VHA PCRA ICRA CATEX ILSM.pdf

SAFETY PIN

I. PCRA

II. ICRA

III. VA CATEX (NEPA)

IV. ILSM

Form Date: 8/1/2024

I. Scope of Work Description II. SHPO form (if applicable)

REQUIRED ATTACHMENTS

(to accompany Safety Pin)

VHA Pre-Construction Risk Assessment (PCRA)

VHA-PCRA-2023-1.0 Page 1 of 5

PCRA Introductory Information and Instructions

Use this template as a baseline for performing facility Pre-Construction Risk Assessments (PCRA) for Construction, Renovation, and Maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity type(s) and safety risk to determine the level of precautions needed to prevent impact related to Construction, Renovation and Maintenance on patients, employees, and contractors.

Ensure that the activity statement of work and any drawings available are used for the PCRA assessment and included in the project file with the completed PCRA.

Communication and coordination of all types of activity with affected areas are to be included among the control measures. The development of communication and coordination plans must begin during the activity planning phase.

Facilities may customize this template to incorporate site-specific information and requirements.

NOTE: This VHA PCRA template pertains specifically to non-infection-related safety for Construction, Renovation, and Maintenance activities. It must be used in conjunction with the VHA Infection Control Risk Assessment (ICRA) for the activity, if required, which specifically addresses infection risks outside the scope of this PCRA.

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

Activity Location:

Activity Name, Number, and/or Brief Description:

Table 1 - Construction, Renovation, and/or Maintenance Activity Type and Control Measures NOTE: If any of the bulleted criteria in a higher activity type pertains to the work that will be done (even if the other criteria are in a lower type), use the higher activity type for the VHA PCRA.

Controls defined in Table 1 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 activity must also include the control measures in the preceding row(s).

As the activity progresses, a full re-evaluation of remaining activity type and risk is required prior to changing the level of control measures.

Activity Type determined from Table 1:

Activity Type and Description Control Measures Inspection/upkeep generally defined as follows:

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

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

• Work that does not create dust or debris.

• Work that does not create vapors or fumes.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection that will not impair fire safety systems and are limited to 1 tile per 50 square feet with limited

1. 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 where a contact is in place. For internal work the

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VHA-PCRA-2023-1.0 Page 2 of 5 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 with hand tools) that do not create vibration or noise.

• Limited building system maintenance that does not require Lock Out Tag Out (LOTO) such as plumbing on potable systems limited to faucet replacement, steam trap replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

shop involved must work with Safety to ensure proper precautions are in place.

4. Must address identified hazards and controls that will be implemented to ensure minimal impact to patients, employees, contractors and facility.

5. Communication and coordination plan for all affected areas

Small scale Construction, Renovation and general maintenance/repair work, generally defined as follows:

• Prolonged work that may take longer than a single shift but not exceeding six months.

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

• Work that creates some noise and vibration due to power tool use.

• Selective demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements that may o disturb asbestos, lead or silica o create the potential for falling objects o create vibration and/or noise in excess of 80 dB(A) in surrounding areas.

o cause penetrations in fire or smoke barrier

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing that requires utility outages or work on the steam system that may require:

o LOTO o The use of compressed gas cylinders

• 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. Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that require LOTO.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit, a single device and the installation of ductwork, diffusers, and terminal units for an area that may require:

o Work on ladders o Rigging, hoisting or lifting of equipment or materials overhead

• Modification of existing fire alarm and suppression systems requiring system outages and ILSMs or obstruction of exits and or impact on corridors.

• Architectural, structural, or any other work that may cause vapors or fumes such as:

o Roofing work o Flooring work o Painting or other large-scale use of such substances.

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. Where construction, Renovation and maintenance are done in an accredited facility, and ILSM assessment is required to be done and ILSMs put into place in accordance with TJC LS.01.02.01 and the local facility policy including Fire watch if necessary. Staff is trained and the ILSM is verified regularly

3. Hot Work or burn permits in place and staff trained

4. LOTO procedures in place and staff trained on their use

5. Site visits will be reviewed using the criteria in standardized guide.

6. Daily inspections of the site are to be conducted by the General Contractor or shop supervisor and documented on their daily log.

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.

