Responding to a Centers for Disease Control and Prevention (CDC) report indicating Legionnaires’ Disease (LD) kills 25% of those who are infected while getting treatment or residing in a healthcare facility, the Department of Health & Human Services, Centers for Medicare & Medicaid Services (CMS), on June 2, 2017, released a memorandum entitled, “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease.”
While the presence of Legionella in any water system presents a danger to occupants, the threat of infection is especially dangerous in healthcare facilities where the residents are more vulnerable to exposure to pathogenic organisms. The fact that these facilities also often contain complex water systems, where Legionella and other pathogens are likely to reside, makes them particularly high-risk locations.
The CMS memorandum indicates, of all “LD outbreaks in the United States occurring in 2000–2014, 19% of outbreaks were associated with long-term care facilities and 15% with hospitals….(CMS) is aware of multiple recent LD outbreaks in hospitals and long-term care facilities as reported by the CDC, state and local health departments, or investigated by State Survey Agencies.”
Areas of a facility commonly vulnerable to Legionella contamination and transmission include: hot and cold-water storage tanks, water heaters, shower heads and hoses, centrally-installed misters, atomizers, air washers, humidifiers, cooling towers, and medical devices, such as CPAP machines, hydrotherapy equipment, bronchoscopes, and heater-cooler units (heater-cooler units have also been identified as a frequent source of nontuberculosis mycobacterium infections).
The document cites multiple sections of Federal Regulation 42 CFR – Public Health, including parts 482, 483, and 485, providing requirements for hospitals, long term care facilities and specialized providers (comprehensive outpatient rehabilitation facilities, critical access hospitals and clinics), respectively. To qualify for participation in Medicare programs, healthcare facilities must have an active program for preventing and controlling communicable diseases, including a Water Management Plan (WMP). The memorandum recommends the first step of the WMP should be conducting, “a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi)” could grow and spread in the facility water systems. Finding a qualified laboratory capable of performing the risk assessment, as well as detecting and identifying waterborne organisms is an important step in developing a program. A laboratory Certified as Proficient in the isolation of Legionella from water samples by the CDC Environmental Legionella Isolation Techniques Evaluation (ELITE) program, is also recommended.
The CDC published a Water Management Plan Toolkit to help organizations design an effective water-system prevention and monitoring program. Another resource recommended in the memorandum is the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE), “Guidance on Reducing the Risk of Legionella.”
The memorandum concludes, “Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.”