By Hilary Nardone, Environmental Group Training Manager
Certified ASSE 12080 Legionella Water Safety and Management Specialist

The Joint Commission has approved a new standard for all Joint Commission-accredited and certified organizations (including hospitals, critical access hospitals, and nursing care centers) that addresses Legionella bacteria and other waterborne pathogens.

The new standard EC.02.05.02 mandates these facilities to implement and maintain a Water Management Program (WMP) to control Legionella bacteria and other waterborne pathogens. Standard EC.02.05.02[1] will be effective January 1, 2022 and contains four elements of performance:

1. The Water Management Program has an individual or team responsible for the oversight and implementation of the program, including but not limited to the development, management, and maintenance activities.
2. The individual or team responsible for the Water Management Program develops the following:
   1. A basic diagram that maps all water supply sources, treatment systems, processing steps, control measures, and all end-use points.
   2. A water hazard analysis 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.
   3. A plan for addressing the use of water in areas of buildings where water may have been stagnant for a period.
   4. An evaluation of the patient populations served to identify patients who are immunocompromised.
   5. Monitoring protocols and acceptable ranges for control measures.
3. The individual or team responsible for the Water Management Program manages the following:
   1. Documented results of all monitoring activities.
   2. 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.
   3. Documented corrective actions taken when control limits are not maintained.
4. The individual or team responsible for the Water Management Program reviews the program annually and when the following occurs:
   1. Changes have been made to the water system that would add additional risk.
   2. New equipment or at-risk water system(s) has been added that could generate aerosols or be a potential source of Legionella bacteria. This includes commissioning of a new wing or building.

EC.02.05.02 references guidance from ASHRAE Standard 188-2018 “Legionellosis: Risk Management for Building Water Systems,”[2], ASHRAE Guideline 12-2020 “Managing the Risk of Legionellosis Associated with Building Water Systems,”[3] and the CDC’s Toolkit “Development a Water Management Program to Reduce Legionella Growth and Spread in Buildings.”[4] Following the guidelines and recommendations in these documents can assist your facility in implementing and maintaining a WMP that is compliant with The Joint Commission’s Water Management Standard EC.02.05.02.

A Water Management Program (WMP) completed by Barclay Water Management, Inc. keeps your facility in compliance with The Joint Commission’s EC.02.05.02. Barclay has created, implemented, validated, and updated hundreds of complete WMPs. In partnership with our customers, Barclay Water Management is dedicated to continually ensuring its WMPs comply with national and local standards and guidelines including ASHRAE Standard 188, The Joint Commission, and local Health Departments. Check out our blog post on the vital elements that must be included in a WMP.

[1] The Joint Commission.New Water Management Requirements: Pre-publication Standards – Effective January 1, 2022. Retrieved from: https://www.jointcommission.org/standards/prepublication-standards/new-water-management-requirements/.

[2] ASHRAE.ANSI/ASHRAE Standard 188-2018, Legionellosis: Risk Management for Building Water Systems. Retrieved from: https://www.ashrae.org/technical-resources/bookstore/ansi-ashrae-standard-188-2018-legionellosis-risk-management-for-building-water-systems.

[3] ASRHAE. ASHRAE publishes updated Legionella guideline. Retrieved from: https://www.ashrae.org/about/news/2020/ashrae-publishes-updated-legionella-guideline.

[4] CDC.Legionella (Legionnaires’ disease and Pontiac Fever): Toolkit: development a Water Management Program to reduce Legionella growth and spread in buildings.Updated April 30, 2018. Retrieved from: https://www.cdc.gov/legionella/wmp/toolkit/index.html.