By Jay Pelton, RA, LEED AP, & Morgan Young

In 2019, the Lebanon, PA Veterans Affairs (VA) Medical Center tapped Miller Remick and Array Architects to design and construct a Community Living Center (CLC) that follows the VA standard small house modelfor their campus. Little did the team know that the pandemic was about to fundamentally change how age-in-place environments are designed. In this article, we’ll review strategies to adapt existing designs to meet new guidelines by exploring how the design team addressed MEP and operational challenges posed by the pandemic.

Project Overview

The existing CLC is located inside the 1940s H-shaped historic nine-story inpatient building on the sprawling campus. Each floor plate was only 30-40’ wide, with the structure and double-loaded corridors limiting each resident room to be no more than about 15’ wide.

Phase one of this project consisted of a full master plan to move their current beds into
small houses to be constructed on campus. This aligns with the guidance of the new small house model, which includes four 14-resident CLCs and one town/community center which will interconnect all residents. During the master plan, the team determined we would need to relocate 56 beds, so the CLCs evolved into four small house models – all connecting to one central town hub through a series of connecting corridors.

The team had completed the CLC’s schematic design when March 2020 arrived. As the pandemic took hold, the VA remained steadfast in protecting their residents with new HVAC solutions in the inpatient hospital. The VA learned a lot at that time, often acknowledging that sealed shut windows were a very difficult obstacle.

Questions and Downstream Implications

The team began their re-evaluation when the building was at 35 percent completion. At this stage, the building was designed with mechanical and available infrastructure efficiency in mind and was equipped with geothermal heat-pumps and a single air handling unit. Working with the VA, Array and Miller Remick looked at what could be done to improve the residents’ outcomes should the pandemic happen again, after the future CLC was occupied.

The first decision was determining how far to take the protection. Would we need to treat each small house separately? Would we need to treat each connected community differently, or address each individual on a case-by-case basis? Would staff need to don and doff equipment differently? How would the normal course of meals and daily resident life be altered? Would they be able to share in the planned small house amenities?

The team first looked at the plan to determine what would create the most versatile solution. We explored how we could prevent airborne virus spread most effectively. The current VA approach to protecting the veterans inside their hospital rooms naturally influenced our thinking. The team considered this approach within the context of the floorplan layout. If we needed to boost our HVAC system, we had to start over, and knew we had to begin with the level of protection necessary to provide residents and staff protection during a pandemic. Our floorplan was a Y-shaped spine and two wings. Each wing contained seven rooms.

Re-assessing Floor Plans

The team looked at the plan for how to limit airflow among all spaces. Originally, there was only one air handling unit (AHU); the building was designed efficiently with geothermal pumps producing a majority of the conditioning with a lower air delivery. The team determined that if there were COVID-positive residents, one AHU will no longer be sufficient because it would make the whole building ‘hot,’ or contaminated. Our design was now at risk and we needed to determine how to revise the HVAC system. But first, we needed to tackle the transmission problems. We established rules for three categories of residents: those who were in contact with COVID, those who were not and those who might have been. In looking at residents who were, the agreement was to limit room air exposure recirculation.

Working with the VA, we developed a series of options. When we compared an isolation room-type scenario to these air delivery needs, it quickly became evident that these rooms needed to be 100-percent exhausted. Along with the design community at large, we learned that contact tracing would not be able to definitively identify the residents with COVID in time for them to properly isolate. Therefore, we needed to treat everyone who went to their own room as if they had COVID. We also needed to designate safe areas for the staff to continue to support residents, both in and out of the hot zones. Very quickly, we decided to limit the access to the resident corridors with closeable doors from the main spine and treat the rest of the rooms as if they were clean.

Determining New Needs

Now that we identified a layout and compartmentalization strategy that accomodates occupants during a pandemic, the next step was to assess the new needs of the mechanical system. We determined that one geothermal-fed unit would not have sufficient capacity for new air requirements because the air changes per hour (ACH) would go from two to a minimum of six per residential room. In order to redesign the system, the team implemented a plan to provide multiple chilled water air handlers, one for each wing’s distribution, plus a 100 percent exhaust system.

Key Takeaways for Updating HVAC in Age-in-Place Environments

Selecting the right HVAC system for age-in-place environments is important to ensure your facility is future ready. Here are five key takeaways from our experience to guide your decision:

1. Select an HVAC system that provides conditioned air by a Variable Air Volume AHU. By doing so, our team was able to provide the VA a “Pandemic-mode” for the resident wings which prevents recirculated air within the building and meets the minimum six ACH per hour.
2. Ensure the AHUs are capable of negatively or positively pressurizing each resident’s room to isolate infected patients from the remaining population. In our case, three AHUs – one for the central core/spine, and one each for the two resident wings – were needed.
3. Specify for versatility. At the CLC, the HVAC system feeding the residents’ rooms will allow for the rooms to be convertible from normal condition, nearly pressure balanced with respect to the adjacent corridor, to a negative pressure condition. This will be accomplished by increasing the air flow of the supply air valve serving each of the resident rooms so that the rooms will go positive relative to the resident bathroom and the adjacent corridor. Additional back-up of natural ventilation can be achieved through operable sashes in the windows.
4. Adopt advanced air purification equipment. For this project, our team used Genesis Air as a basis of design, which utilizes photocatalytic oxidation to reduce infection and improve the indoor environment in hospitals. Data shows that hospitals with this equipment in critical care areas have a significantly lower MRSA standard infection rate.

