36C25618B0679-0001007.pdf

Project No.

Date:

C Medium

TYPE A TYPE B TYPE C TYPE D

I II II III/IV

I II III IV

I II III/IV IV

II III/IV III/IV IV

Pre-Construction Risk Assessment for the Transmission TB to Contracted Construction Workers

Is PPD skin testing necessary for contract workers?

3A-401

Location and brief description of the construction or maintenance project:

Highest

Air Quality

Noise

Site to remain secured at all times

Emergency procedures

Security

Construction Site Location:

High

Other Comments

Notes:

Patient Population Near Construction Site: Yes TB Risk Level of Facility:

Yes

Infection Control Risk Assessment (ICRA) Checksheet

Patient Risk Group

Construction Project Type

Project Class

GI Room 3A-401 Upgrades

Mark Landwert

Project Title or Type of Work:

COR:

Type of construction project--choose from drop-down box (see "Types & Risk" tab):

580-18-123

August 17,2018

Install additional Med Gas and relocate casework and entry door Contractor will access the site through building main corridor

Patient Risk Group--choose from drop-down box (see "Types & Risk" tab):

Install plastic rated dust barrier in corridor 3A-400 outside the work area

Risk for TB exposure to Contractors?

Pre-Construction Risk Assessment (to be filled out by COR)

Class of Infection Control Precautions (select from grid)

Vibrations

Utilities

Negative Air Required. Connect to exhaust in toilet

Limit during normal houre

Coordinate with COR on Meg Gas

III

Coordinate with COR on Demolition

Low Medium

Project Title or Type of Work:

August 17,2018

Class

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

Immediately replace ceiling tile displaced for visual inspection.

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

Wipe work surfaces with disinfectant.

Water mist work surfaces to control dust while cutting. X Wet mop and/or vacuum with HEPA-filtered vacuum before leaving work area.

X Seal unused doors with duct tape.

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

Block off and seal air vents. X Contain construction waste before transport in tightly covered containers.

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

X Remove or isolate HVAC system in areas where work is being performed to prevent contamination of duct system.

Class II (those checked) plus: X Do not remove barriers from work area until completed project is inspected by Safety and Infection Control and thoroughly cleaned by Environmental Management.

X

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.

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

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

Vacuum work area with HEPA filtered vacuums.

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

Wet mop area with disinfectant.

Class III (those checked) plus: See other Classes.

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

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 the worker leaves the worksite.

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

III

IV

Infection Control Risk Assessment (ICRA) Checksheet (check appropriate requirements)

During Construction Project Upon Completion of Project

II

GI Room 3A-401 Upgrades

Project Title or Type of Work:

Deficiency Y or N?

Deficiency Y or N?

Blocking an approved exit path N Rerouting internal patient/staff/visitor traffic flows N A large section of the fire alarm system is out of service

N Rerouting external access to the hospital N

A large section of the sprinkler system is out of service N Fire alarm system out of service > 4 hours N

Major renovation of an occupied floor N Sprinkler system out of service > 4 hours N Significantly modifying smoke barriers or fire walls N One fire alarm zone out of service > 4 hours N

Adding an addition to an existing and occupied building N A few sprinkler zones out of service > 4 hours N

Other system (kitchen hood, FM 200, etc.) out of service

X 6

X 14

Signature and Date

Conduct organization wide safety education programs to promote awareness of fire safety building deficiencies, construction hazards and temporary measures implemented to maintain fire safety.

Train staff to compensate for impaired structural or compartmental fire safety features.

The hospital has a written ILSM policy identifying when and to what extent ILSM are implemented.

Evaluate the project using the criteria below to determine which ILSM are applicable.

Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

Enforce storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

Provide additional training to staff on the use of firefighting equipment.

Conduct one additional fire drill per shift per quarter.

Inspect and test temporary systems monthly. Document the completion date.

Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

Provide additional firefighting equipment.

Use temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.

Interim Life Safety Measures (ILSM) Assessment for Construction and Maintenance

580-18-123

Notify the fire department and initiate a fire watch. Document notification and fire watch times.

