Attachment 3 PCRA-ILSM-Form (rev. 6-22-21).pdf

Pre-construction Risk Assessment PCRA

Orlando VA Medical Center (OVAMC)

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Project Title: Project Number:

Competent Person (CP): Date:

In-House or contracted Out:

CP Qualifications:

Scope of Project:

Low Risk Medium Risk High Risk Highest Risk

▪ Offices or

Conference/

Education

Rooms in

Non-Clinical areas

**For offices in clinical areas, (e.g.

conference room on 3W ICU) follow the risk level for that specific area

▪ Cardiology

▪ Echocardiography

▪ Endoscopy

▪ Nuclear Medicine

▪ Physical Therapy

▪ Radiology/MRI

▪ Respiratory Therapy

▪ DOM

▪ Rehab

▪ PV, Etc

▪ Outpatient Clinic

Exam Areas

▪ Medical Units

▪ Emergency Room

▪ Interventional

Radiology

▪ Laboratories

(specimen)

▪ Dialysis

▪ Minor Surgery

▪ Pharmacy

▪ Post Anesthesia Care

Unit

▪ Surgical Units

▪ CLC

▪ Cardiac Cath Lab

▪ Central Sterile Supply

▪ Intensive Care Units (ICU)

▪ Oncology

▪ Operating rooms

▪ Sterile Processing (SPS)

▪ Pharmacy Compounding areas

DE-ESCALATION CHECKLIST – (IF APPLICABLE)

FINAL INSPECTION (END OF PROJECT):

Infection Control has inspected and approved barrier removal:

Date: ________________ IC staff initials _________________

PATIENT RISK GROUP

Please check all applicable boxes.

___ 1. Dust-producing construction activities are complete.

___ 2. Construction debris/ waste has been removed.

___ 3. Area has been cleaned of all dust AND inspected by Infection Control or Safety.

___ 4. Infection Control or Safety staff approval for removal of negative air or other de-escalation: Date: _________________ Initials: ______________

___ 5. New PCRA classification

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CONSTRUCTION RISK REDUCTION PLAN

Location of Construction: Project Start Date:

Contractor Performing Work: Estimated Duration:

CONSTRUCTION ACTIVITY IC RISK GROUP

Type A: Inspection, non-invasive, minor Low Risk

Type B: Small scale, short duration, moderate levels. Medium Risk

Type C: Moderate to high level of dust. High Risk

Type D: Major demolition and construction projects. Highest Risk

**NOTE: If mold is discovered, stop work and notify COTR

Immediately!

See Appendix A for additional requirements.

RISK ASSESSMENT MATRIX: IC GUIDELINES FOR CONSTRUCTION

TYPE A

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

▪ removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet

▪ painting (but not sanding)

▪ wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

TYPE B

Small scale, short duration activities which create minimal dust

Includes, but is not limited to:

▪ installation of telephone and computer cabling

▪ access to chase spaces

▪ cutting of walls or ceiling where dust migration can be controlled.

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not limited to:

▪ sanding of walls for painting or wall covering

▪ removal of floor coverings, ceiling tiles and casework

▪ new wall construction

▪ minor duct work or electrical work above ceilings

▪ major cabling activities

▪ any activity that cannot be completed within a single work shift.

TYPE D

Major demolition and construction projects

Includes, but is not limited to:

▪ activities which require consecutive work shifts

▪ requires heavy demolition or removal of a complete cabling system

▪ new construction.

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Description of Required Infection Control Precautions by Class

Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II

MEDIUM Risk Group I II III IV

HIGH Risk Group I II IV

HIGHEST Risk Group II IV

During Construction Project Upon Completion of Project

C L

A S

S I

1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace a ceiling tile displaced for visual inspection

C L

A S

S I

I

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area

6. Remove or isolate HVAC system in areas where work is being performed.

1. Wipe work surfaces with disinfectant.

2. Contain construction waste before transport in tightly covered containers.

3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

4. Remove isolation of HVAC system in areas where work is being performed.

C L

A S

S I

II

1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

4. Contain construction waste before transport in tightly covered containers.

5. Cover transport receptacles or carts. Tape covering unless solid lid.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and

Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Department.

