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12-509-005I 9 I • lle',aptistHealth Exhibit a , Sofith rion*da Infection Control Risk Assessment (ICRA) Matrix of Precautions for Construction 7'roject Name and Number: SMH NICU Operating Room Location: 3 ird floor North Tower Description • project: Demo existing area to build out operating room. Note: The ICRA Matrix shall be completed duting preconstruction and approved by the Facilities Safety, and Infection Control Officer. Contractor shall sign the ICRA Agreement as part of the construction contract documents. Prescribed precautions must be in place prior to work start and must be maintained throughout the duration of the project Inspection and Non-Invasive Activities. includes, but is not limited to: Removal of ceiling tiles for visual inspection limited to I tile per 50 square feet 100 Painting (but not standing) Wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or reauirecuttin • of walls • access to ceilings other than for visual inspection. Small scale, short duration activities which create minimal dust. Includes, but is not limited to: 0 Installation of telephone and computer cabling 9 Access • chase spaces * Cutting of walls or ceilino where dust miaration can be controlled Work that generates moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Includes, but is not limited to: • 0 Sanding of walls for painting or wallcovering 0 Removal • floorcovering, wall covering, ceiling tiles and Casework 0 New wall construction * Minor duct work or electrical work above ceilings 0 Major cabling activities * Any acfivitv which cannot be comUleted within a sinqle work shift Major demolition and constructlow projects. I lu•6 but is not limited to nc Type Pa� Activities which require Consecutive work shifts. em • on-6riemo 0 v6l,of a comp ete�ca I • g system RequireSheav • I New construction This project has been identified as CONSTRUCTION PROJECT ACTIVITY TYPE ( D: 0 BHS 107 Agreement Z BHS 107 Agreement Step Two: Using the following table, identify the Patient Risk Groups that will be affected. If more than one risk group will be affected, select the higher risk group: Infection Control Approval_ �Y-D�ate: 2 mfection Control Agreement Risk Assessment (ICRA) Matrix of Precautions - Appendix A 1=67m 61111immewomine NVIEw-MUST21MME Risk-­ -- -- ---- -ftif-Risk, is Highe61M­k • Office Areas • Cardiology • JEmergency Room • uno-compromised Class 1 1. • Echocardiography �_Labor & Delivery Patients Type A: Inspection, non-invasive activity. • Endoscopy • Laboratories (specimen) • Cardiac Cath Lab. 2. • Imaging Services • Newborn Nursery • Central Sterile Supply Type C: Activity generates moderate to high levels of dust, requires • Nuclear Medicine • Outpatient Surgery • All Intensive Care Units Class 11 1. • Physical Therapy • Pediatrics • Medical / Surgical Units Type D: Major duration and construction activities requiring consecutive • Occupational Therapy • Pharmacy • Negative Pressure Isolation Z • Respiratory Therapy • Post Anesthesia Care Unit Rooms 3. • MRI • Interventional, Radiology 4. • Cardiac Rehabilitation 3. • Oncology 5. Remove or Isolate HVAC system In area where work is • Operating rooms including C J being done to prevent contamination of the duct 4. Section Rooms. Infection Control Approval_ �Y-D�ate: 2 mfection Control Agreement Risk Assessment (ICRA) Matrix of Precautions - Appendix A 1=67m 61111immewomine NVIEw-MUST21MME ffl-r � FN wklu� •• - Step 4: Identify the areas surrounding the project area, assessing potential impact using the INFECTION CONTROL RISK GROUP designation from Step Two. El Actions to be performed �glis no Z Actions to be performed E Lateral during Construction or Renovation Superviso el.: upon Completion/ Prior to Occupancy Class 1 1. Execute work by method to minimize raising dust from 1. Wet mop/wipe exposed surfaces with appropriately Type A: Inspection, non-invasive activity. the construction operations. Group 1: Low Risk labeled and BHSF approved hospital disinfectant. 2. Immediately replace any ceiling the displaced for visual Group 2: Medium Risk Type C: Activity generates moderate to high levels of dust, requires inspection. Group 3: Medium/High Risk Class 11 1. Provides active means to prevent air-borne dust from 1. Wet mop/wipe exposed surfaces with appropriately Type D: Major duration and construction activities requiring consecutive dispersing into atmosphere. Group 4• Highest Risk I labeled and BHSF approved label disinfectant, Z Water mist work surfaces to control dust while cutting. 