01 00 10 - MEDICAL CENTER REQUIREMENTS RX.pdf

April 22, 2022 SOP FM-96

SECTION 01 00 10

MEDICAL CENTER REQUIREMENTS

GENERAL

1.1 GENERAL INTENTION

A. This document pertains to station policy for construction projects performed at the Harry S Truman Memorial Veterans' Hospital (HSTMVH) in

Columbia, MO. Safety and health concerns are taken seriously at this facility. Both our staff and yours are expected to strictly adhere to the regulations and requirements. This is exceedingly important since we must be primarily concerned for the safety of our patients. In this regard, OSHA Standards may protect worker safety and health, but they have minimal benefit for protecting the safety and health of our patients, due primarily to their differing medical conditions. Review this information as orientation with your personnel performing work on site. Where the requirements as outlined in this and Section 01 00 00 are differing, the more stringent shall apply.

1.2 REQUIREMENTS

A. Security:

1. Secure all construction areas, especially mechanical and electrical rooms against entry of unauthorized individuals including patients.

2. Notify the Contracting Officer’s Representative (COR) for permission to work after hours and weekends. Standard work hours for this project will be Monday through Friday between 6:30 am and 4:00 pm.

Coordination for work outside these hours must be completed a minimum of 72 hours PRIOR to this work. Night work shall be coordinated at least one week in advance.

B. Correspondence: All correspondence must be typewritten. Handwritten is unacceptable.

C. Outdoor Work: If work or storage involves lawn area, contractor shall be responsible for mowing as required &/or as directed by COR (as often as VA mows).

D. Key Security:

1. A limited number of keys will be issued to the contractor.

Contractor will sign for keys and provide proof of possession whenever asked by COR.

2. See section 01 00 00 for procedures in case the Contractor loses a key.

3. Ensure all doors leading to and from construction are either monitored or locked to prevent access to the area from unauthorized persons.

E. General Safety:

1. Follow all federal, state and local safety and health regulations.

2. Maintain safety in the construction site/area in accordance with the provisions of the contract that includes the Occupational Safety and

Health Administration (OSHA) Regulations; National Electrical Codes;

National Fire Protection Association (NFPA) 70, National Electric

Code; and NFPA 101, Life Safety Code. Work in a safe manner and take all proper precautions while performing your work. Extra precautions shall be taken when working around persons occupying the building during construction.

3. Provide Personal Protective Equipment (PPE) for your employees.

4. Post appropriate signs in specific hazardous areas.

5. Keep tools, ladders, materials, etc., secure and away from patients to prevent injuries.

F. Safety Inspections: The professional Occupational Safety and Health staff at this facility will perform safety inspections of all contract operations. Written reports of unsafe practices or conditions will be reported to the COR and Contracting Officer for immediate attention and resolution.

G. Fire Alarms:

1. The fire alarm system connects all buildings at this facility, and is activated by various heat, duct, manual pull stations and smoke sensors. Manual pull stations are provided at each entrance.

Please survey the area in which you are working to locate the manual pull stations.

2. In the event of a fire alarm sounding, contractor’s on-site supervisor shall investigate their area immediately. Notify COR as soon as reasonably able for any alarm triggered from construction area, by construction personnel or activities.

3. In the event of a fire alarm sounding, you are to remain in your area, unless medical center personnel (Safety, Nursing or

Engineering) instruct otherwise, or unless a fire situation is in your area, in which case you should immediately evacuate.

4. Any work involving the fire protection systems will require written permission to proceed from the COR. Do not tamper with or otherwise disturb any fire alarm system components without prior written permission. To do so without written permission will result in an adverse action.

H. Hazardous Materials:

1. Many of the operations you are scheduled to perform may involve the use of hazardous materials. Prior to locating hazardous materials on site, all Material Safety Data Sheets (MSDS) will be submitted through the COR for evaluation by the facility Safety Officer.

2. Storage of hazardous materials within buildings will be minimal with only enough on hand to perform daily work tasks. Flammable materials will either be removed from buildings at the end of the work shift or stored in approved flammable storage containers.

3. Care must be taken to ensure adequate ventilation to remove vapors of hazardous materials in use. Many of the patients being cared for in the facility are susceptible to environmental contaminants, even when odors seem minimal. You will isolate those areas where vapors are produced, and ventilate to the most extent possible to reduce the number of complaints.

I. Airborne Dust Control During Construction:

1. Generation of dust is of major concern within staff and especially in patient occupied buildings. Where operations involve the generation of dust, all efforts will be directed at reducing airborne generated dust to the lowest level feasible. This may be accomplished by a number of methods. These include misting the area with water, or use of tools attached to high efficiency particulate air (HEPA) filtering vacuums. Where large amounts of materials may be disturbed, resulting in airborne dust, establishment of full ceiling-to-floor plastic barriers may be required.

