Legionella Prevention Plan 5-20-18 rev1 (002).pdf

Approved by: Fernando O. Rivera, FACHE SLVHCS Medical Center Director

Date

Southeast Louisiana Veterans Health Care System New Orleans, LA 70112

Department of Veterans Affairs Healthcare Associated Legionella Disease Prevention Plan ii | P a g e

TABLE OF CONTENTS

1. SCOPE

PURPOSE………..……………

BACKGROUND SUMMARY

BUILDING CHARACTERISTICS………………………………………………………1

CAMPUS MAP………………………

2. RESPONSIBILITY

WATER SAFETY COMMITTEE…………………

3. HAZARD ANALYSIS AND RISK ASSESSMENT

SUMMARY – POTABLE WATER .................................................................... 4-11

4. PROGRAM MANAGEMENT

PROGRAM REVIEW………

VALIDATION. ……….……………………………………………………………..13-16

AWARENESS TRAINING…………

RECORDS AND DOCUMENTATION………

ENGINEERING….…………

OPERATION……….……… ........................................................................... 17,18

MAINTENANCE….…………

NEW CONSTRUCTION………

5. DEAD-LEG ELIMINATION AND PREVENTION PLAN

DEAD-LEG PREVENTION……….……………..... ......................................... 18,19

6. SCALD PREVENTION

WATER SAFETY COMMITTEE……….……………

7. ENVIRONMENTAL VALIDATION

WATER SAMPLING PROTOCOL…………………………

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8. EMERGENCY REMEDIATION OF POTABLE WATER DISTRIBUTION SYSTEMS

THERMAL ERADICATION

HIGH- LEVEL DISINFECTION…

SHOCK CHLORINATION……

9. SCHEMATIC SINGLE LINE DIAGRAMS

CEP……………………….…… ...................................................................... 21-23 TRANSITIONAL LIVING….... ........................................................................ 24,25 DIAGNOSTIC AND TREATMENT…... .......................................................... 26-28 INPATIENT………………….. ........................................................................ 29,30

APPENDIX A CORRECTIVE ACTIONS DOCUMENTATION

APPENDIX B POLICIES, SOPS, AND DOCUMENTATION LOGS

APPENDIX C FLOW CHART FOR INTERPRETATION OF SAMPLING

APPENDIX D QUARTERLY WATER SAMPLING PROCEDURES

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1. SCOPE

1.1. Purpose

The purpose of this plan is to ensure the safety of the Southeast Louisiana Veterans Healthcare System (SLVHCS) patients, visitors and employees by defining the process by which SLVHCS will manage the environmental aspects of its building water streams (e.g., domestic and utility hot / cold water systems).

SLVHCS will implement and maintain an effective management program for the prevention and control of Legionella in domestic water services. The plan will focus on the identification of risks and implementation of engineering control measures, monitoring of control measures, and validation that measures are effective at suppressing Legionella growth.

1.2 Background Summary:

Southeast Louisiana Veterans Health Care System (SLVHCS) is a 1.6 million square

ft. medical center in New Orleans, Louisiana. The SLVHCS campus is a series of buildings organized around a four level concourse. VHA Directive 1061 will apply to three buildings: Inpatient Building B and C, Transitional Living & Rehabilitation, and Diagnostic and Treatment Building.

1.3 Building Characteristics

Building lettering begins near Canal Street and progresses sequentially moving towards Tulane Ave:

