ERIE MATOC DOCUMENTS.pdf

MEDICAL CENTER REQUIREMENTS

ERIE VA MEDICAL CENTER

Privacy Training:

Privacy training must be completed by all contractors and subcontractors assigned to the VA accounts prior to construction or delivery of service and/or onsite visit and annually. There are three (3) options a contractor or subcontractor can choose from to complete privacy training:

1. Complete VHA Privacy Policy Training electronically through EES at the following website: https://www.ees-learning.net/librix/loginhtml.asp?v=librix . or

2. Review the text version of VHA Privacy Policy course included with this contract and complete the training certificate or,

3. Review the text version of VHA Privacy Policy Training PowerPoint presentation included with this contract and complete the training certificate.

The Contractor shall provide to the VA COTR a copy of the completed training certificate(s)

Security Badges/Background Investigations:

All prime contractor personnel and subcontractor personnel will be required to obtain a Flash Badge (Day Pass) prior to reporting to the jobsite. Within ten (10) business days prior to the personnel arriving at the work site, the General Contractor to whom award is made will be responsible for all personnel and subcontractor personnel completing the Background Investigation Request Worksheet and the VHA Service Center Contractor PIV Sponsorship Form and submitting it to the Personnel Security Officer at the Erie VA Medical Center. Badges will be issued to qualified personnel and must be worn and visible at all time while in VA property. The General Contractor will be responsible for completion of the VHA Security Center PIV Credentials Turn-In Inventory Report and forwarding it to the Contracting Officer at the end of the construction project. General Contractor is responsible for obtaining and turning in ALL badges.

Contractor Weekly Progress Meetings:

The contractor is required to hold weekly progress update meetings at the VA construction site with the Contracting Officer and his designated personnel to review all relevant aspects of the construction to be accomplished for current week and for the following two weeks. All pertinent issues which may affect the established construction schedule are to be raised by the contractor with possible recommended solutions to maintain schedule target dates. Contractor is responsible for generating and supplying an agenda one (1) day before the meeting to all participants of the meeting. The Contractor is also responsible for writing the detailed meeting minutes and providing them to the Contracting Officer within three (3) working days after the meeting.

Required Registration with Contractor Performance Assessment Reporting System (CPARS):

As prescribed in Federal Acquisition Regulation (FAR) Part 42.1500, the Department of Veterans Affairs (VA) evaluates General Contractor past performance on all Contracts that exceed the thresholds outlined in FAR Part 42.15, and shares those evaluations with other Federal Government Contract Specialists and procurement officials. The FAR requires that the General Contractor be provided an opportunity to comment on past performance evaluations prior to each report closing. To fulfill this requirement, VA uses an online database, the Contractor Performance Assessment Reporting System (CPARS) which is maintained by the Department of Defense. The CPARS database information is shared with the Past Performance Information Retrieval System (PPIRS) database, which is available to all Federal Agencies. Each General Contractor whose Contract award is estimated to exceed the thresholds outlined in FAR 42.15 is required to provide to the Contracting Officer contact information for the Contractor’s representative with their response to the solicitation. The Contractor is responsible to notify the Contracting Officer of any change to the Contractor’s representative during the contract performance period. Contractor’s representative contact information consists of a name and email address. The Government will register the contract within thirty days after contract award. For Contracts with a period of one year or less, the Contracting Officer will perform a single evaluation when the Contract is complete. For Contracts exceeding one year, the Contracting Officer will evaluate the General Contractor’s performance annually.

Interim reports will be filed each year until the last year of the Contract, when the final report will be completed. The report shall be assigned in CPARS to the General Contractor’s designated representative for comment. The General Contractor representative will have 30 days to submit any comments and reassign the report to the VA Contracting

Officer. Failure by the Contractor to respond within those thirty days will result in the Government’s evaluation being placed on file in PPIRS without Contractor’s comments.

Coordination Drawings:

The contractor is responsible for the submission of coordination drawings which overlay all the new and existing systems (fire protection, plumbing, HVAC, electrical, communications, etc) on one drawing, or set of drawings, per VAAR 852.236-80 Subcontracts and Work Coordination Alternate 1. No work shall commence of the new systems until the Government has approved the coordination drawings.

Submittals and RFI:

The Government has fifteen (15) working days to review and approve/disapprove Contractor required submittals or RFI’s

Project Drawings and Specifications:

The drawings and specifications are not intended to define all details, finish materials, and special construction that may be required or necessary. The Contractor shall provide all installations complete and adequate as implied by the contract specifications and contract documents.

