New Water Management Program Standards: Key Updates & Compliance Strategies

Facilities managers, infection prevention specialists, and water management service providers face significant challenges due to new standards. These changes require broader program scopes, professional certification, increased water testing, detailed documentation, and stricter reporting.

ASSE International 12080

ASSE International 12080, a certification program for “Legionella specialists,” became an ANSI standard in 2020. It didn’t have much impact at first because it was unknown whether the new standard would be adopted, but it has since been listed in proposed state regulations and by the General Services Administration (GSA) for individuals providing Legionella-related services. For credibility and perhaps to reduce legal risk, individuals providing WMP services as well as some facilities personnel consider it essential to be 12080-certified.

To earn ASSE 12080 certification, individuals must complete 24 hours of training and pass a 100-question exam. Recertification is required every three years, which includes 8 hours of additional training and another exam.

Water Quality Monitoring

Although water quality monitoring was mentioned in the original (2015) version ASHRAE 188, it has received (as it should) much more attention since 2020. Several organizations are either recommending or requiring it including the Association of State Drinking Water Administrators (ASDWA), Centers for Disease Control and Prevention (CDC), Veterans Health Administration (VHA), and the Joint Commission (TJC). See Table 1.

Table 1: Water Quality Monitoring Requirements or Recommendations

Healthcare Facilities: Stricter WMP Compliance Inspections

Hospitals and nursing homes that are required to have water management programs – per state regulations, Centers for Medicare and Medicaid Services (CMS) QSO-17-30, Accreditation Commission for Health Care (ACHC) 07.02.06, or Joint Commission Standard EC.02.05.02 – have been impacted primarily because of onsite inspections and remote audits.

Merely having a WMP document is no longer enough – the facilities must produce documentation to show they are implementing it.

ASHRAE 514: Expanding WMP Scope Beyond Legionella

ASHRAE 514, which became an ANSI standard in July, 2023, significantly broadened the scope and increased the level of detail for water management programs. The stated purpose of ASHRAE 188 is to reduce one illness (legionellosis) by managing only one hazard (Legionella) in building water systems. By contrast, the stated purpose of ASHRAE 514 is to “reduce illness and injury from physical, chemical, and microbial hazards,” expanding the scope from one microbe to an unspecified number of microbes as well as to physical hazards (scalding) and chemical hazards. ASHRAE 514 even includes a catch-all statement to reduce “overall risk of illness or injury from hazards associated with building water systems.”

Prior to ASHRAE 514, good water management plans already included measures to limit the risk of scalding, avoid chemical contamination from cross connections, apply chemicals per best practices and EPA rules, and to control pathogens other than Legionella. But after ASHRAE 514 was finalized, even those good WMPs had to be (or should have been) partially rewritten to make the WMP scope, risk/hazard analysis, control measures, and validation procedures in sync with ASHRAE 514 and each other while still making the WMP achievable, limited in scope, specific, and clear – which is no small challenge.

ASHRAE 514 also includes some time-consuming documentation and communication requirements (e.g., listing and describing all points of water use) that ASHRAE 188 does not.

Although the extent to which ASHRAE 514 will be adopted into state regulations is still unknown, it is probably unwise for facilities or their vendors to ignore it.

Association for the Advancement of Medical Instrumentation Standard ST108

Finalized as an ANSI standard on August 4, 2023, AAMI ST108 moved the WMP burden needle for hospitals even more than the standards mentioned above. AAMI Standard ST108 defines levels of water quality suitable for various stages of medical device processing – to make the devices safe for patients. The standard applies to water provided to devices such as automatic endoscope reprocessors (AERs), ultrasonic sterilizers, autoclaves, and local steam generators.

ST108 may become a requirement of other standards (e.g., Joint Commission EC.02.05.02) and has already been included in at least one major medical equipment manufacturer’s IFUs (Instructions for Use).

AAMI ST108 indicates that the medical device processing water quality requirements should be managed by the same team that oversees the water management program for building water systems.

ST108 requires a lot of testing! “Utility water” used for washing devices, steam condensate used for sterilization, and “critical water” used for reprocessing, sterilizing, and rinsing must be tested for a total of about 18 microbial, chemical, and general water quality parameters.

Key Steps for WMP Success in 2024 and Beyond

Table 2 gives an overview of the increase in WMP requirements since 2015. To successfully comply with standards and water quality monitoring expectation, the water management program team must:

1. Maintain ASSE 12080 certification for at least one team member.
2. Provide water management plan content that satisfies ASHRAE 514 (and therefore ASHRAE 188 as well) – and keep it updated.
3. Conduct sampling and use sensors for water quality monitoring and manage, report, and respond to the data well.
4. Manage the documentation of control measure implementation and water quality test results so they can be easily produced and reported.
5. For hospitals, provide AAMI ST108 testing and data management and reporting.

Table 2: Requirements for Compliance with Key WMP Standards and Regulations

Two Key Ingredients for Success

A CDC analysis of 14 LD outbreak investigations conducted 2015 – 2019 showed that:

• 72% of Legionnaires’ disease cases and 81% of the deaths occurred at facilities without a WMP.
• At facilities with WMPs, 70% of the deficiencies were in WMP implementation.

To succeed in minimizing risk, facilities must establish and fully implement a comprehensive water management program. Two key ingredients for success are:

High quality software. In addition to comprehensive content (policies and procedures), the software must at least provide water quality data analytics, automation of much of the documentation and reporting, and performance tracking. Integration with sensors (for automated monitoring), integration with laboratories (to automate entry and analytics of test results), and built-in training are pluses.

Highly qualified help. Organizations with enough properties to justify dedicating an employee to WMP oversight can set up and maintain WMPs with the help of certain vendors. Facility directors for a given property could do it, too, but few will devote the time to the setup process. In most cases, paying a vendor to set up the WMP and help with certain (not all) aspects of the implementation will be money well spent.

How is your facility adapting to these new WMP standards? Share your experiences, challenges, or best practices in the comments below!