CMS again spotlights control of Legionella with revision to surveyors' memo


September 1, 2018

 Be prepared for renewed interest in your water management program and especially how it is designed to prevent the spread of Legionella infection. CMS just updated its memo from last year on requirements to reduce the risk of Legionnaire’s disease, in part to clarify expectations for hospitals and nursing homes (NH).

Also be prepared for questions about how well you manage the risk of Legionella to appear on infection control worksheets used by some CMS surveyors.

While the updated CMS memo to surveyors added no new expectations for hospitals or critical access hospitals (CAH), be aware it does add a specific statement that “facilities must have water management plans” as well as a new note that testing for waterborne pathogens is left “to the discretion of the provider,” according to the letter to CMS’ Quality, Safety and Oversight (QSO) group, formerly the Survey & Certification (S&C) group.

“The terms ‘plans’ and ‘policies’ are sometimes confusing to hospitals,” warns Kurt Patton, the former director of accreditation services for The Joint Commission (TJC) and founder of Patton Healthcare Consulting, now in Naperville, Ill. 

“TJC already requires a utilities management plan and water is a component of that. The unknown will be if CMS surveyors say they don’t want to look at a utilities plan, they want to look at a water management plan,” explains Patton. “At a minimum, I would suggest accredited hospitals have a table of contents and a subject header for ‘Water Management Plan’ inside their overall utilities plan.”

Review your plan against memo 

The memo, QSO 17-30-Hospitals/CAHs/NHs, was published July 6 and supersedes the former S&C 17-30-Hospitals/CAHs/NHs, issued in June 2017 (ECL 6/19/17), and it adds more specific expectations for long-term care (LTC) facilities.

“The memo is fairly prescriptive” in what it expects of facilities, notes Jennifer Cowel, president of Patton Healthcare Consulting and a former TJC director of service operations, adding that hospitals should include the specific items set out in the memo in the water management section of their utilities plan.

“The main difference in the revised July CMS letter is the note that Legionella or other opportunistic waterborne pathogen tests will not be required in the hospital management plan,” says Ernest E. Allen, a former TJC life safety surveyor and now a patient safety executive with The Doctor’s Company in Ohio. “Legionella tests are expensive and most hospitals only perform them after a patient is diagnosed with Legionella.”

ANSI/ASHRAE still go-to standard

Some sections of the memo have been revised to move or edit information, including a reference to what CMS and other organizations consider to be the main industry standard on the management of Legionella released by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) in 2015: ANSI/ASHRAE Standard 188-2015 “Legionellosis: Risk Management for Building Water Systems.”

The reference to the ASHRAE standard and the use of specific control measures is no longer in the section outline expectations for healthcare facilities, but moved to the memo’s background section along with the mention of the CDC’s toolkit on implementing the 2015 standard. 

There is a new expectation added in the revision that facilities will “maintain compliance with other applicable Federal, State and local requirements,” which is also a generic expectation of TJC and other accrediting organizations (AO).

The only entirely new section is devoted to expectations of surveyors and AOs when surveying LTC: “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. Until that occurs, please use this paragraph as guiding instructions,” the CMS memo now states.

Legionella in draft IC worksheet

If your hospital also includes oversight of a nursing home or other long-term care facility, note that while the prevention of Legionella is not specifically stated in the CMS infection control worksheet for hospital surveyors, it is a part of the worksheet now in a draft pilot program for LTCs.

The worksheet is a push by CMS to improve infection control at LTCs. In a QSO memo issued in March, CMS said it was developing an online training course in infection prevention and control for nursing home staff, which was to include a section on water management.

The three-year IC pilot program began in 2015. Much like the draft worksheets tested out by CMS surveyors a few years ago in hospitals before being officially made public for use in 2014, the IC worksheet for LTC facilities is being used in pilot surveys in which CMS hospital surveys are paired with LTC facilities being surveyed, according to CMS information.

That worksheet includes a section that asks surveyors to check if the “Hospital has a water management program to reduce the risk of Legionella growth and spread,” and includes a note to reference the CDC toolkit on Legionella “for key elements of a water management plan.”

Although, as with the earlier draft worksheets, that worksheet is only being used as a guide for now, CMS has cited hospitals in the past for problems with Legionella management.

