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Safety Policy Manual - NYU Langone Medical Center

VIEWS: 1 PAGES: 9

									                                  Safety Policy Manual                          Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                  Page 1 of 9



                                          APPLICATION

                             NYU Langone Medical Center (NYULMC)

                                       POLICY SUMMARY

   NYULMC is committed to protecting employees, patients, and visitors from exposure to mold.
   This policy addresses the responsibilities of key departments, and summarizes the processes for
   preventing mold growth and responding to concerns about mold.

                           POLICY AND GENERAL INFORMATION

   1.0    Policy

          •   NYULMC will prevent mold growth by 1) considering mold-resistant building
              materials in areas conducive to mold growth, and 2) responding promptly and
              appropriately to leaks and floods.

          •   NYULMC will respond to concerns about mold in a manner that is consistent with
              the New York City’s Guidelines on Assessment and Remediation of Fungi in Indoor
              Environments and the OSHA bulletin A Brief Guide to Mold in the Workplace.

   2.0    Introduction

          Mold is ubiquitous in the environment and does not generally pose a hazard to healthy
          individuals. However, mold exposure can lead to or worsen allergies, and contribute to
          more serious health effects in sensitive populations such as immune compromised
          individuals. Some species of mold, such as Stachybotrys, are capable of producing
          harmful mycotoxins.

          There are no regulations that specifically apply to mold found in New York City
          buildings. However, the New York City Department of Health and Mental Hygiene
          (NYC DOHMH) has developed comprehensive guidelines, entitled Guidelines on
          Assessment and Remediation of Fungi in Indoor Environments. These guidelines are
          widely used and referenced by organizations around the country. In addition, OSHA has
          published a bulletin, A Brief Guide to Mold in the Workplace, which contains similar
          guidelines.




   Revised: April 2012
                                  Safety Policy Manual                           Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                   Page 2 of 9


   3.0    Responsibilities

          3.1    Environmental Health and Safety (EH&S) is responsible for:

                 •       Developing the Mold Prevention, Assessment and Remediation Program
                         (the Program);

                 •       Coordinating investigations of employee concerns about mold;

                 •       Consulting with Infection Prevention and Control (IPC) when patients
                         could be impacted;

                 •       Developing specifications for mold remediation projects;

                 •       Maintaining a list of approved consultants and mold remediation
                         contractors;

                 •       At the direction of Facilities Management or Real Estate, coordinating
                         mold remediation projects with consultants and remediation contractors;

                 •       On request, coordinating training for staff (e.g., Facilities Management) on
                         mold remediation procedures; and

                 •       Periodically evaluating the Program and updating it as needed.

          3.2    Facilities Management (FM) has overall responsibility for minimizing or
                 eliminating mold in non-residential areas of properties owned by NYULMC
                 which they maintain.

                 FM is responsible for:

                 •       Maintaining the building infrastructure in a manner that minimizes the
                         possibility of water damage and moisture build-up;

                 •       When mold is identified, ensuring that the underlying cause(s) of water
                         incursion and/or leaks is fixed prior to removal and replacement of mold-
                         damaged materials;

                 •       Ensuring that EH&S approves all individuals (contractors and employees)
                         who conduct mold remediation for FM;

   Revised: April 2012
                                  Safety Policy Manual                           Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                    Page 3 of 9


                 •       Prior to the start of a mold remediation project, coordinating with the
                         necessary parties to prepare the area for the project. For example,
                         arranging for the removal of movable objects from the remediation area,
                         covering of non-moveable objects, removal and re-installation of wall and
                         ceiling fixtures and outlets, cleaning, and shut down of powered electrical
                         outlets and/or ventilation as needed;

                 •       Obtaining an Infection Control Risk Assessment (ICRA) prior to mold
                         remediation in patient care areas;

                 •       Scheduling mold remediation projects with staff in occupied spaces and
                         coordinating the remediation with EH&S;

                 •       Scheduling the restoration of remediated areas with FM employees and/or
                         contractors;

                 •       Coordinating cleaning of the ventilation system as needed;

                 •       Ensuring that FM staff receive training on the Program as needed; and

                 •       Ensuring that FM staff and contractors comply with the Program.

          3.3    Real Estate (RE) has overall responsibility for:

                 •       Minimizing or eliminating mold in NYULMC-owned properties which
                         they manage;

                 •       Working with Building Owners and/or their Agents to minimize or
                         eliminate mold in leased properties in accordance with the property
                         agreements.

