Healthcare Water Management Plan Development

Reviewed by Phenelle Segal, RN, CIC, FAPIC — Founder, Infection Control Consulting Services (40+ years in infection prevention and control)

Water management in healthcare is a regulatory and patient safety obligation — and the requirements have grown more rigorous in recent years. ICCS develops facility-specific water management plans for healthcare organizations across the United States, covering both AAMI ST108 reprocessing water requirements and Legionella building water management under CMS and accreditation body standards. Whether your facility needs to address reprocessing water quality, building water safety, or both, ICCS brings the infection prevention expertise to develop a program that is accurate, defensible, and built for your specific environment.

Request a consultation to discuss water management plan development for your facility. Contact ICCS.

Why Water Management Plans Matter

Healthcare facilities face two distinct but related water management obligations, each governed by its own regulatory framework. Understanding the difference — and ensuring your facility has a program that addresses whichever applies — is essential for accreditation compliance and patient safety.

Reprocessing Water: AAMI ST108

ANSI/AAMI ST108:2023 represents the current nationally recognized consensus standard for water quality in medical device processing — covering cleaning, rinsing, disinfection, and sterilization of surgical instruments and other reusable devices. It replaced AAMI TIR34, which was guidance only. Accreditation bodies including the Joint Commission (via EC.02.05.02) and AAAHC are increasingly referencing ST108, and surveyors are asking organizations to demonstrate how water quality risks are assessed and managed during surveys.

For any facility that reprocesses reusable medical devices, developing a formal water management plan aligned with ST108 is an increasingly important step toward demonstrating compliance. Poor reprocessing water quality — the wrong water type, inadequate monitoring, or no corrective action framework — can compromise sterilization, damage instruments, and create direct patient safety risk.

While CMS and accrediting organizations do not specifically mandate compliance with ANSI/AAMI ST108, facilities should be prepared to demonstrate that their approach to water quality management is based on nationally recognized guidance, accepted standards of practice, manufacturer instructions for use (IFUs), and a documented risk assessment.

Building Water: Legionella and CMS Requirements

Separately, CMS requires hospitals, critical access hospitals, and long-term care facilities to have water management programs that address Legionella and other waterborne pathogens in building water systems. This requirement flows from the CMS Conditions of Participation and aligns with ASHRAE Standard 188 and the CDC Legionella toolkit.

Legionella thrives in complex building water systems — hot water distribution, cooling towers, ice machines, decorative fountains — and healthcare patients are among the most vulnerable populations. A Legionella water management plan is not a reprocessing document; it is a building safety program. For many facilities, both programs are required and must be maintained separately.

How ICCS Supports Water Management Plan Development

ICCS approaches water management plan development the way we approach all infection prevention work: facility-specific, evidence-based, and grounded in the regulatory environment your organization actually operates in. Every program we develop is built around your facility's specific water systems, workflows, and accreditation requirements.

The programs we develop are active with healthcare facilities across the country. That current, hands-on experience — working through the practical realities of ST108 implementation in ambulatory surgery centers, building water program development for hospitals and long-term care facilities — directly informs what we produce for every client.

Water management is an infection prevention responsibility. Infection prevention plays an important role in program oversight, risk assessment, and ongoing review as part of the multidisciplinary team — alongside sterile processing, facilities and engineering, and leadership. ICCS brings that infection prevention lens to every engagement. It is what differentiates our work from a water treatment vendor and better ensures your program is built to withstand scrutiny from an infection control or accreditation standpoint.

ICCS water management plan services include:

• Facility-specific risk assessment aligned with ST108 or ASHRAE 188 frameworks

• Development of complete, written water management programs

• Water quality classification frameworks for reprocessing (utility water, critical water, steam)

• Monitoring and sampling plans with defined frequencies, test points, and acceptance criteria

• Corrective action and preventive maintenance protocols

• Cross-functional responsibility assignment across infection prevention, sterile processing, facilities, and leadership

• Staff training and competency documentation guidance

• Annual review support and program updates

• Alignment with accreditation survey expectations across the Joint Commission, AAAHC, other accreditation organizations, CMS, and applicable state requirements

Two Programs, One Infection Prevention Partner

The table below summarizes the two water management programs ICCS develops and the healthcare settings each applies to.

