Auditing Facility Water Management Plans

Auditing Service Water Management Programs

To avoid the spread of Legionella bacteria in constructing water techniques, an audit begins with a consider the physical framework defined by the program and the construction of associated maintenance actions.

By Benjamin Frieders

Legionella bacteria are generally within facility water techniques. Left unchecked, they are able to cause serious illness and death even. That’s why criteria require most services to possess a water management strategy. Healthcare facilities must spend special attention. Of January 1 as, 2022, the Joint Commission’s new Atmosphere of Care regular (notice summary from ChemREADY right here) mandates these plans. As the Joint Commission is currently conducting inspections of healthcare amenities with respect to The Facilities for Medicare and Medicaid Providers, facility management groups can get more scrutiny of these plans. Now is the proper time for service executives to audit and correct weaknesses in programs and procedures. (Read this author’s February 2022 article in Service Executive, “Water Management Programs For Healthcare” about the Joint Commission changes.)

How To Audit A Drinking water Management Plan

Although the facility servicing crew performs overseeing 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 proprietor if the plan has been implemented as designed. The resulting procedure is described as 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 requirements:

  • May be the plan extensive?
  • When has been the final review completed?well could it be implemented
  • How?
  • Provides it been up-to-date?
  • May be the group trained and involved?

Evaluation The Structures And Duties

An audit starts with a glance at structure: the actual physical framework defined by the program and the construction of associated maintenance routines. A comprehensive program should outline the drinking water system factors and distribution of access. The program should identify the chance associated with each area of the system and explain the maintenance activities that control Legionella. Many facility and maintenance managers don’t realize the extent of what they have to perform and what they have to document to end up being compliant.

Excerpt of a Water Management Plan audit checklist (Thanks to ChemREADY)

What OUGHT TO BE Documented

A verification audit will regulate how thorough the documentation will be with regards to maintenance activities. Maintain maintenance data in a single place, available to auditors and inspectors easily. The data will include monitoring, tests, control, and mitigation activities. Typically, document log scans or bedsheets of log sheets are usually stored electronically. Computerized records within a CMMS are or even more preferred because of the simple review equally.

Monitoring Protocols. Water chemistry ought to be monitored with identified acceptable ranges for parameters. There must be information of the known degrees of disinfectant, pH, and temperature.

Control measures. Control measures are usually maintenance activities designed to avoid an outbreak of Legionella or other waterborne pathogens. For instance, in case a nursing home includes a seldom-utilized shower or faucet, twice per month the audit should discover documentation that the drinking water line is flushed, as recommended in the water management plan.

Mitigation. In case a test for Legionella will be positive, corrective maintenance should be documented then. Much like other maintenance tasks, an employee sees a nagging issue, notifies the individual who’s responsible, defines the corrective action, and sets a deadline. Each one of these steps ought to be recorded.

Validation. The documentation should show the way the plan will be validated in managing the hazardous conditions throughout building water systems, performed through Legionella assessment usually.

Legionella Illustration.(Source: CDC)


ASHRAE 188 takes a facility to get a water management program team with designated members. Generally, the service director or additional senior manager will be on the united group to make sure facility buy-in, together with the director of maintenance, the infection control officer, among others.

The typical also needs that the united group meets and reviews this program at least annually. The objective of the meeting would be to generate continuous improvement of water safety at the facility. A recommended cadence will be once 25 % because that gives plenty of time to get data and implement corrective action prior to the next meeting. Meeting information should be managed to demonstrate that the united group is executing the program.

An average meeting agenda would start out with reviewing the minutes of the prior meeting and what which were required at the final meeting. Do those actions have finished? For example, if there is a confident Legionella test result at a faucet, what corrective action had been taken because the last meeting? Has been the faucet retested and flushed? If the faucet will be longer needed no, do the mechanical contractor cap and slice the pipe?

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

Needless to say, associates shall meet because needed throughout normal work. For example, if lab results arrive positive for Legionella back again, inside a day the drinking water management team will be able to review that issue, choose the action needed, and implement a corrective action with a deadline quickly.


Individuals should understand what Legionella will be and apply that recognition to their careers day-to-day. The continuing business proprietor should have self-confidence that the service 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 definitely in place and a facility can be compliant? Here are usually three questions that every facility executive should request themselves and their teams.

  1. When was the last time we audited or reviewed our water management plan?
  2. How often does we meet, and what gets achieved at these meetings?
  3. Can you show me the documentation of the maintenance activities that our water management plan states we have to do?

Understanding the solutions to these questions can help ensure water safety, help reduce the chance of litigation and lack of Medicaid dollars, and motivate continuous improvement.

Frieders is really a certified Legionella Water Safety and Management specialist at ChemREADY . He began his water treatment career in the US Navy in 2006. In 2019, he finished his naval service and entered the industrial water treatment space, focusing on water-borne pathogens, water hygiene, and traditional water treatment chemistry.