7.17 ICF Water Management Plan

CDC encourages facilities to consider development and implementing water management programs.

Purpose

Water management programs can help reduce the risk for Legionella growth and transmission.

Background

Legionella is found naturally in freshwater environments, but generally the low amounts do not lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, Legionella has to grow and increase and then be aerosolized so people can breathe in small, contaminated water droplets. 

Common individual risk factors making more prone to develop Legionnaire’s disease:

• Age = over 50 years
• Smoking
• Chronic lung disease
• Immune system disorders
• Systemic malignancy
• Underlying illnesses: diabetes, renal or hepatic failure

Factors that can lead to Legionella growth:

• Water main breaks
• Construction changes
• Changes in municipal water quality
• Scale and sediment
• Water temperature fluctuations
• Water pressure changes
• Water stagnation
• Inadequate disinfectant; Ph- Disinfectants effective within narrow range 6.5 to 8.5

Where Legionella can grow and spread:

• Hot and cold water storage tanks
• Water heaters
• Expansion tanks
• Water filters
• Faucets and flow restrictors
• Aerators
• Shower heads and hoses
• Pipes, valves, fittings
• Centralized Misters, atomizers, air washers, humidifiers
• Non-steam aerosol generating devices
• Infrequently used equipment
• Ice machines
• Hot tubs, fountains, cooling towers
• Medical Devices such as CPAP, etc.

Water Management Oversight and System

For Open Door, the designated water management responsibilities will be reviewed each year by Operations department including Executive staff, Operations team, and Facilities Maintenance staff. The Facilities Maintenance, Operation, and Executive team are responsible for provisions outlined in this plan. Refer to the below diagrams that outline the water system from entry point and distribution points.

Water System Flow Diagrams

Preventative Monitoring Water Quality Parameters

The water management program team will regularly monitor water quality parameters, such as temperature levels and disinfectant levels. By monitoring these parameters, the team can ensure that building water systems are operating in a way to minimize hazardous conditions that could encourage Legionella and other waterborne pathogens to grow. 

If anyone finds that a control limit (e.g., temperature, pH testing, disinfectant residual) is not being met, their next step will be to take corrective actions to get conditions back to within an acceptable range.

Examples of chemical and physical control limits to reduce the risk of Legionella growth include:

• Maintain hot water temperature at the highest temperature allowable by state regulations or codes
• Physical inspection of distribution points and places identified in areas of growth/spread above in this policy
• Ensure disinfectant levels are detectable where water enters the building and at points of use
• Only using sterile (not distilled, non-sterile) water to fill and clean reservoirs of respiratory equipment intended for nebulization
• Measure the pH of the water to ensure that disinfectant used in the building will be effective.  (pH testing to be completed at least quarterly)

Facilities and Administration will monitor patterns and trends in water parameter measurements. If any concerning patterns or trends, they must be investigated by Water Management team to provide resolution on underlying problem (Such as flushing system equipment or adjusting the thermostat on the water heater.) These measures will be documented in Life Safety book.

Taking Corrective Actions When You Find Legionella

There is no known safe level of Legionella in building water systems. Cases of Legionnaires’ disease have been associated with very low levels of Legionella in building water systems. The intent of a water management program should be to manage building water systems to reduce hazardous conditions that allow Legionella to grow.

If an individual residing at facility is diagnosed with Legionnaire’s Disease, the local health department must be notified by Infection Control designee immediately.  Public health officials will work closely with facility staff to direct process. This must also be recorded on Infection Control log and follow procedures for Infection Control follow-up and review (refer to series 6.00 policies)

Conducting A Full Investigation

Available epidemiologic evidence may not be strong enough to warrant a full investigation when only a single possible healthcare-associated case has been identified.  The public health officials may recommend an environmental assessment.

An environmental assessment can help determine if conditions for Legionella growth exist in the building water system(s) where the case(s) may have been exposed. This also provides an opportunity to stress the importance of surveillance and prevention measures to facility staff. These additional steps might be particularly useful if the facility has one or more of the following characteristics:

• Has been associated with Legionnaires’ disease in the past
• Legionella has been recently identified in the facility’s water system(s)
• There has been a recent disruption of the facility’s water system(s)
• Other buildings in the area have been associated with Legionnaires’ disease

CDC recommends that public health officials perform a full investigation for the source of Legionella in a facility upon identification of:

• ≥1 case of presumptive healthcare-associated Legionnaires’ disease at any time
• ≥2 cases of possible healthcare-associated Legionnaires’ disease within 12 months of each other

Specimen Collection and Testing

The preferred diagnostic tests for Legionnaires’ disease are culture of lower respiratory secretions (e.g., sputum, bronchoalveolar lavage) on media that supports growth of Legionella paired with the Legionella urinary antigen test. Antibiotic treatment should not be delayed to facilitate this process (and culture can be attempted even after antibiotic therapy has been initiated). 

Immediate Control Measures

If the facility’s potable water (i.e., water used for drinking and bathing) system is a likely source of Legionella transmission, immediate control measures should be implemented, such as:

• Water restrictions
• Installing point-of-use filters (either globally or in areas of greatest risk)
• Periodic flushing of systems
• Restricting showers temporarily (using sponge baths instead)
• Avoiding exposure to hydrotherapy tubs
• Avoiding use of water from sink/tub faucets in rooms to avoid creating aerosols
• Using sterile water for tooth brushing, drinking, and flushing feeding tubs, for other susceptible patients, using bottled water
• Installing point-of-use (POU) microbial filters on any showerheads or sink/tub faucets intended for use
• Avoiding consumption of non-sterile ice from facility ice machines for anyone at risk for aspiration or who has swallowing difficulties
• Halting new admissions or temporarily closing the building, affected area, or device
• Ensuring that contingency responses and corrective actions are implemented if the building already has a water management program
• Distributing notification letters to individuals, families, county board and DODD, ODH contacts

The facility will work with Health Department, county board, DODD, ODH on measures to resolve issue and comply with instructions for investigation, testing, remediation, and further development of the Water Management System.

Last Revised: 7/26/23