Drawings are diagrammatic only and do not show exact routes and locations of equipment and associated wiring. The Contractor shall verify all equipment currently installed along with the work of all other trades and shall arrange their work to avoid conflicts. In the event of a conflict, the Contractor shall discuss the issues with the Contracting Officer Representative (COR) and obtain written corrective action from the Contracting Officer.

SUBMITTAL REGISTER:

The Contractor shall prepare a Submittal Register and submit all items specified in other sections of these specifications on that Submittal Register. Submit electronic file to the Contracting Officer for approval within 10 calendar days after

Notice to Proceed. The Contractor shall keep this electronic file up-to-date and shall submit it to the Government together with the monthly payment request. The approved Submittal Register will become the scheduling document and will be used to control submittals throughout the life of the contract. The Submittal Register and the progress schedules shall be coordinated. At a minimum the Submittal Register will include the following information for each submittal:

1. Transmittal number

2. Section number

3. Description of submittal

4. Date submittal will be issued for review/approval

5. Date submittal to be returned to contractor

6. Date submittal actually submitted

7. Date Submittal approved/disapproved

8. Comments – Approved/Approved as Noted/Rejected

SCHEDULING:

Submittals covering component items forming a system or items that are interrelated shall be scheduled to be coordinated and submitted concurrently. Certifications to be submitted with the pertinent drawings shall be so scheduled. Adequate time (a minimum of 15 working days exclusive of mailing time) shall be allowed and shown on the Submittal Register for review and approval. No delay damages or time extensions will be allowed for time lost in late submittals. The Contractor shall carefully control his procurement operations to ensure that each individual submittal is made on or before the Contractor scheduled submittal date shown on the approved "Submittal Register."

Upon receipt of submittals, Contractor will assign a file number thereto. In any subsequent correspondence all parties shall refer to this file and identification number to expedite replies relative to previously approved or disapproved submittals.

HWP#_______

HOT WORK PERMIT

GRINDING, CUTTING AND WELDING

WITH PORTABLE GAS OR ARC EQUIPMENT

VA Project No: ____________________________________

VA Project Name: ___________________________________________________

Name of Contractor's Firm: ____________________________________________

Date: __________

Building/Location: __________________________________

Work to Be Performed: ________________________________________________

Any Special Precautions: _______________________________________________

Fire Watch Required: ___

Site Preparation:

The location where the work is to be performed has been examined, necessary pre-cautions have been taken, and permission is granted for this work.

Signed_______________________________

(Site Supervisor)

Permit Review: Per the information contained in this permit the appropriate precautions have been taken by the supervisor and employees conducting the work and permission is granted for this work to proceed.

Signed: _________________________________

(VA Official Authorizing Hot Work)

Permit Expires: ___________________________

(Date & Time)

Information to be completed by Supervisor conducting work.

Time Hot Work Started: ______ Time Hot Work Completed: ______

ATTENTION

Before approving any cutting and welding permit, the fire safety supervisor or his appointee shall inspect the work area and confirm the precautions have been taken to prevent fire in accordance with NFPA 51B.

PRECAUTION

Sprinklers in service

Cutting and Welding equipment in good repair

WITHIN 35 FT. OF WORK

Floors swept clean of combustibles.

Combustible floors wet down, covered with damp sand, metal, or other shields.

No combustible material or flammable liquids

Combustible and flammable liquids protected with covers, guards or metal shields

All wall and floor openings covered.

Covers suspended beneath work to collect sparks.

WORK ON WALLS OR CEILINGS

Construction noncombustible and without combustible covering

Combustibles moved away from opposite side of wall

WORK ON ENCLOSED EQUIPMENT

Equipment cleaned of all combustibles

Containers purged of flammable vapors

FIRE WATCH

To be provided during and 30 minutes after operation

Supplied with extinguisher and small hose

Trained in use of equipment and in sounding fire alarm.

FINAL CHECK-UP

To be made 30 minutes after completion of any operation unless fire watch is provided.

Signed: ___________________________

(Employee Signature)

FINAL CHECK-UP

Work area and all adjacent areas to which sparks and heat might have spread (including floors above and below and on opposite sides of walls) were inspected 30 minutes after the work was completed and were found fire safe.

Signed _______________________________

VA Official

CONFINED SPACE ENTRY PERMIT

GENERAL INFORMATION Permit No .

