Developments in State Policy
U.S. Department of Veterans Affairs
Veterans Health Administration
Citation: U.S. Dept. of Veterans Affairs, Veterans Health Administration - Directive 1061 (2/16/2021)
ummary: The U.S. Department of Veterans Affairs owns and operates a wide variety and a large number of healthcare-related facilities, and the agency’s Veterans Health Administration (VHA) is charged with providing medical and hospital service for the care and treatment of veterans. 38 U.S.C. 7301(b). In 2021, the VHA updated its Directive 1061 (initially issued in 2014) outlining prevention and control practices to be implemented to reduce the risk of exposure to Legionella. The directive applies to VHA-owned buildings in which people stay overnight.
The revision: expands and clarifies the scope and applicability of the document; adds provisions on non-potable water; and updates provisions on environmental Legionella testing and actions for potable water systems.
The Directive states: “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.” The program is to be established in writing in accordance with the requirements set forth in the Directive. VHA Amin. Directive 1061, Section 4.
The Directive emphasizes assessment of risks, monitoring of water quality, implementation of engineering controls and validation that control measures are effectively inhibiting the growth of Legionella. Section 2(f). The Directive notes that both environmental monitoring and clinical surveillance are necessary to prevent legionellosis. App. C.
Requirement for a Legionella Management Plan
Each building subject to the Directive must have a written Legionnaires’ disease (LD) prevention plan, recertified annually, that complies with the Directive and any guidance issued by the VHA. Section 5(m)(1). The written plan for each building must contain, at minimum, all of the components delineated in Appendix A (sec. 1) of the Directive, including:
- schematic diagrams of the site distribution and domestic water systems (hot and cold);
- annual risk assessments of the building for factors outlined in the Directive that may indicate increased risk for LD;
- identification of water system management points and locations where monitoring and controls can be implemented;
- identificaiton of engineering control strategies, including mechanisms for preventing scald injury and a plan to eliminate dead legs;
- documentation of water quality and control measure monitoring and any corrective actions taken; and
- environmental and clinical validation of engineering controls (per Appendix C).
Other Specific Requirements
Section 5 of the Directive, “Responsibilities,” details a number of requirements that must be implemented by various personnel of the VHA. Following are selected requirements, which are implemented and overseen chiefly by the medical facility Director and the VHA Facility Chief Engineer or Facility Manager.
Water Sampling.The Directive requires that each building conduct at least quarterly environmental water testing for Legionella in accordance with the requirements set forth in Appendix C of the Directive. Section 5(h)(6).
Water Quality Monitoring. The Directive requires 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). It also requires continuous monitoring of the potable water entering a buidling for water pressure, temperature, pH and dissolved solids, as set forth in Appendix A. Section 5(j).
Flushing. Faucets are required to be flushed regularly. Taps and showers that are not used frequently or have low water flow must be flushed at least twice weekly. App. A, §6.
Corrective Action. According to the Directive, remediation of a building’s potable water distribution system can be triggered by: identification of a presumptive HCA LD case; identification of a possible HCA LD case and Legionella-positive water results; or identification of Legionella-positive water results during routine environmental testing. Appendix C includes specific requirements and detailed information for assessing when remediation is to be conducted and to what extent. Sec. 4.
Construction and Maintenance of Water Systems. The Directive requires that Infection Control Risk Assessments be conducted “in cooperation with other 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.” Section 5(j)(5). Newly installed piping and distribution system components must be flushed of debris and disinfected prior to being placed into service. Section 5(j)(8). In addition, the Directive requires the assessment and documentation of the competency of contractors prior to any work on a building’s water system, including water treatment. Section 5(j)(11).
Other Required Actions. The Directive includes a number of specific actions that must be taken in buildings to help prevent LD. For example, designated personnel are responsible for “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." Section 5(j)(9). The Directive also states that regular flushing of hot and cold water at outlets is necessary. Section 3(d).
Prohibition on Water Features and Devices. The Directive requires the decommissioning of all indoor, open decorative water features and prohibits future design plans from including the installation of such features. Section 5(h)(5). The Directive also prohibits ultrasonic humidifiers, foggers, misters, spray humidifiers and tank-type humidifiers. Section 5(j)(10).
The Directive requires various offices and officials within the VHA to implement and ensure compliance with its Legionella requirements for preventing health care-associated Legionella disease. This includes reviewing and/or approving plans, reports, testing results and other documents required under the Directive.