S02 Atch E PCRA TR Bathrooms - 10 pages.pdf

PCRA Request #168

Initiated by Ellexis BakerPCRA ILSM ICRA

Nebraska Western-Iowa HCS Submitted 4/11/2025

Chair: Approved by vhaomalongs 4/23/2025

1: Location of Project * x Grand Island

1.1: Select which Sections will be required for this request

(Answer yes only for the section(s) needed)

1.1.1: PCRA *

x Yes

1.1.2: ILSM *

x Yes 1.1.3: Patient Safety * x Yes

1.1.4: ICRA *

x Yes

1.1.5: Pre-Construction Risk Assessment (PCRA) Permit 1.1.5.1: Activity Type x Small-scale

1.1.5.1.1: Control measures to be in place for the duration of the activity1. Immediately replace any ceiling tile, close access panels, etc., upon completion of work. 2. Site visits of construction area are required weekly by member of multi-disciplinary team. Site visits will be documented on standard checklist. 3. Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor and approved.4. Must address identified hazards and controls that will be implemented to ensure minimal impact patients, employees, contractors and facility.5. Communication and coordination plan for all affected areas

1.1.5.1.2: All control measures in the row above and the following:

1. Hazard communication chemical inventory required to be provided by the contractor and approved.2. ILSMs in place and staff trained on situation3. Hot Work or burn permits in place and staff trained4. LOTO procedures in place and staff trained on their use5. Site visits will be reviewed using the criteria in standardized guide.6. Daily inspections of the site are to be conducted by the

PCRA ILSM ICRA 1Continued on the next page.

General Contractor and documented on their daily log.

1.1.5.1.3: All control measures in both rows above and the following Activity Hazard Analyses and Control Plans as applicable (check all that apply):

1.1.5.2: Additional Requirements

C, High, IV

1.1.5.3: Attach any necessary documents

1.1.6: Interim Life Safety Measures (ILSM)

1.1.6.1: Evaluated Items 1.1.6.1.1: 1. Will required exit(s) or other means of egress be affected? * x No 1.1.6.1.1.1: *Will pathways or exits be blocked?

1.1.6.1.1.1.1: Potential actions to be taken:*Personnel in the building will receive training on alternate routes and exits. (EP13)*Construction areas will have designated and marked exits to be clear at all times- check daily. (EP4)*Exit signage will be updated to direct occupants to nearest exit. (EP3) 1.1.6.1.2: 2. Will access to emergency services (fire, police, ambulance, etc.) be impacted? * x No 1.1.6.1.2.1: *Will access to fire hydrants, Fire Department connections (interior/exterior) be blocked?*Any road closures?

1.1.6.1.2.1.1: Potential actions to be taken:Construction plans will be reviewed to ensure proper access will be maintained.

1.1.6.1.3: 3. Will any fire detection or suppression system be impaired? * x No 1.1.6.1.3.1: *Will alarms be out of service 8 or more hours in 24 hours or sprinklers out of service more than 10 hours in 24 hours in an occupied building? (EP2)

1.1.6.1.3.1.1: Potential actions to be taken:*Fire watch/Fire Department Notification (EP8)*A temporary but equivalent system must be provided when any fire system is impaired.(EPD). Temporary systems must be inspected and tested monthly (EP12).*Additional fire extinguishers shall be brought to the area (EP6).

1.1.6.1.4: 4. Will the project require a temporary barrier (e.g. fire resistant poly or 1 hour rated wall? * x Yes 1.1.6.1.4.1: *Barrier required by Infection Control?

*Demolition, renovation, or construction activities require a barrier between construction and occupied areas to limit access, noise, dust, and spread of smoke. Fire rated walls may be needed.

PCRA ILSM ICRA 2Continued on the next page.

*Barrier required by Infection Control?

*Demolition, renovation, or construction activities require a barrier between construction and occupied areas to limit access, noise, dust, and spread of smoke. Fire rated walls may be needed. continued x Yes

1.1.6.1.4.1.1: Potential actions to be taken:*Erect temporary construction barriers that won't allow smoke into the area and that are made of fire-resistant materials (EP7).*Increase surveillance

(EPE).

1.1.6.1.5: 5. Will fire hazard be higher? * x No 1.1.6.1.5.1: *Will hot work (e.g. burning, welding, cutting, brazing, soldering, grinding) be required?*Will project require the use of flammable materials?

1.1.6.1.5.1.1: Potential actions to be taken:*Provide additional fire fighting equipment (EP6) and train staff in its use (EP10).*Obtain Hot Work Permit, if required.*Increase surveillance (EP8).

1.1.6.1.6: 6. Will the project require the storage of flammable or combustible materials? * x No 1.1.6.1.6.1: *Increased trash due to debris removal?*Will construction debris need to be stored in the area as timely removal would be impossible (e.g. freight elevator not working)?

1.1.6.1.6.1.1: Potential actions to be taken:*Control combustible load.*Implement housekeeping protocols (EP9).*Enforce housekeeping and debris removal practices.*Fire watch*Increase surveillance (EP8).

1.1.6.1.7: 7. Will the project warrant additional fire drills? * x No 1.1.6.1.7.1: *Safety department will evaluate effects of work on life safety and determine if there is a need to increase frequency of drills.

1.1.6.1.7.1.1: Potential actions to be taken:Conduct a minimum of two fire drills per shift per quarter (EP11).

1.1.6.1.8: 8. Will smoking be permitted in construction areas? * x No

1.1.6.1.8.1: Smoking is prohibited on VA property. This includes, but is not limited to, cigarettes, cigars, pipes, chew, e-cigarettes/cigars, and vape pens.