Confined Space # and Description:___________________ Purpose of Entry:_____________________________

Location/Building: Authorized Duration of Permit: Date: to

Time: ___ to

PERMIT SPACE HAZARDS (Indicate specific hazards.) EQUIPMENT REQUIRED FOR ENTRY AND WORK

______ Oxygen deficiency (less than 19.5%) Specify as required:

______ Oxygen enrichment (greater than 23.5%) Personal Protective Equipment:

______ Flammable gases or vapors (greater than 10% f LFL) __________________________

______ Airborne combustible dust (meets or exceeds LFL) Respiratory Protection: ___________________________________

______ Toxic gases or vapors (greater than PEL) Atmospheric Tester (Orion) Calibration Date/Time____________

______ Electrical shock Atmospheric Monitor (Solaris) Calibration Date/Time:_________

______ Mechanical hazards Communication: ________________________________________

______ Materials harmful to skin Retrieval Equipment: ____________________________________

______ Engulfment Other: ________________________________________________

______ Other: ______________________________________________

PREPARATION FOR ENTRY (Check after steps have been taken) COMMUNICATION PROCEDURES

____ Notification of affected departments of service interruption To be used by Attendants and Entrants:

____ Isolation Methods: ____Lockout/tagout _____Blank/Offset

_____Double/Block/Bleed _____Purge/clean ____Inert

_____Forced Air Ventilation _____ Retrieval System EMERGENCY SERVICE METHOD OF CONTACT

_____Atmospheric test ____Opening Barriers _____Other:_______________________________________

_____Pre-entry briefing on specific hazards and control methods

_____Notify contractors of permit and hazard conditions ENTRANTS

_____List Additional permits (required and/or attached: ) I certify that I have reviewed this Permit and I am aware of the current conditions and hazards of this PRCS.

Printed Name Signature

AUTHORIZED ATTENDANTS (List by name)

Printed Name Signature

TESTING RECORD

Acceptable Result /Time Result /Time Result /Time Result /Time Result /Time Result /Time Conditions Oxygen 19.5% -23.5% _________ _________ _________ _________ _________ _________

Flammability < 10% LEL _________ _________ _________ _________ _________ _________

H2S < 10 ppm _________ _________ _________ _________ _________ _________ _________

CO < 25ppm _________ _________ _________ _________ _________ _________ _________

Toxic (specify) _________ _________ _________ _________ _________ _________ _________

AUTHORIZATION BY ENTRY SUPERVISORS

I certify that all required precautions have been taken and necessary equipment is provided for safe entry and work in this confined space.

Printed Name Signature Date Time

THIS PERMIT MUST BE POSTED ON JOB SITE – GOOD ONLY ON INDICATED DATE

Erie VAMC Outage/Services Memorandum Form

*All outage requests should be made at least 7 calendar days prior to submission for approval.

Project: Date of Request:

Date of Work: Start/Finish Time:

Responsible Party: Contact Number:

Contractor (if applicable): Contact Number:

Cost:

Outage Type: Electrical Natural Gas Steam HVAC Access/Door Elevator IT/Telecom

Other:

FACILITY INFORMATION

Building Number:

Location Description:

Systems Affected and Details of the System:

Details of Work being Performed:

Describe Interim Risks / Life-Safety measures (i.e. patient/staff safety, hospital operations, equipment security):

ADDITIONAL FORMS NEEDED: (all permits located here):

Review procedural information, fill out, and attach necessary forms

Hot Work (Burn) Permit Confined Space

Fire System Impairments ICRA Coordination

Above the Ceiling Work Permit Electrical Shutdown Coordination Form

Tag Out: Review LOCO Procedures Engineering Equipment Room Permit

NOTIFIED DEPARTMENTS/NAME OF CONTACT:

Coordination Meeting Date:

Traffic/Parking Impact

Coordination Meeting Date:

Critical Area Yes No

(Confirm if temperature, pressure, or humidity will affect supplies as pertains to outage)

Critical Area Yes No

(Confirm if temperature, pressure, or humidity will affect supplies as pertains to outage)

M&R Supervisor

List M&R Support Staff present for event:

Infection Control Nurse:

Safety:

Emergency Management:

Police:

Boiler Plant:

Bio-Medical Engineering:

OIT:

Logistics:

SPS:

Affected Department Supervisor(s):

Other:

AFTER HOURS WORK

(Include Name of POC):

Housekeeping:

PCF:

AOD:

I certify this form is complete and all affected personnel were notified, all impacts of this outage have been identified, planned for, documented, and coordinated to maintain hospital operation.

Responsible party (COR or Supervisor)

Authorized by:

Assistant Chief FMS Chief, FMS

VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance

VHA-ICRA-2023-1.0 Page 1 of 7

Introductory Information and Instructions Use this template as a baseline for performing facility Infection Control Risk Assessments (ICRAs) for construction, renovation, and maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity types and patient risk to determine the level of precautions needed to prevent infection risks. Facilities may customize this template to incorporate site-specific information and/or to add more stringent criteria.

NOTE: This VHA ICRA template pertains specifically to infection prevention. It must be used in conjunction with the required Pre-Construction Risk Assessment (PCRA) for the activity which addresses other activity-related safety concerns (e.g., vibration, noise) outside the scope of the ICRA.

