Keeping Up with Proposed Water Management Program Changes from The Joint Commission

By: Morgan Nankivell, Environmental Group Manager, ASSE 12080 Legionella Water Safety and Management Specialist

In early October 2020, The Joint Commission released proposed changes related to Water Management Program (WMP) standards. This standard applies to Hospitals (HAP), Critical Access Hospitals (CAH), and Nursing Care Centers (NCC), which are currently expected to minimize pathogens in water systems without extensive guidance from the existing standard. The new proposed standard aims to create a more robust set of Elements of Performance (EPs), with the goal of reducing diseases related to waterborne pathogens.

Facilities with existing WMPs may be wondering if their documents will be up to par with these new proposed changes, and what kinds of details they will have to include moving forward. The good news is that if facilities have previously created WMP based on the ANSI/ASHRAE Standard 188-2018, ANSI/ASHRAE Guideline 12-2020, and the CDC Toolkit, to comply with the CMS Memorandum QSO 17-30 for example, they will most likely already have the key components outlined in the proposed changes. The Joint Commission specifically includes these resources as tools for building a compliant WMP. Here are some key EPs The Joint Commission is putting forward for review:

  • WMP Team Implementation
    • A team should be created that is responsible for implementing and maintaining all aspects of the WMP.
  • Program Components
    • A WMP team member should be tasked with developing a flow diagram and risk assessment that addresses at-risk populations. This should also include a plan for addressing stagnant or low use area.
  • Documentation
    • The team ensures that results of all monitoring activities are documented, as well as corrective actions and any subsequent monitoring and reporting. Specific procedures in the event of waterborne pathogen cases should also be in place.
  • Updates
    • The team updates the WMP anytime there is a change in risk or components added to the water systems that have an effect on at-risk populations and control locations.

Including these and other vital elements in water management programs ensures that a facility is working towards minimizing waterborne pathogen risk effectively, as well as complying with the most up-to-date standards and guidelines. The review period for these proposed changes ends November 16, 2020.

Contact Barclay for your Water Management Program (WMP) needs. Barclay has created, implemented, and validated hundreds of WMP’s in partnership with our customers.


  1. “Proposed Changes Related To Water Management for HAP, CAH, and NCC Programs Field Review” The Joint Commission, 5 October 2020,
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