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Review your water management plan as CMS intensifies focus on Legionella


November 1, 2018

A good water management plan begins with your facilities management team and a solid risk assessment of your water distribution and storage systems, which must include a walk-through of your hospital with your on-site plumbing expert.

CMS recently updated a memo to its survey teams on reducing the risk of Legionella bacteria to specifically note that facilities must have a water management plan that surveyors can review. That plan should be written and managed by a multidisciplinary committee of people from throughout the hospital with a stake in water use, says Bryan Connors, MS, CIH, HEM, the healthcare practice director at Environmental Health & Engineering Inc., in Newton, Massachusetts. Connors is certified as both an industrial hygienist and a healthcare environmental manager and works as a consultant for hospitals and other facilities, including the management of water systems.

The CMS memo, which was first published last year and then updated this June, continues to point to the ANSI/ASHRAE Standard 188 “Legionellosis: Risk Management for Building Water Systems” and the best practices set out by a 2016 CDC toolkit on developing a water management program to reduce the growth and spread of Legionella in buildings as key resources.

“If you look at the CMS memo, it talks about having a facility assessment,” notes Connors. You should have multidisciplinary team members and ensure one of them knows the plumbing configuration within your hospital, he says, “which typically is the supervisor of the plumbing shop, or the manager of facilities.” 

Surveyors from CMS, The Joint Commission, and other accrediting organizations (AO) will be looking for proof of a water management plan that also has the support of leadership. 

Use memo to review program

Review your program against the memo to ensure you are meeting what CMS—and therefore other AOs—want to see.

“The first thing you would look at in the program—and this is a vulnerability for many hospitals who have not been surveyed in the last year—would be do you have a document or documents that describes the plan,” says Connors.

What those documents would look like is up to you. However, “you are required to have a risk assessment, done by a multidisciplinary team, to identify your hospital’s risk for Legionella bacteria growth relative to the [hospital] population in general, and then specifically relative to at-risk populations,” Connors notes.

You might have a written Legionella plan or a water management plan. Those terms are used interchangeably, but are different, he says. 

CMS is clear that although Legionella is important, it’s just one of several waterborne pathogens to be managing for, Connors emphasizes. To satisfy CMS, you must manage the risk from the other waterborne pathogens too. But in general, says Connors, “if you are controlling for Legionella, you’re controlling for a lot of the other pathogens.”

The written plan should have a description of the water management team, and what their roles and responsibilities are. The plan also should outline what the risks are within the organization regarding your water systems, mitigating factors, and how you are monitoring the system. 

The plan should include process flow diagrams of the water system, including “incoming water, potable water and non-potable water, and distribution systems throughout the facility including water storage, and water treatment tanks—as well as a narrative associated with those .”

It should also identify problem areas and how those areas are being mitigated.

For instance, how are you identifying and eliminating dead legs of plumbing where water can sit still and allow pathogens to grow? What, how, and when are you sampling in cooling towers? Every hospital has some type of renovation or repair going on, Connors notes. How are you flushing pipes during renovation and ensuring that your redesign doesn’t result in water stagnating? How do you monitor water temperatures, and what parameters do you use? What is the schedule for cleaning and maintenance of your water towers or other systems?

When assessing risk, you need to have someone who knows the plumbing system design and configuration, who can look at things like hot water tanks, dead legs, and cross-connects, he says. “You do have to get out and walk around. If you don’t have someone who knows your plumbing system, you’re not doing it right.”

Legionella testing not always required

While the CMS memo requires a documented water plan, it also emphasizes that periodic testing for Legionella bacteria is not required, notes Connors. “The most important point [of the update] being that the plan does not have to include Legionella bacteria sampling as a part of it,” he says, though most hospitals should at least monitor their cooling towers.

What the plan must have, says Connors, is a narrative of the types of monitoring (such as for residual disinfectants like free chlorine) being done, when Legionella sampling would be required, and how you manage that data, he says.

The plan should include what kind of water system monitoring you perform, but measurements can include residual disinfectants, pH, and chlorine—it’s all about the risk assessment for your hospital’s population and risks, he says. However, the CMS memo “is not prescriptive about testing.”

