• Art Goguen

New Hospital Water Management Requirements Take Effect in 2022


Effective water management is a crucial part of hospital operations.


Establishing a comprehensive water management program allows facilities staff to better control water-related, healthcare-associated infections, including Gram-negative pathogenic bacteria like Legionella. However, it's important to be aware that standards change over time.


Does your hospital or nursing care center currently meet Joint Commission standards for water management?


If you answered yes, that’s great.


However, you will soon need to update your water management protocols to comply with new TJC standards beginning in 2022.


If you answered “I’m not sure,” you’ll want to check in with your facilities director or EHS director.


Don't get blindsided by new water management requirements

Effective January 1, 2022, The Joint Commission has approved a new standard on water management programs that addresses Legionella and other waterborne pathogens.


Currently, regulations for hospitals (EC.02.05.01 EP 1-4) and for nursing care centers (EP 6) require organizations to minimize pathogenic biological agents in cooling towers, domestic hot and cold water systems, and other aerosolizing water systems. Current EP standards should continue to be maintained until December 31, 2021 and then replaced with EC.02.05.02, EPs 1–4 standards.


The Joint Commission Prepublication Requirements clearly outline the main elements of a water management program. EC.02.05.02 requires that hospitals have a program that addresses Legionella and other waterborne pathogens. For example:


1. The water management program will have an individual or team responsible for the oversight and implementation of the program, including but not limited to, development, management, and maintenance activities.


2. The water management program must include:

  • A basic diagram that maps all water supply sources, treatment systems, processing steps, control measures, and end-use points, (e.g. a flow chart with symbols showing sinks, showers, water fountains, ice machines, and so forth).

  • A water risk management plan based on the diagram that includes an evaluation of the physical and chemical conditions of each step of the water flow diagram to identify any areas where potentially hazardous conditions may occur (these conditions can most likely occur in areas with slow or stagnant water). Note: Refer to the CDC’s “Water Infection Control Risk Assessment (WICRA) for Healthcare Settings” tool as an example for conducting a water-related risk assessment.

  • A plan for addressing the use of water in areas of buildings where water may have been stagnant for a period (for example, unoccupied or temporarily closed areas).

  • An evaluation of the patient populations to identify areas providing care to immunocompromised patients.

  • Monitoring protocols and acceptable ranges for control measures. Note: Hospitals should consider incorporating basic practices for water monitoring within their water management programs that include monitoring of water temperature, residual disinfectant, and pH. Additionally, protocols should include parameters measured, readings, sampling/monitoring locations, and documentation of corrective actions taken when parameters are out of range.

3. The individual or team responsible for the water management program are responsible for the following:

  • Documenting results of all monitoring activities.

  • Corrective actions and procedures to follow if a test result is outside of acceptable limits.

  • Documenting corrective actions taken when control limits are not maintained.

Note: EC.04.01.01, EP 1 provides the process for monitoring, reporting, and investigating utility system issues.


4. The individual or team responsible for water management must review the program annually or when the following occurs:

  • Changes have been made to the water system that would add additional risk.

  • New equipment or an at-risk water system(s) has been added that could generate aerosols or be a potential source for Legionella. This includes the commissioning of a new wing or building.

Keep in mind that The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) do not currently require culturing for Legionella or other waterborne pathogens. Testing protocols are at the discretion of the hospital unless required by law or regulation.


Refer to ASHRAE Standard 188-2018 “Legionellosis: Risk Management for Building Water Systems” and the Centers for Disease Control and Prevention Toolkit "Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings" for additional guidance on creating a water management plan. For additional guidance, consult ANSI/ASHRAE Guideline 12-2020 “Managing the Risk of Legionellosis Associated with Building Water Systems.”

Need help with your water management plan?


Higgins and Associates, LLC is ready to assist with your program development, training, and sampling programs within your hospital(s) and/or healthcare facilities.


For more information, contact Higgins and Associates' Director of EHS, Art Goguen, at (303) 708-9846 Ext 105. You can also visit higgins-and-associates.com to learn more about our healthcare EHS services.