Danger: Hospitals and the CMS Crackdown

Chances are you know someone who has been hospitalized or stayed in a nursing home and developed pneumonia. How does that happen? The latest science proves some of these cases are coming from the facility water supply.

In June 2017, the Centers for Medicare and Medicaid Services (CMS) released a mandate to reduce Legionella risk in healthcare facility water systems. Inhalation of Legionella bacteria can cause Legionnaires disease, a dangerous form of bacterial pneumonia. The goal is to prevent cases and outbreaks of Legionnaires’ Disease, which became a big concern in the past few years.

With an overabundance of information available, where do you start?

There is an overwhelming amount of information available about this mandate. We’ve decided to culminate almost everything you need to know and create a simple step-by-step guide to help reduce the risk of a legionella outbreak in your facility.

Cases of Legionnaires disease and the Pontiac Fever have increased 286% in the U.S. during 2000-2014, with approximately 5,000 cases reported to the Centers for Disease Control and Presentation.

What is legionnaires disease?

Legionnaires’ Disease is a serious type of pneumonia caused by a bacteria called Legionella, which lives in the water. In normal levels, the bacteria cannot cause harm. However, in large and complex manmade water systems, the chance of having an outbreak is increased. Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization. Approximately 10% of the cases of Legionnaires disease are fatal.

Who is at risk?

Mostly susceptible hosts, such as people over 50 years old, very young people, smokers, and individuals with underlying medical conditions, such as lung disease and immunosuppression.

How can it be transmitted?

Transmission happens via aerosols from devices such as:

  • Showerheads and hoses
  • Cooling Towers
  • Hot tubs / saunas
  • Decorative fountains
  • Hot and cold water storage tanks
  • Water heaters
  • Water-hammer arrestors
  • Pipes, valves, and fittings
  • Expansion tanks
  • Water filters
  • Faucets and faucet flow restrictors
  • Aerators
  • Centrally installed misters, atomizers, air washers, and humidifiers
  • Eyewash stations
  • Medical devices such as CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units
  • Ice machines

*Legionnaires disease is less commonly spread by aspiration of drinking water or ice.

How to prevent Legionella in facilities?

The CMS aims that healthcare facilities:

  • Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases
  • 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

The only way to do this is by developing a comprehensive risk management program. This program is formed by four steps:

1 ) Surveying the building.

2 )  Conducting a risk assessment to identify where Legionella and other opportunistic water pathogens could grow and spread in the system.

3) Implementing a water management program.

4 ) Documenting all the activities of your water management program.

Surveying the Building

Buildings shall be surveyed to determine whether they have:

  • Cooling towers and evaporative condensers that provide cooling and refrigeration for HVAC&R systems in the building.
  • Whirpools and spas.
  • Ornamental fountains, misters, atomizers, air washes, humidifiers, and other nonpotable water systems that release water aerosols.

A building also should be surveyed to determine whether it presents one of the following:

  • Multiple housing units with a centralized potable water-heater system
  • More than 10 stories high (total)
  • It is a healthcare facility where patients stay for more than 24h
  • It is a building where patients receive treatment for burns, chemotherapy, or where organ and bone transplantation is performed
  • It is housing for immunocompromised patients, who have renal, or chronic lung diseases, or diabetes
  • It is housing for occupants over the age of 65.

If the building has any of the building water systems mentioned or presents any of the factors listed above, then all of the building water systems and/or the building design should comply with a series of requirements.

When designing for new construction, renovation, refurbishment, replacement, or repurposing a facility, the following shall be documented in detail:

  • System overview and intended mode of operation.
    • How the water enters the system.
    • How cold water is distributed.
    • How cold water is heated.
    • How hot water is distributed.
    • How hot, cold, and tempered water is discarded.
  • Schematic diagrams of water systems.
  • Monitoring and control diagrams of water systems.
  • Local, regional, and national code compliance.
  • Location of makeup, flush, sampling, temperature monitoring, and drain points.
  • Location of outdoor air intakes.
  • Building water equipment.
  • Balancing and commissioning.
  • Operating instructions and procedures.
  • Maintenance schedule, frequencies, and procedures.
  • No-flow and low-flow portions of the piping and building water systems.
  • Impact of heat loss from hot water and heat gain by cold water in piping and water system components.
  • Possible cross-connections between potable and nonpotable water.
  • Inadequate access to expansion tanks, arrestors, storage tanks, water heaters and other equipment containing water.

