20 - 630A4-22-700 ICRA.pdf

1. PURPOSE

To establish policies and procedures to ensure the Safety & Environment of Care in all patient care buildings is not compromised during any renovations or new construction. When planning demolition, construction or renovation work, Engineering, Infection Control & Safety personnel will conduct a proactive Pre-Construction Risk Assessment (PCRA) using risk criteria to identify hazards that could potentially compromise patient care in occupied areas of the building. The Infection Control Risk Assessment (ICRA) may be modified throughout the project. The risk criteria should address the impact of demolition, renovation or new construction activities on Air and Water Quality requirements, Infection Control, Utility Requirements, Noise, Vibration and Emergency procedures.

2. POLICY

The VA New York Harbor Healthcare System (VANYHHS) will ensure the Safety and the Environment of Care will not be adversely affected due to renovation or new construction.

3. RESPONSIBILITIES:

a) The Chiefs, Engineering Services are responsible to ensure that an Infection Control Risk Assessment Program is developed and that the necessary actions to implement the program are enforced.

b) The Chief of Planning & Design is responsible for the development of Construction design documents that address the Six (6) items identified above as result of renovations or new construction.

c) The Chief, Engineering Services & the Chief of Environmental Services shall coordinate & protect all In-House repairs and maintenance work areas that fall under Class I thru IV category as required in Attachment No. 2.

d) The Infection Control Manager is responsible to ensure the following actions are taken:

1. Participation in the Design Process with Architects & Engineers at the request of the Project Engineer.

2. Participation in the completion and documentation of the PCRA.

3. Review of the Contract Documents prior to acquisition for inclusion of infection Control

Precautions identified in the PCRA.

4. Review and comment on the PCRA/ICRA initiated by the COR in Attachment No. 1 and

Attachment No. 2.

5. Before any construction on site begins, all contractor personnel involved in the construction or renovation activity shall be educated and trained in infection prevention measures established by the medical center.

DEPARTMENT OF VETERANS AFFAIRS

NEW YORK HARBOR

HEALTHCARE SYSTEM

HEALTHCARE SYSTEM POLICY NO: 138-27

SUBJECT: CONSTRUCTION & INFECTION CONTROL

RISK ASSESSMENT

DATE: June 2020

6. Medical center Infection Control personnel will monitor for airborne disease (e.g.

aspergillosis) during construction. A baseline of conditions will be established by the medical center prior to the start of work and periodically during the construction stage to determine impact of construction activities on indoor air quality with safe thresholds established.

7. Participation in weekly Construction Committee Safety Rounds.

8. Membership in Construction Safety Committee

9. Report of findings of Construction Safety to the Infection Control Committee.

10. Providing recommendations to the Design Team (Architects/ Engineering Consultant &

Project Engineers) on any Infection Control issues that arise from construction.

3. PROCEDURES:

Planning & Design

a) The Infection Control Risk Assessment (ICRA) is initiated in design and planning stages and continues through construction and renovation. Project Engineers assigned to the project shall incorporate the specific construction related requirements of IRCA in the contract documents. The contract documents shall require the constructor to implement these specific requirements during construction.

b) The ICRA & the Design Team shall address but not be limited to the following:

1. The impact of disrupting essential services to patients and employees.

2. Patient placement or relocation.

3. Placement of effective barriers to protect susceptible patients from airborne

Contaminants such as Aspergillus sp.

4. Air handling and ventilation needs in surgical services, airborne infection isolation and protective environment rooms, laboratories, local exhaust systems for hazardous agents and other special areas.

5. Determination of additional numbers of airborne infection isolation or protective environment room requirements.

6. Consideration of the domestic water system to limit Legionella sp. and waterborne opportunistic pathogens.

7. Assessment for internal and/or external construction projects also includes patient protection from demolition, ventilation and water management following planned or unplanned power outages, movement of debris, traffic flow cleanup and certification.

