The Centers for Medicare & Medicaid Services (CMS) says hospitals must develop and adhere to policies and procedures that reduce the risk of legionella and other waterborne pathogens. CMS issued a Survey & Certification Group memo stating that surveyors will review policies, procedures, and reports to verify that facilities are:
- Conducting risk assessments to identify where waterborne pathogens could grow;
- Implementing a water management program that considers ASHRAE Standard 188 and CDC guidelines;
- And specifies testing protocols and acceptable ranges for control measures.
Facilities unable to demonstrate measures to minimize the risk of Legionnaire’s Disease will be at risk of citation for non-compliance with the CMS Conditions of Participation. The policy applies to hospitals, critical access hospitals, and long-term care facilities, although CMS said its memo is also intended to provide general awareness of this issue for all health care organizations.
An ASHE monograph provides step-by-step instructions on water management. ASHE members can download a free copy of Water Management in Health Care Facilities: Complying with ASHRAE Standard 188. The ASHE Annual Conference in Indianapolis this August will also feature a session about water management.