• Concourse A

• Inpatient B/C

• Diagnostic & Treatment Building D/E/F/G

• Outpatient – H/J

• Staff Parking Garage – K

• Patient/Visitor Parking Garage – L

• Transitional Living & Rehabilitation Building – M

• CEP Service Center

• Research Building – P

• Administration Building – Q

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L1

Campus Building Organizational/Stacking

ADMINISTRATION

L5 Director’s Suite

L4 Administrative

L3 Human Resources

L2 Medical Media, PR, Workforce Development

L1 Auditorium/Education

DIAGNOSTIC & TREATMENT

L5 inpatient Mental Health

L4 Support Services

L3 Surgery/Procedures

L2 Emergency Dept./Radiology

L1 Canteen

STAFF PARKING GARAGE

STAFF PARKING - L1 - L7

L1 Rehab Pt Parking - L1

TRANSITIONAL LIVING

& REHABILITATION

L4 Transitional Living Beds

L3 Transitional Living Beds

L2 Transitional Living Beds

L1 Physical Rehab/Prosthetics

INPATIENT

Inpatient Bed Unit L4

Inpatient Bed Unit L3

B Inpatient Bed Unit L2 Administrative/Sleep Lab/ L1

Discharge Lounge

E C

OUTPATIENT

Women’s/Oncology/neuro

Medicine L7

Primary Care L6 general Medicine/Audiology L5 g Cardiology/gi/Dental L4

H Surgery Specialties L3

OP Pharmacy/Eye Service L2

OP Mental Health, OP Lab/PT k J Education

TRANSITIONAL LIVING GYM

L M

PATIENT/VISITOR PARKING GARAGE

n Patient/Visitor Parking L1 - L7

RESEARCH

L4 Research P

L3 Research

L2 Research

L1 Psychosocial Rehabilitation Recovery Center

CENTRAL ENERGY PLANT

Warehouse L4

Facilities L3

Engineering L2

Docks/Warehouse Logistics L1

Q D

A f

Figure 1 Campus Map

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2. RESPONSIBILITY

It is the responsibility of the Water Safety Committee (WSC) to ensure all procedures set forth in this document are implemented and updated as outlined herein. Facility personnel will complete the necessary testing and monitoring as outlined. Program tasks may be contracted to qualified service providers, if the competency of the contractors are assessed and documented prior to beginning work and on an on-going basis, at least annually. Responsibility for implementing and following this program, however, cannot be transferred to the service provider.

The Management Plan shall be reviewed by the WSC as defined below:

Chairperson: Deputy Director Co-Chairperson: Industrial Hygienist, Safety Management Voting Members: Chief, Facilities Management Service Hospital Epidemiologist Infection Control Manager, Quality and Performance Patient Safety Representative, Quality and Performance Pathology and Laboratory Representative Sterile Processing Service Representative Dental Service Representative Dialysis Representative Occupational Health Representative Environmental Management Service Representative Pipefitter Supervisor, Facilities Management Service Associate Director Patient Care Services Chief, Safety Management GEMS Coordinator Non-Voting Members: VISN 16 Industrial Hygienist VISN 16 GEMS Coordinator

3. HAZARD ANALYSIS AND RISK ASSESSMENT

The current risk level for Healthcare Associated Legionella Disease (HCA LD) at SLVHCS is High-Risk. See Table 1 for identified hazards for the potable water system.

See Table 2 for the Hazard Analysis and Critical Control Points (HACCP) system summary.

The Water Safety Committee will continue assessing and monitoring the medical center for potential environmental growth of Legionella and proactively deal with any noted deficiencies.

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Table 1 HAZARD ANALYSIS SUMMARY

Processing Steps Potential Hazard Risk Significant? Risk Basis Controls CP CCP B = Biological hazards such as coliforms, Legionella, virus, and protozoa

Medium Risk 1) Obtain product from sources that are certified to the National Drinking Water Regulations (NDWR)

C = Chemical hazards such as heavy metals or disinfection by-products

Municipal water is treated to US Standards for drinking water given in the Code of Federal Regulations (CFR 2002) therefore incoming water is highly regulated and well controlled.

2) Obtain water quality test results from the water provider every six months

P = Radioactive contamination hazards 3) Continuous monitoring of incoming water: Temperature, pH, Pressure, Free Residual Oxidant and Conductivity

Annual temperature averages are above 68 F which allows for the proliferation of microorganisms.

B = Biological – Potential growth as a result of sediment build-up in the vessel and drain l i (d d l ) Th l l h

High Risk 1) Inspections on the storage tank should be performed bi-annually.

C = Chemical – Introduction of heavy metals as a result corrosion in the vessels.

Water supply for the facility flows through the storage vessel in the (CEP Central Energy Plant). This water supply/storage is the origination for all water use at the facility.

2) Cleaning of tank interior is performed at the time of inspection, if needed.

3) High and low level alarms at the storage location to monitor the water level.

4) Continuous monitoring of TRO (Total Residual Oxidant - Chloramine), pH, Conductivity, Turbidity and Temperature

5) Supplemental feed of chlorine to obtain a Free Residual Oxidant level of 1.0 - 2.0 ppm

1BYes1. RECEiVING

2B2B2. STORAGE - Cold Water (CEP)

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B = Biological hazard from growth of microorganisms

High Risk 1) Maintain a minimum discharge temperature of 130 °F in the hot water heat exchangers continuously

P = Physical hazard from scalding Hot water systems have been associated with severe disease from pathogens such as Legionella.

2) Maintain temperature of 124 - 130 °F in hot water loops

Microbial pathogens have been found to grow on surfaces in biofilms and can re-enter the water in hot water systems as the disinfectant (chlorine) has dissipated.

3) Flushing

The potential for this is increased when hot water distribution temperatures are not maintained above 120 °F.

4) Maintain discharge temperature at the fixtures at < 110 °F

Medium Risk For potable water use associated with ice machines and water fountains.

Ice machines and water fountains have been associated with cases of waterborne pathogen disease based on the potential for aspiration by a patient.