8. Pre-Construction Risk Assessment for the Transmission of Tuberculosis (TB) to Contracted Construction Workers.

Construction

a) Projects involving renovation of existing buildings shall include phasing to minimize disruption of existing patient services. Phasing is essential to ensure a safe environment in patient care areas.

b) Phasing will include assurance for clean to dirty airflow, emergency procedures, criteria for interruption of protection, construction of roof surfaces, written notification of interruption, and communication authority.

c) Phasing plan shall include considerations of Noise and Vibration control that result from construction activities.

d) Renovation areas shall be isolated from occupied areas during construction using airtight barriers and exhaust airflow shall be sufficient to maintain negative air pressure in the construction zone.

e) Existing air quality requirements and other utility requirements for occupied areas shall be maintained.

f) Projects involving potential for contracted construction workers to be exposed to Tuberculosis (TB) shall include a requirement that the Contractor provide written certification that all contract employees assigned to the site have had a pre-placement tuberculin screening within 90 days prior to assignment to the worksite and have been found to have negative TB screening reactions. Contractors will be required to show documentation of negative TB screening reactions for any workers who are added after the 90-day requirement before the workers will be allowed to work on the work site.

Commissioning

a) Acceptance criteria for mechanical systems shall be specified. Crucial ventilation specifications for air balance and filtration shall be verified before acceptance. Areas requiring special ventilation include surgical services, protective environments, airborne infection isolation rooms, laboratories, and local exhaust system for hazardous agents. These areas shall be recognized as requiring mechanical systems that ensure infection control, and ventilation deficiencies shall not be accepted.

b) Acceptance criteria for local exhaust system dealing with hazardous agents shall be specified and verified.

1. REFERENCES

AIA Guidelines for Design & Construction of Hospitals (latest edition) APIC Text, Chapter 116, Construction and Renovation, Last Revised 6/6/14.

ASHE PDC (latest edition) DVA VHA Master Specifications 01-35 26, Safety Requirement, 10-01-14 DVA VHA Directive 2011-036 Safety and Health during Construction, September 22, 2011 Guidelines for Design and Construction of Health Care Facilities, The Facilities Guidelines Institute, 2010 Edition The Joint Commission Environment of Care Standard EC.02.06.05 VACO Life Safety Management Guidebook

2. RESCISSION

Healthcare System Policy No. 138-27, “Construction & Infection Control Risk Assessment”, dated June 2015

3. EXPIRATION DATE

June 2023

MARTINA A. PARAUDA

Director

Distribution: SC

VHANYNSituJ Text Box

MEMORANDUM CONTINUE IN USE,

UNTIL NEW MEMO PUBLISHED.

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

Attachment # 1

Infection Control Risk Assessment /Construction Impact Assessment Review

Location of Construction: ALL BLDG(s) Brooklyn Campus

Project Title: EHRM Infrastructure Upgrades - Brooklyn VA Medical Center

Project Coordinator: John Situ Project No. 630A4-22-700

Project Start Date: Estimated Duration: 730 Calendars days from NTP

Impact (Are the following items below affected?) Yes/No Description

❑ Patient Placement or Relocation N/A

❑ Air Quality (containment, HEPA filtration, isolation /negative airflow rooms) Yes, Provide HEPA filtration to be provided.

❑ Noise/Vibration Yes, there will be some noise due to construction activities. Any work that will cause excessive nose will be planned accordingly and nearby occupants will be notified.

❑ Security (work hours) Primary work hours are 8am-4:30pm, but some off-hours work is anticipated.

Yes, some work may require it to be performed off hours. If so, it will be scheduled accordingly

❑ Phasing Yes, GC to follow Design phasing schedule

❑ Life/Safety All life safety plans, and emergency routes have been addressed and ILSM will submit separately

❑ Fire Alarm Fire alarm will be offline

❑ Fire Sprinkler Fire Sprinkler will be offline and caped

❑ Exits Alternate routes have been identified and will be properly maintained.

❑ Emergency Power No

❑ HVAC (Infection Issues Environment) Yes, HVAC System in construction area will be cut and capped prior to demolition.

❑ Asbestos-Containing Materials (ACM) Yes, Asbestos abatement work to be scheduled accordingly

❑ Barriers (smoke, construction, dust) Yes, Construction, dust and smoke barriers will be erected

❑ Medical Gases Yes, any medical gases activities to be scheduled accordingly

❑ Plumbing, Domestic Water System Yes, Isolated. There will be re-routing of water lines in this project

❑ Electrical (occurrence of probable outages) Yes, Contractor will schedule anticipated outages two weeks in advance with the COR who will coordinate with hospital staff for utility shutdown

❑ Containment issues (traffic flow, housekeeping, debris removal) Frequency, scope, route and time will be approved by the COR Workers are to be free of dust prior to existing the work zone. Transport carts will be covered and be free of dust. Housekeeping daily or more frequently as needed. No standing water.

