This member-only article appears in the November issue of Patient Safety Monitor Journal.
A good water management plan begins with your facilities management team and a solid risk assessment of your water distribution and storage systems, which must include a walk-through of your hospital with your on-site plumbing expert.
CMS recently updated a memo to its survey teams on reducing the risk of Legionella bacteria to specifically note that facilities must have a water management plan that surveyors can review. That plan should be written and managed by a multidisciplinary committee of people from throughout the hospital with a stake in water use, says Bryan Connors, MS, CIH, HEM, the healthcare practice director at Environmental Health & Engineering Inc., in Newton, Massachusetts. Connors is certified as both an industrial hygienist and a healthcare environmental manager and works as a consultant for hospitals and other facilities, including the management of water systems.
The CMS memo, which was first published last year and then updated this June, continues to point to the ANSI/ASHRAE Standard 188 “Legionellosis: Risk Management for Building Water Systems” and the best practices set out by a 2016 CDC toolkit on developing a water management program to reduce the growth and spread of Legionella in buildings as key resources.
“If you look at the CMS memo, it talks about having a facility assessment,” notes Connors. You should have multidisciplinary team members and ensure one of them knows the plumbing configuration within your hospital, he says, “which typically is the supervisor of the plumbing shop, or the manager of facilities.”
Surveyors from CMS, The Joint Commission, and other accrediting organizations (AO) will be looking for proof of a water management plan that also has the support of leadership.
Use memo to review program
Review your program against the memo to ensure you are meeting what CMS—and therefore other AOs—want to see.
“The first thing you would look at in the program—and this is a vulnerability for many hospitals who have not been surveyed in the last year—would be do you have a document or documents that describes the plan,” says Connors.
What those documents would look like is up to you. However, “you are required to have a risk assessment, done by a multidisciplinary team, to identify your hospital’s risk for Legionella bacteria growth relative to the [hospital] population in general, and then specifically relative to at-risk populations,” Connors notes.
You might have a written Legionella plan or a water management plan. Those terms are used interchangeably, but are different, he says.
CMS is clear that although Legionella is important, it’s just one of several waterborne pathogens to be managing for, Connors emphasizes. To satisfy CMS, you must manage the risk from the other waterborne pathogens too. But in general, says Connors, “if you are controlling for Legionella, you’re controlling for a lot of the other pathogens.”
The written plan should have a description of the water management team and what their roles and responsibilities are. The plan also should outline what the risks are within the organization regarding your water systems, mitigating factors, and how you are monitoring the system.
The plan should include process flow diagrams of the water system, including “incoming water, potable water and non-potable water, and distribution systems throughout the facility including water storage, and water treatment tanks—as well as a narrative associated with those,” says Connors.
It should also identify problem areas and how those areas are being mitigated.
For instance, how are you identifying and eliminating dead legs of plumbing where water can sit still and allow pathogens to grow? What, how, and when are you sampling in cooling towers? Every hospital has some type of renovation or repair going on, Connors notes. How are you flushing pipes during renovation and ensuring that your redesign doesn’t result in water stagnating? How do you monitor water temperatures, and what parameters do you use? What is the schedule for cleaning and maintenance of your water towers or other systems?
When assessing risk, you need to have someone who knows the plumbing system design and configuration, who can look at things like hot water tanks, dead legs, and cross-connects, he says. “You do have to get out and walk around. If you don’t have someone who knows your plumbing system, you’re not doing it right.”