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["Facility Details"]
["Facility Name"]
["Facility Address"]
["Facility Description"]
["(including key buildings and tenancies)"]
["Average Number of Facility Users per Day"]
["Number of Beds"]
["Auditing Officer ",null,"Inspection Date"]
["Auditing Agency",null,"Reference / Record Number"]
["Site Contact ",null,"Site Contact Telephone Number"]
["Water Treatment Provider Contact",null,"Water Treatment Provider Contact Number"]
["Water Sampling Contact",null,"Water Sampling Contact Number"]
["Other Comments"]
[]
["Water System Details "]
["Uses of Water"]
["Uses of Water (Cross Out Those That Don’t Apply)","Drinking, Food Preparation, Bottled Water Coolers/Dispensers, Drinking Fountains, Ice Machines, Spa Pools, Birthing Pools, Bathing Suites, Showering, Fire Fighting, Garden Watering, Water Features (Aerosolised), Showers Safety/Eyewash Stations, Washdown, Misting Systems, Other (Please Specify)"]
["Potable Water Supply"]
["Water Source "]
["Primary Water Supply Entry Points to Facility "]
["Emergency Supply  (e.g. Tankering Supply Point)"]
["Key Potable Water System Components (Locations and Characteristics)"]
["Cold Water Storages"]
["Centralised Water Treatment "]
["Hot Water Systems "]
["Warm Water Systems"]
["Backflow Prevention Devices"]
["Known Deadlegs"]
["Thermostatic Mixing Valves"]
["Point of Use Filtration Devices "]
["Drinking Fountains "]
["Bottled Water Coolers/Dispensers"]
["Ice Machines"]
["Emergency Safety Showers/Eyewash Stations  "]
["Other Comments "]
["Key Non Potable Water System Components (Locations and Characteristics)"]
["Garden Watering System "]
["Fire Water System"]
["Spa Pools"]
["Water Features / Misting Systems"]
["Other Comments "]
[]
["Air Handling and Cooling Tower System Details"]
["Number of Cooling Towers"]
["Cooling Tower IDs ","LegID003, LegID004, LegID005"]
["Tower Location References"]
["Build Date (if Known)"]
["Other Evaporative Cooling Systems"]
["Other Comments "]

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["Legionella Risk Management Plan Checklist – Facility Name"]
["Criteria",null,null,"Scoring ",null,"Comment ","Recommendation(s) for Improvement "]
["Item","Section","Description","Finding","Score"]
["Guidelines for Legionella Control in the operation and maintenance of water distribution systems in health and aged care facilities",null,null,null,null,null,null,"NA",0,1,2,3]
["Establishing a Legionella Risk Management System",1.1000000000000001,"Has a multi-discipline risk management team been assembled which includes representation from the facility's operational, clinical and engineering business units? ","No stakeholders identified / Stakeholders unknown",{"$f":"IF(D5=H5,$H$4,IF(D5=I5,$I$4,IF(D5=J5,$J$4,IF(D5=K5,$K$4,IF(D5=L5,$L$4)))))","v":0},null,null,{"$f":"'Score Guide'!D6","v":"N/A"},{"$f":"'Score Guide'!E6","v":"No stakeholders identified / Stakeholders unknown"},{"$f":"'Score Guide'!F6","v":"Stakeholders identified in plan without supporting information / anecdotally known"},{"$f":"'Score Guide'!G6","v":"Stakeholders identified in plan with role, responsibilities, skills, experience ect. (ideally in tabular format) "},{"$f":"'Score Guide'!H6","v":"Stakeholders identified with role, responsibilities, skills, experience ect., and  additional commitment and evidence of regular engagement / discussions amongst stakeholders (eg. regular meeting minutes)"}]
[null,1.2,"Has a risk management plan been established in line with the national risk management plan template?","No plan in place",0,null,null,{"$f":"'Score Guide'!D7","v":"N/A"},{"$f":"'Score Guide'!E7","v":"No plan in place"},{"$f":"'Score Guide'!F7","v":"Somewhat completed plan (approx. 33%) in line with Enhealth framework or equivalent"},{"$f":"'Score Guide'!G7","v":"Almost completed plan (approx. 66%) management plan in line with Enhealth framework or equivalent"},{"$f":"'Score Guide'!H7","v":"Fully completed management plan (100%) in line with Enhealth framework or equivalent"}]
[null,1.2,"Is the risk management plan up to date (e.g reflective of current stakeholders, practices and infrastructure, and within document review period)?","N/A","NA",null,null,{"$f":"'Score Guide'!D8","v":"N/A"},{"$f":"'Score Guide'!E8","v":"No plan in place"},{"$f":"'Score Guide'!F8","v":"Plan out of date (> 1 year, significant differences between plan and infrastructure in place)"},{"$f":"'Score Guide'!G8","v":"Plan slightly out of date (< 1 year or currently under review, minor differences between plan and infrastructure in place)"},{"$f":"'Score Guide'!H8","v":"Plan up to date and within review period, contents of plan aligns with infrastructure in place"}]
["Analysing Risk",2.1,"Have flow diagrams, schematics or layouts been developed which illustrate the entire water distribution system?","No diagrams in place",0,null,null,{"$f":"'Score Guide'!D9","v":"N/A"},{"$f":"'Score Guide'!E9","v":"No diagrams in place"},{"$f":"'Score Guide'!F9","v":"Diagrams in place though only show some infrastructure (e.g. heated water systems, or cooling systems) and significant details out of date or missing "},{"$f":"'Score Guide'!G9","v":"Diagram in place which shows overall water system though minor details out of date or missing"},{"$f":"'Score Guide'!H9","v":"Diagram in place which shows overall water system with infrastructure up to date and all key components shown"}]
[null,"2.1.1","Is there a description of the water distribution system which covers the entire process from where water enters the facility through to its final uses?  ","No system description",0,null,null,{"$f":"'Score Guide'!D10","v":"N/A"},{"$f":"'Score Guide'!E10","v":"No system description"},{"$f":"'Score Guide'!F10","v":"Very basic system description / significant number of components missing"},{"$f":"'Score Guide'!G10","v":"General system description, though minor number of components missing"},{"$f":"'Score Guide'!H10","v":"General system description covering all system components"},null,null,null,"                                        "]
[null,"2.1.1","Is the system description supported by an asset register which includes details of all components of the water system from source to its final uses?","No asset register",0,null,null,{"$f":"'Score Guide'!D11","v":"N/A"},{"$f":"'Score Guide'!E11","v":"No asset register"},{"$f":"'Score Guide'!F11","v":"Somewhat completed (approx. 33%)"},{"$f":"'Score Guide'!G11","v":"Mostly completed (approx. 66%)"},{"$f":"'Score Guide'!H11","v":"Fully completed"}]
[null,"2.1.2","Have areas of higher risk of infection to patients, residents and / or staff been identified? ","No locations identified",0,null,null,{"$f":"'Score Guide'!D12","v":"N/A"},{"$f":"'Score Guide'!E12","v":"No locations identified"},{"$f":"'Score Guide'!F12","v":"Locations identified, managed ad-hoc and not referenced in management plan"},{"$f":"'Score Guide'!G12","v":"Locations identified, partial integration into management plan"},{"$f":"'Score Guide'!H12","v":"Locations identified and fully integrated into management plan"}]
[null,2.2000000000000002,"Has a qualitative risk assessment, using an appropriate risk analysis matrix, been undertaken for the system?","No risk assessment complete",0,null,null,{"$f":"'Score Guide'!D13","v":"N/A"},{"$f":"'Score Guide'!E13","v":"No risk assessment complete"},{"$f":"'Score Guide'!F13","v":"Risk assessment done without use of a risk analysis matrix"},{"$f":"'Score Guide'!G13","v":"Risk assessment in place with inappropriate risk matrix"},{"$f":"'Score Guide'!H13","v":"Risk assessment in place with appropriate risk matrix"}]
[null,"2.2.1","Does the risk assessment identify potential hazardous events, and risk level based on consequence / likelihood of each hazardous event?","Not in place",0,null,null,{"$f":"'Score Guide'!D14","v":"N/A"},{"$f":"'Score Guide'!E14","v":"Not in place"},{"$f":"'Score Guide'!F14","v":"Risk assessment only identifies hazardous events, though not risk level  of such hazardous event "},{"$f":"'Score Guide'!G14","v":"Risk assessment identifies hazardous events though consequence/likelihood missing and / or does not include risk level before and after controls"},{"$f":"'Score Guide'!H14","v":"Risk assessment identifies hazardous events and associated consequence/likelihood and risk level, with and without controls"}]
[null,"2.2.2-3","Does the risk assessment analyse all system components including incoming water quality, plumbing systems, cold and heated water systems and other as required equipment and installations?","No risk assessment in place ",0,null,null,{"$f":"'Score Guide'!D15","v":"N/A"},{"$f":"'Score Guide'!E15","v":"No risk assessment in place "},{"$f":"'Score Guide'!F15","v":"Risk assessment missing significant amount of system components"},{"$f":"'Score Guide'!G15","v":"Risk assessment includes most system components"},{"$f":"'Score Guide'!H15","v":"Risk assessment includes all system components"}]
[null,"2.2.4","Does the risk assessment analyse how personnel in areas at higher risk of infection (as per item 2.1.2) might be exposed?","Risk assessment, highlights exposure pathways, applicable areas of concern and associated  level of risk",3,null,null,{"$f":"'Score Guide'!D16","v":"N/A"},{"$f":"'Score Guide'!E16","v":"Not in place"},{"$f":"'Score Guide'!F16","v":"Partial risk assessment complete (e.g. does not identify all applicable areas of concern or exposure pathways)"},{"$f":"'Score Guide'!G16","v":"Risk assessment highlights exposure pathways and applicable areas of concern though not associated level of risk"},{"$f":"'Score Guide'!H16","v":"Risk assessment, highlights exposure pathways, applicable areas of concern and associated  level of risk"}]
["Risk Management  ",3.1,"From the risk assessment have controls been identified which control identified risks to acceptable levels? ","Controls identified and integrated into management plan, with clear linkages between patient / resident and water risk assessments, and integration of additional controls required to address any high residual risks into an improvement plan",3,null,null,{"$f":"'Score Guide'!D17","v":"N/A"},{"$f":"'Score Guide'!E17","v":"Not in place"},{"$f":"'Score Guide'!F17","v":"Anecdotal evidence of controls in place (Note: this answer is also considered applicable to situations where risk assessment not in place)"},{"$f":"'Score Guide'!G17","v":"Controls identified and integrated into management plan\nConsideration has been given to additional controls required to address any ‘high’ residual risks"},{"$f":"'Score Guide'!H17","v":"Controls identified and integrated into management plan, with clear linkages between patient / resident and water risk assessments, and integration of additional controls required to address any high residual risks into an improvement plan"}]
[null,null,"Have minimum staff training requirements been identified (including frequency for renewal)?","Training requirements also specify frequency of renewal ",3,null,null,{"$f":"'Score Guide'!D18","v":"N/A"},{"$f":"'Score Guide'!E18","v":"No training requirements identified"},{"$f":"'Score Guide'!F18","v":"Ad hoc"},{"$f":"'Score Guide'!G18","v":"Training requirements in place (ideally highlighted by a training matrix)"},{"$f":"'Score Guide'!H18","v":"Training requirements also specify frequency of renewal "}]
[null,null,"Has a training program been implemented according to the identified minimum training requirements?","Partially",1,null,null,{"$f":"'Score Guide'!D19","v":"N/A"},{"$f":"'Score Guide'!E19","v":"No training program in place"},{"$f":"'Score Guide'!F19","v":"Partially"},{"$f":"'Score Guide'!G19","v":"Mostly"},{"$f":"'Score Guide'!H19","v":"Yes"}]
[null,"3.1.1","From the risk assessment have appropriate controls been identified for managing the incoming water supply used for the hospital?","N/A","NA",null,null,{"$f":"'Score Guide'!D20","v":"N/A"},{"$f":"'Score Guide'!E20","v":"Controls not identified"},{"$f":"'Score Guide'!F20","v":"Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit"},{"$f":"'Score Guide'!G20","v":"Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required"},{"$f":"'Score Guide'!H20","v":"Controls considered appropriate and can be generally verified through audit"}]
[null,"3.1.2","From the risk assessment has appropriate controls been identified for managing the plumbing system?","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required",2,null,null,{"$f":"'Score Guide'!D21","v":"N/A"},{"$f":"'Score Guide'!E21","v":"Controls not identified"},{"$f":"'Score Guide'!F21","v":"Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit"},{"$f":"'Score Guide'!G21","v":"Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required"},{"$f":"'Score Guide'!H21","v":"Controls considered appropriate and can be generally verified through audit"},"            "]
[null,"3.1.3","From the risk assessment has appropriate controls been identified for disinfection system(s)?","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required",2,null,null,{"$f":"'Score Guide'!D22","v":"N/A"},{"$f":"'Score Guide'!E22","v":"Controls not identified"},{"$f":"'Score Guide'!F22","v":"Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit"},{"$f":"'Score Guide'!G22","v":"Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required"},{"$f":"'Score Guide'!H22","v":"Controls considered appropriate and can be generally verified through audit"},"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ",null,null,"     "]
[null,"3.1.4","From the risk assessment have appropriate controls been identified for regular maintenance?","Controls considered appropriate and can be generally verified through audit",3,null,null,{"$f":"'Score Guide'!D23","v":"N/A"},{"$f":"'Score Guide'!E23","v":"Controls not identified"},{"$f":"'Score Guide'!F23","v":"Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit"},{"$f":"'Score Guide'!G23","v":"Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required"},{"$f":"'Score Guide'!H23","v":"Controls considered appropriate and can be generally verified through audit"},null,null,"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          "]
[null,"3.1.5","From the risk assessment have appropriate exposure controls been identified to reduce exposures to aerosols to personnel in areas at higher risk of infection?","Controls considered appropriate and can be generally verified through audit",3,null,null,{"$f":"'Score Guide'!D24","v":"N/A"},{"$f":"'Score Guide'!E24","v":"Controls not identified"},{"$f":"'Score Guide'!F24","v":"Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit"},{"$f":"'Score Guide'!G24","v":"Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required"},{"$f":"'Score Guide'!H24","v":"Controls considered appropriate and can be generally verified through audit"}]
["Monitoring ",3.2,"Are written procedures in place regarding water quality monitoring, sampling and laboratory analysis?","Guidance provided in management plan with supporting procedures (or equivalent) and implemented",3,null,null,{"$f":"'Score Guide'!D25","v":"N/A"},{"$f":"'Score Guide'!E25","v":"Not in place"},{"$f":"'Score Guide'!F25","v":"Partial guidance provided in management plan / Ad hoc implementation "},{"$f":"'Score Guide'!G25","v":"Guidance provided in management plan and partially implemented"},{"$f":"'Score Guide'!H25","v":"Guidance provided in management plan with supporting procedures (or equivalent) and implemented"}]
[null,"3.2.1-3.2.3","Is an operational monitoring plan in place which highlights testing parameters, testing locations, frequency and performance criteria?","Partial guidance provided in management plan (or equivalent), multiple information parameters gaps",1,null,null,{"$f":"'Score Guide'!D26","v":"N/A"},{"$f":"'Score Guide'!E26","v":"Not in place"},{"$f":"'Score Guide'!F26","v":"Partial guidance provided in management plan (or equivalent), multiple information parameters gaps"},{"$f":"'Score Guide'!G26","v":"Guidance provided in management plan for at least disinfection and temperature monitoring, any gaps in information limited to one parameter only (e.g. locations)"},{"$f":"'Score Guide'!H26","v":"Guidance provided in management plan, where applicable supported by stand-alone document with clear instructions (e.g. monitoring log sheet)"}]
[null,null,"Is a verification monitoring plan in place which highlights testing parameters, testing locations, frequency and performance criteria?","Partial guidance provided in management plan (or equivalent)",1,null,null,{"$f":"'Score Guide'!D27","v":"N/A"},{"$f":"'Score Guide'!E27","v":"Not in place"},{"$f":"'Score Guide'!F27","v":"Partial guidance provided in management plan (or equivalent)"},{"$f":"'Score Guide'!G27","v":"Guidance provided in management plan with consideration to either a risk or rotational based approach. Some information gaps may be present.   "},{"$f":"'Score Guide'!H27","v":"Guidance provided in management plan, supported by both a risk and rotational based approach, and where applicable stand-alone supporting documentation with clear instructions/maps etc."}]
[null,null,"Are testing locations known to facility staff? ","No",0,null,null,{"$f":"'Score Guide'!D28","v":"N/A"},{"$f":"'Score Guide'!E28","v":"No"},{"$f":"'Score Guide'!F28","v":"Partially"},{"$f":"'Score Guide'!G28","v":"Mostly "},{"$f":"'Score Guide'!H28","v":"Yes"}]
[null,"3.2.4 ","Are monitoring results documented?","Results documented and collated in a centralised database",3,null,null,{"$f":"'Score Guide'!D29","v":"N/A"},{"$f":"'Score Guide'!E29","v":"Results not documented"},{"$f":"'Score Guide'!F29","v":"Results documented, not saved in centralised location"},{"$f":"'Score Guide'!G29","v":"Results documented, saved in a centralised filing location, though individual results not collated into a centralised database "},{"$f":"'Score Guide'!H29","v":"Results documented and collated in a centralised database"}]
[null,null,"Is there a process in place to periodically review and report results to identify issues and trends?","Process documented and implemented",3,null,null,{"$f":"'Score Guide'!D30","v":"N/A"},{"$f":"'Score Guide'!E30","v":"No process in place"},{"$f":"'Score Guide'!F30","v":"Process in place but not documented, ad hoc"},{"$f":"'Score Guide'!G30","v":"Process documented and partially implemented,"},{"$f":"'Score Guide'!H30","v":"Process documented and implemented"}]