❑ Underground Utilities (Water, Electric, drainage etc.)

N/A

❑ Vehicle Traffic Flow N/A

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

❑ Structural integrity (potential risk ) N/A

❑ Risk of TB transmission to contract construction workers (annual risk assessment, shared air space pts or specimens, location, travel routes, hospital layout) N/A

❑ Contracted Construction Workers exposure for contacting Tuberculosis (TB) exist (potential risk)

Additional Requirements:

Pre-Construction Risk Assessment for the Transmission of Tuberculosis (TB) to the Contracted Construction Worker The decision to require baseline TST/TB testing will be based on the annual TB Risk Assessment and the Construction Site Location, Ingress/Egress Routes, Patient Population, & Hospital Layout.

BASELINE TESTING:

X NOT REQUIRED: No Potential Risk of Contact & No Potential Risk of Shared Air Space with TB Patients or Clinical Specimens

REQUIRED: Potential Risk of Contact & Potential Risk of Shared Air Space with TB Patients/Clinical Specimens

Exceptions / Additions to this review are noted as follows (attach additional sheets as necessary):

Assessed by Project Engineer/COR: _John Situ__________________________________11-05-2025____ Name (Print) Date

Assessed by the Safety Manager: __________________________________________________________

Assessed by Infection Control Manager/Designee: _____________________________________________

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

Attachment # 2 Infection Control Risk Assessment

Matrix of Precautions for Construction and Renovation

Step One:

Using the following table, identify the Type of Construction Project Activity (Type A-D)

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:

• installation of telephone and computer cabling

• access to chase spaces

• cutting of walls or ceiling where dust migration can be controlled

TYPE C

Work that generates a moderate to high level of dust or required demolition or removal of any fixed building components or assemblies Includes, but is not limited to:

• sanding of walls for painting or wall covering

• removal of floorcoverings, ceiling tiles and casework

• new wall construction

• minor duct work or electrical work above ceilings

• major cabling activities

• any activity which 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

• asbestos abatement work

STEP 1: TYPE C

Step Two:

Using the following table, identify the Patient Risk Groups that will be affected.

If more than one risk group will be affected, select the higher risk group:

Low Risk Medium Risk High Risk Highest Risk

• Office areas

• Cardiology

• Echocardiography

• CCU

• Emergency Room

• Any area caring for immunocompromised

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

• Endoscopy

• Nuclear Medicine

• Physical Therapy

• Radiology / MRI

• Respiratory Therapy

• Laboratories (specimen)

• Outpatient Surgery

• Pharmacy

• Post Anesthesia Care Unit

• Surgical Units patients

• Cardiac Cath Lab

• Central Sterile Supply

• Intensive Care Units

• Medical Unit

• Negative pressure isolation rooms

• Oncology

• Operating Rooms

STEP 2 LOW

Step Three: Match the… Patient Risk Group (Low, Medium, High, Highest) with the planned . . .

Construction Project Type (A, B, C, D) on the following matrix, to find the . . .

Class of Precautions (I, II, III or IV) or level of infection control activities required

Class I – IV or Color-Coded Precautions are delineated on the following page.

IC Matrix – Class of Precautions: Construction Project by Patient Risk

Construction Project Type

Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III /IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III / IV IV

HIGHEST Risk Group II III / IV III / IV IV

Note:

1. Risk classifications of Class II or lower will require approval by the Project Engineer/COR before beginning any construction work.

2. An Infection Control Construction Permit will be required when the Construction Activity and Risk

Level indicate that Class III or Class IV control procedures are necessary.

STEP 3 II

Description of Required Infection Control Precautions by Class

During Construction Project Upon Completion of Project

C L

A 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.

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

C L

A 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 disinfectant.

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

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

4. Remove isolation of HVAC system in areas where work is being performed.

C L

A 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 before transport in tightly covered containers.

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 Control Department and thoroughly cleaned by the owner’s Environmental Services 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 disinfectant.

