Developments in State Policy
U.S. Department of Health & Human Services,
Centers for Medicare & Medicaid Services (CMS)
Citation: U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services - Survey & Certification Memorandum 17-30-Hospitals/CAHs/NHs (2017; rev. 7/6/2018)
Summary: The U.S. Department of Health & Human Services (DHHS) implements the federal Medicare and Medicaid programs through its Centers for Medicare and Medicaid Services (CMS). The agency, which is authorized under federal law to promulgate regulations for those programs, has established minimum health and safety standards that must be met by providers in order for the providers to be certified to participate. DHHS regulations require, e.g., that participating hospitals provide a sanitary environment and have an “active program for the prevention, control, and investigation of infections and communicable diseases.” 42 Code of Federal Regulations (CFR) 482.42. Similar requirements for developing systems to control infections are established in the regulations governing critical access hospitals and long-term care facilities. 42 CFR 485.635(a)(3)(vi); 42 CFR 483.80. In June 2017, pursuant to this regulatory authority, CMS issued a memorandum requiring hospitals, critical access hospitals and long-term care facilities to develop and implement policies and procedures to reduce the risks from Legionella in water systems.
Requirement for a Legionella Water Management Plan
In the memorandum, CMS states that the agency “expects” covered 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 program must “consider” the ASHRAE 188 standard and the CDC Legionella toolkit. The plan must include “control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.”
Other Specific Requirements
Facilities Risk Assessment. Facilities must conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.
Testing Protocols and Control Limits. Facilities are required to specify testing protocols and acceptable ranges for control measures.
Documentation. Facilities must document the results of testing and corrective actions taken when control limits are not maintained.
Surveys of Facilities. The CMS Legionella Memorandum is directed to State Survey Agencies, which are charged with conducting initial and periodic surveys of facilities to determine whether they comply with federal requirements and CMS Conditions of Participation. (In general, facilities that do not comply with CMS requirements face a variety of potential sanctions, including loss of Medicare and Medicaid funding/reimbursement.) The Memorandum states that surveyors will review “policies, procedures, and reports documenting water management implementation results” to verify compliance with requirements of the Memorandum and “will cite non-compliance accordingly.”
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