To complete the template:

1. Use Table 1 to identify the category of the construction, renovation and/or maintenance activity.

2. Use Table 2 to identify the areas affected by the activity.

3. Use Table 3 to identify the overall patient risk category that will be affected by the activity.

4. Use Table 4 to determine the level of infection prevention and control precautions needed for the activity.

Once all 4 steps above are completed: Refer to Table 5 for the minimum required control measures for the level of infection prevention and control precautions needed for the activity. Refer to Table 6 for the minimum infection prevention and control measures required on completion of the activity.

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

Table 1 - Construction, Renovation, and/or Maintenance Activity Category

NOTE: If any of the bulleted criteria in a higher activity category pertains to the work that will be done (even if the other criteria are in a lower category), use the higher activity category for the VHA ICRA.

Activity Category determined from Table 1 (A, B, C, or D):

Category A

Inspection and/or facility upkeep generally defined as follows:

• Work can be completed in a single shift, not to exceed 10 hours.

• Patients and/or employees may be in the area depending on the activity.

• Work that does not create dust or debris.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection limited to 1 tile per 50 square feet with limited 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 without sanding) that do not create dust or debris.

• Limited building system maintenance such as plumbing on potable systems limited to faucet replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

B

General maintenance and repair work generally defined as follows:

• Prolonged inspection and work that may take longer than a single shift but not exceeding a week.

• Patients and employees are not to be in the area until activity is completed.

• Work that creates minimal dust and debris.

VHA-ICRA-2023-1.0 Page 2 of 7

• Interior finish or surface repairs, updates, or modifications such as repair of firewalls and barriers, and new flooring that produces minimal dust and debris. Controlled sanding activities (e.g., wet or dry sanding) that produce minimal dust and debris.

• Plumbing work such as installation or replacement of a single fixture or piping for a single fixture. Any work on sanitary plumbing including snaking of drains.

• Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that produces minimal dust and debris.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit or a single device that produces minimal dust and debris.

C

Small-scale construction, renovation, or maintenance generally defined as follows:

• Work requiring longer than a single week to complete but not exceeding 6 months.

• Patients and employees are not to be in the area until activity is completed.

• Demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements.

• Demolition/removal of more than 32 ft2 of drywall/framing, hard ceilings, and doors/framing and minimal infrastructure such as electrical circuits and branch piping.

• Installation of new walls, ceilings and doors including framing, drywall/plaster and associated work.

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing.

• Shut down of sections of potable water systems.

• 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.

• Modification of existing fire alarm and suppression systems.

• Mechanical work such as the installation of ductwork, diffusers, and terminal units for an area.

D

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.

• Large-scale demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and HVAC.

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work.

• Plumbing work such as the installation of:

o new medical gas systems, o steam/heating hot water, condensate systems, o multiple sinks, showers and toilets including associated plumbing.

• Shutdown of potable water, steam/heating hot water, condensate, and medical gas systems.

• 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.

• Installation of fire alarm and suppression systems.

• Electrical shutdown of multiple panels.

• Mechanical work such as the installation of air handling equipment, associated ductwork, diffusers, heat exchangers, terminal units and controls.

VHA-ICRA-2023-1.0 Page 3 of 7

Table 2 - Affected Area Assessment

Identify the areas and associated patients that will be affected by the construction/renovation/maintenance activity (see the Figure for a visual representation of adjacent affected areas).

Figure: Isometric drawing of affected area assessment

Area Service(s)/Type(s) of Area(s) (e.g., OR, Unit/Ward, Sterile

Processing, Administrative, etc.)*

Point of Contact (POC) POC Contact Information

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.

** List the area(s) in which the construction/renovation/maintenance activity will occur. NOTE: When the Activity Category is B, C, or D, the control measures are determined by the Patient Risk in the adjacent affected areas.

VHA-ICRA-2023-1.0 Page 4 of 7

Table 3 - Patient Risk Category

Using Table 3, identify the patient risk category for each area listed in Table 2. Of the patient risk categories identified, select the one with the greatest risk as the overall Patient Risk Category for the activity.

