and for fire, police emergency medical services.

d. Ensuring fire alarm, detection, and suppression systems are not impaired. A temporary, but equivalent system shall be provided when any fire system is impaired. Temporary systems must be inspected and tested monthly.

NOTE: The Life safety Code, NFPA 101-2009 Edition, requires that the municipal fire department (or applicable emergency forces group) is notified and a fire watch is provided whenever an approved fire alarm or automatic sprinkler system is out of service for more than four hours in a 24-hour period in an occupied building.

e. Ensuring temporary construction partitions are smoke-tight and built of noncombustible or limited combustible materials that will not contribute to the development or spread of fire.

f. Providing additional fire-fighting equipment and use training for personnel.

g. Prohibiting smoking in accordance with GSU policy, in or adjacent to all construction areas.

h. Developing and enforcing storage, housekeeping, and debris removal practices that reduce the flammable and combustible fire load of the building to the lowest level necessary for daily operations.

i. Conducting a minimum of two fire drills per shift per quarter.

j. Increasing hazard surveillance of buildings, grounds, and equipment with special attention to excavations, construction areas, construction storage, and field offices.

k. Provide training to affected personnel when structural or compartmentalization features of fire safety is compromised, such as fire doors or fire walls.

l. Conducting organization wide safety education programs to ensure awareness of any LSC deficiencies, construction hazards, and these

ILSMs.

IV. Distribution:

A. Hospital-wide Policy Manual located in the Performance Improvement Office;

B. Hospital-wide Policy Manual located in the House Supervisor’s Office;

C. GSU Intranet Site for Hospital-wide Policies;

D. E-mail to All Department Heads and GSU Staff

SUBJECT: INTERIM LIFE SAFETY MEASURES (ILSMs)

SIGNATURE PAGE

Safety Officer DATE

Infection Control Officer DATE

Facilities Manager DATE

Safety Committee Chair DATE

INTERIM LIFE SAFETY MEASURES EVALUATION AND

IMPLEMENTATION SHEET

Project Title:

Project #:

PART I: PROJECT EVALUATION

Review the project using the following criteria and indicate whether each item is applicable by marking the appropriate box. For any “YES” responses, review the required action under each section to determine the required

Interim Life Safety Measure or Infection Control. In PART II, document specifically how the required Interim Life

Safety Measures or Infection Controls will be implemented for this particular project. In Part III, list the areas and personnel affected by the implemented Interim Life Safety Measures or Infection Controls.

A. Exits:

1. Does the project have the potential of affecting an exit or other means of egress?

Yes

No

2. Will the affected exit be used by other than the Contractor’s personnel?

Required Actions: If a means of egress is obstructed, an alternate must be designated and training is required for those persons affected. Means of exiting construction areas must be inspected on a daily basis to prevent blockages due to debris.

B. Emergency Access:

1. Does the project have the potential to obstruct access to emergency departments or services?

2. Does the project have the potential of obstructing access of emergency forces to the construction area?

Required Actions: If an emergency access is obstructed, an alternate means of access must be designated and the Gallup

Fire Department and GIMC Security must be notified of the alternative.

C. Fire Protection:

1. Does the project have the potential of impairing existing fire alarm, detection, or suppression systems?

2. Will temporary fire protection systems be required as part this project?

Required Actions: If a fire protection or alarm system is to be rendered non-operational for more than 4 hours out of a

24-hour period, either a substitute system or a fire watch must be initiated. If neither of these methods can be implemented, the area must be closed down and evacuated. All of these measures must be coordinated with the Gallup

Fire Department, GIMC Security, and the affected staff.

D. Temporary Partitions:

Will construction involve the use of temporary partitions?

Required Actions: If construction involves major breaches in fire or smoke barriers, the contractor must erect temporary walls around the construction area equal to the barrier that has been compromised.

E. Additional Fire Fighting Equipment and Training:

1. Does the area affected by the project warrant placement of additional fire protection equipment?

2. Will additional fire fighting training be required by affected personal?

Required Actions: If the fire load of a particular area is significantly increased above the norm due to construction, additional fire fighting equipment (such as fire extinguishers) will be required. If any of this additional fire fighting equipment is of a different type than that already available in the affected area, training in the use of this equipment for staff or contractor personnel is required.

