Accreditation

Hospitals need to test for Legionella

Briefings on Accreditation and Quality, January 1, 2018

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CMS and Joint Commission tell facilities to test for Legionella in off-site and non-patient areas

As we begin 2018, it’s time to crack down on the spread of waterborne pathogens such as Legionella. Because even if you aren’t thinking about them, the federal government and accrediting organizations are. And if surveyors are feeling the pressure, that means you will, too.

Legionella breeds naturally in warm water and can usually be found in the parts of hospital systems that are continually wet. Poorly maintained water systems have been linked to the 286% increase in legionellosis between 2000 and 2014. In 2015, over three-quarters of the cases of Legionnaire’s disease (the respiratory illness caused by Legionella) were healthcare related.

In June, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. At the time the guidance was supposed to apply to all healthcare organizations, but it was revised to just target hospitals, critical care hospitals, and nursing homes.

That was followed by a request from the Centers for Disease Control and Prevention (CDC) in August for more information on best practices for water management programs (WMP). Public comment included calls for better oversight of ambulatory healthcare centers or other sites off traditional hospital campuses.
The topic also came up during the September 2017 session at The Joint Commission’s Executive Briefings in Chicago.

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