AE SOW Upgrade Water Monitoring.pdf

VAMC BUTLER A/E Scope of Work Upgrade Water Monitoring System Project No. 529-22-105

VAMC BUTLER

A/E SCOPE OF WORK

FOR

Project #529-22-105

Bid Documents Ready By 180 Days After NTP Contracting Officer's Representative (COR) Ryan Gallagher

Contents Services

Provide

Project Scope

GENERAL:

SPECIFICS:

Site Investigations

Design Review Schedule

Design Requirements/Submissions

Schematic Submission: Submission Requirements

Design 30% Submission Requirements

Design, 60% Submission Requirements

Construction, 95% Submission Requirements

Design, 100% Submission Requirements

Final Construction Documents Submission (CD):

Construction Period Services

Attachment A

Project Intent Documents

Attachment B

Schematic Drawing Submission Requirements

Attachment C

Design Development 30% Submission Requirements

Attachment D

Design Development 60% Submission Requirements

Attachment E

Design Development 95% Submission Requirements

Attachment F

Design Development 100% Submission Requirements

Attachment G

Contract Document Submission Requirements

Attachment H

As-Builts Requirements

Services Provide

Professional Architect/Engineer (A/E) and healthcare planning services to include but not limited to:

• Site investigation – architectural, mechanical, plumbing, and electrical.

• The preliminary plan for the area is listed in attachment A.

• Contract drawings and specifications for construction, all drawings shall be submitted per the VA's BIM standard.

• 3rd. Party Cost Estimates

• Construction period services - review of submissions, provide recommendations regarding contractor change proposals, visit the site per VA's request and add to drawings as-built conditions from Contractor's record drawings; A/E will respond on-site within a two-hour period when requested.

• Provide File Transfer Protocol (SSFTP) system for use throughout the duration of the project. The site must be in place within 30 days of contract award. The site must remain open until final construction contract is complete. This site is intended for AE, VA, and contractor use. The site must be compatible to access and open Revit 2020, all Microsoft Office programs (Word, Excel, Project), and pdf files. The site must use Secure Socket Layer (SSL) or Secure Shell (SSH) when SSFTPing the files, which will provide encryption during the transfer.

• Note: due to requirements of certain construction submittals (i.e., finishes, profiles, shop drawings, etc.), these must be delivered to COR. Any hand-delivered submittals must also have a backup copy on A/E SSFTP Site. A/E SSFTP site must be secure (password protected), user-friendly for uploading and downloading files, and organized for easy file retrieval by the VA COR, Contracting Officer (CO), and contractors. The site must be organized with folders indicating each level of submission as outlined in this scope of work and corresponding required files. Must also submit hard copies to the VA for Design Review Drawings, Specifications, and Construction Documents.

• Submit documents to Butler VAMC for approval at schematic design, 30% completion, 60 % completion, 90% completion, 100% completion, and at construction document completion.

• Comply with VA Green Energy Management System (GEMS) program as per specifications: 017419.

• Infection Control Risk Assessment.

• Project scheduling and phasing.

• Third party commissioning shall be included as part of the A/E submittal and SF330 process.

Project Scope

GENERAL:

The general scope of this project to bring the Butler VA into compliance with VA directive 1061 (Prevention of Health Care Associated Legionella Disease and Scald Injury from Water Systems).

Included in this scope is a review of all elements of the directive including a water monitoring plan, a response plan for Butler VA Facility’s Management Staff (FMS), and a review of all buildings, structures, and equipment (with the exception of those that have active disposition plans in place) on VA Butler’s campus. The scope of work also includes the evaluation and development of all necessary plans for all buildings, structures, and equipment (with the exception of those that have active disposition plans in place) for backflow preventors. The scope of work shall also include the evaluation of water management plans for closed loop water systems on campus.

SPECIFICS:

The A/E shall provide design, site investigation, and consultation services to cover the following:

• Development of a water testing and monitoring plan, plan shall include a detailed schedule of when and where buildings will be tested.

• Complete a survey of all Butler VA buildings. Buildings shall be evaluated for water safety compliance with any concerns addressed in a statement of deficiencies. This statement of deficiencies shall be included into the construction scope of work.

Included in this survey are but not limited to items such as scald prevention devices, circulation loops, backflow prevention water test locations.

• Develop a water monitoring management system, this system shall be computer controlled and monitored. This system shall be able to integrate into all currently used VA Butler technology as well as all future technology. Water monitoring system shall be accessible to all personal with a bona fide need at the facility through standard building automation systems.

• Development of a response plan in the event that legionella is found within a building on the Butler VA campus, this plan shall include step by step instructions for all parties and outline a course of action that will quickly, effectively, and safely remediate the problem.

• Development of a plan legionella control plan for the current water-cooled cooling towers. This plan shall include all items required by Directive 1061 including but not limited to a testing plan, treatment plan, and response plan.

• Development of a site plume plan based on both the current location of the water-cooled cooling towers as well as the current building layout.

• All designs shall be as future-proof as possible and shall take into account changing technology. All designs shall also take into account the VA's need for high reliability and resiliency

• AE design drawings shall delineate an ICRA and phasing plan to minimize downtime during operations.

