Risk Assessment Revisions for Distributed Building Water: A Recent Update to Your Water Management Plans

Updated Water Management Requirements

According to estimates from the Centers for Disease Control (CDC), over seven million Americans get sick from diseases spread through water each year. The CDC indicates that out of these millions of people, 120,000 are hospitalized, and the associated treatment costs involved exceed three billion dollars.

Utility water systems in hospitals have been under close study for decades. In 2001, the Joint Commission proposed new standards for cooling towers and other aerosolizing water systems designed to “reduce the potential for organizational acquired illness” and “managing pathogenic biological agents in cooling towers.” The standard offered little specific guidance on what was considered acceptable “managing.” The accreditation standard involved in utility water systems was EC.02.05.01.

In 2017, the Centers for Medicare & Medicaid Services (CMS) focused this scrutiny by mandating the development of water management programs (WMP) that prevent cases and outbreaks of Legionnaires’ disease in healthcare environments, specifically hospitals, critical access hospitals, and nursing care centers as outlined in the CMS memorandum 17-30-Hospitals/CAHs/NHs.

Although water management programs have been part of the EC.02.05.01 Joint Commission Standard since 2001, this standard has been updated to include several significant risk areas and incorporated documentation requirements; these changes and additions will be included in the new EC.02.05.02 standard. The update is designed to further improve the quality and safety of care for hospital patients and nursing care residents who are immunocompromised. The EC.02.05.02 standard incorporates the latest research and best practices with the primary goal of improving quality and safety in these settings specific to water management programs.

Accreditation checklist for EC.02.05.02

Standard EC.02.05.02 was approved by CMS in January 2021. Beginning in January 2022, the Joint Commission will require accredited hospitals and long-term healthcare facilities to create and maintain a water management plan that “addresses Legionella and other waterborne pathogens.” The plan must include:

  • An individual or team, responsible for the oversight and implementation of the program, including but not limited to development, management, and maintenance activities. 
  • Flow diagrams developed by the water management team or 3rd party that map water supply sources, treatment systems, processing steps, control measures, and end-use points.
  • A risk assessment based on the water flow diagrams, identifying potential exposure hazards from different modes of transmission, and patient susceptibility.
  • A plan to identify and correct building water that has low flow or developed into a stagnant condition.
  • Evaluate the patient population identifying immunocompromised patients that are served by building water. This evaluation should include areas that are outside of the normal patient staging zones, such overflows due to Covid-19 hospitalizations.
  • Develop control measures and ranges, provide actionable protocols for out of limit conditions, or measured parameters. These out of limit conditions and the corrective actions must be documented.
  • Address and reduce the conditions that create a growth environment for Legionella and other waterborne pathogens.
  • The water management individual or team is required to review the plan annually and update areas where changes to the water systems would impose additional risks.

Senior leadership of the facility must be actively involved in the program; this leadership team must be able to make informed decisions on the risks involved in waterborne pathogen management and the authority to manage the building water (i.e. water restrictions and outages). If there are changes to the personnel on the water management plan (WMP) team, then training must be included for the new members. Members of the water management team must have a working knowledge of the building water systems, be able to recognize potential hazards from water aerosolization, and have the authority to make corrective actions based on a risk assessment. 

Complying with the new standard

If a risk evaluation has not been conducted or a facility is in the beginning stages of planning, then an example of a water-related risk assessment can be found on the CDC’s website under “Water Infection Control Risk Assessment (WICRA) for Healthcare Settings.” The WICRA is an eight-step assessment worksheet that directs WMP team members on how to evaluate water sources, modes of transmission, patient susceptibility, patient exposure, and program preparedness. This worksheet will provide a numerical score on apparent risk, allowing the team to prioritize actions to minimize exposures and prevent infections from waterborne pathogens.

The Joint Commission (TJC) update can be effectively implemented using a third-party consulting firm or can be developed “in-house,” using the ASHRAE 188 standard and the CDC’s toolkit “Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings,” which is available on the CDC website. Once a water management plan has been developed, it must be considered a living document and should be updated regularly, particularly when additions to the utility water system occur or building water is isolated for extended periods (i.e. stagnant water conditions). Healthcare professionals and senior facility leadership on the WMP team must reference the document and follow the program protocol whenever a nosocomial infection is identified.

