Updated on 6/24/19
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) 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 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.
Update June 24, 2019: In July 2018, the CMS updated its requirement (QSO-17-30), clarifying expectations and specifically noting that environmental testing for pathogens is at the discretion of the facility.
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?
How about Ice Machines, Emergency Water Systems for your list of water systems.
Also protocols that need to be followed if the monitoring reveals a positive result.
Hyperchlorination is not an easy as the name suggests in an operating healthcare facility.
Hi Jay. Thanks for your comments. I agree that control measures for ice machines should be included. In our WMPs, we include measures for them within the category of “domestic water systems,” treating them as a point-of-use (POU) device, but it would be fine to put them in a category of their own. In 9d of the proposed checklist, the surveyor asks for the facility’s plan for responding to test results. Some states may end up requiring a specific response rather than giving the facility leeway.
I am a little confused with LD being associated with ice machines. Is it associated with ice? There are two types of cooling process for ice machine refrigeration. One is air cooled that involves a fan blowing over compressor and the only water outlet is manufactured ice. The other is a water cooled compressor where domestic water is used, circulated around compressor, and then warmed water is wasted down a open floor drain. Wasted water would certainly have a possible water mist. Which has been associated with LD? Is it in the ice itself? I thought temperatures in ice would be too low for LD bacteria to thrive. The older I get, the less I can figure out. Thanks Matt for making us aware.
Hi Nelson. Ice and water in ice machines can be prone to Legionella contamination, in part because the line supplying water to the machine is typically small in diameter and warmed by the condenser at the rear of the machine, and some types of ice machine filters provide good conditions for Legionella growth. Patients have contracted Legionnaires’ disease from Legionella in ice (Graman, 1997, Nosocomial Legionellosis Traced to a Contaminated Ice Machine, ICHE). Also, in hospitals in the US, patient are given drinking water from ice machine water dispensers. You might be interested in this recent paper about ice machines and mycobacteria: Guspiel A. Menk J, Streifel A. 2017. Management of Risks From Water and Ice From Ice Machines for the Very Immunocompromised Host: A Process Improvement Project Prompted by an Outbreak of Rapidly Growing Mycobacteria on a Pediatric Hematopoietic Stem Cell Transplant (Hsct) Unit. Infect Control Hosp Epidemiol, March, 1-9. Thanks for your comments
Legionella remains dormant in ice, not dead. When a patient is given the contaminated ice it is possible that he/she aspirates (liquid going down the wrong pipe)the melted ice and introduces it into his/her lungs.
The water (melted ice) which contains legionella bacteria, enters the lungs and legionella grows and spreads in the immuno-compromised patient, ultimately causing Legionnaires Disease.
Thank you, Manuel. Reports of Legionnaires’ disease linked to ice given to patients has been published in scientific literature. Water management programs should include control measures for ice machines.
Hi Matt,
I am curious about minimum sampling frequency requirements. I read someplace that the CDC determined a minimum quarterly sample schedule was recommended/required in long term health care facilities.
Can you confirm?
Thank you.
Hi Dave.
I don’t know of a CDC recommendation for quarterly Legionella sampling but VA Directive 1061 requires testing domestic water systems for Legionella quarterly in VA facilities with overnight stays. The New York laws require quarterly sampling of cooling towers. Also, back in 1991, the EPA stated “It is suggested that hospitals, and other institutions with potential for the growth of Legionella, conduct routine monitoring of their hot water systems at least quarterly” (EPA. 1991. Guidance Manual for the Compliance with the Filtration and Disinfection Requirements for Public Water Systems Using Surface Water Sources, March 1991 Edition, Parts One and Two, Appendix B, “Institutional Control of Legionella,” pages 201-206. Washington, DC: U.S. Environmental Protection Agency).
Four times a year is the LAMPS recommended starting frequency for Legionella testing in hospitals and nursing homes. In most areas of the US, four times a year (Jan, May, July, Sept) is better than a strict quarterly schedule, to sample more frequently during the warmer months.
I believe that HVAC systems that use energy saving “free cooling” are susceptible to legionella. Cooling towers are typically connected to Plate & Frame Heat Exchangers. It is possible, in my opinion, that a HEX (Heat Exchanger) or it’s related pumps and piping, can house the legionella bacteria even when a non-detect test of a cooling tower is observed and documented. These devices are usually indoors, heavily insulated and have very small internal spaces by design. They also house stagnant water for most of the cooling cycle as they circulate water only during the shoulder seasons when it’s relatively cool outdoors, hence the term “free cooling.”
I see potential risk with this equipment. That is why I had requested the ASSE to include Plate & Frame HEXs on their list of equipment at risk of harboring legionella. They included them in their ASSE Guidelines for Infection Control Risk Assessment for all Building Systems Certification which was recently revised this past November.
Thank you for your comments, Manual. In our LAMPS water management plans (WMPs), we have a control measure for circulating water through those systems even when they are offline.
Does CMS require monthly Legionella water testing for nursing homes in the US? If yes, where do they typically send their water samples to? what is typical cost for a test.
Hi Alice. In its 2018 update (QSO-17-30- Hospitals/CAHs/NHs), CMS clarified that it does not require testing for Legionella and other pathogens.
Anti-scalding regs for SNFs ( NHs) in my state of Texas mandate hot water temps be kept no higher than 110 degrees F. ASHREA recommends super heated or super chlorinated flushes be done periodically. My question is- how often should they be done in a facility with no positive cases and hot water temp of 110 degrees F to keep the water system healthy?
Hi Betsy. Periodic hyperchlorination is very, very rarely the best option for managing the risk of Legionella or other pathogens in plumbing (domestic) water systems. If Legionella is not under control despite full implementation of comprehensive operation and maintenance control measures, then continuous supplemental disinfection may be needed.