• Construction will be addressed in phases to allow operations to continue during construction to the extent possible. Phasing will be determined during the 60% design review. Phasing must work within budget and allow the VA to continue operations with minimal interference.

• The AE shall be responsible for working with the various user groups affected by this project to determine their needs, adaptability to the various system interfaces required for system integration, and the locations for new/existing devices work with both the users and existing proposed wall locations.

• Provide specifications for both design and construction period commissioning services. All designs shall be accomplished per VA guidelines and specifications, which are available on the Internet at http://www.cfm.va.gov/TIL/ A/E shall pay particular attention to where VA guidelines and standards differ from national and local building codes, when this occurs, defer to the stricter of the requirements.

• The management plan shall include all applicable information required to be in compliance with The Joint Commission EC.02.05.02,

• All designs and plans shall ensure compliance with ASHRAE, ASHE, VA, and all other required standards regarding healthcare water quality.

• Backflow preventers shall be evaluated in accordance with the VA Plumbing design manual, ASPE standards, and all other applicable plumbing, mechanical, and http://www.cfm.va.gov/TIL/ sanitary standards.

• Water management plans for closed loop systems shall include water quality testing, makeup water monitoring, water treatment analysis, and training.

A/E firm will not have access to VA OIT systems or patient privacy areas. A/E firm shall complete training at Contractor shall complete paper-based privacy training as directed by Butler VA FMS Staff.

Site Investigations Expectation: A/E will make site visits as necessary to survey existing conditions.

Make site visits as required to determine existing as-built conditions affecting this project. Note:

Information including drawings and other documentation provided to the A/E by the VA is used as reference only. All additional references and specifications are available in VHA's Technical Information Library at the address. http://www.cfm.va.gov/TIL/.

The AE is responsible for verifying all existing site conditions and shall not rely on VA-provided information unless provided through an RFI process.

Design Review Schedule

• EXPECTATION: Submit the review package, so they are received on the noted day.

SUBMISSIONS:

Submit review packages so they are received on the noted day (calendar days after NTP) or earlier: This will be a 330 Day design period.

Initial PDT Meeting ................................................................................................................................ 0 days Schematic Submission ......................................................................................................................... 30 days Design Development Documents (30%) .............................................................................................. 60 days Design Development Documents (60%) .............................................................................................. 90 days Design Development Documents (95%) ............................................................................................ 120 days Design Development Documents (100%) .......................................................................................... 150 days Construction Bid Documents ............................................................................................................. 180 days

Note: The Notice to Proceed (NTP) issue will be the first Project Design Team (PDT) Meeting. A/E will be required to attend and take minutes of each PDT meeting. Minutes will be submitted electronically via e-mail to the COR and Contracting Officer within three calendar days of each meeting.

Design Requirements/Submissions EXPECTATIONS: Submit a complete review package per the following requirements and guidelines outlined in https://www.cfm.va.gov/til/aeDesSubReq.asp Volume C Document

Please pay specific attention to the schematic, design, and construction submission requirements.

http://www.cfm.va.gov/TIL/ https://www.cfm.va.gov/til/aeDesSubReq.asp

Deliver all design packages directly to the Project Manager on the established dates to allow the VA Project Development Teams to meet as scheduled. A transmittal letter is required to go to the Contracting Officer on the same day as delivery.

Include all information as follows and as outlined in the attachments for each submission. Information required for each submittal is outlined in Program Guide PG-18-15 Volume C. The manual is at the following address: https://www.cfm.va.gov/til/aeDesSubReq.asp

Schematic Submission: Submission Requirements.

• Provide proposed systems for areas shown on Attachment A, and/or as outlined at the initial PDT meeting.

• Budget estimate for each proposed system.

• Develop Design Approach before proceeding to 30% design

• Define the design elements based on selected systems and submit all information required by the PG-18-15 (Design Development)

• Prepare design calculations.

• Information required for each submittal is outlined in Program Guide PG-18-15

Volume C.

• Follow requirements listed in attachment B

Design 30% Submission Requirements

• Address all comments from the Schematic Submission review.

• Follow requirements listed in attachment C

• Provide Detailed Construction Estimate of Line Items.

• Define the design elements based on the selected option and submit all information required by the PG-18-15 (30% Design Development).

• Identify Working Drawings scope within the construction budget.

• Identify all design calculations.

• Develop plans and marked up specifications to meet all applicable federal and state codes/requirements, including but not limited to The Joint Commission, ASHRAE, OSHA, PADEP, EPA, NEC, NFPA 101 Life Safety Code.

• Identify all design calculations.

• Identify all existing utilities and utility requirements.

• Identify phasing requirements for construction and their implications to the VA.

Construction of project to be performed in a manner that makes phasing have a minimal impact on the VA.

• Develop Infection Control Risk Assessment (VA EC-17) Design, 60% Submission Requirements

• Address all comments from the 30% review.

• Address all comments from the 30% VA Safety & Fire Protection Review.

• Update Detailed Construction Estimate of Line Items.

• Define the design elements based on the selected option and submit all information required by the PG- 18-15 (60% Design Development).

