516-CSI-142 Statement of Work Con .docx

Statement of Work ED CT Replacement– BUILDING 100 Project 516-CSI-142 Bay Pines VA Health Care System (516)

B.1 INTRODUCTION:

This requirement is for Construction Services for Project 516-CSI-142 “ED CT Replacement– BUILDING 100” at VA Medical Center, in accordance with items specified herein. The contractor shall provide all labor, material, equipment, and supervision to construct an approximately 790 SF addition to Bldg. 100 for the ED CT Replacement in accordance with plans and specifications. This will include but not limited to; removal and replacement of CT scanner equipment in room 1E-210 and associated support spaces, to be renamed suite 1E222. The space is in Area H between E-F & 6-8. As the area serving the CT scanner will be increasing, additional lead lined walls will be required. The gantry and patient table will be supported directly by the 1st floor, while other ceiling hung equipment will need to be structurally supported to the 1st floor interstitial framing.

B.2 BACKGROUND / DESCRIPTION OF WORK:

· The project enlarges the CT Scan Room 1E210 to capture additional space from adjacent toilet room and waiting room areas. The new Room 1E210 area is 503 SF.

· A remaining portion of the waiting room will be enclosed to create a new 74 SF Closet accessed via the existing door from the adjacent Control Room (1E210C).

· All work will be limited to inside of the renovated rooms to facilitate continuing functions of the ED in surrounding adjacent spaces. The construction area will be properly sealed off per ICRA requirements.

· All work will be limited to inside of the renovated rooms to facilitate continuing functions of the ED in surrounding adjacent spaces. The construction area will be properly sealed off per ICRA requirements.

· Existing scanner equipment will be removed by the owner’s equipment vendor.

· Existing toilet room walls, door, floor, ceilings and fixtures will be removed.

· Existing waiting room area doors and an interior sliding glass transaction window will be removed.

· The solid surface transaction counter on the waiting room side of the transaction window will also be removed. At removal locations, walls will be infilled and both sides finished to match existing adjacent finishes including those surfaces in the corridor and Control Room.

· New 2x2 acoustical tile ceiling will replace the existing ceiling at the same 8’-6” and 9’-0” heights in CT scan and Closet, respectively.

· New partitions will meet shielding requirements for the new CT Scanner. Shielding will be added to existing perimeter walls to meet the requirements for a fully shielded perimeter around the new equipment. New doors, frames and control room observation window will all require lead-lined and other radiation-shielding provisions to meet the minimum requirements of applicable project specific physicist analysis, testing and reports.

· As the anchor locations for the new CT scanner are anticipated to be in different locations than the existing, GPR scanning shall be utilized to ensure that the installation of post-installed anchors will not cut any floor slab reinforcement. If rebar is found where a post-installed anchor is located, then the CT scanner location may need to be adjusted slightly to avoid cutting the rebar.

· All above ceiling equipment and the bariatric 770lb patient lift will need to have hangers attached to Unistruts spanning to the interstitial space steel beams to ensure adequate bracing to limit horizontal movement of the equipment.

· The existing sprinkler heads will be turned up during construction with any modifications required to accommodate the new floor plan layout of the CT Room and supporting spaces. The A/E will inquire with the AHJ whether the ceiling-grid mounted heads should be replaced. The sprinkler heads in areas with existing gypsum board ceilings will be removed and replaced during the demolition/construction period. Sprinkler head locations will be adjusted for full coverage of the new floor plan configuration. Hydraulic calculations shall be performed by the Fire Protection Engineer/Contractor to ensure adequate protection for the new floor plan layout.

ICRA Level IV requirement:

Refer to VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance. Nonporous materials should be use as barriers.

B.3 CONSTRUCTION DOCUMENT:

Contractor shall furnish all labor, equipment, certification, supervision, and materials necessary to perform all operations in connection with this contract. Contractor shall perform work in strict accordance with the General Specifications, Statement of Work, and all other supporting documents.

B.4 SPECIFICATIONS:

The VA Master Construction Specifications contain work procedures and material requirements designed to meet regulatory compliance requirements.

A. In the case of any differences, the specifications will govern over the drawings. Any discrepancies should be brought to the immediate attention of the Contracting Officer and COR for clarification. Any errors or omissions in the contract drawings or specifications must be provided promptly by the Contractor to the COR, but in no case later than the start of related work.

B.5 SPECIFIC REQUIREMENTS: General requirement spec section 01 00 00 A. The contractor shall provide constructions services in accordance with the attached specifications and construction documents.

B. This requirement will include but will not be limited to preparation and/or performance for, submittals, change orders, field investigations, site visits, meetings and providing construction meeting minutes to the VA COR scheduling, infection control measures, and other related information and services.

