Accreditation

HFAP revised standards: Legionella

Briefings on Accreditation and Quality, August 1, 2018

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To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with a new requirement for Infection Control Standard 07.01.03—Reduce Risk of Legionella in Water Systems.

The accrediting organization (AO) says 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.

CMS issued S&C memo 17-30 last summer, reminding healthcare organizations of the dangers of legionella. Surveyors from all AOs are paying closer attention to facilities’ water systems as a result. 

Alise Howlett, AIA, CFPE, CHFM, is HFAP’s emergency management, physical environment, and life safety standards advisor. And Karen Y. Beem, MS, RN, serves on HFAP’s standards interpretation staff and participates in the development and revision of standards.

This Q&A has been lightly edited for clarity.

Q: In your opinion, what’s one of the most significant changes in HFAP’s legionella standards? And how will they help patients? 

Howlett: The most significant change is in terms of the intent of the standard; that’s most helpful to facilities to know. 

During survey, we’re really going to be assessing facilities for their risk management process for legionella. Before, we might have had questions about it or it might have been a small part of their policy. But right now, they have to outline a very specific risk assessment that identifies: 

  • Where they’ll be testing their water
  • Who’s going to be looking at the results
  • Who’s making decisions about what needs to happen
  • How to ensure the quality of their water is reported through the safety committee and isn’t reviewed by a single entity

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