36C24518B0233-012.pdf

Effective Date 1/2/2018 Replaces v2

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613 121

Est. Project Duration

Title Signer/Alternate Extension Project Section Superviso4400 Jeff Miller 2072

Krista Bowen 4715 Kathy Fiery 3418 Shari Self 3626 Irine Smith 4875 Cynthia Moore 4574

*Note: Krista Bowen can also sign on behalf of Safety Office for the Pre-Construction Checklist

COR signature Date Printed: 7/18/2018

Project Section

I acknowledge that it is my responsibility to submit signed safety documents to Contracting prior to solicitation .

I certify that all project information is correct and complete to the best of my knowledge. I will ensure the precautions listed in the ICRA and ILSM, including those added by the ICRA and ILSM signers and/or their alternates, will be upheld.

All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

Industrial Hygiene Krista Bowen* 4715

4611 / 4612Fire

Department

Infection Control

Scott Smoot 4611/4612

John ShadePolice Department 4110

Contractor Supervisor (CO if TBD) Contractor Contact Number

Project Description This project will engage a Construction Contractor to construct a new 5,500 GSF Domiciliary Clinic Addition, a 4,300 GSF CLC Administrative Addition, and a 5,000 GSF connecting corridor from Building 500 through the Dom Clinic/CLC Administration addition, and connecting to the Tranquility building.

Est. Project Start Date

Facilities Management Services

Version: 3Doc Number: VHA-V05-613-FMS-FORM-PS-0002

Project Data At-A-Glance

15 months

4611/4612

Extension ICRA Signers ILSM Signers

Eric Gray Edwin Aponte-Rivera Chris Gorman

Benjamin Price 4057

Title

Safety Program

1/1/2019

Krista BowenSafety Program

Jeff Miller

Kathy Fiery 3418

Signer/Alternate Project Section Supervisor

Project Section

Work Location Project Number Contractor (or TBD)

COR (or Point of Contact) Name COR (or POC) Extension Project Title Construct Dom Clinic and CLC Administration Addition

Sam Powell

TBD

502 and 501

Project Title:

Project Number: Project Start Date:

Location of Work: Estimated Duration:

VA COR: COR Extension:

Contractor: Contractor Telephone:

Contractor Supervisor:

x Patient Risk Group A B C X Low Risk Group I II II x Medium Risk Group I II III High Risk Group II III III

613 121

FALSE

CLASS III

GROUP 1: Low Risk

Page

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1 of 2Facilities Management Services

Martinsburg VA Infection Control Risk Assessment Doc Number: VHA-V05-613-FMS-FORM-PS-0003 Version: 2

12/22/2016 v1

01/01/19

15 months

4175Sam Powell

Activities that require heavy demolition or removal of a complete cabling system New construction

Administrative Offices

Cutting of walls or ceiling where dust migration can be controlled.

Construct Dom Clinic and CLC Administration Addition

Type C

Access to chase spaces.

Sanding of walls for painting or wall covering.

GROUP 3: High Risk

Class of Precaution

Type of Construction

Inspection and Non-Invasive Activities

Small scale removal of ceiling tiles for visual inspection or minor installation (limited to 1 tile per 50 sq. ft.)

502 and 501

TBD

Type A Painting (but not sanding) Wall covering, electrical trim work, minor plumbing, and activities that do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

Any activity that cannot be completed within a single work shift/ activities that require consecutive work shifts

Major cabling activities, major plumbing activities (including items that expose sewage, such as work on a major stoppage.)

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components, assemblies, or new construction.

Removal of floor coverings, ceiling tiles, and casework

Small scale, short duration activities that create minimal dust.

Installation of telephone and computer cabling.

Central Sterile Supply

Day Rooms

Continued on next page

Type of Construction

Please mark Construction Types and Risk Groups with X's.

Precaution Classes will populate automatically based on this matrix.

FALSE FALSE FALSE TRUE FALSE FALSE

Type B

GROUP 2: Medium Risk

CLASS OF

PRECAUTIONS

Intensive Care Units

Lobbies Patient Risk Groups

New wall construction.

Uncontained duct, HVAC, or electrical work above ceilings.

Any other project where high levels of dust are generated.