Overall Patient Risk Category determined from Table 3 (Low, Medium, High, or Highest):

Low Risk

Non-patient care areas such as:

Medium Risk

Patient care support areas such as:

High Risk

Patient care areas such as:

Highest Risk

Procedural, invasive, sterile support and highly compromised patient care areas such as:

• Public hallways and gathering areas not in clinical areas

• Office areas not in clinical areas

• Breakrooms not in

• Bathrooms or locker rooms not in clinical areas

• Mechanical/electrical

• Waiting areas

• Clinical engineering (biomedical)

• Materials management

• Sterile processing department – dirty side

• Kitchen, cafeteria, gift shop, coffee shop, and food kiosks

• Patient care rooms and areas, including spinal cord injury units

• All acute care units, including mental health

• All outpatient units and clinics

• Emergency department

• Community Living Centers, domiciliaries, and transitional residences

• Employee health

• Pharmacy – general work zone

• Medication rooms and clean utility rooms

• Imaging suites – diagnostic imaging

• Laboratory

• All transplant units

• All intensive care units

• All oncology units and chemotherapy/infusion centers

• OR theaters and restricted areas

• Hemodialysis units

• Procedural rooms*

• Pharmacy compounding area

• Sterile processing department – clean side

• Transfusion services interventional imaging

• Dedicated isolation wards/units for infectious diseases

* Procedural Rooms are designated for the performance of patient care activities that may require high-level disinfected or sterile instruments and some environmental controls but is not required to be performed with the environmental controls of an operating room (OR). The room is intended for procedures that are performed in an aseptic surgical field and penetrates the protective surfaces of a patient’s body (e.g., subcutaneous tissue, mucous membranes, cornea) or entry into or opening of a sterile body cavity. Examples of these spaces include Cardiac Catheterization Suites, Electrophysiology Suites, Endovascular/GI Suites, Angio Suites and other spaces which may have high risk patient populations.

VHA-ICRA-2023-1.0 Page 5 of 7

Table 4 - Level of Infection Prevention and Control Precautions

Match the Overall Patient Risk Category (Low, Medium, High, Highest) determined from Table 3 with the planned Construction/Renovation/Maintenance Activity Category (A, B, C, D) from Table 1 to determine the minimum Level of Infection Prevention and Control Precautions (I, II, III, or IV) using Table 4 below.

Level of Precautions determined from Table 4 (I, II, III, or IV):

An infection prevention and control permit is required for Level III and Level IV. Consult with Infection Prevention and Control for Level I and Level II.

Table 5 - Required Infection Prevention and Control Measures, by Level of Precautions Controls defined below for the Level of Precautions identified 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 Precaution Level must also include the control measures in the preceding Level(s).

As the activity progresses, a full re-evaluation of remaining activity type and patient risk is required prior to downgrading the Level of Precautions.

Level of Precautions

Control Measures

Level I

1. Perform work activity in a manner that does not create dust.

2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

Level II

All control measures in Level I and the following:

1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence. Rebalance system to address diffuser isolation.

Patient Risk Category

Activity Category

A B C D Low Risk I II II III Medium Risk I II III IV High Risk I II IV IV Highest Risk II III IV IV

VHA-ICRA-2023-1.0 Page 6 of 7

4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall be flushed twice a week or isolated from the main system.

5. Seal doors to prevent dust migration.

6. Contain all trash and debris in the work area. Perform daily cleaning and disposal of trash (covered) from work area using an identified exit route.

7. Any equipment, tools, or materials removed from the work area must be in sealed containers and/or cleaned of dust and debris prior to removal from the area.

8. Nonporous/smooth and cleanable containers (with a hard lid) must be used to transport trash and debris from the construction areas. These containers must be damp-wiped cleaned and free of visible dust/debris before leaving the contained work area.

9. Install a sticky (dust collection) mat at entrance of contained work area based on facility policy. Sticky mats must be changed routinely and when visibly soiled.

10. Maintain clean surroundings when area is not contained by damp mopping or HEPA vacuuming surfaces at least daily.

Level III

All control measures in Levels I and II and the following:

1. Ensure availability of equipment for cleaning hands.

2. Construct and complete critical barriers meeting NFPA 241 requirements. Barriers must extend to the ceiling or if ceiling tile is removed, to the deck above.

3. All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to floor and ceiling (or floor/roof deck above) and secure from movement or damage.

4. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop if applicable for barrier type).

5. Maintain .01 inches /water gauge negative pressurization of the entire workspace by use of HEPA exhaust air systems directed outdoors (unless a work specific waiver is approved by VHA’s Office of Healthcare Engineering); this must be maintained continuously 24/7 for the duration of the project. Exhaust discharged directly to the outdoors that is 25 feet or greater from entrances, air intakes and windows is not required to be HEPA-filtered. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

6. Install a differential pressure sensing device (e.g., magnehelic, manometer, or digital monitoring) on exterior of work containment to continually monitor and document negative pressurization. The “ball in the wall” or similar apparatus are not acceptable.

Level IV

All control measures in Levels I, II and III and the following:

1. Barriers must be hard barriers unless temporary to install final barrier.

2. Containment must include an anteroom to ensure pressure control. Anteroom must be large enough for equipment staging, cart cleaning, workers’ PPE and cleaning.

