ATTACHMENT 3 - Pre-Construction Risk Assessment.pdf

Bay Pines VA Healthcare System

Preconstruction Risk Assessment and Exposure Control Checklist

Project ID / Name: 516-21-107 - EHRM Infrastructure Upgrades - Lee County Date: 2/4/2025

Hazard Concern?

(Y/N) Control Measure Remarks

Asbestos N

Dust (Including Silica) Y B,F

Moisture/Water Leaks N

Vapors/Fumes N

Noise N

Vibration N

Air Quality & Infection Control Y

B

Traffic Flow Y A Will request ILSM assement/ Narrowing of coridors.

Open Outside Walls N

Impact to Levels Above and Below Y

A Excecive noise/vibration to be schedule for off hours.

Proximity of Air Intakes N

Pest Control Within Construction Area N

Proximity of Immune Suppressed Patients N

Lead N

TB Risk N

Confined Space Work N

NEPA Issues N

Utility Shutdowns N

Life Safety Y B Fire calked will be applied for penetrations.

Approval Signatures:

Project Manager/COR:

Projects Chief:

Infection Control:

Construction Safety:

GEMS:

Industrial Hygienist:

Control Measures

1. Asbestos

a. Contractor has hired an asbestos abatement contractor for control and cleanup.

b. VA to hire independent Industrial Hygienist to inspect and clear area for re-occupancy based on monitoring and/or professional judgment.

c. Published asbestos protocol to be followed for work through ceilings.

d. Published asbestos protocol to be followed for work above ceilings.

e. Perimeter barrier will be constructed in the interstitial space to isolate the construction area with other areas in the interstitial.

f. Project area will be encased with spray-applied hard surface encasement material.

g. Provide mini containments under negative air in public areas.

h. Sealed gypsum board barrier will be constructed to isolate the construction area from the public.

i. Transit panels will be removed, which is considered Class B removal.

2. Dust

a. Sealed gypsum board barrier will be constructed to isolate the construction area from the public.

b. Trash carts will be covered when transported through the building.

c. Provide negative air machine exhausted to outside.

d. Provide mini containments under negative air in public areas.

e. Provide negative air machine in space as air scrubber.

f. Provide walk off mats at entrances to work area.

g. Perimeter barrier will be constructed in the interstitial space to isolate the construction area with other areas in the interstitial.

VINCENT NAIMO Digitally signed by VINCENT NAIMO Date: 2025.02.05 12:34:38 -05'00'

BRIAN MANRIQUEZ

Digitally signed by BRIAN

MANRIQUEZ

Date: 2025.02.05 12:41:05 -05'00'

MICHELE ROEBUCK Digitally signed by MICHELE ROEBUCK Date: 2025.02.05 12:47:31 -05'00'

PAMELA NELSON Digitally signed by PAMELA NELSON Date: 2025.02.06 14:38:31 -05'00'

3. Moisture Water Leaks

a. Contain any water from core drilling activities.

b. Dike any floor penetrations to minimize risk of leaks from construction zone.

4. Vapors/Fumes

a. Use products with low Volatile Organic Compounds (VOCs).

b. Provide negative air in construction zone exhausted to outside, away from intakes.

c. Seal work area airtight barrier.

d. Cut all metal outside the building.

e. Seal any floor penetrations to minimize risk of fumes through construction zone.

f. Shut down air handler to minimize infiltration of fumes from outside.

5. Noise

a. Schedule demolition work after normal work hours.

b. Schedule work that will produce loud noise after normal work hours.

c. Cut all metal outside the building.

6. Vibration

a. Schedule demolition work after normal work hours.

b. Coordinate with occupants in surrounding areas to explain the work occurring.

7. Air Quality & Infection Control

a. Provide negative air during asbestos abatement.

b. Provide negative air during construction.

c. Seal off supply and exhaust Heating, Ventilation, and Air Conditioning (HVAC) registers.

d. Provide anteroom under negative pressure at entrance to project zone.

8. Traffic Flow

a. Access construction area via exterior door.

b. Schedule delivery of large quantities of material and demolition haul out after hours.

9. Open Outside Walls

a. Construct temporary outside wall to limit the infiltration of wind, air, and temperature differences into the project site.

10. Impact to Levels Above and Below

a. Coordinate with occupants in surrounding areas to explain the work occurring.

b. Follow asbestos protocol when doing under floor work.

c. Vacate areas when doing below floor work off of the catwalk.

11. Proximity of Air Intakes

a. Shut down air handlers to reduce infiltration of fumes from exterior activities such as painting, gasoline powered engines, roofing operations, equipment, etc.

