36C24219B0045-0001002.doc

Attach to Main ICRA

Water Infection Control Risk Assessment /Construction Impact Assessment Review

Location of Construction:

Project Title:

Project Coordinator:

Project No.

Project Start Date:

Estimated Duration:

Step 1. Briefly summarize project aspects that involve modification to plumbing systems

Step 2: Specific site of activity, e.g., room numbers and type patient rooms, offices, etc.

Step 3: Duration and dates of water service interruption and time period ward/area will be unoccupied.

Step 4: Construction while area occupied? If so, will temporary water be required for drinking, hand washing, bathing, cleaning, etc.?

Step 5: Using the following table, identify the Type of Construction Project Activity

Includes, but is not limited to:

· Adjustment and inspection of plumbing systems which do not interrupt water service or creates disturbances of water flow e.g. significant changes in water pressure, system draining, air hammering due to air getting into the lines or vibrations due to cutting off lines or jackhammering in adjacent spaces.

· Installation of new laminar flow devices at sink outlets.

· Installation of new showerheads.

· The shutdown of a single valve to fix a leak.

· Events causing strong shaking; e.g. seismic event, use of ground compaction equipment near the incoming water supply.

Includes, but is not limited to:

· Plumbing work which when possible can be isolated from the overall water distribution system, or

· Work which results in water service interruptions to no more than 3 fixtures

· Work which can be completed within a 72-hour period.

Includes but not limited to:

· Plumbing modifications involving the installation of three (3) or 4 or more fixtures (sinks, showers, drinking fountains) and/or ice machines, eyewashes, or

· Work that creates a water system disruption for more than 72 hours.

Work which results in the vacancy of the ward/area (of three rooms or more) for more than 7 days.

· Work that results in unoccupied areas for up to 7 days after water service has been restored.

· Heavy demolition or replacement of potable water distribution piping, heating devices, storage tanks, treatment or associated systems

· New building construction, major renovation

· Work which creates a water service interruption for more than 7 consecutive days, or results in unoccupied unit >10 days after water service restored.

· Major modifications to specialty systems including but not limited to: dental, hemodialysis, and SPS.

· Work involving major modifications to cooling towers (does not include cleaning or routine maintenance)

Step 5: Fill in Type of Construction as determined above ___________________________________

Step 6: Identify the Patient Risk Group(s) that will be affected

Using the following table of Example Risk Units, identify the Patient Risk Groups will be affected. If more than one risk group will be affected, select the higher risk group.

Public/General Space

(Low Risk)

· Office areas

· Support Services (Mechanical, Environmental, etc.)

· Public Space/ Retail Space

· Echocardiography

· Endoscopy

· Nuclear Medicine

· Physical Therapy

· Radiology/MRI

· Respiratory Therapy

· Laboratories (specimen)

· Pharmacy

· GI Endoscopy

· Post Anesthesia Care Unit

· CLC

· Hoptel

· Sterile Processing areas

· Intensive Care Units

· Inpatient Units

· Operating rooms

· Interventional cardiology

· Interventional radiology

· Oncology

· Dialysis

Step 6: Fill in Risk Category as determined above: __________________________

Step 7: Select the Class of Precaution based on Patient Risk Group and Project Type

Note: Infection Control approval will be required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are necessary.

Step 7: Fill in Class of Precaution as determined above: ___________________ Step 8: Required Water Safety Infection Control Commissioning Procedure by Class

NOTE TO COR/PROJECT MANAGER: The required water flushing and testing procedures noted in the table below must be incorporated in the project design documents so that it is clearly understood that implementation of the procedures is the responsibility of the construction contractor. The report documenting test results must be received and submitted to the COR, Water Safety Committee representative and Infection Control representative prior to the project area being turned over for re-occupancy for staff/patients.

Note: the water sampling must be witnessed by the COR/Designee and be collected no more than two (2) weeks prior to the scheduled re occupancy so that the data are representative of conditions when the area reopens.

Project Design Requirements:

For Class III and IV projects, the Project engineer shall ensure that project design takes into account the VA Plumbing Design Manual (PG 18-10), specifically focusing on paragraph 4.5. “Legionella Mitigation in VA Facilities”. Ensure that requirements for water temperature control to inhibit legionella growth are implemented. Take into account specific design criteria for special use water systems (e.g. hemodialysis, laboratory, sterile processing, pharmacy compounding) and appurtenances (ice machines, drinking fountains, eyewashes, etc.). Ensure that prohibited items (decorative water features, faucet aerators, plumbing modifications that create dead legs) are not included in designs.

Project engineer attests that the A/E has been given a copy of the VA Plumbing Design Manual and that the design is consistent with legionella mitigation provisions of the manual:

Highlight one:

YES/NO If “NO” indicate exceptions below and alternate plan to ensure that legionella growth is mitigated:

system from construction operations.

1. Flush affected distal outlets (sinks and showers) for 10 minutes upon completion of work.

2. Clean work area upon completion of tasks

2. Post notices prohibiting the use of water from fixtures impacted by the work.

3. Keep all new pipes and components scheduled for installation clean and dry. Inspect to ensure they are free of debris and clean.

1. Flush cold water from each affected fixture for 5 minutes per day, beginning at least 2 weeks prior to re-occupancy. and document.

2. Flush hot water from each affected fixture for 5 minutes per day and document.

3. Remove notices prohibiting the use of water.

4. Clean work area upon completion of tasks.

2. Post notices prohibiting the use of water from fixtures impacted by the work.

3. Keep all new pipes and components scheduled for installation clean and dry. Inspect to ensure they are free of debris and clean.

4. Do not remove notices until approved by Infection Control.

5. Notify WSCR and IC at least 2 weeks prior to reopening of ward/area.

1. After completion of work, but at least 2 weeks prior to re-occupancy, begin a daily flushing regime.

2. Flush cold water from each affected (or all) fixture for 5 minutes per day and document.

3. Flush hot water from each affected (or all) fixture for 5 minutes each day and document. Temperatures should be within the goal range (< 110 F).

4. Within (not greater than), two weeks prior to scheduled re-occupancy, general bacterial water sampling must be performed and witnessed by the COR/designee with documentation. See the procedure on pages 8-9.

5. Test a minimum of 10% of distal outlets, both hot and cold water.

6. Maintain daily flushing in the affected areas while culture results are pending and until re-occupancy. Flush all outlets for a minimum of 5 minutes each day to ensure the system does not remain stagnant.

7. Submit lab results to COR, IC, and WSCR. If results are acceptable, maintain daily flushing until area is reoccupied. See #14.

8. If results are unacceptable, perform hyper chlorination procedure per COR and VA directives, re-flush and repeat testing until acceptable results are achieved.

9. If re-occupancy is delayed beyond 7 days of bacterial testing, bacterial testing must be repeated.

10. Obtain approval from IC and WSCR and notify COR to remove notices prohibiting the use of water.

2. Post notices prohibiting the use of water from fixtures impacted by the work.

3. Keep all new pipes and components scheduled for installation clean and dry. Inspect to ensure they are free of debris and clean.

4. Do not remove notices until approved by Infection Control.

5. Notify WSCR and IC at least 2 weeks prior to reopening of ward/area.

1. After completion of work, but at least 2 weeks prior to re-occupancy, begin a daily flushing regime.

2. Flush cold water from each affected fixture for 5 minutes and document temperature.

3. Flush hot water from each affected (or all) fixture for 5 minutes each day and document. Temperatures should be within the goal range (< 110 F).

4. Within (not greater than), two weeks prior to scheduled re-occupancy, general bacterial water sampling and legionella sampling must be performed and witnessed by the COR/designee with documentation. See procedure on pages 8-9.

5. Test a minimum of 20% of distal outlets, both hot and cold water.

6. Maintain daily flushing in the affected areas while culture results are pending and until re-occupancy. Flush all outlets for a minimum of 5 minutes each day to ensure system does not remain stagnant.

7. Submit lab results to COR, IC, and WSCR. If results acceptable, maintain daily flushing until area is reoccupied. See #14.

8. If results are unacceptable, perform hyper chlorination procedure per COR and VA Directives, re-flush and repeat testing until acceptable results are achieved.

9. If re-occupancy is delayed beyond 7 days of bacterial testing, bacterial testing must be repeated.

10. Obtain approval from IC and WSCR and notify COR to remove notices prohibiting the use of water.

NOTE: Identify and communicate the responsibility for project monitoring that includes infection control concerns and risks. The WICRA may be modified throughout the project.

Revisions must be communicated to the Project Manager.

Water Infection Control Construction Permit

Permit No:

Location of Construction:

Project Start Date:

Project Coordinator:

Estimated Duration:

Contractor Performing Work:

Permit Expiration Date:

Supervisor:

Telephone:

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

system from construction operations.

2. Flush affected distal outlets (sinks and showers) for 10 minutes upon completion of work.

3. Clean work area upon completion of tasks.

2. Post notices prohibiting the use of water from fixtures impacted by the work.

3. Keep all new pipes and components scheduled for installation clean and dry. Inspect to ensure they are free of debris and clean.

4. Flush cold water from each affected fixture for 5 minutes per day, beginning at least 2 weeks prior to re-occupancy. and document.

5. Flush hot water from each affected fixture for 5 minutes per day and document.

6. Remove notices prohibiting the use of water.

7. Clean work area upon completion of tasks.

CLASS III

Date

__________ Initial

1. Isolate the water system where work is being performed.

3. Keep all new pipes and components scheduled for installation clean and dry. Inspect to ensure they are free of debris and clean.

4. Do not remove notices until approved by Infection Control.

5. Notify WSCR and IC at least 2 weeks prior to reopening of ward/area.

6. After completion of work, but at least 2 weeks prior to re-occupancy, begin a daily flushing regime.

7. Flush cold water from each affected (or all) fixture for 5 minutes per day and document.

8. Flush hot water from each affected (or all) fixture for 5 minutes each day and document. Temperatures should be within the goal range (< 110 F).

9. Within (not greater than), two weeks prior to scheduled re-occupancy, general bacterial water sampling must be performed and witnessed by the COR/designee with documentation. See the procedure on pages 8-9.

10. Test a minimum of 10% of distal outlets, both hot and cold water.

11. Maintain daily flushing in the affected areas while culture results are pending and until re-occupancy. Flush all outlets for a minimum of 5 minutes each day to ensure the system does not remain stagnant.

12. Submit lab results to COR, IC, and WSCR. If results are acceptable, maintain daily flushing until area is reoccupied. See #14.

13. If results are unacceptable, perform hyper chlorination procedure per COR and VA directives, re-flush and repeat testing until acceptable results are achieved.

14. If re-occupancy is delayed beyond 7 days of bacterial testing, bacterial testing must be repeated.

15. Obtain approval from IC and WSCR and notify COR to remove notices prohibiting the use of water.

CLASS IV

Date

Initial

1. Isolate the water system where work is being performed.

3. Keep all new pipes and components scheduled for installation clean and dry. Inspect to ensure they are free of debris and clean.

4. Do not remove notices until approved by Infection Control.

5. Notify WSCR and IC at least 2 weeks prior to reopening of ward/area that has had water interruption due to construction

6. After completion of work, but at least 2 weeks prior to re-occupancy, begin a daily flushing regime.

7. Flush cold water from each affected fixture for 5 minutes and document temperature.

8. Flush hot water from each affected (or all) fixture for 5 minutes each day and document. Temperatures should be within the goal range (< 110 F).

9. Within (not greater than), two weeks prior to scheduled re-occupancy, general bacterial water sampling and legionella sampling must be performed and witnessed by the COR/designee with documentation. See the procedure on pages 8-9.

10. Test a minimum of 20% of distal outlets, both hot and cold water.

11. Maintain daily flushing in the affected areas while culture results are pending and until re-occupancy. Flush all outlets for a minimum of 5 minutes each day to ensure system does not remain stagnant.

12. Submit lab results to COR, IC, and WSCR. If results acceptable, maintain daily flushing until the area is reoccupied. See #14.

13. If results are unacceptable, perform hyper chlorination procedure per COR and VA Directives, re-flush and repeat testing until acceptable results are achieved.

14. If re-occupancy is delayed beyond 7 days of bacterial testing, bacterial testing must be repeated.

15. Obtain approval from IC and WSCR and notify COR to remove notices prohibiting the use of water.

Additional Requirements: Contractor must adhere to the Required Infection Control Precautions listed above for each class and all provisions of the Contract Documents.