In Closing

Rapid adaptation is possible to a design-in-progress for an age-in-place environment like this Veterans Affairs Community Living Center. When retrofitting a facility or modifying a design, weigh how the layout can be reconfigured to safely compartmentalize patients as needed, and identify the most critical planning elements that must be addressed. Working in tandem with a skilled MEP firm, select and specify the right HVAC system, one that allows for negative and positive pressurization, appropriate AHUs, versatility and air purification.

Prior to the publication of this article, the FGI offered draft guidancefor designing resilient healthcare and residential facilities to adapt to emergency conditions, including pandemic response.

Downloade the high-reg images found in this article by clicking here.

About the Authors

Jay Pelton, RA, LEED AP
A Principal and Project Architect at Array, Jay Pelton is passionate about delivering projects that offer sustainability, energy efficiency and environmental harmony. His technical focus ensures a proper coordination between building engineering elements, the established building program, and the aesthetic goals of the institution.

Morgan Young
An Architectural Designer at Array Architects, Morgan Young is inspired by the opportunity to drive positive change in people’s lives through the built environment. His experience includes work with clients across the mid-Atlantic, and he has earned awards and co-edited grant publications rlating to his design savvy and expertise.

By Aarushi Jain

Concerns related to ‘job security’ are being raised worldwide at a time when various countries are considering mandatory vaccination for workers. The United Kingdom is considering making vaccination mandatory for care home staffwhereas Saudi Arabia is taking a position as hard as ‘no jab. no job.’ A similar stance has been taken by countries like Italy and Serbia for healthcare workers.

The issue that needs to be dealt with in detail is the impact of mandatory vaccination on various fundamental and basic human rights of an individual. The recent judgement of the Meghalaya High court in Registrar General, High Court of Meghalaya v. State of Meghalayaon the validity of the order made by the Deputy Commissioner of Meghalaya mandating vaccination for vendors, shopkeepers and others before resuming their businesses, held forceful vaccination to be unfounded in the existing jurisprudence. The major aspects dealt with in the judgement include Article 21, Article 19 and the related arenas.

In the historic case of Maneka Gandhi v Union of India, the Supreme Court of India held that Article 21 cannot be read in isolation and all the procedural requirements under this article are to be tested for possible contraventions with Article 14 and Article 19. This judgement opened up a new gateway for the legality test of every law on the basis of a ‘Golden Triangle’ of Article 14, 19 and 21. This Golden Triangle provides complete protection to an individual from infringement of their fundamental rights.

Perusal of the Golden Triangle

The right to equality enshrined in Article 14 of the Constitution of India, has been recognized as a part of the basic structure of the Constitution with the conceptof reasonableness and non-arbitrariness running through the whole fabric of the Constitution.

The Epidemic Diseases Act, 1897 under Section 2A and the Disaster Management Act, 2005 under Section 62 provides powers to the State Government to prescribe temporary regulations and to the Central Government to issue directions to the Union Ministries and State Governments, respectively. The above-cited authorities indicate that the Government possesses sufficient power to prescribe compulsory vaccination. A specific phrase mentioned in Section 2A “prescribe such temporary regulations to be observed by the public or by any person or class of persons as it shall deem necessary” indicates that specific guidelines for a ‘class of persons’ (workers in the present situation) stand within the given authority of the Government.

However, any administrative action made for intelligible reasons, must be measured according to the legal standard of reasonableness. A new dimension of Article 14 was laid down in E.P. Royappa v. State of Tamil Naduwhere the Court stated:-

“Where, an administrative action is challenged as ‘arbitrary’ under Article 14 on the basis of Royappa (as in cases where punishments in disciplinary cases are challenged), the question will be whether the administrative order is ‘rational’ or ‘reasonable’ and the test then is the Wednesbury test.”

