Sec. 4-2.4. Sampling and management plan

(a) By December 1, 2016, all covered facilities shall adopt and implement a Legionella culture sampling and management plan for their potable water systems. New covered facilities shall adopt such a plan prior to providing services. The sampling and management plan must include at a minimum:

(1) Legionella culture sampling sites as determined by the environmental assessment;

(2) provisions requiring Legionella culture sampling and analysis at intervals not to exceed 90 days for the first year following adoption of the sampling and management plan. Thereafter, the plan shall include provisions for annual Legionella culture sampling and analysis; provided that the plan shall further require that those portions of any potable water system that serve hematopoietic stem cell transplant or solid organ transplant patients shall continue to be sampled and analyzed at intervals not to exceed 90 days;

(3) provisions requiring actions in response to Legionella culture analysis results, including all responsive actions required by Appendix 4-B of this Title, and specific time frames for such actions.

(b) In addition to the sampling required by the facility’s sampling and management plan, a covered facility shall conduct Legionella culture sampling and analysis of the potable water system in a timeframe to be determined by the department upon:

(1) a determination by the department that one or more cases of legionellosis are, or may be, associated with the facility; or

(2) any other conditions specified by the department.

(c) A covered facility shall review its sampling and management plan annually and under the following conditions:

(1) in the event that one or more cases of legionellosis are, or may be, associated with the facility;

(2) upon completion of any construction, modification, or repair activities that may affect the potable water system;

(3) upon expansion or relocation of a facility’s hematopoietic stem cell transplant and solid organ transplant units; or

(4) any other conditions specified by the department.

(d) A copy of the sampling and management plan and sampling results shall be retained in accordance with section 4-2.6 of this Subpart.