What Are the Requirements Related to Legionella for Healthcare Facilities?

Centers for Medicare & Medicaid Services (CMS) Requirements:

• CMS issued a directive (S&C 17-30) requiring hospitals, critical access hospitals, nursing homes, and other healthcare facilities to develop and adhere to water management policies that inhibit the growth and spread of Legionella and other opportunistic pathogens in building water systems.
• These policies must be in accordance with the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) Standard 188-2015 and the CDC toolkit. Facilities must regularly monitor water systems and take corrective actions when needed to ensure safe water for patients, residents, and visitors.

Joint Commission Requirements:

• The Joint Commission, an accrediting body for healthcare organizations, requires compliance with water management policies to minimize the risk of Legionella. This includes implementing water management programs as outlined by ASHRAE 188-2015 and the CDC guidelines.
• During inspections, The Joint Commission assesses whether a facility has an effective water management plan that includes Legionella risk assessments, Legionella testing, and Legionella remediation when necessary.

ASHRAE Standards:

• ASHRAE 188-2015 provides a framework for building owners and managers, including those in healthcare facilities, to develop water management plans to prevent Legionella growth. This standard is considered the benchmark for creating a water management program in healthcare settings.
• Compliance with ASHRAE 188-2015 is not just recommended but is often required by regulatory bodies and accrediting organizations for healthcare facilities.
• Legionella Control Systems utilizes the Professional Qualifications Standard for Legionella Water Safety and Management Personnel, ASSE/IAPMO/ANSI 12080. Our staff have attained ASSE 12080 Legionella Water Safety and Management Specialist Certification.

CDC Guidelines and Toolkits:

• The CDC provides a comprehensive toolkit for developing a water management program that aligns with ASHRAE 188-2015. The CDC emphasizes the importance of these programs in settings where people are at increased risk of Legionnaires’ disease, such as hospitals and long-term care facilities. See the CDC Legionella risk assessment.
• Facilities are expected to follow these guidelines to mitigate the risk of Legionella growth and transmission.

Implications for Compliance

Healthcare facilities that fail to comply with these requirements can face serious consequences, including:

• CMS Sanctions: Non-compliance with CMS directives can lead to penalties, including loss of Medicare and Medicaid funding.
• Joint Commission Accreditation: Failure to meet The Joint Commission’s standards can jeopardize a facility’s accreditation status, impacting its ability to operate.
• Legal Liability: If a Legionella outbreak occurs due to an inadequate water management program, facilities may face legal action, including lawsuits from affected patients or residents. Calculate your potential Legionella liability.

How Do We Comply with Legionella Requirements as a Healthcare Facility?

Contact the Legionella experts at Legionella Control Systems to learn how to best comply with medical and healthcare facility Legionella requirements.