F. Smoking Policy:

Will variance to existing medical center smoking policy be permitted?

Required Actions: If designated smoking areas are impacted or closed due to construction, temporary areas may need to be established.

G. Combustible Load Levels:

1. Does the project involve the storage of flammable or combustible materials?

2. Does the project have the potential for creating flammable or combustible debris?

Required Actions: Surveillance of construction sites will need to be increased to prevent the accumulation of excess flammable or combustible debris. The fire load of the construction area must be kept to a minimum.

H. Fire Drills:

Does the project warrant additional fire drills within the affected areas?

Required Actions: If the life safety features of a particular area are adversely impacted by construction, then the frequency of fire drills must be increased to two per shift per quarter for hospital occupancies. Adverse impacts would include blocked fire exits, impaired fire alarm or sprinkler systems, or major compromises in fire or smoke barriers or compartments.

I. Hazard Surveillance:

Does the project present additional hazards, such as excavations, construction, storage or field offices that warrant increased hazard surveillance?

Required Actions: If yes, then additional project surveillance is warranted to identify potential life safety issues.

J. Noise and Vibration issues:

1. Does the project have the potential to cause noise or vibration levels that will adversely impact patient care or the environment of care?

Required Actions: Any construction activities that cause noise or vibration levels that might affect patient care or the environment of care must be coordinated with the staff involved so that proper measures can be implemented to avoid an adverse impact to patient care.

K. Additional Personnel Training:

1. Does the project have the potential of affecting structural features of the fire safety systems?

2. Does the project have the potential of affecting compartmentalization features of the fire safety systems?

3. Does the project have the potential for negatively affecting infection control procedures?

Required Actions: Affected personnel must be notified when fire safety systems or infection control procedures are compromised and trained in temporary changes in procedures to compensate for the impaired systems. Examples are the need for alternate fire exits, alarm or sprinkler systems or to evacuate behind secondary fire barriers or compartments due to fire or smoke partition compromises.

L. Facility-Wide Training:

1. Does the project present Life Safety code deficiencies or construction hazards which warrant facility-wide education of personnel concerning the Interim Life Safety

Measures?

2. Does the project present Infection Control deficiencies which warrant facility-wide education of personnel concerning Infection Control procedures?

Required Actions: Training must be provided facility-wide to educate staff, patients and visitors to any life safety system that is impaired throughout the entire building. In addition, the Gallup Fire Department and GIMC Security will be notified.

PART II – INTERIM LIFE SAFETY MEASURES SUMMARY

Provide a list of all Interim Life Safely Measures or Infection Control Issues as indicated in

Part I. Describe in detail how each of these measures will be implemented for this particular project. Attach additional sheets if necessary.

PART III – PERSONNEL OR AREAS WHERE THESE INTERIM LIFE SAFETY

MEASURES OR INFECTION CONTROLS WILL BE IMPLEMENTED

Signature and Title of Evaluator Date

Signature of Safety Officer Date

Signature of Infection Control Coordinator Date

Signature of Chairperson, Life Safety Subcommittee Date

Subject: Infection Control Risk Assessment (ICRA) – 4.21 Effective Date: 09/23/2015

P&P Number: GSU.HLR.INF.06 Review/Revision: 09/2018

Policy

Gallup Service Unit is committed to designing, constructing, and maintaining the environment of care using, the “Guidelines for Design and Construction of Hospitals and Health Care Facilities” as well as all other applicable regulations. Gallup Service Unit selects and implements proper controls to reduce risk and to minimize impact of construction or renovation activities.

Scope

The Infection Control Risk Assessment (ICRA) process shall apply to all projects, including small construction and maintenance work. The risk assessment shall be implemented in the programming phase of each project and resultant infection control measures shall be assessed throughout the project.

Performance Standards

Infection control measures will be selected by the Infection Control Practitioner and the Safety Officer at all appropriate construction sites and areas with Infection Control (IC) deficiencies.

