Attachment 6 537-21-702 - SOW Exhibit B - Project Risk Assessment Form.pdf

MEDICAL CENTER MEMORANDUM NO. 003S-01-23

Appendix D

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PROJECT RISK ASSESSMENT (SAFETY, INFECTION CONTROL & ILSM)

Project Title: Data Drops & Power Outlets Project or Work Order Number: 537-21-702

Location: Jesse Brown VA Hospital Coordinator: Ann Nguyen

Start Date: FY 23 Phone Number: 312-569-5491

Type of Project:

Operation and Maintenance Activities

Repairs/Renovation Project

New Construction Project

Lease

Other______________________________

Description of project: Installation of additional Data Drops and Network Ports in the Telecommunication Rooms (TRs) to support the required network printers and medical devices.

Level of NEPA Analysis:

Categorical Exclusion (CATEX)

Environmental Assessment Needed (EA)

Environmental Impact Statement Needed (EIS)

Other Environmental Permits/Analysis Needed:

PROJECT IMPACTS

Would the proposed activity involve or generate any of the following?

Source Yes No Source Yes No Source Yes No

Air Emissions Including GHG’s Liquid Effluent RCRA or CERCLA Sites Asbestos

Petroleum Storage Wetlands Excess Noise

Solid Waste Permit Modification

Utility Modification Hazardous Waste Chemical Use/Storage

Soil Disturbances Biological Resources Aesthetics

Water Treatment Radioactive Waste Water/Well Use

Water Flow Modification Mixed Waste Other:

DETERMINATION

I find the proposed project qualifies as a CATEGORICAL EXCLUSION with no extraordinary circumstances. Specify which CATEX: Project qualifies as a CATEGORICAL EXCLUSION with no extraordinary circumstances per 38 C.F.R. § 26.6(b) Part 1 _________

I find that the proposed project MAY have a significant effect on the environment; therefore, an

ENVIRONMENTAL ASSESSMENT will be prepared.

EIS

X Project Engineer

GEMS Coordinator

En g in eerin g Ch ief

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Location: Jesse Brown VA Hospital Coordinator: Ann Nguyen

Start Date: FY 23 Phone Number: 312-569-5491

Description of project:

Installation of additional Data Drops and Network Ports in the Telecommunication Rooms (TRs) to support the required network printers and medical devices.

CONSTRUCTION ACTIVITIES

The following projects do not require completion of the Project Risk Assessment form:

1. Painting and installation of new wallpaper in business offices and non-patient areas.

2. Painting in a patient room, if closed for painting and less than 3 square feet of wall area is to be patched and painted. Contractor shall replace the air filter for the room’s air conditioning unit upon completion of painting.

3. Installation of a soap dispenser/needle box/paper towel holder in a patient room

4. Repair of a window blind.

5. Ceiling tile replacement for areas less than ten (10) 2’ x 2’ tiles, if not in business offices and non-patient areas.

6. Ceiling tile replacement for areas less than five (5) 2’ x 2’ tiles in a patient area, if patient is out of the immediate area and clean up can be accomplished before patient returns.

7. Minimal repair of Nurse Call System/TV/Bed/Telephone.

8. Checking or replacing of electric outlet.

9. Replacing a light bulb.

10. Unstopping sink/commode with no water on floor.

11. Unstopping commode when water on floor requires maintenance to have Housekeeping clean area immediately.

12. Repair of a medical gas outlet. (Front Body)

13. Taking air balance measurement readings.

14. Checking air conditioning unit/system.

15. Intermediate jobs that create a moderate amount of dust inside the room with negative air pressure maintained in the room via use of HEPA-equipped unit with minimum 10 ACH, and all air discharged outside. The HEPA unit must continue running 2 hours after completion of job and

Housekeeping must clean room before the HEPA unit is removed from room. All work and use of HEPA unit must be documented and copies forwarded to Infection Prevention and Control and Safety.

NOTE: All duct vents to be sealed off during work!

PRE-CONSTRUCTION RISK ASSESSMENT (PCRA) YES N/A

Off Tour Construction Necessary?