Post signage identifying the location of alternative exits.

Inspect exits in affected areas on a daily basis.

GI Room 3A-401 Upgrades

Date of this Formal Contract:

Yes No

1 X

2 X 3 X

4 X

5 X

6 X

7 X

8 X

9 X

10 X

11 X

12 X

13 X

14 X

Time Time

Interim Life Safety Measures Required?

Responsibility

Safety

Safety

Notify the fire department and initiate a fire watch. Document notification and fire watch times.

Post signage identifying the location of alternative exits.

Inspect exits in affected areas on a daily basis.

Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

Provide additional fire-fighting equipment.

Use temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.

Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

Enforce storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

Provide additional training to staff on the use of firefighting equipment.

Conduct one additional fire drill per shift per quarter.

Inspect and test temporary systems monthly. Document the completion date.

Conduct organization wide safety education programs to promote awareness of fire safety building deficiencies, construction hazards and temporary measures implemented to maintain fire safety.

Train staff to compensate for impaired structural or compartmental fire safety features.

The hospital has a written ILSM policy identifying when and to what extent ILSM are implemented.

Contractor, COR and Safety

Safety

Safety

Contractor

Safety

Contractor will access the site through building main corridor

DateNames/Groups Trained

ILSM Formal Contract

580-18-123

Install additional Med Gas and relocate casework and entry door

Project Title / GI Room 3A-401 Upgrades Project No.:

COTR: Mark Landwert Contractor:

Location and Description of Work:

August 17,2018

Staff Training

Safety

COR

Date Area Date Dates of Fire Drills

Area

COR

Contractor

Safety

Contractor

Contractor, COR and Safety

Project Title: GI Room 3A-401 Upgrades Project #: 580-18-123

Yes No

No Fire Protection Engineer or Safety staff:

Date completed:

Yes No If yes, then:

No Must provide safe access to and egress from excavation. See FMS Policy 138S- 022, Excavation Safety Program.

No Daily excavation permit required. See FMS Policy 138S-022, Excavation Safety Program.

X Permit required. See FMS Policy 138FMS-029, Barrier Penetration Permit Policy.

No Refer to FMS Policy 138FMS-021, Confined Spaces.

No Refer to FMS Polcy 138ENG-026, Hot Work Policy X Refer to FMS Policy 138S-033, FMS Electrical Safety Program.

No Before releasing the site, flush domestic water lines and provide documentation to COR. Observe Note 2.

No Before releasing the site, flush and sanitize domestic water lines and provide documentation to COR. Observe Note 2.

No Notify COR of exact location(s) and type(s) so dampers may be inspected in 1 year.

Fire Prevention Review (see Note 1)

Permits and Other Requirements

Permit and Policy Requirements

Note 2: From FMS Policy 138FMS-002, Infection Control, paragraph II.F.: In the event of maintenance or repair work on existing water lines, Engineering Section [Contractor, if construction project] will accomplish proper disinfection of the affected water lines through the Safety Manager and follow-up bacteriological testing through a certified water testing laboratory or City of Houston... Infection Control will be notified of such maintenance or repair work. The water test results will be reviewed with Infection Control prior to placing new or repaired lines into service. All potable water test results shall be maintained and available from the Safety Section.

Has a fire prevention review been conducted?

Any excavations greater than 4 feet below grade level?

Any excavations greater than 5 feet below grade level?

Either above ceiling work or fire or smoke barrier penetrations?

Entry into permit required confined spaces?

Welding, soldering or other hot work?

Work on energized electrical circuits?

Modification of domestic water lines?

Installation of new domestic water lines?

Installation of new fire or smoke dampers or replacement of existing dampers?

Will this project require:

Note 1 (see VHA Directive 2005-007 and SCVAHCN Policy 16-ES-30 ) :

a) All delegated construction projects must be provided fire code reviews. Delegated construction projects include projects funded from the Major, Minor or NRM programs that are managed at the facility level and other projects completed with local operating funds.

b) A qualified fire protection engineer must conduct the fire protection and life safety review for all Major and Minor projects and any NRM project where the scope of work is primarily (greater than 50 percent of the total project cost) fire protection (i.e., fire alarm or sprinkler systems, etc.) or includes significant renovation and construction where specific fire code and standard requirements would be applicable.

c) Facility safety staff will conduct fire code reviews for all other delegated projects and for locally funded projects.