Selected IC measures will be monitored by the IC Practitioner, Safety Officer, Security Officers on weekends and holidays, Fire Marshall and Facility Manager and/or by their designee.

Affected employees, including construction workers, will be made aware of the particular IC measures for areas where they work.

Responsibilities

The IC Committee shall evaluate, write and maintain the ICRA policy.

The ICRA Panel, including the Project Officer, Safety Officer, Facility Manager and Infection

Control Practitioner, shall evaluate each major construction project and select and implement the appropriate IC measures/actions.

The IC Practitioner, Facility Manager and the Safety Officer shall select and implement appropriate IC measures/actions for existing hazards that violate IC Standards.

The Facility Manager or designee shall conduct an initial evaluation of maintenance and repair projects to determine if work will exceed Class II.

o If Class III or IV will be involved, the ICRA Panel will conduct a full assessment.

o Copies of any assessments indicating Class I or II will be documented and maintained available for review by the IC Practitioner or IC Committee.

If initial scope of work expands, facility management staff will be responsible for coordinating a re-evaluation to ensure appropriate IC measures are taken.

The Facility Manager and the IC Practitioner shall ensure that the ICRA measures/actions are maintained and enforced.

The IC Practitioner and/or the Facility Manager shall provide notification and training to

GSU staff as appropriate.

The Facility Manager shall ensure that ICRA measures/actions are incorporated into all contractor negotiations and contracts.

The Facility Manager shall ensure that contractors and GSU maintenance staff adhere to the identified IC measures/actions.

Contractors are responsible for training their employees and enforcing IC measures/actions with their employees.

GSU employees are responsible for adhering to established IC measures/actions.

Procedures

Each project will be assessed for risk during the programming phase. The project will be assigned a risk group and will be matched with a construction activity type that will determine the class of precautions to be implemented.

The class of precautions will be determined using the matrix on the following assessment form

The ICRA will be initiated by Facilities staff and routed to the IC Practitioner and Safety Officer for review and finalization.

Environmental Monitoring

The Facility Manager or designees, as well as the Safety Officer and IC Practitioner will perform field inspections.

GSU will monitor air quality throughout project as needed.

Implementation

The IC measures shall be specific to each project as determined by the assessment process/form below. In general, the following criteria shall apply when required by the assessment.

Temporary construction barriers, including closures above ceilings, shall be dust tight.

Removal of debris shall be in tightly covered containers.

Adhesive mats or carpets at barrier entrances shall be kept clean and changed in accordance with the manufacturer’s recommendations to prevent accumulation of dust.

Any dust tracked outside of the barrier shall be removed immediately.

Any ceiling access panels opened for investigation beyond sealed areas shall be replaced immediately when unattended.

Removal of construction barriers and ceiling protection shall be done carefully, outside of normal business hours. Vacuum and clean all surfaces free of dust after the removal.

When access panels are opened in occupied areas for work above ceilings, use Control

Cube or polyethylene enclosure around ladder, sealing off opening. The device will be fitted tightly to the ceiling and floor per manufacturer’s instructions.

Enforcement

In the event that this policy is violated, the IC Practitioner, the Safety Officer, the Facility

Manager or a hospital administrator, may halt work on the project. Work will not resume until all violations of IC policies are corrected.

The Safety Officer, IC Practitioner and Facilities Management departments shall record the following:

1. Document each violation with photographs

2. Extract contractor or department information from the work log.

3. Maintain a record of all infection control violations.

Violations of the IC policies may affect status as a responsible contractor for bidding future work.

INFECTION CONTROL RISK ASSESSMENT

Project Narrative Description:

Using the following table, identify the Patient Risk Group by the Type of Area that will be affected. If more than one risk group will be affected, select the higher risk group:

Low Risk Medium Medium-High High

Non-patient area Office Areas

Engineering

General Patient Areas Waiting areas

Outpatient

All other patient units not in other categories

Sensitive Areas 2E

Emergency Dept.

