CMS Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease

PUBLISHED: Jul 9, 2018
Relevant to: Critical Access Hospitals, Hospitals, Long Term Care

The U.S. Centers for Medicare and Medicaid Services (CMS) is clarifying expectations for providers, accrediting organizations, and surveyors about the requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ Disease (LD). The new CMS memorandum does not add any new requirements, rather it seeks to clarify and reinforce existing requirements.

Background:

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:

Hospitals, Critical Access Hospitals and Long Term Care 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. Pertinent regulations include, but are not limited to:

  • 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.”

Compliance Expectations:

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities (including Long Term Care Facilities) must have water management plans and documentation that, at a minimum, ensure each facility:

  • Conducts 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.
  • Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit.
  • Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.
  • Maintains compliance with other applicable Federal, State and local requirements.
  • Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider.

Included with today’s notice is an example water management program as well as a link to the new CMS memorandum.

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