2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with disinfectant.

5. Remove isolation of HVAC system in areas where work is being performed.

C L

A S

S I

V

1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

4. Seal holes, pipes, conduits, and punctures appropriately.

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a

HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.

7. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services

Department.

1. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

2. Contain construction waste before transport in tightly covered containers.

3. Cover transport receptacles or carts. Tape covering unless solid lid

4. Vacuum work area with HEPA filtered vacuums.

5. Wet mop area with disinfectant.

6. Remove isolation of HVAC system in areas where work is being performed.

III

III III

III

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INITIAL STEPS:

1. Identify the source of moisture (see the table below for clean/contaminated categories)

2. Halt further intrusion by repairing the water leak

3. Use moisture detection equipment to evaluate the extent of moisture intrusion (e.g. moisture meter, infrared camera, borescope).

4. Determine how long materials have been wet.

a. If less than 72 hours and Category 1 flood water, attempts to dry materials are acceptable using HEPA wet vacs, air movers, dehumidifiers.

b. If more than 72 hours, wet/ absorbent items must be removed and discarded. The presence of mold should be assumed.

c. If time frame is unknown, treat as wet for more than 72 hours

Category of Flood Water

Caused by

Category 1- Clean water

1. Clean water from a sink overflow,

2. broken water or steam line,

3. rainwater infiltration (roof leak)

4. Condensation

Category 2 – Gray Water

1. treated cooling water,

2. some surface water,

3. fire suppression systems,

4. Discharged water from sinks, washers, etc

Category 3 – Black Water

1. water from sewers,

2. storm drain back ups

3. some surface water

(highly contaminated water)

GUIDELINES TO ADDRESS WATER INTRUSION

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Description of Required Response Procedures for Water Intrusion

Water Intrusion Work Practice Level W-1

1. Non-Porous Surfaces and Hard Surfaces and

Floors:

• remove water as indicated above and mop with floor cleaner.

2. Overhead fixtures and equipment with trapped water:

• open to air, wipe down and dehumidify.

3. Porous Surfaces:

Carpet / Textiles / Fibrous

Coverings

• If wet greater than 72 hours or time frame is unknown, discard and replace porous materials.

• If wet less than 72 hours, determine salvageable status and follow procedure below

• Extract water if possible, disengage carpet and remove pad;

• secure carpet to original tack strips and/or elevate without pad and apply drying procedures (i.e. fans/dehumidification);

• check floor and carpet moisture content and re- install carpet when dried; and,

• complete final carpet or upholstery cleaning to limit microbial growth and development of odors.

4. Wallboard / Hard- line

Ceilings: IMPORTANT ensure all electrical and supply conveyance systems are de-energized

• If wet greater than 72 hours or time frame is unknown, remove all sheetrock to 6 inches beyond the high-water mark and apply drying procedures to area

• In the absence of insulation, and if wet less than 72 hours, may be dried in place.

Open areas (ports) per stud spacing to ventilate

• apply drying procedures; and,

• check for moisture content post drying

• patch/paint over wall ports when appropriately dried

5. Pipe Insulation (overhead):

• open the area to ventilate space;

• remove pipe insulation;

• apply drying procedures to space;

• replace pipe insulation with new material; and, Response Procedures For Water Type Matrix

Patient

Risk

Group (IC)

Category I

(Clean water)

Category II

(Gray water)

Category III

(Black water)

Low Risk W-1 W-2 W-3

Medium Risk W-1 W-2 W-3

High Risk W-1 W-3 W-3

Highest Risk W-1 W-3 W-3

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• replace coverings.

6. Drop Ceilings: • replace wet ceiling tiles.

7. Paper / Files: To be determined based on scenario i.e. amount of water, importance of files.

Water Intrusion Work Practices Level W-2 All persons working in and around Category II (Gray) water during the initial stages of response and prior to completion of cleaning and restoration should be equipped with PPE including but not limited to the following:

• industrial- grade rubber gloves;

• full eye/splash protection (goggles);

• protective suit;

• rubber boots; and,

• hard hat if overhead hazards exist.

Non-Porous Surfaces, Hard Surfaces and Floors:

• remove water as indicated above;

• remove and dispose if penetration is observed (buckling, warping, or bubbling),;

• clean and disinfect sub- floor with EPA-approved disinfectant; and,

• flush clean cracks if floor is intact, (pressure wash) with EPA-approved disinfectant and recover with HEPA filtered extraction unit (use caution and adequate controls to minimize the distribution of bio aerosols and fluid contaminants).

Overhead Fixtures (trapped water):

• open to air and wipe down with EPA-approved disinfectant and dehumidify.

Porous Surfaces:

IMPORTANT ensure all electrical and supply conveyance systems are de- energized

Carpet / Textiles / Fibrous

Coverings:

• If wet greater than 72 hours or time frame is unknown, discard and replace porous materials.

• If wet less than 72 hours, determine salvageable status and follow procedure below

• Extract water if possible,

• disengage carpet and remove pad;

• secure carpet to original tack strips and/or elevate without pad and apply drying procedures (i.e. fans/dehumidification);

• check floor and carpet moisture content and re- install carpet when dried;

and,

• complete final carpet or upholstery cleaning to limit microbial growth and development of odors.

Wallboard/Hard- Ceilings: • If wet greater than 72 hours or time frame is unknown, remove all sheetrock to 6 inches beyond the high water mark and apply drying procedures to area

• In the absence of insulation, and if wet less than 72 hours, may be dried in place. Open areas (ports) per stud spacing to ventilate

• apply drying procedures; and,

• check for moisture content post drying

• patch/paint over wall ports when appropriately dried

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Suspended Ceilings • remove and replace all wet ceiling tiles; and,

• wipe supports with EPA-approved disinfectant.

Pipe Insulation • assess condition (integrity and ACM);

• open to ventilate space;

• remove contaminated pipe insulation;

• wipe structure with EPA-approved disinfectant;

• apply drying procedures;

• replace pipe insulation with new material; and,

• replace coverings.

Paper / Files • Dispose of all highly absorbent saturated materials.

Water Intrusion Work Practices Level W-3

Non-Porous Surfaces and

Hard Surfaces and Floors:

• remove water as indicated above;

• remove and dispose if penetration is observed (buckling, warping, or bubbling);

• clean and disinfect subfloor with EPA-approved disinfectant; and,

• flush clean cracks if floor is intact, (pressure wash) with EPA-approved disinfectant and recover with HEPA filtered extraction unit (use caution and adequate controls to minimize the distribution of bio aerosols and fluid contaminants).

Overhead Fixtures (trapped water):

• open to air and wipe down with EPA-approved disinfectant/ dehumidify.

Porous Surfaces:

IMPORTANT ensure all electrical and supply conveyance systems are de-energized

• carpet / textiles / fibrous coverings;

• clear the area to expose wet surfaces (treat moved items and prevent cross contamination);

• disengage and remove carpet and pad and dispose; and,

• clean and disinfect floor and replace with in kind floor covering.

Wallboard / Hard Ceilings: • remove and dispose all material (including insulation) to nearest seam past affected area;

• remove all sheetrock to at least 6 inches beyond the high water mark

• apply EPA-approved disinfectant to exposed surfaces (studs and plates);

• apply drying procedures; recheck for moisture

• install new drywall.

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Pipe Insulation • assess condition (integrity and ACM);

• open to ventilate space;

• remove pipe insulation;

• disinfect pipe by wiping down with EPA-approved disinfectant;

• apply drying procedures; recheck for moisture

• replace pipe insulation with new material; and,

• replace coverings.