• Identify Working Drawings scope within the construction budget.

• Finalize impact of existing asbestos.

• Develop plans and marked up specifications to meet all applicable federal and state codes/requirements, including but not limited to The Joint Commission, ASHRAE, OSHA, PADEP, EPA, NEC, NFPA 101 Life Safety Code.

• Identify all design calculations.

https://www.cfm.va.gov/til/aeDesSubReq.asp

• Identify all existing utilities and utility requirements.

• Identify all phasing requirements for construction.

• Provide finish selections per discussions with VA Interior Designer

• Consolidate all necessary submittals by specification section on an Excel spreadsheet. Checklist to be utilized to track/monitor submittal process.

• Develop Infection Control Risk Assessment (VA EC-17)

• Follow requirements listed in attachment D

Construction, 95% Submission Requirements

• Address all comments from the 60% review.

• Design finishes required submittals.

• Consolidate all necessary submittals by specification section on an Excel spreadsheet. Checklist to be utilized to track/monitor submittal process.

• Revise and update cost estimates.

• Preparation of project scope for CBD/ negotiated advertisement in the 60% design submission

• Finalize all design calculations.

• Finalize all phasing requirements for construction.

• Finalize Infection Control Risk Assessment (VA EC-17)

• Address all comments from the VA Safety & Fire Protection Review.

• Follow requirements listed in attachment F

Design, 100% Submission Requirements

• Address all comments from the 95% review.

• Address all comments from the 95% VA Safety & Fire Protection Review

• Define the design elements based on the selected option and submit all information required by the PG- 18-15 (100% Design Development).

• Identify Working Drawings scope within the construction budget.

• Finalize impact of existing asbestos.

• Develop plans and marked up specifications to meet all applicable federal and state codes/requirements, including but not limited to The Joint Commission, ASHRAE, OSHA, PADEP, EPA, NEC, NFPA 101 Life Safety Code.

• Identify all design calculations.

• Identify all existing utilities and utility requirements.

• Identify all phasing requirements for construction.

• Consolidate all necessary submittals by specification section on an Excel spreadsheet. Checklist to be utilized to track/monitor submittal process.

• Develop Infection Control Risk Assessment (VA EC-17)

• Follow requirements listed in attachment G

• finalize Cost Estimate

Final Construction Documents Submission (CD):

• Submit a complete document of all contract requirements for approval signatures.

Continue to update and submit until approved.

• Follow requirements listed in attachment H

• As-Built Drawings:

• Submit a complete document of all as-built drawings for VA review and approval.

Continue to update and submit until approved.

• Final submitted record drawings should be incorporated into the most current floor plan submitted by VA at the close of documents

• Follow requirements listed in attachment H

Construction Period Services Expectations: Respond to submittals and other requests in a timely manner—no later than 14 business days after submittal.

Provide services:

• Assist the VA in determining whether the Contractor or subcontractor meets qualification requirements, support by written recommendations of any problems or litigation encountered in the past based on firsthand knowledge.

• Review all submissions and provide recommendations to the VA within fourteen calendar days upon request.

• Review and provide replies to Contractor generated RFI's when required by the project manager within seven calendar days.

• Review contractor's cost estimates and provide recommendations to the VA.

• Make site visits on requests of the VA and prepare written reports to include agreed-upon changed in design as determined necessary during the construction.

Visits made based on errors and omissions in design will be at no cost to the VA.

• Participate in partial/final acceptance inspections as scheduled and generate punch list items for completion. The punch list shall reference the contract documents for specific deficiencies (i.e., specification section, drawing detail, etc.)

• Prepare as-built drawings on original set with A/E's stamp, based on record drawings that the Contractor kept during construction and with correspondence performed during construction. Transpose Contractor's as-builts to Revit 2020 and provide a set of updated as-builts and specifications on CD and on A/E SSFTP site within 30 days to the COR. These should be posted on the A/E SSFTP site for VA retrieval.

• A/E shall be on-site for major work milestones as requested by the Government and at all phase completions.

Attachment A Project Intent Documents

See Attached Files.

T-1

Department of Veterans Affairs VHA DIRECTIVE 1061 VHA Veterans Health Administration Transmittal Sheet Washington, DC 20420 February 16, 2021

PREVENTION OF HEALTH CARE-ASSOCIATED LEGIONELLA DISEASE AND

SCALD INJURY FROM WATER SYSTEMS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive addresses the prevention of health care-associated Legionella disease and scald injury from water systems in VHA buildings in which patients, residents or visitors stay overnight; in VHA buildings where employees are required to sleep overnight; and for the management of select outdoor non-potable water systems.

2. SUMMARY OF MAJOR CHANGES: This revised VHA directive:

a. Expands and clarifies the scope and applicability of the document.

b. Adds provisions on non-potable water.

c. Updates provisions on environmental Legionella testing and actions for potable water systems.

d. Updates definitions for Legionella disease surveillance.

3. RELATED ISSUES: VHA Directive 1131(3), Management of Infectious Diseases and Infection Prevention and Control Programs, dated September 17, 2017; VHA Handbook 1106.01, Pathology and Laboratory Medicine Service (P&LMS) Procedures, dated January 29, 2016; VHA Engineering Standard-Cooling towers, VHA design manuals and specifications.