The heat produced by the machines internal equipment can cause the inlet water temperature to increase, leading to tempered or warm water entering the ice machine. Proper maintenance of equipment is important for safe and reliable operation.

This processing step resides in Dialysis, Laboratory processing centers. See sections 4N, 4O.

B = Biological – Growth of microorganisms on the fi lter media which can turn into an inoculation point within the system

B=Biological hazards can grow in non-maintained fi ltration systems of all types

Yes 1) Change out applicable filters and cleaning based on maintenance specifications

4B

2B 2P2B 2PYes3. HEATING

4I. CONDITIONING - Filtration, Cartridge Style (Micro, Ultra, Nano) (Dialysis - Inpatient Building & Diagnostic and Treatment Building)

No Low Risk

4H. CONDITIONING - Filtration, Carbon and Multi-media

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4N. CONDITIONING - Dialysis Operations B = Biological – Bacteria within supply and growth within the dialysis processing system.

Yes High Risk 1 – Tests are performed Daily and/or per shift. All tests and maintenance performed on the system are in compliance with:

C = Chemical – The presence of residual oxidants and other chemical contaminants.

The quality of water entering the processing room is of greatest concern.

The system was designed around the water quality provided by the municipality. With the addition of secondary disinfection, it is critical to monitor the critical limits of processing step

ANSI / AAMI / ISO 11663:2009; ANSI / AAMI /

ISO 13959:2009; ANSI / AAMI / ISO

26722:2009;

Supply water must meet the standards of the Safe Drinking Water Act.

Total residual oxidant levels must not exceed levels specified in the SDWA (e.g., maximal limit for residual total chlorine of 4.0 mg/L, chlorite of 1.0 mg/L and chlorine dioxide of 0.8 mg/L). If levels must be increased above this for remediation purposes, advance notice must be provided to the Medical Director of the Dialysis Unit and the Chief, Renal Section.

ANSI/AAMI/ISO 23500:2011; and Federal Regulations (42 CFR §494.40) all tests are to identify water and dialysate quality.

P = Physical – Particulate matter in the water Any future changes to secondary disinfection must be discussed with the Medical Director of the Dialysis Unit and the Chief, Renal Section prior to design and implementation.

The critical test relative to hospital-wide mitigation strategies performed (for patient safety) is after the first carbon tank. Residual total chlorine as tested by standard DPD methodology must be below 0.1 mg/L. If results exceed this critical l imit, a second test is performed after the second carbon tank. If the result exceeds 0.1 mg/L, the system is shut down. Safe l imits for chlorite and chlorine dioxide are not defined; hence residual levels for these agents, would need to be undetectable using a high sensitivity, EPA approved point-of-use test.

Additional item of concern which require communication to dialysis:

2 – Final water quality (after RO/DI) is alarmed at the Dialysis Nurses Station

1 - Potable water shut-downs or drastic changes in operating pressure.

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4O. CONDITIONING - Lab Operations B = Biological – Bacteria within supply and growth within the processing system.

No Low Risk 1 – Maintenance of all processing equipment for laboratory operations is performed by an outside service professional.

C = Chemical – The presence of residual oxidants. Supply water must meet the standards of the Safe Drinking Water Act.

Based on the very controlled environment of laboratory and its associated testing equipment; coupled with the purity of the water, there is little risk to the technicians working in this area.

2 - Equipment has internal safeties that do not allow operation if water quality is not adequate.

5. DISTRIBUTION P = Physical – Particulate matter in the water Yes High Risk 1) Thorough Housekeeping procedures, regularly flush all taps to promote water with detectable free residual oxidant.

5B 5P 5B 5P

B = Biological hazards will accumulate on plumbing surfaces, pipe walls, showerheads and in dead legs

Showers 2) Remove all dead legs

C = Chemical hazards from potential backflow issues in housekeeping closets /cleaning chemical systems.

Medium Risk Ice Machines, Drinking Fountains

3) Deliver 110°F water at distal taps within one minute at full on hot

P = Physical hazard from scalding Low Risk 4) Free Residual Oxidant of 0.5 ppm (as chlorine) in discharge water at fixtures

(HW & CW)

Food & Beverage Service Cooking/Cleaning, Housekeeping Cleaning Spigots

5) Control water system access to new construction areas containing stagnant water

Microbial pathogens have been found to grow in biofilms and are released into the water, most notably in hot water systems. The potential for this is increased when hot water distribution temperatures are not maintained above 120°F.

Low Risk 6B Sewage can transmit waterborne pathogens.

6. WASTE B = Biological hazards from fecal coliforms and viruses

No Ensure physical separation of potable water and sewage, backflow preventers

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Table 2 HACCP PLAN DOCUMENT

Product

CCP Processing

Step

Critical Limit Hazard Control

Monitoring Method

Frequency Corrective Actions Records Verification Procedure

Potable Water 2B 2C.