Suspended Ceilings • remove and replace all wet ceiling tiles; and,

• disinfect supports by wiping with EPA-disinfectants.

Paper / Files • dispose of all highly absorbent saturated materials.

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OVAMC ILSM Requirement Assessment Worksheet

• These criteria will be used to evaluate smoke compartments in which a Life Safety Code deficiency has been identified, or in which construction, renovation or alteration activities are planned. Any “Yes” answers below may require ILSM to address occupant safety.

• Document any methods you plan on using, and what measures were taken under comments.

Submitter: ________________ Date Submitted: _____________

Project: _________________

Building: ________________ Floor: ______________ Expected Duration: __________

Criteria YES NO

The issue/work alters or significantly compromises exit access, exiting, or exit discharge building elements

The issue/work compromises building compartmentation including fire or smoke walls, floor/ceiling assemblies, corridor walls, use area doors, or other defend in place elements

The issue/work impairs the building Fire Protection Systems (alarm, sprinklers, suppression) for more than 4 hours in a 24-hour period.

The activity includes Hot Work

The activity includes large quantities of combustible materials, flammable materials, or generation of large amounts of dust and debris.

Access to the area by emergency forces will be impaired

Will non/limited combustible partitions be required?

[ ] ILSM is required* [ ] ILSM are not required*

* A yes answer to any of the above criteria may require that an ILSM be initiated. Use the following check sheet to denote the interim life safety measures appropriate for the issue/work which compromises life safety. Periodic inspections of other aspects of an ILSM shall be completed during the pendency of the ILSM. All forms will be maintained by the COR with copies in the project file.

If an ILSM is not required, provide the completed assessment only to the safety manager for review.

Maintain a copy in the project file.

Work:

Comments:

Reviewed by:___________________________________________ Safety Manager Date:___________

Approved by:___________________________________________ Chief Facilities Management Date:________

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Interim Life Safety Measures Check Sheet to be implemented

Project Name: _________________________

Log Number: _________________________

Place a check mark in each applicable ILSM activity as determined by an assessment of the risks identified in the Assessment Work Sheet.

#1 INSPECTIONS / SURVEILLANCE

Increased surveillance of buildings, grounds, and equipment: shift / daily / other:

Means of exiting construction areas inspected daily

Implementation of Fire Watch

Not applicable

#2 ACCESSIBILITY

Maintenance of escape/egress routes from construction areas

Maintenance of access to emergency services for emergency equipment, fire alarm pull stations, Fire

Department connections (internal & external)

Alternate EXIT signs posted YES NO NA

Not applicable

#3 EQUIPMENT – LIFE SAFETY

Temporary fire alarm, detection, suppression system in place

Monthly testing and inspection of temporary systems

Provide additional firefighting equipment in project area

Provide additional firefighting equipment in adjacent areas

Not applicable

#4 COMMUNICATIONS

Notification to Municipal Fire Department (or applicable emergency forces group)

Not applicable

#5 CONSTRUCTION MATERIALS / PRACTICES

Partitions smoke tight and constructed of noncombustible or limited combustible materials

Prohibition of smoking throughout building and in and near construction areas

Implement appropriate storage practices

Implement appropriate housekeeping practices

Implement appropriate debris removal practices

Not applicable

2 fire drills per shift per quarter throughout Hospital (one additional drill beyond requirement of

EC.5.30).

2 fire drills per shift per quarter in areas adjacent to project (one additional drill beyond requirement of EC.5.30)

More than 2 fire drills per shift per quarter throughout Hospital. If yes, how many_________

More than 2 fire drills per shift per quarter in areas adjacent to project. If yes, how many_______

Not applicable

#6 # 6 FIRE DRILLS

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Additional training for staff in immediate area

Additional training for staff throughout hospital

Additional training for incident response team

Training to promote awareness of fire-safety building deficiencies, construction hazards, ILSM

Training on changes in physical environment (egress routes)

Training on firefighting equipment

Training on compensating for impaired structural or compartmentalization features of fire safety

Not applicable

Other measures: ____________________________________________

Comments: _________________________________________________

Prepared by: ______________________

Reviewed by:___________________________________________ Safety Manager Date:___________

Approved by:___________________________________________ Chief, Facilities Management Date:________

#7 #7 TRAINING

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ADDITIONAL CONSTRUCTION SAFETY QUESTIONS

Will project place contracted workers at risk for transmission of Mycobacterium tuberculosis? _______ If yes, refer to MCP

00Q-09 for guidance.