Conducting a Risk Assessment

The risk assessment is conducted in order to identify areas where Legionella could grow and spread. To facilitate the identification, it is important to create a flow diagram that describes the building water systems, from receiving water to wastewater distribution.

Once you have this diagram, it will be easier to identify where potentially hazardous conditions could occur in your building systems. Consider temperature permissive, stagnation, lack of disinfectant, conditions for bacteria to spread, and even external hazards.

The image below illustrates a flow diagram with these areas identified. Source: U.S. Department of Health and Human Services – Centers for Disease Control and Prevention

Implementing a Water Management Program

Once the hazardous conditions are identified, then the next step becomes easier: to determine the locations in the system where control measures are required, and how to monitor them.

This means that each control measure needs to be accompanied by a control limit (minimum and maximum level), which will work as a sign for you to verify if corrective action should be taken immediately when monitoring the system. Examples of control measures could be temperature and disinfectant levels, for instance.

Control measures require to be constantly monitored to ensure they are performing as designed.  Monitoring control measures methods commonly adopted are a visual inspection and checking disinfectant levels and temperature.

Monitoring control measures also means checking the entire water system, from receiving water from the municipal water to the sanitary sewer water, and taking the corrective actions when necessary.

These actions need to be established before an unfavorable situation is presented, and simply applied when monitoring indicates that the control parameters are out of the control limits.

Building water systems are dynamic and planning ahead is what makes the difference.

Here are a couple of examples of corrective measurements:

  • PROBLEM: during the inspection of a fountain, bacterial growth is observed.

    • To shut down the fountain, drain the water, and clean with recommended detergent.
    • To safely refill the fountain, checking control limits of disinfectant.
    • To document all observations and inform supervisors.
  • PROBLEM: during cooling tower inspection, debris is found in the basin.

    • To investigate where the debris is coming from.
    • To fix the issue, cleaning out the debris.
    • To check the disinfectant level and water quality.

Some basic topics that your water management must include are procedures for system shut-down and start-up, water treatment, and disinfection. And, above all, a contingency response plan.

The contingency response plan has all the procedures to be followed if there are known or suspected cases of legionellosis associated with the use of aerosol generating misters, atomizers, air washers, and humidifiers. It must also contain directions by health department authorities, emergency disinfection plans, and a plan to prevent more exposure to contaminated water.

A water management program also includes procedures to confirm and validate that the program is being designed and implemented, and that it effectively controls the hazardous conditions throughout the building water systems.

There is absolutely no way to implement a water treatment program without assigning a team. The program team identifies the people responsible for its development and implementation. A team is usually formed by:

  • The building owner or designee.
  • Employees.
  • Suppliers.
  • Consultants.
  • Other individuals to whom the owner has delegated the authority and responsibilities for the actions required by the program.

The designated team must have:

  • Knowledge of the water systems.
  • Ability to oversee the program.
  • Ability to identify control locations and control limits.
  • Ability to identify and take corrective actions.
  • Ability to monitor and document program performance.
  • Ability to confirm program performance.
  • Ability to communicate regularly about the program.
  • Ability to oversee the program.

Documenting all the activities of your water management program

Establishing documentation concerning all procedures, and maintaining records appropriate to these principles and their application is extremely important. Documenting all aspects of the legionellosis risk management plan, including development, implementation, verification, and validation are important both to improve your program and for others to review your records when necessary.

All the following information should be documented:

  • Program team: names, titles, contact information, and roles.
  • Building description: location, age, uses, occupants, and visitors.
  • Comprehensive water system description.
  • Control measures, including points in the system where critical limits can be monitored and where control can be applied.
  • Program confirmatory and validation steps.
  • Collection and transport methods and which lab will perform or performed the testing if environmental testing is/was conducted.

A complete risk management assessment is an extremely detailed document, which is usually longer than a hundred pages. It can only be performed by trustworthy companies who have expertise in water management programs. We have seen some companies promising this type of service, and delivering shallow information that wouldn’t help them in a serious case of legionella outbreak, and could possibly aggravate the situation if something happens.

It is more common than you think and requires more attention than you’re probably giving to it.
cdc legionella toolkit