613-22-128 Replace Steam Main B320 to B500__ISLMPCRA - Copy.pdf

Effective Date 12/3/2024 Replaces v6

Doc. Control

Est. Project Duration

Title Signer/Alternate Extension

Bob Johnston 4400

Cynthia Moore 4574 Beverly Simpson 4875

Title Signer/Alternate Extension

Cynthia Moore 4574 Beverly Simpson 4875 Krista Bowen 4715

Andrew Faust 2567

Project Manager Bob Johnston 4400

David Vess 4006

Bob Johnston 4400

COR signature Date Printed: 12/11/2024

613-22-128

COR / O&M Shop Supervisor Name

COR / O&M Shop Supervisor Ext.

Project Title 613-22-128 Replace Steam Main B320 to B500

Mark Suave, Jason Messick, Sam Powell 3131

Work Location

Project Number or Work Order #

Contractor (or TBD) TBD

Between bldgs B320 and B500

Safety Program

Bob Johnston Krista Bowen 4715

Contractor Supervisor (CO if TBD)

Contractor Contact Number

Est. Project Start Date 3/5/2025

12 months

Extension

ICRA Signers ILSM Signers

Project Description This project involves Contractor services to completely prepare site for building operations, including demolition and removal of existing structures and trees, and furnish labor and materials to perform work for the replacement of the High-Pressure Steam and Condensate piping from Building 320 to Building 500

Signer/Alternate David VessCSMC Chair/Co‐Chair or

Designee

Facilities Management Services

Version: 7Doc Number: VHA‐V05‐613‐FMS‐FORM‐PS‐0002

Project Data At‐A‐Glance

I acknowledge that it is my responsibility to submit signed safety documents to Contracting prior to solicitation .

I certify that all project information is correct and complete to the best of my knowledge. I will ensure the precautions listed in the ICRA and ILSM, including those added by the ICRA and ILSM signers and/or their alternates, will be upheld.

Project Manager Andrew Faust

Eric Gray

Assistant Fire Chief

Title

PCRA Signers

All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

4611/4612Fire

Department

Infection Control Brad ChurchPolice Department 4101

Infection Control

Safety Program

CSMC Chair/Co‐Chair or Designee

VHA Pre-Construction Risk Assessment (PCRA)

PCRA Introductory Information and Instructions

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

Activity Type determined from Table 1: D

613-22-128

613-22-128 Replace Steam Main B320 to B500

Between bldgs B320 and B500 and/or Brief Description:

Activity Name

Number This project involves Contractor services to completely prepare site for building ope

Activity Location:

(Building # and Room # if applicable)

Inspection and/or facility 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

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 finsh 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.

All control measures in CATEGORY A 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 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.

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

CATEGORY C

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 and Description Control Measures

CATEGORY A

PERMIT: See the last page of this document for a fillable permit form to be used for posting at the activity site.

Use this template as a baseline for performing facility Pre-Construction Risk Assessments (PCRA) for Construction, Renovation, and Maintenance work (referred to as the “activity” in this document). The template 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.

Facilities may customize this template to incorporate site-specific information and requirements.

NOTE: This VHA PCRA template pertains specifically to non-infection-related safety for Construction, Renovation, and Maintenance activities. It must be used in conjunction with the VHA Infection Control Risk Assessment (ICRA) for the activity, if required, which specifically addresses infection risks outside the scope of this PCRA.

VHA-PCRA-2023-1.0 Page 2 of 18

All control measures of categories A, B, C 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 paper work 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 ☐

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.

• 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.

All control measures in CATEGORY A, B 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 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.

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

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.

• 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 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

VHA-PCRA-2023-1.0 Page 3 of 18 x x x x

Table 2. Affected Adjacent Area Assessment

Service(s)/Type(s) of Area(s)

(e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc.)* Tunnel from B320 to B310 SW side of B314 Mark Suave 3131 Drive & Dock Area B500

Yes No

○ 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

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:

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

○ 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.):

○ 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).

Construction plan communicated to

POC?

NA

Adjacent Area 2 NA

* 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.

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 ICRA required for the Activity?

Adjacent Area 3 NA

Adjacent Area 4 NA

NA

Adjacent Area 1

Area Below NA

Area Point of Contact (POC) POC Contact Information

Activity Area**

Area Above

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

• 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.

VHA-PCRA-2023-1.0 Page 4 of 18

Pre-Construction Risk Assessment (PCRA) Permit

Project start date Completion date Permit expiration date

Activity Type

Inspection/Upkeep

Small Scale

Large-scale

Yes No

Date

Date

Date

Date

3/5/2025

Is an Infection Control Risk Assessment (ICRA) required for the Activity?

