ATTACHMENT B - NNMC NEW PCRA FORM Final_.pdf

Table of Contents

PAGE HEADING PG#

Pre-Construction Risk Assessment – Cover Page (PCRAͿ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

P�ZAͬI�ZA �ŚĞĐŬůŝƐƚ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2A(1). Above Ceiling Permit (ACAP)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

ABOVE CEILING ACCESS PERMIT (ACAP)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2A(2). Interim Life Safety Measure Risk Assessment (ILSM)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2B Utility System Risk Assessment (USRA)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2C Environmental and Occupational Risk Assessment (EORA)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2D Security Risk Assessment (SRA)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2E Infection Control Risk Assessment (ICRAͿ ^dEP ϭ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Step 2 AND ϯ Using the following table, identify the Patient Risk Groups that will be affected.͘

Description of Required Infection Control Precautions by Class͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Step 4. Identify the areas surrounding the project area, assessing potential impact Infection͘͘

IŶĨĞĐƚŝŽŶ Control Construction Permit͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

Section 2F Project Revision Request͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

^ĞĐƚŝŽŶ 3A Fire Watch Request Form͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

^ĞĐƚŝŽŶ 3B Utility Shutdown Request (USR)͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

^ĞĐƚŝŽŶ 3C Daily Construction Area Checklist͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ϭϵ

^ĞĐƚŝŽŶ ϮA;ϯͿ HŽƚ tŽƌŬ PĞƌŵŝƚ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘

PCRA/ICRA CHECKLIST

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Pre-Construction Risk Assessment – Cover Page Project Title: Project/Contract #:

NNMC Coordinator: PCRA Submit Date:

Project Conducted by:

❑Fac. Mgmt. ❑I.T. ❑Telecom ❑Clin. Eng.

❑Contractor:

Proposed Start Date:

Staff/Cont. Name: Est. Duration:

Supervisor Name: Est. Complete Date:

Telephone: Date Project

Completed:Email:

Project Description: (include specific sites and tasks)

Section 1. Initial Project Impact Review Topic Will project negatively impact or involve…? No Yes Action Items If YES to any Fire Safety Section 2A(1)

Ceiling tile removal Complete Above the Ceiling Access Permit (ACAP)Existing fire-stop; minor barrier penetrations

Fire Safety Section 2A(2)

Fire detection/alarm/suppression systems Complete Interim Life Safety Measure (ILSM) evaluation. Exit paths or fire/smoke barriers

Hot work practices Extra fire load or flammable materials

Utilities Section 2B

Water, sewer, electricity, steam, or HVAC (including outside air intakes)

Complete the Utility System Risk Assessment (USRA)

Medical gases or vacuum Call systems, telephones, or IT systems

Environmental/ Occupational Section 2C

Lead or asbestos containing materials Complete Environmental/ Occupational Risk Assessment

(EORA)

Chemical hazards (i.e. mercury, volatile organics) Exposure to infectious agents or mold

Security Section 2D

Security systems (badge readers, cameras) Complete Security Risk Assessment (SRA) Security processes (tours, foot/vehicle traffic)

Infection Control Section 2E

Patient care areas or critical utilities Complete Infection Control Risk Assessment (ICRA). *Classification� ƉoƉƵlatĞs�ǁŚĞn�coŵƉlĞtĞ͘Ύ

Moderate to high levels of dust, noise, vibration More than one work shift

Classification:

Click HERE to choose.

I

L_J LJ L_J LJ

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Project Approval Project Close-out

Evaluator

Facility Manager

Facility Manager

Safety Officer

Safety Officer

Infection Prevention

Infection Prevention

Supervisor (impact area)

Supervisor (impact area)

Title Signature Date Title Signature Date

Section 2A(1). Above Ceiling Permit

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Back to Cover Page

ABOVE CEILING ACCESS PERMIT

PERMIT MUST BE PROMINENTLY DISPLAYED AT THE JOB SITE

NOTICE TO PERMIT HOLDER

READ CAREFULLY

Certain spaces (such as above ceiling tile grids or utility closets) are restricted to authorized personnel, and are controlled in GSU facilities.

Access to these spaces is a privilege, which may be denied for those who do not comply with the Above Ceiling Access Permit Policy. This applies to all staff, as well as vendors and contractor personnel.

This form and the preceding pages are the permit and must be displayed at all times while creating new, or accessing existing penetrations in smoke or fire barriers. It must also be displayed when working above ceiling tile grids, in utility closets or in any other space identified as CONTROLLED SPACE.

