Updating Your WMP per New York Regulations

First of all, be sure to check the New York State and New York City regulations thoroughly to ensure full compliance rather than relying on HC Info to interpret the laws and include required measures within LAMPS.

If you set up your WMP prior to April 20, 2016, here are some suggestions for updating it per the NYCDOHMH Title 24 Chapter 8 rules:

In the Configuration section of your WMP:

Step 1, #3: Add additional team member information in the "Team Member Notes" per the last paragraph of the instructions.

Step 1, #4: Add the required cooling tower details to the utility flow diagram or in a new diagram. See the instructions in the second paragraph.

Step 2, #7: Fill in the fields added to the cooling tower section. Also enter the additional information in the comments box.

Step 2, #8: A second paragraph was added to the Overview section under “organization." Click on the default to copy that paragraph and paste it in. Or, just replace the entire overview section.

Step 2, #9: Changes were made to the Management section. Click on the default to update your plan.

Step 3, CT measures: Update the cooling tower control measures:

a. Add control measure CT17. If you don't see it in your active control measures, click on "Hidden" and "Control Measures Added Since You Set-up Your Plan." Also note that a form for the risk assessment has been added to the documentation section: "Download Cooling Tower System Risk Assessment".

b. Click on the button by "Control Measures Added Since You Set-up Your Plan" to see any other cooling tower control measures HC Info has added to the application since your WMP was set up. Add whatever measures apply to the facility.

c. For each cooling tower control measure, compare the date in the Control Measure, Monitoring, Limits, and Corrective Action fields with the bracketed date in the HC Info default. If the default has a later date, then update the field entry with the default text as applicable. Also check the control measure frequency and update if applicable. It would be best to check all your cooling tower control measures. Be sure to at least update the following: CT01, CT03, CT04, CT07, CT09, CT10, CT11, CT13, CT14, CT15

Documentation Section:

As mentioned, a new form "Cooling Tower System Risk Assessment" has been added in Word and PDF.

The cooling tower inspection form has also been updated.

If you set up your WMP after April 20, 2016 and prior to August 30, 2016, here are some suggestions for updating it per the NYSDOH regulations effective July 6, 2016:

Update the Validation portion of “Confirmation” in Step 2, #10, per the new default. We made the following changes:

  • Added requirement that the laboratory performing Legionella analysis is approved by the New York State Environmental Laboratory Approval Program (ELAP) per 4-1.5 and 4-2.5. 
  • Added notifications for Legionella test results ≥ 1000 CFU/mL per -1.6.
  • Updated the response to cooling tower Legionella results of 100-1000 CFU/mL or > 1000 CFU/mL regarding the use of halogens.
  • Added measures in response to Legionella positivity exceeding 30%, per Appendix 4-B.
  • Added some sampling program details per 4-2.4.

Update the following control measures per the new defaults:

  • CT01: Changed the limits to require circulating biocides at least once every 3 days (was 7 days), to be consistent with the new requirement per 4-1.4 to disinfect a cooling tower that has been shut down without treatment for more than five days (covered in CT13).
  • CT09: Updated the limits box regarding new disinfection requirements in 4-1.7.
  • CT10: Updated the monitoring, limits, and corrective action boxes to cover the requirement for sampling within two weeks after start-up per 4-1.4 and the new disinfection requirements in 4-1.7.
  • CT12: Updated the limits box regarding new disinfection requirements in 4-1.7.
  • CT13: Updated the limits box regarding new disinfection requirements in 4-1.7 and the control measure and limits boxes regarding permanently shut down cooling towers per 4-1.4.
  • CT14: Updated the monitoring and limits boxes regarding certification required by November 1st each year per 4-1.8.
  • CT15: Updated the control measure and limits boxes to include inspection prior to start-up per 4-1.8.

We also added the NYSDOH environmental assessment form required for hospitals and residential health care facilities in New York State per 4-2.3. The site survey forms you download in Step 1, #5 now include a reminder about the NYSDOH environmental assessment form, in case it applies to the facility you’re surveying. To download the NYSDOH "Environmental Assessment of Water Systems in Healthcare Settings" form, go to the WMP Documentation section and click the applicable link under "Regulation-Related Forms." After you complete the assessment and fill in the form, you can upload it to your WMP documents in that same section.

If you set up your WMP after August 30, 2016 and prior to October 4, 2016, here are some additional updates:

  • Step 1, #3: See if you have described your team member roles per the additional instructions for comments in the Team Members section.
  • Step 1, #4: Check your cooling tower schematic to be sure it identifies all that is bullet listed in flow diagram instructions.
  • Step 2, #8: Update the WMP Overview. A "COMMUNICATION AND NOTIFICATION" section has been added at the end, below "Strategy." (If you made no changes to the Overview, you may already see the communication section in your WMP.)
  • Update the following control measures per the new defaults:
    • CT04: Monitoring and limits were updated.
    • CT09: The Limits were updated (minor change).
    • CT10: The Limits were updated (minor change). Also, see the tip for CT10 regarding information to enter in the comments and documentation boxes.
    • DC09: The Limits and Corrective action were updated.
  • Go to WMP Documentation > WMP Auditing and Regulatory Reporting, and click on "Suggestions for regulatory reporting preparation." Follow the instructions, using the New York City and State forms.

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