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

1. Excavation safety plan in place ☐

2. Dust control plan in place ☐

VHA-PCRA-2023-1.0 Page 3 of 5

• Excavation or heavy equipment use taking place o Dig safe required utility location o Trench safety o Dust control plan o Equipment exhaust, Noise, Vibration

• Confined space entry required (permit required or not)

• Requires crane work o General crane work o Lift over buildings

• Includes elevated work o Roof work, fall protection o Window work, scaffolding and fall protection o Odor control

• Welding, cutting or use of torches requiring burn permits

• Demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and HVAC that may o require asbestos, lead or silica abatement o create the potential for falling objects o create vibration and/or noise in excess of 90 dB(A) in surrounding areas.

o cause breaches to fire or smoke barrier

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work that requires transport of significant materials through building and up elevators i.e., weight limits of floors and elevators

• Plumbing work requiring LOTO and system shutdown and startup such as the installation of:

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

• 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. requiring LOTO and system isolation.

• Installation of fire alarm and suppression systems requiring outages of those systems and ILSMs or closure of exits/corridors

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

3. Pollution prevention plan in place ☐

4. Dig safe paper work in place ☐

5. Crane lift plan in place ☐

a. Crane placement

b. Crane swing

c. Crane load evaluation

6. Fall protection plan in place and staff trained ☐

7. Confined entry plan in place and staff trained ☐

Table 2. Affected Adjacent Area Assessment In addition to the minimum precautions noted above for the Activity Type, it is critical that the activity be coordinated with the areas adjacent to the activity to ensure operations in those areas are not disrupted or impacted. List the adjacent areas in Table 2 below and develop activity-specific coordination plans and associated communication plans with each area to address activity work that could impact or disrupt the operation of the areas, in general as follows:

• If adjacent area is vacant (e.g., work outside, construction of new building, etc.):

o Coordination is typically not necessary other than potentially traffic flow and pedestrian access.

VHA-PCRA-2023-1.0 Page 4 of 5

• If adjacent area is non-continuously occupied (e.g., areas where outpatient care is provided, employee health, etc.):

o Develop a list of activities that will potentially impact or disrupt the operation of the area (e.g., work involving noise, vibration or exit obstruction) and meet with POC to coordinate execution of work in a way that mitigates the impact (e.g., conduct work after hours).

• If adjacent area is occupied continuously (e.g., areas where inpatient care is provided, residential areas such as Community Living Centers, etc.):

o Develop a list of activities that will potentially impact or disrupt the operation of the area (e.g., work involving noise, vibration or exit obstruction) and meet with POC to coordinate execution of work in a way that mitigates the impact (e.g., move affected party temporarily).

Area Service(s)/Type(s) of Area(s)

(e.g., OR, Unit/Ward, Sterile Processing, Administrative, etc)*

Point of Contact

(POC)

POC Contact Information

Construction plan communicated to POC?

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. The information entered on this table must be used in the ICRA if required.

** List the area(s) in which the construction/renovation/maintenance activity will occur.

Infection Control Risk Assessment (ICRA)

Consult with Infection Prevention and Control regarding the assessment of potential infection risks associated with the activity and the need for control measures. See VHA Directive 7715 and the VHA ICRA Template for more information.

Is an ICRA required for the Activity? Yes ☐ No ☐

VHA-PCRA-2023-1.0

Pre-Construction Risk Assessment (PCRA) Permit This page must be posted at the entrance to the project area, or other designated area

Unique permit number:

Location and brief description of construction/renovation/maintenance Project manager Project start date Contact phone number Completion date Contractor or lead shop Permit expiration date

Activity Type Inspection/Upkeep, Small-scale, or Large-scale)

Activity Type Control measures to be in place for the duration of the activity (Check the box for the Activity Type to indicate the Control Measures)

Inspection/Upkeep

1. 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

Small-scale

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 situation

3. Hot Work or burn permits in place and staff trained

4. LOTO procedures in place and staff trained on their use

5. Site visits will be reviewed using the criteria in standardized guide.

6. Daily inspections of the site are to be conducted by the General Contractor and documented on their daily log.

Large-scale

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

1. Excavation safety plan in place ☐

2. Dust control plan in place ☐

3. Pollution prevention plan in place ☐

4. Dig safe paperwork in place ☐

5. Crane lift plan in place ☐

a. Crane placement

b. Crane swing

c. Crane load evaluation

6. Fall protection plan in place and staff trained ☐

7. Confined entry plan in place and staff trained ☐

*The location of all Activity Hazard Analyses and Control Plans (excavation, dust, pollution, etc.) as applicable shall be identified on this permit and shall be made available to all workers on the job.

Additional requirements:

Is an Infection Control Risk Assessment (ICRA) required for the Activity? Yes ☐ No ☐ Infection Prevention and Control signature:

Date:

Project Manager signature Date

Construction Safety Officer signature Date

Chair/Co-Chair, Construction Safety Committee signature

Date

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VHACTXSmithN4

Add Chair/Co-Chair signature.

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.

