SAMPLE Policy

Infection Control Construction Risk Policy Number:

Assessment Policy Adopted:
Revised

POLICY
The Infection Control Construction Risk Assessment (ICCRA) is applicable for every
project affecting HVAC, mechanical, plumbing, electrical or life safety of areas subject to
regulatory compliance.

Infection Control Construction Risk Procedures for:

Assessment Policy Adopted:
Revised:

PROCEDURES
Implementing Policy XX

Note: These procedures provide additional information related to Policy XXX, but are
separate and distinct from that policy. The authorized Vice President retains discretion in
implementing these procedures and can change them at any time, with or without notice.

PURPOSE:
To provide a matrix of Precautions for Construction and Renovation and an Infection
Control Construction Risk Assessment Permit (ICCRA) process in order to reduce the
disturbance of existing dust, or avoid creating new dust, during construction and
renovation.

APPLICABILITY:
This policy applies to all NAME owned and operated facilities and areas as described in
Attachment A.

RESPONSIBILITY STATEMENT:
All staff and other individuals working within facility must adhere (comply through
consistent performance) to the facility Infection Control/Employee Health Policies found
on (identify location).

REFERENCE:
1
Infection Control Risk Assessment
APIC Text on Infection Control and Epidemiology, Revised Edition 2009.

SUPPORTIVE DATA:
Construction and Renovation Policy and Procedures:
Infection control is critical in all areas of all facilities. Construction activities causing
disturbance of existing dust, or creating new dust, may be required to be conducted in
tight enclosures cutting off any flow of particles into patient areas.
Infection Control Scope:
Infection Control Department will evaluate construction sites for:
 Adequacy of hand washing facilities
 Adequate work flow of utility rooms
 Need for negative airflow rooms for isolation of airborne diseases
 Adequate space for biomedical waste storage
 Location of waste containers
 Appropriate fixtures for; hand soap, hand hygiene, sharps disposal containers
 Ability to clean and/or disinfect surfaces appropriately
 Appropriate removal of waste and equipment

GUIDELINES:
Permit Process

I. Construction Activity Types and Patient Risk Groups

The construction activity types are defined by the amount of dust which is
generated, the duration of the activity, and the amount of shared HVAC systems as
described in Attachment D, Table 1: Construction Activity Types.
Geographical locations are defined by risk to patients and staff Groups as
determined by geographical areas and status of patients in those areas in
Attachment D, Table 2: Patient Risk Groups.
Contact XXXX and Infection Control if any activity is questionable under these
guidelines.

II. Definitions of Infection Control Risk Groups/Construction Activity /

Infection Control Matrix
If not shown on the chart below, determine the level of Infection Control
classification necessary for the work by matching the construction activity with the
designated risk group. Provide the associated infection control procedures. In
cases where activities affect different risk groups, develop separate coordinated
ICCRAs for the different risk groups.

III. Class of Precautions: Construction Project by Patient Risk

Construction Project Type
2
Infection Control Risk Assessment
Patient Risk Group Type A Type B Type C Type D
Group 1: LOW Risk Class I Class II Class II Class III/IV
Group 2: MEDIUM Risk Class I Class II Class III Class IV
Group 3: HIGH Risk Class I Class II Class III/IV Class IV
Group 4: HIGHEST Risk Class III Class III/IV Class III/IV Class IV

IV. Infection Control Risk Assessment

Step one: Using Policy Attachment D, Table 1: Construction Activity Types, identify the
Type of Construction Project Activity (Type A-D), and mark appropriate box
in Attachment B Permit Table 1.
Step two: Using Policy Attachment D, Table 2: Patient Risk Groups, identify the Patient
Risk Groups that will be affected (Low, Medium, High, Highest Risk) and
mark appropriate box in Attachment B, Permit Table 2.
Step three: Using Permit Table (section III above), match the Construction Project Type
(Step 1) with the Patient Risk Group (Step 2) to find the level of infection
control activities required for the proposed project.
Step four: Identify Construction Precautions by Class in Policy Attachment C for
implementation.

