On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections.  Accredited facilities should double check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys.
Legionellosis is comprised of a sometimes fatal form of pneumonia called LD as well as Pontiac fever. The bacterium grows in the parts of hospital water systems that are continually wet and is spread through inhalation of aerosolized droplets of contaminated water. Legionellosis poses a particular risk to patients older than 50, who smoke or have chronic lung or immunosuppression conditions. Approximately 9% of reported legionellosis cases are fatal.
Badly maintained water systems have been linked to the 286% increase in legionellosis between 2000-2014. There were 5,000 cases of it reported to the Centers for Disease Control and Prevention (CDC) in 2014 alone. About 19% of outbreaks were associated with long-term care facilities and 15% with hospitals. Just a few items that can spread the contamination include:
• Decorative fountains
• Shower heads and hoses
• Electronic and manual faucets
• Hot and cold water storage tanks
• Water heaters and filters
• Pipes, valves, and fittings
• Eyewash stations
• Ice machines
• Cooling towers
• Medical devices (e.g., CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)
“Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of its patients,” the agency writes in its memo. “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.”
The memo tells surveyors to review policies, procedures, and reports documenting water management implementation results to ensure facilities:
1. Conduct a facility risk assessment to identify where Legionella and other waterborne pathogens could grow and spread in the facility water system.
2. Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit. The program should include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
3. Specify testing protocols and acceptable ranges for control measures. Document the results of testing and corrective actions taken when control limits are not maintained.
The contents of this memo go into effect immediately.