FAQ: The CMS Policy Memorandum and its Impact on a Healthcare Provider’s Water Management Program

On June 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a policy memorandum regarding the “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease (LD).” On June 9th, the policy was subsequently revised to clarify the provider types affected including Hospitals, Critical Access Hospitals (CAHs), Long-Term Care (LTC) Facilities and Nursing Homes. The full CMS policy memorandum can be found on the Centers for Medicare & Medicaid Services website at www.cms.gov.

Who is the CMS?
The CMS is part of the U.S. federal government's Department of Health and Human Services and provides health coverage to more than 100 million people through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.

What Does This Mean for Healthcare Providers?
In June of 2015, the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) published the standard ASHRAE 188-2015: Legionellosis: Risk Management for Building Water Systems. The June 2017 policy memorandum requires all healthcare providers to have a water management program in place 30 days from June 2, that is complaint with ASHRAE Standard 188-2015.

What Happens If A Healthcare Provider Does Not Comply?
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 Legionnaire's Disease are at risk of citation for non-compliance with the CMS “Conditions of Participation.” Accrediting organizations (“Surveyors”) will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, and will cite non-compliance accordingly. If not compliant, the affected healthcare facility could lose its government-provided Medicare and Medicaid funding.

How Can a Healthcare Provider Get a Water Management Program in Place?
As a compliment to the ASHRAE 188-2015 Standard, in 2016 the Centers for Disease Control (CDC) and its partners developed a toolkit entitled “Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to Implementing Industry Standards.” This toolkit is available for download at www.cdc.gov/legionella/maintenance/wmp-toolkit.html.

Many healthcare providers are taking on the role of primary developer in their water management program, and form a team of individuals who contribute to creating their facility's specific program. Under the leadership of the healthcare provider, this team will follow the ASHRAE 188-2015 guidelines and utilize additional tools available from the CDC to develop a compliant water management program. U.S. Water representatives are available to provide guidance and input in water management program development as a member of the healthcare provider's water management program team.

Other healthcare providers are choosing to hire an external party to act as the primary developer of their water management program. It is in the best interests, both short and long term, of the healthcare provider to hire an independent and qualified consultant, rather than a traditional water treatment company. An independent entity is best equipped to provide the facility with non-biased guidance as the primary developer of the water management program. Your U.S. Water representative can provide you with a recommendation for several capable professional firms who specialize in water management programs.

Please contact your U.S. Water representative with any questions you may have as to how to manage your action plan going forward to ensure compliance with this critical issue.

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