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Meeting Legionella requirements: Examples from CMS


September 1, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

Review and update your water management plan to include the latest guidelines by CMS and CDC, be ready to present it to surveyors on request, and ensure the plan includes a risk assessment for controlling Legionella and other bacteria that can cause potentially deadly airborne infections during construction or renovation.

CMS and hospital accrediting organizations require facilities to have an ongoing Legionella water management plan and to perform a risk assessment that includes any concerns about infection control before beginning construction and renovation projects. Failure to do so risks not only problems during surveys, but could endanger patients (see p. 1).

The Joint Commission’s (TJC) Environment of Care standard EC.02.06.05 requires hospitals to manage the environment to reduce risks during renovation and construction; element of performance (EP) 2 requires conducting a “preconstruction risk assessment” during planning, which must include an infection control plan; EP 3 requires having a plan to minimize those risks.

While TJC’s standards do not specifically mention Legionella as a concern, TJC’s outlined what its surveyors would look for in Legionella water management in a blog posting last October by its infection prevention director, Sylvia Garcia Houchins.

On the other hand, the Healthcare Facilities Accreditation Program (HFAP) updated its standards last year specifically to address Legionella concerns set out by CMS in a June 2018 memo. HFAP’s Legionella requirements start in the Infection Control chapter under standard 07.01.03, “Reduce Risk of Legionella in Water Systems.”

Water management plans examined

CMS state surveyors are asking for water management plans and are citing hospitals for not having them, or not having a plan that has been updated since the latest recommendations came out from CMS and the CDC, which released a new toolkit for managing Legionella in 2017. (Find the toolkit at https://www.cdc.gov/Legionella/wmp/toolkit/index.html.)

And it doesn’t matter whether the hospital has identified a Legionella problem or not at the time of the survey. Beware: Surveyors could also be checking water temperatures.

CMS deficiency reports on HospitalInspections.org show that problems with Legionella water management are most often cited under Tags A-0747 and A-0749 under the Infection Control Conditions of Participation (CoP), as set out in the State Operations Manual Appendix A of interpretive guidelines for state surveyors.

Tag A-0747 states that hospitals “must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.”

Surveyors are told that the “infection prevention and control program must include appropriate monitoring of housekeeping, maintenance (including repair, renovation and construction activities), and other activities to ensure that the hospital maintains a sanitary environment.”

Under A-0749, which requires hospitals to have an infection control officer or officers who “must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel,” surveyors are told that those activities must include “appropriate monitoring of … maintenance (including repair, renovation and construction activities).”

In addition, hospitals have also been cited under the CoP for Quality Assurance and Performance Improvement (QAPI), under Tag A-0273, which requires hospitals to have a data collection and analysis program that includes parameters set by the hospital’s governing body.

Cases in point

Here are some examples of problems hospitals were cited on by CMS in 2018:

A hospital in Baltimore in December was cited for not having an updated water management plan as part of its QAPI program. In fact, the water management plan in use by the hospital was more than seven years old. “There was no evidence that the plan was reviewed or updated with 2017 recommendations from the Center for Disease Control and Prevention or 2018 recommendations from CMS related to Legionella water testing,” according to the CMS 2567 deficiency report.

“In addition, in November 2018, the hospital identified an outbreak of a bacterial infection that may have had a water source. While subsequent testing failed to identify the water system as the source of the outbreak, there is no evidence that the outbreak spurred the hospital to revise its water management plan.”

A hospital in Oregon in August was cited under Tag A-0749, Infection Control officer responsibilities, for not having a water management plan at all—yet. The deficiency report noted that in interviews with the infection preventionist, the director of quality, and the facilities manager, they stated that “the hospital had not developed and implemented waterborne pathogens policies and procedures.” Said the facilities manager: “We haven't put our water program together yet. It's a work in progress.”

While a contractor had conducted a waterborne pathogens risk assessment, the hospital had yet to determine what information in it they were going to use, including what control measures to set or where to monitor.

The hospital did have a draft of a water management program.

A hospital in New York was cited under the same A-tag in March for failing to ensure water temperatures were maintained “in accordance with generally accepted standards.” The deficiency report said that during a tour of the emergency department, the water temperature was found to be 70.3 degrees Fahrenheit, while water in two surgical suites was measured at 51.9 degrees Fahrenheit.

The hospital policy said that “domestic hot water temperature will be maintained at 110 degrees Fahrenheit or less in all patient and staff areas”; however, it did not provide guidance on what the temperature range should have been.

The report noted the CDC recommendation that “when state regulations or codes do not allow hot water temperatures above the range of 105F-120F (40.6C-49C) for hospitals or 95F-110F (35C-43.3C) for nursing care facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow either of these alternative preventive measures to minimize the growth of Legionella spp. in water systems:

  1. Periodically increase the hot water temperature greater or equal to 150F at the point of use….
  2. Alternatively, chlorinate the water and then flush it through the system.”

The report also noted that recommendations called for hospitals to “maintain constant recirculation in hot-water distribution systems serving patient-care areas.”

A hospital in Florida in March was cited under Tag A-0747—with a reference to A-0749—for failing to maintain an infection control program that minimized the risk of infections. That included, among other things, the failure to “develop and implement water management policies and procedures to reduce the risk of patient exposure to Legionella and other opportunistic pathogens from the facility water systems.”
When asked for its water management policy, the hospital provided a policy effective in November 2010, that showed the facilities department—with assistance from the infection prevention department—was responsible for “the development and review of a Legionella prevention plan and disinfection of potable water in the event of a Legionella case,” and was to report “significant findings of monitoring to the Infection Prevention Committee on an annual basis.”

The policy failed, however, to address current industry standards “for the prevention of Legionella and other opportunistic water pathogens,” including:

Facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, nontuberculous mycobacteria, and fungi) could grow and spread in the facility's water system.

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

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

Surveyors reviewed hospital documents tracking the incidence of pneumonia and associated water pathogens and found “a total of 28 hospital acquired pneumonias were identified in 2017, which have the potential to be acquired from the facility's water.”

While there were no cases of Legionella, the hospital did show the following cases:

  • Pseudomonas (10 cases)
  • Acinetobacter (2)
  • Burkholderia (1)
  • Stenotrophomonas (4)
  • Nontuberculous mycobacteria (3)
  • Candida albicans fungus (4)
  • Candida parapsiliosis fungus (4)

The infection preventionist (IP) later told surveyors that the source of the hospital-acquired pneumonias was not identified and “could not say if they were acquired from the facility water.” The IP also stated the infections were not reported to facilities leadership.

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