3. Worker clothing and/or PPE must be removed or clean and free of visible dust before leaving the work area anteroom. HEPA vacuuming of clothing or use of cover suits is acceptable.

4. Workers must wear shoe covers or have a method to clean shoes in anteroom.

Shoe covers must be removed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be changed immediately.

VHA-ICRA-2023-1.0 Page 7 of 7

Table 6 - Minimum Infection Prevention and Control Measures Required Upon Completion of the Activity

Controls defined below shall be completed upon completion of the activity and inspected prior to terminating measures defined in Table 5.

Precautions Measures

Levels I - II

Cleaning:

1. Clean work areas including all environmental surfaces, high horizontal surfaces and flooring materials.

2. Check all supply and return air registers for dust accumulation on upper surfaces as well as air diffuser surfaces.

HVAC Systems:

1. Remove isolation of HVAC system in areas where work is being performed. Verify that HVAC systems are clean and operational.

2. Verify the HVAC systems meet original airflow and air exchange design specifications.

Water systems:

1. Until the potable water system is activated and in use, flushing shall continue at least twice per week in accordance with VHA Directive 1061.

Levels III - IV

Construction areas must be inspected by an infection preventionist and engineering representative (and others as determined by the facility) for final activity/project close out and removal of infection prevention and control measures.

Work Area Cleaning:

1. Clean work areas including all environmental surfaces, high horizontal surfaces and flooring materials.

2. Check all supply and return air registers for dust accumulation on upper surfaces as well as air diffuser surfaces.

Removal of Critical Barriers:

1. Critical barriers must remain in place during all work involving drywall removal, creation of dust and activities beyond simple touch-up work. The barrier may NOT be removed until a work area cleaning has been performed. Additional cleaning may be needed after removal of barrier.

2. All (plastic or hard) barrier removal activities must be completed in a manner that prevents dust release. Use the following precautions when removing hard barriers:

i. Carefully remove screws and painter tape.

ii. If dust will be generated during screw removal, use hand-held HEPA vacuum.

iii. Drywall cutting is prohibited during removal process.

iv. Clean all stud tracks with HEPA vacuum before removing outer hard barrier.

v. Use a plastic barrier to enclose area if dust could be generated.

Negative Air Requirements:

1. The use of negative air must be designed to remove contaminants from the work area.

2. Negative air devices (fans, filters, monitoring and documentation equipment) must remain operational at all times and in place for a period after completion of dust creating activities to remove contaminants from the work area and before removal of critical barriers.

HVAC systems:

1. Upon removal of critical barriers, remove isolation of HVAC system in areas where work is being performed.

2. Verify that HVAC systems are clean and operational.

3. Verify and document through a TAB the HVAC systems meets original airflow and air exchange design specifications.

Water systems:

1. Until the potable water system is activated and in use, flushing shall continue at least twice per

VHA-ICRA-2023-1.0

Infection Prevention and Control Construction/Renovation/Maintenance Permit This page must be posted at the entrance to the project area for Level III and Level IV activities.

Unique permit number:

Location of construction/renovation/maintenance Project manager Project start date Contact phone number Completion date Contractor Permit expiration date

Activity Category (A, B, C, or D)

Overall Patient Risk Category (Low, Medium, High, or Highest)

Level of Infection Prevention and Control Precautions (I, II, III, or IV)

Level of Precautions

Control measures to be in place for the duration of the activity (Check the box for the activity’s Level of Precautions to indicate the Control Measures)

Level I

1. Perform work activity in a manner that does not create dust.

2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

Level II

All control measures in Level I and the following:

1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence. Rebalance system to address diffuser isolation.

4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall be flushed twice a week or isolated from the main system

5. Seal doors, to prevent dust migration.

6. Contain all trash and debris in the work area. Perform daily cleaning and disposal of trash (covered) from work area using an identified exit route.

7. Any equipment, tools, or materials removed from the work area must be in sealed containers and/or cleaned of dust and debris prior to removal from the area.

8. Nonporous/smooth and cleanable containers (with a hard lid) must be used to transport trash and debris from the construction areas. These containers must be damp-wiped cleaned and free of visible dust/debris before leaving the contained work area.

9. Install a sticky (dust collection) mat at entrance of contained work area based on facility policy. Sticky mats must be changed routinely and when visibly soiled.

10. Maintain clean surroundings when area is not contained by damp mopping or HEPA vacuuming surfaces at least daily.

Level III

All control measures in Levels I and II and the following:

1. Ensure availability of equipment for cleaning hands.

2. Construct and complete critical barriers meeting NFPA 241 requirements. Barriers must extend to the ceiling or if ceiling tile is removed, to the deck above.