12. Pest Control Within Construction Area

a. Provide barriers to any open outside walls.

b. Contact pest controller if any evidence of pests is found during the course of the work.

13. Proximity of Immune Suppressed Patients

a. Relocate patients away from construction zone for entire project.

b. Relocate patients away from construction zone during demolition operations.

14. Lead

a. Bulk sampling of potential lead containing materials to determine if it is present and its concentration.

b. Area and personnel monitoring during abatement activities.

c. Contractor shall ensure all employees are fit tested, certified, and medically cleared

d. Maintain containment with signage, negative air, and critical barriers until clearance.

e. Ensure materials are properly handled and disposed of in accordance with all federal, state, and local regulations.

15. TB Risk

a. Does this project involve the risk of contractors coming into contact either through patient contact, construction site location, or the layout of the hospital with airborne exposure to either a known or a suspected TB case?

16. Confined Space Work

a. VABP confined space entry program must be followed.

17. NEPA Issues

a. Has project been evaluated to ensure appropriate environmental permitting/regulatory notification will be obtained/given?

b. Contractor shall coordinate and obtain any federal/state/local permits required and copies given to the COR, GEMS and Construction Safety Engineer.

c. Has a CATEX been submitted, reviewed, and signed by the GEMS manager.

18. Utility Outages

a. Will any of the following systems need to be out of service during the project?

Fire Alarm Fire Sprinkler Electrical Domestic Water

HVAC

Medical Gasses Sewage

b. VABP utility shutdown requirements must be followed.

c. Building occupancy must be reviewed to verify if afterhours/weekend work will be required.

19. Life Safety

a. Will any work impact exits, stairs or egress routes?

b. Will any work create major breaches in fire or smoke walls?

c. Will any work affect traffic patterns?

d. Will any fire alarm devices be required to be taken offline for more than 8 hours or removed for work?

e. Will any fire suppression system be required to be taken offline for more than 10 hours or removed for work?

VHA Pre-Construction Risk Assessment (PCRA)

PCRA Introductory Information and Instructions

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.

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

Activity Location:

Activity Name, Number, and/or Brief Description:

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

Activity Type and Description Control Measures Inspection/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

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

Lee County Healthcare Clinic

EHRM Infrastructure Upgrades - Lee County

Small Scale 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.

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

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 the row above 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.

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.

All control measures in the two rows above 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

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

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.

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

Table 2. Affected Adjacent Area Assessment 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.):

o Coordination is typically not necessary other than potentially traffic flow and pedestrian access.

VHA-PCRA-202 -1 Page 4 of 5

If adjacent area is non-continuously occupied (e.g., areas where outpatient care is provided, employee health, etc.):

o 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).

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

o 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 temporarily).

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

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

Point of Contact

(POC)

POC Contact Information

Construction plan communicated to POC?

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. 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? Yes No

1B-189.190,191, C1-24 Vincent Naimo vincent.naimo@va.gov Yes Engineering Harry Ritter HARRY.RITTER@VA.GOV Yes N/A Security Todd Harmon todd.harmon@va.gov Yes Pharmacy Janine James Janine.James@va.gov Yes EMS Rodney Arlond rodney.arnold@va.gov Yes

Pre-Construction Risk Assessment (PCRA) Permit This page must be posted at the entrance to the project area, or other designated area

Unique permit number:

Location and brief description of construction/renovation/maintenance Project manager Project start date Contact phone number Completion date Contractor or lead shop Permit expiration date

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

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

Inspection/Upkeep

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

Small-scale

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.

Large-scale

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

*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.

Additional requirements:

Is an Infection Control Risk Assessment (ICRA) required for the Activity? Yes No Infection Prevention and Control signature:

Date:

Project Manager signature Date

Safety Officer signature Date

Chair, Construction Safety Committee signature

Date

512-21-107

Small-scale

Vincent Naimo

TBD

1st floor service elevator area. Upgrading facility HVAC inside tele/com room. Upgrading facility power distribution inside tele/comm rooms. Upgrading fiber throughout the building to each tele/comm room.

TBD

01/28/2025

VINCENT NAIMO Digitally signed by VINCENT NAIMO Date: 2025.01.29 06:59:09 -05'00'

PAMELA NELSON Digitally signed by PAMELA NELSON Date: 2025.02.06 14:56:57 -05'00'

01/29/2025 02/06/2025

BRYAN BAILEY Digitally signed by BRYAN BAILEY Date: 2025.02.06 15:11:06 -05'00' 02/06/2025

MICHELE ROEBUCK

Digitally signed by MICHELE

ROEBUCK

Date: 2025.01.28 14:02:49 -05'00'

PCRA Introductory Information and Instructions

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.

