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Healthcare Facilities: How to Create a Water Treatment Plan and Why You Need One

There are some significant changes happening in healthcare facilities when it comes to the standards required for testing and maintenance of the water systems within their buildings.  The Joint Commission standard EC.02.05.02, which goes into effect on January 2022, mandates that hospitals and other healthcare facilities must have a water treatment plans in place to handle Legionella and other waterborne pathogens in accordance with any laws or regulations the facility may be subject to.

The need for a water treatment plan isn’t news to healthcare facilities, of course. However, the new regulatory mandate means that you’ll now have to document not just the presence of such a plan, but your actual compliance with its dictates.

The ruling holds facilities responsible for regular maintenance, testing and documentation of their water systems and management protocols.  With the deadline fast approaching, you’ll need to take some critical steps in order to remain compliant.  This blog will help answer any questions you might have about the requirements and guide you through each step so you can be confident that your facility is fully prepared for the new year.

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What is a Water Treatment Management Plan?

A water management plan is a program designed to both identify hazardous conditions in your water system with regard to Legionella and other waterborne pathogens, and then document the necessary steps to mitigate those hazards. The plan provides information about current water uses and defines areas for water efficiency improvements, conservation activities and goals.

Step 1:  Define Policy and Goals

The first step and one of the most important is to establish your overarching policy and goals. When defining goals, keep in mind that they should be measurable. They should also align with the overall goal of the joint commission regulation, which is to reduce the risk of Legionella through stringent testing and documentation of the results.

Step 2: Establish Water Management Team

You’ll need to then establish a Water Management Team for your facility or enterprise.  This is a group of people with varied skills sets from various departments who will work together to ensure compliance with the plan you’ve put in place.  Some team members may have in-depth knowledge of water systems while others have the ability to identify control locations and control limits. The team should also include someone who understands accreditation standards and licensing requirements , a staff member with expertise in infection prevention as well as risk management personnel.  Of course, it’s always good to appoint someone who has the time and resources to communicate relevant information to the entire team and keep everyone on task and aware of deadlines.

Step 3: Appoint a Leader

Just like the sports world, a team is only as good as its leader.  That’s why it’s critical to appoint the right person to lead the efforts and keep everyone aligned.  Look for someone with the ability to lead, who has extensive knowledge of the water systems, and who is able to oversee all efforts of the team.  This person must also have the time and resources available to guarantee a successful outcome, as well as a commitment and creativity to solve roadblocks that will inevitably occur.

Step 4:  Perform Research

Once the team is in place, it’s critical to get started right away.  Research should be conducted to identify building water systems for which Legionella control measures are needed.  A complete analysis should be performed to assess the amount of risk those water systems pose.  Then you will have the data you need to define the proper control measures needed to reduce hazardous conditions and include them in your plan.

Step 5:  Key Elements of Water Management Plan.

Now that you’ve done your research, you’re ready to develop your plan.  The following checklist should guide you through it.

  • Develop a written description of all your building water systems. Once you have that completed, it’s also helpful to create an easy-to-follow diagram outlining the process flow. It doesn’t have to be an elaborate design – in fact the simpler the better so all team members can understand it.
  • Next, identify areas where Legionella could grow and spread more easily. Some areas to include are areas where medical procedures may expose patients to water droplets such as hydrotherapy or areas where patients are more vulnerable to infection like oncology floors or intensive care units. Even ice machines can cause a big risk.
  • Then you need to determine where control measures should be applied in those high-risk areas and how to monitor them correctly. Examples of chemical and physical control measures and limits to reduce the risk of Legionella growth include:
    • Measure water quality throughout the system to ensure that no bacteria is spreading
    • Water heaters should be maintained at appropriate temperature
    • Monitor disinfectant and other chemical levels in cooling towers
    • Clean surfaces with any visible biofilm (i.e., slime)
  • Establish ways to intervene when control limits are not properly met. If you find that a control limit such as temperature levels or disinfectant levels are not in compliance or monitored according to your plan’s timetables, you need to take corrective actions to restore them to an acceptable level.
  • To ensure that your program is running as designed and is effective, you should review it at least once per year. Be sure to revise your program when any of the following events occur:
  • Data review indicates control measures are persistently outside of control limits
  • A major maintenance or water service change occurs
  • Changes in treatment products
  • Changes in water usage

If an event requires you to review and update your water management program, remember to update the process flow diagram as well as associated control points, control limits and corrective actions.  You should also update the written description of your building water systems.  Be sure to train those responsible for implementing and monitoring the updated program.

Step 6:  Document and Communicate

Now that you’ve done all of the hard work and your program is all buttoned up, the most important thing to do next is document it.  Write it all down in an easy-to-follow plan that all responsible parties can follow.  Since good communications is key to the success of your program, the document should be shared with all members of the project team.

As experts in developing and maintaining Water Management Plans and service programs for healthcare facilities and building owners, ChemREADY is a valuable resource for sharing best practices and management solutions that will help create a simple management program that is efficient, effective and affordable. Contact our experts today for assistance on how to maintain your legionella Water Management Program.

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