Sampling and Management Plan for Healthcare Facilities ...
left2362200Sampling and Management Plan for Healthcare Facilities: Guidance and TemplateVersion: 1.0New York State Department of HealthBureau of Water Supply Protection035000Sampling and Management Plan for Healthcare Facilities: Guidance and TemplateVersion: 1.0New York State Department of HealthBureau of Water Supply Protection02362200Sampling and Management Plan for Healthcare Facilities: Guidance and TemplatePrepared for:Prepared by:Effective Date: 035000Sampling and Management Plan for Healthcare Facilities: Guidance and TemplatePrepared for:Prepared by:Effective Date: Contents TOC \o "1-3" \h \z \u SECTION 1.Facility Information PAGEREF _Toc483390274 \h 31.1Hospital Location PAGEREF _Toc483390275 \h 31.2Point of Contact PAGEREF _Toc483390276 \h 31.3Developer of Sampling and Management Plan PAGEREF _Toc483390277 \h 31.3.1Point of contact PAGEREF _Toc483390278 \h 31.3.2Address of Company PAGEREF _Toc483390279 \h 31.4Effective Date of Sampling and Management Plan PAGEREF _Toc483390280 \h 31.5Hospital or Facility Information PAGEREF _Toc483390281 \h 4SECTION 2.Personnel Roles and Responsibilities PAGEREF _Toc483390282 \h 52.1SMP Team Members PAGEREF _Toc483390283 \h 52.2SMP Team Functions PAGEREF _Toc483390284 \h 5SECTION 3.Building Water Systems Descriptions PAGEREF _Toc483390285 \h 63.1Potable Water Systems List PAGEREF _Toc483390286 \h 63.2Potable Water Systems Descriptions PAGEREF _Toc483390287 \h 6SECTION 4.Legionella Sampling Plan PAGEREF _Toc483390288 \h 64.1Non-Medical Equipment Sampling PAGEREF _Toc483390289 \h 64.2Infrastructure Equipment Sampling PAGEREF _Toc483390290 \h 7SECTION 5.Potable Water System Monitoring PAGEREF _Toc483390291 \h 7SECTION 6.Potable Water System Maintenance PAGEREF _Toc483390292 \h 76.1Hot Potable Water System Maintenance PAGEREF _Toc483390293 \h 76.2Cold Potable Water System Maintenance PAGEREF _Toc483390294 \h 7SECTION 7.Procedures for Responding to Sampling Exceedances PAGEREF _Toc483390295 \h 8SECTION 8.Procedures in Event of Nosocomial Illnesses PAGEREF _Toc483390296 \h 9References PAGEREF _Toc483390297 \h Error! Bookmark not defined.Facility InformationFacility LocationHospital nameStreet addressBuilding name (if applicable)City, Town or VillageCountyZIP codeLatitude-Longitude (if available)Point of ContactNameTitlePhone numberEmail addressDeveloper of Sampling and Management PlanPoint of contact Point of contact nameTitlePhone numberMobile phone numberEmail addressAddress of CompanyCompany nameAddress 1Address 2City, State, ZIP codePhone numberWebsite (if available)Effective Date of Sampling and Management PlanBeginning date of SMPEnding date SMPFacility InformationHow many potable cold water systems are in the facility?How many potable hot water systems are in the facility?What is the source(s) of potable water provided to the facility?Are there any water reuse systems in the facility?Personnel Roles and ResponsibilitiesSMP Team MembersNameTitleEmployer or company (outside contractor)AddressTelephoneEmail addressSMP Team FunctionsFunctionIndividual chargedMaintenance program administratorPhysical facilities managementEngineeringInfection ControlClinical representativeLaboratory contactExternal consultantBuilding Water Systems DescriptionsPotable Water Systems ListWater system designationLocation or portion of buildingPurposePotable Water Systems DescriptionsDescription:Legionella Sampling PlanSample location designatorSample typeCommentsNon-Medical Equipment SamplingEquipmentWater typeSampling procedure and scheduleInfrastructure Equipment SamplingInfrastructure itemPotential for contactSampling procedure and schedule(excluding cooling towers)Potable Water System MonitoringControl pointMaximum, minimum or rangeValueFrequency monitoredCorrective actionPotable Water System MaintenanceHot Potable Water System MaintenanceSystem componentProcedures/actionCold Potable Water System MaintenanceSystem componentProcedure/actionProcedures for Responding to Sampling ExceedancesDecision algorithm for Legionella sampling resultsProcedure designatorDescription of procedure/activity123Procedures in Event of Nosocomial IllnessesProcedure designatorProcedure/activity123 ................
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