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Legionella Management in Building Water Systems

Developments in State Policy

 

New York State

 

This page describes two related New York State regulations addressing Legionella – regulations governing all cooling towers and regulations governing potable water systems in hospitals and residential healthcare facilities. In addition to the regulatory requirements described below, the state has developed a variety of templates and guidance materials to assist in compliance: https://www.health.ny.gov/environmental/water/drinking/Legionella/hospitals_health_care.htm.

 

I.  Cooling Towers

Citation: 10 N.Y. Codes, Rules and Regs. (NYCRR) §§ 4-1.1—4-1.12

Available: Here and Here

 

Summary: New York State regulations require owners of all cooling towers, as defined in the regulations, to have a maintenance plan and program for each cooling tower in order to prevent and reduce exposure to Legionella. The regulations include specific requirements for testing, inspecting and certifying the cooling towers, as well as for taking corrective action. The regulations also require registration of cooling towers and establish a statewide electronic cooling tower registration and reporting system. First adopted as emergency regulations in 2015 and finalized in 2016, the regulations are overseen by the New York State Department of Health (NYS DOH).

Key Provisions:

Requirement for a Legionella Maintenance Plan

By September 1, 2016, and prior to initial start-up, the owner of a cooling tower must have a maintenance plan and program in place for each cooling tower. The plan/program must be developed in accordance with ASHRAE 188, section 7.2, which establishes requirements for cooling towers and evaporative condensers. 10 NYCRR 4-1.4(a).

The regulations specify several elements that must be included in the plans – Legionella and bacteriological culture sampling and analysis; actions to be taken in response to sampling results; a shutdown and disinfection plan for discontinuing use of a cooling tower and provisions for addressing idle conditions and the start-up of a stagnant cooling tower. 10 NYCRR 4-1.4(b). The regulations also establish specific requirements related to these elements, as described below.

Other Specific Requirements

Sampling/Monitoring. The regulations require a schedule for routine Legionella culture sampling and analysis that includes sampling within 14 days of seasonal start-up and then at intervals not to exceed 90 days; for year-round towers, sampling must be conducted within two weeks after start-up following maintenance and at 90-day intervals. 10 NYCRR 4-1.4(b)(2). The regulations also set forth the conditions that require immediate Legionella culture sampling and analysis. 10 NYCRR 4-1.4(b)(3). The culture analyses must be performed by a laboratory approved by the New York State Environmental Laboratory Approval Program (ELAP). 10 NYCRR 4-1.5. The regulations also require routine bacteriological culture sampling and analysis at least every 30 days while the cooling tower is in use. 10 NYCRR 4-1.4(b)(1).

Inspection. Seasonal and year-round towers must be inspected prior to start-up and at intervals not to exceed 90 day, and all deficiencies found must be documented. The regulations list items to be included in the inspections, along with qualifications that must be met by the inspector. 10 NYCRR 4-1.8(a),(c).

Corrective Action. The plan must include actions to be taken in response to Legionella and bacteriological culture sampling and analysis results, and Appendix 4-A of the regulations sets forth required actions based on Legionella culture results. 10 NYCRR 4-1.4(b)(4), App. 4-A.

Certification. Owners must obtain from a person qualified to inspect cooling towers an annual certification that each cooling tower has the required maintenance program and plan and that the activities in the plan are being implemented. 10 NYCRR 4-1.8(b).

Waivers. The regulation authorizes the NYS DOH to issue a waiver with respect to any requirement if the waiver will not endanger public health. 10 NYCRR 4-1.11(b).

Agency Oversight

Registration. Owners of cooling towers must register their water towers with the Department of Health using a statewide electronic system. Registration, which includes information about the towers, must occur prior to initial operation and whenever ownership changes. 10 NYCRR 4-1.3(a).

Recordkeeping. Owners must maintain records of all required activities for at least three years. 10 NYCRR 4-1.9.

Reporting. Owners of cooling towers must report electronically to the NYS DOH, every 90 days, information including results of culture sampling and inspection dates. 10 NYCRR 4-1.3(b). The local health department must be notified within 24 hours of an exceedance of a Legionella culture sample as specified in the regulations. 10 NYCRR 4-1.6.

