CMS: Facilities must develop and adhere to policies that prevent legionella


Authors: Centers for Medicare & Medicaid Services | Subject Matter: Article | Topics: Codes and standards, Facility management, Infection prevention, Safety/security

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.