ICU

Laboratory

Maternal-Child

Newborn Nursery

Physical Therapy

Radiology/CT

Kitchen/Cafeteria

Sterile areas OR / Recovery

Sterile Processing

C-Section Room

Endoscopy area

Pharmacy admixture

Patient Risk Group: (circle) Low Medium Med-High High

Using the following table, identify the Type of Construction Project Activity

- Descriptions include, but are not limited to examples given

Type A:

Inspection and non-invasive:

Type B:

Low Dust / Short Duration:

Type C:

Dust Generating / Short Duration

Type D:

High Dust / Long Duration

Removal of ceiling tiles for visual inspection limited to 1 tile for 50 sq. feet;

Painting with no sanding;

Wall covering install, electrical trim work, minor plumbing and other activities that do not generate dust.

Setting brackets, hanging items, Cutting of walls or ceilings (<1 sq. ft.)

where dust migration can be controlled to the immediate work area and duration is less than one work shift.

Sanding, Removal of floor coverings, ceiling tiles, and casework;

New wall construction;

Minor HVAC or electrical work above the ceiling;

Major cabling activities;

Any activity that cannot be completed within a single work shift.

Heavy demolition

Removal of complete cabling or ceiling system

New construction requiring multiple work shifts

Construction Type: (circle) Type A Type B Type C Type D

Class of IC Measures Type of Construction

Pt Risk Group Type A Type B Type C Type D

Low Risk I II II III / IV

Medium I II III IV

Medium – High I II III / IV IV

High Risk I-III Consult ICP

III / IV III / IV IV

Gray shaded cells indicate ICRA must be reviewed by the IC Dept.

During Construction Project Upon Completion of Project

C la s s I

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

2. Immediately replace a ceiling tile displaced for visual inspection.

1. Clean work area upon completion of task

C la s s I

I

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area.

6. Remove or isolate HVAC system in areas where work is being performed

1. Wipe work surfaces with cleaner/disinfectant.

2. Contain construction waste in tightly covered containers before transport.

3. Wet mop and/or vacuum with HEPA-filtered vacuum before leaving work area.

4. Upon completion, restore HVAC system where work was performed.

C la s s I

II

1. Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers—i.e., sheetrock, plywood, plastic—to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA-equipped air filtration units.

4. Contain construction waste in tightly covered containers before transport.

5. Cover transport receptacles or carts. Tape covering unless solid lid.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention and Control Department and is thoroughly cleaned by the Housekeeping Department.

2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with cleaner/disinfectant.

5. Upon completion restore HVAC system where work was performed.

C la s s I

V

1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers—i.e., sheetrock, plywood, plastic—to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA-equipped air filtration units.

4. Seal holes, pipes, conduits, and punctures appropriately.

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site, or they can wear cloth or paper coveralls that are removed each time they leave the work site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention and Control Department and is thoroughly cleaned by the owner’s Environmental Services Department.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

3. Contain construction waste in tightly covered containers before transport.

4. Cover transport receptacles or carts. Tape covering unless solid lid.

5. Vacuum work area with HEPA-filtered vacuums.

6. Wet mop area with cleaner/disinfectant.

7. Upon completion restore HVAC system where work was performed.

Identify the areas surrounding the project area, to assess for potential impact Unit Below Unit Above Unit Lateral Unit Lateral Unit Behind Unit In Front

Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

Identify specific site of activities e.g., patient room, medication room, etc.

Does project have potential to affect essential utility services to patients/employees?

Yes No

Precautions: Temporary utilities will need to be provided to establish equal IC measures Water

HVAC

Electricity

Nurse Call

Telephone

Do plans allow for, and IC agree with the required number & type of handwashing sinks?

Yes No Precautions: Verify against AIA guidelines for type and area

Will the domestic water system be impacted in such a manner to increase the potential for water borne opportunistic pathogens?

Yes No Precautions: Necessary IC measures must be implemented for all susceptible patients

Could the project lead to water damage or compromise structural integrity?

Yes No Precautions: Plans to mitigate and respond potential damage need to be developed

Do plans allow for adequate number of isolation / negative airflow rooms?

