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HFAP revises standards to address reduction of Legionella risk


September 1, 2018

To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with a new requirement for Infection Control Standard 07.01.03—Reduce Risk of Legionella in Water Systems.

The accrediting organization (AO) says facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens.

CMS issued S&C memo 17-30 last summer, reminding healthcare organizations of the dangers of legionella. Surveyors from all AOs are paying closer attention to facilities’ water systems as a result. 

Alise Howlett, AIA, CFPE, CHFM, is HFAP’s emergency management, physical environment, and life safety standards advisor. And Karen Y. Beem, MS, RN, serves on HFAP’s standards interpretation staff and participates in the development and revision of standards.

This Q&A has been lightly edited for clarity.

Q: In your opinion, what’s one of the most significant changes in HFAP’s legionella standards? And how will they help patients? 

Howlett: The most significant change is in terms of the intent of the standard; that’s most helpful to facilities to know. 

During survey, we’re really going to be assessing facilities for their risk management process for legionella. Before, we might have had questions about it or it might have been a small part of their policy. But right now, they have to outline a very specific risk assessment that identifies: 

  • Where they’ll be testing their water
  • Who’s going to be looking at the results
  • Who’s making decisions about what needs to happen
  • How to ensure the quality of their water is reported through the safety committee and isn’t reviewed by a single entity

One of the problems in general we see in life safety or in physical environment compliance is that hospitals tend to work in silos. Maybe the facilities people stick to themselves and the clinical people stick to themselves. We really want to see more cross-coordination between medical staff and facilities.

A lot of these reports that are required under the standard need to be reported through either the quality or safety committee so there’s a more global review. The intent of the standard is that they’re doing specific testing and that it’s getting reported up through the committee. 

Q: Is there any new documentation required for this to show that you’re in compliance?

Howlett: I would anticipate, because every facility is a little bit different, some people might already be doing something. But during a survey, they’re going to have to provide a specific risk assessment that doesn’t just include the water supply, but also fixtures in areas in the hospital that they have identified that they have to pay attention to. 

Previously it would have been something where maybe they just provided the water report and that would have sufficed, especially for small facilities. Now they have to risk-assess their own facilities and items inside them that present a hazard. After that, they should have a policy that states how often they should be testing. And [surveyors] will need those test reports to see that they’re doing that testing. These are some things that maybe they weren’t doing before but they need to step up and do now. 

Obviously, once you have an initial test report and you’re not getting anything for a while, we’re not expecting them to test every month or a more frequent interval. But the risk assessment is really the key point that we’re looking at. 

Q: Why the focus on legionella specifically, as opposed to other waterborne ailments? 

Howlett: Part of it is on CMS. We focus on what CMS tells us to focus on.

In CMS’ memo S&C 17-30, which was revised June 2017, they have some great background information on recent outbreaks—particularly for hospitals and long-term nursing facilities because those patient populations are going to be much more subject to fatalities or illness based on legionella.

It came about because [CMS was] looking at data from 2000–2014 and about 9% of those reported cases were fatal. CMS has identified that as a major issue for patient care areas where you’re expected to have an environment that won’t harm patients. 

Beem: It has reached national attention, and we have to respond. As an example, here in the great state of Illinois, there’s been a lot of publicity about legionella found in a Veterans Administration facility. And it came to public attention because of several deaths in a short period of time. 

Q: Anything else you’d like to add? 

Beem: This is a combined effort between the infection control coordinator and the facilities manager. Neither of them can do it in isolation; it’s a team effort. 

Howlett: Facilities believe that being in compliance with their local plumbing code is enough to grant them protection, but that’s probably not true. So this might be a surprise to facilities, or they would be looking to their plumbing code for protection, and they really need to go above and beyond that for the risk assessment. That’s why CMS has gone so far to look for additional requirements.




Legionella overview

The legionella bacterium is responsible for legionellosis: a respiratory disease that can cause a type of pneumonia called Legionnaires’ disease, which kills about a quarter of the people who contract it. Legionellosis is especially dangerous for patients older than 50, who smoke, or have chronic lung or immunosuppression conditions.

The bacterium breeds naturally in warm water and can usually be found in the parts of hospital systems that are continually wet. Poorly maintained water systems have been linked to the 286% increase in legionellosis between 2000 and 2014. The CDC says there were 5,000 reported cases of it in 2014 alone, with about 19% of outbreaks in long-term care facilities and 15% in hospitals.


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