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CENTRAL IOWA HEALTHCARE
Marshalltown, Iowa
HEALTH & SAFETY POLICY
Policy No. HS. 6.2
SUBJECT: INTERIM LIFE SAFETY AND INFECTION CONTROL MEASURES
FOR USE DURING DEMOLITION, CONSTRUCTION AND RENOVATION PROJECTS
PURPOSE:
To define actions, which will minimize the risk to patients, co-workers and visitors posed by demolition,
construction and renovation projects
POLICY:
When planning demolition, construction or renovation work, the Facilities Management Director will lead the
process of conducting a proactive risk assessment, using risk criteria to identify hazards that could potentially
compromise patient care in occupied areas of the organization’s buildings.
The scope and nature of the activities should determine the extent of risk assessment required.
The risk criteria will address the impact demolition, renovation or new construction activities have on air quality
requirements, infection control, utility requirements, noise, vibration and emergency procedures.
As required, proper controls to reduce risk and minimize the impact of these activities will be selected and
implemented.
RESPONSIBILITIES:
Facility maintenance, demolition, construction and/or renovation projects performed by CIH Facilities Management
co-workers is the responsibility of the Facilities Management Director. These projects will be coordinated with the
appropriate Department Director.
The Department Director planning the construction project will notify the Facilities Management Director when the
blue prints for the project are in final draft form.
The Facilities Management Director will coordinate the pre-construction risk assessment process with the following
departments/individuals: Architect, Data Processing, Department Director, Patient Safety and Telephone
Maintenance. The type of construction activity, infection construction risk group and classification of precautions
needed will be determined.
Infection Control will issue an Infection Control Permit when the construction activity and the risk level indicates
that Class III and Class IV control procedures are necessary.
DEFINITIONS:
Construction activity types:
Type A: Inspection, 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 that do not generate dust or require cutting of walls or access to ceilings other than
for visual inspection.
Type B: Small-scale, short duration activities that create minimal dust. Includes but is not limited to installation
of telephone and computer cables, access to chase spaces, cutting of walls or ceiling where dust migration can be
controlled and/or minor demolition for remodeling.
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 walls for painting or wall coverings,
removal of floor coverings, ceiling tiles and casework; new wall construction; minor ductwork or electrical work
above ceilings; major cabling activities and any activity that cannot be completed within a single work shift.
Type D: Major demolition and construction projects. Includes but is not limited to activities that require
consecutive work shifts, heavy demolition or removal of a complete ceiling system and new construction.
Infection Control Risk Groups:
Group 1: Least risk, includes but is not limited to some office areas, boiler rooms, generator areas, Environmental
Services department and closets, Front lobby, family waiting areas and Home Care Plus.
Group 2: Medium risk includes but is not limited to Cardiac Rehab, Cardiac Services, Service Corridor,
mechanical rooms, Physician Clinics, OP Rehab, Data Processing, Laundry/Linen and the Storeroom.
Group 3: Medium/high risk, includes but is not limited to ER, Radiology, ICU, Labor & Delivery, Nursery, ASC,
Registration areas, Cafeteria, Gift Shop, Laboratory, Respiratory Care, OP Clinics, Med/Surg/Peds/ Telemetry
and SCC.
Group 4: Highest risk includes OR/PACU, CSS, Labor & Delivery c-section room, Pharmacy and the Cath Lab.
Construction Activity/ICM Matrix:
An Infection Control Permit will be required when the construction activity and the risk level indicate that Class III
and Class IV control procedures are necessary.
RISK LEVEL
CONSTRUCTION ACTIVITY
TYPE “A” TYPE “B” TYPE “C” TYPE “D”
Group 1
I II II III/IV
Group 2
I II III IV
Group 3
I III III/IV IV
Group 4
III III/IV III/IV IV
Construction Class and ICM requirements:
Class I:
1. Execute work by methods to minimize raising dust from construction operations.
2. Immediately replace any ceiling tile displaced for visual inspection.
Class II:
1. Provides active means to prevent airborne dust from dispersing into atmosphere.
2. Water-mist work surfaces to control dust while cutting.
3. Seal unused doors with duct tape.
4. Block off and seal air 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 isolate HVAC system in areas 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 before construction begins.
4. Maintain negative air pressure within work site and/or use HEPA-equipped air filtration units.
5. Do not remove barriers from work area until complete project is thoroughly cleaned by Environmental
Services Department.
6. Vacuum work with HEPA-filtered vacuums.
7. Wet mop with disinfectant.
8. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.
Sticky mats are required.
9. Contain construction waste before transporting in tightly covered containers.
10. Cover transport receptacles or carts. Tape covering.
11. Remove or isolate HVAC system in areas 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.
4. Maintain negative air pressure within work site and/or use HEPA-equipped air filtration units.
5. Seal holes, pipes, conduits and punctures appropriately.
6. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a
HEPA vacuum cleaner before leaving work site 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 while in the construction area. Clean
shoe covers must be donned when re-entering the construction area from outside of the building.
8. Do not remove barriers from work area until complete project is thoroughly cleaned by Environmental
Services Department.
9. Vacuum work with HEPA-filtered vacuums.
10. Wet mop with disinfectant.
11. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.
Sticky mats are required.
12. Contain construction waste before transporting in tightly covered containers.
13. Cover transport receptacles or carts. Tape covering.
ILSM REQUIREMENTS:
1. Exits shall be free and unobstructed in and around the construction site.
2. If exits must be temporarily obstructed all personnel entering the area shall be advised of alternate exit paths.
Temporary exit signs must be placed sot they are visible from anywhere along common access routes.
3. Access to the Emergency Department must remain free and unobstructed. Ensure that there are no situations,
which would delay identification of the location of the Emergency Department, or impede a patient’s arrival at
the Emergency Department. Access for Emergency forces in the hospital must be maintained.
4. As much as possible, the fire alarm and detection system should remain unimpaired. Otherwise, a temporary
and equivalent system must be provided. Any such temporary system must be inspected and tested at least
monthly.
A. ILSM checklist shall be posted in a prominent location at the entry to all construction sites. Security
will check each site once each shift for fire and safety and initial the form each shift. ILSM checklist
will be replaced weekly. Initialed forms will be filed by construction as part of the project record for
IDPH. The ILSM checklist serves as a documentation of the ILSM items.
B. All construction permits will be obtained by the selected General Contractor.
5. Where smoke and/or fire partitions are breached, temporary construction partitions shall be erected. These
temporary partitions must be smoke tight and built of noncombustible materials.
Where temporary partitions are required to be erected to facilitate construction activities, the following criteria is
to be used to determine the construction of these partitions.
A. If the partition being installed is solely to control dust, is in an open area, and is required for a short
period of time, a plastic barrier is acceptable.
B. All construction partitions are to be constructed of fire-rated drywall and taken to slab above with all
joints sealed to prevent the transmission of dust outside the barricade.
C. If the partition is also being used to temporarily replace a smoke or fire partition, the temporary
partition is to match the rating of the removed partition. All joints are to be sealed to prevent the
passage of dust as well as to meet the smoke/fire rating of the partition.
6. Additional fire fighting equipment shall be provided. The Project Manager and the Director of Facilities
Management shall identify the equipment needed and determine placement.
7. It is the responsibility of the Director of Facilities Management to ensure that all construction site personnel are
trained in the use of fire fighting equipment provided. Where construction personnel are employed by a separate
contractor or subcontractor, the Project Manager shall ensure that the (sub) contractor has provided this training
to their staff. Construction site personnel will be briefed on infection control.
8. Smoking shall be prohibited in all construction areas and throughout the hospital.
9. Storage, housekeeping and debris removal procedures shall be implemented to reduce the flammable and
combustible fire load to the lowest level possible for daily operations by the General Contractor.
10. A minimum of two fire drills per shift per quarter shall be conducted. A tradesman from the construction area
will participate in these drills and their response evaluated.