C. The existing sprinkler heads will be turned up during construction with any modifications required to accommodate the new floor plan layout of the CT Room and supporting spaces.

D. Shut down request should be schedule with minimum of three (3) weeks’ notice.

B.6 CONFORMANCE STANDARDS:

All construction accomplished pursuant to this contract shall comply with the latest edition of the following documents unless the contractor is directed otherwise by the Contracting Officer. Any exceptions shall be approved in writing by the Contracting Officer prior to construction startup.

1. VA Master Construction Specifications – VA Technical Information Library link: https://www.cfm.va.gov/til/spec.asp#01

2. VA Construction Standards

3. NFPA 101, Life Safety Code

4. NFPA 70, National Electric Code

5. NFPA 99, Health Care Facilities

6. International Building Codes

7. State and Local codes and guidelines (as applicable)

B.7 HOURS OF COVERAGE:

Normal hours of operation are Monday through Friday from 7:00 am to 5:00 pm EST time. All work is expected to be performed generally on normal hours of coverage unless requested or approved by the COR or his/her designee.

A. Before commencement of work, the Contractor shall confer with the VHA COR and Contracting Office to agree on a sequence of procedures; means of access to premises and building. All work performed, to include delivery of materials and equipment, shall be made with minimal interference to Government operations and personnel.

B. Federal Holidays observed by Veterans Health Administration are:

1. Federal Holidays are as follows:

For actual dates observed, see the following link:

https://www.opm.gov/policy-data-oversight/pay-leave/federal-holidays/

B.8 IDENTIFICATION, PARKING, NO SMOKING, & VA REGULATIONS:

The Contractor's FSEs shall wear visible badge identification issued by VAHCS Police Section at all times while on the premises of VAHCS. It is the responsibility of the Contractor to park in the appropriate designated parking areas. Information on parking is available from the VA Police Section. VAHCS shall not invalidate or make reimbursement for parking violations of the Contractor under any conditions. Smoking is strictly prohibited anywhere on the Veterans Affairs Health Care Facilities, to include main facility, and any other buildings at or on the premises. Possession of weapons is prohibited. Enclosed containers, including tool kits, shall be subject to search. Violations of VA regulations may result in citation answerable in the United States (Federal) District Court, not a local district, state, or municipal court.

B.9 INFORMATION SECURITY:

In accordance with Appendix A, Handbook 6500.6 Checklist blocks 7, the C&A requirements do not apply to this requirement, and Security Accreditation Package is not required. The nature of this requirement is technical; however, there is no information to be protected.

B.10 POINTS OF CONTACT AND PHYSICAL LOCATION:

Access to worksite shall be coordinated through COR.

CC.W. Bill Young VAMC, Bay Pines VAHCS 10000 Bay Pines Blvd, Bldg. 24 3rd Floor, Bay Pines, FL 33744 COR will be appointed at time of award via COR Delegation Memo.

B.11 PERIOD OF PERFORMANCE:

Commencement of work shall begin within 10 days of receipt of written Notice to Proceed (NTP) and should last no longer than a duration of 180 calendar days after date NTP is issued.

B.12 SUBMITTALS:

A. Contractor shall submit all required material/shop drawing submittals to the Contracting Officer within 10 calendar days of award, or as agreed to by the Contracting Officer for approval. No materials shall be installed prior to approval.

Approval by COR is required.

B. All material submittals and shop drawings shall have the Project Title, Project Number, and Contract number clearly indicated.

C. Material submittals and shop drawings shall be checked and signed by the Contractor’s Quality Control Manager prior to submission to the Government.

D. Submittals shall be legible and shall include all technical data needed to verify that the item meets requirements of listed specifications, and applicable codes.

E. Contractors shall utilize Material Approval Submittal (or similar template) for use as cover sheet when submitting to Government for approval. Forms shall be provided to contractor at post-award, pre-construction conference.

B.13 COMMENCEMENT, COMPLETION, AND PAYMENT FOR WORK: The Contractor shall be required to commence work required at the time specified on the Notice to Proceed (NTP), execute the work, and complete the entire work not later than the completion time specified on the NTP. The time stated for completion shall include final cleanup of the premises. At the government’s option, it may choose to specify a two-stage performance period. For example, separating material lead-time from construction days can considerably decrease the length of time occupied buildings are inconvenienced by construction.

A. Before commencement of work, the Contractor shall confer with the VA COR and Contracting Office to agree on a sequence of procedures; means of access to premises and building; space for storage of materials and equipment; delivery of materials and use of approaches; use of corridors, stairways, elevators, and similar means of communications; location of partitions, eating spaces, and restrooms for the Contractor employees; and the like. Delivery of materials and equipment shall be made with minimal interference to Government operations and personnel.

