Joint Commission Announces New Water Management Program Requirements

Joint Commission Announces New Water Management Program Requirements

Is your hospital or healthcare facility due for a Joint Commission survey in 2021 or 2022?  Whether your next survey is due next quarter or next year, there are some important changes you need to know about now.

  • Water Management Programs – including Water Management Plans – are required in order to achieve Joint Commission Accreditation, effective January 1, 2022.
  • Joint Commission has resumed on-site, unannounced visits as of March, 2021.

You already know the importance of Joint Commission Accreditation: it’s critical for continued CMS reimbursement and your budget, and it’s integral to public perception. It’s also beneficial across a host of other operational and regulatory functions, including enhancing staff recruitment and retention, reducing liability insurance costs, improving risk management and in some states, fulfilling regulatory requirements.

You also know the preparations that go into a successful Joint Commission survey are lengthy, detailed and require the expertise and resources that sweeps across nearly the entire spectrum of your organization, from pharmacy to emergency department to human resources.

New this year, Joint Commission has announced it will require facilities to have Water Management Programs, including Water Management Plans, as part of successful accreditation. Oh, and yes, unannounced, on-site visits of most healthcare organizations. The good news is that Joint Commission is not enforcing the Water Management Program requirement until January 1, 2022, which means you have time to review your existing WMP, or develop a new one if you don’t already have one.

What do you need to know about the new WMP requirement? We did the work fo you.

  1. Joint Commission’s requirement for a Water Management Program applies to critical access hospitals, hospitals and nursing care centers.
  2. Your Water Management Program must include the actions Joint Commission currently requires for EC.02.05.01, Eps 6 and 14, plus a new list of requirements. The current requirements are:
  3. Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread.
  4. Develop a water management plan.
  5. Specify testing protocils and acceptable ranges for control measures.
  6. Document results of testing and any corrective actions.
  7. Maintain compliance with law and regulation.
  8. The new requirements will include both the current expectations listed above, and additional processes such as:
  9. Assign responsibility and oversight for the water management program.
  10. Identify water supply sources, treatment systems, and other areas using a basic diagram.
  11. Evaluate patient populations to identify those who are immunocompromised.

Wondering if your current Water Management Plan is comprehensive? Need assistance in preparing the various components of a successful Water Management Program? Our experts can make this part of the Joint Commission process efficient and stress-free. Contact us at

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