4. RESPONSIBLE OFFICE: The Assistant Under Secretary for Health for Support is responsible for the contents of this directive. Questions related to the application of this directive or engineering aspects may be directed to Healthcare Environment and Facilities Program, the Office of Healthcare Engineering (19HEFE) at OHE water safety@va.gov. Questions related to clinical aspects and validation processes in this directive may be directed to the National Infectious Diseases Service (11SPEC13) at 513-246-0270.

5. RESCISSIONS: VHA Directive 1061, Prevention of Healthcare-Associated Legionella Disease and Scald Injury from Potable Water Distribution Systems, dated August 13, 2014, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of February 2026. This directive will continue to serve as national VHA policy until it is recertified or rescinded.

February 16, 2021 VHA DIRECTIVE 1061

T-2

BY DIRECTION OF THE OFFICE OF THE

UNDER SECRETARY FOR HEALTH:

/s/ Deborah E. Kramer Acting Assistant Under Secretary for Health for Support

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publication Distribution List on February 17, 2021.

i

CONTENTS

PREVENTION OF HEALTH CARE-ASSOCIATED LEGIONELLA DISEASE AND

SCALD INJURY FROM WATER SYSTEMS

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. TRAINING

7. RECORDS MANAGEMENT

8. REFERENCES

APPENDIX A

HEALTH CARE-ASSOCIATED LEGIONELLA DISEASE PREVENTION PLANS FOR

BUILDING POTABLE WATER SYSTEMS ...................................................................A-1

APPENDIX B

POLICY AND GUIDELINES FOR MINIMIZING THE RISK OF SCALD INJURY FROM

EXPOSURE TO HOT WATER FROM THE POTABLE HOT WATER DISTRIBUTION

SYSTEM ......................................................................................................................B-1

APPENDIX C

CLINICAL AND ENVIRONMENTAL VALIDATION OF ENGINEERING CONTROLS

FOR PREVENTION OF LEGIONELLA GROWTH IN BUILDING POTABLE WATER

SYSTEMS ................................................................................................................... C-1

APPENDIX D

PREVENTION OF LEGIONELLA DISEASE FROM COOLING TOWERS AT

VETERANS HEALTH ADMINISTRATION MEDICAL CAMPUSES ............................ D-1

APPENDIX E

OUTDOOR NON-POTABLE, AEROSOL-GENERATING WATER SYSTEMS OTHER

THAN COOLING TOWERS ON VHA MEDICAL CAMPUSES .....................................E-1

PREVENTION OF HEALTH CARE-ASSOCIATED LEGIONELLA DISEASE AND

SCALD INJURY FROM WATER SYSTEMS

1. PURPOSE

This Veterans Health Administration (VHA) directive establishes policy for the prevention and control of health care-associated Legionella disease and possible related scald injury from water systems at Department of Veterans Affairs (VA) medical facilities. This directive addresses primary prevention for areas in health care with a recognized or potential higher risk for Legionella disease. Specifically, this directive pertains to the following areas at VA medical facilities:

a. VA-owned buildings in which patients, residents or visitors stay overnight such as, but not limited to, acute care facilities, Community Living Centers (CLCs), domiciliaries, Fisher Houses and temporary lodging facilities (“hoptels”). NOTE: This includes VHA-owned buildings on the campus in which a tenant provides service that includes an overnight stay and VA maintains and operates the utilities for the building.

b. VA-owned buildings where staff are required to sleep overnight as part of their job such as, but not limited to, fire stations.

c. Outdoor non-potable, aerosol-generating water systems such as, but not limited to, cooling towers and irrigation systems.

NOTE: This directive focuses on primary prevention. Policy and guidance for full case investigations for confirmed or suspected health care-associated Legionella disease are not within the scope of this directive. AUTHORITY: Title 38 United States Code (U.S.C.) § 7301(b).

2. BACKGROUND

a. Legionella is a Gram-negative bacterium that causes diseases collectively referred to as legionellosis. Legionellosis primarily consists of the respiratory diseases Legionella pneumonia (traditionally known as Legionnaires’ disease and, hereafter, abbreviated as “LD” for “Legionella disease”) and Pontiac Fever (a self-limiting influenza-like illness). Legionellosis is most often caused by the species, Legionella pneumophila; however, other species of Legionella can be pathogenic, particularly in transplant and other immunocompromised or high-risk patients. The bacteria, found naturally in water, have been associated with disease from potable and non-potable building water distribution systems. LD occurs after inhalation or aspiration of contaminated water, followed by a general incubation period of 2 to 14 days. LD can be severe, especially in hospitalized patients; however, legionellosis presents as a spectrum of illness and milder cases of pneumonia also may be caused by Legionella.