STORAGE

COLD WATER

See Corrective Actions Documentation

1. Inspections on the storage tank should be performed bi-annually on the tank lining

2. Cleaning of tank interior is performed at the time of inspection, if needed

3. High and low level alarms to monitor the water level

4. Supplemental feed of chlorine to obtain a Free Residual Oxidant level of 1.0 - 2.0 ppm

1. Bi-Annual inspection scheduled by facilities

2. Inspection of bottom of tank (if needed) by facilities or contractor

3. Alarm communication capabilities with alerts

4. Continuous monitoring system with communication and alerts -monthly calibration and reagent refresh to ensure accuracy

1. Bi-Annually

2. Bi-Annually

3. Continuously

4. Continuously

1. Evaluate why actions were not taken, change process if needed

2. Evaluate why actions were not

3. Evaluate why taken, change process if needed

4. Evaluate why actions were not taken, change process

1. phiMetrics

2. phiMetrics

3. Building Automation System with

ALERTS

4. phiMetrics and . Bldg Automation System does not monitor chlorine levels.

1. Chief Engineer and Phigenics verify annually

2. Chief Engineer

3. Chief Engineer verify annually

4. Chief Engineer verify monthly

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Monitoring Method

Frequency Corrective Actions Records Verification Procedure

Potable Water

3B 3P. HEATING

See Corrective Actions Documentation (A)

- HX Temps and HW Loop Temps Low to maintain <1100F at the Fixtures

1. Hot Water temperature at each HW Heat Exchanger of 130°F

2. HHW

recirculation loop at temperature of 124 - 130°F

3. Temperature no greater than 110°F at fixture discharge

4. Supplemental feed of chlorine to obtain a Free Residual Oxidant level of 1.0 - 2.0 ppm

1. Temperature gauge at each heat exchanger

2. Thermal sensors at each

HX

3. Temperature measurement at fixtures

4. Continuous monitoring system with communication and alerts -monthly calibration and reagent refresh to

1. Continuously

2. Continuously

3. Quarterly with Legionella sampling at fixtures

4. Continuously

1. Mechanically troubleshoot and repair specific heat exchanger

2. Mechanically troubleshoot and repair HHW system

3. Mechanical Adjustment

4. Mechanical Adjustment

1. phiMetrics

2. phiMetrics and Building Automation System

3. Maximo

4. phiMetrics

1. Chief Engineer and Phigenics verifies on a monthly basis

2. Chief Engineer notified if limit not met. Chief Engineer and Phigenics verify quarterly

3. Chief Engineer notified if limit not met. Chief Engineer verify quarterly

4. Chief Engineer, verify monthly

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Monitoring Method

Frequency Corrective Actions Records Verification

5B 5P.

DISTRIBUTION

See Corrective Actions Documentation (B)

5B 5P.

DISTRIBUTION

1. Minimum 110°F at representative rooms’ distal showerheads, shower wands, & spigots within one full minute

2. Flush all fixtures in each room, including those that are not occupied or low use, flush at least daily

3. Maintain Free Residual Oxidant (FRO) of 1.0 ppm in building water outlets

1. Temperature gauge

2. Flush Water fixtures. HW until Temp. is at a minimum of 110°F and Flush CW and HW fixtures for a minimum of five minutes

3. Appropriate FRO test procedure monitoring system with communication and alerts -monthly calibration and reagent refresh to

1. Quarterly

2. Upon check-out by Housekeeping.

3. Quarterly

4. Continuously

1.a. Mechanically troubleshoot and repair Heat Exchanger 1.b. Flush outlet

2. Evaluate why

3.a. Troubleshoot & Repair Chlorine control/feed system 3.b. Flush Outlet

4. Evaluate why

1. Maximo

2. EMS completes log daily

3. phiMetrics

4. phiMetrics and Bldg Automation System does not monitor chlorine levels.

1. Chief Engineer verify quarterly

2. Supervisor observations and quarterly water tests with Legionella sampling

3. Chief Engineer and Phigenics to verify quarterly

4. Chief Engineer , Industrial Hygienist, and Phigenics to verify monthly

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Monitoring Method

Frequency Corrective Actions Records Verification monitoring of Free Residual Oxidant, pH, Pressure, Conductivity and Temperature at each building covered in Directive 1061

5. Vendor process for drinking water machine

6. Facilities process for ice machines

5. Replacement of filters

6. Replacement of filters

5. Annually

6. Every six months

5. Evaluate why filters were not changed, change process if needed

6. Evaluate why filters were not changed, change process if needed

5. Maximo

6. Maximo

5. Chief Engineer verify annually

6. Chief Engineer

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5. PROGRAM MANAGEMENT

5.1 Program Review

WSC shall review the Management Plan annually.

