The Centers for Medicare & Medicaid Services (CMS) revised its June 2, 2017 S&C memo, “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)” on July 7, 2018. The revision clarifies both healthcare provider and surveyor expectations related to Legionella management.
Nursing homes are expected to have water management plans in place related to reducing Legionella risk in their facilities, as well as associated documentation which addresses several points. First, facilities must conduct and document a facility risk assessment to identify where Legionella and other “opportunistic” waterborne pathogens could grow and spread in the water system. Facilities must also be able to show that they have developed water management plans that are based on the ASHRAE industry standard as well as the CDC’s related toolkit. Facilities must specify and document the protocols that will be used for testing as well as control measure ranges that are considered acceptable. The corrective actions that will be taken when these control measure ranges are not maintained must also be included in the plan. CMS has added to this revised QSO memo specifically that facilities must maintain “compliance with other applicable Federal, State and local requirements,” but also notes that the Agency does not require water cultures for these pathogens and that testing protocols can be developed by each provider.
The memo further states that long-term care facility surveyors should look to see if the facility has available a water management plan in place that meets the above-mentioned criteria, including a facility-specific risk assessment and testing protocols, but that facilities should not be cited based on their risk assessments or testing protocols. Updated guidance to surveyors is expected in the future to provide clarification to this area.