Legionella are not considered transmissible from person-to-person, although there is one report in the literature of a probable person-to-person transmission.

b. Health care facilities are included in the types of buildings that have been associated with the transmission of Legionella. Cases of health care-associated LD (HCA LD) often arise from exposure to Legionella bacteria in hospital potable water distribution and process water systems.

c. In alignment with the Council of State and Territorial Epidemiologists (CSTE) and the Centers for Disease Control and Prevention (CDC) Legionellosis Case Report Form, VHA considers laboratory-confirmed cases to be “presumptive” HCA LD if a patient or resident of long-term care has spent equal to or greater than 10 continuous days in a health care facility in the 14 days prior to the onset of LD symptoms; or it is “possible” HCA LD, if a patient has spent a portion of the 14 days prior to LD symptom onset in a VA medical facility. NOTE: In accordance with CSTE and CDC, the term “definite HCA LD” is no longer used and has been replaced with “presumptive HCA LD.”

d. This directive focuses on primary prevention activities for VA-owned buildings and water systems (see paragraph 1). However, determination of whether an LD case is presumptively or possibly associated with a VA medical facility must consider contact with all VHA health care settings, including hospitals, residential settings and clinics, whether VA-owned or leased. In the event of an LD case suspected to be associated with any VHA building, case investigation and consideration of secondary prevention activities to prevent further cases would be appropriate. NOTE: Comprehensive policy for secondary prevention of LD cases is beyond the scope of this directive. For more information on case investigations of confirmed or suspected HCA LD, please see the following CDC link: https://www.cdc.gov/legionella/health-depts/healthcare-resources/cases-outbreaks.html.

e. Persons at increased risk for LD include those with a compromised immune system (due to, for example, transplant, malignancy, renal disease or diabetes), those over 50 years of age, those with chronic lung disease and current or former smokers.

However, LD cases reported in the medical literature indicate that the disease also may occur in seemingly healthy individuals.

f. Given the various factors and complexities associated with LD (e.g., host susceptibility, pathogen virulence, water distribution system configurations and water distribution system conditions), 100% prevention of LD is likely not possible. However, prevention and control practices can be implemented to reduce the risk of exposing people to Legionella in building and non-potable water systems. The HCA LD prevention activities in this directive involve assessing risks, monitoring water quality and implementation of commensurate engineering controls to limit the growth of Legionella. Use of engineering controls, such as water temperature and biocide levels, to limit Legionella growth includes ongoing monitoring of implemented controls, validating that the control measures are effective at inhibiting Legionella growth and modifying implementation or type(s) as necessary based on assessment of data. By focusing on engineering controls, this directive can be viewed as a horizontal intervention that can improve the overall microbiological quality of facility water in addition to inhibiting Legionella growth. NOTE: For general information on water https://www.cdc.gov/legionella/health-depts/healthcare-resources/cases-outbreaks.html https://www.cdc.gov/legionella/health-depts/healthcare-resources/cases-outbreaks.html management programs for health care facilities and waterborne pathogens, please see the following CDC link: https://www.cdc.gov/hai/prevent/water-management.html.

3. DEFINITIONS

NOTE: The definitions in this section are provided in the context of Legionella, Legionella control or building and non-potable water management programs.

a. Anti-Scald Device. Anti-scald device is a temperature actuated appurtenance used in plumbing systems to reduce/stop water flow exceeding a defined temperature.

Individual anti-scald devices must meet the American Society of Sanitary Engineers (ASSE) 1062 Standard. Anti-scald devices may be add-on or integrated into plumbing fixtures or integrated into water tempering valves.

b. Biocide. A biocide is a chemical agent or substance that can deter, inactivate or kill microorganisms.

c. Chlorination. Chlorination is the application of sodium hypochlorite or other Environmental Protection Agency (EPA) approved form of chlorine, usually in the form of a solution, to the water distribution system.

d. Chlorine. Chlorine is an EPA listed biocide chemical (oxidant) approved for use in treatment of potable water to control/inactivate waterborne bacteria, viruses and protozoa. In high concentrations, used for disinfection of water systems and their components.

e. Chlorine Dioxide. Chlorine dioxide is an EPA listed biocide chemical (oxidant) approved for use in treatment of potable water to control/inactivate waterborne bacteria, viruses and protozoa.

f. Clinical Testing. Clinical testing encompasses the spectrum of diagnostic modalities that are used to elucidate the cause of a disease process. For diagnosis of LD, these clinical testing modalities include culture for Legionella species; Legionella pneumophila urinary antigen testing; serological testing for IgG and IgM antibodies from acute and convalescent sera; nucleic acid testing (e.g., Legionella polymerase chain reaction); and antibody/molecular diagnostic testing (such as direct fluorescent antibody testing, which is still available though it typically should not be used for diagnosis). It is expected that appropriate clinical testing will be conducted as standard practice by providers when caring for patients with a certain disease process.

g. Clinical Validation. Clinical validation is the process of determining if the primary engineering controls and any supplemental actions are successfully inhibiting Legionella growth in water distribution system(s) by monitoring the occurrence of HCA LD. For the purpose of this directive, clinical validation encompasses diagnostic testing of HCA pneumonia cases for LD when indicated and heightened awareness for diagnostic testing when Legionella is detected in environmental samples. NOTE: See “Validation” in paragraph 3.ss.