                 These responsibilities include:

                 •       Minimizing the possibility of water damage and moisture build-up;

                 •       Providing access when an investigation and/or remediation is needed;

                 •       When mold is identified, ensuring that the underlying cause(s) of water
                         incursion and/or leaks are fixed prior to removal and replacement of mold-
                         damaged materials;

   Revised: April 2012
                                  Safety Policy Manual                             Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                     Page 4 of 9


                 •       Ensuring that EH&S approves all contractors and/or employees who
                         conduct mold remediation;

                 •       Prior to the start of a mold remediation project, coordinating with the
                         necessary parties to prepare the area for the project. For example,
                         arranging for the removal of movable objects from the remediation area,
                         covering of non-moveable objects, removal and re-installation of wall and
                         ceiling fixtures and outlets, cleaning, and shut down of powered electrical
                         outlets and/or ventilation as needed;

                 •       Scheduling mold remediation projects with staff in occupied spaces and
                         coordinating the remediation with EH&S;

                 •       Scheduling the restoration of remediated areas with contractors;

                 •       Coordinating cleaning of the ventilation system as needed;

                 •       Ensuring that RE staff receive training on the Program as needed; and

                 •       Ensuring that RE staff and contractors comply with the Program.

          3.4    Hospital and School departments are responsible for:

                 •       Educating staff to report concerns about mold to EH&S;

                 •       Reporting leaks or other conditions that cause mold growth to FM in a
                         timely manner;

                 •       Providing access when an investigation and/or remediation is needed;

                 •       Prior to the start of remediation, arranging for the removal of furniture,
                         equipment, and other movable objects from the remediation area, and for
                         the covering of non-moveable objects; and

                 •       Prior to the start of remediation, ensuring all personnel vacate the area to
                         be remediated.

          3.5    Infection Prevention and Control (IPC) is responsible for:



   Revised: April 2012
                                 Safety Policy Manual                          Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                   Page 5 of 9


                 •   Providing recommendations regarding the need to relocate hospital patients
                     who occupy space where there is mold contamination; and

                 •   Verifying that the EH&S specifications for mold remediation projects in
                     patient areas provide patients with adequate protection.

          3.6    Employee Health Services (EHS) is responsible for:

                 •   On a case-by-case basis, providing recommendations regarding the need to
                     relocate employees who work in space where there is mold contamination.

          3.7    The department responsible for regular cleaning of the space, Building Services
                 (BS) or Environmental Services (ES) is responsible for:

                 •   Conducting terminal cleaning following remediation and/or as requested by
                     FM or RE.

          3.8    All employees are responsible for:

                 •   Notifying their supervisors of suspected or visible mold problems; and

                 •   Reporting to EHS if they experience health symptoms which they attribute to
                     mold exposure at work.

   4.0    Relocation of Personnel/Patients from Mold Contaminated Areas

          The following groups may be at risk for developing health problems following exposure
          to certain molds: infants (less than 12 months old); individuals recovering from recent
          surgery; and individuals with immune suppression, asthma, hypersensitivity pneumonitis,
          severe allergies, sinusitis, or other chronic inflammatory lung diseases.

          4.1    EH&S provides recommendations on mechanisms to limit mold exposures in
                 occupied spaces (for example, through temporary containment), thereby
                 minimizing the need for relocation until remediation can be accomplished.

          4.2    IPC provides recommendations on the need to relocate patients who occupy space
                 where there is mold contamination.




   Revised: April 2012
                                  Safety Policy Manual                           Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                      Page 6 of 9


          4.3    EHS provides recommendations, on a case-by-case basis, on the need to relocate
                 employees who work in space where there is mold contamination until
                 remediation can be accomplished.

   5.0    Selection of Building Materials

          5.1    FM and RE consider minimizing the use of carpeting, sheetrock, and other
                 building materials that can support mold in areas with a history of frequent
                 flooding or with a high potential for leaks.

          5.2    FM and RE consider eliminating materials such as wallpaper which promote mold
                 growth because they act as vapor barriers.

   6.0    Prevention of Mold following Leaks and Floods

          6.1    FM or RE coordinates the institutional response to leaks and floods in the
                 buildings that they operate or manage. Any initial water infiltration is stopped
                 and cleaned immediately. An immediate response (within 24 to 48 hours) and
                 thorough clean up, drying, and/or removal of water damaged materials prevents or
                 limits mold growth.

          6.2    Methods

                 6.2.1   Water extraction: Excess water is removed from surfaces by mopping or
                         with a wet vacuum. Standing water >1” is removed by pump.

                 6.2.2   Dehumidification: Water vapor is removed from the air using
                         dehumidifiers. Raising the temperature is not used, since this only adds
                         more moisture to the air.

                 6.2.3   Evaporation: Fans are used to increase air circulation and thereby increase
                         the rate of evaporation.

                 6.2.4   Structural drying:

                         6.2.4.1 Rapid response is required (within 24-48 hours).

                         6.2.4.2 Building materials which act as vapor barriers, such as vinyl
                                 wallpaper and cove base, should be removed immediately to
                                 facilitate drying.


