SOW Attch G - Preconstruction Risk Assesment Form.doc

Pre-construction Risk Assessment Lebanon VA Medical Center

Description of project/work activity: Construct New Entryway for Building 17

Construction Activities - The following projects do not require completion of the Pre-construction risk assessment form:

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Repair medical gas outlet.

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Air balance readings.

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Check air-conditioning.

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Replace light bulb.

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Check or replace electric outlet.

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Paint and wallpaper in business offices and non-patient areas.

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Paint in patient room if closed for painting and less than 3 sq.ft. of wall needs patched. Filter for room unit changed after painting.

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Installation of soap dispenser/needle box/paper towel holder in patient room.

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Repair of window blind.

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Ceiling tile replacement for areas less than 10 2 X 2 tiles, if not in business offices and non-patient areas.

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Minimum repair of nurse call system/TV/Bed/Telephone.

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Ceiling tile replacement for area less than 5 2 X 2 tiles in a patient area if patient is out of the immediate area and clean up can be accomplished before patient returns.

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Unstop sink/commode with no water on floor.

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Unstop commode when water on floor requires maintenance to have Housekeeping clean area immediately.

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Intermediate jobs that create a moderate amount of dust inside room and is made negative by use of HEPA-equipped unit with minimum 10 ACH, and all air discharged outside, hepa unit must run 2 hours after completion of job and Housekeeping must clean room before unit is removed from room. All work and use of HEPA unit must be documented and copy forward to Infection Control and Safety.

NOTE: all duct vents to be sealed off during work!

X

Will there be noise generated that will impact a department adjacent to, above, or below the construction area?

· If so, these departments must be notified.

· How are you going to keep the noise level below 60 dBA?

X

Will there be strong odors generated that will impact a department adjacent to, above, or below the construction area?

· How are you going to ensure that the odor does not migrate to the adjacent occupancies?

X

Will there be vibration generated that will impact a department adjacent to, above, or below the construction area?

· If so, these departments must be notified each time this type of work will be performed.

· How are you going to ensure that the vibrations do not impact work activities of the adjacent occupancies?

X

Will the COTR ensure that Emergency Procedures in place and posted on each job for accidental events that could greatly impact Patient Care or Life Safety to the facility? Included in these procedures are such things as:

X

· Emergency telephone numbers of key departments.

X

· A plan that describes where main valves, switches, and controls are for the area in case of an emergency.

X

· A plan for unexpected outages.

Are any of the following environmental hazards present?

X

· Will hazardous chemicals be used on this project? Contractor will be required to keep a paper copy of all pertinent Material Safety Data Sheets on site.

X

· Is asbestos or lead abatement required on this job? If so, notify Safety and Maintenance at the activation.

X

· Will there be hot work done on this project? If there are, then a hot work permit must be posted on the job site. All hot work must have a fire watch assigned to each area while the hot work is being performed.

X

· Will there be a Confined Space Entry required on this project? If so, the Lebanon VAMC confined space entry program must be followed.

Utilities - Planned Outages

Will any of the following systems be out of service at any time during the project?

X

· Fire alarm (if out for more than 4 hours, Interim Life Safety Measures must be implemented.)

X

· Sprinkler (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)

X

· Electrical

X

· Domestic water

X

· Oxygen

X

· Medical Gas

X

· Steam

X

· Sewage

X

· HVAC

Develop of list of shutoff valves that may need to be closed immediately in the event that a utility pipe is broken. Show or describe location of the valve and areas disrupted by the closure. Share list with contractor and shop foremen.

Insert in the list here:

Interim Life Safety Measures (ILSMs)

Objective: To protect occupants during periods when Life Safety Code is not met or during periods of construction.

X

Will there be any work that will require activation of the Interim Life Safety Measures during this project? If so, insert pertinent information into the Interim Life Safety Measure form on the share and advise the Safety Officer.

Some things that will cause ILSM’s to be implemented are but not limited to:

X

· Any construction that impacts an EXIT or stairs, X

· Any construction that impacts major breaches in a fire or smoke wall, X

· Taking the main fire protection system out of service (sprinkler), X

· Taking the main fire alarm system out of service, X

· Taking the ‘area” fire or fire alarm systems out of service for more than 4 hours within a 24-hour period.

X

Can the need for an ILSM be eliminated or mitigated by design or phasing?

Infection Control Risk Assessments (ICRAs)

Objective: To protect occupants from infectious conditions during periods of construction.

The Lebanon VAMC is considered a low risk facility for the transmission of Tuberculosis. However contract employees working in an area where there is known TB, or those working on local exhaust ventilation (or within 25 feet of a labeled biohazard exhaust vent), airborne isolation room, ED, OR or patient treatment room will be required to provide proof of TB testing in accordance with VHA Directive 2011-036..

X

Will there be any work that will require activation of the Infection Control Risk Assessment during this project? If so, consult with Infection Control Practitioner for implementing an ICRA.

