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DEPARTMENT OF HEALTH & 

HUMAN SERVICES 

Announces Expectations for Healthcare Facilities and Surveyors

 

DATE: June 02, 2017

TO: State Survey Agency Directors

FROM: Director Survey and Certification Group.  Center for Clinical Standards and Quality/Survey & Certification Group Ref

SUBJECT: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)

 

Memorandum Summary 

* Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least 50 years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.

 

* Facility Requirements to Prevent Legionella Infections: Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This includes preemptive Legionella testing.

 

Background 

 

LD, a severe sometimes fatal pneumonia, can occur in persons who inhale aerosolized droplets of water contaminated with the bacterium Legionella. In a recent review of LD outbreaks in the United States occurring in 2000-2014, 19% of outbreaks were associated with long-term care facilities and 15% with hospitals. The rate of reported cases of legionellosis, which comprises both LD and Pontiac fever (a milder, self-limited, influenza-like illness) has increased 286% in the US during 2000-2014, with approximately 5,000 cases reported to the Centers for Disease Control and Prevention (CDC) in 2014. Approximately 9% of reported legionellosis cases are fatal. The Centers for Medicare & Medicaid Service (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 (SA).

 

Outbreaks generally are linked to environmental reservoirs in large or complex water systems, including those found in healthcare facilities such as hospitals and long-term care facilities. Transmission from these water systems to humans requires aerosol generation, as can occur from showerheads, cooling towers, hot tubs, and decorative fountains. Legionella is less commonly spread by aspiration of drinking water or ice. Only one case of possible person-to-person transmission has been reported.

 

In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least 50 years old, smokers, and those with underlying medical conditions such as chronic lung disease or immunosuppression. Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization. Examples of these system components and devices include:

 

* Hot and cold water storage tanks

* Water heaters

* Water-hammer arrestors

* Pipes, valves, and fittings

* Expansion tanks

* Water filters

* Electronic and manual faucets

* Aerators

* Faucet flow restrictors

* Showerheads and hoses

* Centrally-installed misters, atomizers, air washers, and humidifiers

* Nonsteam aerosol-generating humidifiers

* Eyewash stations

* Ice machines

* Hot tubs/saunas * Decorative fountains

* Cooling towers

* Medical devices (such as CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)

 

CMS Regulatory Authorities 

 

Pertinent regulations include, but are not limited to, the following:

 

42 CFR §482.42 for hospitals:

“The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.”

 

42 CFR §483.80 for skilled nursing facilities and nursing facilities: “The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.”

 

42 CFR §485.635(a)(3)(vi) for critical access hospitals (CAHs): CAH policies must include: “A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.”

 

Expectations for Healthcare Facilities and Surveyors 

 

CMS expects Medicare certified healthcare 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. Legionella testing is vital to this end. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard. Environmental, clinical, and epidemiologic considerations for healthcare facilities are described in this toolkit.

 

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

 

* Conduct 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 system.

 

* Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

 

* Specify Legionella testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

 

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.

 

Contact: For questions or concerns regarding this policy memorandum, please contact Dr. Daniel Schwartz at Daniel.schwartz2@cms.hhs.gov.

 

Effective Date: Immediately. This guidance should be communicated with all survey and certification staff, their managers and the State/Regional Office training coordinators within 30 days of this memorandum.

 

Contact Environmental Safety Technologies, Inc to schedule Legionella testing for your facility.

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The below article was published by The CDC on CDC.gov here.

Legionnaires’ (LEE-juh-nares) disease is a very serious type of pneumonia (lung infection) caused by bacteria called Legionella. If you develop pneumonia symptoms and may have been exposed to Legionella, see a doctor right away. Be sure to mention if you have used a hot tub, spent any nights away from home, or stayed in a hospital in the last two weeks.

Legionnaires’ Disease Can Cause Pneumonia Symptoms

Signs and symptoms of Legionnaires’ disease can include:

► Cough  ► Muscle aches ► Fever ► Shortness of breath ► Headache

Doctors use chest x-rays or physical exams to check for pneumonia. Your doctor may also order tests on a sample of urine and sputum (phlegm) to see if your lung infection is caused by Legionella.

Legionnaires’ Disease Is Serious, but Can Be Treated with Antibiotics

Legionnaires’ disease is treated with antibiotics (drugs that kill bacteria in the body). Most people who get sick need care in a hospital but make a full recovery. However, about 1 out of 10 people who get Legionnaires’ disease will die from the infection.