B. The Contractor shall be paid monthly upon submission of proper invoices for work completed. If the performance period exceeds 30 days and a progress schedule (approved by the Government) has been submitted, partial payment(s) may be authorized. Final payment shall be withheld until all discrepancies are corrected and as-built drawings are approved by the Government.

C. The contractor shall coordinate no less than weekly progress meetings with the COR and/or Contracting Officer to discuss at a minimum; progression of work, projected progress versus actual progress, action items due from the contractor, submittals, invoicing, payroll submission and associated 1413’s, change order request, RFI’s, safety action items due from the government, and any other significant issues that require attention. The contractor also shall document the meeting minutes and forward a signed copy to the COR for concurrence of the documentation. Copies of all minutes shall be forwarded to the Contracting Officer and COR. In the event of any discrepancies, the Contracting Officer or COR shall be notified immediately for clarification. Contractor shall use the Meeting Minutes form (or similar template) provided for use at the post-award, pre-construction conference.

B.14 MODIFICATIONS:

Modifications for this project shall be submitted to the assigned COR who shall then submit a formal request to the Contracting Officer (CO). Work, time, cost, or scope changes are not allowed to commence prior to Contracting Officer’s signed and/or written approval via fully executed Standard Form (SF) 30 modification.

B.15 GENERAL REQUIREMENTS FOR PRIVIACY INFORMATION:

a. Information Systems Officer, Information Protection: The contractor will not have access to VA Desktop computers, nor will they have access to online resources belonging to the government while conducting services.

b. Privacy Officer: The contractor will not have access to Patient Health Information (PHI) nor will they have the capability of accessing patient information during the services provided to the VA.

c. Records Manager: There will be no federal records created, maintained, used or dispositioned with this contract; regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.].

B.16 RECORD MANAGEMENT OBLIGATIONS LANGUAGE

A. Applicability This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

B. Definitions “Federal record” as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

The term Federal record: includes Bay Pines VA Healthcare System records. Does not include personal materials. Applies to records created, received, or maintained by Contractors pursuant to their Bay Pines VA Healthcare System contract. may include deliverables and documentation associated with deliverables.

C. Requirements

1. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

2. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

3. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

4. Bay Pines VA Healthcare System and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of Bay Pines VA Healthcare System or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to Bay Pines VA Healthcare System. The agency must report promptly to NARA in accordance with 36 CFR 1230.

5. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the contract. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to Bay Pines VA Healthcare System control, or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the contract. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

6. The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and Bay Pines VA Healthcare System guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

7. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with Bay Pines VA Healthcare System policy.

8. The Contractor shall not create or maintain any records containing any non-public Bay Pines VA Healthcare System information that are not specifically tied to or authorized by the contract.

9. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

10. The Bay Pines VA Healthcare System owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which Bay Pines VA Healthcare System shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

11. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take [Agency]-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

Note: To the extent an agency requires contractors to complete records management training, the agency must provide the training to the contractor.] D. Flow down of requirements to subcontractors

1. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this [contract vehicle], and require written subcontractor acknowledgment of same.

2. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE

VA INFORMATION CUSTODIAL LANGUAGE:

a. Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

b. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

c. A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

d. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

SECURITY INCIDENT INVESTIGATION:

a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

b. To the extent known by the contractor/subcontractor, the contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law.

enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

LIQUIDATED DAMAGES FOR DATA BREACH:

a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

b. The contractor/subcontractor shall provide notice to VA of a “security incident” as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

SECURITY CONTROLS COMPLIANCE TESTING:

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-days’ notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time.

Contractor will be required to comply with physical security guidelines by either checking in with the VA Police each time they come on-site to perform contracted services or by obtaining a VA Contractor ID badge from the VA Police.

Contractor may not have access to any VA sensitive information under this contract. Contractor must be escorted at all times while performing work in sensitive areas with patient information.

Each Contractor employee must be escorted at all times by a VA employee (or)Contractor employee working on-site must complete training course “VA Privacy and Information Security Awareness and Rules of Behavior”

VA ACQUISITION REGULATION SOLICITATION PROVISION AND CONTRACT CLAUSE

B.17 ACRONYMS:

A. ABAAS - Architectural Barriers Act Accessibility Standard B. ADAAG - Americans with Disabilities Act Accessibility Guidelines.

C. AIA - American Institute of Architects' AIA D. CAC - Certified Asbestos Consultant E. CADD - Computer Aided Design and Drawing F. CO - Contracting Officer. The Federal employee who is warranted by the Government to enter into contracts on behalf of the Government and is the only person authorized to make changes to those contracts.

G. COR - Contracting Officer's Representative. Individual designated by the CO to place orders, furnish technical guidance, advice, certify invoices, and provide general supervision of the work performed under the executed contract.

H. EOSH - Environmental and Occupational Safety and Health I. EPA - Environmental Protection Agency J. FSE - Field Service Engineer K. HIPAA - Health Insurance Portability and Accountability Act of 1996 L. ICRA - Infection Control Risk Assessment M. IPRM - Information Protection Risk Management N. ILSM - Interim Life Safety Measures O. ISO - International Standards Organization P. LBVAHCS - Long Beach VA Health Care System Q. MOU - Memorandum of Understanding R. NFPA - National Fire Protection Association S. NTP - Notice to Proceed T. OEM - Original Equipment Manufacturer U. OSHA - Occupational Safety and Health Administration V. SF - Standard Form W. SME - Subject Matter Expert X. SOW – Statement of Work Y. TIL – Technical Information Library Z. TWA - Time-Weighted Average AA. VA – Veteran Affairs AB. VAHCS – Veteran Affairs Health Care System AC. VHA - Veterans Health Administration

(END OF SOW)

image1.jpeg image2.emf

VHA ICRA-1.3 (Jan 3 2025).pdf

VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance

VHA ICRA-1.3 (December 2024) Page 1 of 7

Introductory Information and Instructions Use this template as a baseline for performing facility Infection Control Risk Assessments (ICRAs) for construction, renovation, and maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity types and patient risk to determine the level of precautions needed to prevent infection risks. Facilities may customize this template to incorporate site-specific information and/or to add more stringent criteria.

This VHA ICRA template pertains specifically to infection prevention. It must be used if required by the VHA Pre-Construction Risk Assessment (PCRA) for the activity. NOTE: The PCRA addresses other activity-related safety concerns (e.g., vibration, noise, hazardous materials) outside the scope of the

ICRA.

To complete the template:

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.

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

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 basic plumbing on potable systems (e.g., faucet replacement) or basic electrical work such as replacement of light bulbs, receptacles, or switches.

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.

VHA ICRA-1.3 (December 2024) Page 2 of 7

• 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.

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.

• 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.

D

Large-scale construction, renovation, or maintenance generally defined as follows:

• Work exceeding 6 months in duration.

• 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.

VHA ICRA-1.3 (December 2024) Page 3 of 7

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).

Figure: Isometric drawing of affected area assessment

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

Processing, Administrative, etc.)*

Point of Contact (POC) POC Contact Information

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.

** 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.

VHA ICRA-1.3 (December 2024) Page 4 of 7

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.

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

Low Risk

Non-patient care areas such as:

Medium Risk

Patient care support areas such as:

High Risk

Patient care areas such as:

Highest Risk

Procedural, invasive, sterile support and highly compromised 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

• Waiting areas

• Clinical engineering (biomedical)

• Materials management

• Sterile processing department – dirty side

• Kitchen, cafeteria, gift shop, coffee shop, and food kiosks

• Patient care rooms and areas, including spinal cord injury units

• All acute care units, including mental health

• All outpatient units and clinics

• Emergency department

• Community Living Centers, domiciliaries, and transitional residences

• Employee health

• Pharmacy – general work zone

• Medication rooms and clean utility rooms

• Imaging suites – diagnostic imaging

• Laboratory

• All transplant units

• All intensive care units

• All oncology units and chemotherapy/infusion centers

• OR theaters and restricted areas

• Hemodialysis units

• Procedural rooms*

• Pharmacy compounding area

• Sterile processing department – clean side

• Transfusion services

• Imaging suites – interventional imaging

• Dedicated isolation wards/units for infectious diseases

* 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, and are not limited to, Cardiac Catheterization Suites, Electrophysiology Suites, Endovascular/GI Suites, Angio Suites and other spaces which may have high risk patient populations.

VHA ICRA-1.3 (December 2024) Page 5 of 7

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.

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

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.

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.

Level of Precautions

Control Measures

Level I 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.

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.

Patient Risk

Activity Category

A B C D

Low Risk I II II III

Medium Risk I II III IV

High Risk I II IV IV

Highest Risk II III IV IV

VHA ICRA-1.3 (December 2024) Page 6 of 7

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, or comply with the alternative method outlined in Appendix A of this document. These control measures must be maintained continuously 24/7 for the duration of the project. HEPA filtered exhaust if discharged directly to the outdoors must be at a distance of 25 feet or greater from entrances, air intakes and operable windows. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

6. 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.

4. 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.

VHA ICRA-1.3 (December 2024) Page 7 of 7

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.

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.

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.

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 or hard) barrier removal activities must be completed in a manner that prevents dust 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-held 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 completion 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.

VHA ICRA-1.3 (December 2024)

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.

Unique permit number:

Location of construction/renovation/maintenance

Project manager Project start date

Contact phone number 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)

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. 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.

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…