Can Acute Care and Long Term Care Construction Projects Benefit from Custom Audits?

Hospital and long term care facility construction is not just a logistical challenge — it is an infection control event. Every drill into a wall, every section of pipe disconnected and reconnected, every day that dust circulates through an HVAC system shared with an oncology unit or a memory care wing, represents a potential exposure pathway for patients who are among the most immunologically vulnerable people in the building. The connection between healthcare facility construction and increased patient infection risk is, in the words of the American Society for Health Care Engineering, "well documented" [1].

What is less well understood in many organizations is that construction-period infection risks are not simply managed by posting warning signs and installing plastic sheeting. They require the same disciplined, evidence-based audit approach applied to hand hygiene, device care, and environmental cleaning — customized to the specific hazards, patient populations, and project scope present in each unique construction scenario. This article examines why custom audits are not only beneficial but essential during healthcare construction projects, and what an effective construction audit program looks like in practice.

The Scale of the Risk

Approximately half of all healthcare-associated Aspergillus outbreaks are caused by construction or renovation activities within or around hospitals [2]. The mortality rate of construction and renovation-associated invasive fungal infection is approximately 50% — a staggering figure that underscores what is at stake when construction infection control measures fail [3]. The infective dose for invasive pulmonary aspergillosis in immunocompromised patients can be as low as 1 colony-forming unit per cubic metre of air [4]. A single failure of a dust barrier, a temporarily propped-open fire door, or an inadequately sealed ventilation penetration can introduce that dose into a patient-care environment.

Fungal spores are not the only hazard. Construction activities that disturb building water systems — shutting down sections of piping, creating low-flow zones, or leaving unused fixtures dormant — create conditions that promote biofilm formation and proliferation of Legionella and other waterborne pathogens [5]. The U.S. healthcare sector spends an estimated $58 billion per month on renovations, additions, and new construction [6], and every one of those projects that involves the domestic water system carries a Legionella risk that must be actively monitored and documented.

In long term care, the risk profile is different but no less serious. It is estimated that 1 to 3 million serious infections occur every year in long term care facilities under ordinary operating conditions [7]. Residents in these settings are older, more likely to have chronic conditions, and more likely to be immunocompromised than the general population. Introducing the disruptions of active construction — elevated dust, temporary ventilation changes, increased traffic from contractors, disruption to normal cleaning routines — into this environment without a structured monitoring and audit program represents an unacceptable and largely preventable risk.

The ICRA Framework: Necessary but Not Sufficient

The standard tool for managing infection risk during healthcare construction is the Infection Control Risk Assessment (ICRA). In April 2022, the American Society for Health Care Engineering published a significantly updated version — ICRA 2.0 — developed by a multidisciplinary team including infection preventionists, industrial hygienists, construction professionals, facilities managers, and regulatory authorities [1]. ICRA 2.0 expanded the scope of the original framework in several important ways:

• A fifth class of precautions was added to provide more precise guidance for high-risk renovation projects
• Assessment of surrounding areas — including noise, vibration, and dust impact on adjacent patient-care spaces — was formalized as a required step
• The framework was broadened to cover in-house maintenance activities, not just contracted construction work
• Pre-construction, during-construction, and post-construction monitoring was specified as a continuous obligation, not a one-time assessment [1]

The ICRA process matches the patient risk group (Low, Medium, High, or Highest) with the construction activity type (A through D) to determine the required class of infection control precautions. This is a valuable starting point. But an ICRA is fundamentally a planning document — a risk stratification tool that determines what precautions are required. It does not, by itself, verify that those precautions are being implemented correctly, consistently, and in real time throughout the duration of the project. That verification function belongs to the audit.

Where Custom Audits Add Value

The distinction between an ICRA and a construction-period audit is the distinction between a plan and its execution. Every major incident report on construction-related infection outbreaks in the published literature traces the failure not to the absence of a plan, but to the failure to monitor whether the plan's requirements were actually being followed [4][8]. Dust barriers were not maintained. Negative pressure differentials were not checked. Ventilation penetrations were not sealed. Fire doors were propped open. These are not planning failures — they are monitoring and accountability failures. They are exactly the class of failures that structured, regular audits are designed to catch and correct before they result in patient harm.

Custom audits designed specifically for construction projects differ from generic infection prevention checklists in three important ways. First, they are scoped to the specific project — the type of work being done, the patient populations in adjacent areas, the particular precaution class required under ICRA 2.0, and the specific risk factors identified in the pre-construction assessment. Second, they are time-phased — structured differently for the pre-construction, active construction, and post-construction periods, each of which carries distinct risks. Third, they are frequency-matched to the risk level — a Class V project adjacent to a bone marrow transplant unit warrants daily audits; a Class II project in a low-traffic administrative corridor may warrant weekly checks.

Construction-Specific Audit Domains

An effective custom audit program for healthcare construction should address the following distinct risk domains, each of which has its own evidence base, monitoring requirements, and failure modes.

Airborne Pathogen and Dust Control

Dust containment is the most visible and most frequently cited failure mode in construction-related infection outbreaks. Audit instruments for this domain should verify physical barrier integrity (no gaps, tears, or unsealed edges), pressure differential readings between the construction zone and adjacent patient areas, HEPA vacuum use during debris removal, and contractor compliance with clean and dirty traffic routing. ICRA 2.0 specifies that monitoring should use direct-reading instruments that provide real-time data — not visual inspection alone [1].

Air sampling is a complementary monitoring tool. A 2023 review in Mycopathologia recommended a minimum air sample volume of 1,000 litres when sampling in highly filtered areas, and noted that settle plates are not recommended for fungal spore monitoring because individual spores can remain suspended indefinitely [3]. Culture-based portable air samplers remain the most practical device for routine construction-period fungal monitoring in healthcare settings [3].

