Exhibit 3. Water Management Program 06.2025.pdf

Spring Grove Hospital Center Water Management Program

Policy & Procedure SGHC12292022

Purpose

To identify hazardous water conditions and take steps to mitigate or prevent the growth and transmission of Legionella and other waterborne pathogens in the building water systems. To minimize, prevent or eliminate waterborne pathogens in building water systems.

References

• The Joint Commission 2022 Hospital Accreditation EC Standards for Water Management Programs (effective 1/1/2022)

• 2017 CMS Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires Disease (LD)

• CDC Water Management Program Toolkit

• MDH Local Health Department Guidelines for Epidemiologic Investigation and Control of Legionnaires’ Disease (2019)

• COMAR 10.07.14.42 Water Supply Regulations

• SGHC Policy 022091 Legionella Bacteria

• OSHA Legionellosis osha.gov/legionnaires-disease/control-prevention

Oversight and Responsibilities

A. Monitoring for waterborne pathogens including Legionella in cooling towers, domestic hot water, buildings, and other aerosolizing water systems are conducted by the SGHC Safety Department and SGHC Maintenance Department or designated contractor per contract management procured by the SGHC Finance Department at the request of one of the above.

B. Assessment of water distribution systems for waterborne pathogen risks are conducted by the SGHC Safety Department and SGHC Maintenance Department collaboratively. The SGHC Infection Prevention & Control Department (IP&C) may be accessed for consultation.

C. The SGHC Water Management Team will be led by the SGHC Safety Department and consist of members from the SGHC QAPI Department, SGHC IP&C Department and SGHC Maintenance Department. The SGHC Water Management Team will be responsible for overseeing the SGHC Water Management Program to include the following:

a. Regular communication about the program and program updates.

b. Maintain knowledge of the water system and monitor changes.

c. Confirm the program performance with specified event triggers.

d. Monitor and document program performance.

e. Identify control locations and control limits.

f. Ensure ability to identify and take corrective actions and follow ups related to corrective actions.

g. Complete routine flushings through patient and staff buildings.

h. Conduct superheating in the identified building that has water heaters comparable with the heating range monthly.

i. Conducted routine testing every 6 months on 10 identified buildings to endure there are no waterborne pathogens.

j. Test chlorine levels on two main water feeds for campus annually.

D. An external contractor will be hired to conduct periodic water testing every six months for annual inspections and as needed when contamination is suspected.

Building Water Systems and Flow Diagrams

A. Attached to this plan are flow diagrams for the water feed system at SGHC.

B. There are two water main feeds that provide water into SGHC campus. One main source is from Bloomsbury Avenue and feeds into Asylum Lane. The other main source comes down Wade Avenue to Pecan Street. Both mains connect to each other and create a large loop around SGHC

Exhibit 3

Policy & Procedure SGHC12292022 grounds and branch out to the different buildings. The backflow prevention system prevents used water from recirculating into clean potable water.

C. Water main breaks are assessed and reported to the Maintenance Department and corrected/fixed by an external contractor.

Water Sources/Reservoir and Utility Company

A. SGHC’s water source is Loch Raven Reservoir. Attached to this plan are maps outlining the reservoir feed area.

B. Baltimore City Department of Public Works is the utility company for SGHC.

C. Cooling Towers:

a. SGHC has two cooling towers located behind the Benjamin Rush (ADAA) building and on top of the Smith building.

D. Cold water is heated to 120 degrees Fahrenheit (at the appliance) by instant hot systems and distributed on demand.

a. Hot water is distributed to plumbing fixtures in each building.

b. Hot, cold, and tempered wastewater is discarded through the sewer line.

Risk Assessment

A. A 6-month risk assessment of water distribution systems for waterborne pathogen risks will be conducted by the SGHC Water Management Team and will be led by the SGHC Maintenance Director or designee within the Maintenance Department. The report will be written by the Safety Department and submitted to the QAPI Department for review. Additional risk assessments will be completed as needed for water emergencies.

B. Water system risks are primarily in the hot water piping systems, shower heads and faucets in the patient care buildings: Smith, Dayhoff, White, Noyes, Tawes, Red Bricks.

C. The water system recirculates which enhances the hot water circulation and reduces the risk of stagnation (an associated risk of Legionella).

D. Categorization of risk

a. Highest: Any area caring for immunocompromised patients (primarily Smith unit, but any patient care area may have immunocompromised patients)

b. High Risk: Dental Clinic, Medical Clinic (Smith building)

c. Medium Risk: Food Services/Central Kitchen, Café on the Grove, IP&C Department (Tuerk building)

d. Low Risk: Office areas/buildings

Operational Management of Risk

A. Hot Water Heating System

B. Cooling Towers and Evaporative Condensers

a. The chemical treatment applied to the cooling tower system prevents bacterial growth within the tower. The cooling towers are chemically treated monthly during the cooling season by the contracted provider per a maintenance schedule.

C. Patient Showers

a. Patient shower lines are flushed daily by routine use in patient occupied areas.

b. Shower lines are not flushed when not in use or in patient occupied areas.

c. Shower lines will be flushed during repair work or cleaning of a clogged line.

D. Inspection (and documentation) of shower heads and hoses, whirlpool tubs, electronic and manual faucets and water fountains is completed at least quarterly in collaboration with the SGHC Maintenance Department and the SGHC Safety Department.

E. Cleaning (and documentation) of shower heads and hoses, whirlpool tubs, electronic and manual faucets and water fountains is

Policy & Procedure SGHC12292022 completed daily by the Housekeeping Department.

