They may not need “a minor in plumbing,” but infection preventionists should familiarize themselves with their facility water systems and work with colleagues in engineering to ensure an outbreak of Legionella is not percolating in pipes, advised Frank Sidari, PE, BCEE, technical director of the Special Pathogens Laboratory in Pittsburgh.

In now requiring water management programs for Legionella, the Centers for Medicare & Medicaid Services (CMS) is essentially enforcing the 2015 recommendations by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE),^1,2 Sidari said recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology.

“The CMS has now taken that voluntary standard and put enforcement teeth into it,” he said. “Now, they are saying if you don’t follow ASHRAE 188 in healthcare, there are potential penalties, dings, and checkmarks.” There also is a lot of complementary guidance and overlap in the Legionella toolkit issued last year by the CDC.³

The first step in the process is to form a water management team. “Again — this is a team. One person probably does not have all of this information,” he said. “It is facility engineering, risk management, or quality folks. It is yourselves, with understanding of Legionella and Legionnaires’ disease. It may include outside experts that help you fill in the gaps.”

With your team in place, adopt a water management program that reflects the ASHRAE industry standard and the CDC toolkit, he said. Some of the key elements and issues of a water management program include:

Water systems/flow diagrams. These should include the potable and non-potable water system schematics.

“Could you tell a health department inspector how the water gets to patient rooms on the 7th floor?” Sidari said by way of example. “Is there a pump somewhere on the 5th floor that serves all of the upper floors? The water safety team needs to really understand how the water flows through. Understanding that and coupling it with the information you have on your patient population will help you better assess risk.”

Water system analysis/control measures. Evaluate where hazardous conditions may occur and decide where control measures should be applied.

“Put together control measures, including temperature, chlorine levels, cooling towers,” he said. “How often are you cleaning the decorative water feature?”

Monitoring/corrective actions. Establish procedures for monitoring whether control measures are within operating limits and if not, take corrective actions.

“If the temperatures drop or the chlorine levels are out of whack, what are you going to do to get back on track? This all becomes part of the program,” Sidari said.

Confirmation. Establish procedures for verification to confirm the program is being implemented as designed. Follow this with validation to make sure it effectively controls the hazardous conditions.

“I think the most important piece of this is the confirmation step,” he said. “There are two pieces to it. One is verification — are you actually implementing your water safety program? This is where I see folks struggle. They will put together a great water safety plan, but they don’t know if it is actually being implemented correctly.”

That means going beyond checking the box and having a stack of papers, he added.

“Don’t just assume that some group, or engineering, is taking care of this. The confirmation step to verify is important,” Sidari said.

The validation component should be met by your water testing program. “The only way to validate that your water safety program is working is to test for Legionella and see if you are controlling it.”

Documentation: Establish documentation and communication procedures for all activities of the program. You will be glad you have this if a CMS inspector calls.

“When the health department shows up, you can say, ‘Here’s our program and monitoring,’” Sidari said.

“We have been testing quarterly for the last two years and here are our lab results. Here are our corrective actions.”

REFERENCES

1. CMS. Center for Clinical Standards and Quality/Survey & Certification Group. Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD). Ref: S&C 17-30-ALL. June 02, 2017: http://go.cms.gov/2r3ue6B.
2. ASHRAE — Legionellosis: Risk Management for Building Water Systems (ANSI Approved) Standard 188-2015. 2015
3. CDC. Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards. June 5, 2017: https://bit.ly/2tWhxR2.