Committee meeting will be held monthly to assess, at a minimum, documented verification of policy implementation, any results from water testing for Legionella, whether any engineering controls were not within specified limits and why that may have occurred, whether any corrective actions were taken on engineering controls, whether the HCA LD plan needs to be updated, and whether there have been any cases of LD diagnosed at or potentially associated with each building.

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Table 3 Validation Criteria

WSMP/CCP Hazard Control Monitoring Validation Criteria(VC) Frequency

1. Receiving – Each Building applicable to Directive 1061

Continuous monitoring of potable water pressure, temperature, pH, dissolved solids (conductivity) and Free Residual Oxidant

(TRO).

City of New Orleans Water Department primary and secondary national drinking water standards as defined by Safe Drinking Water Act.

Baseline information to monitor incoming potable water quality.

Specified by VHA Directive 1061

Semi-annual

Manual

2. Heating and 3.

Potable Water Storage

AND

5. Cold Water Distribution - Ice Machines / Dispensers and Drinking Fountains

AND

5a. Cold Water Distribution - Sinks / Showers / Tubs

AND

5d. Hot Water Distribution - Sinks / Showers / Tubs

Temperature and Microbiological

Potable Water Temperature:

• The minimum discharge temperature for instantaneous and semi-instantaneous heat exchangers must be 130°F.

• 124◦F to 130◦F in hot water distribution system

• Not greater than 110◦F at water fixture discharge.

• Not greater than 67◦F in cold water distribution to the greatest extent practicable to inhibit growth

Disinfectant:

Environmental Validation:

• Legionella – Presence of viable Legionella by culture methodology such as dipslides or spread plates.

• Validation Criteria - Legionella- ND (Non-Detected)

An ELITE certified lab will determine Legionella Serogroup 1, 2 to 14, and non-pneumophila species in water samples.

Polymerase Chain Reaction (PCR) and Direct Fluorescent Antibody (DFA) methods can be used in combination with culture methods, but not by themselves.

Perform temperature, disinfectant (oxidant), and pH monitoring concurrent with Legionella water sample collection. DUSHOM Memorandum 7-9-2014

Potable Water – o Minimum of ten hot water and ten cold water samples from water fixtures within qualifying buildings.

Validation Criteria – If Legionella are found to be present, then the WSC WG will develop a validation response in accordance with Directive 1061 .2. ENVIRONMENTAL VALIDATION section c. The validation response must result in a negative Legionella result.

Included Below: Directive 1061 FLOW CHART FOR

Environmental Validation

• Temperature – weekly (HW Loop)

• Quarterly –

Legionella Cultures

Clinical Validation

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Monitoring Validation Criteria(VC) Frequency

5. Utility Water - Cooling Towers

• 1.0 ppm in hot and cold water distribution, sentinel locations (as free chlorine)

0.5 to 1.5 mg/L TOTAL residual oxidizing biocide in cooling tower water in accordance with EPA FIFRA label

INTERPRETATION OF ROUTINE QUARTERLY

ENVIRONMENTAL WATER TESTING RESULTS IN THE

ABSENCE OF HCA LD.

New Construction (Fixtures and Water Supply Piping Systems):

To ensure compliance to this plan, all new construction fixtures and water supply piping will be validated prior to going into service use.

Total Bacteria (THAB) - less than 104 CFU/ml Legionella- ND (Non-Detected)

• Presence of viable Legionella by culture methodology such as dipslides or spread plates

• If Legionella are present, determine why hazard control is inadequate, then improve or upgrade hazard control. Retest Legionella positive water sample point during next round of testing.

o If retest Legionella negative, return cooling tower to normal validation schedule.

o If retest Legionella positive WSC WG to critically re-evaluate hazard control then improve or upgrade CCP may need to be fortified and/or added.

• If Legionella culture results are detected:

o Review antimicrobial treatment program with utility water treatment service provider.

o Review and adjust hazard controls as described directly above.

o When operationally practical, perform cooling tower cleaning and chemical sanitization using EPA-approved biocides per product recommendations.

Prior to activation and acceptance THAB – Quarterly Legionella - Quarterly

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Clinical Validation:

o Consider a company with remediation capabilities independent from the utility water treatment service provider to perform cleaning.

o After completing the sanitization and normal operation resumed, collect a water sample for re-test to validate that the validation response was effective.

Document recommendations and actions taken by water treatment service and cleaning providers.

Clinical Validation:

Urine antigen and/or sputum specimens by laboratory approved molecular diagnostics.

Determination of Epidemiological Linkage of LD Cases to the Healthcare Facility for Assessment of Remediation Needs.

If diagnostic testing determines that any case of pneumonia is caused by any species of Legionella, then determine if the case is epidemiologically-linked to the building using the following guidance:

(1) Definite HCA LD - If the person has spent 10 or more days continuously in a VHA facility prior to the onset of pneumonia symptoms.