Further, the principle of proportionality, which is considered as a part of ‘Wednesbury test’ has been applied as a part of Article 14 in India. The ‘Doctrine of Proportionality’, adopted by the Supreme Court of India in Om Kumar v. Union of India, is a principle here a major concern of the court is the process, manner or method in which the priorities are ordered by the decision-maker to reach a conclusion or arrive at a decision. The conditions for the principle of proportionality as laid down in the landmark case of KS Puttaswamy v Union of India include:-

1. Legislative action must be sanctioned by the law
2. Rational (reasonable) connection to a legitimate aim
3. Existence of no equally effective less restrictive measure

In the current scenario, even if the first condition of “the action being sanctioned by the law” is fulfilled, the other two conditions are not satisfied. ‘Irrational’ most naturally means ‘devoid of reasons’ whereas ‘unreasonable’ means ‘devoid of satisfactory reasons’, as explained by the House of Lords in R v. Secretary of State for the Environment. This indicates that any administrative action must be based on satisfactory reasons or else the doctrine of arbitrariness and in turn proportionality can be invoked.

The Statutory power provided to the executive extends only to “prescribe regulations and issue directions” in the interest of general public. However, there exists a marked distinction between the “regulation or governance” of a trade and the “restriction or prohibition” of it. A fine line was drawn between “regulation” and “restriction” by the Orissa High Court in Lokanath Misra v The State of Orissa:-

“Restriction may be complete or partial and where it is complete it would imply absolute prohibition. The dictionary meaning of the word ‘restriction’ includes ‘prohibition’ too…the word ‘reasonable’ implies intelligent care & deliberation, that is the choice of a course which reason dictates…”

The complete prohibition of the workers from going to work without vaccination indicates a failure on the part of government to base the action on rational and satisfactory reasons. Thus, invading the rights guaranteed under Article 14 as well as Article 19 of the Constitution.

While Article 19(g) assures the right to trade and profession, Article 21 is inclusive of the right to live with dignity which is ensured by the right to adequate work and livelihood. The right to livelihood has been accepted as a part of Article 21 by the Supreme Court in Olga Tellis and others v Bombay Municipal Corporation and others. Mandatory vaccination is a step that is compelling instead of boosting people up to get vaccinated. The concept of bodily autonomy concerned with the right to make decisions for one’s own life and future has been recognized by various international rights agreements such as the Convention on the Elimination of All Forms of Discrimination against Women and recognized by India through the landmark case of KS Puttaswamy v Union of India. It was held in Munn v Illinois that the expression ‘life’ means “not merely a person’s animal existence, but a right to the possession of each of his organs-his arms and legs, etc.”

Additionally, the right to informed consent has been recognized in Samira Kohli v. Dr. Prabha Manchanda & Anr. The Delhi HC while reviewing a noticeregarding compulsory vaccination against Measles and Rubella in children, held that such a requirement without permitting the parents of such children to give informed consent stands in violation of Article 21. Even the right to refuse medical treatment has been recognized by the court in Aruna Ramchandra Shanbaug v. Union of India & ors.

The right to bodily autonomy, to refuse medical treatment, and to informed consent and choice are facets of the right to privacy. The right to privacy is a part of the right to “life” and “personal liberty” enshrined under Article 21 of the Constitution. It has been recognized as a basic human right by Article 12 of United Nations Declaration of Human Rights, 1948and by Article 17 of the International Covenant on Civil and Political Rights, 1976.

Conclusion

There is an imminent need to strike a balance between the severity of the threat and the intensity of the response. The principle of “least restrictive means” (third condition of the principle of proportionality) needs to be upheld while protecting the population. The Government, instead of imposing mandatory vaccination capriciously, shall encourage people to get vaccinated voluntarily by creating maximum awareness and providing incentives just as Russian authorities tried to cajole people to get the shot by offering sweeteners, such as free cars and circus tickets. Social distancing and lockdowns are a kind of preventive measures that require the voluntary application of such rules.

The obligation of the State recognized under Article 21 in State of Punjab and Others v Ram Lubhaya Bagga has been further reinforced by Article 47which provides a basis for the right to health. The right to health and medical care has been recognized as a fundamental right under Article 21 read with Articles 39(e), 41and 43. Just as such Directive Principles of State Policy cast a positive obligation on the Government to protect the public health, there is a pressing need at this time to remind citizens of their fundamental duties enshrined under Article 51-Aof the Constitution. Citizens are expected to adhere to the basic norms of civilized conduct, respecting the protocols and the honest observance of duties.

Considering that COVID-19 is an infectious disease, the erroneous conduct of the citizens such as a sizeable number of foreigners found living in one place in Delhi testing positive for covid or the reverse migration of a large number of migrant laborers from cities to villages, might jeopardise the efforts of the government to contain the spread of the virus resulting in damage to the society as a whole, raising fundamental questions about their responsibility as a citizen. Education and awareness are thus, the major instruments that need to be combined with discipline. A joint response by the Government at the global as well as the citizens at an individual level can allow for effective vaccination drives.

Author’s Information

Aarushi Jain is an undergraduate student at Dr. Ram Manohar Lohiya National Law University, India. She finds her interest in Human Rights and Public health policy. She can be contacted through her LinkedIn.

This piece was previously published by TheLawExpress.