3. All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to floor and ceiling (or floor/roof deck above) and secure from movement or damage.

4. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop if applicable for barrier type).

5. Maintain .01 inches /water gauge negative pressurization of the entire workspace by use of HEPA exhaust air systems directed outdoors (unless a work specific waiver is approved by VHA’s Office of Healthcare Engineering); this must be maintained continuously 24/7 for the duration of the project. Exhaust discharged directly to the outdoors that is 25 feet or greater from entrances, air intakes and windows is not required to be HEPA-filtered. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

6. Install a differential pressure sensing device (e.g., magnehelic, manometer, or digital monitoring) on exterior of work containment to continually monitor and document negative pressurization. The “ball in the wall” or similar apparatus are not acceptable.

Level IV

All control measures in Levels I, II and III and the following:

1. Barriers must be hard barriers unless temporary to install final barrier.

2. Containment must include an anteroom to ensure pressure control, Anteroom must be large enough for equipment staging, cart cleaning, workers’ PPE and cleaning.

3. Worker clothing and/or PPE must be removed or clean and free of visible dust before leaving the work area anteroom. HEPA vacuuming of clothing or use of cover suits is acceptable.

4. Workers must wear shoe covers or have a method to clean shoes in anteroom Shoe covers must be removed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be changed immediately.

Additional requirements:

Project Manager signature Date

Infection Preventionist signature Date

VHA-ICRA-2023-1.0 Page 1 of 7

Introductory Information and Instructions Use this template as a baseline for performing facility Infection Control Risk Assessments (ICRAs) for construction, renovation, and maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity types and patient risk to determine the level of precautions needed to prevent infection risks. Facilities may customize this template to incorporate site-specific information and/or to add more stringent criteria.

NOTE: This VHA ICRA template pertains specifically to infection prevention. It must be used in conjunction with the required Pre-Construction Risk Assessment (PCRA) for the activity which addresses other activity-related safety concerns (e.g., vibration, noise) outside the scope of the ICRA.

To complete the template:

1. Use Table 1 to identify the category of the construction, renovation and/or maintenance activity.

2. Use Table 2 to identify the areas affected by the activity.

3. Use Table 3 to identify the overall patient risk category that will be affected by the activity.

4. Use Table 4 to determine the level of infection prevention and control precautions needed for the activity.

Once all 4 steps above are completed: Refer to Table 5 for the minimum required control measures for the level of infection prevention and control precautions needed for the activity. Refer to Table 6 for the minimum infection prevention and control measures required on completion of the activity.

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

Table 1 - Construction, Renovation, and/or Maintenance Activity Category

NOTE: If any of the bulleted criteria in a higher activity category pertains to the work that will be done (even if the other criteria are in a lower category), use the higher activity category for the VHA ICRA.

Activity Category determined from Table 1 (A, B, C, or D):

A

Inspection and/or facility upkeep generally defined as follows:

• Work can be completed in a single shift, not to exceed 10 hours.

• Patients and/or employees may be in the area depending on the activity.

• Work that does not create dust or debris.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection limited to 1 tile per 50 square feet with limited 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 without sanding) that do not create dust or debris.

• Limited building system maintenance such as plumbing on potable systems limited to faucet replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

B

General maintenance and repair work generally defined as follows:

• Prolonged inspection and work that may take longer than a single shift but not exceeding a week.

• Patients and employees are not to be in the area until activity is completed.

• Work that creates minimal dust and debris.

VHA-ICRA-2023-1.0 Page 2 of 7

• Interior finish or surface repairs, updates, or modifications such as repair of firewalls and barriers, and new flooring that produces minimal dust and debris. Controlled sanding activities (e.g., wet or dry sanding) that produce minimal dust and debris.

• Plumbing work such as installation or replacement of a single fixture or piping for a single fixture. Any work on sanitary plumbing including snaking of drains.

• Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that produces minimal dust and debris.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit or a single device that produces minimal dust and debris.

C

Small-scale construction, renovation, or maintenance generally defined as follows:

• Work requiring longer than a single week to complete but not exceeding 6 months.

• Patients and employees are not to be in the area until activity is completed.

• Demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements.

• Demolition/removal of more than 32 ft2 of drywall/framing, hard ceilings, and doors/framing and minimal infrastructure such as electrical circuits and branch piping.

• Installation of new walls, ceilings and doors including framing, drywall/plaster and associated work.

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing.

• Shut down of sections of potable water systems.

• 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.

• Modification of existing fire alarm and suppression systems.

• Mechanical work such as the installation of ductwork, diffusers, and terminal units for an area.

