Centers For Medicare & Medicaid Services (CMS) Updated Requirements to Reduce Legionella Risk

Written by: Hilary Nardone, Lead Environmental Group Manager

On July 6, 2018, the Centers for Medicare & Medicaid Services (CMS) updated its policy memorandum, which was originally implemented on June 2, 2017. The CMS policy memorandum (S&C 17-30-Hospitals/CAHs/NHs) requires all healthcare facilities, in all 50 states, to “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.”

The purpose of the 2018 update is to clarify existing expectations set in 2017, and does not impose any new requirements.

Expectations for Healthcare Facilities:

 Facilities must have a Water Management Plan and documentation that, at a minimum, ensures that the 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 188 industry standard and the CDC toolkit
  • Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions taken when control limits are not maintained
  • Maintains compliance with other applicable Federal, State, and local requirement

Update Highlights:

  • While the memorandum requires having testing protocols, specific testing protocols are at the discretion of the provider
  • Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocol) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use

If you are interested in creating a Water Management Plan and other solutions for minimizing Legionella bacteria risk in your facility, contact Barclay Water Management, Inc. 

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