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Department of Veterans Affairs VHA DIRECTIVE 1061(4) 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:

Amendment dated October 21, 2024:

a. Clarified biocide assessment requirements for incoming water in Appendix A, paragraph 2.c.(1).

b. Clarified Requirement for biocide residual monitoring in Appendix A, paragraph 2.c.(4).

Amendment dated March 4, 2024, clarified the VA medical facility Water Safety Committee Chair responsibilities in paragraphs 5.m.(4)., 5.m.(5), and 5.m.(6) to align with Appendix C.

Amendment dated, September 26, 2022:

a. Updated link in paragraph 2.f. Background and 5.j.(10) Responsibilities.

b. Removed outdated and redundant links in paragraph 5.d.(3) and 5h.(3).(a).

c. Clarified paragraph 2.a. of Appendix A.

d. Corrected the chorine concentration unit in paragraph 4.a.(2) of Appendix A.

e. Corrected paragraph numbering in Appendix D.

f. Updated link in paragraph 3.b.(5). of Appendix D.

g. Corrected and clarified information about bacteria testing in paragraph 4.b. of Appendix D

h. Corrected a paragraph reference in paragraph 1 Background of Appendix E.

As of February 16, 2021, this revised VHA directive:

a. Expanded and clarified the scope and applicability of the document.

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AMENDED

October 21, 2024

February 16, 2021 VHA DIRECTIVE 1061(4)

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b. Added provisions on non-potable water.

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

d. Updated definitions for Legionella disease surveillance.

3. RELATED ISSUES: VHA Directive 1131(5), 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.

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.

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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

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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.

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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/environment/water.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.

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.This is an 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 collection of environmental data to facilitate analysis and action. Actions are defined in the appendices of this directive and will be dependent on findings.

e. Director of the National Infectious Diseases Service. The Director of the National Infectious Diseases Service (NIDS) is responsible for:

(1) Developing procedures and guidelines within VHA for Legionella prevention in conjunction with other VHA program offices, as necessary. NOTE: Supportive documents and guidelines can be found at the Water Safety Management & Legionella Resources site at http://vaww.hefp.va.gov/healthcare-engineering/water-safety-management-legionella. This is an internal VA website that is not available to the public.

(2) Managing the centralized collection of LD case data from VA medical facilities through the following:

(a) Reviewing LD case data (presumptive HCA LD, possible HCA LD and community-associated LD) reported by VA medical facilities (see paragraph 5.g.(8)(b)) at least annually to understand LD rates and trends in VHA.

(b) Contacting the VISN and VA medical facility for additional information regarding LD cases, as necessary.

(c) Providing consultative assistance to VISNs and VA medical facilities related to LD risk, clinical aspects of LD and validation requirements, as needed.

f. Veterans Integrated Services Network Director. The VISN Director is responsible for:

(1) Ensuring that all VA medical facilities within the VISN comply with this directive and any policies and guidance from VHA Central Office for prevention of HCA LD, prevention of scald injuries and water safety.

(2) Prioritizing resources and funding for implementation of this directive for all VA medical facilities within the VISN.

(3) Ensuring completion of annual HCA LD prevention plans, reporting requirements and clinical and environmental testing by all VA medical facilities within the VISN.

(4) Assigning a VISN-level staff member that reports to VISN leadership as the VISN Water Safety Liaison for communication between VHA Central Office and VISN or VA medical facility staff regarding water safety and Legionella prevention actions, policies and guidance.

(5) Working with VA medical facility Directors to identify a representative within the VISN to participate on the Facility Water Safety Committee when the VA medical facility does not have a required member (e.g., Infectious Diseases). See paragraph 5.g.(1).

(6) Ensuring that all VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

g. Veterans Integrated Services Network Water Safety Liaison. The VISN Water Safety Liaison is responsible for:

(1) Obtaining and reviewing annual HCA LD prevention plans, reports and clinical and environmental testing from all VA medical facilities within the VISN. This includes the collection and analysis of data indicating VA medical facility compliance with this directive and reporting requirements as well as analysis and validation of WSMT data and consultation with VA medical facilities to improve performance.

(2) Coordinating communication between VHA Central Office and VISN or VA medical facility staff regarding water safety and Legionella prevention actions, policies, guidance or events, as needed.

(3) Being knowledgeable of VHA policies and guidance for prevention of HCA LD, prevention of scald injuries and water safety.

(4) Developing VISN-level policy and procedure related to HCA LD prevention.

h. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring that the VA medical facility maintains a multi-disciplinary Facility Water Safety Committee that is chaired by the VA medical facility Associate Facility Director, or equivalent, and reports to the VA medical facility Director. This committee must include, at minimum, representation from the following areas: Engineering/Facilities Management, Infectious Diseases, Infection Prevention and Control, Pathology and Laboratory Medicine, Hemodialysis (if performed on site), Safety/Industrial Hygiene, Occupational Health and Environmental Management Service. NOTE: If the VA medical facility does not have a required member (e.g., Infectious Diseases) then the VA medical facility Director must work with the VISN Director to identify a representative within the VISN to participate on the Facility Water Safety Committee. Other stakeholders in VA medical facility water use (e.g., labor partners, dental, sterile processing and supply) may be included on the Facility Water Safety Committee, as appropriate.