D

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.

• Large-scale demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and HVAC.

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work.

• Plumbing work such as the installation of:

o new medical gas systems, o steam/heating hot water, condensate systems, o multiple sinks, showers and toilets including associated plumbing.

• Shutdown of potable water, steam/heating hot water, condensate, and medical gas systems.

• 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.

• Installation of fire alarm and suppression systems.

• Electrical shutdown of multiple panels.

• Mechanical work such as the installation of air handling equipment, associated ductwork, diffusers, heat exchangers, terminal units and controls.

VHA-ICRA-2023-1.0 Page 3 of 7

Table 2 - Affected Area Assessment

Identify the areas and associated patients that will be affected by the construction/renovation/maintenance activity (see the Figure for a visual representation of adjacent affected areas).

Figure: Isometric drawing of affected area assessment

Area Service(s)/Type(s) of Area(s) (e.g., OR, Unit/Ward, Sterile

Processing, Administrative, etc.)*

Point of Contact (POC) POC Contact Information

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.

** List the area(s) in which the construction/renovation/maintenance activity will occur. NOTE: When the Activity Category is B, C, or D, the control measures are determined by the Patient Risk in the adjacent affected areas.

VHA-ICRA-2023-1.0 Page 4 of 7

Table 3 - Patient Risk Category

Using Table 3, identify the patient risk category for each area listed in Table 2. Of the patient risk categories identified, select the one with the greatest risk as the overall Patient Risk Category for the activity.

Overall Patient Risk Category determined from Table 3 (Low, Medium, High, or Highest):

Low Risk

Non-patient care areas such as:

Medium Risk

Patient care support areas such as:

High Risk

Patient care areas such as:

Highest Risk

Procedural, invasive, sterile support and highly compromised patient care areas such as:

• Public hallways and gathering areas not in clinical areas

• Office areas not in

• Breakrooms not in

• Bathrooms or locker

• Mechanical/electrical

• Waiting areas

• Clinical engineering (biomedical)

• Materials management

• Sterile processing department – dirty side

• Kitchen, cafeteria, gift shop, coffee shop, and food kiosks

• Patient care rooms and areas, including spinal cord injury units

• All acute care units, including mental health

• All outpatient units and clinics

• Emergency department

• Community Living Centers, domiciliaries, and transitional residences

• Employee health

• Pharmacy – general work zone

• Medication rooms and clean utility rooms diagnostic imaging

• Laboratory

• All transplant units

• All intensive care units

• All oncology units and chemotherapy/infusion centers

• OR theaters and restricted areas

• Hemodialysis units

• Procedural rooms*

• Pharmacy compounding area

• Sterile processing department – clean side

• Transfusion services interventional imaging

• Dedicated isolation wards/units for infectious diseases

* Procedural Rooms are designated for the performance of patient care activities that may require high-level disinfected or sterile instruments and some environmental controls but is not required to be performed with the environmental controls of an operating room (OR). The room is intended for procedures that are performed in an aseptic surgical field and penetrates the protective surfaces of a patient’s body (e.g., subcutaneous tissue, mucous membranes, cornea) or entry into or opening of a sterile body cavity. Examples of these spaces include Cardiac Catheterization Suites, Electrophysiology Suites, Endovascular/GI Suites, Angio Suites and other spaces which may have high risk patient populations.

VHA-ICRA-2023-1.0 Page 5 of 7

Table 4 - Level of Infection Prevention and Control Precautions

Match the Overall Patient Risk Category (Low, Medium, High, Highest) determined from Table 3 with the planned Construction/Renovation/Maintenance Activity Category (A, B, C, D) from Table 1 to determine the minimum Level of Infection Prevention and Control Precautions (I, II, III, or IV) using Table 4 below.

Level of Precautions determined from Table 4 (I, II, III, or IV):

An infection prevention and control permit is required for Level III and Level IV. Consult with Infection Prevention and Control for Level I and Level II.

Table 5 - Required Infection Prevention and Control Measures, by Level of Precautions Controls defined below for the Level of Precautions identified 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 Precaution Level must also include the control measures in the preceding Level(s).

As the activity progresses, a full re-evaluation of remaining activity type and patient risk is required prior to downgrading the Level of Precautions.

Precautions

Control Measures

Level I

1. Perform work activity in a manner that does not create dust.

2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

Level II

All control measures in Level I and the following:

1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence. Rebalance system to address diffuser isolation.

Patient Risk Category

Activity Category

A B C D Low Risk I II II III Medium Risk I II III IV High Risk I II IV IV Highest Risk II III IV IV

VHA-ICRA-2023-1.0 Page 6 of 7

4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall…