Exhibit 3 ICRA Form.pdf

3/2021

Infection Control Risk Assessment Matrix

Please complete this form, attach the Scope of Work document and submit this form to the Infection Prevention and Control contact as follows:

PAD - Laura Markman RN (x64168) or Adrianne Tong RN (x67533) Menlo Park – Jackie Dugyon-Escalante RN (x22999) Livermore - Maricar Telmo RN (x32260)

Project #: _____________________

Project Title: __________________________________________________________

Project Location: _______________________________________________________

Project Start Date: _________________ Estimated Duration: _______________

COR (print): ________________________________ Phone: ________________

Part I (Engineering to complete):

Using the following table, identify the type of construction project activity (Types A-D):

Type A Inspection and Non-invasive Activities Includes, but is not limited to:

• Removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet;

• Painting but not sanding; and

• Wall covering, electrical trim work, minor plumbing and other 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; and

• 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 floor coverings, ceiling tiles and casework;

• New wall construction;

• Minor duct work or electrical work above ceilings;

• Major cabling activities; and

• Any activity which cannot be completed within a single work shift.

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; and

• New construction.

Type (circle one): A B C D

Part II (Engineering to complete):

Please answer the following questions (circle yes or no):

1. Is disruption of essential services (e.g., ventilation, water) to patients/employees anticipated?

Yes No Comments: ______________________________________________________

2. Is relocation of patients to alternate units required or being considered?

3. Will the removal of debris pass through patient care areas?

Part III (Infection Prevention/Control to complete):

Using the following table, identify the patient risk groups that will be affected:

Low Risk

Medium Risk

High Risk

Highest Risk

Office areas - Cardiology

- Echocardiography

- Endoscopy

- Nuclear medicine

- Physical therapy

- Radiology/MRI

- Respiratory therapy

- CCU

- Emergency room

- Labor and delivery

- Laboratories

- Newborn nursery

- Outpatient surgery

- Pediatrics

- Pharmacy

- Post anesthesia

- Any area caring for immunocompromised patients

- Burn unit

- Cardiac cath lab

- Central sterile supply

- Intensive care units

- Medical unit

- Negative pressure isolation rooms

- Oncology

- ORs

Risk Level (circle one): Low Medium High Highest

Part IV (Infection Prevention/Control to complete):

Using the following table, identify the Precaution Class (I, II, III, or IV) or level of infection control activities required for the planned construction project. Match the construction type (A,B,C,D) with the risk level (low, medium, high, highest).

Patient Risk Group Type A Type B Type C Type D

LOW risk I II II III/IV

MEDIUM risk I II III IV

HIGH risk I II III/IV IV

HIGHEST risk II III/IV III/IV IV

Source: Virginia Kennedy, St. Luke’s Episcopal Hospital, Houston/ icanPREVENT.com

Precaution Class (circle one): I II III IV

Precaution Classes (Levels of Required Infection Control Activities)

All precautions in the determined class must be followed:

Class Precautions/procedures that are required for each class

I During work:

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

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

3. Minimize traffic (decrease exposure of patients to construction).

4. If disruption of water supply is necessary, schedule interruptions during low activity.

After work: General clean up as needed

II During work:

1. All Class I activities listed above

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

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

4. Seal unused doors with duct tape.

5. Block off and seal air vents.

6. Provide and use walk-off mats at work areas. Replace used mats with new mats in accordance with manufacturer’s recommendations and when dirty.

7. Contain construction waste before transport in tightly covered containers. For removal of construction waste, follow pre-determined route.

8. Seal off isolate heating, ventilation and air conditioning (HVAC) system in areas where work is being performed.

After work:

1. Clean and wipe work surfaces with hospital-approved disinfectant.

2. Wet mop and/or vacuum with HEPA-filtered vacuum before leaving the work area.

3. Remove isolation of HVAC system from work area.

III During work:

1. All Class I and II activities listed above

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

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

4. Cover transport receptacles or carts. Tape covering unless the cart has a solid lid.

1. Do NOT remove barriers from work area until completed project is inspected by the Safety Office and Infection Control and the area has been thoroughly cleaned by Environmental Management.

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

3. Vacuum work area with HEPA-filtered vacuums.

4. Wet mop area with hospital-approved disinfectant.

5. Remove isolation of HVAC system in area where work is being performed.

Class Activity

IV During work:

1. All Class I, II, and III activities listed above

2. Relocate patients away from construction areas.

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

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

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

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

7. Provide and use adhesive walk-off mats within the anteroom. Replace used mats with new mats in accordance with manufacturer’s recommendations and when dirty.

8. Contain construction waste before transport in tightly covered clean (wiped clean with wet cloth) containers. For removal of construction waste, follow pre-determined route.

9. Construction/work area should be periodically inspected by Safety Office and Infection Control as appropriate

1. Do NOT remove barriers from work area until completed project is inspected by the Safety Office and Infection Control and the area has been thoroughly cleaned by Environmental Management.

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. Vacuum work area with HEPA-filtered vacuums.

5. Wet mop area with hospital-approved disinfectant.

6. Remove isolation of HVAC system in area where work was performed.

Additional Risk Assessment (Completed by IPC only):

Is work being conducted in area where exposure to active TB is possible? Yes / No.

If yes, contractor must provide documentation that construction workers have been screened for active TB within 90 days of work commencing. Anyone screening positive must show proof of being on treatment.

Legionella Risk – Is Legionella and other environment water testing required before occupancy Yes / No

Additional Comments:

Part V: Persons completing the Infection Control Risk Assessment:

Print name (Engineering) Signature Date

Print name (Infection Prevention/Control) Signature Date