Date:

Type of Project (check appropriate box):

Operation and Maintenance Lease X Repairs/Renovation Other

New Construction

Level of NEPA Analysis: Other Environmental Permits/Analysis Needed:

X Categorical Exclusion (see next page)

Environmental Assessment (EA) Needed Environmental Impact Statement (EIS) Needed

Would the proposed activity involve or generate any of the following?

Y/N Y/N Y/N

N N N N N N N N N N N N N N N N N N N

X

COR:

GEMS Coordinator:

Source Source Source

Determination

Mark Landwert

I find the proposed project qualifies as a CATEGORICAL EXCLUSION with no extraordinary circumstances.

I find that the proposed project MAY have a significant effect on the environment; therefore, an ENVIRONMENTAL ASSESSMENT (EA) will be prepared.

ENVIRONMENTAL IMPACT STATEMENT (EIS)

Specify which CATEX: 5

Biological Resources Radioactive Waste Mixed Waste

Project Impacts

Soil Disturbance Water Treatment Water Flow

RCRA or CERCLA Sites

Wetlands Permit Modification Chemical Use/Storage Water/Well use Other:

National Environmental Policy Act (NEPA) Risk Assessment

Project Title:

COR:

Air Emissions including GHGs Asbestos

Install additional Med Gas and relocate exist casework and door

Contractor will access the site through building main corridor

Petroleum Storage

GI Room 3A-401 Upgrades

Mark Landwert

Liquid Effluent

Utility Modification

580-18-123

August 17,2018

Location and Description of Work:

Excessive Noise Solid Waste Hazardous Waste

*38CFR Part 26.6(b)(1)

13. Actions, activities. Or programs that do not require expenditure of Federal funds.

CATEX Form Categorical Exclusions List*

8. Actions which involve support or ancillary appurtenances for normal operation;

9. Leases, licenses, permits, and easements;

10. Reduction in force resulting from workload adjustments, reduced personnel or funding levels, skill imbalances or other similar causes;

11. VA policies, actions and studies which do not significantly affect the quality of the human environment;

12. Preparation of regulations, directives, manuals, or other guidance that implement, but do not substantially change, the regulations, directives, manuals, or other guidance of higher organizational levels or another Federal agency, and

3. Routine VA grounds and facility maintenance activities;

4. Procurement and activities for goods and services for routing facility operations maintenance and support;

5. Interior construction or renovation;

6. New construction of 75,000 gross square feet or less;

7. Development of 20 acres of land or less within an existing cemetery, or development on acquired land of five acres or less.

1. Repair, replacement and new installation of primary or secondary electrical distribution systems;

2. Repair, replacement and new installation of components such as windows doors, roofs, and site elements such as sidewalk, patios, fences, retaining walls, curbs, water distribution line and sewer lines which involve work totally within VA property boundaries;

TYPE A

TYPE B

TYPE C

TYPE D

Low Risk Medium Risk High Risk Highest Risk

Office areas Medical records Non-patient care areas

Cafeteria Cardiology clinic Echocardiography Endoscopy Nuclear Medicine Physical Therapy Radiology/MRI Respiratory Therapy

CCU

Emergency Room Laboratories (specimen) Admissions Outpatient Surgery Pharmacy Post Anesthesia Care Unit (PACU) Surgical Units

Any area caring for immunocompromised patients Cardiac Cath Lab

SPD

Intensive Care Units Medical Units Negative pressure isolation rooms Oncology Operating rooms Invasive procedure rooms

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.

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

Work that generates a moderate to high level of dust or requires 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 floor coverings, 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 single work shift

Major demolition and construction projects Includes, but is not limited to:

Activities which require consecutive work shifts Requires heavy demolition or removal of complete cabling systems New Construction