IFB Attachment 8 - Risk Assessment.pdf

PROJECT RISK ASSESSMENT (SAFETY, INFECTION CONTROL & ILSM)

US Department of Veterans Affairs: Categorical Exclusion from NEPA Requirement for EA or EIS Project Title: Project or Work Order No:

Location: Project Manager/COR:

Start Date: Coordinator Phone Number:

Address or intersection:

Description of project:

City, State:

ZIP:

County:

Type(s) of project:

☐Operations/ maintenance ☐ Repairs/renovation ☐ New Construction ☐ Lease ☐ Grant ☐ Other (describe)

Specify applicable categorical exclusion(s) (38 CFR 26.6(b)(1)):

☐ Electrical ☐ Components or site elements within VA property line ☐ Routine maintenance ☐ Procurement for routing facility ☐ Interior construction/renovation ☐ New construction ≤75,000 GSF ☐ Cemetery development ≤20 acres existing property; development ≤5 acres new land

☐ Support/appurtenances for normal operations ☐ Leases, licenses, permits, and easements ☐ Reduction in force ☐ Policies, actions, studies with no significant environmental effect ☐ Regulations/guidance implement requirements from higher VA levels or other agencies ☐ No expenditure of federal funds

Review for extraordinary circumstances (38 CFR 26(b)(3)) - Check each box to confirm review and item is not applicable:

☐ N/A: Greater scope or size than normally experienced for a particular categorical exclusion ☐ N/A: Actions in highly populated or congested areas ☐ N/A: Potential for degradation, although slight, or existing poor environmental conditions

☐ N/A: Use of unproven technology ☐ N/A: Potential presence of an endangered species, archaeological remains, or other protected resources ☐ N/A: Potential presence of hazardous or toxic substances

List other potentially significant environmental effects reviewed, if any:

Indicate (check out) whether the proposed activity would involve or generate any of the following:

☐ Air emissions including GHGs ☐ Asbestos ☐ Excess Noise ☐ Utility Modification ☐ Soil disturbance ☐ Water treatment

☐ Water flow modification ☐ Liquid effluent ☐ Petroleum storage ☐ Solid Waste ☐ Hazardous waste ☐ Biological resource

☐ Mixed waste ☐ Radioactive Waste ☐ RCRA or CERCLA site ☐ Wetlands ☐ Permit modification ☐ Chemical use/storage

☐ Aesthetics ☐ Water/well use ☐ Historic property ☐ Other (describe):

Determination ☐ The proposed project qualifies as a categorical exclusion (specified above) with no extraordinary circumstances.

☐ The proposed project may have a significant effect on the environment. Therefore, an environmental assessment will be prepared.

☐ Environmental impact statement.

Reviewed by COR Signature

Title Approved by GEMS Coordinator

Signature

Title

Project Title: Project or Work Order Number: MCP 001S-01-28 Appendix C

THE FOLLOWING PROJECTS DO NOT REQUIRE COMPLETION OF THE PROJECT RISK

ASSESSMENT FORM:

1. Painting and installation of new wallpaper in business offices and non-patient areas.

2. Painting in a patient room, if closed for painting and less than 3 square feet of wall area is to be patched and painted. Contractor shall replace the air filter for the room’s air conditioning unit upon completion of painting.

3. Installation of a soap dispenser/needle box/paper towel holder in a patient room

4. Repair of a window blind.

5. Ceiling tile replacement for areas less than ten (10) 2’ x 2’ tiles, if not in business offices and non-patient areas.

6. Ceiling tile replacement for areas less than five (5) 2’ x 2’ tiles in a patient area if patient is out of the immediate area and clean up can be accomplished before patient returns.