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

Chair, Construction Safety Committee signature or Designee

Project Manager signature

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

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.

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.

*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.

Safety Officer signature

Infection Prevention and Control signature:

This page must be posted at the entrance to the project area for Level III and Level IV activities.

Unique permit # (Project Number or Work order):

Location of construction/renovation/maintenance Between bldgs B320 and B500

Additional requirements:

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

Contact phone number Extension 3131 Contractor TBD

613-22-128

Project manager Mark Suave, Jason Messick, Sam Powell3131

VHA-PCRA-2023-1.0

VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance

Category A

Category B

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):

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.

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.

VHA‐ICRA‐2024‐1.2 Page 6 of 18

Category C

Category D

Figure: Isometric drawing of affected area assessment

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.

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).

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.

VHA‐ICRA‐2024‐1.2 Page 7 of 18

Service(s)/Type(s) of Area(s)

(e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc.)*

Low Risk Medium Risk High Risk Highest Risk Non-patient care areas such as:

Patient care support areas such as:

Patient care areas such as:

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 dafeteria, 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

* 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.

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.

Adjacent Area 3

Adjacent Area 4

* 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):

Adjacent Area 1

Adjacent Area 2

Area Above

Area Below

Area Point of Contact

(POC)

POC Contact Information

Activity Area**

VHA‐ICRA‐2024‐1.2 Page 8 of 18

Table 4 - Level of Infection Prevention and Control Precautions

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

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

Level of Precautions

Level I

Level II

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.

Control Measures

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.

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.

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

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).

VHA‐ICRA‐2024‐1.2 Page 9 of 18

Level III

Level IV

Level of Precautions

Levels I - II

Controls defined below shall be completed upon completion of the activity and inspected prior to terminating measures defined in Table 5.

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.

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.

Measures

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

Table 6 - Minimum Infection Prevention and Control Measures Required Upon Completion of the Activity

VHA‐ICRA‐2024‐1.2 Page 10 of 18

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.

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.

VHA‐ICRA‐2024‐1.2 Page 11 of 18

Project start date Completion date Permit expiration date

Level of Precautions Level I

Level II

Level III

Level IV

Date

Date

This page must be posted at the entrance to the project area for Level III and Level IV activities.

II

3/5/2025

Unique permit number (Project Number):

Location of construction/renovation/maintenance Project manager Contact phone number Extension Contractor

Overall Patient Risk Category 0 0

Infection Prevention and Control signature

Additional requirements:

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

Activity Category

(A, B, C, or D )

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)

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.

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.

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 the VHA ICRA template. These control measures must be maintained continuously 24/7 for the duration of the project. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

Check box to indicate exhaust method: Exterior Alternative Interior Method

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.

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.

Project Manager signature

(Low, Medium, High, or Highest )

Between bldgs B320 and B500

613-22-128

Mark Suave, Jason Messick, Sam Powell3131

TBD

VHA‐ICRA‐2024‐1.2

Appendix A: Alternative To Outdoor Exhaust Requirements

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:

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 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 .

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

VHA‐ICRA‐2024‐1.2

Project Title:

Work Location:

Project Number:

Point of Contact: Extension:

Deficiency:

Start Date: Estimated Duration:

PART I: PROJECT EVALUATION Review each of the following categories and indicate whether each is acceptable to the project/Life Safety code deficiency by checking the appropriate response.

A. EXITS

B. EMERGENCY ACCESS

C. FIRE PROTECTION

D. TEMPORARY PARTITIONS

E. ADDITIONAL FIRE FIGHTING EQUIPMENT and TRAINING

F. COMBUSTIBLE FUEL LOAD LEVELS

G. FIRE DRILLS

H. HAZARD SURVEILLANCE

Project Title Project Number

I. ADDITIONAL PERSONNEL TRAINING

613-22-128 Replace Steam Main B320 to B500

Between bldgs B320 and B500 613-22-128

12 months

1. Does the project/deficiency have the potential of affecting an exit or other components of the means of egress?

N/A

1. Will construction involve the use of temporary partitions?

YES NO

1. Does the project/deficiency have the potential of impairing existing fire alarm, fire detection, or fire suppression systems?

YES NO

YES NO

YES

X

X

Mark Suave, Jason Messick, Sam Po 3131

2. Will temporary fire protection systems be required as part of the project/deficiency?

NO N/A

1. Does the project/deficiency have the potential of obstructing access to emergency departments, services or vehicles?

YES NO N/A

X

N/A X

N/A X

2. Does the project/deficiency have the potential of obstructing access of emergency responders to the construction area?