https://www.cdc.gov/hai/prevent/water-management.html

h. Community-Associated Legionella Disease. In general, community-associated Legionella disease (CA LD) is a laboratory-confirmed case of Legionella disease in which the patient has not had contact with the health care setting in the 14 days prior to onset of illness.

i. Control Measure. Control measure is any action or activity that can be used to prevent or eliminate a hazard or reduce the hazard to an acceptable level.

j. Continual/Continuous Monitoring. Continual/continuous monitoring refers to the almost uninterrupted monitoring and control of water quality, water pressure, biocide levels and water temperatures. This can be achieved through the use of automated measurement/control devices, typically connected to the Building Automation System (BAS), at various locations.

k. Cooling Tower. A cooling tower is a heat rejection device, which transfers waste heat to the atmosphere through the cooling of a water stream by using media to disperse the water, water spray systems and fans to enhance airflow. Cooling towers can be grouped into multiple cells however for the purpose of this document the term cooling tower means one fan and basin with associated fill and structure.

l. Cooling Tower System. A cooling-tower system consists of the equipment, piping and appurtenances associated with a cooling tower(s) used to transport the water to and from the cooling tower(s).

m. Corrective Action. A corrective action is any action to be taken to modify or correct the engineering controls when the results of monitoring indicate that a primary control measure(s) is not within the established control limits.

n. Dead Leg. A dead leg is a length of pipe with one end open to the system and the other end terminating at a cap, blind flange or closed valve.

o. Disinfection. Disinfection is an irreversible inactivation of microorganisms on a surface or in a system and reduction to non-hazardous levels. Disinfection for new installations or maintenance of piping, equipment and components is conducted in accordance with the requirements of the International Plumbing Code (IPC 2018), American Water Works Association (AWWA C651-05) and VA Master Construction Specifications.

p. Electronic Health Record. Electronic health record (EHR) is the digital collection of patient health information resulting from clinical patient care, medical testing and other care-related activities. Authorized VA health care providers may access EHR to facilitate and document medical care. EHR comprises existing and forthcoming VA software including Computerized Patient Record System (CPRS), Veterans Information Systems and Technology Architecture (VistA) and Cerner platforms. NOTE: The purpose of this definition is to adopt a short, general term (EHR) to use in VHA national policy in place of software-specific terms while VA transitions platforms.

q. Engineering Control Limit. An engineering control limit is a minimum and maximum value at which a parameter must be maintained in order to prevent or eliminate a hazard or reduce the hazard to an acceptable level. For example, a minimum hot water temperature of 124 degrees Fahrenheit (°F) inhibits Legionella growth in building hot water systems.

r. Environmental Validation. See “Validation” in paragraph 3.ss. In this directive, environmental validation specifically refers to the process of testing water systems to determine if engineering controls are successfully inhibiting growth of Legionella.

s. Flushing. The flushing of outlets is the process of opening outlets such that hot and cold water flow out of the outlet for a specified amount of time to provide water with improved biocide, temperature and chemical composition to the piping system.

t. Health Care-Associated Legionella Disease. Health care-associated Legionella disease (HCA LD) is a laboratory-confirmed case of Legionella disease that is epidemiologically linked to the health care facility. HCA LD cases may be “presumptive” or “possible.” The definitions in paragraphs 3.t.(1) and 3.t.(2) for these classifications are based on information in the CSTE Position Statement on case definitions for Legionella disease and the CDC Legionellosis Case Report form. NOTE: Each case of LD must be assessed for linkage to the VA medical facility using the definitions in this paragraph on a case-by-case basis, and taking into account any related factors (e.g., a change in definition during a LD outbreak or molecular relatedness of patient and environmental isolates). Determination of association of a LD case with a VHA health care building is not limited to assessing exposure at only those buildings under the purview of this directive.

(1) Presumptive Health Care-Associated Legionella Disease. Presumptive Health Care-Associated Legionella Disease (Presumptive HCA LD) is a laboratory-confirmed case of Legionella disease with contact at a health care facility continuously for 10 or more days within the 14 days prior to LD symptom onset. Overnight stays that can lead to this type of continuous contact within a VA medical facility include, but are not limited to, inpatient admissions, observation stays and CLC resident stays. NOTE:

In accordance with CSTE and CDC, the term “definite HCA LD” is no longer used and has been replaced with the term “presumptive HCA LD.” As with the previous status category, “definite HCA LD,” contact with a VA medical facility for “presumptive HCA LD” must be continuous for at least 10 days; however, the time period during which that contact may occur has been expanded to 14 days prior to the LD symptom onset. In VHA, “presumptive HCA LD” is further categorized, below, based on when the contact with the VA medical facility occurred within that 14-day window:

(a) Presumptive Health Care-Associated Legionella Disease (Immediate) is a laboratory-confirmed case of Legionella disease in which the continuous 10-day or more exposure to the VA medical facility was immediately prior to the LD symptom onset date (i.e., the patient or resident did not leave the facility prior to the onset of symptoms).

NOTE: This corresponds to the former category known as “definite HCA LD.”