Inspections and Sampling. An officer or employee of the Department of Health or local health department may enter onto any property to inspect a cooling tower for compliance and may take water samples. Additionally, the Department of Health or a local health department may require an owner to conduct Legionella culture sampling and analysis if there is a determination that the cooling tower may be associated with a case of legionellosis. 10 NYCRR 4-1.10(a),(b).

Enforcement. If an owner fails to register, have a maintenance program and plan, obtain certification, disinfect, perform culture sampling and analysis or inspect a cooling tower, the Department of Health or local health department may determine that this constitutes a nuisance and may take action as authorized by law. An owner who violates the regulations is subject to all civil and criminal penalties as provided by law, and each day in violation is a separate and distinct violation. 10 NYCRR 4-10(c),(d).

 

II.  Healthcare Facilities

Citation: 10 N.Y. Codes, Rules and Regs. §§ 4-2.1—4-2.9

Available: Here and Here

 

Summary: New York State regulations require all general hospitals and residential healthcare facilities, as defined by state law, to perform an environmental assessment of the facilities and adopt a Legionella culture sampling and water management plan. The regulations are authorized under Section 225(5)(a) of the state Public Health Law, which authorizes adoption of a sanitary code that may “deal with any matters affecting the security of life or health or the preservation and improvement of public health in the state of New York.”

Key Provisions:

Requirement for a Legionella Management Plan

The regulations require that all general hospitals and residential healthcare facilities adopt and implement a Legionella culture sampling and management plan for their potable water systems. New facilities must adopt a water sampling and management plan prior to providing services. The owner must review the plan: annually; when one or more cases of legionellosis may be associated with the facility; following construction or repairs that may affect the potable water system and under any other conditions specified by the NYS DOH. 10 NYCRR 4-2.4(a),(c).

The regulations specify three main elements that must be included in the plan: (1) the sites for Legionella culture sampling, as determined by an environmental assessment; (2) a plan for routine Legionella culture sampling and analysis and (3) actions to be taken in response to Legionella culture analysis results. 10 NYCRR 4-2.4(a)(1),(2),(3). The regulations also establish specific requirements related to these elements, as described below.

Other Specific Requirements

Environmental Assessment. By September 1, 2016, all general hospitals and residential healthcare facilities were required to perform an environmental assessment of the facility. The assessment must be updated: annually; when one or more cases of legionellosis are or may be associated with the facility; following construction or repairs that may affect the potable water system and under other conditions specified by the NYS DOH. 10 NYCRR 4-2.3(a),(b).

Sampling. Covered facilities must undertake Legionella culture sampling and analysis at intervals not to exceed 90 days for the first year after the adoption of the plan, and annually thereafter for most portions of the potable water system. The facilities must also conduct sampling as determined by the NYS DOH when one or more cases of legionellosis may be associated with the facility or under other conditions determined by the agency. 10 NYCRR 4-2.4(a),(b). The analyses must be performed by a laboratory that is approved by the New York State Environmental Laboratory Approval Program (ELAP). 10 NYCRR 4-2.5.

Corrective Action. Appendix 4-B of the regulations requires covered facilities to institute certain control measures and to resample if more than 30% of test sites are positive for Legionella. 10 NYCRR 4-2.4(a)(3), App. 4-B.

Recordkeeping. Covered facilities must maintain the management plan, environmental assessment and sampling results for at least three years. 10 NYCRR 4-2.6.

Waivers. The regulations authorize the NYS DOH to issue a waiver with respect to any requirement if the waiver will not endanger public health. 10 NYCRR 4-2.8(b).

Agency Oversight

Inspection. The Department of Health may at any time conduct an assessment and/or Legionella culture sampling and analysis of the potable water system. 10 NYCRR 4-2.7(a).

Enforcement. A facility that violates the regulations is subject to all civil and criminal penalties as provided by law, and each day in violation is a separate and distinct violation. 10 NYCRR 4-2.7(b).

 

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