Category 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.

Category 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.

Category 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 clinical areas

• Bathrooms or locker rooms not in clinical areas

• Mechanical/electrical rooms not in clinical areas

• 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

• 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.

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.

Level of 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 week in accordance with VHA Directive 1061.

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 or lead shop 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

VHACTXSmithN4

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VHA CATEX form

Updated: 09/24/2013

Type of Project:

Operation and Maintenance Activities Repairs/Renovation Project New Construction Project Lease Other

Level of NEPA Analysis: Other Environmental Permits/Analysis Categorical Exclusion Needed:

Environmental Assessment Needed Environmental Impact Statement Needed

Project Impacts:

Would the proposed activity involve or generate any of the following?

SOURCE YES NO SOURCE YES NO SOURCE YES NO

Air Emissions including GHGs

Liquid Effluent RCRA or CERCLA Sites

Asbestos Petroleum Storage Wetlands

Excess Noise Solid Waste Permit Modification

Utility Modification Hazardous Waste Chemical Use/Storage

Soil Disturbance Biological Resources

Aesthetics

Water Treatment Radioactive Waste Water/Well Use

Water Flow Modification

Mixed Waste Other

I find the proposed project qualifies as a CATEGORICAL EXCLUSION with no extraordinary circumstances. Specify which CATEX:

I find that the proposed project MAY have a significant effect on the environment;

therefore, an ENVIRONMENTAL ASSESSMENT will be prepared.

EIS

Recommended by: Date:

Approved by: Date:

Approved by: Chief, Eng. Service Date:

Project Description:

Project Manager

GEMS

Location:

Project Number:

Project:

Determination:

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VABHS CATEX Form Categorical Exclusions List

1. Repair, replacement and new installation of primary or secondary electrical distribution systems;

3. Routine VA grounds and facility maintenance activities;

4. Procurement and activities for goods and services for routing facility operations maintenance and support;

5. Interior construction or renovation;

6. New construction of 75,000 gross square feet or less;

8. Actions which involve support or ancillary appurtenances for normal operation;

9. Leases, licenses, permits, and easements;

11. VA policies, actions and studies which do not significantly affect the quality of the human environment;

13. Actions, activities. Or programs that do not require expenditure of Federal funds.

*38CFR Part 26.6(b)(1)

7. Development of 20 acres of land or less within an existing cemetery, or development on acquired land of five acres or less.

10. Reduction in force resulting from workload adjustments, reduced personnel or funding levels, skill imbalances or other similar causes;

12. Preparation of regulations, directives, manuals, or other guidance that implement, but do not substantially change, the regulations, directives, manuals, or other guidance of higher organizational levels or another Federal agency, and

2. Repair, replacement and new installation of components such as windows doors, roofs, and site elements such as sidewalk, patios, fences, retaining walls, curbs, water distribution line and sewer lines which involve work totally within VA property boundaries;

Interim Life Safety Risk Assessment Form

Project: ____________________________________________________________________

Date: ____________

For construction activities: Prior to the start of any construction project, and continually through the duration of the project, the Contracting Officer Representative (COR) or approved employee will evaluate the need for ILSM. The COR or approved employee will complete an

ILSM Evaluation and submit it to the Safety Office and the Chief, FMS for approval.

For significant existing Life Safety Code deficiencies: The Safety Manager, or other knowledgeable individual, will complete an ILSM Evaluation for significant existing LSC deficiencies. The Life Safety Code deficiencies that would generally be documented by TJC as Low (harm could happen but would be rare) and Moderate (harm could happen occasionally) on the Safer Matrix are not considered significant. Where Life Safety Code deficiencies are identified that are not significant, they must be repaired within 45 days. The Safety Manager or designee may evaluate the conditions and document any ILSM necessary on the quarterly report to the Environment of Care Committee without using the attachments.

Life Safety Risk Assessment Guidelines Yes/No Comments Interim Life Safety

Measure (ILSM)

1. Will exit egress routes from occupied areas remain unchanged?

2. Will exit stairs remain unobstructed and fire separated?

3. Will fire and smoke compartments remain intact and unchanged?

4. Will fire alarm detection systems remain functional and unimpaired?

5. Will fire suppression systems remain functional and unimpaired?

6. Will construction area be separated by noncombustible smoke-tight partitions?

7. Will emergency access by fire department remain obstructed?

8. Excessive distance to exit?

9. Hazardous areas not protected?

Untitled

(1) FIRE WATCH

(2) HEAT DETECTION INTERFACED WITH VA NOTIFIER ALARM SYSTEM

(3) INSTALLATION OF UPRIGHT SPRINKLERS