11. Additional surveillance of the facility shall be conducted, with special attention to excavations, construction
areas, construction storage, and field offices. Daily inspections of the construction site is the responsibility of
the General Contractor. The inspections will be documented and the results submitted weekly.
12. The Director of Facilities Management shall provide additional hazard training to both hospital staff and
construction workers when structural or compartment features of the fire safety are compromised.
A. It is extremely important that construction staff be educated about the extraordinary importance of fire
and smoke compartment in a health care facility.
B. The General Contractor is responsible for sealing all penetrations through firewalls and smoke
partitions with appropriate UL rated material.
C. All construction sites have varying levels of ILSM in place. The monthly construction report
distributed at the Leadership Meeting will indicate the locations where ILSM’s are in place.
13. Hospital personnel working in areas where construction hazards are present shall be notified of the special
hazards of the construction sited. General and Sub-Contractors shall be required to provide a list of all
hazardous materials used on the construction site and maintain an MSDS file on the construction site.
14. Any tradesman found to be in violation of any of these requirements will be asked to be removed from the job
site by the Director of Facilities Management. General or Sub-Contractors which fail to take corrective action
with their tradesmen will be removed from the bidders list.
CROSS REFERENCE:
1. Infection Control Policy
2. Hazardous Communication Policy
3. Emergency Preparedness Manual
ATTACHMENT
Interim Life Safety Checklist
Infection Control Construction Permit
Originated By: Safety
Effective Date: June 1992
Environment of Care Facilitator
(Life Safety)
_____________________________________________
Quality Executive
_____________________________________________
Chief Operating Officer
Revised: June 1995
Revised: August 1998
Revised: July 2001
Revised to include Infection Control Measures: June 2002
Reviewed: April 2004
Reviewed: April 2007
Reviewed: November 2010
Reviewed: March 2015
Central Iowa Healthcare
Infection Control Construction Permit
Permit no.
Location of construction Project start date
CIH project coordinator Estimated duration
Contractor performing work Permit expiration date
Supervisor Telephone
YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP
TYPE A: Inspection, non-invasive activity
Group 1: Least risk
TYPE B: Small scale, short duration,
moderate to high levels of dust
Group 2: Medium risk
TYPE C: Activity generates mod - high levels
of dust, requires >1 work shift for completion
Group 3: Medium/high risk
TYPE D: Major duration and construction
activities requiring consecutive work shifts
Group 4: Highest risk
CLASS III
Date
Initials
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 before construction
begins.
4. Maintain negative air pressure within work site
and/or use HEPA-equipped air filtration units.
5. Do not remove barriers from work area until
complete project is thoroughly cleaned by
Environmental Services Department.
6. Vacuum work with HEPA-filtered vacuums.
7. Wet mop with disinfectant.
8. Remove barrier materials carefully to minimize
spreading of dirt and debris associated with
construction. Sticky mats are required.
9. Contain construction waste before transporting
in tightly covered containers.
10. Cover transport receptacles or carts. Tape
covering.
11. Remove or isolate HVAC system in areas where
work is being performed.
CLASS IV
Date
Initials
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.
4. Maintain negative air pressure within work site
and/or use HEPA-equipped air filtration units.
5. Seal holes, pipes, conduits and punctures
appropriately.
6. Construct anteroom and require all personnel to
pass through this room so they can be vacuumed
using a HEPA vacuum cleaner before leaving
work site 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 while in the construction area.
Clean shoe covers must be donned when re-
entering the construction area from the outside of
the building.
8. Do not remove barriers from work area until
complete project is thoroughly cleaned by
Environmental Services Department.
9. Vacuum work with HEPA-filtered vacuums.
10. Wet mop with disinfectant.
11. Remove barrier materials carefully to minimize
spreading of dirt and debris associated with
construction. Sticky mats are required.
12. Contain construction waste before transporting
in tightly covered containers.
13. Cover transport receptacles or carts. Tape
covering.
Additional requirements:
_____________
Date Initials 12-hour uninterrupted exchange required
____________ Exceptions/Additions to this permit
Date Initials are noted by attached memo.
Permit requested by
Permit authorized by
Date
Date
Central Iowa Healthcare
Interim Life Safety Check List
PROJECT ________________ DATE __________ PROJECT MANAGER ___________________
Note: This document is to be posted in a prominent location at each construction project site. It will be
reviewed weekly with the staff of each project.
INSPECTION RECORD DATE SIGNATURE A. All exits are free and clear of any obstruction or debris that would
prohibit normal exiting.
B. All temporary partitions for construction shall follow the policy
guidelines.
C. Fire safety systems, i.e., fire detection system (smoke, heat, water
flow and the fire suppressions system (sprinklers) are not
compromised to a point of causing potential danger. Temporary
systems are inspected and tested monthly by the Maintenance
Director.
D. Provide hand fire-fighting equipment that is readily available
within the construction area as well as the adjacent areas. The
Maintenance Director trains hospital staff.
E. There is a hospital wide policy prohibiting smoking. This policy
covers construction areas as well as the adjacent areas. Smoking is
permitted outside of the hospital only. Contractor has trained staff and
subcontractors have been notified.
F. No construction debris, material, equipment, flammable gases or
any other combustible material is stored in the construction area
overnight.
G. Two fire drills per shift each quarter are conducted.
H. Routine hazard surveillance is made of the entire construction area
ensuring a safe environment for workmen as well as adjacent
occupancies is required. This survey is to include storage areas,
staging areas, excavation areas, etc.
I. Training of personnel with regard to the structural
compartmentation and the need for constant maintenance has been
communicated. Training of staff for alternate exiting has been done.
J. Safety programs covering OSHA as well as the Life Safety aspects
of construction safety have been conducted by the General Contractor.
K. Contractor has provided a list of hazardous substances used on the
construction site and MSDS sheets are maintained on site.
L. All emergency exits are clear and free for emergency traffic,
including exterior sites.
M. Fire watch does not apply as temporary fire detection system is in
place.
Central Iowa Healthcare
Jobsite Inspection Report
Job/Location: __________________________________________________________________
- Acceptable X – correction needed NA – Not applicable
WEEK OF _______________
DATE
1. First-aid facilities - convenient, adequate
2. Employee work practices MMH, safety rules
3. Floor & wall openings covered, rails
4. Housekeeping debris, storage plan
5. Environmental controls, lighting, heat, water
6. Personal Protective Equipment available and in use
7. Fire control, extinguishers, plan
8. Traffic control on & off site, pedestrians
9. Hand tools, condition, use
10. Welding, ventilation, fire watch
11. Electrical, GFCI, inspection
12. Ladders & scaffolds, type, setup, use
13. Power equipment, condition, maintenance
14. Trenching & excavation, egress, retention,
barricades
15. Wearing required identification
16. Construction barriers appropriate for patient
population (sealed plastic with overlay, plywood
barrier with door, closed patient doors, etc.)
17. Following safe work practices (e.g., observe for trip
and fall hazards, ladder safety, smoking rules met)
18. Walk-off mats clean and adequate to contain
construction dust
19. Barricade doors have closures
20. Door frames have gaskets, doors close and seal
properly
21. Signs posted cautioning about spread of dust
22. Patient care equipment & items removed from the
construction area
23. Adjacent ceiling areas intact
24. Adjacent floor areas clean, no dust tracked
25. Air pressure barriers active (e.g., negative pressure
maintained, exhaust fans functioning, air quality
adequate, no excess fumes/vapors)
26. All windows and doors closed behind barricade
27. Project area clean, debris removed daily
28. Debris removed in suitable containers
29. Debris removed at time specified, using the elevator
specified
30. Work authorized and scheduled
31. Visqueen barricade in place and properly sealed
32. Ceiling tiles replaced when space above the ceiling
is not being accessed (if occupied area, adjacent
patient room doors are closed
33. Surrounding area clean
Those marked with an “X” have been corrected with the following comments: (use the bottom of
this form if necessary) ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reviewed ____________________ Inspector ________________________________________
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