Permit Required Confined Space (PCRS) Entry Necessary?

Cutting, Burning, or Welding Necessary?

Lead or Other Hazardous Abatement Necessary?

Legionella Assessment: Will potable water system(s) be affected in any way?

Does this Project involve a Mental Health Unit (Bed Tower 7E/W or ED rooms 1470A or 1470B)?

If yes has the Mental Health EOC Team been notified?

Lock-Out/Tag-Out of the following systems will be necessary:

Domestic Water Electrical Systems HVAC Systems

Medical Gases Steam Systems Security Alarms

The following departments will be involved in this project:

Infection Control Construction Paint Shop Engineering Biomed

Safety Patient Safety Carpenter IRM Other

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List other:

Asbestos removal need? YES NO Asbestos Assessment:

Conducted by wall or ceiling penetration visual inspection?

Conducted via access panel visual inspection?

Conducted by review of facility diagrams and/or prior removal paperwork?

MEASURES TO BE TAKEN FOR ALL PROJECTS CLASSIFICATIONS

Involve Infection Prevention & Control Section in planning before construction begins

Negative-pressure containment and ventilation shall be used during any dust-producing activity. When exhausting to indoor space, HEPA filtration must be used. Unused doors shall be sealed with tape. Existing air supply and exhaust ducts shall be sealed. HEPA vacuum all surfaces at least once per shift and then prior to completion. Remove containment only after approval of VA COR.

“Sticky” dust mats and carpeting remnants shall be maintained at all construction area entrances & exits to control dust.

Contractors shall thoroughly sweep & mop construction & entrance/exit areas at least daily.

All trash shall be removed from the building at least every shift using tightly covered containers.

Project coordinator and contractor safety manager (designated competent person) to check site daily & log in project folder.

Appropriate safety and project signage shall be posted.

All doors into the work area are smoke-tight, self-closing and self-locking (where required).

Temporary (solid) partitions separating construction from public areas shall be smoke-tight. Only remove after approval of VA. A temporary plastic sheeting enclosure is required to contain dust while removing temporary walls.

Firefighting equipment shall be in place & accessible. Inspection tags shall remain attached and current.

Ceiling tiles shall be replaced as soon as possible to prevent impairment of sprinklers.

All power equipment shall be UL listed and properly grounded, extension cords protected, and plugged into GFCI receptacle.

Flammable & combustible liquids/gases/solids shall be used properly and stored in fire-safe containers and cabinets.

No smoking policy shall be enforced.

Smoke detectors disconnected to prevent dust from activating the fire alarm (typically only occurs during demolition).

Replace with heat detectors.

Trailers, sheds, and dumpsters shall be no closer than10 feet of buildings.

Gang boxes and tool carts shall be secured at all times when not in use.

If water systems were affected, conduct system flushing and testing.

If HVAC, air exchanges or ventilation systems were affected, conduct system balancing and testing.

Upon completion, HEPA vacuum all horizontal surfaces, and then wipe all surfaces with disinfectant, and then damp-mop floors. Then notify EMS for terminal cleaning.

ILSM Assessment

This project will require Interim Life Safety Measures if any of the following are checked YES YES NO

Approved exits/means of egress passages will be obstructed

Emergency access ways will be obstructed

Fire alarm/detection/suppression system(s) will be impaired longer than 4 hours

Smoke barrier or vertical shaft will be compromised

Removal of any corridor or more than 5% of a room’s ceiling tiles

Floors or ceilings will be penetrated during construction

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Significant renovation of an occupied floor

Are ILSM measures required for this project? ____ YES ____ NO

ILSM Checklist

CONTRACTOR BRIEFINGS & TRAINING N/A INITIALS

Ensuring free and unobstructed access to emergency department/services and for emergency forces.

Ensuring fire alarm, detection, and suppression systems are not impaired; a temporary but equivalent system shall be provided when any fire system is impaired.

Contractor will schedule work to minimize how long the systems are impaired and shall notify safety section prior to system being impaired.