7. Minimal repair of Nurse Call System/TV/Bed/Telephone.

8. Checking or replacing of electric outlet.

9. Replacing a light bulb.

10. Unstopping sink/commode with no water on floor.

11. Unstopping commode when water on floor requires maintenance to have Housekeeping clean area immediately.

12. Repair of a medical gas outlet.

13. Taking air balance measurement readings.

14. Checking air conditioning unit/system.

15. Intermediate jobs that create a moderate amount of dust inside the room with negative air pressure maintained in the room via use of HEPA-equipped unit with minimum 10 ACH, and all air discharged outside. The HEPA unit must continue running 2 hours after completion of job and Housekeeping must clean room before the HEPA unit is removed from room. All work and use of HEPA unit must be documented, and copies forwarded to Infection Prevention and Control and Safety.

NOTE: All duct vents are to be sealed off during work!

ILSM ASSESSMENT TOOL

STEP #1

FOR THE FOLLOWING QUESTIONS, TAKE THE ACTION IN THE ASSOCIATED 'NO' OR 'YES' COLUMNS TO DETERMINE IF ILSM IS

REQUIRED

NO YES

A. Will this work restrict EGRESS from the affected space? PROCEED TO STEP B ILSM REQUIRED B. Is the equipment, component, etc., part of a building LIFE SAFETY system? ILSM NOT REQUIRED PROCEED TO STEP C C. Is the activity in a PATIENT CARE AREA or will it affect a PATIENT CARE AREA? ILSM NOT REQUIRED PROCEED TO STEP D D. Removal of any corridor or more than 5% of a room’s ceiling tiles? ILSM NOT REQUIRED PROCEED TO STEP E E. Floors or ceilings will be penetrated during construction? ILSM NOT REQUIRED PROCEED TO STEP F F. Significant renovation of an occupied floor? ILSM NOT REQUIRED ILSM REQUIRED

STEP #2

Today’s Date Building Project Loc.

Start Date Est Comp. Date Project Mgr.

Project /WO Number Project Name Specific Deficiency and Location

STEP #3

USE THE CRITERIA BELOW TO DETERMINE THE APPROPRIATE INTERIM LIFE SAFETY (ILSM) FOR CONSTRUCTION, MAINTENANCE, REPAIR, OR INSPECTION ACTIVITIES

Unless otherwise noted below, these requirements apply to impairments of a duration extending beyond the current shift (greater than 8 hours)

ILSM

ILSM

ILSM

ILSM

ILSM

ILSM

ILSM

7**

ILSM

ILSM

ILSM

ILSM

ISLM

ILSM

ILSM

14 Check all that apply.

Any impairment of a required egress less than 4 hours X X X X X Any impairment of a required egress greater than 4 hours X X X X X X X X X X X Fire detection ALARM system impairment greater than 8 hours *** X X X X X X X X X Fire SUPPRESSION system impairment greater than 8 hours X X X X X X X X Problem with a single fire or smoke door hardware X X Fire or smoke barriers with unprotected penetrations X X Missing or incomplete fire or smoke barriers X X Missing or impaired NFPA 101 required fire or smoke dampers X X Hazardous use areas not properly separated from corridors X X Accumulation of combustibles and/or materials X X X X X Temporary construction doors not latching or missing hardware X X X Activity involving ignition sources (welding, torching) X X X X X Major utility failure or outage affecting a life safety system greater than 4 hours X X X X X X X X X X X Multiple LS impairments within the same fire or smoke zone X X X X X X X X X X X

**Requires review by Construction Safety Subcommittee Members prior to ILSM commencement.

*** The following functions shall be actuated and considered as part of a complete fire alarm system: Release of hold-open devices for doors or other opening protectives, Stairwell or elevator shaft pressurization, Smoke management or smoke control systems, unlocking of doors, Elevator recall and shutdown, and HVAC shutdown.

STEP #4

INTERIM LIFE SAFETY IMPLEMENTATION MEASURES

ILSM 1 Inspect exits in affected areas on a daily basis and resolve problems immediately.

ILSM 2 Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

ILSM 3 Provide additional firefighting equipment as needed.

ILSM 4 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.

