Since 2001, the Joint Commission (TJC) has required that accredited hospitals minimize “pathogenic biological agents in cooling towers, domestic hot-and cold-water systems, and other aerosolizing water systems” per Standard EC.02.05.01.
Standard EC.02.05.01 will soon be replaced with EC.02.05.02, which was approved by the Centers for Medicare and Medicaid Services (CMS) on January 7, 2021, issued March 19, 2021, and becomes effective January 1, 2022.
EC.02.05.02 requires hospitals and nursing care centers to have a water management program (WMP) that “addresses Legionella and other waterborne pathogens.” A designated individual or team must oversee the entire WMP – development, management, maintenance – to ensure it meets applicable laws and regulations and includes the following:
EC.02.05.02 requires a basic drawing that shows the flow of all water system points (e.g., entry to the building) and processing steps (e.g., heating).
For “end-use points,” EC.02.05.02 notes, as an example, “a flow chart with symbols showing sinks, showers, water fountains, ice machines, and so forth.” Laura Smith, Project Director for the Department of Standards and Survey Methods at Joint Commission, clarified that all point-of-use (POU) types must be identified, but not every POU location.
EC.02.05.02 requires that hospitals and nursing care centers “identify any areas where potentially hazardous conditions may occur.” ASHRAE Standard 188 calls this step “analysis of building water systems.” For WMPs aimed to control Legionella and other waterborne pathogens, the procedure amounts to identifying water systems where pathogens can grow, be transmitted to humans, and be controlled.
In addition to assessing risk based on the types of water systems, EC.02.05.02 requires “an evaluation of the patient populations served to identify patients who are immunocompromised” and refers to the CDC’s tool, Water Infection Control Risk Assessment (WICRA) for Healthcare Settings.
The WMP must include control measures to minimize conditions that promote the growth of Legionella and other pathogens. EC.02.05.20 specifically requires control measures to minimize stagnation.
Monitoring, Limits, and Corrective Actions for Control Measures
EC-02.05.02 does not require tests for Legionella or other waterborne pathogens unless required by regulations, leaving such tests to the discretion of the WMP team. Monitoring water temperatures, disinfectant levels, and pH should be “considered.”
Corrective actions must be taken if results for any parameters or pathogens tested are outside acceptable limits (“ranges”).
Documentation is required for all testing (e.g., what was tested and where) and corrective actions.
The WMP must be reviewed annually and whenever any water system changes or additions (e.g., new equipment, system, wing, or building) could affect Legionella growth or transmission (e.g., via aerosols) or otherwise increase risk.
In sum, the EC.02.05.02 requirements boil down to documenting compliance with ASHRAE Standard 188.
For guidance, TJC refers its accredited hospitals and nursing care centers to ASHRAE 188, the CDC Toolkit, “Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings,” and ASHRAE Guideline 12-2020.
Note: If you have a WMP in LAMPS, refer to Training Note 3.006 to prepare for a Joint Commission inspection of your WMP.
Has your WMP been inspected by TJC? If so, what was requested? Please comment below.