Yes No Precautions: Additional rooms may need HVAC adjustments to provide necessary air movement relationships

What Types of containment measures will be utilized?

Solid barriers Soft Barriers HEPA Filtration Other:

Does project have potential to cause noise or vibration adversely affect patient care?

Yes No Precautions: Work Practices to be utilized need to be reviewed

Will any patients need to be relocated due to construction activities?

Yes No Precautions: Relocation must be coordinated with each before and after relocation.

Can or will the work be done during non-patient care hours?

Yes No Precautions: Plans to ensure area prepared to resume operations need to be developed

Does infection control staff agree with the plans relative to clean and soiled utility rooms?

Yes No Precautions: Plans to ensure adequate access must be developed

Are there any concerns/precautions related to the following?

Yes No Precautions:

Traffic flow Security Housekeeping Material storage Debris Removal Const. Worker Training

Does this project involve risk of airborne exposure to known or suspected TB case? This facility is classified as "Low Risk" for Tuberculosis.

No Contractors will not be required to work in internal environments involving risk of airborne exposure to known or suspect TB cases. Baseline TB skin testing is not required for contractors. (Any roof work must be preceded by Engineer Contract Supervisor and Infection Prevention verification of proximity to exhaust from room currently occupied by known or suspect TB cases.)

Yes The Contractor must provide written certification that all contract employees assigned to the worksite have had a pre-placement tuberculin screening within 90 days prior to assignment to the worksite and been found to have a negative TB screening reactions. Contractors will be required to show documentation of negative TB screening reactions for any additional workers who are added after the 90-day requirement before they will be allowed to work on the work site. Contract employees manifesting positive screening reactions to tuberculin must be examined according to current CDC guidelines prior to working on facility property.

Infection Control Construction Permit This Permit must be posted in Construction and Remodel Areas during Work

Location of Construction:

Permit No:

Project Start Date:

Project Coordinator:

Estimated Duration:

Contractor Performing work:

Permit Expiration Date:

Supervisor: Telephone

Yes No CONSTRUCTION ACTIVITY Yes No INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk

TYPE B: Small Scale, short duration, moderate to high levels GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater than1 work shift for completion.

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities requiring consecutive work shifts

GROUP 4: Highest Risk

Class I

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

2. Immediately replace any ceiling tile displaced for visual inspection.

3. Clean work area upon completion of task(s)

Class II

1. Provide active means to prevent air-borne dust from dispersing into the atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused door with duct tape.

4. Block off and seal air vents.

5. Wipe Surfaces with disinfectant.

6. Contain construction waste before transport tin tightly covered containers.

7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

8. Place dust mat at entrance and exit or work area.

9. Remove or isolate HVAC system in areas where work is being performed.

Class III

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

5. Do not remove barriers from work area until complete project is thoroughly cleaned by Housekeeping Dept.

6. Vacuum work area with HEPA filtered vacuums.

7. Wet mop with disinfectant

8. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

9. Contain construction waste before transport in tightly covered containers.

10. Cover transport receptacles or carts. Tape covering.

11. Remove or isolate HVAC system in area where work is being performed.

Class IV

1. Obtain infection control permit before construction begins

2. Isolate HVAC system in area where work is being done to prevent contamination of duct system. Complete all critical barriers or implement control cube method before construction begins

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units

4. Seal holes, pipes, conduits, and punctures appropriately

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls can wear cloth or paper coveralls that are removed each time they leave the work site.

6. All personnel entering work site are required to wear shoe covers.

7. Do not remove barriers from work area until completed project is thoroughly cleaned by the Housekeeping Dept.

8. Vacuum work area with HEPA filtered vacuums.

9. Wet mop with disinfectant.

10. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction

11. Contain construction waste before transport in tightly covered containers

12. Cover transport receptacles or carts. Tape covering

13. Remove or isolate HVAC system in areas where work is being done.

Additional Requirements:

Appendix: Identify and communicate the responsibility for project monitoring that includes infection control concerns and risks. The ICRA may be modified throughout the project. Revisions must be communicated to the Project Manager by the Requestor.

Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX ; C Fine, CA

Steps 4-14 Adapted with permission Fairview University Medical Center, Minneapolis MN by ECSI Inc 2001 Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

Date of projected start of construction/renovation:

Signature and Title of Project Officer Date

Signature of Facility Manager Date

Signature of Infection Control Practitioner Date

Date Submitted: Aug. 3, 2016 By: Ali Ali

GIMC ED Expansion Project: Infection Control Risk Assessments (ICRA) and Interim Life Safety Measures (ILSM) Review

On Aug. 2, 2016 and during previous design development meetings for ED Expansion Projects, both Infection Control and Safety Officers were involved in those meetings and participated. The expectation is for the selected Construction Contractor(s) to comply with Gallup Service Unit’s ICRA and ILSM policy and procedures (see attachments) before, during and after construction with weekly construction progress meetings to review impact on existing hospital operations, utility systems, indoor air quality…etc. to ensure safe and clean environment for patients, staff and visitors before, during and after construction. Navajo Area Office Construction Inspector assigned to this project shall facilitate these weekly construction progress meetings for effective communication, and coordination.

From Merriam Abeita, Infection Control Officer

Infection Control:

Infection Preventionist will be notified and kept apprised of plans weekly during each phase of the work project.

Preconstruction Preventive Measure:

Identify essential services (i.e., water supply, ventilation systems, electricity) that may be disrupted and the measures to compensate for the disruption. This will include the plan for reinstating the essential services once the project is complete, flushing water supply, cleaning vents etc.

Assure that risks are minimized in exposing debris, dust etc. to the rest of the operational hospital and patient care areas.

Identify the process for debris removal, seal and transport to an appropriate container.

Identify the area for the placement of the debris containment, near the work zone.

Identify traffic patterns for staff and patients-work zones. Divert pedestrian traffic away from the work zones and materials.

Identify restroom and handwashing facilities for the construction workers.

Designated entrances and exits for the construction workers.

Personal Protective Equipment (foot gear, head gear, coveralls, masks etc.)

Construction Preventive Measure:

Construct “airtight” barriers to prevent dust from construction areas entering patient care areas; ensure that barriers are impermeable to fungal spores and in compliance with local fire codes. Create and maintain negative air pressure in work zones adjacent to patient care areas and ensure that required engineering controls are maintained-monitor negative pressure. Exhaust airflow in the renovation area will maintain negative pressure (i.e., windows, supply air to renovation suspended, exhaust fans utilized.)

Dust and other microbial contamination is minimized during the work phase(s) of the construction/renovation project. Dust containment and removal of construction debris.

Implement dust control measures on surfaces. Dust and debris allowed to become aerosolized is a risk to patients because it carries microbes, such as Asperfillus and other fungus species. The potential for disrupting dust collected above the ceiling panels, a barrier must be constructed to contain the dust. The area will need to be cleaned as soon as possible using a wet vacuum or damp mopping to prevent tracking of dust throughout the facility. Do not sweep or dry mop.

Demolition debris is covered and sealed during transport. Transport is done in a way that minimizes exposure to patients and staff. It should be done during the lowest activity periods. If using a chute, HEPA filtered air machines, fans are used as possible.

Care is taken to ensure air from the construction/renovation areas are not recirculated to other areas of the hospital. Any changes to the airflow are to be communicated to the affected units prior to the beginning and completion of the project.

Maintain and clean the ventilation system on a regular basis, and after construction/renovation projects-likely to increase contamination to the system.

Monitor and document the presence of negative airflow within the construction zone or renovation area on a daily basis.

Water lines are thoroughly flushed after an interruption in water service and in areas adjacent to the construction due to increased risk of loosening internal debris/corrosion in water pipes, which harbor microbes and may lead to water contamination.

Post Construction Preventive Measures:

Thoroughly clean the construction zone, including all horizontal surfaces, before the barrier is removed, and again after the barrier is removed. Install barrier curtains to contain dust and debris before removing rigid barriers. Allow time for all the dust to settle before doing final cleaning.

