As crucial as water is to the cleanliness of a hospital and the well-being of all who enter, this essential element still can harbor pathogens that may pose a threat to patient safety and lead to healthcare-associated infections. That makes the hospital’s water management programs important for protecting patients as well as staff and visitors.

Water management regulation requirements highlighted by the Centers for Disease Control and Prevention help ensure that as water enters a healthcare facility, it meets all quality standards, plumbing is mapped and designed in a way that minimizes growth and spread of pathogens, and infection risk due to exposure is mitigated and minimized.

The CDC noted that recent evidence indicates sinks and other drains may become contaminated with multidrug resistant organisms. Patients may become exposed to organisms in drains when water splashes. The CDC has also observed that ice machines may be a source for germs and pathogens.

The Accreditation Commission for Health Care (ACHC) Accreditation Standards Manuals for Acute Care and Critical Access Hospital programs address the requirements for reducing waterborne pathogens through the hospital’s Water Management Program and Infection Control Plan.

Stay Informed

ACHC Standard 07.02.01 ACH | 18.02.01 CAH (Risk mitigation measures for infection control) requires hospitals to have an infection control program as documented in its policies and procedures that employs methods for the prevention and control of infections.

ACHC Standard 07.02.06 ACH | 18.02.06 CAH (Reduce risk of Legionella in water systems) requires hospitals to have an infection control plan that outlines a water management program that includes but is not limited to implementing actions that reduce the growth and spread of Legionella and other opportunist water pathogens.

ACHC Standard 11.06.08 ACH | 03.06.08 CAH (Plant equipment and systems: Maintenance) requires hospitals to have a strategy for equipment preventive maintenance that follows manufacturer recommendations or to have performed a risk assessment to allow for an alternate equipment maintenance (AEM) strategy.

Maintaining Compliance

When a Surveyor Visits

When an ACHC Surveyor conducts a survey, they will:

• Assess documentation of hospital policies and procedures that explain how patients are protected from waterborne pathogens at your hospital via your Water Management and Infection Control plans.
• Tour the facility and inspect sink locations to verify appropriate distance is established or splashguards are in place in accordance with industry practice.
• Inspect ice machines and review the machines’ maintenance documentation.

Tips for Compliance

• Conduct Infection Prevention Environmental Surveillance rounds to assess sinks and the adjacent space to ensure 3 feet of distance and to assess the effectiveness of the maintenance strategy for ice machines.
• Install splashguard barriers to protect counterspace for clean patient care supplies or medication that is being prepared within 3 feet of distance between the sink and supplies or preparation area, if supplies or medication may not be relocated or prepared elsewhere.
• Conduct staff education on the distance requirement for counterspace for clean supplies and medication preparation.
• Inventory ice machines and initiate preventive maintenance in the hospital’s computerized maintenance management system (CMMS).

Ready to Help

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242.