F. Eye Wash Stations

a. Eye Wash Stations are located in the Pharmacy (Garrett building), the Lab (Smith building), and Dietary (Central Kitchen building).

b. The Maintenance Department is responsible for saline concentrate maintenance and solution changes every 3 months.

c. The Maintenance Department is responsible for documenting and maintaining eye wash station logs.

G. Ice Machines and Ice Bins

a. Ice machines/ice bins are located in the Central Kitchen, Café on the Grove, Dayhoff pantry, Tawes pantry, and Red Brick 1 - 4 pantries. A filtration system and backflow system facilitate clean and non-contaminated water.

b. The ice machines/ice bins are cleaned and flushed per manufacturer’s recommendations which are every six

(6) months for the clean and sanitized service.

c. Deep cleaning and flushing are coordinated through an external contractor. The Dietary Department is responsible for regular cleaning.

H. Condensate Trays

a. HVAC Systems’ condensate trays and evaporator coils are inspected and cleaned in the Spring and Fall by an external HVAC contractor. Condensate trays are treated with an antibacterial tablets as needed.

b. Maintenance is responsible for supervising the contractor, documenting, and maintaining inspections and logs.

I. Water Shock

a. Certain water shocks are unavoidable as they may be caused by actions uncontrollable by SGHC.

b. Whenever a water main supply line is disrupted or opened, care is taken to open valves slowly to prevent major disturbance of sediment that could be present in the lines.

c. Following the completion of any water main work, the system is flushed through the fixtures within the affected building(s) to ensure water cleanliness.

J. Backflow Preventers

a. SGHC has Backflow Preventers that are tested annually by an external contractor.

K. Soil/Dust Disturbance

a. Soil/dust contains contaminants that could be harmful to the water source. Awareness is heightened during construction projects to prevent the disruption and/or introduction of soil into the water lines. Water lines may be tested more frequently when/if contamination is suspected.

L. Legionella Prevention Measures

a. Regular and zone flushing are performed as needed by an external contractor or through routine use.

b. Heating water lines in the patient care buildings are chemically treated by an external contractor at least quarterly to keep pipes clean, prevent rust and bacteria growth. The Maintenance Department oversees the work of this contractor.

c. Water line disruption management flushing will occur once the disruption is resolved (e.g., water main break). All faucets, showerheads, water fountains and toilets in the affected area are flushed systematically prior to area use.

Legionella/Other Testing

A. Testing frequency is determined by the level of risk associated with the age of the pipes and the SGHC patient population.

B. Testing of potable water and sources of aerosolized water shall occur at least semi-annually in the Smith Building and annually

Policy & Procedure SGHC12292022 in other distal sites, and when indicated due to suspected contamination. Testing shall be conducted by a contracted agent and supervised by the SGHC Safety Department and the SGHC Maintenance Department. IP&C is included for consultation, reporting, communication, and follow-up. Tests shall include all hot water production and storage equipment and a representative sample of distal sites including those sites that are considered highest risk or high risk due to existing patient populations and pipe age. Distal site testing includes several remote sites to include representative samples from showerheads, ice machines and faucets.

C. Cooling towers are tested annually by a contractor and treated accordingly.

D. When there are detectable Legionella (or other pathogen) levels in the water, SGHC will follow the contracted service provider’s recommended actions and support.

E. All reports shall be shared with IP&C and QAPI. Contracts are obtained by Finance.

Legionella Remediation

A. Collaboration between Maintenance, QAPI, IP&C, and Safety Department to solicit ongoing support from Finance and contractors.

B. When levels of contaminants are less than the established limit (< 10), no response is required. Continue preventive maintenance activities in accordance with established protocols, procedures, and equipment manufacturer recommendations. Repeat tests will be done as scheduled.

C. When levels are above the established limit (> 10 but <100) an external contractor will be consulted for recommendations and further testing if indicated. Corrective actions will be taken immediately and affected water sources will not be used until the external contractor determines that the limit is < 10. Water will be retested 3-7 days following corrective actions.

Repeat the process of corrective action until the level is < 10.

D. For levels > 100, immediately perform a flushing/cleaning of the system to discharge any debris in the system; consult an external contractor for further recommendations and corrective actions.

Perform actions listed above, retest the water 3-7 days following corrective actions and repeat until level is < 10.

E. Water source may be used once a level of < 10 is re-established.

Evaluation

A. An annual risk assessment of the water distribution systems will be conducted by the Water Management Team led by the Safety Officer. The report will be documented by the Safety Division of the Maintenance and shared with the Water Management Team, COO, CMO, and CEO.

B. Contracts for testing and routine services will be obtained by Finance prior to June 30th of each calendar year.

Documentation

A. All results and reports will be kept by the SGHC Safety Department and Maintenance Department on a shared google drive. Additional superheating and flushing logs will be maintained by the SGHC Maintenance Department. Copies will be provided to QAPI, IP&C, CEO, COO, Finance, and the Dietary Director.

B. Results and reports are communicated in the AEC Committee and QAPI Committee.

C. Water quality issues, disruption of water or other urgent/emergent water problems and when the problems have been resolved will be communicated through a SGHC mass email or overhead PA announcement. The Chief Operating Officer will submit an MDH Incident Report, as well.

Policy & Procedure SGHC12292022

Approved by

Signature on File 6/26/2025 Dorothy Steinhice, MSN, RN, Date Director- Infection Prevention & Control

Jorel Fleming-Smallwood, MBA-HC, Date Chief Operating Officer

Marie Rose Alam, M.D., FAPA, Date Chief Executive Officer

MRA/tg

Originated: 12/29/2022/sjb, ds, dk

Revised: 1/24/2023, 8/7/24, 6/24/25