Legionella Draft New Standards and Elements of Performance (EPs) from The Joint Commission

Below are the draft Legionella standards from The Joint Commission for healthcare facilities that are schedule to go into effect January 1, 2022.

For more information about what these mean or how the affect your hospital or healthcare facility with regard to Legionella and Legionnaires Disease water management plans, contact the Legionella experts at Legionella Control Systems. They can support your implementation of new Legionella standards and EPs through Legionella engineering consulting, testing, risk assessment, prevention, and control of Legionella and other waterborne pathogens.

Standard EC.02.05.02

This standard will go into effect January 1, 2022: The organization has a water management program that addresses Legionella and other waterborne pathogens.

Note: The water management program is in accordance with law and regulation.

EC.02.05.02, EP 1

This element of performance will go into effect January 1, 2022: The water management program has an individual or team responsible for the oversight and implementation of the program, including but not limited to, development, management, and maintenance activities.

EC.02.05.02, EP 2

This element of performance will go into effect January 1, 2022: The individual or team responsible for the water management program develops the following:

• A basic diagram that maps all water supply sources, treatment systems, processing steps, control measures, and end-use points

Note: An example would be a flow chart with symbols showing sinks, showers, water fountains, ice machines, and so forth. 

• A water risk management plan based on the diagram that includes an evaluation of the physical and chemical conditions of each step of the water flow diagram to identify any areas where potentially hazardous conditions may occur (these conditions can most likely occur in areas with slow or stagnant water)

Note: Refer to the Centers for Disease Control and Prevention’s “Water Infection Control Risk Assessment (WICRA) for Healthcare Settings” tool as an example for conducting a water-related risk assessment. 

• A plan for addressing the use of water in areas of buildings where water may have been stagnant for a period. (for example, unoccupied or temporarily closed areas)
• An evaluation of the patient populations served to identify patients who are immunocompromised
• Monitoring protocols and acceptable ranges for control measures

Note: Hospitals should consider incorporating basic practices for water monitoring within their water management programs that include monitoring of water temperature, residual disinfectant, and pH. Additionally, protocols should include specificity around the parameters measured, locations where measurements are made, and appropriate corrective actions taken when parameters are out of range.

This element of performance will go into effect January 1, 2022: The individual or team responsible for the water management program manages the following:

• Documenting results of all monitoring activities
• Corrective actions and procedures to follow if a test result outside of acceptable limits is obtained, including when a probable or confirmed waterborne pathogen(s) indicates action is necessary
• Documenting corrective actions taken when control limits are not maintained

Note: See EC.04.01.01, EP 1 for the process of monitoring, reporting, and investigating utility system issues.

EC.02.05.02, EP 4

This element of performance will go into effect January 1, 2022: The individual or team responsible for the water management program reviews the program annually and when the following occurs:

• Changes have been made to the water system that would add additional risk.
• New equipment or at-risk water system(s) has been added that could generate aerosols or be a potential source for Legionella. This includes the commissioning of a new wing or building.

Note 1: The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) do not require culturing for Legionella or other waterborne pathogens. Testing protocols are at the discretion of the hospital unless required by law or regulation. 

Note 2: Refer to ASHRAE Standard 188-2018 “Legionellosis: Risk Management for Building Water Systems” and the Centers for Disease Control and Prevention Toolkit “Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings” for additional guidance on creating a water management plan. For additional guidance, consult ANSI/ASHRAE Guideline 12-2020 “Managing the Risk of Legionellosis Associated with Building Water Systems.”

Contact Legionella Control Systems for expert Legionella control advice, planning, service, systems and support for your hospital or healthcare facility.