(b) Presumptive Health Care-Associated Legionella Disease (Not Immediate) is a laboratory-confirmed case of Legionella disease in which the continuous 10-day or more exposure to the VA medical facility was within the 14-day exposure window, but did not occur immediately prior to the LD symptom onset date (i.e., the patient or resident left the facility prior to the onset of symptoms).

(2) Possible Health Care-Associated Legionella Disease. “Possible Health Care- Associated Legionella Disease (Possible HCA LD)” is a laboratory-confirmed case of Legionella disease with contact at a health care facility for a portion of the 14 days prior to LD symptom onset (but less than 10 days of continuous exposure). In VHA, “possible HCA LD” is further categorized, below, based on the type of contact with the facility:

(a) Possible Health Care-Associated Legionella Disease (Inpatient) is a laboratory-confirmed case of Legionella disease in which a person had only inpatient or other overnight exposure to a health care facility for a portion of the 14 days prior to LD symptom onset (but less than 10 days of continuous exposure).

(b) Possible Health Care-Associated Legionella Disease (Outpatient/Non-Clinical) is a laboratory-confirmed case of Legionella disease in which a person had only non-overnight exposure to a health care facility in the 14 days prior to onset of illness. Non-overnight exposure includes, for example, outpatient clinic visits or non-clinical activities, such as picking up a pharmacy prescription or attending bingo at the health care facility.

(c) Possible Health Care-Associated Legionella Disease (both Inpatient and Outpatient/Non-Clinical) is a laboratory-confirmed case of Legionella disease in which the person had both inpatient and outpatient/non-clinical exposure to a health care facility for a portion of the 14 days prior to LD symptom onset (but less than 10 days of continuous exposure).

u. Health Care-Associated Legionella Disease Prevention Plan. The health care-associated Legionella disease (HCA LD) prevention plan is the written plan required for every building or outdoor device under the purview of this directive at a VA medical facility. The HCA LD prevention plan focuses on identification of risks and implementation of engineering measures for control of Legionella growth, monitoring of the control measures, validation that the measures are effective at suppressing Legionella growth and implementation of corrective actions when indicated.

v. Hyper-Chlorination. Hyper-chlorination is a remediation process that involves the addition of sodium hypochlorite to a water distribution system above routine levels for a specified duration for remediation purposes.

w. Immersion Bath. An immersion bath is a bath in which an individual’s entire body, or a body part, is submerged in water.

x. Legionella. Legionella is the genus name of a group of Gram-negative bacteria that are naturally found in water and have been associated with building water distribution systems and cooling towers. Over 50 species and 70 serogroups have been identified.

y. Legionella Disease. Legionella disease (LD) is the term used in this directive for the disease traditionally known as “Legionnaires’ disease;” a type of pneumonia caused by pathogenic species of the bacterium, Legionella. Most, but not all, cases of LD in the United States are caused by the species, Legionella pneumophila serogroup 1.

z. Legionellosis. Legionellosis refers to diseases (Legionnaires’ disease, Pontiac Fever, extrapulmonary legionellosis) caused by pathogenic species of the bacterial genus, Legionella. Legionnaires’ disease is defined above (see “Legionella disease”).

Pontiac fever is a milder respiratory infection with no indication of pneumonia;

symptoms resolve without treatment. Extrapulmonary legionellosis is infection with Legionella at a site other than the lungs; occurrence is rare and often in immunocompromised patients.

aa. Legionnaires’ Disease. See “Legionella disease”.

bb. Low Flow Fixtures. Low flow fixtures are fixtures that either due to modification or age have flow capabilities below the standard IPC requirements. Low flow fixtures are similar to irregularly used fixtures, which are fixtures that are used less than once a day.

cc. Mitigation. Mitigation is a process of undertaking an action or set of actions to reduce the severity of a situation.

dd. Mixing Valve. Mixing valve is a generic reference to a class of water tempering devices. Mixing valves used for tempering hot water in potable water systems must meet the requirements of the International Plumbing Code (IPC 2009), American Society of Sanitary Engineers (ASSE 1016/1069/1070) and VA Master Construction Specifications.

ee. Monitoring. Monitoring, for the purpose of this directive, refers to the process of measuring water quality of incoming water (from municipal or central plant) and at representative outlets/areas to determine if the engineering controls are within established minimum and maximum limits.

ff. Monochloramine. Monochloramine is a type of chloramine. Chloramines are most often formed when ammonia is added to chlorine. Monochloramine is an EPA listed biocide chemical (oxidant) approved for use in treatment of potable water to control/inactivate waterborne bacteria, viruses and protozoa.

gg. Non-Potable Water System. A non-potable water system is a water system primarily used for non-drinking purposes such as aesthetic use or industrial use (e.g., cooling towers and irrigation systems).

hh. Outlet. An outlet is a point in the potable water distribution system where an individual (also known as the “end user”) accesses the water. Examples include faucets, showers, ice machines and drinking fountains.

ii. Oxidant Residual. An oxidant residual is an indication of the amount of available oxidant present in the water system and at the outlet after system demand has been satisfied.

jj. Point-of-Use Filter. Point-of-use filter refers to a micropore (approximately 0.2 micrometer) filter specifically designed for use in preventing the passage of bacteria, such as Legionella, present in water. Typically, these filters are fitted to water outlets or installed in water supply lines proximal to equipment (e.g., ice machines, drinking fountains).

