Inspecting Legionella Water Management Programs Effectively

It took only a few years after ASHRAE 188 was finalized in 2015 for it to become clear that most facilities will not implement a Legionella water management program (WMP) unless required. Many hospitals have established water management plans because they are mandated by the Centers for Medicare and Medicaid Services (CMS) to receive reimbursements and by the organizations (e.g., The Joint Commission or ACHC) that accredit them. But more than 99% of the buildings that should have WMPs under the criteria outlined in ASHRAE Standard 188 are not healthcare facilities, and among those, only a minuscule percentage implement them. Moreover, approximately 66% of Legionnaires’ disease outbreaks investigated by the CDC from 2000 to 2014 were not associated with hospitals or long-term care facilities. Notably, 44% of the outbreaks were associated with hotels.

That most facilities will not implement water management plans unless required is apparently on the radar of health departments. New Jersey is the first state to adopt a law—effective September this year—requiring water management programs for Legionella risk reduction in non-healthcare as well as healthcare facilities for all building water system types that present a Legionella risk. Based on recent legislative proposals, it appears a few other states will be following New Jersey’s lead.

Whether the state regulations will ultimately reduce Legionella infections could depend in large part on how well health departments and other auditors inspect water management programs.

If the saying “people will do what is expected only if it is inspected” holds true for water management programs, it is crucial that health departments, insurers, and accreditation organizations – as well as building owners and portfolio managers – inspect WMPs effectively and efficiently.

A strong inspection should determine whether the program is being implemented, monitored, validated, and corrected in a way that actually reduces Legionella risk.

Keys to inspecting water management programs effectively and efficiently include these six:

1. Focus on the Water Management Program Process, Not Just the Document

Comprehensive water management programs will reduce Legionella in building water systems only if effectively and fully implemented. The Centers for Disease Control and Prevention (CDC) study of Legionnaires’ outbreaks occurring from 2015 to 2019 highlighted the crucial difference between a WMP document and a process. The CDC found that 82% of environmental deficiencies were due to missing or inadequate processes and concluded: “all of the deficiencies associated with outbreaks could have been prevented by comprehensive, properly implemented WMPs.”

ASHRAE Standards 188 and 514 require a process rather than just a document and align with the ISO 9001 plan-do-check-act framework (Table 1).

This is an important distinction for ASHRAE 188 and ASHRAE 514 compliance. A facility may have a written water management plan, but the inspection should focus on whether the program is actively being used to manage building water system risk. For a deeper look at why this matters, see A Water Management Program Is Not a Document, Policy, or Binder.

Table 1. ISO 9001 Quality Management System Versus ASHRAE Standards 188 and 514.

2. Focus on Legionella Risk Factors and Control Measures

According to ASHRAE Guideline 12 and ASHRAE Standard 514, the primary 7 factors affecting microbial growth are temperature, disinfectant residual, water age, system cleanliness, cross connections, surface area (because of biofilm development), and plumbing materials.

The 5 main activities that affect the 7 microbial factors are system design, operation, maintenance, monitoring, and corrective actions. A practical water management program inspection checklist should thus prioritize control (preventive) measures, monitoring records, validation procedures, and corrective actions since those are most closely related to the 5 activities tied to Legionella control.

Since test results ultimately show whether corrective actions have been effective, inspections could arguably be focused on just two WMP elements: control measures and test results. Those are the big rocks.

3. Avoid Inspecting WMP Details That Do Not Reduce Legionella Risk

Inspecting WMP details that do not directly affect disease risk could result in serious damage – much more damage than simply wasting time. Inspecting nonconsequential WMP details could even increase disease by diverting both the inspector’s and the facility’s attention and time from what really reduces risk. Facilities will ultimately focus on what is inspected, so direct their attention to the big rocks – and let go of the rest.

