Waterborne pathogen transmission is a major concern for health care facilities. Due to the nature of long term care, residents are exposed to water in a variety of ways. Facilities need to be able to ensure that resident risk is reduced when using municipal water sources for hygiene, medical care or food preparation. Of all waterborne pathogens associated with health care systems, Legionella species are the most often implicated and most frequently discussed pathogen.
In June 2017, the Centers for Medicare and Medicaid Services (CMS) released a memorandum detailing expectations for acute care, critical access and long term care facilities for controlling Legionella and other waterborne pathogens. The memo outlines the three critical elements that surveyors will be addressing to fully meet CMS standards.
- Facilities must perform a risk assessment for Legionella and other waterborne pathogens.
- Facilities must have a plan to monitor water systems to ensure that risks are mitigated.
- Facilities must document and review this plan to ensure that it is effective.
The memo refers facilities to the CDC Legionella Toolkit and to the ASHRAE 188 standard for more details. These two documents form the accepted standards for creating a water management program. Both documents spell out the basic steps in ensuring your facility has a functioning program.
The CDC Toolkit outlines seven basic elements of a successful program:
- Establish a water management program team
- Describe the building water systems using text and flow diagrams
- Identify areas where Legionella or other pathogens could grow and spread
- Decide where control measures should be applied and how to monitor them
- Establish interventions when control limits are not met
- Make sure program is effective
- Document and communicate activities
Perhaps the most important step for any facility is setting up an appropriate program design. This includes forming an appropriate team, conducting a facility risk assessment, describing the facility water system, identifying potential problem areas, and setting monitoring and control measures. All other efforts, including surveillance, enhanced testing, response measures, or documentation and reporting are all dependent on ensuring that the assessment and identification are completed. The types of controls and processes will depend on the type of system in the building and the areas of hazard identified in the beginning. For example, a building with numerous hydrotherapy rooms will need to ensure these areas are monitored. This is also why the first step, establish a team, is critical to make sure the proper expertise is at the table.
An important aspect to remember is that CMS does not proscribe any specific set of measures that need to be implemented. The CDC Toolkit and the ASHRAE 188 standard are also broad, leaving each facility the ability to implement controls and measures that fit their individual water distribution systems, environment, and patient populations. In this way, each facility can ensure they adhere to local laws and use the best measures for them.
For us in Florida, our natural environment and water sources provide an ample source for natural pathogens, contrary to what might be other climates. Therefore, it is vitally important that facilities establish the proper team and program to demonstrate effective mitigation of risks to residents.