402-23-794 - ICRA.pdf

402-23-794 Modernize Campus Corridors - ICRA

Request #774

Initiated by Abigail CampbellInfection Control Risk Assessment (ICRA)

Togus Submitted 4/30/2026

Safety CSO Approval: Signed by vhatogjensek 6/9/2026

1: Project 1.1: Location *

Main Corridor 1.2: Project COR/Responsible Party (Last, First) *

Abigail Campbell 1.3: Contractor

TBD

1.3.1:

1.4: Start Date *

01/01/2027

1.5: End Date *

01/01/2029

1.6: Add PCRA *

1.6.1: Add SOW *

2: Construction, Renovation, and/or Maintenance Activity Category

2.1: See below for activity type guidance 2.2: Identify the Construction Activity Category * x Category D

2.2.1: Category A: Inspection and/or facility upkeep.

Includes, but is not limited to: 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 within the shift. (Not to exceed an hour for each tile) Minor interior updates that do not create dust or debris: replacing floor or ceiling tiles, carpentry work, hanging signage, and painting without sanding.Limited building system maintenance: plumbing on potable systems limited to faucet replacement etc. and electrical

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work such as replacement of bulbs, receptacles or switches.

2.2.2: Category B: General maintenance and repair work.Includes, but is not limited to:Prolonged inspection and work that may take longer than a single shift but not exceed a week.Patients and employees are not to be in the area until activity is completed. Work 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. Control sanding activities

(wet/dry) 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 light fixture that produces minimal dust and debris. Air Handles 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.

2.2.3: Category C: Small-scale construction, renovation, or maintenance.Includes, but is not limited to: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.

2.2.4: Category D: Large-scale construction, renovation, or maintenance. Includes, but is not limited to: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: > new medical gas systems, > steam/heating hot water, condensate systems, >

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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.

3: Affected Area Assessment

3.1: Identify the areas and associated patients that will be affected.* 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.*** For LARGE-SCALE/FACILITY wide: Activity Area - Facility wide - (POC) COR - COR email - COR Phone * Area Service(s)/Type(s) of Area(s) Point of Contact

(POC)

POC Email POC Phone

**Activity Area Campus Corridors Mark Roberts mark.roberts6@va.gov 207-623-8411

4: Patient Risk Category

4.1: Identify the patient risk category for each area affected.

Select the one with the greatest risk as the overall Patient Risk Category.

4.1.1: Non-patient care areas such as:Public hallways and gathering areas not in clinical areas. Office areas not in clinical areas.Breakrooms not in clinical areas.Bathrooms or locker rooms not in clinical areas.Mechanical/electrical rooms not in clinical areas.

x Low Risk 4.1.2: Patient care support areas such as:

Waiting areas.Clinical engineering (biomedical)Materials management.Sterile processing department - dirty sideKitchen, cafeteria, gift shop, coffee shop, and food kiosks.

4.1.3: Patient care areas such as:Patient care rooms and areas, including spinal cord injury unitsAll acute care units, including mental healthAll outpatient units and clinicsEmergency departmentCommunity Living Centers, domiciliaries, and transitional residencesEmployee healthPharmacy – general work zoneMedication rooms and clean utility roomsImaging suites – diagnostic imagingLaboratory

4.1.4: Procedural, invasive, sterile support and highly compromised patient care areas such as:All transplant unitsAll intensive care unitsAll oncology units and chemotherapy/infusion centersOR theaters and restricted areasHemodialysis unitsProcedural rooms*Pharmacy compounding areaSterile processing department – clean sideTransfusion servicesImaging suites – interventional imagingDedicated isolation wards/units for infectious diseases

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Procedural, invasive, sterile support and highly compromised patient care areas such as:All transplant unitsAll intensive care unitsAll oncology units and chemotherapy/infusion centersOR theaters and restricted areasHemodialysis unitsProcedural rooms*Pharmacy compounding areaSterile processing department – clean sideTransfusion servicesImaging suites – interventional imagingDedicated isolation wards/units for infectious diseases continued

4.1.4.1: Procedural RoomsFor patient care activities that may require high-level disinfected or sterile instruments and some environmental controls. Not required to be performed with the environmental controls of an operating room (OR).