Has the Job Site been evaluated for ACM (asbestos) or other environmental hazards? _____ If yes provide comments.

Will Project create potential air quality issues other than identified in ICRA? _____ Is any work or equipment near air intakes?

______ Are Volatile Organic Compounds VOC being used? ______ If yes, please explain and note plans to minimize:

Will project create potential noise issues? ___ If yes, please explain and note plans to minimize:

Will project create potential vibration issues? ___ If yes, please explain and note plans to minimize:

Is contractor required to provide 14 days-notice for utility shutdowns? ____ Will contractor/COR follow Utility Shutdown SOP when utilities are shut down? ____ Will contractor be given emergency notification telephone numbers for unplanned utility failures? ____

Will project create a potential for leaks? ___ If yes, please include in contract for contractor to dike any floor penetration in construction area.

Any additional potential issues that affect EOC( Environment of Care).

Will contractors be instructed to wear badges at all times while on site? ___ Will badges identify name, employer name, project name and location and expiration date? ___ Will police be notified if project takes place on off-hours? ____

Will contract require general and sub-contractor’s construction workers all complete the OSHA 10-hour construction worker course or the 30-hour construction course with OSHA certified training? ______

Has/will the construction safety committee reviewed drawings and specs and signed off on each design submission? ______

Will Contracting Officer be requested to evaluate and consider past safety records of prospective contractors in the awarding of contracts? _______

Will contractor submittals include the names, qualifications and training dates for contractor CP designated to administer the site specific safety program, as well as the CP for other activities as required by OSHA regulation (such as scaffolds, cranes, excavation, etc.) ____ Will COR provide copy of the site specific safety program to the Construction Safety Committee? ___

Is any portion of the project related to a special field that the CP does not have the required background for (for example, scaffolding, cranes, or excavation)? _______ Will another VA Employee be CP for those special fields? ______

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APPENDIX A

MOLD REMEDIATION

MOLD REMEDIATION AMOUNT IDENTIFIED REQUIREMENTS

Source Containment Total area of mold less than 3 sq ft

1. Contact COR

2. Apply self-adhering plastic to entire moldy surface or SECURELY tape 6-mil poly over the ENTIRE moldy surface

3. Remove material and wrap or bag and securely. Enclose ALL moldy contents or materials in 6 mil poly or comparable packaging,

4. Avoid crushing materials or other actions that would generate dust and disperse fungal spores and fragments into the air.

5. Identify and remove any source of water intrusion

6. Remediators must wear appropriate PPE

Local Containment Area of mold greater than 3 sq ft but less than 100 sq ft

1. Contact COR immediately

2. Treat as ICRA Type C (or type D if work meets criteria for Type D) work and follow requirements based Patient Risk Group. (Refer to ICRA Matrix at the bottom of page 2)

3. Construction should stop until barriers have been erected and negative air established.

4.Identify and remove any source of water intrusion

5. Remediators must wear appropriate PPE

Full Containment Area of mold greater than 100sq feet

Contact COR, Safety and Infection Control for guidance.

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I have read and understand the requirements of this Pre-Construction Risk Assessment and will comply with its requirements.

SIGNATURES:

Project COR

Infection Control

Chief of Police & Law Enforcement

GEMS Coordinator

Chief Engineer

Date:

Union Safety Officer

Safety Manager

Chair – Construction Safety Committee

Contractor

Other as Applicable

Date: