Redacted WMP_Redacted.pdf

This is a Healthcare Associated Legionella Disease (HCA LD) Prevention Plan for Bay Pines VA Healthcare System (VISN 8) in Bay Pines, Florida, dated October 5, 2017. The document serves as a working guide for the facility's Water Safety Committee to manage water systems and prevent Legionella contamination across all potable and utility water systems.

The plan establishes comprehensive water management protocols organized by facility building and system type, including Building 100 (Main Hospital), Building 1 (Mental Health), Building 101 (Community Living Center), Building 71 (Community Living Center), Building 102 (Domiciliary), Building FH (Fisher House), and facility-wide utility systems. For each area, the document specifies hazard analyses, control limits, monitoring procedures, frequencies, corrective actions, record-keeping requirements, and verification schedules. Key monitoring parameters include temperature ranges (typically 57°F or below for cold water, above 124°F for hot water), pH levels (7.0-9.0), and total residual oxidant (TRO) levels (0.5-4.0 mg/L). The plan mandates regular flushing of fixtures, quarterly bacterial testing, monthly residual oxidant monitoring, and implementation of preventive maintenance for ice machines, cooling towers, and water treatment systems. Validation criteria include environmental testing for Legionella using ISO standards and clinical validation through urinary antigen testing. The Water Safety Committee, led by the Chairperson from the Executive Office, is responsible for monthly reviews and annual verification of plan compliance, with quarterly assessments by the Assistant Chief of Engineering and annual comprehensive reviews by the full committee.