And whatever management plan you have, ensure that it is being followed.

CMS may take water temperature

In March, a hospital in Brooklyn, New York, was cited under CMS Tag A-0749, outlining responsibilities of the infection control officer, for failure “to ensure that water temperature was maintained at an acceptable range in accordance with generally accepted standards.”

The citation came after a surveyor touring the hospital’s Emergency Department found that the water in the Trauma/Critical section was cold — 70.3 degrees Fahrenheit — when measured by the supervisory plumber on staff. In addition, the water at two scrub sinks in two operating suites was measured at 51.9 degrees Fahrenheit.

The hospital’s own policy stated, “The domestic hot water temperature will be maintained at 110 degrees Fahrenheit or less in all patient and staff areas. However, the facility's policy does not provide guidance on the temperature range for domestic hot water,” according to the deficiency report, found on the Association of Health Care Journalists site

The report said that in a review of CDC recommendations, “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,” according to the deficiency report.

Further, the report stated recommendations call for the facility to “Periodically increase the hot water temperature greater or equal to 150F at the point of use,” or “alternatively, chlorinate the water and then flush it through the system,” and to “maintain constant recirculation in hot-water distribution systems serving patient-care areas.”

The deficiency report noted that it was the senior associate director of facilities operation and plumbers’ supervisor who were questioned about the water management plan



Review your water management plan against newly revised CMS memo

Review your water management plan against a revised CMS letter to surveyors on expectations to reduce risk of Legionella and update against the specific expectations outlined in QSO 17-30-Hospitals/CAHs/NHs.

The memo to the Quality, Survey and Oversight (QSO) group, issued July 6, is a revision of a June 2017 letter to surveyors under the since-renamed Survey & Certification (S&C) group.

The main changes are to emphasize that hospitals and other facilities should now have a stated water management plan and that testing is not necessarily required (more on the memo, see p. 1).  Although rewritten in sections, the memo still points to the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) standard released in 2015 — ANSI/ASHRAE Standard 188-2015 “Legionellosis: Risk Management for Building Water Systems” — as the main industry guideline for the prevention of Legionella. The memo also advices facilities to again consult the CDC’s toolkit, released in 2017, on implementing the ASHRAE standard. 

Highlight water plan under utilities

The utilities management already required by accrediting organizations such as The Joint Commission (TJC) should include a water management plan that encompasses prevention of waterborne infections such as Legionella. 

Clearly mark your water management program under your utilities management plan and includes the specifics outlined in the revised memo, advises Jennifer Cowel, president of Patton Healthcare Consulting. That includes ensuring you:

Complete a hospital-wide water safety risk assessment. “You could also consider adding Legionella to your HVA [hazard vulnerability assessment] if it is not part already,” notes Cowel.

Review the ASHRAE standards and CDC toolkit on water management when updating your utility plan. Remember that these were both referenced in the memo, Cowel emphasizes.

Define and document your planned testing protocols. Include the acceptable ranges for those measures, advises Cowel.  “Also, document the specific actions that the hospital will take if limits are exceeded.”

Testing not necessarily required

Note that the QSO memo now states that CMS does not require regular, and often expensive, testing for Legionella or other opportunistic waterborne pathogens, notes Ernest E. Allen, a patient safety executive with The Doctor’s Company in Ohio. 

That doesn’t mean no testing at all.

“Testing for chlorine levels that are high enough to help prevent Legionella and other pathogen growth should be performed on a regular basis,” recommends Allen. That includes “regular testing from different locations in the hospital. For example, the Ohio Department of Health recommends 0.5-1 ppm of chlorine level at the fixture when the faucet is opened, at both hot- and cold-water faucet locations in varied locations of the hospital.”

Beware if your facility, as do many hospitals, contracts out water management, Allen advises. “The hospital should check to see if the long list — 18 bullet points — of system components and devices listed in the letter are included in their program,” says Allen.

He adds that for hospitals with LTC units or nursing homes, the revised letter also notes that CMS surveyors and accrediting organizations will review the LTC facility’s risk assessment and testing protocols. The memo also says that surveyors “will not cite the facility based on the specific risk assessment or testing protocols in place.” 

However, it warns that more guidance is expected in the future.



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