(2) Establishing a VA medical facility HCA LD prevention policy, which specifies responsibilities and incorporates the requirement for written HCA LD prevention plans in alignment with the appendices of this directive.

(a) This VA medical facility policy must include a listing of all buildings and outdoor non-potable water systems and equipment that require an HCA LD prevention plan as defined in this directive.

(b) The policy must be reviewed and updated at least every 5 years or when a change in use of areas is implemented, major renovations are executed or new space is constructed.

(3) Ensuring that each building and outdoor non-potable, aerosol-generating water system subject to this directive has a written HCA LD prevention plan and approving these plans. (See Appendix A.)

(a) Requirements for building HCA LD prevention plans are detailed in Appendix A, with provisions necessary for the prevention of scald injury in Appendix B and validation requirements in Appendix C. Requirements for HCA LD prevention plans pertaining to cooling towers are listed in Appendix D with requirements for other outdoor water devices in Appendix E. The written HCA LD prevention plans also must consider any supportive guidance issued by VHA. NOTE: Supportive documents and guidelines can be found at the Water Safety Management & Legionella Resources site at http://vaww.hefp.va.gov/healthcare-engineering/water-safety-management-legionella.

This is an internal VA websites that are not available to the public.

(b) Multiple buildings and outdoor non-potable water systems may have HCA LD prevention plans collated into one document if each building/non-potable system is described in its own section that identifies unique features and plans associated with each item.

(c) The written HCA LD prevention plan(s) must be reviewed, updated as necessary and recertified through the VISN at least annually. This recertification must be communicated to the VISN Water Safety Liaison.

(4) Ensuring that the actions in the written HCA LD prevention plan(s) are implemented.

(5) Ensuring that the VA medical facility has decommissioned all indoor and outdoor, open, decorative water features, and that future design plans do not include the installation of indoor and outdoor, open, decorative water features. NOTE: This requirement does not apply to open water features installed for a non-decorative purpose such as devices used to aerate ponds (refer to Appendix E for additional information).

(6) Ensuring that environmental water testing for Legionella is conducted for designated potable (see Appendix C, paragraph 2.a.) and non-potable (see Appendix D, paragraph 4.a.) water in accordance with this directive and its appendices, and that results are submitted to the VHA Water Safety Management Tool, or most current reporting system, as specified in the reporting system User Manual.

(7) Providing an annual summary of the VA medical facility’s clinical Legionella testing results and number of cases of LD (presumptive HCA LD, possible HCA LD and community-associated LD) to the VISN Director.

(8) Ensuring that cases of LD (VA-associated and community-associated) are:

(a) Reported to the appropriate public health authority in accordance with applicable statutes and regulations as well as the current VHA directive regarding infectious disease reporting, and protection and disclosure of health information (see VHA

Directive 1131(5), Management of Infectious Diseases and Infection Prevention and Control Systems, dated November 7, 2017).

(b) Reported to both the VHA Inpatient Evaluation Center (IPEC) Legionella Case Report data module and the IPEC Legionella Clinical Information data module, or most current reporting system, as specified in the reporting system User Manual. NOTE: The User Manual for the Legionella reporting modules in IPEC can be found at the Water Safety Management & Legionella Resources site at http://vaww.hefp.va.gov/healthcare-engineering/water-safety-management-legionella. This is an internal VA website that is not available to the public.

(9) Requesting consultative assistance from HEFP OHE, NIDS or the VISN Water Safety Liaison on issues related to Legionella prevention efforts, if needed.

i. VA Medical Facility Chief of Staff and VA Medical Facility Associate Director of Patient Care Services. The VA medical facility Chief of Staff and the VA Medical Facility Associate Director of Patient Care Services are responsible for:

(1) Collaborating to ensure that the VA medical facility has access to clinical care staff with expertise in Legionella pneumonia to assist in diagnosis and treatment (e.g., infectious diseases, pulmonology, general internal medicine). NOTE: Diagnostic testing of pneumonia patients for LD, especially when health care-association is suspected, can provide important information for surveillance and remediation purposes. Full details on requirements and recommendations for clinical testing and diagnostic awareness can be found in Appendix C.

(2) Collaborating to ensure that clinical staff involved in direct patient care are notified in a timely manner when cases of presumptive or possible HCA LD are identified to increase diagnostic awareness (see Appendix C, paragraph 4).

(3) Collaborating to ensure that clinical staff involved in direct patient care are notified in a timely manner when routine environmental water testing is positive for Legionella, to increase diagnostic awareness (see Appendix C, paragraph 3 for more information).

j. VA Medical Facility Chief Engineer or VA Medical Facility Manager. NOTE: VA medical facility Chief Engineer and VA medical facility Manager are used interchangeably to indicate engineering leadership. The VA medical facility Chief Engineer or VA medical facility Manager or equivalent is responsible for:

(1) Documenting the VA medical facility’s policy and engineering procedures for the implementation and monitoring of temperature and biocide limits in the hot and cold potable water distribution systems (e.g., hot water tanks, if used, circulating water in the distribution systems and at the outlets) in accordance with Appendices A and B and the VA medical facility’s approved HCA LD prevention plan(s).

