CMS Legionella Requirement - Inspecting Hospitals and Nursing Homes for the CMS Legionella

To avoid a citation and receive Medicare or Medicaid reimbursements, hospitals and long-term care facilities must “demonstrate measures” that show compliance with the June 2017 Centers for Medicare & Medicaid Services (CMS) “requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ disease (LD).”

The June 2 CMS memorandum (S&C 17-30) does not give prescriptive, detailed procedures to follow. It simply requires a water management program that minimizes the risk of Legionnaires’ disease, giving the facility flexibility in the policies and procedures toward that outcome provided the program “considers the ASHRAE industry standard and the CDC toolkit, and includes…environmental testing for pathogens.”

Even the ASHRAE standard (ANSI/ASHRAE Standard 188-2015) and CDC toolkit to which the CMS memorandum refers outlines only a framework for a WMP, still requiring the facilities to determine the specific policies, procedures, and control measures with which to fill the framework. Decisions about those details are crucial. Ideally, hospitals and nursing homes will implement an effective WMP—one that truly reduces Legionella risk—without wasting money on unnecessary procedures.

Inspections of hospitals and nursing homes will be a key to success (real prevention at a reasonable cost) of the CMS requirement. Assuming the inspections are short, surveyors will have limited time to determine whether the facility has established and implemented an effective WMP, so they should ask clear and objective questions that reveal whether crucial criteria have been met. The checklist should be consistent from state to state, facility to facility.

The following 11 -point checklist—based on wording in the CMS memorandum—might provide a good starting point:

1. Has the facility conducted a 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?

Based on ASHRAE 188 and the CDC toolkit, a facility’s risk is based primarily on the types of water systems it has. Does the WMP document list a brief description of each one of the following types of water systems on the property?

Type of Water System No. of systems
on the property
Each
described?
Domestic cold water
Domestic hot water
Cooling tower or evaporative condenser systems
Decorative Fountains
Whirlpool spas

2. Has the facility established a water management program (WMP) for the water systems listed in #1?

3. Does the WMP list specific preventive measures (control measures) for the operation and maintenance of the types of water systems listed in #1 (e.g., physical controls, temperature management, disinfectant level control, visual inspections)? How many control measures are listed for each system type?

Type of Water System No. of control measures
Domestic cold water
Domestic hot water
Cooling tower systems
Decorative Fountains
Whirlpool spas

4. Does the WMP include Legionella control measures for the design, specification, construction, and commissioning phases of new building and major renovation projects?

5. Does the WMP outline specific steps for responding to incidents such as water main breaks, and for planning temporary system shutdowns?

6. Per ANSI/ASHRAE Standard 188-2015 and the CDC toolkit, does the WMP list performance criteria (control limits) for each control measure, a monitoring procedure for determining control measure performance, and corrective actions to take if the control measure is not performed within the control limit?

7. Does the WMP outline specific steps for responding to a suspected or confirmed case of Legionnaires’ disease?

8. Does the WMP outline specific and meaningful validation procedures? The facility should be able to provide brief and clear answers to the following questions:

a. What are the specific method(s) of validating its WMP for effectiveness in controlling Legionella?
b. Why are the validation methods reliable in indicating whether the WMP is effective in controlling Legionella?
c. How can the validation method(s) help the facility improve its water management practices for reducing waterborne pathogen risk?

9. Is the facility validating its WMP by environmental testing for Legionella or other pathogens? If so:

a. For what pathogen(s) is it testing samples from the water systems?
b. Which water systems are being sampled?
c. On what criteria is the facility interpreting test results?
d. Does the facility have a specific plan for responding to test results?
e. Does the facility have tools (e.g., spreadsheet or database) for monitoring test result trends?

10. Does the WMP include a written plan for communication and notification (e.g., of test results)? Are all necessary departments (e.g., facilities engineering; infection control) included?

11. Did the facility show documentation to verify that the WMP control measures, validation procedures, and corrective actions have been implemented for the past 12 months?

As surveyors get more experience, the checklist could be expanded and refined.

What do you think should be added to or deleted from the above checklist? What has been your hospital’s or nursing home’s experience with inspections for the CMS Legionella requirement?

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