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Legionella Management in Building Water Systems

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 (8/13/2014)

Available: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3033

 

Summary: 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 2014, the VHA issued Directive 1061 outlining prevention and control practices to be implemented to reduce the risk of exposure to Legionella in potable water distribution systems. The directive applies to VHA-owned buildings in which people stay overnight.

Key Provisions:

The Directive states: “It is VHA policy that an ongoing program for [health care-associated Legionnaires’ disease] prevention, including provisions necessary for the prevention of scald injury, is implemented in all VHA buildings in which patients, residents or visitors stay overnight.” The program is to be established in writing in accordance with the requirements set forth in the Directive. VHA Amin. Directive 1061, Section 3.

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(d). The Directive notes that both environmental monitoring and clinical surveillance are necessary to prevent legionellosis. App. A (§1).

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 (4)(e)(3). The written plan for each building must contain, at minimum, all of the components delineated in Appendix A 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;
  • process flow diagrams of control strategies and monitoring for each building’s hot and cold water distribution systems;
  • establishment 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).

Section (4)(i)(2); App. A (§1).

Other Specific Requirements

Section 4 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 VHA medical facility Director is responsible for ensuring that each building conducts at least quarterly environmental water testing for Legionella. Section (4)(e)(6). Each building must have an environmental water testing policy that meets the requirements set forth in Appendix C of the Directive. Section (4)(i)(4).

Appendix C of the Directive sets forth sampling requirements for testing the building’s hot and cold water distribution system(s) for Legionella at least quarterly and for processing samples at a testing laboratory with experience in microbial testing of potable water as determined VHA personnel. App C (2).

Water Quality Monitoring. The Directive requires that the VHA Facility Chief Engineer or Facility Manager continuously monitor the potable water distribution system for biocide and disinfection byproduct levels and for incoming water pressure, temperature, pH and dissolved solids, as set forth in Appendix A. The Directive authorizes facilities to implement a systemic supplementary water treatment system in buildings to supplement municipal or source treatment of water, and lists actions required if such a system is used. Section (4)(g)(2),(3); App A, §2(a)-(c).

Water Temperature. Building personnel must maintain water temperatures in the hot and cold potable water distribution system(s) in accordance with numerical limits set forth in Appendices A and B. Section (4)(g)(1); App A, §2(b); App B.

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, §2(d).

Corrective Action. According to the Directive: “Emergency remediation of a building’s potable water distribution system(s) is triggered, at a minimum, by certain occurrences: identification of a definite [health care-associated] LD case, identification of a possible [health care-associated] LD case and Legionella-positive water results, or identification of Legionella-positive water results during routine environmental testing.” App A, §4. The Directive specifies action to be taken (e.g., assessment of engineering controls, further testing, remediation, documentation) if environmental testing detects any amount of Legionella. App C, §2(c). The Directive also sets out minimum action that must be taken if routine monitoring determines that the water temperatures or biocide residual levels from an installed system are not within the established limits. App A §2(e).

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 (4)(g)(5). Newly installed piping and distribution system components must be cleaned and protected from accumulation of debris and contamination prior to and during installation and must be flushed of debris and disinfected prior to being placed into service. Section (4)(g)(6). 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 (4)(g)(9).

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 unused water branch lines and dead-legs are removed and capped at the main supply/recirculation supply lines to limit stagnation and reservoirs for Legionella growth” in accordance with the building’s plan. Section (4)(g)(7). The Directive also states that regular flushing of hot and cold water at outlets is necessary. App. A §2(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 (4)(e)(5). The Directive also prohibits ultrasonic humidifiers, foggers, misters, spray humidifiers and tank-type humidifiers. Section (4)(g)(8).

Agency Oversight

As noted above, 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.

 

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