ILSM 5 Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

ILSM 6 Enforce storage, housekeeping, and debris-removal practices that reduce the buildings flammable and combustible fire load to the lowest feasible level.

ILSM 7 Provide additional training on use of firefighting equipment, impaired structural or fire safety features, temporary measures implemented, construction hazards, and building deficiencies. (NOTE: ILSM7 requires VEHS notification. Additional staff training is required for project duration exceeding 8 hours.)

ILSM 8 Conducts one additional fire drill per shift per quarter as called for by policy, best practice, or at the discretion of the VUMC Safety Officer.

ILSM 9 Inspect and test ILSM systems monthly or once per project if the duration is less than one month.

ILSM 10 Notify the local fire department and internal responders of the ILSM steps in place using the Interim Life Safety Measures form as required.

ILSM 11 Notify the occupants in the area of the deficiency and the ILSM steps in place using the Interim Life Safety Measures form as required.

ILSM 12 Install signage identifying the location of alternate exits to everyone affected.

ILSM 13 Refer to MCP 001S-39-28 "Fire Watch Policy" (The Fire Watch Policy may require a time limit less than 8 hours.)

ILSM 14 Blocked egress paths are never left unattended.

Name of Person(s) Completing this Assessment Date the assessment was completed

OSH Staff Reviewing this Assessment Date the review was completed

ILSM ALERT

Situation: Effective immediately , Interim Life Safety Measures are in effect for the until cancelled. This alert is due to

Background: Contracted personnel will be:

Assessment:

(Work to be done)

However, handheld fire extinguishers are located throughout the floor. The rest of are protected by a fully functional fire system including sprinklers.

Requirements: All personnel MUST be on high alert for signs of fire.

A review of emergency response, evacuation procedures, and handheld fire extinguishers locations MUST be completed by all hands.

JBVAMC Police will increase patrols of the during off-shift hours.

You are required to pass this information to all staff members, patients in the and anyone who may on occasion be in this building.

Any questions should be addressed by calling extension 56985.

Mr. Paul L. King

Safety and Occupational Health Manager Jesse Brown VA Medical Center

CONTRACTOR BRIEFINGS & TRAINING

CONTRACTOR BRIEFINGS & TRAINING INITIALS

Ensuring free and unobstructed access to emergency department/services and for emergency forces.

☐ N/A

Ensuring fire alarm, detection, and suppression systems are not impaired; a temporary but equivalent system shall be provided when any fire system is impaired.

☐ N/A

Contractor will schedule work to minimize how long the systems are impaired and shall notify safety section prior to system being impaired.

☐ N/A

Ensuring temporary construction partitions are smoke tight and built of noncombustible or limited combustible materials which will not contribute to the development or spread of fire.

☐ N/A

Providing additional firefighting equipment and use training for personnel. ☐ N/A Developing and enforcing storage, housekeeping, and debris removal practices which reduce the potential (flammable or combustible) fire load of the work area to the lowest possible level.

☐ N/A

INFECTION CONTROL MEASURES ARE IN PLACE I/C STAFF HAS VERIFIED

CONTRACTOR BRIEFINGS & TRAINING

INITIALS

Met with VA services/sections surrounding construction area to inform them of impacts and precautions to be taken, and to inform them in basic I.C. requirements (see attached) NOTE:

address in design & planning phase

☐ N/A

Met with the contractor project manager, construction crews, and subcontractors to inform them of precautions to be taken, and to educate them in basic I.C. requirements. NOTE: address in design & planning phase

☐ N/A

Informed the contractor that barriers are not to be removed from work area until completed project is inspected by the Safety and Infection Control Departments, and thoroughly cleaned by Environmental Management Service.

☐ N/A

ILSMs ARE IN PLACE SAFETY STAFF HAS VERIFIED NOTIFICATIONS & TRAINING INITIALS VA Police have been notified of responsibility to conduct a fire watch at least once per shift during non-business hours whenever any portion of the fire alarm, detection, or suppression systems are impaired for more than four hours within a twenty-four-hour period.