5. Remove isolation of HVAC system in areas

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

C L

A 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.

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

8. Note: all asbestos abatement work shall be performed as Class IV work, and is further subject to additional provisions of the NY State asbestos regulations (NY Department of Labor Industrial Code Rule 56).

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

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

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

4. Vacuum work area with HEPA filtered vacuums.

5. Wet mop area with disinfectant.

6. Remove isolation of HVAC system in areas where work is being performed.

7. For asbestos abatement work, confirm that the licensed Project Monitor has performed a final visual inspection and conducted clearance air sampling as required under NY State asbestos regulations (NY Department of Labor Industrial Code Rule 56).

Step 4:

Identify the areas surrounding the project area, assessing potential impact

Unit Below Unit Above Lateral Lateral Behind Front

Entire Facility / All IT- Rooms

Entire Facility / All IT- Rooms

Entire Facility / All IT- Rooms

Entire Facility / All IT- Rooms

Entire Facility / All IT- Rooms

Entire Facility / All IT- Rooms

Risk Group

LOW

Risk Group

LOW

Risk Group

LOW

Risk Group

LOW

Risk Group

LOW

Risk Group

LOW

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 ECSE Inc 2001

Step 5:

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

The overall intent of this project is to upgrade and improve the facility OIT infrastructure to support the new infrastructure upgrades to all IT Rooms throughout the entire campus, and the Reginal Data Center (RDC) located within BLDG. 14. Including closet replacements, demolition/backfill of existing data closets after switch-over and some closet expansions/modifications), provide a redundant fiber run throughout the Clinical and Administrative buildings to each Telecommunication Rooms. Repurposing the existing Reginal Data Center (RDC) into the new Main Computer Room (MCR). Including replacement and demolition/backfill of existing data center / server room after switch-over), provide redundant fiber-cabling and pathways in between the new Main Computer Room (MCR) and other building.

Step 6:

Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages including protection of patients during planned and unplanned utility outages.

There will be planned OIT, mechanical, plumbing and electrical outages at various points during the construction project. COR and contractor will coordinate all planned outages with the departments involved so that alternate provisions can be made if necessary, during the planned outages. Contractor will schedule anticipated outages 7 days in advance with the COR who will coordinate with hospital staff.

Step 7:

Identify containment measures, using prior assessment. What types of barriers (e.g. solid wall barriers)? Will HEPA filtration be required? ______________ (Note: Renovation / construction area shall be isolated from the occupied areas during construction and shall be negative with respect to surrounding areas)

A construction barrier will be constructed at the entrance of each construction site or area involved. All the construction sites will be kept under negative pressure HEPA filtration exhausted to the exterior of the building using heavy duty flexible steer reinforced ventilation blower hoses.

Negative pressure will be monitored. Plastic barriers and wet methods will also be used around core drilling, or any other work performed within the work zone that might create dust, debris, or water. All supply and return vents within the construction area will be capped and sealed. Sticky mats will be placed both outside and inside the construction site while work is being conducted and be changed as often as required to maintain clean work areas directly outside the construction area.

Barriers will be constructed inside temporary zip walls to the ceiling

Ceiling tiles will be removed as necessary to seal the existing perimeter walls to the deck above. One (1) hour fire rated drywall partition will be constructed and extended to the deck above. Drywall will be installed on both the interior and exterior sides and be sealed with fire rated tape. Contractor will receive approval of the Construction Safety team prior to beginning any demolition.

Fire Alarm, Mechanical, Electrical, and Plumbing systems will be isolated at the beginning of construction. Area will not be put back in service until WCRA requirements are met.

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

Step 8:

Will project involve asbestos abatement?

Yes. Asbestos Abatement Removal will be involved, and Air Monitoring Services will be in place to ensure site safety.

Step 9:

Consider potential risk of water damage. Is there a risk due to compromising structural integrity (e.g. wall, ceiling, roof)? __ No_____

Step 10:

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

Yes, some work will be performed off hours where applicable to not affect patient care, but majority of work will be done during normal hours.

Step 11:

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

N/A This will be a construction site that will be kept negative.

Step 12:

Do the plans allow for the required number & type of hand washing sinks? ____N/A_____

Step 13:

Does the Infection Control staff agree with the minimum number of sinks for this project?

(Verify against AIA Guidelines for types and area) ____N/A_______

Step 14:

Does the Infection Control staff agree with the plans relative to clean and soiled utility rooms? ____N/A____

Step 15:

Plan to discuss the following containment issues with the project team, e.g. traffic flow, House-keeping, debris removal (how and why) and spill cleanup

The route to the construction area for worker access, and material deliveries, will be through the freight elevators in the main building to the construction site.

Transport carts will be covered with a hard cover or covered, and tape closed to contain debris and dust.

Transport carts and wheels will be cleaned prior to exiting construction barrier to prevent dust from beginning to be tracked outside the work zone. Any dust traced outside the work zone shall be immediately removed.

Debris will be removed via the freight elevator in the main building to the ground loading dock after normal hours. Debris removal will start after 5 p.m. and be completed by 7 a.m.

Step 16:

Were contracted construction workers determined to be at risk for transmission of TB to them based upon the TB pre-construction risk assessment? _N/A___ If yes, contractor shall provide written certification that all contract employees assigned to the work site have had a pre-placement tuberculin screening within 90 days prior to assignment to the worksite and been found to have negative TB screening reactions. Contractors shall 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. Note: this can be the Center for Disease Control (CDC) and Prevention and two-step skin testing or a Food and Drug Administration (FDA) approved blood test.

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 ECSE Inc 2001

1. Contractor employees manifesting positive screening reactions to the tuberculin shall be examined according to current CDC guidelines prior to working on VHA property.

2. Subsequently, if the employee is found without evidence of active (infectious) pulmonary TB, a statement documenting examination by a physician shall be on file with the employer (construction Contractor), noting that the employee with positive tuberculin screening test is without evidence of active (infectious) pulmonary TB.

3. If the employee is found with evidence of active (infectious) pulmonary TB, the employee shall require treatment with subsequent statement to the fact on file with the employer before being allowed to return to work on VHA property.

Exceptions / Additions to this review are noted as follows (attach additional sheets as necessary):

Assessed by Engineering______JOHN SITU__________________________________________

Assessed by Infection Control: _____________________________________________________

Assessed by Safety: ______________________________________________________________

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.

Infection Control Construction Permit

Permit No:

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

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 ECSE Inc 2001

Forms modified and provided courtesy of J Bartley, ECSI Inc 2002

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 1 work shift for completion

GROUP

3:

Medium / High Risk

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

GROUP

4:

Highest Risk

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. Minor demolition for remodeling

CLASS II 1. Provides active means to prevent air-borne 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. Wipe surfaces with disinfectant.

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

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

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

9. Remove or isolate HVAC system in areas

CLASS III

Date

__________Initial

1. Obtain infection control permit before construction begins

2. Isolate HVAC system in area where work is being done to prevent contamination of the 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 Environmental Services Department

6. Vacuum work 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 areas

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 ECSE Inc 2001

CLASS IV

Date

Initial

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

6. 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 unit.

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

8. Do not remove barriers from work area until completed project is thoroughly cleaned by the Environmental Service Department

9. Vacuum work area with HEPA filtered vacuums.

10. Wet mop with disinfectant.

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

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

13. Cover transport receptacles or carts. Tape covering.

14. Remove or isolate HVAC system in areas where it is being done.

15. For asbestos abatement projects, confirm that the licensed Project Monitor has performed clearance air testing and verified that safe re-occupancy criteria have been met.

Additional Requirements: Contractor must adhere to the Required Infection Control Precautions listed above for each class and as indicated in DVA VHA Master Specifications 01-35 26, Safety Requirement, 10-01-14.

Exceptions / Additions to this permit are noted

Date Initials by attached memoranda

Permit Requested By:(Contractor’s Supervisor)

Permit Authorized By:

Project Engineer/COR

Date: Date:

Project Engineer Reviewed ICRA and all attachments with Infection Control and Contractor _____________

Project Engineer/COR: Print name________________ Signature ___________________Date___________

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 ECSE Inc 2001

Infection Control Manager/Designee: Print name _________________Signature__________ Date____

Contractor: Print name of Company______________________________________________________

Supervisor: Print name ________________ Signature ___________________Date________________