Persons found working in these spaces without a valid permit visible are in violation of the ABOVE CEILING ACCESS PERMIT POLICY, and may lose their access privileges. Chronic non-compliers will be disciplined.

SOME EXAMPLES OF POLICY VIOLATIONS:

• Accessing a controlled space without a permit

• Failure to hold and display a valid permit

• Failure to close out a permit

• Performing work outside the scope of a permit

• Providing false information to a permit issuer

• Falsifying data on a permit

• Allowing someone to work under the scope of a permit issued in another’s name

All individuals performing work in a CONTROLLED SPACE shall read and be familiar with the ABOVE CEILING ACCESS PERMIT POLICY, copies of which can be obtained in Facility Management.

I have read and understand the ABOVE CEILING ACCESS PERMIT POLICY, and agree to comply with it.

Staff/Contractor Signature

Back to Cover Page

Date:

Section 2A(2) Interim Life Safety Measure Risk Assessment

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Topic Issue for Evaluation No Yes Response (If YES to any) Date Initiated Exits 1.Any exit access or travel distances altered/excessive?

• Post signage for an alternate means of egress

• Train staff on alternate means of egress*

• Inspect exit daily for blockage or debris

• Double fire drill frequency*

• Increase hazard surveys*

2.Any exits used by anyone other than contractors obstructed?

3.Absence of two remote exits?

Emergency Access

1.Access to emergency depts. or services obstructed?

• Designate an alternate means of access

• Notify NNMC Security

• Notify Shiprock Fire Dept.

2.Access to construction area obstructed for emergency forces?

Fire Protection 1.Fire alarm/detection impaired >4 hrs?

• Submit fire watch request;

o Or, use/monthly test temp.

alarm/detection/ suppression system

• Notify Shiprock Fire Dept.

• Double fire drill frequency*

• Make affected staff aware

• Increase hazard surveys*

2.Fire suppression impaired >10 hrs?

Fire & Smoke Barriers

1.Major breaches of fire/smoke barriers (including vertical)?

• Construct 1-hr smoke tight temp. barrier (as needed)

• Inspect exits daily

• Double fire drill frequency

• Train staff to compensate*

• Increase hazard surveys*

2.Unprotected corridors or Haz. Areas?

3.Fire/smoke door maintenance/latching problem not immediately repairable?

Addl. Firefighting Equipment

1.Fire load significantly increased above normal for area/building?

• Provide additional fire extinguishers in area

Addl. Firefighting Training

1.Additional firefighting equipment differs from normal equipment?

• Train equipment staff/ contractors to use

Combustible Load Levels

1.New/increased storage of flammable/ combustible materials?

• Minimize debris accumulation

• Increase hazard surveys2.Flammable/combustible debris?

Hazard Surveillance 1.Addl. hazards such as excavations, etc? • Initiate additional surveillance of area

Facility-wide Training

1.Life safety deficiencies or hazards impaired throughout entire building?

• Train employees on ILSM

• Notify Shiprock Fire Dept.

*-Need for response may be waived upon approval of Authority Having Jurisdiction based on scope and duration of project.

Describe any other life safety impacts, as well as specific actions to be implemented, for these and those above.

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Back to Cover PageBack to Cover Page

Title Date

Facility-wide

SignatureSignature Evaluator

Facily Manager Safety Officer

Saff/Contractor

Section 2A(3): Hot Work Permit Project Title: Project/

Contract #:

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated

Duration:

REYhIRE��PRECAhTIONS�C,EC<�LIST� tEL�ING�ĂŶĚ�BhRNING�PERMIT� (Work is not permitted unless this card is filled in and posted in work area) Time: Fire protection system(s) in service (sprinklers, CO2, foam).

Cutting and welding equipment in good condition.

Floor: Floor/ground clean (wet down when necessary).

Combustibles at least 35 feet from welding area.

Flammable liquids and other hazards removed from area.

All floor and wall openings within 35 feet covered.

Non-combustible covers used to protect nearby combustibles and equipment.

Date:

Building:

Department:

Work to be done:

Special Precautions:

Fire Watch Required: Containers, tanks, ducts, and other enclosures cleaned and purged of flammable vapors, liquids, dusts, and other hazardous materials.

The location where work is to be done has been examined by me, the necessary precautions have been taken (see checklist), and permission is granted for this work.

Fire extinguishers or small standpipe fire hose provided.