☐ N/A

If exits are obstructed, then personnel in building were trained on alternate routes and exits. ☐ N/A Construction areas will have designated and marked exits, maps delineating new exit pathways are in place.

☐ N/A

TB RISK ASSESSMENT

Is there a risk based upon construction site location, patient population, hospital layout, and the defined risk as outlined in the “CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Setting? (IF SO, SEE COMMENTS BELOW): ☐ YES ☐ NO Ensure that VHA-required content regarding TB is included in every contract.

Contractor shall provide written certification that all contract employees assigned to the work site have had a pre-placement tuberculin screening within 90 days prior to assignment to the worksite and been found have negative TB screening reactions. Contractors shall be required to show documentation of negative TB screening reactions for any additional workers who are added after the 90-day requirement before they will be allowed to work on the work site.

Review the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings (MMWR 54-RR17) and select the risk category. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm VHACHSThakkJ1 Typewritten Text NOTE: THE REQUIRED INITIALS ON THIS PAGE SHALL BE OBTAINED FROM AWARD WINNING CONTRACTOR ONCE THE CONTRACT IS AWARDED.

VHACHSThakkJ1 Line

VHACHSThakkJ1 Line

VHACHSThakkJ1 Line

VHACHSThakkJ1 Typewritten Text Will be completed after the project is awarded to a contractor

VHACHSThakkJ1 Line

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Pre-Construction Risk Assessment (PCRA)

This form provides minimum requirements for categorizing activity type(s) and safety risk to determine the level of precautions needed to prevent impact related to Construction, Renovation and Maintenance on patients, employees, and contractors.

Ensure that the activity statement of work and any drawings available are used for the PCRA assessment and included in the project file with the completed PCRA.

Communication and coordination of all types of activity with affected areas are to be included among the control measures. The development of communication and coordination plans must begin during the activity planning phase.

Table 1 - Construction, Renovation, and/or Maintenance Activity Type and Control Measures

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

Controls defined in Table 1 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 activity must also include the control measures in the preceding row(s).

As the activity progresses, a full re-evaluation of remaining activity type and risk is required prior to changing the level of control measures.

Activity Type determined from Table 1:

Activity Type and Description Control Measures Inspection/upkeep generally defined as follows:

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

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

• Work that does not create dust or debris.

• Work that does not create vapors or fumes.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection that will not impair fire safety systems and are 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 with hand tools) that do not create vibration or noise.

Limited building system maintenance that does not require Lock Out Tag Out (LOTO) such as plumbing on potable systems limited to faucet replacement, steam trap replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

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

2. Site visits of construction area are required weekly by member of multi-disciplinary team. Site visits will be documented on standard checklist.

3. Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor and approved where a contact is in place.

For internal work the shop involved must work with Safety to ensure proper precautions are in place.

4. Must address identified hazards and controls that will be implemented to ensure minimal impact to patients, employees, contractors, and facility.

5. Communication and coordination plan for all affected areas

Small scale Construction, Renovation, and general maintenance/repair work, generally defined as follows:

• Prolonged work that may take longer than a single shift but not exceeding six months.

All control measures in the row above and the following:

1. Hazard communication chemical inventory required to be provided by the contractor and approved.

2. Where construction, Renovation and maintenance are done in an accredited facility, and ILSM assessment is

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

• Work that creates some noise and vibration due to power tool use.

• Selective demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements that may o disturb asbestos, lead or silica o create the potential for falling objects o create vibration and/or noise in excess of

80 dB(A) in surrounding areas.

o cause penetrations in fire or smoke barrier

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing that requires utility outages or work on the steam system that may require:

o LOTO o The use of compressed gas cylinders

• 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. Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that require LOTO.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit, a single device and the installation of ductwork, diffusers, and terminal units for an area that may require:

o Work on ladders o Rigging, hoisting, or lifting of equipment or materials overhead

• Modification of existing fire alarm and suppression systems requiring system outages and ILSMs or obstruction of exits and or impact on corridors.