Commission the HVAC system for newly constructed healthcare facilities and renovated spaces before occupancy and use, with emphasis on ensuring the proper ventilation for patient care rooms.

Infection Control and Safety should check the finished area before the staff and patients can move into the area for patient care activities.

Flush and disinfect unused cooling towers and water supply in unoccupied portions of the building before they are put in use.

Assess the hot water temperature to determine that it meets the standards.

From Anson Damon, Safety Officer

Safety Measures for ED Expansion Project,

1. Exits – Identify and maintaining means of egress while construction is in process

2. Contractors having a separate exit for contractor personnel.

3. Not obstructing emergency (Ambulance, Police, or Fire) personnel access to emergency department.

4. Not impairing existing fire alarm, detention, or suppression system.

5. If a fire watch is initiated this will be coordinated with the Gallup Fire Department and GIMC Security.

6. Identify any phases in project that warrant placement of additional fire protection equipment.

7. No smoking will allowed by contractor personnel.

8. Surveillance of construction sites will need to be increased to prevent the accumulation of excess flammable or combustible debris.

9. Will construction phases have the potential to cause noise or vibration levels that will adversely impact patient care.

10. Having daily safety huddles with Foreman, Building Inspector, Infection Control, Facilities, and Safety Officer.

Subject: Interim Life Safety Measures Policy

Organizational Level: GSU.HR.SAF.00c

I. Purpose:

To provide a level of life safety comparable to that described by the Life Safety Code

(LSC) when necessary to temporarily compensate for LSC deficiencies, system failures, or construction activities. The purpose of the interim life safety measures (ILSMs) is to protect patients, visitors, and staff from any additional safety risks.

II. Policy:

It is the policy of the Gallup Service Unit (GSU) to implement ILSMs when appropriate and necessary in accordance with The Joint Commission Life Safety Standards.

III. Procedure:

The facility will implement those relevant interim life safety measures identified below anytime that life safety is jeopardized. The ILSMs will be implemented during construction or renovation that reduces or negatively impacts on life safety, or while a system is inoperative which lowers the required level of safety. Interim life safety measures may also be implemented in the event existing conditions pose hazards that violate the National Fire Protection Agency (NFPA) 101-2000 Life Safety Code. The implementation of ILSM will be continuously enforced throughout the duration of the project, system failure, or prior to the correction of the existing condition.

A. Application:

The ILSM will apply to all personnel in the facility including construction workers on the job, physicians, nurses, other staff, and contractors; whether temporary or permanent employees or volunteers.

B. Frequency and Duration:

The ILSMs will be implemented throughout the duration of the project, system failure, or existence of the diminished life safety feature. Frequencies of inspection, testing, monitoring, evaluation, and training will be determined on a case-by-case basis and will be determined prior to when the measures are implemented.

C. Documentation:

The following attached forms will document the implementation of the ILSMs

1. NAIHS Interim Life Safety Measures Condition Project Evaluation Form

(ATTACHMENT A) - used to evaluate each situation to determine if ILSM are necessary and develop a written plan for each project or situation that requires ILSM.

2. NAIHS Interim Life Safety Measures Inspection/Compliance Form

(ATTACHMENT B) - a documentation form and checklist that validates and documents inspections and compliance of each project or situation requiring ILSM implementation according to established and required frequencies.

3. NAIHS Training Log (ATTACHMENT C) - used to document all required training as a result of ILSM implementation.

D. Responsibilities:

The responsibility for ensuring that projects, conditions, renovations, or other situations are evaluated to determine whether ILSM are necessary belongs to the

Safety Officer (SO) and Facility Manager (FM). Other responsibilities associated with inspection, monitoring, and training may be delegated by the SO and FM and specified in the written plan for each ILSM. It is the responsibility of each individual (employee, volunteer, contractor, permanent or temporary) to comply with the ILSM.

