Healthcare organizations accredited by The Joint Commission must maintain a water management program (WMP) that complies with current standards for controlling Legionella and other waterborne pathogens. This guide explains the 2026 The Joint Commission water management program requirements under PE.04.01.05, how they align with ASHRAE Standard 188, and what hospitals and nursing care centers should include in their water management program.
The Joint Commission (TJC) has required accredited hospitals to minimize “pathogenic biological agents in cooling towers, domestic hot-and cold-water systems, and other aerosolizing water systems” since 2001, when it established Standard EC.02.05.01. In January 2022, per Standard EC.02.05.02, TJC expanded the water system management requirements to align with ASHRAE Standard 188.
Effective January 1, 2026, The Joint Commission incorporated these requirements into Standard PE.04.01.05, which contains elements of performance that are nearly identical to the former EC.02.05.02 requirements.
PE.04.01.05 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:
Flow Diagram Requirements
PE.04.01.05 requires a basic flow diagram showing the building water system, including water entry points and major processing steps (e.g., heating).
The flow diagram should represent the overall building water system, from where water enters the facility through the major treatment, storage, heating, and end-use points, as applicable.
For “end-use points,” PE.04.01.05 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 The Joint Commission, clarified that all point-of-use (POU) types must be identified, but not every POU location.
Risk and Hazard Analysis
PE.04.01.05 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.”
The purpose of the risk assessment is to identify where conditions may allow Legionella growth, amplification, or transmission so appropriate control measures can be established.
For WMPs aimed at controlling Legionella and other waterborne pathogens, the analysis focuses on identifying building water systems where pathogens can grow, spread, and expose patients, staff, or visitors to waterborne pathogens so appropriate control measures can be implemented.
In addition to assessing risk based on the types of water systems, PE.04.01.05 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.
Required Control Measures
The WMP must include control measures to minimize conditions that promote the growth of Legionella and other pathogens. PE.04.01.05 specifically requires control measures to minimize stagnation.
Examples of control measures may include maintaining appropriate hot and cold water temperatures, maintaining disinfectant residuals where applicable, reducing water stagnation, flushing infrequently used outlets, maintaining equipment, and following facility-specific water management procedures.
Monitoring, Limits, and Corrective Actions
PE.04.01.05 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.
Facilities should also document how often monitoring occurs, who is responsible for each activity, what corrective actions were implemented when control limits were exceeded, and retain this documentation as part of the water management program so it is readily available during a Joint Commission survey.
Annual Water Management Program Reviews
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.
Annual reviews should also verify that the water management program remains current following building renovations, equipment replacements, occupancy changes, or updates to applicable guidance or regulations.
Key Takeaways
For most accredited healthcare facilities, compliance with The Joint Commission’s PE.04.01.05 standard largely means maintaining a documented water management program that follows ASHRAE Standard 188 principles. A complete water management program should include a system flow diagram, risk assessment, control measures, monitoring procedures, documentation, corrective actions, and annual reviews to reduce the risk of Legionella and other waterborne pathogens.
For additional guidance on developing and maintaining a compliant water management program, TJC refers its accredited hospitals and nursing care centers to ASHRAE Standard 188, the CDC Toolkit, “Developing a Legionella Water Management Program,” and ASHRAE Guideline 12.
Organizations using digital water management software can simplify documentation, annual reviews, corrective action tracking, and survey preparation by maintaining all required records in a centralized system.
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 water management program been inspected by The Joint Commission? If so, what documentation or information did surveyors request? Please share your experience in the comments below.