The materials to outline your water management program need to show that the plan is an effective and implemented document, “not just a binder on a shelf,” notes Connors. “Typically, what we’re talking about here are committee minutes and action plans from water management committee meetings.”

That water management committee should be multidisciplinary and include your infection preventionist, a nurse manager, a representative from clinical labs, and other areas with a key stake in the use of water at your facility.

The frequency of the committee meetings is up to you, he notes. “But you do have to show that this plan is being implemented.” 

One tactic is to use the committee meetings as a continuing way to implement and manage the plan, Connors suggests.

In the first meeting, go through the roles and responsibilities of the water management committee and each of its team members. Gather all of the committee members in the room and discuss what they will be doing. Document changes to the plan suggested during the meeting. 

In each subsequent meeting, review a different section of the plan. “Make the committee meeting a time to review the effectiveness of the plan,” suggests Connors. 

Show your progress

The process must remain dynamic. Surveyors “want to see that action is being taken.”

The plan should also include input from the clinical side, including what steps must be taken if Legionella is either identified in the building water or in a patient. That will require strong communication between clinical and facilities management teams, he notes.

Legionnaires’ disease as well as the less severe Pontiac fever present similarly to pneumonia, notes Connors. There should be appropriate screening of patients and staff, and a plan for the steps to take both clinically and within the facility system once Legionella is suspected or confirmed.

Your water management plan should outline both the proactive and reactive parts of pathogen management from a facilities and clinical perspective, Connors says. That should include whatever triggers your facility sets to activate that algorithm: concentrations of Legionella bacteria, patient diagnoses, or other “screen parameters out of tolerance that might be of concern.” 

“If you are going to come up for survey in the next 12 months, you want to make sure ... you or one of your consultants has done a risk assessment, and that risk assessment was done by a multidisciplinary team,” he says. You should also have a written water management plan. That document should include process flow diagrams, screen parameters, and other such elements, as well as “things like committee minutes and committee rosters to show that this plan is being implemented,” says Connors.

—A.J. Plunkett (aplunkett@h3.group)



CMS looking for governing board to make water management a priority 

Alert your hospital leadership that CMS and other surveyors are not only looking for water management plans to control Legionella and waterborne pathogens, they may ask for governing board minutes or other proof that such plans are a priority. 

Hospitals failing to implement water management plans could face patient safety deficiencies or even an Immediate Jeopardy ruling. During a CMS survey in 2017 after a Legionella outbreak at a California hospital, the facility’s infection control director was asked, among other things, to “provide documentation of meetings with the governing body, the medical executive committee, the Legionella outbreak and plans that were implemented including the water management plan,” according to the CMS deficiency report outlined on HospitalInspections.org. 

“She indicated there were none. There was no documentation for review of a policy and procedure for the water management plan or meeting minutes documenting approval for the water management company to participate in the water management plan,” according to the report.

The hospital was cited under nine different A-tags found in Medicare’s State Operations Manual, the Interpretive Guidelines for surveyors implementing the Conditions of Participation, including failures under A-0043, “Governing Body,” which holds that group “legally responsible for the conduct of the hospital.”

Governing board called out

The surveyors ruled there was an immediate jeopardy to patient safety regarding infection control “in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), and Chief Nurse Executive (CNE),” according to the deficiency report.

Among other findings, according to the report, the governing board failed to:

  • “Oversee the facility plan for addressing Legionella outbreak including: following recommendations of the Public Health department; and implementing Center for Disease Control (CDC) guidelines in surveillance of the facility; and monitor the [safety] and effectiveness of the water management plan.”
  • “Assure a contractual agreement with the water management company conducting the water management plan, and to assure the facility had a method to monitor the company’s services for safety, effectiveness, and quality assurance.”
  • “Have an ongoing Quality Assessment Performance Improvement (QAPI) program that had implemented studies that monitored: the recommendations for Legionella outbreak; services provided by the water management company; infection including: incorporating the water management plan; legionella outbreak; and the water management company as contracted Hemodialysis Services at Hospital A and Hospital B.”
  • “Maintain equipment to ensure the safety of the patients. The facility staff failed to: monitor for the presence of Legionella bacteria from ice machines; ensure filters on ice machines were appropriate membrane rating, to prevent passage of Legionella bacteria into the ice and drinking water and ensure the filters were changed on a quarterly basis per the facility’s Utility Water Safety Management Plan.”
  • “Coordinate and oversee hospital wide infection control program including: Implementing an infection control program that followed acceptable standards of practice for overseeing the Sterile Processing Department (SPD); assure the facility followed recommendations of the Acute Communicable Disease Control and Centers for Disease Control and Prevention (CDC) guidelines, when implementing a remediation and water management plan to address the Legionella outbreak at the facility.”