V. Performance Requirements
A. This facility requires any sub-contractor(s), material suppliers, vendors,
employees, or agents to be bound by these same requirements. Before any
construction on site begins, the Contractor’s on-site management team shall
attend a mandatory meeting held by Infection Control authorities, or their
designated representatives, for instructions on required precautions.
B. HEPA equipped air filtration machines shall provide airflow into construction
area not less than 100 FPM at barricade entrances with doors fully open.
HEPA equipped air filtration machines shall be connected to normal power and
ganged to a single switch for emergency shutoff and shall run continuously.
C. The Safety or Infection Control may modify performance requirements for
certain activities. Any modification made by facility personnel does not relieve
the Contractor of compliance with proper infection control procedures.

VI. Submittals
A. Submit a Infection Control Construction Permit Application to include
location, and details of barriers.
B. Product Data: Submit product data for products used in the Infection Control
Program.

VII. Infection Control Permit

A. An Infection Control Permit is required for Class III or higher procedures and
any activity in a Group 4 (Highest Risk) Infection Control Group. Refer to
3
Infection Control Risk Assessment
 shaded area on Construction Activity/Infection Control Matrix (section III
above). Facilities will send Class I or II applications to Infection Control for
review only.
B. The project manager will complete a Infection Control Construction Permit
Application (Attachment B) for all projects before beginning any demolition
or construction work. When required, obtain Infection Control Permit from
Infection Control Department before beginning any demolition or construction
work.
C. If emergency construction is necessary, the work should be performed using
the appropriate precautions as listed in Attachment C; Construction
Precautions by CLASS. The Infection Control Permit must be filled out and
submitted to the Infection Control Department as follows:
 CLASS I or CLASS II: Submit Permit application (Attachment B) within
48 hours of completion of emergency work.
 CLASS III or CLASS IV: Submit Permit application (Attachment B) as
soon as the situation is stabilized or within 24 hours, whichever comes first.
D. Where Infection Control Permits are required, the permit is to be displayed at
entrance to work area during entire construction period.
E. Return the Infection Control Permit to the project manager at the completion
of work.
F. All infection control procedures, matrix and permit for a designated project
shall be added to the construction documents, to comply with Department of
Health documentation recommendations.

VIII. Quality Control

A. The Infection Control Department may monitor or require monitoring of
biological counts in vicinity of construction work on an as needed basis.
Whenever safe levels are exceeded, contractor will be notified to correct
conditions immediately.
B. All work shall be stopped on the project whenever a hazardous infection
control deficiency exists as ordered by a Facilities representative, Infection
Control Department representative or the project manager.
C. Contractor shall take immediate action to correct all deficiencies.
D. Failure of Contractor to correct such deficiencies will result in corrective
action taken by and their representatives, deducting all costs from the contract.

IX. Products and Materials

A. Sheet Plastic: Fire retardant polystyrene, 6-mil thickness.
B. Barrier Doors: Solid core wood in metal frame, painted.
C. HEPA-Equipped Air filtration Machines
D. Exhaust Hoses: Heavy duty, flexible steel reinforced. Ventilation Blower Hose.
4
Infection Control Risk Assessment
 E. Adhesive Walk-Off Mats: Provide minimum size mats of 24 inches x 36 inches
F. Disinfectant: GHC approved disinfectant or equal (EPA approved hospital-
grade disinfectant).
G. Control Cube: Portable Ceiling Access Module

X. Barriers
A. Closed door with masking tape applied over the frame and door is acceptable
for projects that can be contained.
B. Construction, demolition or reconstruction not capable of containment within a
single room must have barriers erected compliant with the following:
1. Airtight plastic barrier that extends from floor to ceiling. Seams must be
sealed with duct tape to prevent dust and debris from escaping.
2. Drywall barriers erected with joints covered or sealed to prevent dust and
debris from escaping.
3. Seal all penetrations in existing barrier airtight.
4. Barriers at penetration of ceiling envelops, chases and ceiling spaces to
stop movement of air and debris.
5. Anteroom or double entrance openings that allow workers to remove
protective clothing or vacuum off existing clothing.
6. At elevator shafts or stairways within the field of construction.
7. Overlapping flap minimum 2 feet wide at polyethylene enclosures for
personnel access.