All hazardous operations discontinued in area.

Permit Expires: Time:

Fire watch should be present during, and at least on-half hour after, welding/burning has ceased.

Location of nearest fire alarm box identified.

Signed:

Individual responsible for work authorization (Facility Manager) Time Started: Time Completed:

FINAL CHECK

(Where Fire Watch is Required)

Work area, and all adjacent area where sparks might have spread, were continuously inspected during the entire time cutting, welding, or other hot work was conducted, and 30 minutes after completion. In addition, the work area was check four (4) hours after the cutting, welding, or other hot work was completed, and no fire conditions were noted.

When possible, do work in a non-combustible area.

An individual should generally be assigned to watch for dangerous sparks in the area and the floor below.

YES NO

Signed:

Return this permit, after work is completed, to Facilities Manager or designee for filing.

Section 2B. Utility System Risk Assessment

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

No Yes Minimum Recommended Precautions: (If Yes)

Describe any specific actions to be implemented:

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Back to Cover Page

Title Signature Date Evaluator

Facility Manager

Staff/Contractor

Safety Officer

Will project affect?

Noise

Vibration

Water

Sewer

Electricity

Steam

Natural Gas

HVAC

Medical Gas & Vacuum

IT Systems

Telephones

Call Systems

Observation Cameras

• Review project and patient care schedules to identify least impactful times, or options to curtail or relocate patient care operations

• Review how workers will access worksite and isolate from patient care as feasible

• Review tools and processes to be used for reasonable, quieter alternatives;

• Install sound attenuating barriers where feasible. Monitor as needed.

• Review work schedules for project and work area to identify least impactful times

• Review tools and processes to be used for reasonable alternatives

• Assess potential impacts on sensitive patient care equipment/processes; Monitor as needed.

• Submit ICRA and Utility Shutdown Request; Submit fire watch request per ILSM evaluation

• Pre-position materials needed to respond to a water leak

• Review need/options to isolate adjacent areas and equipment (i.e. lab analyzers, ice machines, HVAC appurtenances, etc.)

• Flush and/or treat system if potential for residue or stagnation (See Legionella Plan)

• Submit ICRA and Utility Shutdown Request

Pre-position materials needed to respond to leaks or spills, and to handle contaminated construction debris.

• Review need/options to isolate adjacent areas and to curtail or alter patient care routines.

• Review work schedules for project and work area to identify least impactful times

• Review potential impacts to connected utility systems and electronic equipment

• Submit Utility Shutdown Request

• Submit Utility Shutdown Request

• Notify steam-based equipment users of potential impacts

• Submit Utility Shutdown Request

• Submit ICRA and Utility Shutdown Request

• Review work schedules for project and work area to identify least impactful times

• Identify alternate environmental condition options

• Submit Utility Shutdown Request

• Ensure work will be done in accordance with NFPA 99 or other relevant codes

• Notify patient care staff of potential impacts to prompt clinical intervention planning

• Ensure that post-completion testing is completed

• Collaboratively plan project between Facility Mgmt and IT Departments

• Notify patient care staff to plan for clinical process modification as needed

• Collaboratively plan project between Facility Mgmt and IT Departments

• Notify patient care security staff to plan for emergency response modifications

• Collaboratively plan project between Facility Mgmt and IT Departments

• Notify patient care staff to plan for clinical process modification as needed

• Plan for alternate notification means (standalone systems, bells, etc.)

• Collaboratively plan project between Facility Mgmt and IT Departments

• Notify patient care staff to plan for clinical process modifications as needed

SĞĐƚŝŽŶ�ϮC͘�EŶǀŝƌŽŶŵĞŶƚĂů�ĂŶĚ�OĐĐƵƉĂƚŝŽŶĂů�RŝƐŬ�AƐƐĞƐƐŵĞŶƚ�

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Will project involve: Yes No Minimum Recommended Precautions: (If Yes)

Lead-based paint

• Review facility lead-based paint assessment and management plan

• Ensure project staff are properly trained in precautions necessary to protect facility occupants and themselves

• Establish plan to implement appropriate isolation, work practices, housekeeping, and waste handling

• Establish plan for required air or surface sampling

Asbestos

• Review facility asbestos assessment and management plan

• Ensure project staff are properly trained in precautions necessary to protect facility occupants and themselves

• Establish plan to implement appropriate isolation, work practices, housekeeping, and waste handling