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. *

4.1.4.1.1: *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.

5: Level of Infection Prevention and Control Precautions 5.1: Activity Category * x D 5.2: Patient Risk Category * x Low 5.3: Activity and patient risk category * x D - Low Risk 5.4: *

5.5: *

5.6: * x Level of Precaution: III 5.7: *

5.8: An infection prevention and control permit is required for Level III and Level IV. * x Prepare permit 5.9: Consult with Infection Prevention and Control for Level I and II. *

6: Required Infection Prevention and Control Measures, by Level of Precautions 6.1: Level of Precautions *

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Level of Precautions continued * x Level III

6.2: Control Measures for Duration of the Activity

6.2.1: 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.

6.2.2: 4. 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).

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

6. 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. 7. 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.8. Seal doors to prevent dust migration.9.

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.10. 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.11. 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.12.

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

6.2.3: 14. Ensure availability of equipment for cleaning hands.15. 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.16. 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.17. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop if applicable for barrier type).18. 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

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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.19. 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.

6.2.4: 20. Barriers must be hard barriers unless temporary to install final barrier.21. Containment must include an anteroom to ensure pressure control. Anteroom must be large enough for equipment staging, cart cleaning, workers’ PPE and cleaning.22. 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.23. 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.

6.3: Minimum Measures Required Upon Completion of the Activity

6.3.1: 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 the 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.

6.3.2: Construction areas must be inspected by an infection prevention and engineering representative (and others) 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 of hard) barrier removal activities must be completed in a manner that prevents dust

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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-help 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 completions 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.

6.4: Appendix A: Alternative To Outdoor Exhaust Requirements

6.5: 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:

6.6: If the facility is not able to exhaust to the building exterior

6.7: 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

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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.

7: Description 7.1: Describe activity and identify specific site of activity, e.g., patient rooms, medication room, etc. *

Construction activity will take place in the main campus corridors from building B209 to B221. Full renovation including selective demolition and installation of new finished and fixtures.

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7.2: Identify issues related to: ventilation, plumbing, electrical, in terms of the occurrence of probable outages. *

Power outages to tie in new electrical fixtures (lighting) HVAC outages to tie in new heating/cooling fixtures.

7.3: Identify containment measures using prior assessment. What type of barriers, e.g., solid wall barriers? Will HEPA filtration be required? (Note:

Renovation/construction area shall be isolated from the occupied areas during construction.) *

Construction areas will have solid wall barriers with HEPA filtration.

7.4: Consider potential risk of water damage. Is there a risk due to compromising structural integrity, e.g., wall, ceiling and roof? *

No/Low Risk

7.5: Work hours: Can or will the work be done during non-patient care hours? * x No

7.6: Include negative pressure plan:

7.6.1: How many negative pressure machines? *

7.7: Are sinks present? * x No 7.7.1: Specify Number of Sinks

7.8: Describe plans relative to clean and soiled utility rooms.

Clean and Soiled utility rooms should see little impact.

7.9: Describe the following containment issues and plan to discuss with the project team: traffic flow, housekeeping, debris removal (how and when). * Traffic Flow Housekeeping Debris Removal

TBD this will need to be determined during phasing meetings w/ contractor

Captured in project specifications Captured in project specifications

8: Water 8.1: Water Shutdown * x No 8.1.1: Days *

8.1.1.1: Flush

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9: For Infection Prevention and Safety Use ONLY

9.1: For Infection Prevention and Safety Use ONLY

9.2: Upload permit if level III or IV.

* = required field

Infection Control Risk Assessment (ICRA) 10This form was generated by LEAF on 6/30/2026