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Updates to the CMS Mandates on Legionnaires’ Disease

Updates to the CMS Mandates on Legionnaires’ Disease
Updated: Nov 16, 2018
CMS Mandates on Legionnaires’ Disease
Recent Updates to the CMS Mandates on Legionnaires’ Disease

On July 6, 2017, CMS (Centers for Medicare & Medicaid Services) published a revision memo concerning their policies on Legionella management and industry standards for water management plans. The memo indicated that Medicare-certified healthcare facilities are expected to have water management plans and policies to combat the growth and spread of the Legionella bacterium and other water borne organisms in their water systems.


This memo follows an increased number in the breakouts of Legionnaires’ Disease during the past few months within the country reported by the CDC as well as other state and local health departments. Occurrences of Legionnaires’ Disease have been linked to poorly maintained water systems. Exposure can happen via aerosol water droplets from showerheads, hot tubs, decorative fountains, cooling towers, water filters and more.


Healthcare Facilities must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building systems.


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 could grow and spread in the facility water system.


· Develop and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit.


· 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.


· Maintains compliance with other applicable Federal, State and local requirements.


Healthcare 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 noncompliance with the CMS Conditions of Participation. Accrediting organizations will survey healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.


Access the full memorandum posted by the CMS here.


Listed resources include the Risk Assessment of Legionellosis published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) calling for the development and implementation of water management programs in large or complex building water systems to reduce risks of Legionellosis, and the CDC toolkit to facilitate implementation of this ASHRAE Standard. Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit.


For guidance on the latest on local and national laws and mandates contact IWC Innovations.  We can help your organization navigate this complicated issue and keep you in compliance with our defensible Water Management Plans. We provide the easiest solution for these mandates and regulations. IWC is fully equipped and ready with an armory of assets to develop a compliant plan for your facility in the most cost-effective way possible.





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