• Establish plan for required air or surface sampling

Chemical hazards

• Review area or initial project plan to identify hazards inherent to work area

• Compile and review listing of chemicals to be used; ensure Safety Data Sheets available

• Review chemicals to be used for potential impacts on areas adjacent to project

• Ensure project staff have receive Haz. Communications training including emergency response processes/responsibilities

• Conduct Job Hazard Assessment and ensure appropriate personal protective equipment is available and used

Infectious Agents

• Review area or initial project plan to identify hazards inherent to work area

• Ensure staff have received Bloodborne Pathogen Training including exposure response processes/responsibilities

• Review need for medical screening/vaccination with employee health program

• Conduct Job Hazard Assessment and ensure appropriate personal protective equipment is available and used

Mold

• Review area or initial project plan to identify hazards inherent to work area

• Consider potential risk of water damage due to compromising wall, ceiling, roof

• Ensure project staff are properly trained in precautions necessary to protect facility occupants and themselves

• Establish plan to implement appropriate isolation, work practices, housekeeping, and waste handling

Describe any specific actions to be implemented:

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Evaluator

Facilities Manager

Employee Health

Safety Officer

Staff/Contractor

Title Signature Date

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Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Will project affect... Yes No Minimum Recommended Precautions: (If Yes)

• Collaborative plan project with IT Department

• Notify Security staff of impaired system to plan for alternative access control methods

• Notify affected work area staff of alternative access control methods

Security Cameras

• Collaboratively plan project between Facility Mgmt and IT Departments

• Notify security to plan for surveillance process modifications

Physical Barriers

• Review need for temporary physical barriers

Security Processes

• Review changes to area access with security to plan for alternate rounding paths

• Review pedestrian/facility occupant foot traffic patterns to identify potential vulnerabilities

• Review vehicle traffic patterns with security to ensure required access and to plan for traffic management as needed Security sensitive areas

• Review project staff listing with security

• Notify project staff of access control requirements

• Provide identification as needed.

Emergency Response Procedures

• Notify external first responders/partners as appropriate

• Provide training to staff regarding procedural changes

• Relocate equipment and/or signage as needed

• Review emergency response communications procedures/plan

Describe any specific actions to be implemented:

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Title Signature Date Evaluator

Staff/Contractor

Security Supervisor

Safety Officer

Facility Manager

Section 2E. Infection Control Risk Assessment

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Building: Floor(s): Department Name(s): Room Number(s) & Description(s)

Project Description: (include specific sites and tasks)

Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation

Step 1: Using the following table, identify the Type of Construction Project Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

▪ removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet

▪ painting (but not sanding)

▪ wallcovering, 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 floorcoverings, ceiling tiles and casework

▪ new wall construction

▪ minor duct work or electrical work above ceilings

▪ major cabling activities

▪ any activity which cannot be completed within a single workshift.

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.

Step 1:

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Scott Lund

Scott Lund

Scott Lund

Step 2: Using the following table, identify the Patient Risk Groups that will be affected.

Low Risk Medium Risk Medium-High Risk Highest Risk

▪ Office areas ▪ Cardiology ▪ Emergency Room ▪ Any area caring for

▪ Nonpatient-care areas not otherwise

Echocardiography Endoscopy Local Room

Labor & Delivery Laboratories (specimen) Medical Units immunocompromised patients

▪ Central Sterile Supply

▪ Intensive Care Units specified

(NOS)

Physical Therapy Radiology/MRI Respiratory Therapy Infusion Clinic Orthopedic Clinic

Newborn Nursery Outpatient Surgery Pediatrics Pharmacy Post Anesthesia Care Unit

▪ Negative pressure isolation rooms

▪ Operating rooms including C-section rooms

If more than one risk group will be affected, select the higher risk group:

Step 2:

Step 3: Match the following;

Construction Project Type (A, B, C, D) oQ tKe IoOOoZLQg PatrL[� to ILQG tKe « Patient Risk Group (Low, Medium, High, Highest) with the planned … Class of Precautions (I, II, III or IV) or level of infection control activities required.

Type of Construction Patient Risk Group Type A Type B Type C Type D

Low Risk Group I II II III/IV Medium Risk Group I II III IV

Medium-High Risk Group

I II III/IV IV

Highest Risk Group I –III Consult ICP

III/IV III/IV IV

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* Note Infection Preventionist approval will be required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are necessary.