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

Activity Location:

Activity Name, Number, and/or Brief Description:

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

Activity Type and Description Control Measures Inspection/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

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

Lee County Healthcare Clinic 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.

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

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 the row above 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.

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.

All control measures in the two rows above and the following Activity Hazard Analyses and Control Plans (check all that apply):

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

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.

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

Table 2. Affected Adjacent Area Assessment 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 non-continuously occupied (e.g., areas where outpatient care is provided, employee health, etc.):

o 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).

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

o 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 temporarily).

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

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

Point of Contact

(POC)

POC Contact Information

Construction plan communicated to POC?

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. 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? Yes No

Radiology Joseph Bucknavahe Joseph.Bucknavage@va.gov Yes Periop Shanna Hutchens Shanna.Hutchens@va.gov Yes N/A Lab Norma Lukasika Norma.Lukasik@va.gov Yes N/A N/A N/A

Unique permit number:

Location and brief description of construction/renovation/maintenance Project manager Project start date Contact phone number Completion date Contractor or lead shop Permit expiration date

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

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

Inspection/Upkeep

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.

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.

All control measures in both rows above and the following Activity Hazard Analyses and Control Plans as applicable

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

*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.

Additional requirements:

Is an Infection Control Risk Assessment (ICRA) required for the Activity? Yes No Infection Prevention and Control signature:

Date:

Project Manager signature Date

Safety Officer signature Date

Chair, Construction Safety Committee signature

Date

516-21-107

Small Scale

Vincent Naimo

TBD

1st Floor Radiology. Upgrading facility HVAC inside tele/com room. Upgrading facility power distribution inside tele/comm rooms. Upgrading fiber throughout the building to each tele/comm room.

TBD

01/28/2025

VINCENT NAIMO Digitally signed by VINCENT NAIMO Date: 2025.01.29 07:07:18 -05'00'

PAMELA NELSON Digitally signed by PAMELA NELSON Date: 2025.02.06 14:50:27 -05'00'

01/29/2025 02/06/2025

BRYAN BAILEY Digitally signed by BRYAN BAILEY Date: 2025.02.06 15:11:46 -05'00' 02/06/2025

MICHELE ROEBUCK

Digitally signed by MICHELE

Date: 2025.01.28 13:14:59 -05'00'

PCRA Introductory Information and Instructions

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.

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

Activity Location:

Activity Name, Number, and/or Brief Description:

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

Activity Type and Description Control Measures Inspection/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

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

Lee County Healthcare Clinic 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.

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

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 the row above 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.

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.

All control measures in the two rows above and the following Activity Hazard Analyses and Control Plans (check all that apply):

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

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.

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

Table 2. Affected Adjacent Area Assessment 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 non-continuously occupied (e.g., areas where outpatient care is provided, employee health, etc.):

o 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).

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

o 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 temporarily).

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

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

Point of Contact

(POC)

POC Contact Information

Construction plan communicated to POC?

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. 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? Yes No

ACC Amy Wink Amy.Wink@va.gov Yes Audiology Charles Trulack Charles.Truluck@va.gov Yes N/A N/A N/A N/A

Unique permit number:

Location and brief description of construction/renovation/maintenance Project manager Project start date Contact phone number Completion date Contractor or lead shop Permit expiration date

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

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

Inspection/Upkeep

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.

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.

All control measures in both rows above and the following Activity Hazard Analyses and Control Plans as applicable

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

*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.

Additional requirements:

Is an Infection Control Risk Assessment (ICRA) required for the Activity? Yes No Infection Prevention and Control signature:

Date:

Project Manager signature Date

Safety Officer signature Date

Chair, Construction Safety Committee signature

Date

516-21-107

Small-scale

Vincent Naimo

TBD

1st Floor Acc. Upgrading facility HVAC inside tele/com room. Upgrading facility power distribution inside tele/comm rooms. Upgrading fiber throughout the building to each tele/comm room.

TBD

01/28/2025

VINCENT NAIMO Digitally signed by VINCENT NAIMO Date: 2025.01.28 14:41:54 -05'00'

PAMELA NELSON Digitally signed by PAMELA NELSON Date: 2025.02.06 14:55:57 -05'00'

01/28/2025 02/06/2025

BRYAN BAILEY Digitally signed by BRYAN BAILEY Date: 2025.02.06 15:06:16 -05'00' 02/06/2025

MICHELE…