R3 Report Issue 32: New Standard for Water Management Program
The new water management standard (EC.02.05.02, EPs 1 through 4) will go into effect January 1, 2022. This standard will appear in the July 1, 2021 spring update so that organizations will have the opportunity to become familiar with the requirements and begin planning for the additional expectations. EC.02.05.01, EP 14 (for hospitals and critical access hospitals) and EP 6 (for nursing care centers) will continue to be utilized for scoring purposes until January 1, 2022 and will then be deleted from these programs.
Currently, EC.02.05.01, EPs 14 and 6 address the need for organizations to minimizes pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems. The expectation is that this process includes a risk assessment, water management plan, and testing protocols and acceptable ranges.
The new standard and EPs are designed to further improve the quality and safety of care provided to hospital patients and nursing care residents who are immunocompromised. This new standard incorporates the latest research and best practices with the primary goal of improving quality and safety in these settings. The Joint Commission evaluated expert literature to determine what additional requirements were needed to help protect immunocompromised patients and residents from waterborne pathogen–related illnesses. The literature review revealed that in addition to the need for a risk assessment, water management plan, and testing protocols and acceptable ranges, there was a need for more specific requirements related to a water management program. The new standard requires that an individual or team be responsible for the oversight and implementation of the water management program, including but not limited to, development, management, and maintenance activities. It also specifies required elements to be included in the water management program, such as a basic diagram that maps water supply sources, treatment systems, processing steps, control measures, and end-use points. The water risk management plan is based on the information in the diagram and includes an evaluation of the physical and chemical conditions of each step of the water flow diagram. There is also a requirement for an annual review of the water management program and when any changes have occurred.
This approach was supported by a Standards Review Panel assembled by The Joint Commission, discussions with the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services’ (CMS) memorandum QSO-17-30.