B01 RFP ATTACHMENT J01I Example Risk assessment forms.pdf

Version: September 18th, 2019

Pre-Construction Risk Assessment – Cover Page Project Title:

PRSU 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)

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

Section 1. Initial Project Impact Review

Topic Will project negatively impact or involve…? No Yes Responses (If YES to any) Fire Safety Section 2A(1)

Ceiling tile removal (less than 4 hours total) 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 (1)

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

Confined Space Section 2B (2)

Area designated confined space Confined Space Risk Assessment

Environmental/ Occupational Section 2C

Lead or asbestos containing materials Complete Env./Occ. Risk Assessment (EORA) Chemical hazards (i.e. mercury, volatile organics)

Exposure to infectious agents or mold Crushing or falling hazard

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 an Infection Control Risk Assessment (ICRA) Moderate to high levels of dust, noise, vibration

More than one work shift Project Approval

Project Manager Signature Date: Required for: All Facility Manager Signature Date: Required for: All Safety Officer Signature Date: Required for: All IP Signature Date: Required for: USRA and ICRA Supervisor (affected area) Date: Required for: All

Project Close-out Facility Manager Signature Date: Required for: All Safety Officer Signature Date: Required for: All IP Signature Date: Required for: ICRA-Class III & IV Supervisor (affected area) Date: Required for: All

Section 2E. Infection Control Risk Assessment Project Title:

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 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

Nonpatient-care areas not otherwise specified

(NOS)

Cardiology Echocardiography Endoscopy Local Room Physical Therapy Radiology/MRI Respiratory Therapy Infusion Clinic Orthopedic Clinic

Emergency Room Labor & Delivery Laboratories (specimen) Medical Units Newborn Nursery Outpatient Surgery Pediatrics Pharmacy Post Anesthesia Care Unit

Any area caring for immunocompromised patients

Central Sterile Supply Intensive Care Units 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 3: Match the following;

Patient Risk Group (Low, Medium, High, Highest) with the planned … Construction Project Type (A, B, C, D) on the following matrix, to find the … 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

Class of IC Measures Class I Class II Class III* Class IV*

* 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.

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

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

2. 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

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

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

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

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

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

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

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

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

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

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

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

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

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

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

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

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave work site.

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

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.

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.

Infection Control Construction Permit Project Title:

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration, moderate to high levels GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities Requiring consecutive work shifts

GROUP 4: Highest Risk

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

2. Immediately replace any ceiling tile displaced for visual inspection.

3. Minor Demolition for Remodeling

CLASS II 1. Provides active means to prevent air-borne dust from dispersing into atmosphere

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

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Wipe surfaces with cleaner/disinfectant.

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

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

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

9. Isolate HVAC system in areas where work is being performed; restore when work completed.

CLASS III

1. Obtain infection control permit before construction begins.

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

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

5. Do not remove barriers from work area until complete project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental Services.

6. Vacuum work with HEPA filtered vacuums.

7. Wet mop with cleaner/disinfectant

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

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

10. Cover transport receptacles or carts. Tape covering.

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

Date

Initial

CLASS IV

1. Obtain infection control permit before construction begins.

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

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

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

6. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

7. All personnel entering work site are required to wear shoe covers.

8. Do not remove barriers from work area until completed project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental. Services.

9. Vacuum work area with HEPA filtered vacuums.

10. Wet mop with disinfectant.

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

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

13. Cover transport receptacles or carts. Tape covering.

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

Date

Initial

Additional Requirements:

Date Initials Exceptions/Additions to this permit Date.

Permit Request By: Permit Authorized By:

Date: Date:

***Post Completed and Signed ICRA at worksite