   Revised: April 2012
                                  Safety Policy Manual                           Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                   Page 7 of 9


                         6.2.4.3 Air gaps may be created to prevent capillary action from the floor
                                 to the walls. For example, an inch may be removed from the
                                 bottom of sheetrock walls to allow the wall cavity to dry. This
                                 approach may not be suitable for patient areas due to infection
                                 control standards.

                         6.2.4.4 Wet carpet and padding should be picked up and/or removed as
                                 soon as possible if it is not completely dry within 24 hours.

   7.0    Environmental Assessment

          7.1    EH&S coordinates investigations of concerns about mold. Trained inspectors
                 conduct the investigations. A visual inspection is the most important component
                 of each investigation. As a rule, sampling is not necessary if there is visible mold
                 colonization.

                 7.1.1   Visual inspection: The inspector visually assesses the extent of water
                         damage and mold growth. If appropriate, the inspector uses a moisture
                         meter to detect moisture in building materials, or a boroscope to view
                         spaces in ductwork or behind walls.

                 7.1.2   Bulk / surface sampling: The inspector determines the need for bulk or
                         surface sampling, for example, because information on specific fungal
                         contaminants is important to the investigation. An individual trained in
                         appropriate sampling methodology collects samples.

                 7.1.3   Air monitoring: The inspector does not routinely use air sampling to
                         assess mold.

                 7.1.4   Analysis of environmental samples: The inspector sends samples to
                         laboratories that are currently accredited by the Environmental
                         Microbiology Laboratory Accreditation Program.

   8.0    Remediation of Water Source

          8.1    FM or RE identifies and remediates all underlying causes of water incursion or
                 leaks prior to the start of remediation. The emphasis is on ensuring proper repairs
                 to the building infrastructure, so that water damage and moisture buildup will not
                 recur.


   Revised: April 2012
                                  Safety Policy Manual                            Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                   Page 8 of 9


   9.0    Removal and Restoration of Mold Damaged Materials

          9.1    Only properly trained personnel can remove mold contaminated material

                 9.1.1   Employees who have been trained by EH&S can remove up to 30 SF of
                         mold contaminated material, except in patient care areas.

                 9.1.2   All other remediation projects will be performed by a contractor approved
                         by EH&S.

          9.2    FM or RE have overall responsibility for coordinating the remediation project

                 9.2.1   FM or RE schedules the work with the departments who occupy the space

                 9.2.2   FM or RE informs EH&S of the date(s) when mold-damaged material can
                         be removed.

                 9.2.3   FM/or RE schedules and coordinates restoration.

                 9.2.4   FM or RE arranges for BS or ES to conduct terminal cleaning as needed
                         following abatement and/or restoration.

          9.3    EH&S coordinates the removal of mold-damaged materials.

                 9.3.1   The goal of remediation is to remove or clean contaminated materials in a
                         way that prevents mold and dust contaminated with mold from leaving a
                         work area and entering an occupied or non-abatement area, while
                         protecting the health of workers performing the abatement.

                 9.3.2   EH&S or a qualified consultant develops specifications for remediation.
                         The specifications are derived from and consistent with the NYC
                         DOHMH Guidelines on Assessment and Remediation of Fungi in Indoor
                         Environments.

                         9.3.2.1 Specifications state that contractors should discard waste from
                                 mold remediation projects in the medical center’s bulk waste
                                 container.

                         9.3.2.2 On a case-by-case basis, EH&S evaluates the need to specify
                                 cleaning of the ventilation system, for example, disinfection of


   Revised: April 2012
                                  Safety Policy Manual                         Policy No. 112


Policy: Mold Prevention, Assessment and Remediation Program                                  Page 9 of 9


                                vents in the work area, cleaning of ductwork, and replacement of
                                filters. Such cleaning may be needed in sensitive areas, such as
                                ICUs and the operating rooms.

                 9.3.3   EH&S obtains bids from approved contractors, and selects the abatement
                         contractor.

                 9.3.4   EH&S retains consultants as needed to provide proper oversight of
                         remediation projects, for example, in patient care areas.

          9.4    FM or RE coordinates the replacement of mold-damaged materials. As a rule,
                 this is done immediately following mold removal.

   10.0   Reporting and Oversight

          10.1   EH&S periodically evaluates the effectiveness of the program, and reports
                 significant concerns to the Environment of Care Committee and/or the Infection
                 Prevention and Control Committee.


   Issue date       4/12
   Replaces         4/09
   Reviewed by      J.Goldberg, Environmental Health and Safety
                    R.Cohen, Facilities Management
                    B.Everett, Real Estate
                    M. Phillips, Infection Prevention & Control




   Revised: April 2012

								
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