On June 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a new communication to surveyors on health care facility requirements to prevent Legionella infections. Legionella is a ubiquitous, waterborne bacteria often found in complex building water systems. Legionnaires’ disease (LD), which is caused by inhalation of aerosolized water containing Legionella bacteria, causes severe pneumonia in at-risk populations including: patients older than 50, who smoke or have chronic lung or immunosuppression conditions or other chronic health conditions. The CMS memo instructs surveyors to review policies, procedures, and reports documenting that the facility’s water management program complies with CMS requirements to protect the health and safety of its patients. Specifically, 42 CFR §482.42 states, “The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable disease. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.”
On June 6, the Centers for Disease Control and Prevention (CDC) published a Morbidity and Mortality Weekly Report (MMWR) on LD surveillance data from 21 jurisdictions. The majority of health care-associated LD outbreaks were attributed to water system exposures that could have been prevented by an effective water management program. LD exposure sources often include showerheads, certain medical equipment (e.g., respiratory equipment), hydrotherapy equipment, cooling towers, or decorative fountains.
In 2015, the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) published Standard 188: Risk Management for Building Water Systems, which has a specific Health Care Facilities Annex. CDC then developed a toolkit to support implementation of water management programs incorporating ASHRAE Standard 188 recommendations. CMS’s memo instructs surveyors to review documentation to ensure that facilities:
- Have conducted a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system
- Have implemented a water management plan that considers ASHRAE Standard 188 and CDC’s toolkit
- Established testing protocols, documented results of testing, and taken corrective actions when acceptable ranges are not maintained
The MMWR also states that health care facilities are well positioned to build on existing infection control and patient safety activities to establish and maintain a compliant water management program. Facilities in New York State are uniquely positioned since the New York State Department of Health and the New York City Department of Health and Mental Hygiene already require compliance with ASHRAE Standard 188 following one of the largest LD outbreaks in the US, which happened in New York City in the South Bronx in 2015. The CMS memo instructions go into effect immediately.