(2) Possible HCA LD (inpatient) - if the person has spent between 2 and 9 days in a VHA facility prior to the onset of pneumonia symptoms.

(3) Possible HCA LD (inpatient and outpatient) - if the patient had exposure to a healthcare facility for a portion of the 10 days prior to onset of illness, regardless of whether

Legionella Testing

• hospitalized healthcare associated pneumonia patients

Urine antigen for Community or Healthcare associated patients on admission or at the discretion of the Healthcare provider.

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Table 4 VALIDATION SUMMARY

Validation Activity Validation Frequency Responsibility Reviewer

Environmental Water Testing * Quarterly - Potable Water – Minimum of ten hot water and ten cold water samples from water fixtures within qualifying buildings per VHA Directive 1061 criteria (20 total per building).

* Quarterly – Utility Water – Each cooling tower system tested for THAB

Industrial Hygienist Chief of Safety

FMS

Water Safety Committee

VERIFICATION Annually or upon changes in the HCA-LD and Scald Prevention program.

VISN 16 Water Safety Committee

VISN 16

Water Safety Committee

Table 5 VALIDATION REVIEW

Activity Frequency Responsibility Reviewer Verification that CCP monitoring is according to plan

Once per month Engineering Service/Safety Management

Water Safety

Subsequent validation of the Water Management Program

Change in critical limit Change in equipment Change in process System failure 1x per Month (WSC Meetings)

Water Safety Committee

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Review of corrective action monitoring to verify that it is according to plan

2x per year Water Safety

Scheduling verification activities 1x per year or if system changes

Water Safety Committee

Water Safety Committee

Comprehensive HACCP plan verification and reassessment

1x per year Phigenics and Water Safety Committee

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WSC will meet as necessary to address any non-routine Legionella control issues and

HCA LD.

The results of the review meetings shall be communicated to the healthcare system leadership team, Environment of Care Committee, Infection Control Committee, and other committees as appropriate.

5.2 Awareness Training

Awareness training for Legionella risk associated with water systems will be conducted for operators or employees with responsibilities pertaining to the domestic water services. Training goals are to improve awareness and understanding of risks associated with Legionella.

5.3 Records and Documentation

Documentation of monitoring results and remedial actions shall be recorded in respective logs, checklists, or equivalent documentation. Sufficient historical data shall be readily available to the WSC or other interested parties. See Appendix B for a listing of documentation reviewed by the WSC for legionella prevention.

The committee meeting minutes shall document any corrective actions that were initiated and the effectiveness of the corrective actions taken. All data shall be retained for at least five years.

5.4 Engineering

Installation of new domestic water services or modifications to existing systems must be designed to aid safe operation that avoids conditions that promote microbial proliferation, limits excessive release of water aerosols, and meets local plumbing codes.

System drawings shall be maintained in the Facility Management Projects section and updated as necessary.

5.5 Operation

The WSC will maintain awareness to operate domestic water services and associated equipment at all times when possible to avoid idle periods. Affected systems shall be flushed when need is identified.

Stagnant situations to be addressed may include but is not limited to:

• Dead zones (dead legs or dead ends which are greater than 6-times pipe diameter),

• Infrequently used outlets,

• Construction or renovation activity, 19 | P a g e

• Closed or vacant areas

• Low occupancy, and

• Cross connections

EMS SOP “Running of Water in Unoccupied Areas” address flushing of infrequently used outlets and unoccupied areas.

5.6 Maintenance

The domestic water services shall be maintained to limit scale, sediment, excessive release of water droplets (water aerosols), and temperatures that favor microbial growth.

Strategies to limit conditions that favor microbial growth may include but is not limited to the following:

• Regular annual inspection of mechanical conditions

• Maintenance of backflow prevention devices per local requirements

• Utilization of approved plumbing materials

• Maintaining hot and cold piping insulation where necessary

• Clean and disinfect outlets as required (e.g., shower heads and aerators

• Flush outlets as required

All equipment associated with the domestic water services such as water cooler filters, ice machines, or the like, shall be maintained per the required preventative maintenance program recommended by the manufacturer. All routine maintenance required by this management plan shall be documented.

Plumbing systems shall be maintained according to VHA Directive 1061 and local code to avoid conditions that may support Legionella risk.

5.7 New Construction

Newly installed piping and distribution system components shall be flushed of debris and disinfected before commission. Piping and components must be cleaned and protected from accumulation of debris and contamination prior to and during installation.

Documentation of flushing and disinfection will be provided to the Contracting Officer Representative (COR).

6. DEAD-LEG ELIMINATION AND PREVENTION PLAN

The WSC will develop a program to identify, remove, and prevent dead-legs in the water distribution systems.

