Legionella and Opportunistic Waterborne Pathogens Requirements for Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC) Facilities
The Center for Clinical Standards and Quality/Survey & Certification Group at the Centers for Medicare & Medicaid Services (CMS) issued a “Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ Disease (LD)” as well as other opportunistic waterborne pathogens noted below.
This CMS memo applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, the CMS policy memorandum is also intended to provide general awareness for all healthcare organizations.
The memorandum provides a summary of the 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.”
The memorandum continues by citing pertinent regulations that include, but are not limited to, the items below:
- 42 CFR §482.42 for hospitals:
“The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.”
- 42 CFR §483.80 for skilled nursing facilities and nursing facilities:
“The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.”
- 42 CFR §485.635(a)(3)(vi) for critical access hospitals (CAHs):
CAH policies must include: “A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.”
What are the CMS Expectations for Healthcare Facilities and Surveyors?
CMS expects Medicare certified healthcare facilities to have water management policies & procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by ASHRAE. The CDC and its partners then developed a toolkit to facilitate implementation of this ASHRAE Standard.
Based on the above, the surveyors review policies, procedures, and reports documenting water management implementation results to verify that facilities:
- Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
- Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
- Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
According to CMS, healthcare facilities are expected to comply with these requirements to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of Legionnaires’ Disease are at risk of citation for non-compliance. Accrediting organizations will survey healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite non-compliance accordingly.
As you can see from the above, CMS has robust requirements for the control of Legionella and other other opportunistic waterborne pathogens including Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi. Compliance is required and carries serious penalties for non-compliance.
Due to the complexities and seriousness of this subject, we recommend that organization not attempt to create their own water management program. Independent consulting will provide both assurance of compliance as well as broad-based knowledge that can lead to an appropriately robust but cost-effective solution. Nancrede Engineering is one of the few truly independent consultants in this area. Contact us today.