Step 3: ___________________________

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Description of Required Infection Control Precautions by Class

Before Construction During Construction Project Upon Completion of Project

C L

A

SS

I 1. Notify Department Supervisor

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

�� Immediately replace a ceiling tile displaced for visual inspection

1. Clean work area upon completion of task.

C L

A

SS

II

1. Notify Department Supervisor

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

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

�� Seal unused doors with duct tape.

�� Block off and seal air vents.

�� Place dust mat at entrance and exit of work area �� Remove or isolate HVAC system in areas where work is being performed.

1. Wipe work surfaces with cleaner/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. Upon completion, restore HVAC system where work was performed.

C L

A

SS

II

I

1. Contact Housekeeping Supervisor to schedule Post-work cleaning

2. Review ICRA with Department Supervisor(s)

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

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

�� 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.

�� Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

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

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

vacuums.

4. Wet mop area with cleaner/disinfectant.

5. Upon completion, restore HVAC system where work was performed.

C L

A

SS

IV

1. Contact Housekeeping Supervisor to schedule Post-work cleaning

2. Notify Tour Supervisor

3. Review ICRA with Department Supervisor(s)

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

�� 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.

�� Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

�� Seal holes, pipes, conduits, and punctures.

�� 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 work site.

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

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

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

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

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

5. Vacuum work area with HEPA filtered vacuums.

6. Wet mop area with cleaner/disinfectant.

7. Upon completion, restore HVAC system where work was performed.

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Step 4. Identify the areas surrounding the project area, assessing potential impact Adjacent Area Impacts: Identify the areas surrounding the project area, to assess potential impact

Below Above Lateral Lateral Behind in Front Adjacent Unit Name

Patient Risk Group (per Table 1)

Step 5. Identify specific site of activity e.g., patient rooms, medication room, etc.

Step 6. Identify containment measures, using prior assessment. What type of barriers? (E.g., solid wall barriers);

Will HEPA filtration be required. Do plans allow for adequate number of isolation/negative airflow rooms?

(Note: Renovation/construction area shall be isolated from the occupied areas during construction and shall be negative with respect to surrounding areas)

Step 7. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)

Step 8. Work hours: Can or will the work be done during non-patient care hours?

Step 9. Do plans allow for adequate number of isolation/negative airflow rooms?

Step 10. Do the plans allow for the required number & type of handwashing sinks?

Step 11. Does the infection prevention & control staff agree with the minimum number of sinks for this project?

Step 12. Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?

Step 13. Plan to discuss the following containment issues with the project team. (E.g., traffic flow, housekeeping, debris removal [how and when])

Appendix: Identify and communicate the responsibility for project monitoring that includes infection prevention & control concerns and risks. The ICRA will be modified throughout the project.

Revisions must be communicated to the Project Manager.

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Infection Control Construction Permit Permit No:

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contr� 'oLQg Work� Permit Expiration Date:

Supervisor: Telephone:

Additional Requirements:

Date� Initials� Exceptions/Additions to this permit Date�

Permit Request By: Permit Authorized By:

Date: Date:

**Post Completed & Signed ICRA at worksite.

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Section 2F: Project Revision Request

KSU Coordinator: Facility Management Original PCRA Date:

Project Conducted ❑Fac. Mgmt. ❑I.T. ❑Telecom ❑Clin. Eng. Original Start Date:

by: ❑Contractor: __________________________ Original Duration:

Staff/Cont. Name: Orig Complete Date Supervisor Name: Actual Start Date:

Telephone: Revised Duration:

Email: Rev. Complete Date

Changes to Project Project Description: (include specific sites and tasks)

ICRA Classification Class I Class II Class III* Class IV*

Reasons for Project Changes Summary of Reasons:

New Areas Affected by Project:

Building: Floor(s): Department Name(s): Room Number(s) & Description(s)

Changes to Initial Impact Assessment Topic Will project revision affect the…? No Yes Responses (If YES) Fire Safety Section 2A(1)

Above the Ceiling Access Permit (ACAP) • Consult with Facility Manager

Fire Safety Section 2A(2)

Interim Life Safety Measure (ILSM) evaluation • Consult with Facility Manager and Safety Officer

Utilities Section 2B

Utility Risk Assessment (URA) • Consult with Facility Manager

Environmental/ Occupational Section 2C

Env./Occ. Risk Assessment (EORA) • Consult with Safety Officer

Security Section 2D

Security Risk Assessment (SRA) • Consult with Safety Officer

Infection Control Section 2E

Infection Control Risk Assessment (ICRA) • Consult with Infection Prevention

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Project Revision Approval

Title Signature Date Evaluator

Facilities Manager

Safety Officer

Infection Prevention

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Section 3A. Fire Watch Request Form