2. Classification of Jobs: see Attachment A

J. Infection Control Procedures: see Attachment A

1. Implement the requirements of VAMC’s Infection Control Risk

Assessment (ICRA) team. ICRA Group may monitor dust in the vicinity of the construction work and require the Contractor to take corrective action immediately if the safe levels are exceeded.

2. Establish and maintain a dust control program as part of the contractor’s infection preventive measures in accordance with the guidelines provided by ICRA Group. Prior to start of work, prepare a plan detailing project-specific dust protection measures, including periodic status reports, and submit to COR for review for compliance with contract requirements in accordance with Section 01 33 23, SAMPLES AND SHOP DRAWINGS. All personnel involved in the construction or renovation activity shall be educated and trained in infection prevention measures established by the medical center.

3. Medical center Infection Control personnel shall monitor for airborne disease (e.g. aspergillosis) as appropriate during construction. A baseline of conditions may 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. In addition:

a. The COR and VAMC Infection Control personnel shall review pressure differential monitoring documentation to verify that pressure differentials in the construction zone and in the patient-care rooms are appropriate for their settings. The requirement for negative air pressure in the construction zone shall depend on the location and type of activity. Upon notification, the contractor shall implement corrective measures to restore proper pressure differentials as needed.

b. In case of any problem, the medical center, along with assistance from the contractor, shall conduct an environmental assessment to find and eliminate the source.

4. In general, following preventive measures shall be adopted during construction to keep down dust and prevent mold.

a. Dampen debris to keep down dust and provide temporary construction partitions in existing structures where directed by COR.

b. Do not perform dust producing tasks within occupied areas without the approval of the COR. For construction in any areas that will remain jointly occupied by the medical Center and Contractor’s workers, the Contractor shall:

1) Provide dust proof construction barriers to completely separate construction from the operational areas of the hospital in order to contain dirt debris and dust. A fire retardant polystyrene, 6-mil thick or greater plastic barrier meeting local fire codes may be used where dust control is the only hazard, and an agreement is reached with the COR. This will be required in the ICU, the Step-Down Unit, and possibly other areas.

2) Adhesive Walk-off Mats, minimum 24” x 36”, shall be used at all interior transitions from the construction area to occupied medical center area. These mats shall be changed as often as required to maintain clean work areas directly outside construction area at all times.

3) Vacuum and wet mop all transition areas from construction to the occupied medical center at the completion of each window and at the end of each workday. Vacuum shall utilize HEPA filtration. Maintain surrounding area frequently. Remove debris as they are created. Transport any dusty debris outside the construction area in containers with tightly fitting lids.

4) All equipment, tools, material, etc. transported through occupied areas shall be made free from dust and moisture by vacuuming and wipe down.

K. Contact with Asbestos Containing Materials (ACM):

1. Due to the age of buildings, many contain asbestos containing materials (ACM). Primary ACM uses in the medical center includes floor tile, mastic, piping and HVAC insulation. The medical center has performed a comprehensive asbestos survey and has identified accessible ACM. Some areas contain damaged asbestos and should not be accessed without prior abatement.

2. The most common type of ACM insulation you may encounter includes thermal system insulation (TSI) and floor tile. ACM TSI is generally covered with a cloth wrap or lagging, and the asbestos substrate generally appear white in color. Do not sand, drill, gouge or otherwise disturb this type of insulation. Contractors disturbing or releasing asbestos containing materials will be liable for all damages and cleanup costs.

3. Where disturbance of asbestos is likely, it has been addressed in the contract for removal. If contact with the presence of asbestos is presented, stop all work in the immediate area and immediately contact the COR or Safety Officer to make necessary arrangements for removal.

4. In some areas, asbestos insulation has been identified on elbows, between fiberglass piping insulation, as patching materials among the fiberglass insulation. Fiberglass insulation used in this facility is usually yellow or pink in color, wrapped either by cloth or paper lagging.

5. To protect and ensure all your employees are aware that asbestos containing materials have been used in the construction of this facility, you are required to have them review this section and complete the awareness statement included as Attachment B. Once this documentation has been signed by all employees, forward to the

COR for documentation.

6. A complete assessment of asbestos materials and conditions are available for viewing by contacting the facility Industrial

Hygienist at extension 56370. Prior to performing work above any ceiling or starting in a new area, consult with the COR concerning existing conditions of ACM.

7. Some of the areas in the facility are identified as restricted areas due to condition of ACM. These are readily labeled. Do not enter these areas unless first contacting the COR. Entry requirements to these areas are awareness of the hazards, proper protective clothing

(coveralls and respirators) and personal monitoring in accordance with OSHA requirements.

8. Submit contractor asbestos awareness statements for all persons working on the site prior to commencing work.

L. Environmental Protection:

1. It may help you to be aware of the seriousness that the environmental protection requirements of each contract are regarded.

Adherence to these requirements is subject to continuing scrutiny from the community and backed by severe penalties, such as fines and incarceration. These environmental requirements will be strictly enforced.

