Protection Against Legionella: Residential and Health Care Facility Requirements

All general hospitals and residential health care facilities in New York State are required to perform an Environmental Assessment, prepare and implement a Sampling and Management Plan to sample their potable water systems for Legionella, and institute control measures in the event of a Legionella exceedance. 

Resources for hospital and residential health care facilities are provided below. Please refer to Protection Against Legionella: Subpart 4-2 for a full listing of regulatory requirements.

Covered (Article 28) Facilities

In accordance with the definitions of Covered Article 28 Facilities, Subpart 4-2 applies to buildings of general hospitals that provide in-patient services or buildings of residential healthcare facilities that provide a “health related service,” such as lodging, board and physical care. The regulation does not apply to administrative buildings of such facilities, general hospital buildings that only provide out-patient services, or to diagnostic and treatment centers providing only out-patient services.

Environmental Assessment

All covered facilities must perform an Environmental Assessment of the facility using the Environmental Assessment Form 5222 prior to providing services, and when specified by the NYS Department of Health, such as when there are suspected or actual cases of legionellosis, after certain construction and repairs, and after expansion and relocation of certain medical units (Subpart 4-2.3).

Sampling and Management Plan

All covered facilities must adopt and implement a Legionella culture Sampling and Management Plan for their potable water systems (Subpart 4-2.4). You may use this template.

New covered facilities must adopt this plan prior to providing services. Culture sampling and analysis must occur at 90-day intervals during the first year of Sampling and Management Plan implementation. Additional guidance for sampling and water system management can be found in these documents:

Legionella Culture Analysis

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, Subpart 4-2.5). Please contact ELAP@health.ny.gov or call (518) 485-5570 to find a certified laboratory.

Exceedances

When 30% or more of Legionella culture samples contain Legionella, regardless of species, facilities are required to institute control measures, resample their water system and notify the NYS Department of Health as described in Appendix 4-B.

Variances and Waivers

A facility may submit a written application to the NYS Department of Health for a variance or waiver from any provision of Subpart 4.2, accompanied by an explanation of why such variance or waiver will not present a danger to public health (Subpart 4-2.8).

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