2. Contain construction waste before transport in tightly 3. Seal unused doors with duct tape. covered solid lid containers. 4. Block off and seal air vents. 3. Wet mop and/or vacuum with HEPA filtered vacuum 5. Remove or Isolate HVAC system In area where work is before leaving work area. J being done to prevent contamination of the duct 4. Remove isolation of HVAC system in areas where work system. 1. Provides active means to prevent air -home dust from dispersing Into Is being performed. 6. Place dust mat at entrance and exit of work area approved label disinfectant. 7. Wipe surfaces with disinfectant. 3. Seat unused doors with duct tape. 8. Cover transport receptacles or carts. Tape covering 4. Block off and seal air vents. 3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving unless solid lid. work area. Class 111 1. Remove and isolate HVAC system in area where work 1. Do not remove barriers from work area until completed performed. is being done to prevent contamination of the duct 7. Wipe surfaces with disinfectant. project is thoroughly inspected by Owners staff. Cornm.No: 11087.00 system. 2. Vacuum work with HEPA filtered vacuums. Z Complete all critical barriers i.e. sheet rock, plywood, 3. Wet mop/wipe exposed surfaces with appropriately thoroughly inspected by Owners staff. plastic, to seal area from non work area or implement 2. Complete all critical barriers i.e. sheet rock, plywood, plastic, to seat labeled and BHSF approved hospital disinfectant. control cube method (cart with plastic covering and 4. Contain construction waste in tightly covered containers with plastic covering and sealed co work site with HEPA vacuum sealed co work site with HEPA vacuum prior to exit) before transporting. 4. Contain construction waste In tightly covered containers before before construction begins. 5. Cover transport receptacles or carts. Tape covering 3. Maintain negative air pressure within work site utilizing 5. Cover transport receptacles or carts. Tape covering unless solid lid. unless solid lid. 4. Contain construction waste in tightly covered containers before HEPA equipped air filtration units. 6. Remove isolation of HVAC system In areas where work 4. Contain construction waste in tightly covered 5. Cover transport receptacles or carts. Tape covering unless solid lid. is being performed. containers before transporting. 7. Remove barrier materials carefully to minimize 5. Cover transport receptacles or carts. Tape covering spreading of dirt and debris associated with 1. Do not remove barriers for work area until completed project is unless solid lid. contamination of duct system. construction. 6. Seal holes, pipes, conduits and punctures 8. Final cleaning by Environmental Services prior to area from non work area or Implement control cube method (cart appropriately occupana. Class IV 1. Isolate HVAC system in area where work is being 1. Do not remove barriers for work area until completed done to prevent contamination of duct system. transporting. project Is Inspectstaff. , by the Owners staff. 2. Complete all critical barriers i.e. sheet rock, plywood, 2. Vacuum work area with HEPA filtered vacuums. 6. Remove isolation of HVAC system in areas where work Is being plastic, to seal area from non work area or implem I ent 3. Wet mop/Wipe exposed surfaces with appropriately control cube method (cart with plastic covering and 7. Remove barrier Materials carefully to minimize spreading of dirt and labeled and BHSF approved hospital disinfectant. before leaving work site or they can wear cloth or paper overalls that sealed co work site with HEPA vacuum prior to exit) 4. Contain: construction waste in tightly covered containers 8. Final cleaning by Environmental Services prior to occupancy. before construction begins. 6. All personnel entering work site are required to wear shoe covers. before transporting. 3. Maintain negative air pressure within work site utilizing 5. Cover transport receptacles or carts. Tape covering area. HEPA equipped air filtration units. unless solid lid. 4. Seal holes, pipes, conduits, and punctures 6. Remove isolation of HVAC system in areas where work appropriately. is being performed. 5. Construct anteroom and I require all personnel to pass 7. Remove barrier materials carefully to minimize I d cep_t_i`�;sIAddItIons to this area noted by attached memoranda. through this room so they can be vacuumed using a Contractor Agreed to Comply spreading of dirt and debris associated with By I Date: HEPA vacuum cleaner before leaving Work site or.they construction. can wear cloth or paper overalls that are removed 8. Fina , I cleaning by Environmental Services prior to each time they leave the work site, Occupancy. 6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time orker exits the work area. the worker` 7. Contain construction waste in tightly covered containers before transporting. 8. Cover transport receptacles or carts. Tape covering unless solid lid. ffl-r � FN wklu� •• - Step 4: Identify the areas surrounding the project area, assessing potential impact using the INFECTION CONTROL RISK GROUP designation from Step Two. El Locatiomof Construction: 3 North Tower L&D �glis no Z Project Coordinator/Tel.: Luigi Ramudo E Lateral Wlmn Superviso el.: Yes /No I Construction Activity Yes/No Infection Control Risk Group Type A: Inspection, non-invasive activity. 6 Group 1: Low Risk 3MUNIIIIIIIIIIII Risk Group a Group 2: Medium Risk Type C: Activity generates moderate to high levels of dust, requires x Group 3: Medium/High Risk I I Step 6 Identify specific site of activities (e.g., patient rooms, medication room, etc.) 3rd floor of the north tower adjacent to the sterile corridor where there male and female restrooms are located that are connected to the doctors lounge. � tep 6 Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages. Low, shut downs will be coordinated with end users and facility Step 7 Consider potential risk of water damage. Is there a risk due to compromising elements of the building envelope or structure? If so, what steps will be taken to keep water out of the building? Very low plumbing work will have shut downs coordinated with all parties involved. Step 8 Identify containment measures. Describe how the barriers will be constructed. Describe how negative -57f filtration will be *,rovided? Attach draVi" ,s if necessary. Z-4inktnattin kaffta-?3 air machines running at all times. Sticky mats and damp clothes are to be utilized within the containment area near opening. Step 9 Work hours: Can the work be performed during off -peak hours? What will be your work schedule? Normal working hours Step 10 Discuss the following containment issues with the project team (comment as to how these will be addressed): Traffic flow - Low interruption :Iousekeeping - Swept and damp mopped as often as needed by construction wor ers. Debris removal - In covered carts to be cleaned upon re-entry into L&D Step 11 Will air sampling be performed prior, during or after the project? Provide details of the air-monitoring plan. NIA Revised 10108 5 BHS 107 Agreement EMT-T-11 I It r-1 1.7f 5TRXI Project Name and Number: SMH NICU Operating Room I Permit No & Ex p. Date: Locatiomof Construction: 3 North Tower L&D I Project Start Date: TBD Project Coordinator/Tel.: Luigi Ramudo Estimated Duration: 2 months Contractor Performing Work/Tel.: Superviso el.: Yes /No I Construction Activity Yes/No Infection Control Risk Group Type A: Inspection, non-invasive activity. 6 Group 1: Low Risk Type B: Small scale short duration, moderate to high levels. INt Group 2: Medium Risk Type C: Activity generates moderate to high levels of dust, requires x Group 3: Medium/High Risk greater I work shift for completion. J X Type D: Major duration and construction activities requiring consecutive Group 4• Highest Risk I work shifts. During Construction or Renovation Upon CompletionlPriorto Occupancy 1. Execute work by method to minimize raising dust from the 1. Wet mop/wipe exposed surfaces with appropriately labeled and BHSF CO) construction operations. approved hospital disinfectant. 2. Immediately replace any ceiling the displaced for visual inspection. J 1. Provides active means to prevent air -home dust from dispersing Into 1. Wet moptwipe exposed surfaces with appropriately labeled and BHSF W atmosphere. approved label disinfectant. 2. Water mist work surfaces to control dust while cutting. 2. Contain construction waste before transport In tightly covered solid lid 3. Seat unused doors with duct tape. containers. 4. Block off and seal air vents. 3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving 5. Remove or Isolate HVAC system in area where work Is being done work area. to prevent contamination of the duct system. 4. Remove isolation of HVAC system in areas where work Is being • 6. Place dust mat at entrance and exit of work area performed. CO) 7. Wipe surfaces with disinfectant. • Cornm.No: 11087.00 8. Cover transport receptacles or carts. Tape covering unless solid lid. Date: 01/18/12 1. Remove and Isolate HVAC system In area where work Is being 1. Do not remove barriers from work area until completed project is done to prevent contamination of the duct system. thoroughly inspected by Owners staff. 2. Complete all critical barriers i.e. sheet rock, plywood, plastic, to seat 2. Vacuum work with HEPA filtered vacuums. area from non work area or implement control cube method (cart 1 Wet mop/wipe exposed surfaces with appropriately labeled and BHSF with plastic covering and sealed co work site with HEPA vacuum approved hospital disinfectant. prior to exit) before construction begins. 4. Contain construction waste In tightly covered containers before 0 0 3. Maintain negative air pressure within work site utilizing HEPA transporting. equipped air filtration units. 5. Cover transport receptacles or carts. Tape covering unless solid lid. 4. Contain construction waste in tightly covered containers before 6. Remove Isolation of HVAC system In areas where work Is being transporting. performed. 5. Cover transport receptacles or carts. Tape covering unless solid lid. 7. Remove barrier materials carefully to minimize spreading of dirt and 6. Seal holes, pipes, conduits and punctures appropriately debris associated with construction. 8. Final cleaning by Environmental Services prior to occupancy. 1: Isolate HVAC system In area where work Is being done to prevent 1. Do not remove barriers for work area until completed project is contamination of duct system. Inspected by the Owner's staff. 2. Complete all critical barriers I.e, sheet rock, plywood, plastic, to seal Z. work area with HEPA A-filtered vacuums. area from non work area or Implement control cube method (cart 'Vacuum 3.: Wet moptmpe exposed surfaces with appropriately labeled and BHSF with plastic, covering and sealed co work site with HEPA vacuum approved hospital disinfectant. prior to exit) before construction begins. 4. Contain construction waste In tightly covered containers before 3. Maintain negative air pressure Within work site utilizing HEPA transporting. > equipped air filtration units. 5. Cover transport receptacles or carts. Tape, covering unless solid lid. 4, Seal holes, pipes, conduits, and punctures appropriately, 6. Remove isolation of HVAC system in areas where work Is being ai 5. Construct anteroom and require all personnel to pass through this performed. room so they can be vacuumed using sing a HEPA vacuum cleaner 7. Remove barrier Materials carefully to minimize spreading of dirt and before leaving work site or they can wear cloth or paper overalls that debris associated with construction, are removed each time they leave the work site.' 8. Final cleaning by Environmental Services prior to occupancy. 6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area. 7. Contain construction waste in tightly covered containers before transporting. 8. Cover transport receptacles or carts. Tape covering unless solid lid. Additional Requirements: Parties agree to Implement required precautions, notify the ICRA Team of necessary changes and Institute corrective actions Immedlatety should violation of precautions be found. Contractor agrees to disseminate this Information to subcontractors and assume reN2nslbU for their compliance. Date: Initials: -:: ' Initials: I d cep_t_i`�;sIAddItIons to this area noted by attached memoranda. Requested By I Date: Contractor Agreed to Comply By I Date: Facility's Manager I Date AN Infection Control Practitioner By / Date: Safe Officer/ Date: Adapted with ton V. Kg!, nedy, B. Barnard, developed at St. Luke Episcopal Hospital, Houston, TX, ICRA Permit Revised 10/08 8 BHS 107 Agreement PRINTED 24X36 NOT TO SCALE U l_ LU Revised: IN Ica 53, g I E a: in r,- 'C& rZ 0 d, - I? 1st con CU 6 0 r- Z 0, `It 6 121 0 0 INt 20 M 0 0. CU m C c- E LL LL , 0 a. cra i­- Revised: IN Ica 0 a: 0 J INt U. J 10- I CO 0. CO) 0 J W a. D 0 • 0 W CO) CD • Cornm.No: 11087.00 Date: 01/18/12 .�.�01111101111111 Revised: IN