2. No hazardous materials will be disposed of on Government property.

All waste will be hauled off-site or disposed in contractor owned and operated waste removal containers.

3. A copy of all waste manifests for special or hazardous wastes will be forwarded to the COR. Environmental requirements will be strictly enforced.

M. Permit Required Confined Spaces:

1. Contractors performing work on this facility will follow all requirements outlined in OSHA Standards for working in confined spaces. There are numerous permit required confined spaces on this facility. These spaces have been identified. Some spaces have been posted, but the majority have not due to their configuration. A complete listing of these areas is located in the Safety Office.

2. Confined spaces are areas that are large enough to be entered, have limited egress/exit potential and are not designed for permanent human occupancy. If you encounter any space that meets this definition, and if it is a suspected confined space, contact the

COR.

3. Contractors performing work in confined spaces are responsible for compliance with all applicable standards and regulations.

N. Housekeeping:

1. Protect patients and VA personnel in occupied areas from the hazards of dust, noise, construction debris and material associated with a construction environment. Keep work area clear, clean and free of loose debris, construction materials and partially installed work that would create a safety hazard or interfere with VA personnel duties and traffic.

2. Wet mop occupied areas clean and remove any accumulation of dust/debris from cutting or drilling from any surface at the end of each workday.

3. Make every effort to keep dust and noise to a minimum at all times.

Take special precautions to protect VA equipment from damage including excessive dust.

4. Maintain clear access to mechanical, electrical devices, equipment and main corridors. This will ensure access to existing systems in the event of an emergency.

5. Clean area of all construction debris and dust upon completion of demolition and/or renovation.

6. During construction operations, keep existing finishes protected from damage. Cover and protect all carpets during construction.

Any carpets or surfaces damaged as a result of construction activities will be replaced at the contractor expense.

O. Hot Work:

1. Welding rods MUST be put in a bucket of water immediately upon removal from welding machine

2. Contractor must protect EVERYTHING (including floor, benches, grating, etc.) when performing cutting operations (acetylene, etc.)

P. Hot Work Permits:

1. Any hot work operations including cutting, welding, thermal welding, brazing, soldering, grinding, thermal spraying, thawing pipes or any other similar activity, will require a Hot Work Permit to be obtained by the Contractor from the Safety Officer (Hot Work Permit will be as shown in Attachment C or similar, at COR discretion).

The Contractor will be responsible for conforming to all Medical

Center regulations, policies and procedures concerning Hot Work

Permits as outlined below:

a. Prior to the performance of hot work, a request for a Hot Work

Permit will be made to the COR. Submit request at least 48 hours in advance of anticipated work beginning. Designate contractor's responsible project-site fire prevention program manager to supervise permitted hot work.

b. The COR will inspect the area and ensure that the requirements of

NFPA 241 and OSHA standards have been satisfied. The Hot Work

Permit will be granted and will be posted in the immediate area of the work.

c. The Hot Work Permit will apply only to the location identified on the permit. If additional areas involve hot work, additional permits must be requested.

d. Upon completion of all hot work, the COR will be notified by the responsible individual to perform a re-inspection of the area.

2. Do not use any of the extinguishers in the medical center for standby purpose while conducting hot work. Contractors are required to supply their own Class ABC extinguishers. Medical center extinguishers are only to be used in the event of a fire.

Q. Emergency Medical Services: Emergency medical services for stabilization purposes are available for contractors at this facility.

For medical emergencies, dial 911 when inside any building. Report the nature of the emergency and location. The operator will coordinate outside emergency assistance based on the nature of the emergency.

R. Use of Government-Owned Material and Equipment: Use of Government-owned material and equipment is prohibited.

S. Contractor Safety Orientation: All personnel on site for contractor as well as subcontractors, are required to review the Contractor Safety

Orientation.

T. ID Badges: Contractor's employees, as well as subcontractors’ employees shall be provided with identification badges by VA upon completion of

Contractor Safety Orientation. These badges shall be returned to VA upon completion of the contract/project. A charge of $10.00 each shall be assessed for any and all badges not returned. This charge shall be made in the form of a deduct change order to the contract.

U. Superintendent Communications: At all times during the performance of this contract, the Contractors Superintendent is to be available by cellular phone. At the beginning of the contract and prior to beginning any construction, supply the COR with the telephone number for the Superintendent.

V. Parking: General contractor parking shall be as referenced in specification section - 01 00 00. No subcontractor parking will be permitted.

W. Traffic:

1. Traffic hazards are minimal at this facility. Drivers should be particularly concerned with pedestrian traffic.

2. Seat belt use is mandatory on the station.

3. Federal police officers maintain a 24-hour patrol of the area.

X. Contractor's Trailers: Shall be as referenced in specification section

- 01 00 00.

1. Job office trailers, job storage trailers, and parking are subject to VA approval and may be revoked at any time for any reason at no cost to the government.

Y. Smoking: No smoking is permitted in buildings or around hazardous areas. Any smoking inside a government building is subject to a fine without warning.

