EXHIBIT10_VAPA ICRA V1_3.pdf

VHA Infection Control Risk Assessment (ICRA) for Construction, Renovation and Maintenance

VAPA ICRA 1.3 12.9.2024

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. This 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.

Infection Prevention and Control Construction/Renovation/Maintenance Permit (last page) should be posted at the entrance of the project. 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 Jayasree Sureshkumar RN (x64849) or Maribel Marron RN (x67533) Menlo Park – Jackie Dugyon-Escalante RN (52-22999) Livermore - Maricar Telmo RN (53-32260)

To complete the template:

• Table 1 ((Project Manager to complete) to identify the category of the construction, renovation and/or maintenance activity.

• Table 2 (Project Manager to complete) to identify the areas affected by the activity.

• Table 3 (Infection Prevention & Control to complete) to identify the overall patient risk category that will be affected by the activity.

• Table 4 (Infection Prevention & Control to complete) 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.

Project #: _____________________

Project Title: __________________________________________________________

Project Location: _______________________________________________________

Project Start Date: _________________ Estimated Duration: _______________

COR (print): ________________________________ Phone: ________________

Table 1: (Project Manager to complete) 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):

VAPA ICRA 1.3 12.9.2024

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.

• 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.

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.

D

• 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.

Table 2:(Project Manager to complete) 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.

Table 3 Infection Prevention & Control: 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 clinical areas

• Bathrooms or locker rooms not in clinical areas

• Mechanical/electrical rooms not in clinical areas

• Outside spaces

• 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, domiciliary, and transitional residences

• Employee health

• Pharmacy – general work zone

• Medication rooms and clean utility rooms

• Imaging suites – diagnostic imaging

• Laboratory

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

• Imaging suites – 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.

Additional Risk Assessment:

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? Yes No Comments: ________________________________________________________

3. Will the removal of debris pass through patient care areas? Yes No Comments: _________________________________________________________

4. Is Legionella and other environment water testing required before occupancy? Yes No

5. Is there possible exposure to active TB in the construction area? Yes No

If yes, contractor must provide documentation of TB screening result of construction workers within 90 days of work commencing. Anyone with positive TB screening must show proof of starting treatment.

Table 4 (Infection Prevention & Control to complete): 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. ICRA should be completed for all projects regardless of Precaution Level.

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:

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

VAPA ICRA 1.3 12.9.2024

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 other approved dust containment system or process).

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. 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, or comply with the alternative method outlined in Appendix A of this document. These control measures must be maintained continuously 24/7 for the duration of the project. HEPA filtered exhaust if discharged directly to the outdoors must be at a distance of 25 feet or greater from entrances, air intakes and operable windows. 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.

VAPA ICRA 1.3 12.9.2024

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.

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.

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

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 overnight stay areas.

Levels III - IV

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.

VAPA ICRA 1.3 12.9.2024

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 week in accordance with VHA Directive 1061.

Keep this ICRA on file Post

Infection Prevention and Control Construction/Renovation/Maintenance Permit At Work Site

Additional requirements:

Reviewed by: Project Manager name: Infection Preventionist name:

Project Manager signature

Date

Infection Preventionist signature

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)

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 i f 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.

Check box to indicate exhaust method: Exterior ☐ Alternative Interior Method ☐

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

Appendix A: Alternative To Outdoor Exhaust Requirements This Appendix provides an equivalent ICRA control measure to requirements detailed in this VHA ICRA template (Table 5 Level III, item 5) that would allow interior construction space exhaust.

Interior Construction Space Exhaust:

If the facility is not able to exhaust to the building exterior, the Healthcare Environment and Facilities program office has identified an alternate industry-recognized standard interior exhaust procedure that is accepted as providing an equivalent level of infection prevention and control (IPC), and safety. The alternate interior exhaust procedure is implemented by completing the following:

a. If exhaust is directed indoors, then the system must be HEPA filtered. Prior to start of work, including assembly of the ICRA barriers, initial baseline air sampling measurements for particulate levels must be taken in the planned area of discharge. Once containment is erected and completed, HEPA filtration must then be verified by particulate measurement, using a particle counter with multi-channel capabilities to measure down to 0.3 microns, to confirm that the discharge of the HEPA unit does not exceed the baseline particulate count of the area to which the exhaust is directed. Verification must continue at least three times per day (once every 8 hours), 7 days per week, during the use of the negative air machine and HEPA filter. Any exceedance must trigger a work stoppage and an immediate response and resolution. All particulate measurements, including the baseline measurement, must be documented and retrievable.

b. To accommodate the sampling, the negative air pressure machine must be fitted with a 2 ft section of rigid ductwork at the discharge. The sample port for monitoring must be in the rigid ductwork section.

c. Vapor generating processes must be assessed and appropriate filtration must be installed to mitigate transmission to the facility.

d. Engineering must do a complete flow and pressure analysis and document the area to which the air is being discharged to ensure the flow and pressure relationships in that area are not being adversely impacted by the additional flow. Ideally, this is done as part of the construction package to ensure the design is implementable and no additional HVAC changes are required to accommodate the exhaust from the negative air equipment.

e. Install device on exterior of work containment to continually monitor negative pressurization. To ensure proper pressure is continuously maintained, the device(s) shall have a visual pressure indicator, data collection and alarm.

f. Exhaust must be directed to Low Risk areas as defined in Table 3 in this VHA ICRA template. Ideally this discharge must be located so as not to impinge on high traffic areas or create a nuisance with noise or excessive airflow.

NOTE: Exhaust into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is not acceptable.