Project Engineer/COR Reviewed WICRA and all attachments with Contractor: ______Yes _______No

Project Engineer/COR: Print name________________ Signature ___________________Date___________

Contractor: Print name of Company

Contractor Supervisor: Print name

Signature _________________Date_____________

Water Safety Rep: Print name ________________ Signature ___________________Date________________

Infection Control Manager/Designee: Print name _________________Signature____________ Date____

Water Testing Clearance Procedure (general bacterial analyses)

1. This procedure must be completed successfully prior to opening the ward/area for occupancy. Sampling must be performed no more than two (2) weeks prior to reopening.

2. Sampling must be performed by an independent environmental consulting firm. Samples must be collected under strict chain of custody procedures using dedicated sterile bottles with the appropriate preservative(s) provided by the laboratory. Notify the Safety Department prior to sampling so that the sampling may be witnessed.

3. Collect grab samples from both hot and cold water distal outlets at the ratio required by the class of work (described above). Sampling ratio shall be maintained for each type of outlet (e.g. for Class I, minimum 10% of showers must be sampled, minimum 10% of sinks, a minimum 10% of water fountains, etc.)

4. Samples shall be conveyed under a strict chain of custody procedures to an independent testing laboratory certified by the New York State Environmental Laboratory Approval Program (ELAP).

5. Samples shall be analyzed for: total coliform, e.coli and heterotrophic plate count (HPC) bacteria.

6. All samples must meet the following criteria: total coliform and e. Coli must be absent, and HPC bacteria must not exceed 500 colony-forming units per milliliter (CFU/ml).

7. If any samples fail the criteria, repeat flushing and resample the locations which failed until the acceptable water quality is achieved.

8. Upon completion of the sampling, the contractor shall submit a written report prepared by the laboratory describing the sample collection procedure and analytical results.

Water Testing Clearance Procedure (legionella analyses)

1. This procedure must be completed successfully prior to opening the ward/area for occupancy. Sampling must be performed no more than three (3) weeks prior to reopening.

2. Sampling must be performed by an independent environmental consulting firm. Samples must be collected under strict chain of custody procedures using dedicated sterile bottles with the appropriate preservative(s) provided by the laboratory. Notify the Safety Department prior to sampling so that the sampling may be witnessed.

3. Collect grab samples from both hot and cold water distal outlets at the ratio required by the class of work. Sampling ratio shall be maintained for each type of outlet.

4. Samples shall be conveyed under a strict chain of custody procedures to an independent testing laboratory certified by the New York State Environmental Laboratory Approval Program (ELAP).

5. The Contractor shall measure and record the following parameters at the time of sampling: temperature, pH, free, and total chlorine.

6. The laboratory that processes the water samples for Legionella must be certified by the Centers for Disease Control and Prevention (CDC) Environmental Legionella Isolation Techniques Evaluation (ELITE) program as proficient at performing the culture of Legionella from environmental samples. Information about ELITE certified laboratories can be found at https://wwwn.cdc.gov/elite/Public/MemberList.aspx. Laboratories must also be able to determine if the Legionella detected in environmental samples is the species Legionella pneumophila and whether it is serogroup 1. NOTE: rapid testing method, such as polymerase chain reaction (PCR) and direct fluorescent antibody (DFA) are not permitted.

7. In addition to the CDC ELITE certification, the laboratory must be certified by the New York State Department of Health Environmental Laboratory Approval Program (ELAP) for environmental analyses of potable water.

8. All samples must be negative for l. pneumophila.

9. If any samples fail the criteria, repeat flushing and resample the locations which failed until the acceptable water quality is achieved.

10. Upon completion of the sampling, the contractor shall submit a written report prepared by the laboratory describing the sample collection procedure and analytical results.

Shock Chlorination Procedure This method involves increasing the chlorine level of the hot and cold water distribution systems to at least 2 mg/L and maintaining that level throughout the systems for at least 2 hours and flushing all outlets. After the shock chlorination procedure is complete, the system must be thoroughly flushed before reuse. If post-shock chlorination water testing indicates that unacceptable levels of bacteria are still present in the water distribution system(s), it may be necessary to repeat shock chlorination with consideration for use of a higher concentration of chlorine (e.g., at least 10 mg/ml free chlorine residual throughout the system and at outlets for 24 hours or 200 mg/L for three hours).

Figure � SEQ Figure \* ARABIC �1�Type D