Z. Fluorescent (PCB Containing) Fixtures: All fluorescent lighting fixtures being removed as part of this project are to have their ballasts removed and turned over to the VAMC Safety Officer for disposal. All other components of the lighting fixture are to be disposed of by the Contractor.

AA. Interim Life Safety: The contractor shall coordinate, evaluate, and institute ILSMs, with the COR, to temporarily compensate for hazards posed by life safety deficiencies. (See attachment D)

BB. Core Drilling: Pre-Approval by the COR required for ALL core drilling inside the facility. The contractor shall drill pilot hole prior to any core drilling between floors. The intent is to identify any impediments and ensure location between floors is absolutely confirmed prior to core drilling.

CC. Hammer Drilling and other excessive noise: Hammer drilling will not be allowed when critical clinical procedures are in progress or if they cause disruption to patient care. Hammer drilling, or other excessive noise making tools, may only be used during times approved and scheduled with COR, and at any time may require cessation based on clinical procedures in progress. This also applies to tools that cause vibrations or radiate sound to other parts of the hospital. Repeated failure to gain approval or schedule the use of tools or equipment that cause disruption to hospital procedures may result in work only being permitted during non-clinical hours.

DD. General Labor:

1. Moving of systems furniture, cabinets, shelf units, or other items necessary to facilitate this construction shall be the responsibility of contractor unless otherwise specified.

2. All personnel performing specialty work (electrician, plumber, etc.)

that have a journeyman program, shall be completed by a qualified journeyman.

EE. Countertops: Any exposed portion of countertops including the underside of overhang or edges, shall be of non-pervious surface. This can be either the countertop surface as “wrapped” around, or a finish that will not allow absorbance of liquid or bodily fluids. Painted finish is not an acceptable method unless an approved epoxy based waterproof paint is approved specifically for this purpose.

FF. Faucets: Aerator devices are prohibited. In any faucet that specifies an aerator device, a laminar flow device shall be substituted to reduce splashing. In areas that require tamper resistance, a submittal shall be made for laminar flow device that can be reviewed for project requirements.

GG. Weekly Onsite Construction Progress Meetings: The GC shall be required to establish and conduct weekly onsite construction progress meetings.

1. It shall be the responsibility of the GC to initiate, present, and take minutes to distribute to the team. The meeting purpose is to discuss day to day operations including but not limited to safety measures, outages required in the near future, scope clarity, design clarity, delay issues, submittal progress, RFI’s, 7 day look ahead, master schedule changes, etc.

2. A meeting agenda shall be provided at least 4 hours prior to the meeting.

3. The GC shall be required to have the PM and superintendent on site at the Truman VA for every meeting.

4. The meeting will be held in person, at the Facilities Management conference room, unless an alternate location is approved by the

COR.

1.3 ATTACHMENTS:

A. VHA Pre-Construction Risk Assessment (PCRA)

B. VHA Infection Control Risk Assessment for Construction, Renovation, and

Maintenance (ICRA)

C. Infection Prevention and Control Construction, Renovation, and

Maintenance Permit

D. Contractor/Subcontractor/Employee Notification of Asbestos Form

E. Cutting and Welding with Portable Gas or Arc Equipment Permit Form.

F. Interim Life Safety form

VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance

Introductory Information and Instructions

Use this template as a baseline for performing facility Infection Control Risk Assessments (ICRAs) for construction, renovation, and maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity types and patient risk to determine the level of precautions needed to prevent infection risks. Facilities may customize this template to incorporate site-specific information and/or to add more stringent criteria.

This VHA ICRA template pertains specifically to infection prevention. It must be used if required by the VHA Pre- Construction Risk Assessment (PCRA) for the activity. NOTE: The PCRA addresses other activity-related safety concerns (e.g., vibration, noise, hazardous materials) outside the scope of the ICRA.

To complete the template:

1. Use Table 1 to identify the category of the construction, renovation and/or maintenance activity.

2. Use Table 2 to identify the areas affected by the activity.

3. Use Table 3 to identify the overall patient risk category that will be affected by the activity.

4. Use Table 4 to determine the level of infection prevention and control precautions needed for the activity.

Once all 4 steps above are completed: Refer to Table 5 for the minimum required control measures for the level of infection prevention and control precautions needed for the activity. Refer to Table 6 for the minimum infection prevention and control measures required on completion of the activity.

PERMIT: See the last page of this document for a fillable permit form to be used for posting at the activity site as needed.

Table 1 - Construction, Renovation, and/or Maintenance Activity Category

NOTE: If any of the bulleted criteria in a higher activity category pertains to the work that will be done (even if the other criteria are in a lower category), use the higher activity category for the VHA ICRA.

Activity Category determined from Table 1 (A, B, C, or D):

Category A

Inspection and/or facility upkeep generally defined as follows:

• Work can be completed in a single shift, not to exceed 10 hours.

• Patients and/or employees may be in the area depending on the activity.

• Work that does not create dust or debris.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection limited to 1 tile per 50 square feet with limited exposure time (not to exceed an hour for each tile) within the shift.

• Minor interior updates (e.g., replacing floor or ceiling tiles, carpentry work to include hanging signage, and painting without sanding) that do not create dust or debris.

• Limited building system maintenance such as basic plumbing on potable systems (e.g., faucet replacement) or basic electrical work such as replacement of light bulbs, receptacles, or switches.

B

General maintenance and repair work generally defined as follows:

• Prolonged inspection and work that may take longer than a single shift but not exceeding a week.

• Patients and employees are not to be in the area until activity is completed.

• Work that creates minimal dust and debris.

• Interior finish or surface repairs, updates, or modifications such as repair of firewalls and barriers, and new flooring that produces minimal dust and debris.

Controlled sanding activities (e.g., wet or dry sanding) that produce minimal dust and debris.

• Plumbing work such as installation or replacement of a single fixture or piping for a single fixture. Any work on sanitary plumbing including snaking of drains.

• Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that produces minimal dust and debris.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit or a single device that produces minimal dust and debris.

C

Small-scale construction, renovation, or maintenance generally defined as follows:

• Work requiring longer than a single week to complete but not exceeding 6 months.

• Patients and employees are not to be in the area until activity is completed.

• Demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements.

• Demolition/removal of more than 32 ft2 of drywall/framing, hard ceilings, and doors/framing and minimal infrastructure such as electrical circuits and branch piping.

• Installation of new walls, ceilings and doors including framing, drywall/plaster and associated work.

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing.

• Shut down of sections of potable water systems.

• Electrical work such as installation of conduit and wire for lighting, receptacles and switches for an area, the installation of conduit and wire for new devices such as terminal units, fans etc.

• Modification of existing fire alarm and suppression systems.

• Mechanical work such as the installation of ductwork, diffusers, and terminal units for an area.

D

Large-scale construction, renovation, or maintenance generally defined as follows:

• Work exceeding 6 months in duration.

• Patients and employees are not to be in the area until activity is completed.

• Large-scale demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and

HVAC.

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work.

• Plumbing work such as the installation of:

o new medical gas systems, o steam/heating hot water, condensate systems, o multiple sinks, showers and toilets including associated plumbing.

• Shutdown of potable water, steam/heating hot water, condensate, and medical gas systems.

• Electrical work such as installation of electrical feeders, distribution panels, conduit and wire for lighting, receptacles and switches for an area, the installation of conduit and wire for new devices such as terminal units, fans etc.

• Installation of fire alarm and suppression systems.

• Electrical shutdown of multiple panels.

• Mechanical work such as the installation of air handling equipment, associated ductwork, diffusers, heat exchangers, terminal units and controls.

Table 2 - Affected Area Assessment

Identify the areas and associated patients that will be affected by the construction/renovation/maintenance activity (see the Figure for a visual representation of adjacent affected areas).

Figure: Isometric drawing of affected area assessment

Area Service(s)/Type(s) of

Area(s)

(e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc.)*

Point of Contact

(POC)

POC Contact Information

Activity Area**

Area Above

Area Below

Adjacent Area

* There may be more than one Service/type of area for each row. List all.

** List the area(s) in which the construction/renovation/maintenance activity will occur. NOTE: When the Activity Category is B, C, or D, the control measures are determined by the Patient Risk in the adjacent affected areas.

Table 3 - Patient Risk Category

Using Table 3, identify the patient risk category for each area listed in Table 2. Of the patient risk categories identified, select the one with the greatest risk as the overall Patient Risk Category for the activity.

Overall Patient Risk Category determined from Table 3 (Low, Medium, High, or Highest):

Low Risk

Non-patient care areas such as:

Medium Risk

Patient care support areas such as:

High Risk

Patient care areas such as:

Highest Risk

Procedural, invasive, sterile support and highly compromised patient care areas such as:

• Public hallways and gathering areas not in clinical areas

• Office areas not in clinical areas

• Breakrooms not in

• Bathrooms or locker rooms not in

• Mechanical/electric al rooms not in

• Waiting areas

• Clinical engineering (biomedical)

• Materials management

• Sterile processing department – dirty side

• Kitchen, cafeteria, gift shop, coffee shop, and food kiosks

• Patient care rooms and areas, including spinal cord injury units

• All acute care units, including mental health

• All outpatient units and clinics

• Emergency department

• Community Living Centers, domiciliaries, and transitional residences

• Employee health

• Pharmacy – general work zone

• Medication rooms and clean utility rooms

• Imaging suites – diagnostic imaging

• All transplant units

• All intensive care units

• All oncology units and chemotherapy/infusi on centers

• OR theaters and restricted areas

• Hemodialysis units

• Procedural rooms*

• Pharmacy compounding area

• Sterile processing department – clean side

• Transfusion services

• Imaging suites – interventional imaging

• Dedicated isolation wards/units for infectious diseases

• Laboratory

* Procedural Rooms are designated for the performance of patient care activities that may require high-level disinfected or sterile instruments and some environmental controls but is not required to be performed with the environmental controls of an operating room (OR). The room is intended for procedures that are performed in an aseptic surgical field and penetrates the protective surfaces of a patient’s body (e.g., subcutaneous tissue, mucous membranes, cornea) or entry into or opening of a sterile body cavity. Examples of these spaces include, and are not limited to, Cardiac Catheterization Suites, Electrophysiology Suites, Endovascular/GI Suites, Angio Suites and other spaces which may have high risk patient populations.

