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The Joint Commission Proposes New Water Management Standard

In its October 7, 2020 issue of Joint Commission Online, The Joint Commission requested comments on its proposed new water management program standard, through a field review of the proposed new standard.  The Joint Commission field review is accepting comments through November 16, 2020.

A Joint Commission speaker at the Virtual ASHE Annual Conference presentation entitled “2020 Environment of Care, Life Safety Code Updates” on October 6, 2020 also presented an overview of the anticipated proposed changes.

The existing water  management program requirements are in one element of performance, Standard EC.02.05.01 (Managing Utility System Risks), Element of Performance 14 (EP14), “The hospital minimizes pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems.”  Although existing EP14 does not provide details, the CMS Document CMS QSO 17-30-Hospitals/CAHs/NHs REVISED 07.06.2018, “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)” does clarify CMS expectations for providers, accrediting organizations and surveyors.

The proposed new EC.02.05.02 (The organization has a water management program) standard is expected to have four new elements of performance (EPs) with topics covering but not limited to:

EP1 – Individual or team accountability for program development, management and maintenance

EP2 – Requirements for a detailed water system diagram, a related risk management plan that also considers patient populations, processes for dealing with stagnant/slow systems or water, and monitoring protocols and with control measures

EP3 – Documentation of monitoring activities, required corrective actions if problems are found, and documentation of corrective actions

EP4 – Updates reflecting changes, maintenance of the water management program and risk assessments, new equipment or at-risk systems

As healthcare organizations consider taking a new look at their existing water management programs, it can be useful to review and consider recent industry updates now.  ASHRAE Guideline 12-2020, Managing the Risk of Legionellosis Associated with Building Water Systems, published this year, is referenced by the proposed new EP4 “for guidance on operational best practices …” and is also now under Continuous Maintenance.  Furthermore, a useful new industry standard addressing personnel qualifications and training is ASSE/IAPMO/ANSI 12080 for Legionella Water Safety and Management Personnel.