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Diving into CMS expectations for having water management policies and procedures

Hospital Safety Insider, July 19, 2018

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Editor's note: This was originally published on Steve MacArthur's blog, Mac's Safety Space.

Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers, guidance and/or equivalencies good for? Answer: It depends (with more permutations that you can shake a stick at...).

Last week, we chatted a little bit about the whole water management thing, including mention of what CMS is telling surveyors to look for. But I thought it might be useful to extract some of the specifics from that missive. So, here we have:

Expectations for Healthcare Facilities

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

• Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
• Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit.
• Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
• Maintains compliance with other applicable federal, state, and local requirements.

Note: CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

Healthcare facilities are expected to comply with CMS requirements and Conditions of Participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance.

Expectations for Surveyors and Accrediting Organizations

Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update. Until that occurs, please use this paragraph as guiding instructions.

Just so you know, I chose to use some of the text in bold font because I think that’s probably the most important piece of this for folks moving forward (kind of makes me think that, just perhaps, there have been citations for folks not actively pursuing water cultures). But it does establish the expectation that a piece of the required risk assessment is going to include something that relates to whether you choose to culture, how often, and how you came to make that determination. I think this helps folks manage some of the ins and outs of this process, but I still feel like this could end up being a source of consternation as surveyors “kick the tires” in the field.

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