CLASS II

Non-Patient Care Space

High Risk Laboratories (Specimen)

Operating RoomsSurgical Units Interventional Radiology

Protective Care 6A

Negative Pressure Isolation RoomsCCU/Emergency Room

Laboratory (non-specimen)

Interim Care/ Medical UnitsPrimary Care and Urgent Care

Medium Risk Food Service/ Dietary Care Radiology/MRI

Respiratory Therapy

Public Corridors

Medical Units

Bronch Suite Post Anesthesia Care Unit

Endocardiography SPD Storage/Sterilization

Areas w/ immuno-compromised patients

Pharmacy I.V. Room Newborn Nursery/PediatricsOncology

Outpatient Surgery

Low Risk Canteen Retail Store

TYPE OF

CONSTRUCTION

TYPE A

TYPE C

TYPE B

PATIENT RISK GROUP

CLASS I

Cardiology

Physical Therapy Pharmacy

Labor & Delivery

Vacant Floor Elevators

Endoscopy

Outdoors

Nuclear Medicine Outpatient Clinics

ADDITIONAL CONCERNS

Printed:

CLASS II

4. Clean work area upon completion of task

CLASS III

YES

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

10. Upon completion, wipe work surfaces with disinfectant, wet mop and/or vacuum with HEPA filtered vacuum.

1. Obtain infection control permit before construction begins, and notify staff in the immediate area.

2. 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. Cover transport receptacles or carts. Tape covering.

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

3. Isolate HVAC system in areas where work is being performed. Upon completion, remove isolation.

7. Place dust mats at entrance and exit of work area.

8. Vacuum work with HEPA filtered vacuums.

9. 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.

Will the project produce any fumes or vapors, or otherwise affect air quality?

YES NO

NO

x

Date:

4. Isolate HVAC system in areas where work is being performed. Upon completion, remove isolation.

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

6. Seal unused doors with duct tape.

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

YES NO

10. Do not remove barriers from work area until completed project is thoroughly cleaned by Environmental Management Service.

Does the project involve work in any of the following locations: 4A-107, 4A-132, 4C-124, 4C-125, OR 2C-136 or any GI Suite Rooms?

NO

x

Form A

Date:

PRECAUTIONS

Date:

Infection Control

ADDITIONS AND/OR MODIFICATIONS TO

7. Block off and seal air vents.

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

has been found?

x

Construct Dom Clinic and CLC Administration Addition

1. Obtain infection control permit before construction begins.

2. Notify staff in the immediate area

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

CLASS I

Project:

1. Obtain infection control permit.

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

All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

x

Will the project create vibrations that could loosen dust or other particulates, impair construction barriers, or otherwise affect areas outside of the work area?

CLASS II

x

Does the project involve any removal or disturbance to the HVAC filters in the above locations?

YES NO

x

Does the project involve any modifications or removal of the duct work or supply/exhaust in the above locations?

YES NO

Safety Program

Project Section Supervisor

Will work activity include asbestos abatement or containment, or take place in areas where ACM YES

7/18/2018

Project Title:

Work Location:

Project Number:

Point of Contact: Extension:

Deficiency:

Start Date: Estimated Duration:

PART I: PROJECT EVALUATION Review each of the following categories and indicate whether each is acceptable to the project/Life Safety code deficiency by checking the appropriate response.

A. EXITS

B. EMERGENCY ACCESS

C. FIRE PROTECTION

D. TEMPORARY PARTITIONS

E. ADDITIONAL FIRE FIGHTING EQUIPMENT and TRAINING

F. COMBUSTIBLE FUEL LOAD LEVELS

G. FIRE DRILLS

H. HAZARD SURVEILLANCE

Facilities Management Services Page 1 of 2

Martinsburg VA Medical Center Interim Life Safety Measure Permit

Effective Date 12/22/2016

Replaces v1

Doc Number: VHA-V05-613-FMS-FORM-PS-0004 Version: 2 Doc. Control x

2. Will affected exit be used by other than contractor personnel? YES NO N/A x

3. Will hazard communication training be provided, including location of spill kits, and advisement to notify Fire Department in the event of spills?

YES NO N/A

x

3. Will alternate exit route be sufficiently marked and lit? YES NO N/A x

1. Does the project/deficiency present added hazards, such as: excavations; construction/ chemical storage; or field offices, which warrant increased hazard surveillance?

YES NO N/A

x

2. Does the project/deficiency have the potential of creating flammable or combustible debris?

YES NO N/A

x

2. Contractor or COR is to provide Material Safety Data Sheets to the Safety Office for all chemicals, cleaning agents, solvents, etc., to be used during project. Has this been done?