• Architectural, structural, or any other work that may cause vapors or fumes such as:

o Roofing work o Flooring work o Painting or other large-scale use of such substances.

required to be done and ILSMs put into place in accordance with TJC LS.01.02.01 and the local facility policy including Fire watch if necessary. Staff is trained and the ILSM is verified regularly

3. Hot Work or burn permits in place and staff trained

4. LOTO procedures in place and staff trained on their use

5. Site visits will be reviewed using the criteria in standardized guide.

Daily inspections of the site are to be conducted by the General Contractor or shop supervisor and documented on their daily log.

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.

• Excavation or heavy equipment use taking place o Dig safe required utility location o Trench safety o Dust control plan o Equipment exhaust, Noise, Vibration

• Confined space entry required (permit required or not)

• Requires crane work o General crane work

All control measures in the two rows above and the following Activity Hazard Analyses and Control Plans (check all that apply):

1. Excavation safety plan in place ☐

2. Dust control plan in place ☐

3. Pollution prevention plan in place ☐

4. Dig safe paperwork in place ☐

5. Crane lift plan in place ☐

a. Crane placement

b. Crane swing

c. Crane load evaluation

6. Fall protection plan in place and staff trained ☐

7. Confined entry plan in place and staff trained ☐ o Lift over buildings

• Includes elevated work o Roof work, fall protection o Window work, scaffolding and fall protection o Odor control

• Welding, cutting or use of torches requiring burn permits

• Demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and HVAC that may o require asbestos, lead or silica abatement o create the potential for falling objects o create vibration and/or noise in excess of

90 dB(A) in surrounding areas.

o cause breaches to fire or smoke barrier

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work that requires transport of significant materials through building and up elevators i.e., weight limits of floors and elevators

• Plumbing work requiring LOTO and system shutdown and startup such as the installation of:

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

• 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. requiring LOTO and system isolation.

• Installation of fire alarm and suppression systems requiring outages of those systems and ILSMs or closure of exits/corridors

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

Table 2. Affected Adjacent Area Assessment

In addition to the minimum precautions noted above for the Activity Type, it is critical that the activity be coordinated with the areas adjacent to the activity to ensure operations in those areas are not disrupted or impacted. List the adjacent areas in Table 2 below and develop activity-specific coordination plans and associated communication plans with each area to address activity work that could impact or disrupt the operation of the areas, in general as follows (see the Figure for a visual representation of adjacent affected areas):

• If adjacent area is vacant (e.g., work outside, construction of new building, etc.):

o Coordination is typically not necessary other than potentially traffic flow and pedestrian access.

• If adjacent area is non-continuously occupied (e.g., areas where outpatient care is provided, employee health, etc.):

o Develop a list of activities that will potentially impact or disrupt the operation of the area (e.g., work involving noise, vibration or exit obstruction) and meet with POC to coordinate execution of work in a way that mitigates the impact (e.g., conduct work after hours).

• If adjacent area is occupied continuously (e.g., areas where inpatient care is provided, residential areas such as Community Living Centers, etc.):

o Develop a list of activities that will potentially impact or disrupt the operation of the area (e.g., work involving noise, vibration or exit obstruction) and meet with POC to coordinate execution of work in a way that mitigates the impact (e.g., move affected party temporarily).

Area Service(s)/Type(s) of Area(s) (e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc.)

Point of Contact

(POC)

POC Contact Information

Construction plan communicated to POC?

Activity Area**

Area Above

Area Below

Adjacent Area 1

Adjacent Area 2

Adjacent Area 3

Adjacent Area 4

* There may be more than one Service/type of area for each row. List all. The information entered on this table must be used in the ICRA if required.