XI Infection Control Procedures

A. General
1. Maintain manpower and equipment including: Facility approved
disinfectants, dust mops, wet mops, brooms, buckets and clean wiping
rags for cleaning fine dust from floors in adjacent occupied areas.
2. Contain work areas outside of construction barriers, including spaces
above ceilings, with a full-height polyethylene sheet barrier, tightly taped.
3. Cleanup dust tracked outside of construction area immediately.
4. Assure construction plans follow the “separation of clean and dirty”
principal.
5. Assure hand washing sinks are in all work areas or are readily available.
B. Implementation
1. Temporary construction barriers or closures above ceilings shall be dust
tight.
2. Removal of debris shall be in tightly covered containers.

5
Infection Control Risk Assessment
 3. Adhesive mats or carpets at barricade entrances and in the anteroom shall
be kept clean and changed daily, or as necessary, to prevent accumulation
of dust.
4. Any dust tracked outside of barrier shall be removed immediately.
Cleaning outside barrier to be by HEPA filtered vacuum or damp mop.
5. Any ceiling access panels opened for investigation beyond sealed areas
shall be replaced immediately when unattended.
6. Block off all existing ventilation ducts within the construction area.
Method of capping ducts shall be dust tight and withstand airflow.
7. When openings are made into existing ceilings, use environmental
containment unit or provide polystyrene enclosure around ladder sealing
off opening, fitted tight to ceiling and floor. Provide thorough cleaning of
existing surfaces, which become exposed to dust.
8. Removal of construction barriers and ceiling protection shall be done
carefully, outside of normal work hours. Vacuum and clean all surfaces
free of dust after the removal.
9. When access panels are opened in occupied areas for work above ceilings
use environmental containment unit or polyethylene enclosure around
ladder sealing off opening, fitted tight to ceiling and floor.
10. All vacuuming outside areas not under negative pressure to be with a UL
certified HEPA filtered vacuum.
11. Construct anteroom to maintain negative airflow from clean area through
anteroom and into work area.
C. Responsibilities: General and by Activity CLASS
1. The Facilities/Construction agent in concert with Infection Control will
evaluate every work order for infection control risks. These
representatives reserve the right to add requirements to a project on an
individual basis.
2. The Contractor is responsible for ensuring an Infection Control
Construction Permit is in place before commencement of construction, and
for complying with the Infection Control Construction Permit from the
GHC Infection Control Department.
3. Infection Control Department or designee will make daily visits to work
site to ensure compliance of policy and document findings on posted log
for all CLASS III and IV projects (Attachment E).
4. Enhancement/Maintenance: Vendors will apply via e-mail for an Infection
Control Construction Permit from the Infection Control Department before
commencing construction. They will also e-mail a copy of the Permit
Application to Facilities so work can be coordinated.
D. Environmental Monitoring

6
Infection Control Risk Assessment
 1. Contractor is responsible for maintaining equipment and replacement of
HEPA and other filters in accordance with manufacturer’s
recommendations.
2. The Safety Department and Infection Control Department or their
representative may perform field inspections.
3. The Facilities/Construction agent will confirm specified air velocity
whenever barricades are erected or modified.
4. Infection Control Department may require monitoring of the air quality in
a project, if needed.
E. Enforcement
1. Breach of this Infection Control Policy may result in the facility or their
designated representatives stopping the work of the Project. The
Contractor shall pay for all associated costs incurred by or representative
as well as for correction of the work.
2. The Safety Department, Facilities/Construction Department and/or
Infection Control Department will record the following:
a. Document each violation with photographs.
b. Extract Contractor or Department information from the work log.
c. Maintain a record of all infection control violations.
3. Violations of infection control policies may affect status as a responsible
Contractor for bidding future work.

ATTACHMENTS:
A: Covered Sites (many not be necessary-should cover entire facility)
B: Infection Control Construction Permit
C: Construction Precautions by CLASS
D: Definition Tables
Table 1: Construction Activity Types
Table 2: Patient Risk Groups
E: Infection Control Measures Verification Checklist

REVIEW:

7
Infection Control Risk Assessment