New survey and certification letter on water management

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The Centers for Medicare and Medicaid Services (CMS) has posted a Survey and Certification Letter that outlines the responsibilities of health care providers, including Medicare-certified Skilled Nursing Facilities (SNFs), to develop and implement water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Specifically, CMS expects Medicare certified healthcare facilities to have An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard. Environmental, clinical, and epidemiologic considerations for healthcare facilities are described in this toolkit.

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

  • 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.

Health care facilities are expected to comply with CMS requirements to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.