["Responding to Detections or Cases",4,"Are there written response procedures in place which highlight a defined list of incidents, corrective action requirements and responsibilities ?","Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented",3,null,null,{"$f":"'Score Guide'!D31","v":"N/A"},{"$f":"'Score Guide'!E31","v":"No procedures in place"},{"$f":"'Score Guide'!F31","v":"Partial guidance provided in management plan / Ad hoc implementation"},{"$f":"'Score Guide'!G31","v":"Guidance provided in management plan and some evidence of implementation"},{"$f":"'Score Guide'!H31","v":"Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"}]
[null,4.0999999999999996,"Do response procedures cover control measures to implement in response to a Legionella detection in a facility’s water distribution system?","Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented",3,null,null,{"$f":"'Score Guide'!D32","v":"N/A"},{"$f":"'Score Guide'!E32","v":"No procedures in place"},{"$f":"'Score Guide'!F32","v":"Partial guidance provided in management plan / Ad hoc implementation"},{"$f":"'Score Guide'!G32","v":"Guidance provided in management plan and some evidence of implementation"},{"$f":"'Score Guide'!H32","v":"Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"}]
[null,4.2,"Do response procedures cover response to a suspected or confirmed case of Legionnaires’ disease to determine the extent of potential Legionella colonisation in the water distribution system? ","Partial guidance provided in management plan / Ad hoc implementation",1,null,null,{"$f":"'Score Guide'!D33","v":"N/A"},{"$f":"'Score Guide'!E33","v":"No procedures in place"},{"$f":"'Score Guide'!F33","v":"Partial guidance provided in management plan / Ad hoc implementation"},{"$f":"'Score Guide'!G33","v":"Guidance provided in management plan and some evidence of implementation"},{"$f":"'Score Guide'!H33","v":"Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"}]
[null,4.3,"Do response procedures cover contingency measures to implement if problems persist?","No procedures in place",0,null,null,{"$f":"'Score Guide'!D34","v":"N/A"},{"$f":"'Score Guide'!E34","v":"No procedures in place"},{"$f":"'Score Guide'!F34","v":"Partial guidance provided in management plan / Ad hoc implementation"},{"$f":"'Score Guide'!G34","v":"Guidance provided in management plan and some evidence of implementation"},{"$f":"'Score Guide'!H34","v":"Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"}]
["Review",5,"Is there a process in place to review the risk management plan annually, or following defined triggers (e.g. after a significant change or case of Legionnaire’s disease)?","Review process documented though no evidence that it occurs / Ad hoc process",1,null,null,{"$f":"'Score Guide'!D35","v":"N/A"},{"$f":"'Score Guide'!E35","v":"No review process"},{"$f":"'Score Guide'!F35","v":"Review process documented though no evidence that it occurs / Ad hoc process"},{"$f":"'Score Guide'!G35","v":"Review process in place though happens less frequently than documented"},{"$f":"'Score Guide'!H35","v":"Review process in place and happens at least as frequent as documented"}]
[null,"-","Are records kept of documents (e.g. training records, inspection records, procedures, monitoring data) and held for a minimum of 7 years?","Records not kept ",0,null,null,{"$f":"'Score Guide'!D36","v":"N/A"},{"$f":"'Score Guide'!E36","v":"Records not kept "},{"$f":"'Score Guide'!F36","v":"Records kept, though for less than three years"},{"$f":"'Score Guide'!G36","v":"Records kept, though for less than 7 years (and more than 3 years)"},{"$f":"'Score Guide'!H36","v":"Records kept for at least 7 years"}]
[null,"-","Is there an improvement plan in place to track progress against identified deficiencies and opportunities for improvement?","No improvement plan",0,null,null,{"$f":"'Score Guide'!D37","v":"N/A"},{"$f":"'Score Guide'!E37","v":"No improvement plan"},{"$f":"'Score Guide'!F37","v":"Partial improvement plan in place / Ad hoc "},{"$f":"'Score Guide'!G37","v":"Improvement plan in place though not embedded into business processes"},{"$f":"'Score Guide'!H37","v":"Improvement plan in place and embedded into business processes"}]
["AS 3666 Air-handling and water systems of buildings—Microbial control",null,null,null,null,null,null,{"$f":"'Score Guide'!D38","v":0},{"$f":"'Score Guide'!E38","v":0},{"$f":"'Score Guide'!F38","v":0},{"$f":"'Score Guide'!G38","v":0},{"$f":"'Score Guide'!H38","v":0}]
["Cooling Tower Operations and Maintenance","Part 2, 2.2.1","Have suitable training requirements been identified for cooling system maintenance and operations personnel?","N/A",{"$f":"IF(D38=H38,$H$4,IF(D38=I38,$I$4,IF(D38=J38,$J$4,IF(D38=K38,$K$4,IF(D38=L38,$L$4)))))","v":"NA"},null,null,{"$f":"'Score Guide'!D39","v":"N/A"},{"$f":"'Score Guide'!E39","v":"Training requirements not identified"},{"$f":"'Score Guide'!F39","v":"Ad hoc / anecdotal"},{"$f":"'Score Guide'!G39","v":"Yes, documented requirements for contractors "},{"$f":"'Score Guide'!H39","v":"Yes, documented requirements for contractors and Department staff"}]
[null,"Part 2, 2.2.1, 2.5","Is there a maintenance program in place in accordance with the supplier’s published requirements?","N/A","NA",null,null,{"$f":"'Score Guide'!D40","v":"N/A"},{"$f":"'Score Guide'!E40","v":"No"},{"$f":"'Score Guide'!F40","v":"Somewhat completed (approx. 33%)"},{"$f":"'Score Guide'!G40","v":"Almost completed (approx. 66%) or outdated / unverified"},{"$f":"'Score Guide'!H40","v":"Fully completed and up to date"}]
[null,"Part 1, 4.1.3, Part 2, 2.5","Is an appropriate water treatment program in place?","N/A","NA",null,null,{"$f":"'Score Guide'!D41","v":"N/A"},{"$f":"'Score Guide'!E41","v":"No"},{"$f":"'Score Guide'!F41","v":"Some (approx. 33%) parameters in place"},{"$f":"'Score Guide'!G41","v":"Most parameters (approx. 66%) in place"},{"$f":"'Score Guide'!H41","v":"All required parameters in place"}]
[null,"Part 2, 2,6","Is there an up to date operations and maintenance manual(s)?","N/A","NA",null,null,{"$f":"'Score Guide'!D42","v":"N/A"},{"$f":"'Score Guide'!E42","v":"No"},{"$f":"'Score Guide'!F42","v":"Somewhat completed (approx.. 33%)"},{"$f":"'Score Guide'!G42","v":"Almost completed (approx. 66%) or outdated / unverified"},{"$f":"'Score Guide'!H42","v":"Fully completed and up to date"}]
[null,"Part 2, 2.6.2-2.6.3, Part 3, 3.7-3.8","Are records of manuals, risk assessment reports, test results and maintenance records kept for a minimum period of 7 years? ","N/A","NA",null,null,{"$f":"'Score Guide'!D43","v":"N/A"},{"$f":"'Score Guide'!E43","v":"No"},{"$f":"'Score Guide'!F43","v":"Records kept, though for less than three years"},{"$f":"'Score Guide'!G43","v":"Records kept, though for less than 7 years"},{"$f":"'Score Guide'!H43","v":"Records kept for at least 7 years"}]
[null,"Part 1, 4.1.1","Is the discharge exhaust away from occupied areas, pedestrian thoroughfare, air intakes, building openings and trafficable areas? ","N/A","NA",null,null,{"$f":"'Score Guide'!D44","v":"N/A"},{"$f":"'Score Guide'!E44","v":"No"},{"$f":"'Score Guide'!F44","v":"Partially"},{"$f":"'Score Guide'!G44","v":"Mostly"},{"$f":"'Score Guide'!H44","v":"Yes"}]
["Cooling Tower Performance","Part 1, 4.1","Has a review of the system been conducted to confirm compliance with AS 3666?","N/A","NA",null,null,{"$f":"'Score Guide'!D45","v":"N/A"},{"$f":"'Score Guide'!E45","v":"No review done "},{"$f":"'Score Guide'!F45","v":"Ad hoc / partial review (approx. 33%) completed"},{"$f":"'Score Guide'!G45","v":"Mainly completed (approx. 66%) or last completed over 2 years ago"},{"$f":"'Score Guide'!H45","v":"Fully completed and within last 2 years"}]
[null,"Part 3, 2.2-2.3","Has a risk assessment or risk management plan of the cooling tower system been completed in accordance with AS 3666.3 Section 2.3?","N/A","NA",null,null,{"$f":"'Score Guide'!D46","v":"N/A"},{"$f":"'Score Guide'!E46","v":"No risk assessment in place"},{"$f":"'Score Guide'!F46","v":"Somewhat (completed approx. 33%)"},{"$f":"'Score Guide'!G46","v":"Mainly completed (approx. 66%) or last reviewed over 2 years ago"},{"$f":"'Score Guide'!H46","v":"Fully completed and reviewed within last 2 years"}]
[null,"Part 3, 3.4","Are performance indicators in place that are monitored at least monthly to confirm that the water chemistry is under control?","N/A","NA",null,null,{"$f":"'Score Guide'!D47","v":"N/A"},{"$f":"'Score Guide'!E47","v":"No"},{"$f":"'Score Guide'!F47","v":"Some (approx. 33%) parameters in place"},{"$f":"'Score Guide'!G47","v":"Most parameters (approx. 66%) in place"},{"$f":"'Score Guide'!H47","v":"All required parameters in place"}]
[null,"Part 3, 3.2-3.3","Is legionella and HPC monitoring undertaken at a minimum monthly frequency?","N/A","NA",null,null,{"$f":"'Score Guide'!D48","v":"N/A"},{"$f":"'Score Guide'!E48","v":"No"},{"$f":"'Score Guide'!F48","v":"One parameter only"},{"$f":"'Score Guide'!G48","v":"Both parameters but not correct frequency"},{"$f":"'Score Guide'!H48","v":"Yes"}]
