A Water Management Plan helps to identify the critical areas of concern within a facility’s domestic water systems that can promote or harbor Legionella bacterial growth. The plan includes forming an accountable team, mapping the water systems, identifying critical control points, establishing monitoring procedures and identifying corrective actions to be taken if control criteria are not met.
In July 2016, New York State adopted a permanent (non-emergency) regulation addressing Legionella exposure in general hospitals and residential healthcare facilities as defined in Article 28 of the Public Health Law (collectively, “covered facilities”). It took effect upon publication in the State Register, following a 45 public comment period. The State’s requirements pertaining to covered facilities are listed in the regulation, Protection Against Legionella and are found in Subpart 4-2.
Under section §4-2.3, the law required an environmental assessment be performed no later than September 1, 2016, unless it was performed on or after September 1, 2015. The regulation requires an annual update of the environmental assessment and, in specified conditions. Copies of the completed environmental assessment form are to be retained for three years in accordance with section §4-2.6.
Under section §4-2.4, all covered facilities shall adopt and implement a Legionella Culture Sampling and Management Plan (SMP) for their potable water systems by December 1, 2016. New covered facilities shall adopt such a plan prior to providing their services. Once adopted the plan shall be reviewed annually under the following conditions described in subpart (c). Sampling sites are determined in accordance with section §4-2.3. Legionella culture sampling and analysis is to be performed at intervals not to exceed 90 days for the first year following plan adoption. Thereafter, annual Legionella culture sampling and analysis will satisfy compliance with the plan; except wherein portions of potable water systems serving hematopoietic stem cell transplant or solid organ transplant patients, surveillance for the presence of Legionella is to continue at intervals not to exceed 90 days. Actions and specific time frames for such actions in response to Legionella culture analysis results are required by Appendix 4-B of the regulation. Concurrent with subpart (b) of this section, the department may require further sampling in a timeframe to be determined.
All Legionella culture analyses must be performed by a laboratory that is approved to perform such analysis by the New York State Environmental Laboratory Approval Program (ELAP) (section §4-2.4).
The owner is responsible for full implementation of the SMP. The owner or owner’s representative must update the SMP as required by section §4-2.4. A covered facility must maintain the environmental assessment, SMP required by section §4-2.4 and any associated sampling results, on the facility premises for at least three years. Fee’s may incur if Gotham is needed to provide training or assistance with SMP upkeep or updates. The SMP is to be used as a tool and guide for members of the management and maintenance team.
A violation of any provision of Subpart 4-2 is subject to all civil and criminal penalties as provided for by law. Each day that an owner remains in violation of any provision of Subpart 4-2 shall constitute a separate and distinct violation of each such provision. Under no circumstance will Gotham Refining Chemical Corporation be held responsible for any fines or penalties levied by any Federal, State, or Local government or their agencies.