X

Can the need for an ICRA be eliminated or mitigated by design or phasing?

Additional Safety Concerns

X

Will construction affect exit routes from occupied areas adjacent to construction site?

X

Will project affect traffic patterns in area? If yes, explain plan.

We will be rerouting the traffic from in front of building 17 during construction and will be creating a new drop off and pick up area for patients.

X

The following must be completed prior to any construction activities.

X

· Separation wall must be constructed prior to project beginning.

X

· Fire protection systems must remain intact.

X

· Provide extra fire extinguishers in work areas.

X

· Maintain exit lights in work area.

X

· Maintain negative air in construction area (24/7) through duration of project.

X

· There cannot be any return air from within the construction area to the rest of the building.

X

· Redirect exiting not to go through construction area.

X

· Put signs on doors into construction area “Construction Area Do Not Enter”.

X

· Maintain daily logs and keep a current Hot Work Permit.

X

· Place sticky mats at doors exiting construction area.

X

· All debris removal must be by covered cart.

X

· Maintain clean and orderly work area on a daily basis.

X

· How will this project affect the departments above, below and adjacent to this project?

Flooding Mitigation

X

Are there any active wet piping systems within the construction area? If so, develop a list of shutoff valves noting exact location of valve and who is authorized to close them and share list with those authorized to shutoff valves.

Security Issues

Objective: To ensure the construction work site is kept secure to prevent patients and employees from entering these areas at all times of the day.

X

Are there any security vulnerabilities? How they will be addressed?

X

Will any keys be issued to the contractor gain access to their workspace(s) and how will the space be secured?

X

Are there any areas of contractor’s work site(s) not requiring to be secured 24/7? If so, where?

X

Are construction cores required? If so, where?

X

Are there any security phasing issues?

X

Any chance of a construction worker being locked in a space without means of emergency exiting?

_1306833801.doc Infection Control Risk Assessment (ICRA)

Construction Location:

Bldg.#/section:

Project Start Date:

Project Title/#:

Est. Duration:

COTR/Supervisor:

Signature:

Date:

Infection Preventionist:

Signature:

Date:

Phone #:

Contractor/Shop:

Supervisor: (print) (sign) yes

CONSTRUCTION ACTIVITY

yes

INFECTION CONTROL RISK GROUP

TYPE A: Inspections 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 wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

GROUP 1:

· Office areas

· Engineering & Environmental Services

GROUP 2:

· At patient care units(example: Cardiac Rehab. ultrasound)

· Outpatient clinics(CBOCs)

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, cuffing of walls or ceiling where dust migration can be controlled.

GROUP 3:

· Emergency Dept/ED

· Radiology/MRI/CT scanner/Nuclear Medicine

· Cafeteria/Kitchen

· Laboratories/Central Sterile Supply • Oncology/Cardiology

TYPE C: Any 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 wall for painting or wallcovering, removal of floorcoverings, ceiling tiles and casework, new wall construction, minor ductwork or electrical work above ceilings, major cabling activities, and any activity which cannot be completed within a single work shift.

GROUP 4:

· ASU, Sterile Processing

· ICU/Cardiac Catheterization

· Endoscopy/Pharmacy

Determine Class

Risk Level “GROUP”

Construction Activity

“TYPE”

class

TYPE D: Major demolition and construction projects. Includes, but is not limited to, activities which require consecutive work shifts, require heavy demolition or removal of a complete ceiling system, and new construction.

A

I

I

I

III

B

II

II

III

III / IV

C

II

III

III / IV

III / IV

D

III / IV

IV

IV

IV

CLASS I

1. Execute work to minimize raising of dust from construction operation.

2. Immediately replace any ceiling tile displaced for visual inspection. 3. Minor demolition form remodeling

CLASS II

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

2. water mist work surface to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal duct vents.

5. Wipe surfaces with disinfectant.

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

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

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

9. Remove or isolation HVAC system in area where work is being performed.

CLASS III

1. Obtain infection control permit before construction begins.

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

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

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

5. Do not remove barriers from work site until complete & project is thoroughly cleaned by EMS.

6. Vacuum work with HEPA filtered vacuum

7. Wet mop with disinfectant.

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

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

10. Cover transport receptacles or cart and tape covering.

11. Remove or isolate HVAC systems in area where work is being performed.

CLASS IV

1. Obtain infection control permit before construction begins.

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

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

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

5. Seal hole, pipes, conduits and penetrations appropriately.

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

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

8. Do not remove barriers from work site until complete & project is thoroughly cleaned by EMS.

9. Vacuum work with HEPA filtered vacuum

10. Wet mop with disinfectant.

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

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

13. Cover transport receptacles or cart and tape covering.

14. Remove or isolate HVAC systems in area where work is being performed at completion of job.

Additional Requirements:

Permit requested by:

Date:

Permit authorized by:

Date: