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NORTHERN COCHISE COMMUNITY HOSPITAL
WATER MANAGEMENT PROGRAM
DEPARTMENT: Safety
SUBJECT: Water management Program
Reviewed By:
| Review Date:
| Committee
| 11/17/17
| Med Staff
| 11/28/17
| Governing Board
| 11/28/17
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REFERENCES: CMS and CDC water monitoring for Legionella bacteria, ASHRE standard 188.
SCOPE/RESPONSIBILITY: The scope of the Water Protection plan is to meet CMS & CDC guidelines for preventing Legionella bacteria infections throughout the hospital plumbing system. The Water Management Team is made up of the NCCH Facilities Director, Infection Control Director, and the Safety and Infection Control Committees oversight.
POLICY: NCCH is following the HCCP (Hazard Identifications and Control Points). Hazard Risk Assessment of the Water Management program includes control measures and monitoring processes. The plan also includes the mapping of our building's water system.
PROCEDURE:
1. Hazard Risk Identification, (see attached Map of NCCH Water System). The Main Hazard Points have been identified as the following:
- Municipal Water Supply and risks from water main breaks or system construction.
- Stagnation points in our water systems that include sinks and showers, water storage tanks, water heaters, pipes, valves and fittings, eye-wash stations, ice machines, and filters.
- Temperature permissive risks, with hot water storage, hot water heaters, and ice machines.
- Hospital Acquired Infections as diagnosed.
2. Control measures include the following:
- Monitoring any Municipal Water issues on water mains, construction, or other such work. This includes regular back-flow device testing.
- Temperature monitoring of water, in hot water storage tanks, hot water heaters, and the in-flow and out-flow temps. Will randomly test sink and shower temp outputs on monthly basis.
- Stagnation risk points will include sanitation flush of little used toilets, sinks and showers, flush of hot water storage tanks and hot water heaters.
- Sanitation of Ice Makers and filter changer per recommended by manufacturer.
3. Monitoring, documentation, and validation of the Water Management System.
- NCCH will test water supply, an initial base line water will be conducted, and continual water testing annually.
- NCCH will also conduct quarterly random selected outlets - sinks, and measure chlorination level present in downstream use fixtures.
- Results will be documented and if corrective action is required, these will be conducted and out water program consultant partner will assist in corrective action solutions.
SAFE-POL-007
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