** List the area(s) in which the construction/renovation/maintenance activity will occur.

ADDITIONAL QUESTIONS

Off Tour Construction Necessary? ☐ YES ☐ N/A Permit Required Confined Space (PCRS) Entry Necessary? ☐ YES ☐ N/A Cutting, Burning, or Welding Necessary? ☐ YES ☐ N/A Lead or Other Hazardous Abatement Necessary? ☐ YES ☐ N/A Legionella Assessment: Will potable water system(s) be affected in any way? ☐ YES ☐ N/A Does this Project involve a Mental Health Unit (Bed Tower 7E/W or ED rooms 1470A or 1470B)? ☐ YES ☐ N/A If yes has the Mental Health EOC Team been notified? ☐ YES ☐ N/A Lock-Out/Tag-Out of the following systems will be necessary:

☐ Domestic Water ☐ Electrical Systems ☐ HVAC Systems ☐ Medical Gases ☐ Steam Systems ☐ Security Alarms

The following departments will be involved in this project:

☐ FAC

Grounds

☐ FAC

PLAN/ID

☐ Paint Shop ☐ Electric Shop ☐ Biomed

☐ HVAC ☐ Plumbing ☐ Carpenter ☐ IRM/ITOPs ☐ Police List Other:

Asbestos assessment Asbestos removal needed?

☐ YES ☐ NO

☐ Conducted by wall or ceiling penetration visual inspection ☐ Conducted via access panel visual inspection?

☐ Conducted by review of facility diagrams and/or prior removal paperwork?

If Yes, an infection control permit is required.

Has the Pre-Construction Risk Assessment been reviewed by the Safety Office? Yes ☐ No ☐

Safety Representative (Print Name) Signature Date

Construction Risk Assessment Completion Permit This page must be posted at the entrance to the project area, or other designated area

Project or Work Order No:

Location:

Project manager/COR Project start date Contact phone number Expected Completion date Contractor or lead shop

Activity Type (Inspection/Upkeep, Small-scale, or Large-scale)

Activity Type Control measures to be in place for the duration of the activity (Check the box for the Activity Type to indicate the Control Measures)

Inspection/Upkeep

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

2. Site visits of construction area are required weekly by member of multi-disciplinary team. Site visits will be documented on standard checklist.

3. Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor and approved.

4. Must address identified hazards and controls that will be implemented to ensure minimal impact patients, employees, contractors, and facility.

5. Communication and coordination plan for all affected areas

Small-scale

All control measures in the row above and the following:

1. Hazard communication chemical inventory required to be provided by the contractor and approved.

2. ILSMs in place and staff trained on situation

3. Hot Work or burn permits in place and staff trained

4. LOTO procedures in place and staff trained on their use

5. Site visits will be reviewed using the criteria in standardized guide.

6. Daily inspections of the site are to be conducted by the General Contractor and documented on their daily log.

Large-scale

All control measures in both rows above and the following Activity Hazard Analyses and Control Plans as applicable (check all that apply):

1. Excavation safety plan in place ☐

2. Dust control plan in place ☐

3. Pollution prevention plan in place ☐

4. Dig safe paperwork in place ☐

5. Crane lift plan in place ☐

a. Crane placement

b. Crane swing

c. Crane load evaluation

6. Fall protection plan in place and staff trained ☐

7. Confined entry plan in place and staff trained ☐

*The location of all Activity Hazard Analyses and Control Plans (excavation, dust, pollution, etc.) as applicable shall be identified on this permit and shall be made available to all workers on the job.

Additional requirements:

Was an Infection Control Risk Assessment (ICRA) conducted for the Activity? Yes ☐ No ☐ Is an Infection Control Permit required for the Activity? Yes ☐ No ☐ Infection Prevention and Control signature (only if Infection Control Permit is required): _____________________________ Date:

Project Manager/COR signature Date

Safety Officer signature Date

INFECTION CONTROL RISK ASSESSMENT FOR

CONSTRUCTION, RENOVATION, AND MAINTENANCE

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.