The Joint Commission update to EC.02.05.01 closely mirrors the water management requirements outlined in the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) 188-2018 document: “Legionellosis: Risk Management for Building Water Systems.”  ASHRAE 188 provides a framework for proactively managing building water systems for reducing the potential for Legionella. The ASHRAE document was developed in 2015 as a consensus standard to help building engineers and designers incorporate preventative measures for minimizing the exposure to Legionella bacteria. It is considered the authoritative guide for minimizing the risk of legionellosis in distributed building water. 

Many healthcare facilities currently have a water management plan as required by the current EC.02.05.01 standard. If a plan is in place, then a gap analysis review should be performed with the objective of identifying and correcting deficiencies in the current water management program and comparing it against the updated standard requirements to ensure Joint Commission compliance.

The intent of the new update is not only to have a water management plan in place physically or electronically but to actively implement items outlined in the plan. These will include monitoring protocols and acceptable ranges for control measures, such as water temperatures, pH, disinfection residuals, documenting out of limit conditions, and corrective actions. 

If a healthcare facility has Joint Commission accreditation, then examination of the water management plan and the associated documentation will be part of the standards compliance survey and Conditions of Participation adopted by CMS. If a facility is involved in a Joint Commission survey, then the water management plan along with the supporting documentation, such as monitoring logs and analytical testing log sheets, must be immediately available for review when requested by the Joint Commission Life Safety Surveyor. Joint Commission surveys are conducted a minimum of once every three years and are unannounced.

Managing the Program

Although the updated version of EC.02.05.02 does not require testing of Legionella or other waterborne pathogens unless it is a requirement of local or state mandate, a decision has to be made on testing. There are many reasons to test regularly, such as monthly or quarterly for Legionella, and when the WMP team completes the risk assessment of the facility, the choice of whether to test or not will be better defined. Old building piping, irregular water temperature distribution, stagnant or low flow water conditions, and low disinfectant residuals may help in making the decision to test for Legionella. Some facilities may rely solely on the water management program platform with control limit monitoring and corrective actions as a means of judging the effectiveness of the plan. Collected data on water temperatures, disinfectant residual levels, building construction, and water outages can be part of the decision strategies discussed during the regular WMP meetings. Other facilities will decide to actively culture for Legionella and other waterborne pathogens along with monitoring building data and react to the results. From a regulatory perspective, there is little guidance on testing or if testing is performed, how often it should be conducted. If a nosocomial case of legionellosis occurs, then the WMP team must increase patient surveillance and review of the program and may include testing for Legionella to determine if the water contains the bacteria.  Actionable priorities should be specifically called out in the WMP if Legionella is detected in the building water system.

As accredited healthcare facilities incorporate the new updates from the Joint Commission, they will likely encounter an increase in required resources from management, facility operations, and environmental services as an outcome of the risk assessments. As with any new management requirements, this will include increased personnel time for monitoring and planning; this should be planned and allocated for. Each group will play a significant role in ongoing risk reduction and prevention of Legionella bacteria and other waterborne pathogens, and each will be relied on for support in the event of confirmed cases of nosocomial infections.

Water management teams will often have outside contractors and third-party vendors as part of the support group to the water management program. Vendors with detailed knowledge of plumbing design and water treatment disinfection chemistry can be valuable, both in the planning stages and with the ongoing management support of the program. Facility management and operations personnel may not have expert knowledge in water management programs; having a third-party vendor as part of the team can provide details (i.e. disinfection strategies) that can be a critical part of an actionable response to either a case of legionellosis or a positive Legionella bacteria water culture. Time is a vital parameter in the event of an outbreak condition, and having the right vendors on board to help advise on various aspects of remedial actions is crucial. The updated Joint Commission standard EC.02.05.02 is the latest improvement to the tools available for keeping Legionella and other waterborne pathogens out of the utility and potable water in healthcare buildings. Reviewing and updating your facility’s water management plan will become a tool because of it. You should use comprehensive treatment packages to stay in regulatory compliance in your current disinfection strategy or improvement of your Legionella management program. Having a good partnership and a total-solutions approach to incorporate treatment chemistry, disinfection protocols, water treatment equipment and automation, inspection services, and remote monitoring will lead to a faster delivered results and overall lowered cost of ownership.

About the Author
Paul Sharpe is an industry consultant at Kurita America, specializing in boiler and cooling water. Paul has over 30 years of water treatment experience, including chemical treatment formulations, sales, marketing, and technical product applications.


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