E. Interim Life Safety Measures Defined:

1. ILSMs consist of the following actions:

a. Inspection of exits in the affected areas on a daily basis. This inspection will be conducted by a staff member designated by the

Safety Officer or Facilities Management Director, such as heating plant operator or security personell. The daily inspection will be documented. Inspection will be done to ensure exits provide free and unobstructed egress.

b. Personnel in the affected areas shall receive training if alternative exits must be designated. Buildings or area under construction must maintain escape facilities for construction workers at all times. Means of egress in construction areas must be inspected daily.

c. Ensuring free and unobstructed access to emergency departments/services and for fire, police emergency medical services.

d. Ensuring fire alarm, detection, and suppression systems are not impaired. A temporary, but equivalent system shall be provided when any fire system is impaired. Temporary systems must be inspected and tested monthly.

NOTE: The Life safety Code, NFPA 101-2009 Edition, requires that the municipal fire department (or applicable emergency forces group) is notified and a fire watch is provided whenever an approved fire alarm or automatic sprinkler system is out of service for more than four hours in a 24-hour period in an occupied building.

e. Ensuring temporary construction partitions are smoke-tight and built of noncombustible or limited combustible materials that will not contribute to the development or spread of fire.

f. Providing additional fire-fighting equipment and use training for personnel.

g. Prohibiting smoking in accordance with GSU policy, in or adjacent to all construction areas.

h. Developing and enforcing storage, housekeeping, and debris removal practices that reduce the flammable and combustible fire load of the building to the lowest level necessary for daily operations.

i. Conducting a minimum of two fire drills per shift per quarter.

j. Increasing hazard surveillance of buildings, grounds, and equipment with special attention to excavations, construction areas, construction storage, and field offices.

k. Provide training to affected personnel when structural or compartmentalization features of fire safety is compromised, such as fire doors or fire walls.

l. Conducting organization wide safety education programs to ensure awareness of any LSC deficiencies, construction hazards, and these

ILSMs.

IV. Distribution:

A. Hospital-wide Policy Manual located in the Performance Improvement Office;

B. Hospital-wide Policy Manual located in the House Supervisor’s Office;

C. GSU Intranet Site for Hospital-wide Policies;

D. E-mail to All Department Heads and GSU Staff

SUBJECT: INTERIM LIFE SAFETY MEASURES (ILSMs)

SIGNATURE PAGE

Safety Officer DATE

Infection Control Officer DATE

Facilities Manager DATE

Safety Committee Chair DATE

INTERIM LIFE SAFETY MEASURES EVALUATION AND

Project #:

PART I: PROJECT EVALUATION

Review the project using the following criteria and indicate whether each item is applicable by marking the appropriate box. For any “YES” responses, review the required action under each section to determine the required

Interim Life Safety Measure or Infection Control. In PART II, document specifically how the required Interim Life

Safety Measures or Infection Controls will be implemented for this particular project. In Part III, list the areas and personnel affected by the implemented Interim Life Safety Measures or Infection Controls.

A. Exits:

1. Does the project have the potential of affecting an exit or other means of egress?

2. Will the affected exit be used by other than the Contractor’s personnel?

Required Actions: If a means of egress is obstructed, an alternate must be designated and training is required for those persons affected. Means of exiting construction areas must be inspected on a daily basis to prevent blockages due to debris.

B. Emergency Access:

1. Does the project have the potential to obstruct access to emergency departments or services?

2. Does the project have the potential of obstructing access of emergency forces to the construction area?

Required Actions: If an emergency access is obstructed, an alternate means of access must be designated and the Gallup

Fire Department and GIMC Security must be notified of the alternative.

C. Fire Protection:

1. Does the project have the potential of impairing existing fire alarm, detection, or suppression systems?

2. Will temporary fire protection systems be required as part this project?

Required Actions: If a fire protection or alarm system is to be rendered non-operational for more than 4 hours out of a

24-hour period, either a substitute system or a fire watch must be initiated. If neither of these methods can be implemented, the area must be closed down and evacuated. All of these measures must be coordinated with the Gallup

Fire Department, GIMC Security, and the affected staff.

D. Temporary Partitions:

Will construction involve the use of temporary partitions?

Required Actions: If construction involves major breaches in fire or smoke barriers, the…