YES NO N/A

x

1. Does the project/deficiency warrant additional fire drills?

1. Does the project/deficiency involve the storage of flammable or combustible materials? YES NO N/A x

N/A x

YES NO

1. Does the area affected by the project/deficiency warrant placement of additional fire protection equipment? YES NO N/A x

2. Will additional fire safety training be required of affected personnel? YES NO N/A x

2. Will temporary fire protection systems be required as part of the project/deficiency? NO N/A

1. Does the project/deficiency have the potential of obstructing access to emergency departments, services or vehicles?

YES NO N/A

x

N/A x

N/A x

2. Does the project/deficiency have the potential of obstructing access of emergency responders to the construction area?

01/01/19

YES NO N/A

Construct Dom Clinic and CLC Administration Addition 502 and 501

613 121

15 months

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

N/A1. Will construction involve the use of temporary partitions? YES NO

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

YES NO

YES NO

YES

x x

Sam Powell 4175

Project Title Project Number 121

I. ADDITIONAL PERSONNEL TRAINING

J. FACILITY-WIDE TRAINING

K. FIRE/SMOKE BARRIERS

L. GENERAL SAFETY

M. ACCESSIBILITY

N. UTILITIES

Construction Safety Committee Chair - ILSM Evaluator Date

Safety Program Date

Fire Chief Date

Police Service Representative Date

Printed:

Form B

Fill out Supplimental Form C Form C

N/A x

2. Does the project/deficiency have the potential to affect compartmentation features of the fire safety systems? YES NO N/A x

1. Does the project/deficiency present Life Safety Code deficiencies or construction hazards, which warrant facility-wide education of personnel concerning these Interim Life Safety Measures?

YES NO N/A

x

1. Will the project produce significant noise levels outside the construction site? YES NO N/A

1. Will the project cause penetrations to be made in Fire/Smoke Barriers? YES NO N/A x

2. Will fire/smoke barriers be temporarily sealed with a UL-Listed material filler on both sides of the barrier? YES NO N/A x x

3. Will these temporary UL-Listed material adequately compensate for the penetrations made in the fire/smoke barriers?

YES NO

1. Does the project/deficiency have the potential to affect structural features of the fire safety system? YES NO N/A x

Construct Dom Clinic and CLC Administration Addition 613

3. Does project involve relocation (or changes in designation) of functions or services requiring eyewashes or chemical showers?

YES NO

N/A x

YES NO N/A

x

2. Does Personal Protective Equipment and relevant training need to be provided for staff, patients or visitors?

N/A x

2. Will there be sufficient clearance around the construction site to prevent tripping hazards, falling debris, or other safety concerns?

YES NO

7/18/2018 All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

1. Will signage be required to limit access to work area? YES NO N/A x

PART II: INTERIM LIFE SAFETY MEASURES: Provide a description of all items indicated as applicable in Part I. Explain Interim Life Safety measures or procedures which will then be incorporated into the project.

YES NO N/A1. Will the project involve an operational shutdown or modified operation of utilities?

A.1. Rerouting and temp. exit signs needed.

N.1. Temp. shutdowns will be scheduled with sufficient notification.

X

Facilities Management Services Page 1 of 1

Project Re-Evaluation And Review Effective Date 12/22/2016

Replaces v1

Doc Number: VHA-V05-613-FMS-FORM-PS-0005 Version: 2 Doc. Control

Project: Construct Dom Clinic and CLC Administration Addition

Projects are to be re-evaluated prior to construction and every sixty (60) days from initial start of construction to ensure all information is correct, complete, and current. Changes to the work location, construction type, or other factors necessitating any modification to the Infection Control Precautions as listed must be documented below, with approval from Infection Control, Industrial Hygiene, Safety, and Project Section.

Ye s

NoProject Re-Evaluation Date

COR Signature Date

New Class of Precautions

Since the original risk assessment, has the location of the work changed to a different Patient Risk Group? (Low Risk, Medium Risk, High Risk) Since the original risk assessment, has the nature of the work to be performed changed to a different Construction Type? (Type A, Type B, Type C) Have any other factors changed that would cause a modification to the Infection Control Precautions? (Asbestos or other hazardous material, timing changes, correlation with other projects, etc.)

If "No" to all of the above, COR certifies that no changes need to be made to Infection Control Precautions as listed on the ICRA.

If "Yes" to any of the above, Infection Control, Industrial Hygiene, Safety, and Project Section must review and initial the changes/remarks below.

