Healthcare facilities must meet myriad requirements to operate safely and maintain an accredited status. When it comes to hospital piping infrastructure, what do these requirements entail? The Joint Commission requires the implementation and maintenance of a water management program for potable water systems, pipe labeling (among other things) for medical gas and vacuum systems, and documentation and maintenance of fire protection systems.
Note: While the Joint Commission is not the only accrediting body for healthcare facilities, it has significant authority in setting standards for hospitals—even those they do not accredit.
Protect + Prevent
Legionella Contamination in Healthcare Facilities
Water Management Programs
Our first area of business: potable water. When it comes to potable water, many regulatory and accreditation bodies—including CMS—point back to the same thing: a water management program in line with ASHRAE Standard 188. The Joint Commission accreditation requirements take a similar route.
Hospitals need to maintain a water management program to address the inherent risks of Legionella and other waterborne pathogens. Dead legs, stagnant water, and backflow can all cause contamination and put patients at risk. According to CDC review, approximately 20% of Legionella cases originate in and/or are associated with healthcare facilities, underscoring the need for effective and proactive water management.
Under PE.04.01.05, the Joint Commission requires hospitals to:
- Designate an individual or team to oversee water program management
- Create water flow diagrams
- Develop a water risk management plan that includes an evaluation of physical and chemical hazards and conditions
- Develop a plan to address water use in areas or buildings at risk of stagnant water
- Evaluate patient populations to determine those at higher risk or immunocompromised
- Establish monitoring protocols and control measures
- Document program activities and corrective actions
- Review the program annually and when changes to the system occur
Facility managers need to answer critical questions about how they’ll develop the plan, gather information about the existing potable water piping system, and create flow diagrams. A whole-system survey helps you get a better understanding of the current state—from pipe labels to valve locations to hazards like dead legs and cross-connections.
Some hospitals go beyond flow diagrams to develop comprehensive piping schematics, which provide an even deeper understanding of the pipes, valves, backflow preventers, and points of use. Building this depth of knowledge can also drive safer operations, better emergency response, and improved maintenance in alignment with accreditation requirements.
Pipe Labeling
Under PE.04.01.01, the Joint Commission requires hospitals to comply with NFPA 99-2012 standards for pipe labeling on medical gas and vacuum piping systems. These labeling standards are rigorous and require upkeep, maintenance, and verification.
NFPA 99 requires medical gas and vacuum piping to be clearly identified by stencil or adhesive marker. Additionally, these systems must be labeled with:
- Identification including the system name or chemical symbol
- Proper color-coding
- Operating pressure (when the system operates at a non-standard pressure)
Hospitals must install pipe labels no more than 20 feet apart, on both sides of wall penetrations, and in every room through which piping passes. NFPA 99 also requires healthcare facilities to label shut-off valves with the specific system and area they affect.
Fire Protection Systems
Finally, PE.03.01.01 requires current, accurate drawings of fire safety features and related square footage within a healthcare facility. Hospitals need to keep detailed records of fire protection system design, maintenance, inspection, and testing. While the requirements don’t include tracing fire protection system piping specifically, piping schematics can be helpful for effectively managing and maintaining these systems in compliance with Joint Commission and NFPA standards.
Additionally, Joint Commission requirements point to NFPA 101-2012 and NFPA 25-2011 for life safety system requirements and water-based fire system inspection, testing, and maintenance (ITM). Critically, NFPA 25 also requires weekly inspection and annual testing of sprinkler system backflow prevention assemblies.
Ready to learn more about how HydroCorp can support safer operations and compliance with piping system surveys, schematics, and water management programs?