[null,"Part 3, Appendix A","Is monitoring undertaken in accordance with AS3666.3 Appendix A: Cooling Water Sampling Procedure","N/A","NA",null,null,{"$f":"'Score Guide'!D49","v":"N/A"},{"$f":"'Score Guide'!E49","v":"No"},{"$f":"'Score Guide'!F49","v":"Reportedly though no supporting documentation"},{"$f":"'Score Guide'!G49","v":"Yes, supporting documentation reportedly in place but not sighted"},{"$f":"'Score Guide'!H49","v":"Yes and supporting documentation in place, and sighted"}]
[null,"Part 3, 3.7","Is a report prepared each month detailing results of water quality indicators (including water treatment performance indicators, legionella and HPC) and corrective action undertaken where results are not in specification?","N/A","NA",null,null,{"$f":"'Score Guide'!D50","v":"N/A"},{"$f":"'Score Guide'!E50","v":"No"},{"$f":"'Score Guide'!F50","v":"Partially"},{"$f":"'Score Guide'!G50","v":"Mostly"},{"$f":"'Score Guide'!H50","v":"Yes"}]
[null,"Part 3, 3.2-3.3","Is action taken in response to high Legionella spp. and HPC counts in accordance with AS 3666.3 Table 3.1 and 3.2?","N/A","NA",null,null,{"$f":"'Score Guide'!D51","v":"N/A"},{"$f":"'Score Guide'!E51","v":"No action taken"},{"$f":"'Score Guide'!F51","v":"Ad hoc or only HPC related documented and implemented procedures "},{"$f":"'Score Guide'!G51","v":"Yes documented and implemented procedures but only for Legionella spp. "},{"$f":"'Score Guide'!H51","v":"Yes documented and implemented procedures for both parameters "}]
["Building Guidelines: Western Australian Health Facility Guidelines for Engineering Services (Hydraulic Services)",null,null,null,null,null,null,{"$f":"'Score Guide'!D52","v":0},{"$f":"'Score Guide'!E52","v":0},{"$f":"'Score Guide'!F52","v":0},{"$f":"'Score Guide'!G52","v":0},{"$f":"'Score Guide'!H52","v":0}]
["Cold Water Supply Configuration","13.7.1","Does the cold water source meet the quality specified in the Australian Drinking Water Guidelines?","Somewhat in place (approx. 33%)",{"$f":"IF(D52=H52,$H$4,IF(D52=I52,$I$4,IF(D52=J52,$J$4,IF(D52=K52,$K$4,IF(D52=L52,$L$4)))))","v":1},null,null,{"$f":"'Score Guide'!D53","v":"N/A"},{"$f":"'Score Guide'!E53","v":"No"},{"$f":"'Score Guide'!F53","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G53","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H53","v":"Fully in place"}]
[null,"13.3.4","Is the water distribution system of ring main or star sub-main arrangements that allow the water supply to the majority of the site to be maintained through all credible system maintenance and alteration events? ","Fully in place",3,null,null,{"$f":"'Score Guide'!D54","v":"N/A"},{"$f":"'Score Guide'!E54","v":"No"},{"$f":"'Score Guide'!F54","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G54","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H54","v":"Fully in place"}]
[null,"13.3.8","Is the cold water distribution in building internals of ring main arrangement to minimise spur/branch lines (recommended to contain a maximum volume of three litres)?","Somewhat in place (approx. 33%)",1,null,null,{"$f":"'Score Guide'!D55","v":"N/A"},{"$f":"'Score Guide'!E55","v":"No"},{"$f":"'Score Guide'!F55","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G55","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H55","v":"Fully in place"}]
["Hot and Warm Water Supply Configuration ","13.9.1","Is the hot water distribution system on site designed to minimise spur/branch lines (recommended maximum length of 6m of DN 20 or 10m of DN 15 pipe)?","No",0,null,null,{"$f":"'Score Guide'!D56","v":"N/A"},{"$f":"'Score Guide'!E56","v":"No"},{"$f":"'Score Guide'!F56","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G56","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H56","v":"Fully in place"}]
[null,"13.9.1","Are only thermostatic mixing valves used in clinical areas?","Fully in place",3,null,null,{"$f":"'Score Guide'!D57","v":"N/A"},{"$f":"'Score Guide'!E57","v":"No "},{"$f":"'Score Guide'!F57","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G57","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H57","v":"Fully in place"}]
[null,"13.9.1","Are thermostatic mixing valves a point of use arrangement and integrated into the tapware to avoid mixed warm water dead legs?","N/A","NA",null,null,{"$f":"'Score Guide'!D58","v":"N/A"},{"$f":"'Score Guide'!E58","v":"No"},{"$f":"'Score Guide'!F58","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G58","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H58","v":"Fully in place"}]
[null,"-","Are thermostatic mixing valves accessible for maintenance purposes?","Somewhat in place (approx. 33%)",1,null,null,{"$f":"'Score Guide'!D59","v":"N/A"},{"$f":"'Score Guide'!E59","v":"No"},{"$f":"'Score Guide'!F59","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G59","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H59","v":"Fully in place"}]
[null,"-","Do thermostatic mixing valves have multiple isolating valves to deliver flushing and disinfection through both cold and mixed water outlets?","N/A","NA",null,null,{"$f":"'Score Guide'!D60","v":"N/A"},{"$f":"'Score Guide'!E60","v":"No"},{"$f":"'Score Guide'!F60","v":"Somewhat in place (approx. 33%)"},{"$f":"'Score Guide'!G60","v":"Mostly in place (approx. 66%)"},{"$f":"'Score Guide'!H60","v":"Fully in place"}]
["Note: If Score 'False' review finding selection"]
["Select most appropriate finding from drop down menu"]

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["Score Guide"]
["Criteria",null,null,"Score Guide"]
["Item","Section0","Description","N/A",0,1,2,3]
[null,null,null,"Not applicable","Not demonstrated ","Slightly demonstrated ","Mostly demonstrated ","Fully demonstrated "]
["Guidelines for Legionella Control in the operation and maintenance of water distribution systems in health and aged care facilities"]
["Establishing a Legionella Risk Management System",1.1000000000000001,"Has a multi-discipline risk management team been assembled which includes representation from the facility's operational, clinical, and engineering business units?","N/A","No stakeholders identified / Stakeholders unknown","Stakeholders identified in plan without supporting information / anecdotally known","Stakeholders identified in plan with role, responsibilities, skills, experience ect. (ideally in tabular format) ","Stakeholders identified with role, responsibilities, skills, experience ect., and  additional commitment and evidence of regular engagement / discussions amongst stakeholders (eg. regular meeting minutes)"]
[null,1.2,"Has a risk management plan been established in line with the national risk management plan template?","N/A","No plan in place","Somewhat completed plan (approx. 33%) in line with Enhealth framework or equivalent","Almost completed plan (approx. 66%) management plan in line with Enhealth framework or equivalent","Fully completed management plan (100%) in line with Enhealth framework or equivalent"]
[null,1.2,"Is the risk management plan reflective of current stakeholders, practices and infrastructure, and within document review period?","N/A","No plan in place","Plan out of date (> 1 year, significant differences between plan and infrastructure in place)","Plan slightly out of date (< 1 year or currently under review, minor differences between plan and infrastructure in place)","Plan up to date and within review period, contents of plan aligns with infrastructure in place"]
["Analysing Risk",2.1,"Have flow diagrams, schematics or layouts been developed which illustrates the entire water distribution system?","N/A","No diagrams in place","Diagrams in place though only show some infrastructure (e.g. heated water systems, or cooling systems) and significant details out of date or missing ","Diagram in place which shows overall water system though minor details out of date or missing","Diagram in place which shows overall water system with infrastructure up to date and all key components shown"]
[null,"2.1.1","Is there a description of the water distribution system which covers the entire process from where water enters the facility through to its final uses?2","N/A","No system description","Very basic system description / significant number of components missing","General system description, though minor number of components missing","General system description covering all system components"]
[null,"2.1.1","Is the system description supported by an asset register which includes details of all components of the water system from source to its final uses?2","N/A","No asset register","Somewhat completed (approx. 33%)","Mostly completed (approx. 66%)","Fully completed"]
[null,"2.1.2","Has the location of areas where patients, residents and / or staff are at higher risk of infection been identified? ","N/A","No locations identified","Locations identified, managed ad-hoc and not referenced in management plan","Locations identified, partial integration into management plan","Locations identified and fully integrated into management plan"]
[null,2.2000000000000002,"Has a qualitative risk assessment, using a risk analysis matrix, been undertaken for the system?3","N/A","No risk assessment complete","Risk assessment done without use of a risk analysis matrix","Risk assessment in place with inappropriate risk matrix","Risk assessment in place with appropriate risk matrix"]
[null,"2.2.1","Does the risk assessment identify potential hazardous events, and risk level based on consequence / likelihood of each hazardous event?","N/A","Not in place","Risk assessment only identifies hazardous events, though not risk level  of such hazardous event ","Risk assessment identifies hazardous events though consequence/likelihood missing and / or does not include risk level before and after controls","Risk assessment identifies hazardous events and associated consequence/likelihood and risk level, with and without controls"]
[null,"2.2.2-3","Does the risk assessment analyse all systems components including incoming water quality, plumbing systems, cold and heated water systems and other as required equipment and installations?4","N/A","No risk assessment in place ","Risk assessment missing significant amount of system components","Risk assessment includes most system components","Risk assessment includes all system components"]
[null,"2.2.4","Does the risk assessment analyse how personnel in areas at higher risk of infection (as per item 2.1.1) might be exposed?5","N/A","Not in place","Partial risk assessment complete (e.g. does not identify all applicable areas of concern or exposure pathways)","Risk assessment highlights exposure pathways and applicable areas of concern though not associated level of risk","Risk assessment, highlights exposure pathways, applicable areas of concern and associated  level of risk"]
["Risk Management  ",3.1,"From the risk assessment have controls been identified which control identified risks to acceptable levels? ","N/A","Not in place","Anecdotal evidence of controls in place (Note: this answer is also considered applicable to situations where risk assessment not in place)","Controls identified and integrated into management plan\nConsideration has been given to additional controls required to address any ‘high’ residual risks","Controls identified and integrated into management plan, with clear linkages between patient / resident and water risk assessments, and integration of additional controls required to address any high residual risks into an improvement plan"]
[null,null,"Has staff training requirements been identified (including frequency for renewal)?6","N/A","No training requirements identified","Ad hoc","Training requirements in place (ideally highlighted by a training matrix)","Training requirements also specify frequency of renewal "]
[null,null,"Has a training program been implemented according to the identified minimum training requirements?","N/A","No training program in place","Partially","Mostly","Yes"]
[null,"3.1.1","From the risk assessment has appropriate controls been identified for managing the incoming water supply?7","N/A","Controls not identified","Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required","Controls considered appropriate and can be generally verified through audit"]
[null,"3.1.2","From the risk assessment has appropriate controls been identified for managing the plumbing system? 7","N/A","Controls not identified","Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required","Controls considered appropriate and can be generally verified through audit"]
[null,"3.1.3","From the risk assessment has appropriate controls been identified for disinfection systems? 7","N/A","Controls not identified","Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required","Controls considered appropriate and can be generally verified through audit"]
[null,"3.1.4","From the risk assessment has appropriate controls been identified for regular maintenance? 7","N/A","Controls not identified","Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required","Controls considered appropriate and can be generally verified through audit"]
[null,"3.1.5","From the risk assessment has appropriate exposure controls been identified to reduce exposures to aerosols to personnel in areas at higher risk of infection? 7","N/A","Controls not identified","Clear gaps in controls identified in risk assessment / controls generally not able to be verified during audit","Controls identified through are not able to be verified through audit, and / or some require review, and / or some additional controls required","Controls considered appropriate and can be generally verified through audit"]
["Monitoring ",3.2,"Are written procedures in place regarding water quality monitoring, sampling and laboratory analysis?8","N/A","Not in place","Partial guidance provided in management plan / Ad hoc implementation ","Guidance provided in management plan and partially implemented","Guidance provided in management plan with supporting procedures (or equivalent) and implemented"]
[null,"3.2.1-3","Is an operational monitoring plan in place which highlights testing parameters, testing locations, frequency and performance criteria?9","N/A","Not in place","Partial guidance provided in management plan (or equivalent), multiple information parameters gaps","Guidance provided in management plan for at least disinfection and temperature monitoring, any gaps in information limited to one parameter only (e.g. locations)","Guidance provided in management plan, where applicable supported by stand-alone document with clear instructions (e.g. monitoring log sheet)"]
[null,null,"Is a verification monitoring plan in place which highlights testing parameters, testing locations, frequency and performance criteria?10","N/A","Not in place","Partial guidance provided in management plan (or equivalent)","Guidance provided in management plan with consideration to either a risk or rotational based approach. Some information gaps may be present.   ","Guidance provided in management plan, supported by both a risk and rotational based approach, and where applicable stand-alone supporting documentation with clear instructions/maps etc."]
[null,null,"Are the testing locations known to facility staff? ","N/A","No","Partially","Mostly ","Yes"]
[null,"3.2.4 ","Are monitoring results documented?","N/A","Results not documented","Results documented, not saved in centralised location","Results documented, saved in a centralised filing location, though individual results not collated into a centralised database ","Results documented and collated in a centralised database"]
[null,null,"Is there a process in place to periodically review and report results to identify issues and trends?11","N/A","No process in place","Process in place but not documented, ad hoc","Process documented and partially implemented,","Process documented and implemented"]
["Responding to Detections or Cases",4,"Are there written response procedures in place which highlight a defined list of incidents, corrective action requirements and responsibilities?","N/A","No procedures in place","Partial guidance provided in management plan / Ad hoc implementation","Guidance provided in management plan and some evidence of implementation","Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"]
[null,4.0999999999999996,"Do response procedures cover control measures to implement in response to a Legionella in a facility’s water distribution system?12","N/A","No procedures in place","Partial guidance provided in management plan / Ad hoc implementation","Guidance provided in management plan and some evidence of implementation","Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"]
[null,4.2,"Do response procedures cover response to a suspected or confirmed case of Legionnaires’ disease to determine the extent of potential Legionella colonisation in the water distribution system? ","N/A","No procedures in place","Partial guidance provided in management plan / Ad hoc implementation","Guidance provided in management plan and some evidence of implementation","Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"]
[null,4.3,"Do response procedures cover contingency measures to implement if problems persist?","N/A","No procedures in place","Partial guidance provided in management plan / Ad hoc implementation","Guidance provided in management plan and some evidence of implementation","Guidance provided in management plan, embedded into supporting procedures (or equivalent) and implemented"]
["Review",5,"Is there a process in place to review the risk management plan at least annually, or following defined triggers (e.g. after a significant change or case of Legionnaire’s disease)?","N/A","No review process","Review process documented though no evidence that it occurs / Ad hoc process","Review process in place though happens less frequently than documented","Review process in place and happens at least as frequent as documented"]
[null,"-","Are records kept of documents (e.g. training records, inspection records, procedures) and held for a minimum of 7 years?","N/A","Records not kept ","Records kept, though for less than three years","Records kept, though for less than 7 years (and more than 3 years)","Records kept for at least 7 years"]
