Set your facility up for success when Joint Commission surveyors come to check on your water management program. January 1, 2022 marked the start day for the new water management standard: EC.02.05.02.  Joint Commission surveyors will be looking for additional requirements and evidence in relation to water management programs for hospitals, critical access hospitals and nursing care centers.

Water Management Program Process


The new elements of performance require that an individual or team be responsible for the oversight and implementation of the water management program, including but not limited to:

  1. Water management plan development

  2. Execution of the water management plan

  3. Fulfillment and thorough documentation of maintenance activities


The water management program must include a basic diagram that maps water supply sources, treatment systems, processing steps, control measures, and end-use points.

Note: An example of end-use points would be a flow chart with symbols showing sinks, showers, water fountains, ice machines, etc.

The water risk management plan is based on the information in the diagram and includes an evaluation of the physical and chemical conditions of each step of the water flow diagram. TJC also requires an annual review of the water management program and an additional review when any changes have occurred to the water system such as commissioning or construction of new wings or buildings. 

The Joint Commission refers its accredited health care facilities and hospitals to:

  1. ASHRAE 188
  2. The CDC Toolkit
  3. CMS Mandate
  4. CTI GDL-159

Water Management Programs – including Water Management Plans – are required in order to achieve and maintain Joint Commission Accreditation.  

During surveys, The Joint Commission surveyors look for evidence of compliance with the following key elements:

  • Facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system or equipment that contain or use water

  • Water management program that considers ASHRAE, CMS, CTI GDL-159 and the CDC toolkit Developing a water management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards 

  • Testing protocols and acceptable ranges for control measures, with results of testing and corrective actions taken, or to be taken, when control limits are not maintained. If testing is not completed, a narrative to explain the verification and validation of the water management program should be provided.

Water Management Plan App

These elements must be thoroughly documented and your data should be readily available for the surveyor’s analysis.  Record keeping should be a new key focus of your water management program and is crucial now during the Joint Commission surveyor’s visit.  IWC Innovations provides the Smart Plan App to assist in the creation of your water management plan.  IWC Innovations supports the detailed digital record keeping and documentation of completion of the crucial steps in your water management plan. 


The experts at IWC Innovations that develop defensible water management plans and programs all across the country are ready to help you and your facility keep your Joint Commission accreditation or help you obtain that certification.  IWC Innovations offers The Joint Commission Standard EC.02.05.02 aligned Water Management Programs and Plans.  Our experts will guide you through creating and updating a proper water management program with proper documentation, verification and validation for your healthcare facility.

 The Joint Commission Accredidation


Will your team be ready when the surveyors come to your facility?  Contact IWC’s experts with questions or to receive a quote.