Your Duty

The survey and certification memo released by the CMS June 2, 2017 states hospitals and other healthcare facilities "must develop" policies to inhibit Legionella growth in water systems to prevent Legionnaires' disease cases. Hospitals have complex water systems that require consistent management. 

Per the memo, from the director of CMS survey and certification group, "CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems." Hospitals need to conduct a risk assessment, implement a water management program and specify testing protocols. Moving forward, CMS surveyors will review facilities' water management implementation policies, procedures and reports.

Patient in hospital

New Water Management Requirements 

The Joint Commission

Effective January 1, 2022, The Joint Commission has approved a new standard on water management programs that addresses Legionella and other waterborne pathogens.  

During surveys, The Joint Commission  look for evidence of compliance with the following key elements:

Facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system or equipment that contain or use water

Water management program that considers American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 188 and the CDC toolkit Developing a water management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards 

Testing protocols and acceptable ranges for control measures, with results of testing and corrective actions taken, or to be taken, when control limits are not maintained

In addition, surveyors may ask about situations that could put a facility’s water system at risk and what the facility has done or would do to mitigate the risk.  Read more about this new standard in our blog post going live July 21, 2021. 
Joint Commission

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