The facility HCA LD Prevention Plan will be used to assess monitored data on a monthly basis to identify potential areas that will require the in depth review of the

20 | P a g e system that is insufficient and the implementation of engineering controls, potential for increased monitoring, review of the process flow diagrams for the system in question and revalidation of systems after changes are made.

7. SCALD PREVENTION PLAN

One of the primary methods for preventing Legionella growth in building potable water distribution systems is water temperature. However, it is not possible to maintain water temperatures at the outlet that will kill Legionella bacteria and simultaneously eliminate the possibility of scald injury in persons partially or fully insensitive to hot water temperature, or having delayed or impaired response capabilities.

The medical facility will determine the type(s) of mixing valve and/or anti-scald guard that will be installed in accordance with VA Plumbing Design Manual/Master Construction Specifications and the International Plumbing Code.

The installation of mixing valves will be tracked through the facility Water Safety Committee to ensure completeness.

8. ENVIRONMENTAL VALIDATION

For this policy, environmental validation is the process of testing the building’s potable water distribution system(s) to determine if the engineering controls are successfully inhibiting growth of Legionella.

Water samples from at least 10 outlets on the hot water distribution system and at least 10 outlets on the cold water distribution system must be tested from each building for each quarterly testing cycle. At the time each water sample is taken, test and document the following for each sample: water temperature, level of residual biocide, and pH.

All samples shall be analyzed using a CDC-ELITE certified lab and follow the International Organization of Standardization ISO method 11731:1988 entitled “Water Quality – Detection and Enumeration of Legionella”. Specialized testing is the only means by which to detect and enumerate Legionella. Test results require up to 14 days for confirmation.

Appendix D contains the protocol for conducting Legionella testing.

9. EMERGENCY REMEDIATION OF THE POTABLE WATER DISTRIBUTION SYSTEMS

This facility will perform Emergency Remediation of the potable water distribution systems when the following occurs:

• Identification of a confirmed HCA LD case

• Identification of a possible HCA LD case and Legionella positive water results

• Identification of Legionella positive water sample results during routine environmental testing

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9.1 Thermal Eradication

The management team shall have discretion over when this procedure is used. This procedure involves the temporary resetting of the temperature in the hot water distribution system to 160°F – 170°F while continuously flushing each outlet in the system for at least 30 minutes. Consideration needs to be given as to the feasibility of implementing thermal eradication depending on the design of the mixing valves in place.

NOTE: When thermal disinfection is being performed, warning notices must be posted.

There is significant risk for scalding and care needs to be taken to protect end users of the water distribution system, as well as the employees who are administering the measure.

9.2 High-Level Disinfection

This method involves increasing the chlorine level of the hot and cold-water distribution systems to 50 mg/L and maintaining at least 10 mg/L (free chlorine residual) throughout the system at outlets for 24 hours; or 200 mg/L for three hours.

9.3 Shock Chlorination

This method involves increasing chlorine level of the hot and cold-water distribution systems to 2 mg/L and maintaining at least that level throughout the system for at least 2 hours (but not exceeding 24 hours).

See FMS SOP “Legionella Remediation Hyperchlorination Process” for the procedure used to hyper-chlorinate the water system.

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APPENDIX A

Corrective Actions Documentation

A. HOT WATER DISTRIBUTION – HW TEMPERATURE REQUIREMENTS (1300F at HX, >1240F in

HW Loop and < 1100F at FIXTURE DISCHARGE)

B. CONTINUOUS MONITORING OF INCOMING WATER AT EACH BUILDING COVERED IN

DIRECTIVE 1061 – pH, Free Residual Oxidant, Conductivity, Temperature (Hot & Cold) and Pressure

C. FREE RESIDUAL OXIDANT (CHLORINE) >0.5 ppm in HOT & COLD WATER SYSTEMS

DATE LOCATION ISSUE ACTION TAKEN REVIEWER

4/9/2015 Throughout Facility

A. HX Temps <1300F & HW Loop Temps <1240F to maintain HW Temps at Fixtures <1100F due to scald risk

Scald Guards/Mixing Valves to be installed by project if not in place

4/9/2014 D&T;IP;CLC B. No systems installed for continuous monitoring of incoming water quality at each building

Continuous Monitoring systems to be installed by project COMPLETED

4/9/2015 Throughout Facilities

C. Low Free Chlorine Residual in CW and HW Systems (<0.5 ppm)

Secondary Disinfection systems to be installed by project -COMPLETED

APPENDIX B

POLICIES, SOPS, AND LOGS

Number Name Responsible Service

Status

002B-141 Water Safety Committee SAFETY Under Review Quarterly Water Sampling Procedures SAFETY SOP-022 Ice Machine Cleaning FMS Under Review SOP-024 Water Fountain Cleaning FMS Under Review SOP-043 Domestic Water Systems and Legionella Prevention FMS Under Review Legionella Remediation Hyperchlorination Process FMS Under Review Total Chlorine Procedure for Water Testing for Legionella FMS Under Review Running of Water in Unoccupied Areas EMS Under Review EMS Flushing Logs EMS Under Review

