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Compliance News: CMS Strengthens Regulations against Legionella in Healthcare Facilities

| David Stymiest

The fight against Legionella bacteria within healthcare facilities has been a topic of healthcare industry discussions and concern for more than a decade.

CMS substantially raised the bar in June 2017 when it issued a revised Survey & Certification Letter [S&C 17-30-Hospitals/CAHs/NHs REVISED 06.09.2017] PDF entitled “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD).”  This letter had been issued on June 2, 2017 but the June 9, 2017 revision was necessary “to Clarify Provider Types Affected” per CMS.

The CMS S&C Letter’s summary states:

  • Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least 50 years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.
  • Facility Requirements to Prevent Legionella Infections: Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water.
  • This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs), and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations.”

CMS also made available its 35-page water management program toolkit entitled “Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings” as a resource.

The CMS water management program toolkit content includes special considerations for healthcare facilities, along with the following more general topics:

  • Identifying buildings at increased risk
  • Legionella ecology
  • Establishing a water management program team
  • Describing building water systems using both text and flow diagrams
  • Identifying areas where legionella could grow & spread
  • Control measures & corrective actions – basics, where to measure, monitoring
  • Ways to intervene when control limits are not met
  • Examples of corrective actions and contingency response
  • Keeping the program running as designed & effective
  • Documenting & communicating water management program activities
  • Identifying & investigating legionnaires’ disease cases

The CMS water management program toolkit webpage also includes links to the following additional resources:

ASHE is also contributing to the healthcare industry’s body of knowledge with its recent news post entitled 7 Steps to Creating a Water Management Program as well as its recently-published Management Monograph entitled Water Management in Health Care Facilities: Complying With ASHRAE Standard 188.

The readers of this article are urged to avail themselves of the resources identified above as well as other salient resources.

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