kk. Potable Water System. A potable water system is a water distribution system (for both hot water and cold [unheated] water) within a building or structure that is primarily used for drinking, sanitation, food service or personal hygiene, which meets EPA and state drinking water standards.

ll. Potable Water Treatment. Potable water treatment is a permanently installed system that is designed and installed to inject a biocide into the potable water system to provide additional treatment to the water supplied by the municipality or utility. The system(s) normally operate continuously to maintain biocide levels in the building and must be permitted by the state for operation.

mm. Primary Control Measures. Primary control measures are the main or routine methods used to suppress Legionella growth in building potable water distribution systems. The primary control measures often used in building potable water distribution systems include at least one of the following: appropriate water temperature(s) and biocide(s) levels (e.g., oxidizing agent).

nn. Remediation. Remediation is the process of implementing actions to reduce the amount of Legionella in a water distribution system through actions such as the addition of a biocide or increasing the temperature to inactivate bacteria through thermal means.

oo. Resident. Resident is defined here for the purpose of clarifying which buildings fall subject to this directive. In the phrase, “VHA buildings in which patients, residents or visitors stay overnight”, the term “resident” refers to Veterans who are under residential-type care such as provided at a Community Living Center or domiciliary.

pp. Schematic Diagram. A schematic diagram is a single line schematic representation of the entire building water distribution system (including process equipment, controls and general system layout) to facilitate a full understanding of the system interconnection and operational parameters. This diagram includes all major equipment and its relation to the system, including water heaters, tanks, pumps and instrumentation. NOTE: This is not to be confused with a process flow diagram, which is a simple diagram of the system.

qq. Supplemental Action. A supplemental action is a process, system or action executed in addition to the routine (primary) control measures (such as temperature and biocide control) to facilitate the inhibition of Legionella growth in building water distribution systems.

rr. Thermal Remediation. Thermal remediation is the temporary resetting of the temperature in the water distribution system to 160°F - 170°F (71°C - 77°C) while continuously flushing each outlet in the system for at least 30 minutes (also known as “super heat and flush" and “thermal eradication”) to remediate the system.

ss. Validation. Validation is the process of obtaining evidence that a plan is effective. In this directive, validation specifically refers to verifying that control measures, and any supplemental actions, are effective at inhibiting the growth of Legionella in building potable water distribution systems or non-potable systems. The two validation methods used are environmental water testing for Legionella, and clinical testing of pneumonia patients for Legionella.

tt. VHA Building. VHA buildings are individual buildings associated with a VA medical facility. The term is used in this directive because only certain VHA-owned buildings at a VA medical facility are required to have an HCA LD prevention plan.

uu. Water Distribution System. Water distribution system is a system used for the distribution of water (site and building) which includes all piping, water treatment, equipment, controls, fixtures and components.

vv. Water System Management Point. A specific location, device, fixture, or water distribution system component used for the monitoring of conditions or performance or the control of the system or its individual components.

4. POLICY

a. It is VHA policy that ongoing HCA LD prevention, including provisions necessary for the prevention of scald injury, will be implemented in all VA medical facilities for:

(1) VHA-owned buildings in which patients, residents or visitors stay overnight;

(2) VHA-owned buildings in which staff are required to sleep overnight; and

(3) Outdoor non-potable, aerosol-generating water systems such as cooling towers.

b. This program must be established with written policy in accordance with, at a minimum, the requirements outlined in this directive.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for:

(1) Ensuring that sufficient resources and funding are available to attain both Veteran Integrated Service Network (VISN) and VA medical facility compliance with this directive.

(2) Ensuring overall VHA compliance with directive.

b. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the VISNs.

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to assure compliance with this directive, relevant standards and applicable regulations.

d. Director of the Healthcare Environment and Facilities Program, Office of Healthcare Engineering. The Director of the Healthcare Environment and Facilities Program (HEFP), Office of Healthcare Engineering (OHE), is responsible for:

(1) Overseeing VHA’s program for prevention of HCA LD and scald injury from water systems.

(2) Periodically assessing VHA’s program for the prevention of health care-related

LD and scald injury from water systems for continued need, currency and effectiveness.

(3) Developing and issuing any additional engineering requirements, standards and guidelines for the prevention of LD. NOTE: HEFP regularly updates these supportive documents as needed and they can be found at the VHA Water Safety Management & Legionella Resources website at http://vaww.hefp.va.gov/healthcare-engineering/water-safety-management-legionella and the HEFP program site at https://dvagov.sharepoint.com/sites/VHA10NA5E.These are internal VA websites that are not available to the public.

(4) Conducting assessments and surveys related to the implementation and ongoing monitoring of this directive as related to engineering requirements.

(5) Providing consultative assistance related to engineering requirements to VISNs and VA medical facilities, as needed.

(6) Administering the Water Safety Management Tool (located at the VHA Water Safety Management & Resources website), or most current reporting system, for the http://vaww.hefp.va.gov/healthcare-engineering/water-safety-management-legionella…