Heartland Behavioral Healthcare Biannual Legionella Testing.pdf

This Scope of Work outlines the procedures and responsibilities for conducting Legionella testing within the water systems of Heartland Behavioral Healthcare. The primary objective is to assess and mitigate the risk of Legionella pneumophila, the causative agent of Legionnaires' disease, ensuring a safe environment for patients, staff, and visitors.

1. Objectives

• Baseline Assessment: Establish initial Legionella concentrations to inform water management strategies.

• Routine Monitoring: Implement periodic testing to detect and control Legionella growth.

• Compliance: Adhere to relevant regulations and guidelines, including CMS, ASHRAE 188, and CDC recommendations.

• Risk Mitigation: Identify and address potential sources of Legionella within the facility's water systems.

2. Regulatory Compliance

• Centers for Medicare & Medicaid Services (CMS): Ensure adherence to infection prevention and control standards as per 42 CFR §482.42 for hospitals.

• ASHRAE Standard 188: Comply with guidelines for the design, installation, and operation of building water systems to minimize Legionella growth.

• CDC Guidelines: Follow the CDC's Routine Testing for Legionella and Environmental Assessment recommendations.

3. Testing Frequency and Locations

• Initial Testing: Conduct comprehensive testing upon implementation of the water management plan.

• Routine Testing: Perform testing biannually.

• High-Risk Areas: Prioritize testing in areas with aerosolizing water devices, such as showers, faucets, cooling towers, and decorative fountains.

4. Sampling Procedures

• Sample Collection: Collect 250 mL water samples from representative points within the water system, ensuring coverage of all major branches and devices.

• Laboratory Analysis: Utilize accredited laboratories following ISO 11731:2017 or CDC-approved methods for Legionella culture. PCR methods are not acceptable for routine testing.

• Chain of Custody: Maintain strict documentation and handling procedures to ensure sample integrity and traceability.

5. Data Interpretation and Reporting

Heartland Behavioral Healthcare Biannual Legionella Testing

• Result Evaluation: Analyze Legionella concentrations in colony-forming units per milliliter (CFU/mL) and identify species present.

• Action Thresholds: Refer to CDC's Routine Testing guidelines for interpreting results and determining necessary corrective actions.

• Reporting: Provide detailed reports to hospital administration, infection control teams, and relevant stakeholders.

6. Remediation and Corrective Actions

• Identification of Issues: If Legionella concentrations exceed acceptable thresholds, initiate immediate corrective actions.

• Strategies: Implement measures such as temperature adjustments, biocide treatments, or system modifications to eliminate Legionella growth.

• Documentation: Record all remediation efforts, including methods used, areas treated, and outcomes.

7. Documentation and Record Keeping

• Comprehensive Records: Maintain detailed logs of all testing activities, results, corrective actions, and training sessions.

• Accessibility: Ensure records are readily accessible for review by regulatory bodies and accreditation agencies.

** Initial water sampling plan will include the following locations.

Location, Room # Spigot, Shower, Other Notes

City water point of entry

Hot water storage tanks

Administration, Lobby Water fountain

B1, Room 120 Shower

B1, Room 122 Shower

B1, Seclusion Room Sink

C1, Room 126 Shower

C1, Seclusion Room Sink

D1, Room 118 Shower

D1, Room 120 Shower

D1, Seclusion Room Sink

B2, Room 227 Shower

B2, Seclusion Room Sink

C2, Room 224 Shower

C2, Seclusion Room Sink

D2, Room 218 Shower

D2, Seclusion Room Sink

Dietary, Kitchen Sink #1 Sink

Dietary, Kitchen ice machine Ice machine

Mech Room under police dept, hot water heater

Outlet