1.1.6.1.8.2: Potential actions to be taken:Refer to NWI Smoking Policy 1.1.6.1.9: 9. Will any smoke/firewalls, doors, assemblies and/or other structural features be impaired? * x No 1.1.6.1.9.1: *Are you working on a fire/smoke wall, hazardous area, on floor/ceiling slab, suite doors? Verify area on LS Drawings?

PCRA ILSM ICRA 3Continued on the next page.

1.1.6.1.9.1.1: Potential actions to be taken:*Contact Safety if questions.*Train staff to compensate for impaired structural or compartmentalization features of life safety and/or fire safety, such as doors and walls (EP14).*Increase surveillance (EP8).

1.1.6.1.10: 10. Will any additional training be required? (Select YES if any of the above questions were answered YES) * x No

1.1.6.1.10.1: Potential actions to be taken:Conduct education programs to promote awareness of LSC building deficiencies, construction hazards, alternate exit routes, and

ILSMs.

1.1.6.2: Additional Requirements

This permit is only for the bathrooms section of the attached SOW.

1.1.6.3: Attach any necessary documents

1.1.7: Patient Safety

1.1.7.1: CONSTRUCTION ACTIVITY

1.1.7.1.1: Does this project involve a patient care area?

x No 1.1.7.1.2: Is this project adjacent to a patient care area?

x No 1.1.7.1.3: Will this project alter patient access/egress to/from the building/patient care area, either temporarily or permanently?

x No 1.1.7.1.4: Access/Egress

1.1.7.1.5: Hazardous Areas/Materials

1.1.7.1.6: Critical clinical alarms should be functional and audible within and adjacent to the construction zone. Including but not limited to:

1.1.7.1.7: Additional requirements

1.1.7.1.8: Attach any necessary documents

1.1.8: ICRA

1.1.8.1: Level of Precautions Select the Level determined in the Table above x Level IV

PCRA ILSM ICRA 4Continued on the next page.

1.1.8.1.1: Control measures to be in place for the duration of the activity:Level I1. 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.

1.1.8.1.2: 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 system5. 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.

1.1.8.1.3: Level IIIAll 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

PCRA ILSM ICRA 5Continued on the next page.

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.

1.1.8.1.4: Level IVAll 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.

1.1.8.2: Additional Requirements

1.1.8.3: Attach any necessary documents 1.1.8.4: Category Type * x Category C

1.1.8.4.1: Category AInspection 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

PCRA ILSM ICRA 6Continued on the next page.

replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

1.1.8.4.2: Category BGeneral 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.

1.1.8.4.3: Category CSmall-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.

PCRA ILSM ICRA 7Continued on the next page.

• Modification of existing fire alarm and suppression systems.

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

1.1.8.4.4: Category DLarge-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.

1.1.8.5: Affected Area AssessmentIdentify the areas and associated patients that will be affected by the construction/renovation/maintenance activity.There may be more than one Service/type of area for each row. List all

1.1.8.5.1: Activity Area * Service/Type of Area(s) (e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc.)

Point of Contact (POC) POC Contact Information

Building 5, Transitioning house bathrooms (single floor)

Kelly Arends 308.382.3660 x3261

1.1.8.5.2: Area Above * Service/Type of Area(s) Point of Contact (POC) POC Contact Information

Roof Benjamin Redman (308) 382-3660 x 2413

PCRA ILSM ICRA 8Continued on the next page.

1.1.8.5.3: Area Below * Service/Type of Area(s) Point of Contact (POC) POC Contact Information none N/A N/A

1.1.8.5.4: Adjacent Area(s): Add Additional Rows as Needed * Service/Type of Area(s) Point of Contact (POC) POC Contact Information

Bedroom Kelly Arends 308.382.3660 x3261

Bathroom Kelly Arends 308.382.3660 x3261

Hallway Kelly Arends 308.382.3660 x3261

1.1.8.6:

1.1.8.7: Level of Infection Prevention and Control Precautions * x High Risk

1.1.8.7.1: Low RiskNon-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

1.1.8.7.2: Medium RiskPatient care support areas such as:• Waiting areas• Clinical engineering

(biomedical)• Materials management• Sterile processing department – dirty side• Kitchen, cafeteria, gift shop, coffee shop, and food kiosks

1.1.8.7.3: High RiskPatient care areas such as:• 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

1.1.8.7.4: Highest RiskProcedural, invasive, sterile support and highly compromised patient care areas such as:• 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• Imaging suites – interventional imaging• Dedicated isolation wards/units for infectious diseases

1.1.8.7.5: * 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

PCRA ILSM ICRA 9Continued on the next page.

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.

1.1.8.8: Match the Overall Patient Risk Category (Low, Medium, High, Highest) with the planned

Construction/Renovation/Maintenance Activity Category (A, B, C, D) to determine the minimum

Level of Infection Prevention and Control Precautions (I, II, III, or IV) using the Table below.

1.1.9: Permit Information 1.1.9.1: Location and brief description of construction/renovation/maintenance *

•Location of Project: 2201 N. Broadwell, Grand Island, NE 68803 Building 5, Transitioning (TR) house (single floor)

Renovating Nine (9) bathrooms in TR house including modifications of room finishes and replacement of bathroom fixtures with no change to overall SF.

1.1.9.2: Project manager *

Ellexis Baker 1.1.9.3: Contact phone number *

402-926-9384

1.1.9.4: Contractor or lead shop * pending

1.1.9.5: Project start date *

06/02/2025 1.1.9.6: Expected end date *

10/20/2025 1.1.9.7: Permit expiration date *

10/20/2025 1.1.9.8: Project complete date

1.2: Specify Floor/Room Location *

Building 5, Transitioning house (single floor

1.3: Optional: Full Risk Assessments may be viewed by visiting the sites below

VHA PCRAVHA ICRA

* = required field PCRA ILSM ICRA 10This form was generated by LEAF on 4/23/2025