Attachment A - Legionella Sampling Plan rev 1-14-2026 02.docx

September 17, 2025 MCP 138.73

ATTACHMENT A

GEORGE E. WAHLEN VA MEDICAL CENTER

ENVIRONMENTAL TESTING PROTOCOL (Legionella Detection Program)

1. The determination of the sampling sights is controlled by the VASLCHCS Water Safety Committee with the support of the Infection Preventionist, and Engineering Service as needed.

1. Water testing frequency for Legionella is controlled by Directive 1061, the VASLCHCS, and with the advisement of the Infection Preventionist.

2. The water sampling, lab testing, and result documentation for Legionella is the responsibility of the Engineering Service. Comment by O'Bryan, Jacqueline L.: VA or contractor? Comment by Keene, Joshua R.: Its engineering's responsibility, but it’s the VA’s decision whether we will be doing this with a contractor or on our own. This is just saying the testing of legionella is our domain.

3. Routine testing for Legionella at distribution endpoints in patient care areas of buildings 1, 3, and 14, and non-patient building 27, 32, 42, and 43 will be performed monthly by Engineering Service with the assistance of the Infection Preventionist. The VASLCHCS Environmental Sampling Plan is as follows: Comment by O'Bryan, Jacqueline L.: Tests are conducted monthly, but only 3 months listed in the table. Are bldg 27 and 42 not monthly? The structure of this table should be revised to reflect all twelve months or one month with all bldgs and tests, Comment by Keene, Joshua R.: There is only three months because this is a rotating schedule for the quarter. SO Month 1 is the first month of the quarter.

*Note: for each site there are two tests – one hot, and one cold

a. Core Testing Sites:

Building 1 – Cold Tank Room Building 27 – Cooling Tower Building 42 – Unit 1 Soft Comment by O'Bryan, Jacqueline L.: Not listed in para 3 above Comment by Keene, Joshua R.: Fixed Building 42 – Unit 2 Hard Building 42 – Unit 3 Hard Building 43 – Pumphouse

7. Engineering Services staff will collect the water samples and transport them to the testing lab immediately after collection. Water samples from outlets will be collected as follows:

a. Samples must be “first draw”.

b. Fill the specimen container provided by the testing laboratory with approximately 125 (ml) of water. Comment by O'Bryan, Jacqueline L.: VA or Contractor? Comment by Keene, Joshua R.: It’s a contract, but really its just whatever lab recieves it. This isnt going to a VA lab. No VA has the ability to test this.

c. Label the container with the sample number.

d. Two water samples from hot only source:

(1) Open the drain valve and immediately fill one specimen container with 1000 ml of water. Label the container with the sample number. Comment by O'Bryan, Jacqueline L.: Is this industry standard or VASLCHSC preference? Comment by Keene, Joshua R.: Industry standard

e. Two water samples from cold only source:

(1) Open the drain valve and immediately fill one specimen container with 1000 ml of water. Label the container with the sample number.

8. Engineering Service staff will receive written laboratory results and forward copies to the Infection Preventionist as soon as possible to minimize exposure risk to patients.

9. Tested site areas and environmental results for the Medical Center will be tracked in VASLCHCS Water Safety Committee Environmental Sampling Spreadsheet reflecting environmental testing results from core test sites, active test sites, and cleared test sites.

10. Tested site areas and environmental results for the Medical Center will be logged into the VHA Water Safety Management Tool each quarter following receipt of test results.

5. Post-Construction Legionella testing will be conducted per the requirements of the Infection Control Risk Assessment conducted by the Infection Control Preventionist for each applicable project.

6. Following any disturbance to the water line, recovery procedures will be performed to ensure chlorine dioxide is present at the distal most site affected by the disturbance. This includes flushing the line until a chlorine dioxide concentration of 0.06 ppm is reached.

7. Upon receipt of any positive environmental sample result, the Chair of the VASLCHCS Water Safety Committee will write a VHA Issue Brief detailing the following: Comment by O'Bryan, Jacqueline L.: Is this pertinent to the contract/contractor or is this simply VA procedures after contractor performance? Comment by Keene, Joshua R.: VA procedure after contractor performance.

a. Issue Title: Legionella Water Test Results

b. Date of Report

c. Brief Statement of Issue and Status

d. Actions, Progress, and Resolution Date

e. Public Affairs Contacts

f. Contact for Further Information

(1) Issue Brief will be sent via email to the Issue Brief Approval Group VHASLCIssueBriefApprovalGroup@va.gov, who will in turn send it via email to VISN 19 Leadership. Comment by O'Bryan, Jacqueline L.: Is this contractor or VA responsibility? If VA, is it pertinent to this contract? Comment by Keene, Joshua R.: VA responsibility. Remove.