Since we develop Water Management Plans for both Nursing Homes and Hospitals throughout the country, we receive calls from facility managers who are undergoing inspections by the state or accreditation agencies.
We thought it would be best to share the information with everyone so you know what may be asked and how to answer most inquiries.
Common Questions by Inspectors
Are you testing the water in your facility for Legionella?
You do not have to test the water for Legionella under the guidelines unless your specific water management plan states that you will be testing the water. Review your plan and see if it calls for testing. If it does, you need to be following the plan or amend your plan.
You may ask, how do I answer if I am not testing the water that the water system in the facility is safe? The whole idea of the Water Management Plan is to perform specific tasks (taking temperatures, flushing, etc.) outlined in the plan to prevent the bacteria from developing. If you are following your plan, then you do not have to test.
We would like to review your Water Management Plan – is it available?
Here are the items the inspectors are looking for when reviewing your Water Management Plan:
Who is on the Water Management Team?
It is important to establish clear lines of communication between representatives of your Water Management Plan.
For Nursing Homes, the group may consist of:
- three or more individuals representing management
- nursing (someone filling the role of infection control)
- the facilities engineer
Some cases may require outside training or hiring professionals who have specific experience and knowledge of the types of bacteria that can grow in your water systems.
Water Flow Chart for the Facility
The Water Management Plan should have a thorough assessment of the facility’s water management systems and sources. This can be documented with a combination of text and diagrams. Write a simple description of how water comes into and flows through the building and use flow diagrams to identify areas within the building where Legionella could grow and spread. Examples include cooling towers, showerheads, ice machines, and even certain medical devices like CPAP machines that could spread Legionella through aerosols or aspiration.
Water Management Agenda & Meeting Frequency
Your facility’s Water Management Plan is a multi-step, continuous process, and should clearly state how often your team meets. A proper program review should occur at least once a year. Agenda topics might include recommended testing methods for Legionella. These meetings are also a good time to conduct practice sessions on a positive case scenario and what steps your team will take.
Verification & Validation – How Are the Tasks Tracked?
A thorough water management plan will outline the tasks required by the water management team to confirm, both initially and on an ongoing basis, that the facility’s program is being implemented as designed. After verifying the team is doing what they said they would do, the plan should be validated to make sure it is effective in controlling the hazardous conditions throughout the building’s water systems.
The plan should also outline events that may require intervention when control measures are not met. When these scenarios occur – for example, a major construction or maintenance project, or changes in water services – the plan may require revisions. If an event triggers revisions to your plan, it’s important to update your descriptions and flow diagrams and then train your team accordingly.
Contact Thom Wellington if you need suggestions for Water Management meeting topics or help with your plan.
Email Thom or call: 314-575-1281