NNMC

Coordinator:

Fire Watch Start Date:

Staff/Cont. Name: Fire Watch Start Time:

Supervisor Name: Est. Complete Date:

Telephone: Date Project

Completed: Email:

Building: Floor(s): Department Name(s): Room Number(s) & Description(s)

A written ILSM assessment is required on all construction projects, repairs, or other activities that will impair any part of the life safety features. Whenever the automatic fire alarm system is disabled for four (4) or more hours in a given 24-hour period, or whenever the automatic sprinkler system is disabled for ten (10) or more hours in a given 24-hour period, a Fire Watch shall be implemented in all areas affected. Project manager must send a completed copy of the ILSM assessment form along this request to the Facility Manager, Safety Officer, and Security Department Manager who will conduct the fire watch in the areas affected for the duration of impairment according to facility procedures. A fire watch log must be maintained to document each inspection.

The following elements must be included in all fire watch inspections:

1. Outside doors are closed and secured, and windows, fire doors are closed.

2. All waste, rags, paint residue, rubbish, and similar combustible items are removed from the building.

3. All remaining operable fire protection equipment is in place and not obstructed.

4. Ensure that all aisles are clear.

5. Confirm that all motors or machines not required to operate are turned off.

6. All unsecured offices and conference rooms are checked for unapproved smoking material that may have been carelessly discarded.

7. All unnecessary heat-producing devices are turned off in the impairment area

8. Ensure that flammable and combustible materials are properly stored in approved containers. (NOTE: Flammable compressed gas cylinders must be stored in a 1-hour fire resistance rated room.)

9. Ensure that sprinkler valves are in the open position. (NOTE: If sprinkler control valves are electronically supervised by the Automatic Fire Alarm System and are not impaired by this scope of work, then visual examination is not required.

10. Check for proper ventilation in the impaired area.

11. Ensure there are no leaks from the plumbing fixtures and piping

Individuals performing the Fire Watch will make clear precise entries on the Fire Watch Log, and immediately report any unsafe or unusual situations to the Safety Officer and Facility Manager, or their designees. At the conclusion of the Fire Watch, a copy of the Fire Watch Log must be forwarded to the Safety Officer and project file.

Fire Watch Approval

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Title Signature Date Requestor

Facilities Manager Safety Officer

Security Supervisor

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Section 3B. Utility Shutdown Request

NNMC Coordinator: Request submit date Staff/Cont. Name:

Prime Contractor (if different)

Requested Shutdown Date:

Supervisor Name: Shutdown Time:

Telephone: Est. Duration:

Email:

NOTE: A separate utility shutdown request must be submitted for each separate work period during which the utility(ies) will be interrupted.

Utility Requested to be Shutdown Yes Comments

Water

Sewer

Electricity

Steam

Natural Gas

HVAC

Medical Gas & Vacuum

IT Systems

Telephones

Call systems

Observation Cameras

Title Signature Date

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Section 3C. Daily Construction Area Checklist

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration Telephone: Est. Complete Date

Building: Floor(s): Department Name(s): Room Number(s) & Description(s)

Requirements First Check Second Check

YesNo N/A YesNo N/A

1. Entrance Doors/ ICRA Barriers properly closed and sealed. Doors secured.

2. Enclosures free of penetrations

3. Holes, pipes, conduits sealed at ICRA Barrier

4. Air vents sealed (supply and return)

5. HVAC system isolated

6. Unused doors taped

7. Windows closed

8. HEPA filtration on and running

9. HEPA filter log up-to-date

10. HEPA vacuum and/or coveralls available

11. Negative pressure monitor in place and running

• Negative Pressure reading: ________________

12. Hot work permit obtained

13. Exit signs installed and lighted

14. Fire extinguishers in place and tag up-to-date

15. All routes of egress clear of debris

16. Construction signs in place

17. Dust (sticky) mats in place and clean

18. Routine cleaning completed

19. Surrounding areas free of dust

20. Debris removed daily

21. Transport carts covered and wiped down

22. Trash in appropriate containers

23. All workers wearing ID badges (If no – provide #): _____________

24. FIRE WATCH IN EFFECT (note time complete)

25. Compressed Gas Cylinders Secured

Describe any deficiencies and specific actions taken to correct:

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