Circle Changes Below

New Construction Type

A B C New Risk Group

1 2 3

I II III

Initial and Date Below

Infection Control Industrial Hygiene Project Section Supervisor Safety Program

Ye s

NoProject Re-Evaluation Date

COR Signature Date

Infection Control Industrial Hygiene Project Section Supervisor Safety Program

A B C

1 2 3 New Class of Precautions

I II III

Initial and Date Below

Have any other factors changed that would cause a modification to the Infection Control Precautions? (Asbestos or other hazardous material, timing changes, correlation with other projects, etc.)

If "No" to all of the above, COR certifies that no changes need to be made to Infection Control Precautions as listed on the ICRA.

If "Yes" to any of the above, Infection Control, Industrial Hygiene, Safety, and Project Section must review and initial the changes/remarks below.

Circle Changes Below

New Construction Type

Printed: 7/18/2018

All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

New Risk Group

Since the original risk assessment, has the location of the work changed to a different Patient Risk Group? (Low Risk, Medium Risk, High Risk) Since the original risk assessment, has the nature of the work to be performed changed to a different Construction Type? (Type A, Type B, Type C)

2/13/2017 v2 Doc Number: VHA-V05-613-FMS-FORM-PS-0006 Version: 3 Doc. Control

Pre-Construction Checklist Effective Date

Replaces

Facilities Management Services Page

Notice: For projects with Class II and III Infection Control precautions, work is not to begin until after checklist has been signed.

15 months

Project Location: 502 and 501 Point Of Contact: Sam Powell P.O.C. Phone Ext.: 4175 After-Hours Contact #:

Project Title:

Construct Dom Clinic and CLC Administration Addition Start Date: 1/1/2019 Est. Duration:

Ye s

N/ AInfection Control (Construction Barriers - Containment - Ventilation)

Have all infectious materials been removed?

Have all hand-sanitizer dispensers been removed?

Is the Infection Control Risk Assessment (ICRA) visibly posted on-site?

Is the ICRA complete and up-to-date?

Are the project conditions/scope the same as indicated on the signed ICRA?

8 Have provisions been made to immediately protect the ventilation/adjacent systems?

7 Are sticky walk-off mats provided for access to Medical Center areas?

Have all conditions/controls indicated in the ICRA been satisfied for work to start?

Ye s

N/ AFire Detection and Prevention; Hazard Surveillance/ Life Safety

5 Are means of egress clear and free of obstruction in construction and adjacent areas?

13 If items 9, 10 or 11 are "no", what temporary measures or fire watch will be instituted for duration of project?

Smoke tight 1-hour rated 2-hour rated

Are construction barriers made of fire-rated or fire-resistant materials on both sides of metal steel studs? If so, check below as applicable:3

12 Are smoke detectors active and uncovered?

If the existing ceiling of the room is significantly breached then has the temporary construction barrier been extended to the deck above?

Is the ILSM form complete and up-to-date?

Are all signage, exit routes, and directional chevrons appropriately in place?

Is the Interim Life Safety Measures evaluation (ILSM) visibly posted on-site?

Is access for fire department and emergency services clear and free of obstruction?

Are fire extinguishers readily available in construction area?

Are flammables and combustibles in proper containers?

Is fire sprinkler system active?

Is fire alarm system active?

Ye s

N/ AGeneral Safety and Security

COR Representative (Print name and sign)

Infection Control Representative (Print name and sign) Alternate Safety Program Representative

Fire Chief/Fire Dept. Representative (Print name and sign)

Safety Program Representative (Print name and sign)

Printed:

All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

Description/Scope/Remarks/Details (To be filled out by Infection Control, Fire Department, or Safety Program Representatives)

Are all construction site access points closed and equipped with key access locks?

Has all appropriate VA-owned property been removed from the area?

Phone extension:

Phone extensions: x3626; x4875; x4574

Date

7/18/2018

Phone extensions: x4314; x4611; x4612

Phone extensions: x4582; x4715; x3418

Has a worksite Safety Health Officer been assigned?

Has all patient-sensitive information been removed from the area?

Is there proper signage in place at the entrance to the construction site denoting appropriate PPE required for entry?

Is construction site entrance door metal framed, properly rated, and self-closing?

Utility Assessment (Check all that apply)

Type Impact Duration Interventions Required Short No special interventions required

Notify work areas prior to activity

Relocate patients/staff to another area of the facility for duration of activity

Schedule activity during non-working hours or when department is closed

Other: Please explain below

See specific procedures for utility shut downBrief

Intermittent

Frequent

Prolonged

Continuous

Modified Operational

Shut Down

Other

HVAC

Medical Gas

Power

Water

Suction

Other