03/05/25

YES NO N/A

1. Does the area affected by the project/deficiency warrant placement of additional fire protection equipment?

YES NO N/A

X

2. Will additional fire safety training be required of affected personnel?

YES NO N/A

X

1. Does the project/deficiency involve the storage of flammable or combustible materials?

YES NO N/A

X N/A

X

YES NO

YES NO N/A

X

YES NO N/A

2. Contractor or COR is to provide Safety Data Sheets to the Safety Office for all chemicals, cleaning agents, solvents, etc., to be used during project. Has this been done?

YES NO N/A

X

613-22-128 Replace Steam Main B320 to B500 613-22-128

1. Does the project/deficiency warrant additional fire drills?

X

3. Will hazard communication training be provided, including location of spill kits, and advisement to notify Fire Department in the event of spills?

YES NO N/A

X

3. Will alternate exit route be sufficiently marked and lit?

YES NO N/A

X

1. Does the project/deficiency present added hazards, such as: excavations; construction/ chemical storage; or field offices, which warrant increased hazard surveillance?

YES NO N/A

X

2. Does the project/deficiency have the potential of creating flammable or combustible debris?

Facilities Management Services Page 1 of 2

Martinsburg VA Medical Center

Interim Life Safety Measure Permit Effective Date 1/1/2025

Replaces v4

Doc Number: VHA‐V05‐613‐FMS‐FORM‐PS‐0004 Version: 5 Doc. Control

X

2. Will affected exit be used by other than contractor personnel? YES NO N/A

J. FACILITY-WIDE TRAINING

K. FIRE/SMOKE BARRIERS

L. GENERAL SAFETY

M. ACCESSIBILITY

N. UTILITIES

O. Other

1. Will the project present any other potential Life Safety deficiencies or require additional measures?

Construction Safety Committee Chair or Designee - ILSM Evaluator Date

Safety Program Date

Fire Chief Date

Police Service Representative Date

Printed: 12/11/2024 All hard copies should be checked against the current electronic version within the Document Control System and a current version printed for documentation.

1. Will signage be required to limit access to work area?

YES NO N/A

X

PART II: INTERIM LIFE SAFETY MEASURES: Provide a description of all items indicated as applicable in Part I. Explain Interim Life Safety measures or procedures which will then be incorporated into the project.

YES NO N/A1. Will the project involve an operational shutdown or modified operation of utilities?

Confined space work in steam tunnel. Excavation.

X

YES NO N/A

X

YES NO N/A

X

2. Does Personal Protective Equipment and relevant training need to be provided for staff, patients or visitors?

N/A X

3. Does project involve relocation (or changes in designation) of functions or services requiring eyewashes or chemical showers?

YES NO

N/A X

2. Will there be sufficient clearance around the construction site to prevent tripping hazards, falling debris, or other safety concerns?

YES NO

1. Does the project/deficiency have the potential to affect structural features of the fire safety system? X

1. Will the project produce significant noise levels outside the construction site?

YES NO N/A

1. Will the project cause penetrations to be made in Fire/Smoke Barriers?

YES NO N/A

X

2. Will fire/smoke barriers be temporarily sealed with a UL-Listed material filler on both sides of the barrier?

YES NO N/A

X

X

3. Will these temporary UL-Listed material adequately compensate for the penetrations made in the fire/smoke barriers?

YES NO N/A

X

2. Does the project/deficiency have the potential to affect compartmentation features of the fire safety systems?

YES NO N/A

X

1. Does the project/deficiency present Life Safety Code deficiencies or construction hazards, which warrant facility-wide education of personnel concerning these Interim Life Safety Measures?

YES NO N/A

X

Form B

Fill out Supplimental Form C Form C

Project: 613‐22‐128 Replace Steam Main B320 to B500

Projects are to be re‐evaluated prior to construction and every sixty (60) days from initial start of construction to ensure all information is correct, complete, and current. Changes to the work location, construction type, or other factors necessitating any modification to the Infection Control Precautions as listed must be documented below, with approval from Infection Control, Industrial Hygiene, Safety, and Project Section.

Facilities Management Services Page 1 of 1

Project Re‐Evaluation And Review Effective Date 1/22/2016

Replaces v1

Doc Number: VHA‐V05‐613‐FMS‐FORM‐PS‐0005 Version: 2 Doc. Control

Y es N oProject Re-Evaluation Date

COR Signature Date

I II III

Initial and Date Below

Infection Control Industrial Hygiene Project Section Supervisor Safety Program

New Class…