Ensuring temporary construction partitions are smoke tight and built of noncombustible or limited combustible materials which will not contribute to the development or spread of fire.

Providing additional fire-fighting equipment and use training for personnel.

Developing and enforcing storage, housekeeping, and debris removal practices which reduce the potential (flammable or combustible) fire load of the work area to the lowest possible level.

INFECTION CONTROL MEASURES ARE IN PLACE I/C STAFF HAS VERIFIED CONTRACTOR

BRIEFINGS & TRAINING

N/A INITIALS

Met with VA services/sections surrounding construction area to inform them of impacts and precautions to be taken, and to inform them in basic I.C. requirements (see attached) NOTE: address in design & planning phase

Met with the contractor project manager, construction crews, and subcontractors to inform them of precautions to be taken, and to educate them in basic I.C. requirements. NOTE: address in design & planning phase

Informed the contractor that barriers are not to be removed from work area until completed project is inspected by the Safety and Infection Control Departments, and thoroughly cleaned by Environmental Management Service.

ILSM’S ARE IN PLACE SAFETY STAFF HAS VERIFIED NOTIFICATIONS & TRAINING N/A INITIALS

VA Police have been notified of responsibility to conduct a fire watch at least once per shift during non-business hours whenever any portion of the fire alarm, detection, or suppression systems are impaired for more than four hours within a twenty-four-hour period.

If exits are obstructed, then personnel in building were trained on alternate routes and exits.

Construction areas will have designated and marked exits, maps delineating new exit pathways are in place.

Staff in the affected area(s) will conduct 2 fire drills within every three-month period.

TB RISK ASSESSMENT YES NO

Is there a risk based upon construction site location, patient population, hospital layout, and the defined risk as outlined in the “CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Setting, (IF SO, SEE COMMENTS BELOW):

Ensure that VHA-required content regarding TB is included in every contract.

Contractor shall provide written certification that all contract employees assigned to the work site have had a pre-placement tuberculin screening within 90 days prior to assignment to the worksite and been found have negative TB screening reactions. Contractors shall be required to show documentation of negative TB screening reactions for any additional workers who are added after the 90-day requirement before they will be allowed to work on the work site.

Review the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings

(MMWR 54-RR17) and select the risk category. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm

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INFECTION CONTROL RISK ASSESSMENT

This Project will require Infection Control Measures if any of the following are checked “Yes” YES NO

TYPE A – Inspection and Non-Invasive Activities

TYPE B -- Small scale, short duration activities which create minimal dust, fumes/odors, noise, or vibration

TYPE C -- Will generate a moderate amount of dust, fumes/odors, noise, or vibration

TYPE D -- Major demolition and construction projects.

I. LOW Risk Area (affects one or more of the following areas):

Office Areas/Shops Locker Rooms Mechanical Equip Rooms Non-Public Access Areas

Equip Storerooms Boiler/Chiller Plants Other: _________________________________________

II. MODERATE Risk Area (affects one or more of the following areas):

Medical Inpatient Units Outpatient Clinics Respiratory Therapy Canteen, Kitchen Areas Psychiatric Inpatient Physical Therapy Radiology/MRI/CT Nuclear Medicine Endoscopy Cardiology Echocardiograph Other: _____________________

III. HIGH Risk Area (affects one or more of the following areas):

Post-Anesthesia Care Unit Emergency Room CCU’s Laboratories Surgical Units

Outpatient Surgery Pharmacy SCM Other: _________________________

I. HIGHEST Risk Area (affects one or more of the following areas):

Operating Rooms Sterile Supply Surgical Recovery Unit

Oncology Endoscopy Cardiac Catheter Lab

Surgical Inpatient Area ICU’s Other: ______________________________

Immunocompromised patient areas or negative pressure Isolation Rooms

USING THE FOLLOWING TABLE, IDENTIFY THE

PROJECT CLASS A B C D

LOW Risk Area I II II III/IV

MODERATE Risk Area I II III IV

HIGH Risk Area I II III/IV IV

HIGHEST Risk Area II III/IV III/IV IV

Project Classification (I, II, III, or IV) ______

ALL CLASS III AND IV PROJECTS REQUIRE AN INFECTION CONTROL PERMIT

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MEASURES DURING CLASS I, & II PROJECTS

See: Listing of Measures to be Taken for All Projects Classifications (page 3)

MEASURES DURING CLASS III & IV PROJECTS MEASURES UPON COMPLETION

Above measures PLUS:

• Do not remove barriers from work area until completed project is inspected by the Resident Engineer, Project Manager, and Facility Safety Manager/Officer or Contracting Officer Representative.

