Auditing Facility Water Management Plans

To prevent the spread of Legionella bacteria in building water systems, an audit starts with a look at the physical structure defined by the plan and the structure of associated maintenance activities.

By Benjamin Frieders

Legionella bacteria are commonly found in facility water systems. Left unchecked, they can cause serious disease and even death. That’s why standards require most facilities to have a water management plan. Healthcare facilities must pay special attention. As of January 1, 2022, the Joint Commission’s new Environment of Care standard (see summary from ChemREADY here) mandates these plans. Because the Joint Commission is now conducting inspections of healthcare facilities on behalf of The Centers for Medicare and Medicaid Services, facility management teams can expect more scrutiny of their plans. Now is the time for facility executives to audit and correct weaknesses in plans and processes. (Read this author’s February 2022 article in Facility Executive, “Water Management Plans For Healthcare” about the Joint Commission changes.)

How To Audit A Water Management Plan

Although the facility maintenance crew performs monitoring and mitigation, the business executives will be responsible should inspectors find lapses or if there is a lawsuit over Legionella. An audit will tell the facility owner or executive if the plan is being implemented as designed. The resulting process is defined as verification by ASHRAE 188. This may be performed by a member of a facility’s team or by an external facilitator. A good audit will review these elements at the heart of the standards:

  • Is the plan comprehensive?
  • When was the last review completed?
  • How well is it implemented?
  • Has it been updated?
  • Is the team trained and engaged?

Review The Structures And Tasks

An audit starts with a look at structure: the physical structure defined by the plan and the structure of associated maintenance activities. A comprehensive plan should outline the water system distribution and points of access. The plan should identify the risk associated with each part of the system and describe the maintenance activities that control Legionella. Many facility and maintenance managers don’t realize the extent of what they need to do and what they need to document to be compliant.

Excerpt of a Water Management Plan audit checklist (Courtesy of ChemREADY)

What Should Be Documented

A verification audit will determine how thorough the documentation is in terms of maintenance activities. Keep maintenance data in one place, easily accessible to auditors and inspectors. The data should include monitoring, testing, control, and mitigation activities. Typically, paper log sheets or scans of log sheets are stored electronically. Computerized records in a CMMS are equally if not more preferred due to the ease of review.

Monitoring Protocols. Water chemistry should be monitored with known acceptable ranges for parameters. There should be records of the levels of disinfectant, pH, and temperature.

Control measures. Control measures are maintenance activities intended to prevent an outbreak of Legionella or other waterborne pathogens. For example, if a nursing home has a seldom-used faucet or shower, the audit should find documentation that the water line is flushed twice a month, as prescribed in the water management plan.

Mitigation. If a test for Legionella is positive, then corrective maintenance must be documented. As with other maintenance tasks, a worker sees a problem, notifies the person who’s responsible, defines the corrective action, and sets a due date. Each of these steps should be recorded.

Validation. The documentation should show how the plan is validated in controlling the hazardous conditions throughout building water systems, typically performed through Legionella testing.

Legionnaires’ Disease
Legionella Illustration.(Source: CDC)

Team Meetings Are Key

ASHRAE 188 requires a facility to have a water management program team with designated members. Generally, the facility director or other senior manager is on the team to ensure facility buy-in, along with the director of maintenance, the infection control officer, and others.

The standard also requires that the team meets and reviews the program at least annually. The purpose of the meeting is to drive continuous improvement of water safety at the facility. A recommended cadence is once a quarter because that gives enough time to collect data and implement corrective action before the next meeting. Meeting notes should be maintained to prove that the team is executing the plan.

A typical meeting agenda would begin with reviewing the minutes of the previous meeting and the actions that were required at the last meeting. Did those actions get done? For example, if there was a positive Legionella test result at a faucet, what corrective action was taken since the last meeting? Was the faucet flushed and retested? If the faucet is no longer needed, did the mechanical contractor cut and cap the pipe?

The second agenda item would be the review of data and logs entered since the last meeting. This information should include testing, monitoring, and maintenance activities. The review will uncover issues for discussion. For example, let’s say the team planned for a certain task to be performed weekly, but it didn’t get done. Why not? Is weekly testing not feasible? The team may decide that reducing the activity to monthly would not increase the risk of Legionella.

Of course, team members will meet as needed in the course of normal work. For example, if lab results come back positive for Legionella, the water management team should be able to review that issue within a day, decide on the action needed, and quickly implement a corrective action with a due date.


People should know what Legionella is and apply that awareness to their jobs day-to-day. The business owner should have confidence that the facility director, facility manager, and maintenance team understand what they’re doing and why.

3 Questions Related To Water Management Plans

What questions are the right questions to make sure a water management plan is in place and a facility is compliant? Here are three questions that every facility executive should ask themselves and their teams.

  1. When was the last time we audited or reviewed our water management plan?
  2. How often does our team meet, and what gets accomplished at these meetings?
  3. Can you show me the documentation of the maintenance activities that our water management plan says we need to do?

Knowing the answers to these questions will help ensure water safety, help reduce the risk of litigation and loss of Medicaid dollars, and encourage continuous improvement.

Frieders is a certified Legionella Water Safety and Management specialist at ChemREADY. He started his water treatment career in the US Navy in 2006. In 2019, he finished his naval service and entered the industrial water treatment space, focusing on water-borne pathogens, water hygiene, and traditional water treatment chemistry.