Table 4 - Level of Infection Prevention and Control Precautions Match the Overall Patient Risk Category (Low, Medium, High, Highest) determined from Table 3 with the planned Construction/Renovation/Maintenance Activity Category (A, B, C, D) from Table 1 to determine the minimum Level of Infection Prevention and Control Precautions (I, II, III, or IV) using Table 4 below.

Level of Precautions determined from Table 4 (I, II, III, or IV):

Patient Risk

Activity Category

A B C D

Low Risk I II II III

Medium Risk I II III IV

An infection prevention and control permit is required for Level III and Level IV. Consult with Infection Prevention and Control for Level I and Level II.

Table 5 - Required Infection Prevention and Control Measures, by Level of Precautions

Controls defined below for the Level of Precautions identified for the activity must be in place before the activity begins and maintained until work is completed and the area is activated. Control measures for each Precaution Level must also include the control measures in the preceding Level(s).

As the activity progresses, a full re-evaluation of remaining activity type and patient risk is required prior to downgrading the Level of Precautions.

Level of Precautions

Control Measures

Level I

1. Perform work activity in a manner that does not create dust.

2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

Level II

All control measures in Level I and the following:

1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence. Rebalance system to address diffuser isolation.

High Risk I II IV IV

Highest Risk II III IV IV

4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall be flushed twice a week or isolated from the main system.

5. Seal doors to prevent dust migration.

6. Contain all trash and debris in the work area. Perform daily cleaning and disposal of trash (covered) from work area using an identified exit route.

7. Any equipment, tools, or materials removed from the work area must be in sealed containers and/or cleaned of dust and debris prior to removal from the area.

8. Nonporous/smooth and cleanable containers (with a hard lid) must be used to transport trash and debris from the construction areas. These containers must be damp-wiped cleaned and free of visible dust/debris before leaving the contained work area.

9. Install a sticky (dust collection) mat at entrance of contained work area based on facility policy. Sticky mats must be changed routinely and when visibly soiled.

10. Maintain clean surroundings when area is not contained by damp mopping or HEPA vacuuming surfaces at least daily.

Level III

All control measures in Levels I and II and the following:

1. Ensure availability of equipment for cleaning hands.

2. Construct and complete critical barriers meeting NFPA 241 requirements.

Barriers must extend to the ceiling or if ceiling tile is removed, to the deck above.

3. All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to floor and ceiling (or floor/roof deck above) and secure from movement or damage.

4. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop if applicable for barrier type).

5. Maintain .01 inches /water gauge negative pressurization of the entire workspace by use of HEPA exhaust air systems directed outdoors, or comply with the alternative method outlined in Appendix A of this document.

These control measures must be maintained continuously 24/7 for the duration of the project. HEPA filtered exhaust if discharged directly to the outdoors must be at a distance of 25 feet or greater from entrances, air intakes and operable windows. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

6. Install a differential pressure sensing device (e.g., magnehelic, manometer, or digital monitoring) on exterior of work containment to continually monitor and document negative pressurization. The “ball in the wall” or similar apparatus are not acceptable.

Level IV

All control measures in Levels I, II and III and the following:

1. Barriers must be hard barriers unless temporary to install final barrier.

2. Containment must include an anteroom to ensure pressure control.

Anteroom must be large enough for equipment staging, cart cleaning, workers’ PPE and cleaning.

3. Worker clothing and/or PPE must be removed or clean and free of visible dust before leaving the work area anteroom. HEPA vacuuming of clothing or use of cover suits is acceptable.

4. Workers must wear shoe covers or have a method to clean shoes in anteroom. Shoe covers must be removed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be changed immediately.

Table 6 - Minimum Infection Prevention and Control Measures Required Upon Completion of the Activity

Controls defined below shall be completed upon completion of the activity and inspected prior to terminating measures defined in Table 5.

Precautions Measures

Levels I - II

Cleaning:

1. Clean work areas including all environmental surfaces, high horizontal surfaces and flooring materials.

2. Check all supply and return air registers for dust accumulation on upper surfaces as well as air diffuser surfaces.

HVAC Systems:

1. Remove isolation of HVAC system in areas where work is being performed. Verify that HVAC systems are clean and operational.