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 plumbing on potable systems limited to faucet replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

Category 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.

Category 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.

Category

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.

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

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).

Use the information gathered from Table 2 of the PCRA (Page 7) for this section.

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.

Low Risk

Non-patient care areas

Medium Risk

Patient care support areas

High Risk

Patient care areas

Highest Risk

Procedural, invasive, sterile support and highly compromised patient care areas

I. LOW Risk Area (affects one or more of the following areas): ALL NON-PATIENT CARE AREAS ☐ Office Areas/Shops ☐ Equipment Storerooms ☐ Breakrooms

☐ Locker Rooms ☐ EMS Closets ☐ Boiler/Chiller Plants

☐ Mechanical Rooms ☐ Public hallways and gathering areas not on clinical units

☐ Outside Access Areas (list where under other) ☐ Bathrooms

Other:

II. Medium Risk Area (affects one or more of the following areas): PATIENT CARE SUPPORTSUPPORT AREAS ☐ Waiting areas ☐ Clinical engineering

☐ VCS Canteen ☐ Sterile processing department dirty

☐ NFS Kitchen Areas ☐ Materials Management

Other:

III. HIGH Risk Area (affects one or more of the following areas): PATIENT CARE AREAS ☐ All Acute Care Unit ☐ Employee Health ☐ Emergency Department

☐ Clean Utility Rooms ☐ Medication Rooms ☐ Laboratories

☐ Imaging Suites – Diagnostic Imaging ☐ Pharmacy – General Work Zone ☐ Patient Care Rooms and Areas

Other:

IV. HIGHEST Risk Area (affects one or more of the following areas):

☐ Surgical Units ☐ Endoscopy ☐ Pharmacy Compounding ☐ Cardiac Catheter Lab

☐ Surgical Recovery Unit ☐ Sterile Processing Dept. – Clean side ☐ All transplant and Intensive Care Units ☐ Imaging Suites: Invasive imaging

☐ Procedural Suites ☐ Oncology ☐ Transfusion Services ☐ Surgical Inpatient Area

☐ Dedicated Immunocompromised Patient Areas or Negative Pressure Isolation Rooms ☐ Operating Rooms and Restricted Areas

Other:

* 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 Cardiac Catheterization Suites, Electrophysiology Suites, Endovascular/GI Suites, Angio Suites and other spaces which may have high risk patient populations.

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

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.

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.

ENVIRONMENTAL CONDITIONS THAT COULD AFFECT HUMAN HEALTH, SUCH AS SEWAGE, MOLD,

ASBESTOS, GRAY WATER, AND BLACK WATER WILL REQUIRE CLASS OF PRECAUTIONS IV FOR ALL

RISK GROUPS.

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.

Patient Risk Category

Activity Category

A B C D Low Risk Area I II II III

Medium Risk Area I II III IV

High Risk Area I II IV IV

Highest Risk Area II III IV IV

LEVEL OF PRECAUTIONS CONTROL MEASURES

Level I

1. Involve Infection Prevention & Control section in planning before construction begins.

2. Determine how, if at all, this project will affect the departments above, below, and adjacent to this project?

3. Redirect egress routes: do not allow egress routes to pass through construction areas.

4. Construct separation walls prior to project start.

5. Provide and maintain “Construction Area-Do No Enter” signs on doors leading into the construction area.

6. Appropriate safety and project signage shall be posted.

7. Provide and install no-slip (“Sticky”) mats at doors exiting construction area. Mats and carpeting remnants shall be maintained at all construction area entrances & exits to control dust.

8. Negative-pressure containment and ventilation shall be used during any dust-producing activity. Maintain negative air pressure in construction area (24/7) throughout project duration. Unused doors shall be sealed with tape. Existing air supply and exhaust ducts shall be sealed. HEPA vacuum all surfaces at least once per shift and then prior to completion. Remove containment only after approval of VA

COR.