Certain People Are at Increased Risk for Legionnaires’ Disease

Most healthy people do not get Legionnaires’ disease after being exposed to Legionella. Being 50 years or older or having certain risk factors can increase your chances of getting sick. These risk factors include:

► Being a current or former smoker

► Having chronic lung disease, such as emphysema or chronic obstructive pulmonary disease (COPD)

► Having a weakened immune system from diseases like cancer, diabetes, or kidney failure

► Taking medication that weakens your immune system

Legionella Are Usually Spread through Water Droplets in the Air

In nature, Legionella live in fresh water and rarely cause illness. In man-made settings, Legionella can grow if water is not properly maintained. These manmade water sources become a health problem when small droplets of water that contain the bacteria get into the air and people breathe them in. In rare cases, someone breathes in Legionella while they are drinking water and it “goes down the wrong pipe” into the lungs. You can’t catch Legionnaires’ disease from someone else. You also can’t get someone else sick if you have it.

Are you looking for more information about Legionnaire’s disease? Do you think you need Legionella testing services? Environmental Safety Technologies is on your side. Contact us today, and our team will be ready to help you.

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During this time of the Coronavirus outbreak, we have heard from many of our hospital partners that they are shutting down units and sometimes entire floors as elective surgeries and non-critical procedures are being postponed preparing for COVID-19 victims. This has led to some hospitals laying off staff to separate them from the campus and reduce the possibility of exposure. While these are necessary steps in many institutions, it leaves open the possibility of allowing water to stagnate in piping and decreases the use of cooling towers, which may already be in low demand due to moderate temperatures.

A recent rapid response study at the University of Purdue and a team of industry experts discussed the possibility of Legionella amplification and increased risk of Legionnaires disease in buildings with low or limited water usage during the current COVID-19 Response. That study and its recommendations can be found at this link https://tinyurl.com/wo5ybto. This is one of the reasons why a Legionella test is more important than ever.

The following articles have discussed the importance of maintaining low-use water systems during this unprecedented time.

Click To Read An Article From Reuters On Flushing Pipes

Click To Read An Article From WVXU Radio On Flushing Pipes

It is therefore important to keep showers, faucets, toilets, and other water outlets flushed on a regular basis during these periods of limited use. Most organizations, including EST, follow the recommendations of ASHRAE Guideline 12-2020, and the CDC (cdc.gov) in recommending the flushing be done every three days, or on a twice-weekly basis. ASHRAE Guideline 12-2020 also further addresses Cooling Towers, stating that when a cooling tower system is to be shut down for three or more days, the entire system (cooling tower, system piping, heat exchangers, etc.) should ideally be drained to waste. If draining the system is not practical for shutdowns of short duration, then circulate biocide once or twice a week in the offline tower to achieve a residual and use the ASHRAE startup procedures for undrained towers. (Consult with your water treatment service provider to determine the frequency and duration of disinfection, as well as getting a Legionella test should the need arise.)

For potable water systems, follow the building’s Legionella Water Management Plan (WMP) regarding shutdowns or, for facilities without a WMP, the following recommendations would be prudent if that facility has not had additional biocides or frequent flushing during this time of limited use.

• Collect first draw water samples to evaluate the residual chlorine available at the water source and multiple points, including the furthest point in the building.
• If these samples indicate a reduction in residual chlorine or water discoloration or odor, a building flush should be implemented to reduce the risk of Legionnaires disease.
• Follow the recommendations of your water treatment vendor or your local municipality to perform a thorough flush of your facility.
• Reevaluate the residual chlorine and water condition (discoloration, odor, etc.)
• Collect bulk water samples (for Legionella analyses) from distal fixtures to validate the effectiveness of the procedure.
• Contact us for a Legionella test.

For starting up Cooling Tower systems that have been drained, follow the water treatment vendor recommendations, while also considering these ASHRAE guidelines:

• Clean all debris (e.g., leaves and dirt) from the cooling tower.
• Fill the system with water. While operating the condensing water pump(s)—and prior to operating the cooling tower fans—bring the system under good biological control by either method below.
• Maintaining the maximum recommended residual for the biocide used prior to shut down for a sufficient period of time.
• Adding sodium hypochlorite to achieve 4-5 ppm free chlorine residual at a pH of 7.0 to 7.6, held for six hours.
• After step 2 has been successfully completed, the fan can be turned on, and the system returned to service.

Maintenance of your water systems in accordance with your water management plan and ASHRAE guidelines will help us all ensure that we don’t enter an increased period of Legionella outbreaks as we return to regular activity following this Coronavirus Pandemic. Contact us at Environmental Safety Technologies for the Legionella test you may need.

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