APPENDIX C

SUMMARY FLOW CHART FOR INTERPRETATIONOF ROUTINE QUARTERLY

ENVIRONMENTAL

APPENDIX D

QUARTERLY WATER SAMPLING PROCEDURES

1. Purpose and Scope

This protocol details the procedure for sample collections including Legionella culture and field measurements of temperature, pH, and oxidant residual. This protocol is to be used as a guide to test physicochemical sampling from various water sources to conduct water quality monitoring and quarterly testing of the buildings hot and cold water distribution systems required by the VHA Directive 1061.

2. Sampling Preparation

2.1 Assemble Supplies

1. Request Legionella water sample collection bottles (250 mL with sodium thiosulfate neutralizer) from a CDC ELITE certified laboratory.

2. Complete performance check/calibration for thermometer, pH meter, and colorimeter.

3. Prepare chain of custody documents for logging field measurements and samples.

4. Obtain water-proof pen/marker for writing on sample collection bottles.

3. Sampling Methods

3.1 Temperature

1. When possible immerse tip of thermometer in flowing stream of water, wait until temperature has stabilized and record temperature.

2. If measurement from stream is not possible, collect a volume of water and immediately immerse thermometer in sample, wait until temperature has stabilized and record temperature. Note: sample will cool off or warm up in sample container, so measure temperature immediately.

3.2 pH via Colorimeter

1. Follow manufacturer’s instructions for use of the colorimeter to measure pH.

2. Record pH measurement in log.

3.3 Total Chlorine via Colorimeter

1. Follow manufacturer’s instructions for use of the colorimeter to measure total chlorine.

2. Record total chlorine measurement in log.

3.4 Legionella for Laboratory Culture

1. Collection of water

a. Complete bottle label using water-proof pen or marker.

b. When ready to collect sample carefully remove cap and place aside to avoid cross contamination with other surfaces or your hand.

c. Place bottle under faucet and turn on water to collect “first-flush” sample. Avoid touching the inside lip of bottle with the faucet, valve, or other surfaces.

d. Secure cap on bottle and invert to mix the neutralizer tablets.

4. Sampling Procedures

4.1 Chain of Custody

1. Complete the chain of custody document during sampling. For each sampling location record on the log:

a. Sample Name: Be descriptive including room number or location. If multiple sinks indicate location (i.e. right, left). Include hot or cold descriptor in name. Example, Patient Room 321 – Hot or Men’s RR Sink, Left – Cold

b. Indicate laboratory analysis to be performed.

c. Complete sample descriptors for water source, sample type, and outlet type

d. Record measured temperature, pH, and oxidant values.

e. Record any notes regarding sample location, discoloration, room use, etc.

4.2 Hot and Cold Distal Outlets

1. All measurements and Legionella sampling should be done on hot water before cold water.

2. Location selection:

a. Select a minimum of 10 distal outlets from each hot water system.

b. Outlets should be representative of water system, i.e. on different loops/risers and a minimum of 2 locations per floor.

c. Locations should focus on patient areas (patient room sink vs.

environmental services slop sink) and areas where immunocompromised patients are located.

d. Locations should be dual handled fixtures to allow collection of separate hot and cold water samples. If dual handled fixtures are not possible, consult with facilities Water Safety Committee regarding site selection for monitoring hot and cold water.

3. Turn on hot water and immediately collect sample for Legionella directly into the sampling container.

4. Continue to run hot water (pencil sized stream).

5. At 30 seconds record temperature reading from hot water stream, record value on log.

6. At 60 seconds record temperature reading from hot water stream and collect sample for pH, oxidant residual, and record values on log.

7. Turn off hot water.

8. Turn on cold water and run (pencil sized stream) for 60 seconds.

9. At 60 seconds record temperature reading from cold water stream and collect sample for pH oxidant residual, record values on log.

10. Collect sample for Legionella directly into the sampling container.

11. Complete chain of custody.

5. Post Sampling

1. Cross-check sample bottle labels with sampling locations indicated on the chain of custody.

2. Complete the chain of custody by noting the total number of samples collected, completing the page numbers, and relinquish the form.

3. Copy the chain of custody and place the original document in a zip lock bag with the samples for shipment.

4. Samples should be shipped overnight for receipt at laboratory, Monday through Thursday.

5. Ship samples in the shipping container that the empty sample bottles were received in.

Department of Veterans Affairs