Healthcare ICRA Compliance Checklist

Verify HEPA filter on Negative Air Machine (NAM) is properly sealed and undamaged. Visually inspect the filter and housing for any gaps or tears.

Confirm NAM airflow rate meets or exceeds the required air changes per hour (ACH) for the contained area, as specified in the ICRA plan. Document readings.

Measure and record negative pressure differential between the contained area and adjacent spaces. Ensure a minimum of -0.01 inches of water column (WC) is maintained.

Ensure NAM exhaust is directed outside the building or to a location away from air intakes and pedestrian traffic. Verify exhaust is not recirculating within the facility.

Verify NAM is connected to a reliable power source, preferably a backup generator circuit. Check for any loose connections or damaged cords.

Inspect NAM pre-filter for excessive dust accumulation. Replace or clean the pre-filter as needed to maintain optimal airflow.

Confirm NAM operation log is maintained, documenting daily readings, filter changes, and any maintenance performed.

If equipped, test the NAM alarm system to ensure it functions correctly and alerts personnel to pressure loss or equipment failure.

Verify the NAM's calibration date is current. Schedule recalibration as needed per manufacturer's recommendations.

Assess NAM noise levels to ensure they do not exceed acceptable limits for patient care areas. Implement noise reduction measures if necessary.

Inspect all seams and joints of the dust partition for complete sealing. Use tape or sealant to close any gaps or openings.

Verify the barrier material (e.g., polyethylene sheeting) is intact and free from tears, punctures, or damage. Repair or replace damaged sections immediately.

Confirm the ante-room is properly configured with appropriate airlocks and signage. Ensure personnel are using the ante-room for entry and exit.

Inspect all ductwork within the contained area for proper sealing. Seal any leaks or gaps with appropriate tape or sealant to prevent dust migration.

If a pass-through is used, verify it is properly sealed and maintained to prevent dust migration. Ensure doors or covers are tightly closed when not in use.

Check that the barrier is securely anchored to the walls, floor, and ceiling. Ensure the anchoring method is appropriate for the surface material.

Verify appropriate ICRA signage is prominently displayed at all entrances to the contained area, warning of potential hazards and required PPE.

Assess the overall stability of the barrier. Ensure it can withstand normal traffic and environmental conditions without collapsing or shifting.

Confirm the barrier material meets fire resistance requirements, if applicable. Use fire-retardant materials in accordance with local codes.

Ensure all access points to the contained area are clearly marked and controlled. Limit access to authorized personnel only.

Verify sticky mats are in place at all entrances to the contained area and are being replaced regularly when soiled. Check for proper disposal procedures.

Confirm appropriate PPE (e.g., respirators, gloves, gowns) is readily available and being used by all personnel entering the contained area.

Ensure hand hygiene stations (e.g., hand sanitizer dispensers) are readily accessible at all entrances and exits to the contained area.

Verify tools and equipment are being cleaned and disinfected before being removed from the contained area. Check for appropriate cleaning agents.

Confirm waste disposal procedures are being followed, including proper segregation, labeling, and containment of potentially contaminated materials.

Review personnel training records to ensure all workers have received adequate ICRA training and understand the required protocols.

If a material tracking system is in place, verify it is being used to track the movement of materials in and out of the contained area.

Ensure equipment and materials are stored properly within the contained area to minimize dust generation and maintain a clean work environment.

Implement controls to limit visitor access to the contained area. Ensure visitors are informed of the required safety protocols and PPE.

Verify emergency procedures are in place and communicated to all personnel, including evacuation routes and contact information.

Confirm the ICRA plan is readily available on-site and accessible to all personnel involved in the renovation project.

Verify the daily ICRA checklist is being completed and signed by a designated person. Review completed checklists for any identified issues.

Ensure communication protocols are in place to inform hospital staff and patients about the renovation project and any potential disruptions.

Verify an incident reporting system is in place to document any ICRA-related incidents or near misses. Ensure incidents are investigated and corrective actions are implemented.

Confirm contact information for key personnel (e.g., infection control officer, project manager) is readily available and up-to-date.

If a permit-to-work system is in place, verify all required permits are obtained before starting any renovation work.

Ensure a change management process is in place to address any changes to the ICRA plan or renovation project. Document all changes and communicate them to relevant personnel.

Review meeting minutes to ensure ICRA-related issues are being discussed and addressed in a timely manner.

Verify all required regulatory compliance documentation (e.g., permits, licenses) is readily available and up-to-date.

Confirm the schedule for ICRA audits and inspections is being followed. Review audit reports for any identified deficiencies.