[null,"-","Is there an improvement plan in place to track progress against identified deficiencies and opportunities for improvement?","N/A","No improvement plan","Partial improvement plan in place / Ad hoc ","Improvement plan in place though not embedded into business processes","Improvement plan in place and embedded into business processes"]
["Extract of AS 3666 Air handling and water systems of buildings – Microbial control"]
["Cooling Tower Operations and Maintenance","Part 2, 2.2.1","Has suitable training requirements been identified for cooling system maintenance and operations personnel?6","N/A","Training requirements not identified","Ad hoc / anecdotal","Yes, documented requirements for contractors ","Yes, documented requirements for contractors and Department staff"]
[null,"Part 2, 2.2.1, 2.5","Is there a maintenance program in place in accordance with the supplier’s published requirements?","N/A","No","Somewhat completed (approx. 33%)","Almost completed (approx. 66%) or outdated / unverified","Fully completed and up to date"]
[null,"Part 1, 4.1.3, Part 2, 2.5","Is an appropriate water treatment program in place?","N/A","No","Some (approx. 33%) parameters in place","Most parameters (approx. 66%) in place","All required parameters in place"]
[null,"Part 2, 2,6","Is there an up-to-date operations and maintenance manual(s)?","N/A","No","Somewhat completed (approx.. 33%)","Almost completed (approx. 66%) or outdated / unverified","Fully completed and up to date"]
[null,"Part 2, 2.6.2-2.6.3, Part 3, 3.7-3.8","Are records of manuals, risk assessment reports, test results and maintenance records kept for a minimum period of 7 years? ","N/A","No","Records kept, though for less than three years","Records kept, though for less than 7 years","Records kept for at least 7 years"]
[null,"Part 1, 4.3","Is the discharge exhaust away from occupied areas, pedestrian thoroughfare, air intakes, building openings and trafficable areas? ","N/A","No","Partially","Mostly","Yes"]
["Cooling Tower Performance","Part 1","Has a review of the system been conducted to confirm compliance with AS 3666?","N/A","No review done ","Ad hoc / partial review (approx. 33%) completed","Mainly completed (approx. 66%) or last completed over 2 years ago","Fully completed and within last 2 years"]
[null,"Part 3, 2.2-2.3","Has a risk assessment or risk management plan of the cooling tower system been completed in accordance with AS 3666.3 Section 2.3?","N/A","No risk assessment in place","Somewhat (completed approx. 33%)","Mainly completed (approx. 66%) or last reviewed over 2 years ago","Fully completed and reviewed within last 2 years"]
[null,"Part 3, 3.4","Are performance indicators in place that are monitored at least monthly to confirm that the water chemistry is under control?","N/A","No","Some (approx. 33%) parameters in place","Most parameters (approx. 66%) in place","All required parameters in place"]
[null,"Part 3, 3.2-3.3","Is legionella and HPC monitoring undertaken at a minimum monthly frequency?","N/A","No","One parameter only","Both parameters but not correct frequency","Yes"]
[null,"Part 3, Appendix A","Is monitoring undertaken in accordance with AS3666.3 Appendix A: Cooling Water Sampling Procedure?","N/A","No","Reportedly though no supporting documentation","Yes, supporting documentation reportedly in place but not sighted","Yes and supporting documentation in place, and sighted"]
[null,"Part 3, 3.7","Is a report prepared each month detailing results of water quality indicators (including water treatment performance indicators, legionella and HPC) and corrective action undertaken where results are not in specification?","N/A","No","Partially","Mostly","Yes"]
[null,"Part 3, 3.2-3.3","Is action taken in response to high Legionella spp. and HPC counts in accordance with AS 3666.3 Table 3.1 and 3.2?","N/A","No action taken","Ad hoc or only HPC related documented and implemented procedures ","Yes documented and implemented procedures but only for Legionella spp. ","Yes documented and implemented procedures for both parameters "]
["Extract of Building Guidelines: Western Australian Health Facility Guidelines for Engineering Services (Hydraulic Services)"]
["Cold Water Supply Configuration","13.7.1","Does the potable water source meet the quality specified in the Australian Drinking Water Guidelines?","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
[null,"13.3.4","Is the water distribution system of ring main or star sub-main arrangements that allow the water supply to the majority of the site to be maintained through all credible system maintenance and alteration events? ","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
[null,"13.3.8","Is the cold water distribution in building internals of ring main arrangement to minimise spur/branch lines (recommended to contain a maximum volume of three litres)?","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
["Hot and Warm Water Supply Configuration","13.9.1","Is the hot water distribution system on site designed to minimise spur/branch lines (recommended maximum length of 6m of DN 20 or 10m of DN 15 pipe)?","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
[null,"13.9.1","Are only thermostatic mixing valves used in clinical areas?","N/A","No ","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
[null,"13.9.1","Are thermostatic mixing valves a point of use arrangement and integrated into the tapware to avoid mixed warm water dead legs?","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
[null,"-","Are thermostatic mixing valves accessible for maintenance purposes?","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
[null,"-","Do thermostatic mixing valves have multiple isolating valves to deliver flushing and disinfection through both cold and mixed water outlets?","N/A","No","Somewhat in place (approx. 33%)","Mostly in place (approx. 66%)","Fully in place"]
["0 – For each criteria refer to reference section of appropriate guideline for further guidance as required. The above score guide provides examples for determining a finding/score for each criteria however professional judgement should be exercised when determining the finding/score. "]
["1 - Information which should be included in flow diagrams, layouts or schematics at a minimum includes:  Potable water: Supply points to health care facility, cold and hot water supply layout, cold water storage tanks, centralised hot water storage systems, centralised water treatment systems, locations where water is used within hospital. Non potable water: Cooling tower and associated treatment systems, irrigation, fire and recycled water layout (and any cross connection with the health care facilities potable water supply system). Ideally a simplified flow diagram should be established which highlights the aforementioned infrastructure, which is supported by more detailed engineering drawings, where available."]
["2 - The description of the water system should give context to the flow diagrams, schematics or layouts. Where applicable consideration should be given to providing details of water system layouts across multi-level buildings and highlighting any infrastructure which is not in scope of the health service provider facility, but may be present on the same lot for which the facility is located. "]
["       The description should also include the key components of the scheme and water uses as transcribed in the Water System Details section of this tool.  This information should also form the basis for the asset register (consideration should also be given to include each outlet – e.g. showers, taps, basins, ect. in the asset register). "]
["3 - An example risk matrix is shown in Appendix 1 of the 'Guidelines for Legionella Control in the operation and maintenance of water distribution systems in health and aged care facilities'"]
["4 - The risk assessment should include hazardous events for all key components and water uses as transcribed in the Water System Details section of this tool.  "]
["5 - Methodology at discretion of health service provider. Seek advice from infection control staff (or equivalent) as required. The risk assessment should be supported by a description of the areas where patients are at higher risk of infection, Findings from this risk assessment used in conjunction with those for the water system risk to determine if such areas may require additional attention. "]
["6 - At a minimum training requirements should include awareness of legionella for personnel involved in the management, operation and maintenance of the health care facility’s water and air handling systems , and other appropriate job-based requirements. "]
["7 - Refer to Section 3.1 of 'Guidelines for Legionella Control in the operation and maintenance of water distribution systems in health and aged care facilities' for guidance on appropriate controls for management of legionella spp. within a health care facility. Seek water quality specialist advice as required. "]
["8 - Guidance on of water samples is available from: Water sample collection for verification monitoring purposes | Queensland Health. Further guidance will be made available from WA Health in due course .  "]
