Auditing Facility Water Management Plans

Auditing Facility Water Management Plans

To avoid the spread of Legionella bacteria in building water systems, an audit starts with a consider the physical structure defined by the program and the structure of associated maintenance activities.

By Benjamin Frieders

Legionella bacteria are generally within facility water systems. Left unchecked, they are able to cause serious illness and death even. That’s why standards require most facilities to possess a water management plan. Healthcare facilities must pay special attention. Of January 1 as, 2022, the Joint Commission’s new Environment of Care standard (see summary from ChemREADY here) mandates these plans. As the Joint Commission is currently conducting inspections of healthcare facilities on behalf of The Centers for Medicare and Medicaid Services, facility management teams can get more scrutiny of these plans. Now is the proper time for facility executives to audit and correct weaknesses in plans and processes. (Read this author’s February 2022 article in Facility Executive, “Water Management Plans For Healthcare” concerning the Joint Commission changes.)

HOW EXACTLY TO Audit A Water Management Plan

Even though facility maintenance crew performs monitoring and mitigation, the business enterprise executives will be responsible should inspectors find lapses or when there is case over Legionella. An audit will tell the facility executive or owner if the program has been implemented as designed. The resulting process means verification by ASHRAE 188. This can be performed by way of a known person in a facility’s team or by an external facilitator. An excellent audit will evaluation these elements in the centre of the specifications:

  • Is the program extensive?
  • When was the last evaluation completed?well could it be implemented
  • How?
  • Has it been updated?
  • Is the group trained and engaged?

Evaluation The Structures And Duties

An audit begins with a look at construction: the physical framework defined by the strategy and the construction of associated maintenance actions. A thorough plan should outline the water system points and distribution of access. The plan should identify the risk associated with each area of the system and describe the maintenance activities that control Legionella. Many facility and maintenance managers don’t realize the extent of what they need to do and what they have to document to be compliant.

Excerpt of a Water Management Plan audit checklist (Courtesy of ChemREADY)

What Should Be Documented

A verification audit will determine how thorough the documentation is in terms of maintenance activities. Keep maintenance data in one place, accessible to auditors and inspectors easily. The information should include monitoring, testing, control, and mitigation routines. Typically, paper log scans or sheets of log sheets are stored electronically. Computerized records in a CMMS are or even more preferred because of the simple review equally.

Supervising Protocols. Drinking water chemistry should be monitored with known appropriate ranges for parameters. There must be records of the known degrees of disinfectant, pH, and temperature.

Manage measures. Manage measures are maintenance actions intended to avoid an outbreak of Legionella or additional waterborne pathogens. For example, in case a nursing home includes a seldom-used shower or faucet, twice per month the audit should find documentation that the water line is flushed, as prescribed in the drinking water management plan.

Mitigation. If a test for Legionella will be positive, corrective maintenance should be documented then. As with other maintenance tasks, an employee sees a nagging problem, notifies the person who’s responsible, defines the corrective action, and sets a due date. Each of these steps should end up being documented.

Validation. The documentation should show how the plan can be validated in managing the hazardous conditions throughout building water systems, performed through Legionella testing usually.

Legionella Illustration.(Source: CDC)

Team Meetings Are Key

ASHRAE 188 requires a facility to get a water management program team with designated members. Generally, the facility director or other senior manager is on the united team to make sure facility buy-in, together with the director of maintenance, the infection control officer, and others.

The typical also requires that the united team meets and reviews the program at least annually. The objective of the meeting will be to generate continuous improvement of water safety at the facility. A recommended cadence will be once a quarter because that provides enough time to collect data and implement corrective action before the next meeting. Meeting notes ought to be maintained to prove that the united team is executing the program.

A typical meeting agenda would start with reviewing the minutes of the previous meeting and the actions that had been required at the final meeting. Do those actions have finished? For example, if there clearly was a positive Legionella test result at a faucet, what corrective action has been used since the last meeting? Was the faucet retested and flushed? If the faucet is longer needed no, did the mechanical contractor cap and slice the pipe?

The next agenda item will be the overview of logs and data entered because the last meeting. This given information will include testing, monitoring, and maintenance routines. The review shall uncover issues for discussion. For example, let’s say the united team planned for a particular task to be performed weekly, but it didn’t have finished. Why not? Will be weekly testing not really feasible? The team might decide that reducing the experience to monthly wouldn’t normally increase the threat of Legionella.

Of course, associates shall meet as needed throughout normal work. For example, if lab results come positive for Legionella back, inside a day the water management team can review that issue, decide on the action required, and implement a corrective action with a deadline quickly.


People should understand what Legionella will be and utilize that awareness to their jobs day-to-day. The continuing business proprietor must have confidence that the facility director, facility manager, and maintenance team realize what they’re carrying out and why.

3 Questions Related To Water Management Plans

What questions are usually the right questions to ensure a water management plan is certainly in place and a facility will be compliant? Here are usually three questions that every facility executive should request themselves and their teams.

  1. When had been the last time we audited or examined our water management plan?
  2. So how exactly does our team meet, and what gets achieved at these meetings?
  3. Can you display me the documentation of the upkeep activities that our drinking water management program says we have to do?

Knowing the answers to these relevant questions can help ensure water safety, help reduce the chance of loss and litigation of Medicaid dollars, and encourage continuous enhancement.

Frieders is a qualified Legionella Water Protection and Management expert at ChemREADY . He started his drinking water treatment profession in the US Navy in 2006. In 2019, he completed his naval services and entered the commercial water treatment room, focusing on water-borne pathogens, water hygiene, and conventional water therapy chemistry.