Water System and Legionella Risk

Since January 1, 2022, The Joint Commission requires accredited hospitals and long term care facilities to maintain a water management plan that addresses Legionella and other waterborne pathogens — and to update that plan whenever construction changes are made to the water system [5]. This requirement creates a direct regulatory obligation to audit construction-period water management practices.

A Water Management for Construction Infection Control Risk Assessment (WMC-ICRA) tool, modelled after the airborne ICRA framework, was developed specifically to address this gap [9]. Custom audit instruments built on this framework should verify water system shut-down and isolation procedures, document which fixtures are out of service and for how long, specify flushing protocols for reactivation, and confirm that Legionella testing has been conducted and documented before restored systems go back into service.

Contractor Compliance with IPC Requirements

One of the most significant and underappreciated sources of construction-period infection risk is contractor behaviour — specifically, the extent to which construction personnel understand and consistently follow the facility's infection prevention requirements. Construction workers are not healthcare workers. They may not intuitively understand why it matters that a fire door stays closed, why they cannot walk through a patient care area in dusty work boots, or why hand hygiene between the construction zone and clean areas is required. Custom audit instruments that include observation of contractor compliance — not just physical environment checks — close this gap.

ICRA 2.0 explicitly requires that "the whole team is responsible for monitoring IPC compliance throughout the project" and specifies contractor staff as part of that team [1]. Audit programs should include periodic unannounced observation of contractor practices, not just scheduled walkthroughs that contractors can prepare for. Findings should be documented, shared with the construction project manager, and corrective actions tracked to closure.

Ventilation and Pressure Differential Monitoring

Negative pressure in the construction zone — relative to adjacent patient-care areas — is the primary engineering control for preventing airborne pathogen migration. It needs to be not only established at the start of a project but continuously verified throughout. A pressure differential that fails at 2:00 a.m. when construction workers have temporarily opened a barrier panel is not captured by a morning walkthrough. Facilities with the strongest track records combine real-time pressure monitoring alarms with scheduled manual verification audits at multiple times per day on high-risk projects [8].

Application in Long Term Care: Unique Considerations

Long term care facilities face a specific challenge when undertaking construction or renovation: residents live in the facility. This is not an outpatient environment where patients leave at the end of the day and the space can be reset. Residents sleep, eat, and receive care continuously in the same building where construction is occurring, often in rooms or common areas immediately adjacent to active work zones.

The SHEA/APIC/AMDA multisociety guidance for infection prevention in nursing homes, published in 2025, explicitly recommends that an ICRA be performed prior to any construction or renovation activity, with monitoring of risk mitigation measures — barriers, negative pressure, HEPA filtration — throughout the project [10]. The guidance notes that IPC professionals should be involved in facility design and renovation planning from the outset, not consulted after decisions have already been made.

Custom audit programs in long term care should additionally account for the home-like environment that these facilities are legally and ethically obligated to provide. Audit instruments should include resident impact assessments — verifying not only that infection control barriers are in place but that noise, vibration, and access disruptions are being managed in ways consistent with residents' right to a dignified living environment. The IPC obligation and the residential obligation are not in conflict; they both require that construction be carefully managed, monitored, and documented.

Closing the Loop: From Audit to Action

The value of any audit program depends entirely on what happens with the findings. In a construction context, where risks can escalate rapidly and where patient exposure may be occurring concurrently with the compliance failure, the feedback loop must be immediate. Construction audit findings are not candidates for a monthly report — they require same-day or next-shift corrective action with documented verification that the issue was resolved.

Effective construction audit programs establish clear escalation protocols before the project begins: which findings trigger immediate work stoppage, which require same-day remediation, which can be scheduled for correction within 24 hours, and who has the authority to make each decision. The audit instrument should capture not only whether a precaution is in place but the time the finding was made, the corrective action taken, and the time the correction was verified. This documentation is not only a patient safety measure — it is essential protection in the event of a post-construction infection cluster investigation.

The Regulatory Imperative

The regulatory environment reinforces the clinical case for construction-period audits. The Joint Commission's 2022 update to its Environment of Care standard (EC.02.05.02) on water management programs means that construction activities affecting water systems must be documented, monitored, and auditable [5]. In 2023, The Joint Commission cited hospitals with an average of more than two infection prevention Requests for Improvement per hospital surveyed — a figure that reflects ongoing gaps between written IPC plans and verified implementation [11].

For long term care facilities, CMS requires an annual facility-wide assessment to determine what IPC resources are necessary to provide safe care, with explicit consideration of the probability of infections based on the resident population and risk factors [7]. A facility undergoing active construction and unable to demonstrate a structured, documented audit program for construction-period infection controls is exposed to significant regulatory risk — independently of whether any patient harm has yet occurred.

Conclusion

Healthcare construction is a necessary and ongoing reality. Aging infrastructure, evolving care models, and growing patient volumes mean that acute care hospitals and long term care facilities will continue to build, renovate, and repair — often while continuing to provide care to the patients most vulnerable to construction-related infection risks. The question is not whether to manage those risks but how rigorously.

The ICRA provides the framework. Custom audits provide the verification. An ICRA without a structured audit program is a plan that no one is checking. A custom audit program built around the specific hazards, patient populations, and project phases of each construction project is how organizations ensure that the protections they have planned on paper are actually protecting patients in practice. For infection preventionists, facilities managers, and quality improvement leaders, the argument for construction-period custom audits is not complicated: the mortality rates, the regulatory requirements, and the evidence from decades of outbreak investigations all point in the same direction.