On June 9th, CMS posted a Survey and Certification Letter that outlines the responsibilities of health care providers, including Medicare-certified Skilled Nursing Facilities, to develop and implement water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.
Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:
- Conduct 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.
- Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
- Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
