Revised Memorandum to Prevent Legionella Infections

Regulation | July 09, 2018 | by Janine Finck-Boyle

On July 6th, 2018, the Centers for Medicare & Medicaid (CMS), Quality, Safety and Oversight Group(QSO) released the REVISED QSO-17-30-Hospitals/CAHs/NHs memo on the Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)

The memorandum has been revised to Clarify Expectations for Providers, Accrediting Organizations, and Surveyors. Over the past six (6) months, LeadingAge has heard from members, throughout the country, challenges during the survey process regarding water cultures and testing for Legionella. The revised memorandum outlines the expectations for surveyors and healthcare facilities.

CMS expects health care 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.

The water management plan and documentation, at a minimum, must ensure:

  • A facility risk assessment is conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.
  • The development and implementation of a water management program that considers the ASHRAE industry standard and the CDC toolkit.
  • Testing protocols and acceptable ranges for control measures are specified, the results of testing and corrective actions are documented and taken when control limits are not maintained.
  • Compliance with other applicable Federal, State and local requirements.

CMS notes that they are not requiring water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

LTC surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update.

LeadingAge will monitor for the upcoming survey process update and alert members upon its publishing.