Attachment 2 - ICRA forms EHRM project.pdf

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Construction Risk Assessment Project Name: jE/1fftq/lij r/-,.-'-ic/-,iyi (7'def Planned Project Start Date:

Location of Construction: 4..[f Estimated Duration: /2 cM!

Types of Contractor(s)Performing Work: I /-y I,'c I

Safety/Life Safety Risk Assessment-Safety officer should be involved in the design/planning of all projects N LIFE SAFETY IMPACTS OF PROJECT If NO, indicate ILSM from below list or

Will exit egress routes from occupied areas remain unchanged?

Will exit stairs remain unobstructed & fire separated?

Will fire & smoke compartments remain intact & unchanged?

Will fire alarm detection systems remain functional & unimpaired?

/ Will fire alarm suppression systems remain functional & unimpaired?

j7' Will construction area be separated by non-combustible smoke tight partitions?

Will access to emergency department remain unobstructed?

Will emergency access by fire department remain unobstructed?

I CONSTRUCTION ACTIVITY below list or

V

Will there be any anticipated utility shutdowns? (Communications, electrical /j heating/cooling, HVAC, medical gases, vacuum, water, server) ,'/t4ë (/1(41

!) Ot') I)) c-j I, ) I I) ,/ Will there be unusual noise levels for adjacent areas?

Will vibration levels be excessive for hospital machinery to operate properly?

&/ Will there be excessive distance to exit?

V )Vill there be hazardous area not protected?

/ Will there be conflicts with emergency disaster plan?

PHYSICAL SECURITY IMPACTS

If YES, describe necessary intervention(s)

7 Will the construction compromise security?

V

N

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If YES, indicate ILSM from below list or describe other intervention

/ Will the construction compromise employee safety?

I . N ,, CONTRACT COMPLIANCE

If YES, describe necessary intervention(s)

1fr i/ill contract clauses be included for enforcement of identified risks?

Life Safety/ConstructionlSecurity/Employee Safety/Contractin Additional Requirements:

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Interim Life Safety Measures (ISLM)

1. Egress. Ensure free and unobstructed exits. 5. Additional Fire Fighting Equipment 9.

2. Emergency Forces Access 6. Prohibit Smoking. 10.

3. Ensuring Operational Life Safety Systems 7. Control Combustible Loading 11.

4. Temporary Construction 8. Conduct 2 Fire Drills Per Shift in Local Area 12.

13.

Increase Hazard Surveillance Compartmentation Training of Personnel Conduct Organization Training on Life Safety Noti' Fire Department of system impairment Install temporary suppression or Detection system

Safeer<j Date9/ 2O4Project Manage TR: Date:

Police and Security: Date:

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AFGEUnión( Date:

Contracting: Date:

Infection Control Risk Assessment Location and type of construction: 41,!/ (d f'& f Project Start Date: .j 72 L

Project Manager: 44.t -k _eL61 Estimated Duration: 12- ,ti/tJ Supervisor of Area: Date notified of project: g/' )//'2 I

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity. GROUP 1: Least Risk

TYPE B: Small scale, short duration, minimal dust GROUP 2: Medium Risk generating activity.

TYPE C: Activity that generates moderate to high levels of

GROUP 3: MediumfHigh Risk dust, requires greater than one work shift for completion.

TYPED: Major duration and construction activities

GROUP 4: High Risk requiring consecutive work shifts.

Class:

Class aetermined by completing above and referring to FM-O1 (Red Book) Section II Chapter 7, Risk Assessment Matrix of Precautions for Construction and Renovation.

CLASS I 1. Execute work by methods to minimize raising dust from construction operations.

Circle all that apply 2. Immediately replace a ceiling tile displaced for visual inspection CLASS II 1. Use tools equipped with dust collectors.

(Circle all 2. Seal unused doors with tape.

that 3. Block off and seal air vents.

apply) 4. Remove or isolate HVAC system in areas where work is being performed.

5. Utilize air filtration machine

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

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

8. Wipe work surfaces with disinfectant.

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

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

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

LAS Obtain infection control approval before construction begins.

111/ 1. Implement measures from Class II above, plus.

(i.cl' all Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area before construction begins. * that Consider off-shift work if critical barrier is not constructed.

apply) 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

Cover transport receptacles or carts. Tape covering unless solid lid. Implement measures from Class II above, plus.

Do not remove barriers from work area until completed project is inspected by Safety Section & Infection Control & thoroughly cleaned by Facilities Management.

Contain construction waste before transport in tightly covered containers.

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

8. Vacuum work area with HEPA filtered vacuums.

Wet mop area with disinfectant.

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

/CLAS Obtain infection control approval before construction begins.

IV ) 1. Consideroff-shiftwork.

(Oircja{l 2. Consider Moving Patients out of area.

that 3. Implement measures from Class Ill above, plus apply) 4. Construct anteroom and require all personnel and tools etc. to pass through this room so they can be vacuumed using a I-IEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

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

6. Do not remove barriers from work area until completed project is inspected by Safety Section & Infection Control & thoroughly cleaned by Facilities Management.

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

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

Cover transport receptacles or carts. Tape covering unless solid lid Vacuum work area with I-IEPA filtered vacuums.

Wet mop area with disinfectant.

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

Exceptions/Additional requirements to this permit are noted by comments or attached memoranda:

Infection Control Manager: Date:

21 -c;72J

Attachment A-3

Patient Safely Risk Assessment

V N

CONSTRUCTION ACTIVITY

Does this project involve a patient care area?

Is this project adjacent to a patient care area?

Will this project alter patient access/egress to/from the building/patient care area, either temporarily or permanently?

Will this project Impact utilities serving patient care areas?

If any are YES, the patient safety manager shall further assist in design/planning, especially with regard to the following items:

1. The new/temporary access/egress path should be intuitive, i.e. easy to 3. The access/egress path should be smooth, without tripping hazards.

Access/ follow. 4. The access/egress path should be handicap accessible.

Egress 2. Signage should be adequate for decreased visual acuity and at appropriate 5. For applicable clinical areas, the construction barriers prevent viewing levels for both ambulating and w/c bound patients/visitors, unauthorized patient egress.

azar,dous 1. Hazardous areas should not be accessible by patients/visitors. 3. Hazardous chemicals and tools should be stored appropriately to

Materials 2. Signage for hazardous areas should be visually adequate (see above), preclude patient/visitor access?

Critical clinical alarms should be functional and audible within and adjacent to the construction zone? Including but not limited to:

Critical Alarms

. . .a. Emergency Code Systems c. Wander guard technology e. Medication/Nutrition Delivery Systems

b. Medical Gas alarms (Oxygen, Air, Suction) d. Cardiac and other vital sign Monitoring Systems f. Nurse Call Systems

Patient Safety Additional Requirements v;v k (At' t 4... 2/t1TJ'1

Patient Safety Date: