Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems Revised July 2018

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

CMS released an updated Survey & Certification notice – now identified as QSO-17-30- Hospitals/CAHs/NHs  – on Friday, July 6, 2018.  The subject of this QSO is: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD).

  • “This policy memorandum clarifies expectations for providers, accrediting organizations, and surveyors and does not impose any new expectations nor requirements for hospitals, CAHs and surveyors of hospitals and CAHs. For these provider types, the memorandum is merely clarifying already existent expectations.
  • This policy memorandum supersedes the previous Survey & Certification (S&C) 17-30 released on June 02, 2017 and the subsequent revisions issued on June 9, 2017.”

The clarifications show in red ink on this 4-page notice and include these items:

  • Facilities must have water management plans and documentation that, at a minimum, ensure each facility:
    • Now includes an additional component: Maintains compliance with other applicable Federal, State and local requirements.
  • Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider.
  • 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.
  • Updated website addresses for:
    • Hospitals
    • Critical Access Hospitals and
    • Long-Term Care Facilities