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

▪ Complete all critical barriers i.e. sheet rock, 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.

▪ Maintain negative air pressure, 0.01 inches of water gauge, within work site utilizing HEPA equipped air filtration units and continuously monitored with a digital display, recording and alarm instrument, which must be calibrated on installation, maintained with periodic calibration and monitored by the contractor.

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

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

▪ If exiting to a patient care area, 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 site.

▪ Walk-off mats are recommended to minimize tracking of heavy dirt and dust from construction areas. Shoe covers may be considered in certain areas.

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Project Title: Project or Work Order Number:

ADDITIONAL SAFETY CONCERNS YES NO

Will the project involve the deployment of a crane to deliver equipment over occupied facilities?

Must submit a Lift Safety Plan to the Safety Office for approval a minimum of 3 weeks prior to the arrival of the crane on JBVAMC property. The Lift Safety Plan will include the following information: crane specifications, crane inspection list, and crane staff training record/certification. Contractors shall maintain and present the following items prior to crane start (items can be kept in crane cab):

crane certifications, crane registration, fire extinguisher, and crane operating and safety manual.

The following must be completed prior to any construction activities:

• Construct separation walls prior to project start.

• Fire protection systems must remain intact.

• Provide extra fire extinguishers in work areas.

• Maintain exit lights in work area.

• Maintain negative air pressure in construction area (24/7) throughout project duration.

• There cannot be any return air from within the construction area to the rest of the building.

• Redirect egress routes: do not allow egress routes to pass through construction areas.

• Provide and maintain “Construction Area-Do No Enter” signs on doors leading into the construction area.

• Maintain up-to-date daily logs and maintain a current Hot Work Permit.

• Provide and install no-slip mats at doors exiting construction area.

• All debris removal must be by covered cart.

• Maintain a clean and orderly work area.

• Determine how, if at all, this project will affect the departments above, below, and adjacent to this project?

COMMENTS: (Required special PPE will be listed here)

Contracting Officer’s Representative Date Telephone

Infection Prevention and Control Date Telephone

Safety Date Telephone

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Jesse Brown Space Reactivation Report (Pre-Occupancy)

Project Title: ______________________ Project or Work Order Number: _________

Location: ___________________ Room Number(s): ___________ Dates: ________

Description of work completed___________________________________________ See attached sheet if additional explanation is required.

The room/area described above and in the attached PRA, has previously been determined to be unsafe, unsanitary, or unusable by patients and/or staff. It should remain locked and/or with restricted access until the work is complete, the area is terminally cleaned, and all designees below agree to its reopening.

By signing below, each person is attesting that they have personally viewed/inspected the area and find it is now suitable for its intended use, safe for patient care.

• If this Project involved a Mental Health Unit (Bed Tower 7E/W or ED rooms 1470A or 1470B) it must have a Mental Health EOC Inspection.

________________________ _______ Approve / Disapprove

• Mental Health Service Chief Date

___________________________________ _________ Approve / Disapprove Area Nurse Manager or Service/Sect. Chief Date

__________________________________ _________ Approve/Disapprove Patient Safety Date

___________________________________ _________ Approve/Disapprove Chief, Occupational Safety & Health Service Date

__________________________________ _________ Approve / Disapprove Chief, Environmental Management Service Date

___________________________________ _________ Approve / Disapprove Chief, Engineering Service Date

___________________________________ _________ Approve / Disapprove Infection Prevention and Control Date

___________________________________ _________ Approve / Disapprove Medical Center Director Date

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