1 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. 1.0 Policy POLICY AND GENERAL INFORMATION 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.
2 Policy: Mold Prevention, Assessment and Remediation Program Page 2 of 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 molddamaged materials; Ensuring that EH&S approves all individuals (contractors and employees) who conduct mold remediation for FM;
3 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 molddamaged materials;
4 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:
5 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.
6 Policy: Mold Prevention, Assessment and Remediation Program Page 6 of 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 Water extraction: Excess water is removed from surfaces by mopping or with a wet vacuum. Standing water >1 is removed by pump 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 Evaporation: Fans are used to increase air circulation and thereby increase the rate of evaporation Structural drying: Rapid response is required (within hours) Building materials which act as vapor barriers, such as vinyl wallpaper and cove base, should be removed immediately to facilitate drying.
7 Policy: Mold Prevention, Assessment and Remediation Program Page 7 of Environmental Assessment 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 Wet carpet and padding should be picked up and/or removed as soon as possible if it is not completely dry within 24 hours. 7.1 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 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 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 Air monitoring: The inspector does not routinely use air sampling to assess mold 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.
8 Policy: Mold Prevention, Assessment and Remediation Program Page 8 of Removal and Restoration of Mold Damaged Materials 9.1 Only properly trained personnel can remove mold contaminated material Employees who have been trained by EH&S can remove up to 30 SF of mold contaminated material, except in patient care areas 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 FM or RE schedules the work with the departments who occupy the space FM or RE informs EH&S of the date(s) when mold-damaged material can be removed FM/or RE schedules and coordinates restoration 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 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 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 Specifications state that contractors should discard waste from mold remediation projects in the medical center s bulk waste container On a case-by-case basis, EH&S evaluates the need to specify cleaning of the ventilation system, for example, disinfection of
9 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 EH&S obtains bids from approved contractors, and selects the abatement contractor 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 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
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