For example, don’t inspect flow diagram symbols, sample points, formatting, or colors. The flow diagram doesn’t need to look like the one in the CDC WMP Toolkit. People at the CDC who wrote the toolkit included the flow diagram as an example – it isn’t supposed to be a template and won’t work for all facilities, especially large or complex ones. Flow diagrams are important but inspecting how they are drafted is counterproductive. Just make sure the WMP has one.

The team list is another example. Simply make sure the water management plan includes the name, phone number, and email address of each member and denotes which member is the team leader and don’t inspect other details such as team member roles.

Inspecting nonconsequential WMP details can sap a facility’s motivation to reduce risk, too. Facility personnel who are devoting time and money to manage their water well can find it exasperating to receive a citation for a WMP document issue that does not affect public health. Such citations can make facilities want to quit focusing on water safety and simply try to pass inspections.

No studies have shown a case of Legionnaires’ disease associated with flow diagram symbols or colors, the contents of a team list, or WMP formatting, so don’t focus inspections on such issues.

Don’t go soft on facilities, though. Issue citations to the ones missing the big rocks.

In other words, routine WMP inspections should focus less on document appearance and more on whether the program is helping prevent Legionnaires’ disease through measurable water safety practices. Related reading: Study Reveals the Successes and Failures of ASHRAE 188 Water Management Plans.

4. Use Objective Metrics for Water Management Program Inspections

Inspections subject to inspectors’ opinions tend to be inconsistent.

Look for objective metrics such as the number of potable water disinfectant readings, temperature readings, and documentation of specific procedures such as cooling tower and water heater cleaning reports (see Table 2). 

Objective metrics make Legionella water management program inspections more consistent, repeatable, and easier to defend. They also help facilities understand exactly what is expected for WMP compliance

5. Inspect only what requires minimal knowledge and experience.

Inspectors shouldn’t be expected to be water management experts because that takes years of experience and a lot of training. Hence, the importance of focusing on objective metrics and minimizing subjectivity (#4 above). 

A good routine inspection process should allow health departments and auditors to evaluate water management program performance without requiring every inspector to have advanced technical expertise in building water systems, Legionella testing, or engineering design.

Table 2. Suggested Checklist for Routine Water Management Program Inspections

For facilities that need help understanding what a water management program should include, see HC Info’s Water Management Plans resources and Water Management Plans FAQ.

6. Use Remote Inspections for Routine Legionella Water Management Program Reviews

Conducting most Legionella water management program inspections remotely is crucial for a regulatory program to be efficient and sustainable.

Compared to onsite visits, remote inspections can be performed more frequently, too, which keeps facilities on their toes, like stepping on the scale weekly rather than quarterly will make one more weight-conscious.

On-site inspections may be necessary to confirm the types of water systems on the property instead of relying on what the owner reported, to investigate a case of disease possibly associated with the facility, or to follow up on an unsatisfactory remote inspection. Otherwise, routine inspections can be performed remotely if facilities are required to report objective, big-rock metrics electronically.

Remote WMP inspections can also make it easier for health departments, auditors, and insurers to review Legionella water management program compliance across larger groups of facilities without relying only on periodic onsite visits. For related guidance, see Monitoring Building Water Quality to Reduce Risk and Stay in Legionella Compliance.

LAMPS Tools for Legionella Water Management Program Compliance

Take advantage of water management program tools in LAMPS depending on your role:

• Facility Managers: Use the LAMPS Performance Report to evaluate and improve your water management program, and to prepare for inspections. Show the LAMPS Compliance Report to inspectors.
• Portfolio Managers: Use the LAMPS Portfolio Report to quickly evaluate the water management program performance at your properties based on several metrics.
• Health Departments: Ask facilities to show you their LAMPS WMP Compliance Report, which includes the site’s Water Quality Summary Report. The report gives you a high-level view of the contents of the water management plan and key metrics, saving you time.
• Insurers: Ask to see the LAMPS Performance Score and preferably the entire Performance Report.

In the comments below, please share an experience you have had with inspections, good or bad, as a facility operation or as an inspector.