How to develop a water management program

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Mark Goins
Mark Goins

Approximately 8000 cases of legionellosis (Legionnaires' disease, Pontiac fever, and any illness caused by exposure to Legionella bacteria) are reported in United States each year, according to the Centers for Disease Control and Prevention. CDC data also indicate the rate of reported cases of legionellosis in the U.S. increased 286% between 2000 and 2014. Of the overall reported cases of legionellosis, 10% result in death. 

However, among those that occur in healthcare facilities such as hospitals, nursing homes and long-term care facilities, the mortality rate jumps to 25%. 

While the presence of Legionella in any water system presents a danger to occupants, the threat of infection is particularly dangerous in healthcare facilities where residents are more vulnerable to exposure since many are senior citizens and/or immunocompromised due to illness. The fact that these facilities often contain complex water systems, where Legionella bacteria are likely to thrive, makes them particularly high-risk locations.

In June, the Centers for Medicare & Medicaid Services released a memo, “Requirement to Reduce Legionella Risk in Health Care Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease.” The CMS memorandum cites data from 2000 to 2014 indicating 34% of all Legionellosis outbreaks were associated with long-term care facilities or hospitals. Therefore, if healthcare facilities want to continue to participate in the Medicare program they must demonstrate measures to minimize the risk of Legionella contamination in their water systems or risk a citation for non-compliance with the CMS Conditions of Participation. Developing a water management program that addresses Legionella is an important step in achieving compliance with the CMS Directive.

Since legionellosis is almost exclusively contracted via inhalation of the bacteria in droplets of water, fixtures that aerosolize water pose the highest risk. Areas of a facility commonly vulnerable to Legionella contamination and transmission include: hot and cold-water storage tanks, water heaters, shower heads, humidifiers, and cooling towers. Cooling towers pose a particular risk. A CDC study found Legionella bacteria in 84% of 196 cooling towers surveyed across nine geographic regions of the United States.  

Federal Regulation 42 CFR – Public Health, including parts 482, 483, and 485, provides requirements for hospitals, long-term care facilities and specialized providers (comprehensive outpatient rehabilitation facilities, critical access hospitals and clinics), respectively. To qualify for participation in Medicare programs, these facilities must have an active program for preventing and controlling communicable diseases, including a Water Management Program. The CMS memorandum recommends the first step of the Water Management Program should be conducting, “a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Finding a qualified laboratory capable of detecting and identifying waterborne organisms is an important step in developing a program.

To help facilities develop an effective water management program, the CDC has published a toolkit. It includes a worksheet for determining to what degree a Water Management Program is needed for a specific facility and lists seven elements:

  • Establish a water management program team
  • Describe the building water systems using text and flow diagrams
  • Identify areas where Legionella could grow and spread
  • Decide where control measures should be applied and how to monitor them
  • Establish ways to intervene when control limits are not met
  • Make sure the program is running as designed and is effective
  • Document and communicate all the activities

After the program is implemented, the CDC recommends reviewing the plan annually with your laboratory or if changes occur such as new construction, equipment changes, changes in the municipal water supply, etc.

Released in 2015, ASHRAE-188 establishes minimum legionellosis risk management requirements for the design, construction, operation, and maintenance of new and existing buildings and their associated (potable and non-potable) water systems. It is intended to be utilized for commercial, institutional, multiunit residential, and industrial buildings. Included in ASHRAE-188 is Appendix A which specifically addresses water systems in health care facilities. The CMS Directive specifically cites ASHRAE as guidance for reaching compliance.


In order to assist facility managers in locating qualified laboratories for Legionella analysis, the CDC administers the Environmental Legionella Isolation Techniques Evaluation (ELITE) Program for certifying laboratories as proficient in the isolation of Legionella from water samples. Participating labs must demonstrate proficiency using blind-coded check samples twice a year to be granted ELITE status. 

Contacting a CDC ELITE Certified and ISO 17025 accredited laboratory is a good first step in developing an effective Water Management Program and assuring compliance with the CMS Directive. 

These labs can help you, or refer you to someone who can help you, design a Water Management Program or evaluate your existing program to determine if it is meeting appropriate standards. Once the program is designed and optimized, the lab can help you set up a testing regimen to periodically verify that the program is working and Legionella is not present in the water system. 

These labs are usually equipped to provide other testing services as well, such as testing for other pathogens, performing microbial counts of potable and non-potable water and testing for heavy metals and other contaminants.

Mark A. Goins is the Director of Business Development at Q Laboratories Inc. 

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