36E77618B0083-0001005.pdf

Safety Manual Central Arkansas Veterans Healthcare System

Attachment A Project Name / Location: _______________________________________________

CAVHS

Construction and Renovation Risk Assessment

(Joint Commission Standard EC.02.06.05) Demolition, Renovation and Construction Risk Assessment Application

EC.02.06.05 Intent Statement The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.

When planning for demolition, construction, or renovation, the hospital conducts a preconstruction risk assessment for life safety, air quality requirements, infection control, utility requirements, noise, vibrations, and other hazards that affect care, treatment, and services.

The hospital takes action based on its assessment to minimize risks during demolition, construction, or renovation.

Determination of need for risk assessment:

Do patients occupy the work area?

Do employees occupy the work area?

Do patients occupy adjacent (side or above/below) areas?

Do employees occupy adjacent areas?

Asbestos Management drawings indicate ACM in area?

Constructed prior to January 1, 1980?

Are there any other reasons a risk assessment should be conducted?

If you checked “yes” to any of the above questions, you must complete this application.

Scope of Work and Drawings Briefly describe the demolition, renovation and construction project and the areas impacted.

Project Name: __________________________________________________________________

Project /COR _____________________________ Phone # _________________

PRINT NAME

Project Location (be as specific as you can - give room numbers)

Start Date _________________________ Anticipated length of project____________________

Brief description _______________________________________________________________

Yes

Yes

No

No

Yes

Yes

No No

Yes

Yes

No No

VHALITRISNEM

Text Box

APPENDIX F

Risk Criteria (√ all risks that are present )

General Hazards ⇒ Describe air handler(s) servicing the affected area and list other areas serviced

Noisy operations: drilling, impact devices, coring, chipping, hammering, sawing, etc.

Vibration: jack hammer, impact devices, etc.

Trip or bump hazards: cords over floor, uneven walking surfaces, dangling wires or equipment, gang boxes, etc.

Exposed electrical circuits Illumination impaired Lockout/tagout required: electrical, mechanical, pneumatic, hydraulic, etc.

Confined space entry: pits, tanks, sewers, silos, air handlers, etc.

Internal combustion engines or heaters used in a patient or employee occupied building Will there trenching or excavation?

Life Safety Open flame, welding, brazing, or cutting (CAVHS Hot Work Permit required) Flammable gases: propane, butane, acetylene, MAP, storage tanks, etc.

Means of egress obstructed or changed Fire detection or suppression system impaired, defeated, removed, or modified Ceilings tile removal Temporary construction partitions (fire resistive and smoke tight and proper location) Combustible materials storage on the worksite Wall or floor penetrations through fire rated barriers? (Complete Penetration Permit – MCM 138-021) Asbestos and Lead-Based Paint Suspect or presumed asbestos containing materials (PACM) Structural member demolition Pipe or joint lagging, packings or gaskets Spray-applied fireproofing Acoustic plaster Decorative plaster: cornice or molding Floor tile, sheet flooring or mastics Existing roofing Transite Ceiling tile moved or removed Drywall and joint compound Unknown

Suspect or presumed lead-based paint Cutting, grinding, or burning any painted surfaces Unknown

Infection Control, Industrial Hygiene, and IAQ Dusty operations – exterior Heavy equipment

Location of nearest air intakes:

Select the "construction / renovation project type" from the table below:

Type A Type B Type C Type D 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

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

requires heavy demolition or removal of a complete cabling system new construction.

Enter "Construction Project Type": ______

Identify the "patient risk groups" that will be affected from the table below. If more than one risk group will be affected, select the higher risk group. If unable to identify the risk group then enter the unit location(s).

Low Risk Medium Risk High risk Highest Risk Office areas Corridors Engineering spaces Unoccupied units

Cardiology Echocardiography Endoscopy Nuclear Medicine Physical Therapy Radiology/MRI Respiratory Therapy Occupational therapy General store rooms Linen storage area Medical outpatient Cafeteria seating areas Waiting Rooms

Emergency Department General

Radiology/CT/MRI (not interventional)

Post Anesthesia Care Units / Recovery Rooms

MICU/SICU

Nuclear Medicine Physical Therapy

Hydrotherapy Kitchen /Galley areas Echocardiography Laboratories Laundry Surgical Outpatient areas

Areas caring for immunocompromised patients

Oncology outpatient Radiation Oncology Operating rooms Central sterile supply Cardiac cath. and

Interventional radiology Dialysis Anesthesia areas Pharmacy admixture area Same day surgery

All general patient care units

General pharmacy Enter "patient risk group" (if unknown enter unit location(s)):

Transmission of Tuberculosis (TB): Does the construction site require Contractors to have TB screening? (Infection Prevention Control to Determine)

Determine Construction "Project Class":

Match the Patient Risk Group (Low, Medium, High, Highest) with the planned Construction Project Type (A, B, C, D) on the following matrix, to determine the construction project class (I, II, III or IV)

Construction Project Type Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III/IV IV

HIGHEST Risk Group II III/IV III/IV IV

Enter "project class": ___________________________

Identify the areas surrounding the construction / renovation project Location / Unit below:

Location / Unit above:

Locations / Units lateral:

Other potentially affected areas:

IT work Wire pull Quad installation

Ceiling tile removal Single tiles – visual inspection only Intermittent tiles – for wiring Multiple tiles – significant ceiling work

HVAC system impaired, defeated, removed, or modified Need to recirculate air from site to other areas (i.e., not able to vent to outside) Construction workers travel through direct patient care areas to enter/exit site Debris will be move through hallways or patient care areas Patients will travel past or through the construction area

Identify any containment measures in current construction plans i.e., type of barriers (solid wall / plastic), HEPA filtration, negative air etc. for dust containment:

Positive pressure isolation or negative pressure isolation rooms affected by the project

List room numbers and dates out-of-service

Mold risk present (evidence of leaky pipes, wet surfaces, or wall cavities) Small isolated area 10 sq. ft or less Mid-sized isolated area 10-30 sq. ft Large isolated area 30-100 sq. ft Extensive contamination of mold

Legionella risk (piping, hot water tanks, stagnant water or water storage devices affected)

Cooling towers affected

Location and location of nearest air intakes

Plumbing, service taps or water hoses affected

Describe backflow prevention

Hazardous materials (Safety Data Sheet must be provided for all chemicals) Solvents Paints, varnishes, polyurethanes, or epoxies Adhesives Roofing coal tar related products Chemical strippers Corrosives or caustics Compressed gases Odorous materials or irritants:

Hazardous materials not otherwise listed:

Laboratories: chemical, biological, radiological Local ventilation systems: fume hood, biological safety cabinet, glove box, slot hood, canopy Underground storage tank removal

Contaminated soils or ground water

Utilities impacted Hazardous energy sources: electrical, mechanical, pneumatic, hydraulic, etc.: Lockout/Tagout Electrical shut-off Water supply compromised Oxygen or other medical gas shut-off Suction shut-off Underground utilities

Radioactive materials and X-rays Radioactive materials currently used in the project area Radioactive materials formerly used in the project area X-ray facility in the project area X-ray facility above, below, adjacent, or across from the project area Accelerator facility in the project area Accelerator facility above, below, adjacent, or across from the project area

Construction Safety Committee Rep Date

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