CMS Memorandum Regarding Legionella

Policy Memorandum from the Centers for Medicare & Medicaid Services (CMS) regarding the requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)

 

Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least 50 years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including critical access hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.

 

CMS, Facility Requirements to Prevent Legionella Infections include development of, and adherence 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.

 

Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization.   Components of compliance required by the facilities include:

 

  • Conduct 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.

 

  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

 

  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

 

Aires Consulting has assisted many clients, including commercial, institutional and HEALTHCARE, in the identification and assessment of waterborne pathogens including but not limited to Legionella.

 

Call us today to discuss how we may assist you in the development and implementation of your programs.