This year, other hospitals have been cited by CMS for not having current risk assessments to include control of Legionella, for failing to have a water management plan, and for failing to follow state regulations or even their own hospital policy in testing for waterborne pathogens. And those are hospitals that didn’t necessarily have reported cases of Legionella contamination.

CMS updates memo on Legionella

While several waterborne pathogens can be a concern, Legionella has taken the forefront in the last several months after CMS published a key memo about the dangers of the bacteria to its surveyors in June 2017 and recently updated it with a specific statement that “facilities must have water management plans.”

While Legionella can be present in any water system, it can become deadly when it is aerosolized in showers or other areas of hospitals where patients’ immunity is already compromised. Exposed patients or staff can contract the pneumonia-like Legionnaires’ disease or the lesser version of it, Pontiac fever. 

CMS as well as accrediting organizations such as The Joint Commission will be looking for evidence that hospitals are serious about water management, says Bryan Connors, MS, CIH, HEM, the healthcare practice director at Environmental Health & Engineering Inc., in Newton, Massachusetts.

EH&E is one of several consulting firms across the nation that offer hospitals and other facilities help in managing their water systems to control waterborne pathogens, including Legionella.

Ensure consultants have expertise

You don’t have to necessarily hire outside help to establish, improve, or implement a water management plan, says Connors. But if you do, the outside consultants need to know what they are doing, and your facility needs to demonstrate a knowledge of risks unique to your hospital, he notes—an observation borne out by the attention of CMS surveyors illustrated above.

Any consulting firm should have an industrial hygienist and an engineer with expertise in water systems at a minimum, recommends Connors. And the contract should reference all the applicable standards and established best practices—especially those set out in the 2017 CMS memo to surveyors on Legionella that was updated in June, he says.

That memo points to two resources, in particular (links in Resources, at end): 

The 2015 standard published by the American National Standards Institute (ANSI) and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), ANSI/ASHRAE Standard 188, “Legionellosis: Risk Management for Building Water Systems”

The 2016 CDC toolkit for targeting Legionella, “Developing a water management program to reduce Legionella growth and spread in buildings”

You may want to use an outside firm or vendor to regulate and monitor water pathogens and to maintain such equipment as cooling towers. If that vendor also seeks to provide overall water management consulting, ensure the vendor is capable and can handle any nonroutine conditions. 

If you are buying chemicals or services to maintain water systems from the vendor that also monitors Legionella levels in those water systems, you will need to have a way to manage the effectiveness of that vendor’s work and avoid a conflict of interest, Connors advises.

Use committee to manage plan

Furthermore, all of your water management must be overseen by a committee organized just for that. Use the committee’s regular meetings to keep track of the effectiveness of the program, he says, and document the meeting minutes so you can show them to surveyors when they ask.

Those minutes should show when specific actions are needed, when they are implemented, and when the effectiveness of those actions is measured, recommends Connors. The committee needs to be multidisciplinary, and, depending on the size of your hospital and staff, should include such titles as:

  • Director of engineering
  • Director of infection prevention and control
  • Medical director or director of epidemiology
  • A nursing manager
  • A dialysis team representative
  • A senior-level support services director
  • A member from your public affairs team
  • A representative from clinical labs
  • And, of course, a facility manager

As with many things in hospitals, a good water management plan begins with a risk assessment, Connors says. If your plan was done exclusively in a conference room, “it was probably done wrong,” advises Connors. The risk assessment must involve a building tour, be documented, and show how the plan was developed and is being actively implemented to manage the risks you've identified. 

“This is a vulnerability for many hospitals who have not been surveyed in the last year,” says Connors. “Do you have a document or documents that describes the plan?” 



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