["9 - Verification monitoring consists of collecting water samples from selected locations within your water distribution system and testing for the hazards that are being controlled. "]
["10 - Operational monitoring assesses the effectiveness of a control measure, at a specific point within your water distribution system, through scheduled, usually real-time monitoring of specific parameters, such as temperature and disinfection residual."]
["9, 10 - For further advice on developing monitoring programs seek specialist water quality advice as required."]
["11 – Results are recommended to be compiled monthly and reported to members of the multi-discipline risk management team"]
["12 – At a minimum response procedures should align with the Department’s Decontamination protocol for warm water systems. "]
["Further information on Legionella spp. control in cooling towers and water systems can be found here: Legionella control (health.wa.gov.au) "]

{"sheet":"Graph and Tables","index":3,"n_rows":112,"n_cols":13,"rows_kept":112,"cut":false,"hidden":false,"merged":[]}
[]
[null,"Facility Name ","Number of Questions","Total Possible Score","Number of NAs","Revised Possible Score","Score","%","Weighting","Weighted Percentage "]
[null,"Establishing a Legionella Risk Management System",{"$f":"COUNTA('Audit Tool'!C5:C7)","v":3},{"$f":"C3*3","v":9},{"$f":"COUNTIF('Audit Tool'!E5:E7, \"NA\")","v":1},{"$f":"(C3-E3)*3","v":6},{"$f":"SUM('Audit Tool'!E5:E7)","v":0},{"$f":"IF(F3=0, \"NA\", G3/F3)","v":0},{"$f":"IF($F$10=0, 10%, 5%)","v":0.1},{"$f":"IF(F3=0, \"NA\", H3*I3)","v":0}]
[null,"Analysing Risk",{"$f":"COUNTA('Audit Tool'!C8:C15)","v":8},24,{"$f":"COUNTIF('Audit Tool'!E8:E15, \"NA\")","v":0},24,{"$f":"SUM('Audit Tool'!E8:E15)","v":3},0.125,{"$f":"IF($F$10=0, 20%, 15%)","v":0.2},{"$f":"IF(F4=0, \"NA\", H4*I4)","v":2.5000000000000001E-2}]
[null,"Risk Management  ",{"$f":"COUNTA('Audit Tool'!C16:C23)","v":8},24,{"$f":"COUNTIF('Audit Tool'!E16:E23, \"NA\")","v":1},21,{"$f":"SUM('Audit Tool'!E16:E23)","v":17},0.80952380952380953,{"$f":"IF($F$10=0, 20%, 15%)","v":0.2},0.16190476190476191,null,{"$f":"IF('Audit Tool'!G5=\"\",\"\",'Audit Tool'!B5)","v":""},{"$f":"IF(L5=\"\",\"\",'Audit Tool'!G5)","v":""}]
[null,"Monitoring ",{"$f":"COUNTA('Audit Tool'!C24:C29)","v":6},18,{"$f":"COUNTIF('Audit Tool'!E24:E29, \"NA\")","v":0},18,{"$f":"SUM('Audit Tool'!E24:E29)","v":11},0.61111111111111116,{"$f":"IF($F$10=0, 15%, 10%)","v":0.15},9.1666666666666674E-2,null,{"$f":"IF('Audit Tool'!G6=\"\",\"\",'Audit Tool'!B6)","v":""},{"$f":"IF(L6=\"\",\"\",'Audit Tool'!G6)","v":""}]
[null,"Responding to Detections or Cases",{"$f":"COUNTA('Audit Tool'!C30:C33)","v":4},12,{"$f":"COUNTIF('Audit Tool'!E30:E33, \"NA\")","v":0},12,{"$f":"SUM('Audit Tool'!E30:E33)","v":7},0.58333333333333337,{"$f":"IF($F$10=0, 10%, 7.5%)","v":0.1},5.8333333333333341E-2,null,{"$f":"IF('Audit Tool'!G7=\"\",\"\",'Audit Tool'!B7)","v":""},{"$f":"IF(L7=\"\",\"\",'Audit Tool'!G7)","v":""}]
[null,"Review",{"$f":"COUNTA('Audit Tool'!C34:C36)","v":3},9,{"$f":"COUNTIF('Audit Tool'!E34:E36, \"NA\")","v":0},9,{"$f":"SUM('Audit Tool'!E34:E36)","v":1},0.1111111111111111,{"$f":"IF($F$10=0, 10%, 7.5%)","v":0.1},1.1111111111111112E-2,null,{"$f":"IF('Audit Tool'!G8=\"\",\"\",'Audit Tool'!B8)","v":""},{"$f":"IF(L8=\"\",\"\",'Audit Tool'!G8)","v":""}]
[null,"Sub Total - Enhealth",{"$f":"SUM(C3:C8)","v":32},{"$f":"SUM(D3:D8)","v":96},{"$f":"SUM(E3:E8)","v":2},{"$f":"SUM(F3:F8)","v":90},{"$f":"SUM(G3:G8)","v":39},0.43333333333333335,null,"-",null,{"$f":"IF('Audit Tool'!G9=\"\",\"\",'Audit Tool'!B9)","v":""},{"$f":"IF(L9=\"\",\"\",'Audit Tool'!G9)","v":""}]
[null,"Cooling Tower Systems - Operations and Maintenance",{"$f":"COUNTA('Audit Tool'!C38:C43)","v":6},{"$f":"C10*3","v":18},{"$f":"COUNTIF('Audit Tool'!E38:E43, \"NA\")","v":6},{"$f":"(C10-E10)*3","v":0},{"$f":"SUM('Audit Tool'!E38:E43)","v":0},{"$f":"IF(F10=0, \"NA\", G10/F10)","v":"NA"},{"$f":"IF($F$10=0, 0, 12.5%)","v":0},{"$f":"IF(F10=0, \"NA\", H10*I10)","v":"NA"},null,{"$f":"IF('Audit Tool'!G10=\"\",\"\",'Audit Tool'!B10)","v":""},{"$f":"IF(L10=\"\",\"\",'Audit Tool'!G10)","v":""}]
[null,"Cooling Tower - Performance",{"$f":"COUNTA('Audit Tool'!C44:C50)","v":7},{"$f":"C11*3","v":21},{"$f":"COUNTIF('Audit Tool'!E44:E50, \"NA\")","v":7},{"$f":"(C11-E11)*3","v":0},{"$f":"SUM('Audit Tool'!E44:E50)","v":0},{"$f":"IF(F11=0, \"NA\", G11/F11)","v":"NA"},{"$f":"IF($F$10=0, 0%, 12.5%)","v":0},{"$f":"IF(F11=0, \"NA\", H11*I11)","v":"NA"},null,{"$f":"IF('Audit Tool'!G11=\"\",\"\",'Audit Tool'!B11)","v":""},{"$f":"IF(L11=\"\",\"\",'Audit Tool'!G11)","v":""}]
[null,"Engineering Guidelines - Cold Water Supply Configuration",{"$f":"COUNTA('Audit Tool'!C52:C54)","v":3},{"$f":"C12*3","v":9},{"$f":"COUNTIF('Audit Tool'!E52:E54, \"NA\")","v":0},{"$f":"(C12-E12)*3","v":9},{"$f":"SUM('Audit Tool'!E52:E54)","v":5},0.55555555555555558,{"$f":"IF($F$10=0, 7.5%, 7.5%)","v":7.4999999999999997E-2},4.1666666666666664E-2,null,{"$f":"IF('Audit Tool'!G12=\"\",\"\",'Audit Tool'!B12)","v":""},{"$f":"IF(L12=\"\",\"\",'Audit Tool'!G12)","v":""}]
[null,"Engineering Guidelines - Hot Water Supply Configuration",{"$f":"COUNTA('Audit Tool'!C55:C59)","v":5},{"$f":"C13*3","v":15},{"$f":"COUNTIF('Audit Tool'!E55:E59, \"NA\")","v":2},{"$f":"(C13-E13)*3","v":9},{"$f":"SUM('Audit Tool'!E55:E59)","v":4},0.44444444444444442,{"$f":"IF($F$10=0, 7.5%, 7.5%)","v":7.4999999999999997E-2},3.3333333333333333E-2,null,{"$f":"IF('Audit Tool'!G13=\"\",\"\",'Audit Tool'!B13)","v":""},{"$f":"IF(L13=\"\",\"\",'Audit Tool'!G13)","v":""}]
[null,"Total",{"$f":"SUM(C3:C13)-C9","v":53},{"$f":"SUM(D3:D13)-D9","v":159},{"$f":"SUM(E3:E13)-E9","v":17},{"$f":"SUM(F3:F13)-F9","v":108},{"$f":"SUM(G3:G13)-G9","v":48},{"$f":"G14/F14","v":0.44444444444444442},{"$f":"SUM(I3:I13)","v":0.99999999999999989},{"$f":"SUM(J3:J13)","v":0.42301587301587307},{"$f":"J14","v":0.42301587301587307},{"$f":"IF('Audit Tool'!G14=\"\",\"\",'Audit Tool'!B14)","v":""},{"$f":"IF(L14=\"\",\"\",'Audit Tool'!G14)","v":""}]
[null,"Items in red may need manual entering (see comment for weightings)",null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G15=\"\",\"\",'Audit Tool'!B15)","v":""},{"$f":"IF(L15=\"\",\"\",'Audit Tool'!G15)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G16=\"\",\"\",'Audit Tool'!B16)","v":""},{"$f":"IF(L16=\"\",\"\",'Audit Tool'!G16)","v":""}]
[null,"Score","Category","Description",null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G17=\"\",\"\",'Audit Tool'!B17)","v":""},{"$f":"IF(L17=\"\",\"\",'Audit Tool'!G17)","v":""}]
[null,"0 to ≤ 20%","None or ad-hoc risk management system in place","Risk management process are informal and ad-hoc ",null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G18=\"\",\"\",'Audit Tool'!B18)","v":""},{"$f":"IF(L18=\"\",\"\",'Audit Tool'!G18)","v":""}]
[null,">20% to ≤ 40%","Developing risk management system in place","Basic risk management processes in place, with developing formal or structured processes",null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G19=\"\",\"\",'Audit Tool'!B19)","v":""},{"$f":"IF(L19=\"\",\"\",'Audit Tool'!G19)","v":""}]
[null,">40% to ≤ 60%","Partially developed risk management system in place","Risk management processes are generally applied with formal structure and process",null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G20=\"\",\"\",'Audit Tool'!B20)","v":""},{"$f":"IF(L20=\"\",\"\",'Audit Tool'!G20)","v":""}]
[null,">60% to ≤ 80%","Substantially developed risk management system in place","Generic risk processes are consistent, formalised and widespread, though benefits are not always consistently achieved  ",null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G21=\"\",\"\",'Audit Tool'!B21)","v":""},{"$f":"IF(L21=\"\",\"\",'Audit Tool'!G21)","v":""}]