(2) Ensuring maintenance of appropriate water temperatures and biocide levels in the hot and cold potable water distribution system(s) in accordance with Appendices A and B, the VA medical facility’s approved policy and HCA LD prevention plan(s).

(3) Ongoing monitoring, data analysis, corrections to engineering controls (if required) and documentation of the temperature and biocide levels in the water distribution system(s) as well as corrective actions implemented to ensure they are within the requirements defined in Appendices A and B and the VA medical facility’s approved HCA LD prevention plan(s).

(4) Continuous monitoring of incoming water quality (from municipal or central plant sources) as required in Appendix A and the VA medical facility’s approved HCA LD prevention plan(s).

(5) Ensuring that when a potable water treatment system that injects biocide into the system is present on a building potable water system, an operating permit is in place.

The appropriate biocide levels for Legionella control in the building’s potable water distribution system(s) must be maintained in accordance with the permit and Appendix A, and in compliance with applicable EPA and local requirements for safe drinking water and effluent concentrations.

(a) Biocide-based water treatment systems must comply with applicable law and regulations, which typically identify acceptable biocide(s) and specify construction and operating requirements. Installed systems must be specifically approved or recognized for the intended use by the State regulatory water authority. Documentation of system(s) approval, design, installation and operation must be maintained and current.

(b) Documentation of the VA medical facility’s policy for biocide concentration levels in the hot and cold potable water distribution systems. This includes documentation of minimum and maximum biocide levels, allowable disinfection byproduct levels, biocide monitoring method and frequency and any other requirements in accordance with Appendix A and in compliance with operating permits.

(c) Ongoing monitoring of biocide and disinfection byproduct levels in the building’s potable water distribution systems to ensure they are within the guidelines defined in Appendix A and in compliance with operating permit requirements.

(d) Ensuring that any potable water treatment system implemented in a building potable water distribution system is functioning according to the manufacturer’s specifications for the treatment system that is being used and at recommended capacity for Legionella inhibition.

(6) Documenting the VA medical facility policy for cooling towers in accordance with Appendix D and other outdoor non-potable, aerosol-generating water systems in accordance with Appendix E. The policy must provide an overview of the equipment and systems on site, define who is responsible for the equipment and systems and establish the general operational and testing requirements to ensure the systems operate as designed and the potential for aerosolizing pathogens is mitigated.

(a) Ensuring there is a written Cooling Tower Management Plan as part of the HCA LD prevention plan(s) and that there is documentation of engineering procedures and actions according to the requirements in Appendix D.

(b) Ensuring implementation of requirements for the maintenance, cleaning and monitoring of cooling towers (refer to Appendix D) and other outdoor aerosol-generating water systems (refer to Appendix E) at the VA medical facility.

(c) Documentation of the VA medical facility’s policy for biocide concentration levels in the cooling tower and distribution systems. This includes documentation of minimum and maximum biocide levels, biocide monitoring method and frequency and any other requirements in accordance with Appendix D.

(d) Ongoing monitoring and documentation of biocide and chemistry in the cooling tower and cooling tower systems to ensure they are within the guidelines defined in Appendix D and the VA medical facility’s approved Cooling Tower Management Plan(s).

(7) Ensuring an Infection Control Risk Assessment is conducted in cooperation with other VA medical facility stakeholders, to address the potential impact of construction and maintenance of water systems on growth or transmission of waterborne pathogens and to determine the extent of precautions, disinfection and system or component commissioning requirements.

(8) Ensuring that newly installed potable water piping, equipment and distribution system components are flushed of debris and disinfected prior to being placed into service as defined by VHA specifications (https://www.cfm.va.gov/til/) and American Water Works Association (AWWA) through the following:

(a) Documentation of flushing and disinfection must be maintained for at least 3 years.

(b) Equipment must be commissioned to ensure operation meets the design intent (i.e., water heaters, circulation pumps, injections systems) and documentation retained for 3 years for record.

(c) Newly installed water piping, equipment and distribution system components that had been disinfected but not put into use within a week of the action must be disinfected again prior to building occupancy due to stagnation of water in the system.

(9) Ensuring the VA medical facility has a plan for removal of unused potable water branch lines and dead legs and capping at the main supply/recirculation supply lines to limit stagnation and the potential for Legionella growth.

(10) Ensuring that only steam is used for building humidification purposes. See VA HVAC Design Manual at https://www.cfm.va.gov/til/dManual.asp. The use of ultrasonic humidifiers, foggers, misters, spray humidifiers or tank type humidifiers is prohibited.

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

(11) Assessing and documenting competency of contractors and the contractor’s personnel as part of the acquisition process prior to the start of any work on VA medical facility water systems,…