AAMI ST108 Water Management Plan

Required for facilities that reprocess reusable medical devices

• Ambulatory surgery centers (ASCs)

• Hospitals and critical access hospitals

• Outpatient and imaging centers

Standards: ANSI/AAMI ST108:2023, TJC EC.02.05.02

Facilities We Serve

ICCS develops water management plans for healthcare organizations across facility types. Water management requirements vary by setting — reprocessing obligations, building water complexity, accreditation body, and applicable state regulations all differ. ICCS works within the specific regulatory context of your facility.

• Ambulatory surgery centers — AAMI ST108 water management plans for reprocessing; state-specific requirements where applicable

• Hospitals and critical access hospitals — Both ST108 reprocessing water and Legionella building water programs; Joint Commission, CMS, and state requirements

• Long-term care facilities — Legionella building water management under CMS Conditions of Participation

• Outpatient and imaging centers — ST108 reprocessing water programs where device reprocessing occurs

• Federally qualified health centers — Reprocessing water management aligned with CMS and accreditation requirements

• Dentistry and oral surgery practices — ST108 reprocessing water management where reusable instruments are processed

• Physician practices — ST108 reprocessing water management where reusable medical devices are processed

Ready to get started? Contact ICCS to discuss your facility's water management needs.

Frequently Asked Questions About Water Management Plans

What is the difference between an AAMI ST108 water management plan and a Legionella water management plan?

These are two distinct programs addressing different water systems and different risks. An AAMI ST108 water management plan governs the quality of water used in medical device reprocessing — the water that contacts surgical instruments during cleaning, rinsing, and sterilization. A Legionella water management plan addresses building water systems — hot water distribution, cooling towers, and other sources where Legionella can grow and be transmitted to patients through aerosolization. Many healthcare facilities need both, but they are separate programs with separate regulatory drivers.

Does AAMI ST108 apply to our facility if we only perform a small number of procedures?

ST108 applies to any facility that reprocesses reusable medical devices using water, regardless of procedure volume or facility size. A smaller ambulatory surgery center or outpatient facility has the same obligation to ensure reprocessing water quality as a large hospital sterile processing department. The risk-based approach in ST108 means the program is scaled to your system's complexity, but a formal, documented program is required.

What does a water management plan actually include?

A complete water management plan under AAMI ST108 includes a facility risk assessment, water quality classifications tied to each reprocessing step, defined acceptance criteria aligned with device manufacturer IFUs, a monitoring and sampling framework, corrective action protocols, preventive maintenance requirements, cross-functional responsibility assignments, and staff training documentation. For Legionella programs, the plan addresses building water system mapping, control measures, temperature management, disinfectant monitoring, and environmental testing protocols. ICCS develops both as complete, facility-specific programs.

How does ICCS deliver water management plan development — remotely or on-site?

ICCS delivers water management plan development services primarily remotely, which allows us to work efficiently with facilities across the U.S. Depending on the complexity of your water systems and the scope of work, on-site assessment may also be part of the engagement. Contact ICCS to discuss the approach that best fits your facility's needs.

Is there a compliance deadline for AAMI ST108?

There is no single hard compliance deadline for ST108, but the standard has been in effect since August 2023 and accreditation bodies are already using it as a benchmark during surveys. Facilities that do not have a formal water management plan in place are carrying real compliance risk at every survey cycle. The right time to address this is before a surveyor raises the issue.

Request a Water Management Plan Consultation

Complete the form below to request a consultation. An ICCS representative will follow up to discuss your facility's water management needs. If your matter is time-sensitive, contact ICCS directly.