2. Verify the HVAC systems meet original airflow and air exchange design specifications.

Water systems:

1. Until the potable water system is activated and in use, flushing shall continue at least twice per week in accordance with VHA Directive 1061.

Levels III - IV

Construction areas must be inspected by an infection preventionist and engineering representative (and others as determined by the facility) for final activity/project close out and removal of infection prevention and control measures.

Work Area Cleaning:

1. Clean work areas including all environmental surfaces, high horizontal surfaces and flooring materials.

2. Check all supply and return air registers for dust accumulation on upper surfaces as well as air diffuser surfaces.

Removal of Critical Barriers:

1. Critical barriers must remain in place during all work involving drywall removal, creation of dust and activities beyond simple touch-up work. The barrier may NOT be removed until a work area cleaning has been performed. Additional cleaning may be needed after removal of barrier.

2. All (plastic or hard) barrier removal activities must be completed in a manner that prevents dust release. Use the following precautions when removing hard barriers:

i. Carefully remove screws and painter tape.

ii. If dust will be generated during screw removal, use hand-held HEPA vacuum.

iii. Drywall cutting is prohibited during removal process.

iv. Clean all stud tracks with HEPA vacuum before removing outer hard barrier.

v. Use a plastic barrier to enclose area if dust could be generated.

Negative Air Requirements:

1. The use of negative air must be designed to remove contaminants from the work area.

2. Negative air devices (fans, filters, monitoring and documentation equipment) must remain operational at all times and in place for a period after completion of dust creating activities to remove contaminants from the work area and before removal of critical barriers.

HVAC systems:

1. Upon removal of critical barriers, remove isolation of HVAC system in areas where work is being performed.

2. Verify that HVAC systems are clean and operational.

3. Verify and document through a TAB the HVAC systems meets original airflow and air exchange design specifications.

Water systems:

1. Until the potable water system is activated and in use, flushing shall continue at least twice per week in accordance with VHA Directive 1061.

Infection Prevention and Control Construction/Renovation/Maintenance Permit

This page must be posted at the entrance to the project area for Level III and Level IV activities.

Unique permit number:

Location of construction/renovation/maintenance

Project manager Project start date

Contact phone number Completion date

Contractor Permit expiration date

Activity

(A, B, C, or D)

Overall Patient Risk

(Low, Medium, High, or Highest)

Level of Infection Prevention and Control Precautions (I, II, III, or IV)

Precautions

Control measures to be in place for the duration of the activity

(Check the box for the activity’s Level of Precautions to indicate the Control Measures)

Level I

1. Perform work activity in a manner that does not create dust.

2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

Level II

All control measures in Level I and the following:

1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence.

Rebalance system to address diffuser isolation.

4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall be flushed twice a week or isolated from the main system

5. Seal doors, to prevent dust migration.

6. Contain all trash and debris in the work area. Perform daily cleaning and disposal of trash (covered) from work area using an identified exit route.

7. Any equipment, tools, or materials removed from the work area must be in sealed containers and/or cleaned of dust and debris prior to removal from the area.

8. Nonporous/smooth and cleanable containers (with a hard lid) must be used to transport trash and debris from the construction areas. These containers must be damp-wiped cleaned and free of visible dust/debris before leaving the contained work area.

9. Install a sticky (dust collection) mat at entrance of contained work area based on facility policy. Sticky mats must be changed routinely and when visibly soiled.

10. Maintain clean surroundings when area is not contained by damp mopping or HEPA vacuuming surfaces at least daily.

Level III

All control measures in Levels I and II and the following:

1. Ensure availability of equipment for cleaning hands.

2. Construct and complete critical barriers meeting NFPA 241 requirements. Barriers must extend to the ceiling or if ceiling tile is removed, to the deck above.

3. All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release.

Plastic barriers must be effectively affixed to floor and ceiling (or floor/roof deck above) and secure from movement or damage.

4. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop if applicable for barrier type).

5. Maintain .01 inches /water gauge negative pressurization of the entire workspace by use of HEPA exhaust air systems directed outdoors, or comply with the alternative method outline in Appendix A of the VHA ICRA template. These control measures must be maintained continuously 24/7 for the duration of the project.

Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

Check box to indicate exhaust method: Exterior ☐ Alternative Interior Method ☐

6. Install a differential pressure sensing device (e.g., magnehelic, manometer, or digital monitoring) on exterior of work containment to continually monitor and document negative pressurization. The “ball in the wall” or similar apparatus are not acceptable.

Level IV

All control measures in Levels I, II and III and the following:

1. Barriers must be hard barriers unless temporary to install final barrier.

2. Containment must include an anteroom to ensure pressure control, Anteroom must be large enough for equipment staging, cart cleaning, workers’ PPE and cleaning.

3. Worker clothing and/or PPE must be removed or clean and free of visible dust before leaving the work area anteroom. HEPA vacuuming of clothing or use of cover suits is acceptable.

4. Workers must wear shoe covers or have a method to clean shoes in anteroom Shoe covers must be removed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be changed immediately.