9. There cannot be any return air from within the construction area to the rest of the building, except when not possible. When exhausting to indoor space, HEPA filtration to a constructed ante room must be used.

10. All doors into the work area are smoke-tight, self-closing, and self-locking (where required).

11. Temporary (solid) partitions separating construction from public areas shall be smoke-tight. Only remove after approval of VA. A temporary plastic sheeting enclosure is required to contain dust while removing temporary walls.

12. All power equipment shall be UL listed and properly grounded, extension cords protected, and plugged into GFCI receptacle.

13. Gang boxes and tool carts shall be secured at all times when not in use.

14. Firefighting equipment shall be in place & accessible. Provide fire extinguishers in work areas. Inspection tags shall remain attached and current.

15. Smoke detectors disconnected to prevent dust from activating the fire alarm (typically only occurs during demolition). Replace with heat detectors.

16. Flammable & combustible liquids/gases/solids shall be used properly and stored in fire-safe containers and cabinets.

17. Ceiling tiles shall be replaced as soon as possible to prevent impairment of sprinklers.

18. Project manager and contractor safety manager (designated competent person) to check site daily & log in project folder.

19. Maintain up-to-date daily logs and maintain a current Hot Work Permit.

20. No smoking policy shall be enforced.

21. Trailers, sheds, and dumpsters shall be no closer than 10 feet of buildings.

22. Maintain exit lights in work area.

23. Maintain a clean and orderly work area. Contractors shall thoroughly sweep & mop construction & entrance/exit areas at least daily. All trash shall be removed from the building at least every shift using tightly covered containers.

24. If water systems were affected, conduct system flushing and testing.

25. If HVAC, air exchanges or ventilation systems were affected, conduct system balancing and testing.

26. upon completion, HEPA vacuum all horizontal surfaces, and then wipe all surfaces with disinfectant, and then damp-mop floors. Then notify EMS for terminal cleaning.

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 (unless a work specific waiver is approved by VHA’s Office of Healthcare Engineering); this must be maintained continuously 24/7 for the duration of the project. Exhaust discharged directly to the outdoors that is 25 feet or greater from entrances, air intakes and windows is not required to be HEPA-filtered. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

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.

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.

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

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.

Level of 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.

3. Notify EMS for terminal cleaning.

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.

3. Notify EMS for terminal cleaning.

Removal of Critical Barriers:

4. 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.

5. 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:

a. Carefully remove screws and painter tape.

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

c. Drywall cutting is prohibited during removal process.

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

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

Negative Air Requirements:

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

7. 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:

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

9. Verify that HVAC systems are clean and operational.

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

Water systems:

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

ADDITIONAL SAFETY CONCERNS

Will the project involve the deployment of a crane to deliver equipment over occupied facilities?

☐ YES ☐ NO

Must submit a Lift Safety Plan to the Safety Office for approval a minimum of 3 weeks prior to the arrival of the crane on JBVAMC property. The Lift Safety Plan will include the following information: crane specifications, crane inspection list, and crane staff training record/certification. Contractors shall maintain and present the following items prior to crane start (items can be kept in crane cab): crane certifications, crane registration, fire extinguisher, and crane operating and safety manual.

COMMENTS (Required special PPE will be listed here):

Project Manager/COR (Print Name) Signature Date

Infection Control Risk Assessment (ICRA) Consult with Infection Prevention and Control regarding the assessment of potential infection risks associated with the activity and the need for control measures. See VHA Directive 7715 and the VHA ICRA Template for more information.

Is an Infection Control Permit required for the Activity? Yes ☐ No ☐

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.

Project or Work Order No:

Location Project manager Project start date Contact phone number Expected Completion date Contractor Permit expiration date Activity Category (A, B, C, or D)

Overall Patient Risk Category (Low, Medium, High, or Highest)

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

Level of 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.