[null,">80% to ≤ 100%","Full developed risk management system in place","Risk management processes are optimized and are continually reviewed to further the effectiveness and integration of processes",null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G22=\"\",\"\",'Audit Tool'!B22)","v":""},{"$f":"IF(L22=\"\",\"\",'Audit Tool'!G22)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G23=\"\",\"\",'Audit Tool'!B23)","v":""},{"$f":"IF(L23=\"\",\"\",'Audit Tool'!G23)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G24=\"\",\"\",'Audit Tool'!B24)","v":""},{"$f":"IF(L24=\"\",\"\",'Audit Tool'!G24)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G25=\"\",\"\",'Audit Tool'!B25)","v":""},{"$f":"IF(L25=\"\",\"\",'Audit Tool'!G25)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G26=\"\",\"\",'Audit Tool'!B26)","v":""},{"$f":"IF(L26=\"\",\"\",'Audit Tool'!G26)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G27=\"\",\"\",'Audit Tool'!B27)","v":""},{"$f":"IF(L27=\"\",\"\",'Audit Tool'!G27)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G28=\"\",\"\",'Audit Tool'!B28)","v":""},{"$f":"IF(L28=\"\",\"\",'Audit Tool'!G28)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G29=\"\",\"\",'Audit Tool'!B29)","v":""},{"$f":"IF(L29=\"\",\"\",'Audit Tool'!G29)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G30=\"\",\"\",'Audit Tool'!B30)","v":""},{"$f":"IF(L30=\"\",\"\",'Audit Tool'!G30)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G31=\"\",\"\",'Audit Tool'!B31)","v":""},{"$f":"IF(L31=\"\",\"\",'Audit Tool'!G31)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G32=\"\",\"\",'Audit Tool'!B32)","v":""},{"$f":"IF(L32=\"\",\"\",'Audit Tool'!G32)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G33=\"\",\"\",'Audit Tool'!B33)","v":""},{"$f":"IF(L33=\"\",\"\",'Audit Tool'!G33)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G34=\"\",\"\",'Audit Tool'!B34)","v":""},{"$f":"IF(L34=\"\",\"\",'Audit Tool'!G34)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G35=\"\",\"\",'Audit Tool'!B35)","v":""},{"$f":"IF(L35=\"\",\"\",'Audit Tool'!G35)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G36=\"\",\"\",'Audit Tool'!B36)","v":""},{"$f":"IF(L36=\"\",\"\",'Audit Tool'!G36)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G37=\"\",\"\",'Audit Tool'!B37)","v":""},{"$f":"IF(L37=\"\",\"\",'Audit Tool'!G37)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G38=\"\",\"\",'Audit Tool'!B38)","v":""},{"$f":"IF(L38=\"\",\"\",'Audit Tool'!G38)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G39=\"\",\"\",'Audit Tool'!B39)","v":""},{"$f":"IF(L39=\"\",\"\",'Audit Tool'!G39)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G40=\"\",\"\",'Audit Tool'!B40)","v":""},{"$f":"IF(L40=\"\",\"\",'Audit Tool'!G40)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G41=\"\",\"\",'Audit Tool'!B41)","v":""},{"$f":"IF(L41=\"\",\"\",'Audit Tool'!G41)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G42=\"\",\"\",'Audit Tool'!B42)","v":""},{"$f":"IF(L42=\"\",\"\",'Audit Tool'!G42)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G43=\"\",\"\",'Audit Tool'!B43)","v":""},{"$f":"IF(L43=\"\",\"\",'Audit Tool'!G43)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G44=\"\",\"\",'Audit Tool'!B44)","v":""},{"$f":"IF(L44=\"\",\"\",'Audit Tool'!G44)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G45=\"\",\"\",'Audit Tool'!B45)","v":""},{"$f":"IF(L45=\"\",\"\",'Audit Tool'!G45)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G46=\"\",\"\",'Audit Tool'!B46)","v":""},{"$f":"IF(L46=\"\",\"\",'Audit Tool'!G46)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G47=\"\",\"\",'Audit Tool'!B47)","v":""},{"$f":"IF(L47=\"\",\"\",'Audit Tool'!G47)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G48=\"\",\"\",'Audit Tool'!B48)","v":""},{"$f":"IF(L48=\"\",\"\",'Audit Tool'!G48)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G49=\"\",\"\",'Audit Tool'!B49)","v":""},{"$f":"IF(L49=\"\",\"\",'Audit Tool'!G49)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G50=\"\",\"\",'Audit Tool'!B50)","v":""},{"$f":"IF(L50=\"\",\"\",'Audit Tool'!G50)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G51=\"\",\"\",'Audit Tool'!B51)","v":""},{"$f":"IF(L51=\"\",\"\",'Audit Tool'!G51)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G52=\"\",\"\",'Audit Tool'!B52)","v":""},{"$f":"IF(L52=\"\",\"\",'Audit Tool'!G52)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G53=\"\",\"\",'Audit Tool'!B53)","v":""},{"$f":"IF(L53=\"\",\"\",'Audit Tool'!G53)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G54=\"\",\"\",'Audit Tool'!B54)","v":""},{"$f":"IF(L54=\"\",\"\",'Audit Tool'!G54)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G55=\"\",\"\",'Audit Tool'!B55)","v":""},{"$f":"IF(L55=\"\",\"\",'Audit Tool'!G55)","v":""}]
[null,"POST AUDIT IMPLEMENTATION PLAN",null,null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G56=\"\",\"\",'Audit Tool'!B56)","v":""},{"$f":"IF(L56=\"\",\"\",'Audit Tool'!G56)","v":""}]
[null,"Section","Auditor’s Recommendation","Person Responsible","Target date for Completion",null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G57=\"\",\"\",'Audit Tool'!B57)","v":""},{"$f":"IF(L57=\"\",\"\",'Audit Tool'!G57)","v":""}]
[null,{"$f":"'Audit Tool'!B5","v":1.1000000000000001},{"$f":"IF('Audit Tool'!G5=0,\"\",'Audit Tool'!G5)","v":""},null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G58=\"\",\"\",'Audit Tool'!B58)","v":""},{"$f":"IF(L58=\"\",\"\",'Audit Tool'!G58)","v":""}]
[null,{"$f":"'Audit Tool'!B6","v":1.2},{"$f":"IF('Audit Tool'!G6=0,\"\",'Audit Tool'!G6)","v":""},null,null,null,null,null,null,null,null,{"$f":"IF('Audit Tool'!G59=\"\",\"\",'Audit Tool'!B59)","v":""},{"$f":"IF(L56=\"\",\"\",'Audit Tool'!G59)","v":""}]
[null,{"$f":"'Audit Tool'!B7","v":1.2},{"$f":"IF('Audit Tool'!G7=0,\"\",'Audit Tool'!G7)","v":""}]
[null,{"$f":"'Audit Tool'!B8","v":2.1},{"$f":"IF('Audit Tool'!G8=0,\"\",'Audit Tool'!G8)","v":""}]
[null,{"$f":"'Audit Tool'!B9","v":"2.1.1"},{"$f":"IF('Audit Tool'!G9=0,\"\",'Audit Tool'!G9)","v":""}]
[null,{"$f":"'Audit Tool'!B10","v":"2.1.1"},{"$f":"IF('Audit Tool'!G10=0,\"\",'Audit Tool'!G10)","v":""}]
[null,{"$f":"'Audit Tool'!B11","v":"2.1.2"},{"$f":"IF('Audit Tool'!G11=0,\"\",'Audit Tool'!G11)","v":""}]
[null,{"$f":"'Audit Tool'!B12","v":2.2000000000000002},{"$f":"IF('Audit Tool'!G12=0,\"\",'Audit Tool'!G12)","v":""}]
[null,{"$f":"'Audit Tool'!B13","v":"2.2.1"},{"$f":"IF('Audit Tool'!G13=0,\"\",'Audit Tool'!G13)","v":""}]
[null,{"$f":"'Audit Tool'!B14","v":"2.2.2-3"},{"$f":"IF('Audit Tool'!G14=0,\"\",'Audit Tool'!G14)","v":""}]
[null,{"$f":"'Audit Tool'!B15","v":"2.2.4"},{"$f":"IF('Audit Tool'!G15=0,\"\",'Audit Tool'!G15)","v":""}]
[null,{"$f":"'Audit Tool'!B16","v":3.1},{"$f":"IF('Audit Tool'!G16=0,\"\",'Audit Tool'!G16)","v":""}]
[null,null,{"$f":"IF('Audit Tool'!G17=0,\"\",'Audit Tool'!G17)","v":""}]
[null,null,{"$f":"IF('Audit Tool'!G18=0,\"\",'Audit Tool'!G18)","v":""}]
[null,{"$f":"'Audit Tool'!B19","v":"3.1.1"},{"$f":"IF('Audit Tool'!G19=0,\"\",'Audit Tool'!G19)","v":""}]
[null,{"$f":"'Audit Tool'!B20","v":"3.1.2"},{"$f":"IF('Audit Tool'!G20=0,\"\",'Audit Tool'!G20)","v":""}]
[null,{"$f":"'Audit Tool'!B21","v":"3.1.3"},{"$f":"IF('Audit Tool'!G21=0,\"\",'Audit Tool'!G21)","v":""}]
[null,{"$f":"'Audit Tool'!B22","v":"3.1.4"},{"$f":"IF('Audit Tool'!G22=0,\"\",'Audit Tool'!G22)","v":""}]
[null,{"$f":"'Audit Tool'!B23","v":"3.1.5"},{"$f":"IF('Audit Tool'!G23=0,\"\",'Audit Tool'!G23)","v":""}]
[null,{"$f":"'Audit Tool'!B24","v":3.2},{"$f":"IF('Audit Tool'!G24=0,\"\",'Audit Tool'!G24)","v":""}]
[null,{"$f":"'Audit Tool'!B25","v":"3.2.1-3.2.3"},{"$f":"IF('Audit Tool'!G25=0,\"\",'Audit Tool'!G25)","v":""}]
[null,null,{"$f":"IF('Audit Tool'!G26=0,\"\",'Audit Tool'!G26)","v":""}]
[null,null,{"$f":"IF('Audit Tool'!G27=0,\"\",'Audit Tool'!G27)","v":""}]
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{"sheet":"Admin Only","index":4,"n_rows":23,"n_cols":55,"rows_kept":23,"cut":false,"hidden":false,"merged":[]}
["Cooling Tower IDs","Facility Name","Has a multi-discipline risk management team been assembled","Has a risk management plan been established","Is the risk management plan up to date","Have flow diagrams, schematics or layouts been developed","Is there a description of the water distribution system","Is the system description supported by an asset register","Have areas of higher risk of infection been identified","Has a qualitative risk assessment been undertaken","Does the risk assessment identify potential hazardous events","Does the risk assessment analyse all system components","Does the risk assessment analyse personnel risk","have controls been identified","have minimum staff training requirements been identified","Has a training program been implemented","managing the incoming water supply","managing the plumbing system","disinfection systems","regular maintenance","reduce exposures to aerosols to personnel","written procedures in place","operational monitoring plan in place","verification monitoring plan in place","testing locations known to facility staff","monitoring results documented","periodically review and report results","written response procedures in place","response procedures cover control measures","response procedures cover response to a suspected case","response procedures cover contingency measures","process in place to review the rmp","records kept of documents (review)","improvement plan in place (review)","suitable training requirements - operations","maintenance program in place - operations","appropriate water treatment program in place - operations","up to date operations and maintenance manual","records of manuals, risk assessment reports","discharge exhaust away from occupied areas - operations","review of the system been conducted - performance","risk assessment or risk management plan - performance","performance indicators in place - performance","legionella and HPC monitoring undertaken - performance","monitoring undertaken under AS3666-3 Appendix A - performance","report prepared each month - performance","action taken in response - performance","cold water source meet the ADWG","water distribution system of ring main meet the ADWG","arrangement to minimise spur/branch lines ADWG","HW minimise spur/branch lines","HW thermostatic mixing valves used in clinical areas","HW avoid mixed warm water dead legs","HW thermostatic mixing valves accessible","HW multiple isolating valves to deliver flushing"]
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