Additional requirements:

Project Manager signature Date

Infection Preventionist signature Date

Appendix A: Alternative To Outdoor Exhaust Requirements

This Appendix provides an equivalent ICRA control measure to requirements detailed in this VHA ICRA template (Table 5 Level III, item 5) that would allow interior construction space exhaust.

Interior Construction Space Exhaust:

If the facility is not able to exhaust to the building exterior, the Healthcare Environment and Facilities program office has identified an alternate industry-recognized standard interior exhaust procedure that is accepted as providing an equivalent level of infection prevention and control (IPC), and safety. The alternate interior exhaust procedure is implemented by completing the following:

a. If exhaust is directed indoors, then the system must be HEPA filtered. Prior to start of work, including assembly of the ICRA barriers, initial baseline air sampling measurements for particulate levels must be taken in the planned area of discharge. Once containment is erected and completed, HEPA filtration must then be verified by particulate measurement, using a particle counter with multi-channel capabilities to measure down to 0.3 microns, to confirm that the discharge of the HEPA unit does not exceed the baseline particulate count of the area to which the exhaust is directed. Verification must continue at least three times per day (once every 8 hours), 7 days per week, during the use of the negative air machine and HEPA filter. Any exceedance must trigger a work stoppage and an immediate response and resolution. All particulate measurements, including the baseline measurement, must be documented and retrievable.

b. To accommodate the sampling, the negative air pressure machine must be fitted with a 2 ft section of ridged ductwork at the discharge. The sample port for monitoring must be in the ridged ductwork section.

c. Vapor generating processes must be assessed and appropriate filtration must be installed to mitigate transmission to the facility.

d. Engineering must do a complete flow and pressure analysis and document the area to which the air is being discharged to ensure the flow and pressure relationships in that area are not being adversely impacted by the additional flow. Ideally, this is done as part of the construction package to ensure the design is implementable and no additional HVAC changes are required to accommodate the exhaust from the negative air equipment.

e. Install device on exterior of work containment to continually monitor negative pressurization. To ensure proper pressure is continuously maintained, the device(s) shall have a visual pressure indicator, data collection and alarm.

f. Exhaust must be directed to Low Risk areas as defined in Table 3 in this VHA ICRA template. Ideally this discharge must be located so as not to impinge on high traffic areas or create a nuisance with noise or excessive airflow.

NOTE: Exhaust into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is not acceptable.

Contractor/Subcontractor/Employee Notification of Asbestos Form

THE DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER LOCATED IN COLUMBIA, MO, WAS CONSTRUCTED

DURING A PERIOD WHEN ASBESTOS WAS COMMONLY USED IN BUILDING MATERIALS.

THE MEDICAL CENTER HAS COMPLETED A SURVEY FOR ASBESTOS. ALL BUILDINGS CONTAIN SOME TYPE OF

ASBESTOS (I.E., STEAM LINES, FLOOR TILES, CRAWL SPACES, ETC.).

IF YOU OR YOUR EMPLOYEE ENCOUNTERS SUSPECTED FRIABLE ASBESTOS OR CONDITIONS THAT MAY CAUSE

SUSPECTED ASBESTOS TO BECOME FRIABLE, NOTIFY THE CONTRACTING OFFICER’S TECHNICAL REPRESENTATIVE

(COR) IMMEDIATELY.

WHEN WORKING IN AREAS THAT ARE SUSPECTED OF HAVING ASBESTOS, RELOCATE EMPLOYEES AND PATIENTS

FROM THE AREA UNTIL WORK IS COMPLETED.

IF THERE ARE ANY QUESTIONS, PLEASE FEEL FREE TO CONTACT THE COR AT EXT. 6370.

THANK YOU FOR YOUR ASSISTANCE.

CONTRACTOR/SUBCONTRACTOR/EMPLOYEE SIGNATURE, PLEASE SIGN AND DATE BELOW AS

ACKNOWLEDGEMENT OF THE ABOVE INFORMATION.

Employee Name Contractor/Subcontractor Date

Cutting and Welding with Portable Gas or Arc Equipment Permit Form

VA Project No: ________________________________________________________________

Name of Contractor's Firm: ______________________________________________________

Date: ________________________________________________________________________

Building/Location: _____________________________________________________________

Work To Be Done: _____________________________________________________________

Special Precautions:

Fire Watch Required: ____Yes ____No

The location where the work is to be performed has been examined, necessary precautions have been taken and permission is granted for this work.

Signed _____________________________________ (Fire Department Official Authorizing Hot Work)

Permit Expires: _______________________________________________ (Date)

Time Hot Work Started: ___________________ Time Hot Work Completed: _________________

Final Check-Up:

Work area and all adjacent areas to which sparks and heat might have spread (including floors above and below and on opposite sides of walls) were inspected 30 minutes after the work was completed and were found fire safe.

Signed _________________________________________ (Contractor's Fire Watch)

Attention:

Before approving any cutting and…