Review Your Water Management Plan as CMS Intensifies Focus on Legionella

By A.J. Plunkett

A good water management plan begins with your facilities management team and a solid risk assessment of your water distribution and storage systems, which must include a walk-through of your hospital with your onsite plumbing expert.

CMS recently updated a memo to its survey teams on reducing the risk of Legionella to specifically note that facilities must have a water management plan that surveyors can review. That plan should be written and managed by a multidisciplinary committee of people from throughout the hospital with a stake in water use, says Bryan Connors, MS, CIH, HEM, the Healthcare Practice Director at Environmental Health & Engineering Inc., in Newton, Mass. Connors is certified as both an industrial hygienist and a healthcare environmental manager and works as a consultant for hospitals and other facilities, including the management of water systems.

The CMS memo, which was first published last year and then updated this June, continues to point to the ANSI/ASHRAE Standard 188 “Legionellosis: Risk Management for Building Water Systems” and best practices set out by a 2016 CDC toolkit on developing a water management program to reduce the growth and spread of Legionella in buildings as key resources.

“If you look at the CMS memo, it talks about having a facility assessment,” notes Connors. You should have multidisciplinary team members and be sure that one of them is somebody who knows the plumbing configuration within your hospital, he says, “which typically is the supervisor of the plumbing shop, or the manager of facilities.”

Surveyors from CMS, The Joint Commission (TJC) and other accrediting organizations (AO) will be looking for proof of a water management plan that also has the support of leadership.

Use memo to review program

Review your program against the memo to ensure you are meeting what CMS — and therefore other AOs — want to see.

“The first thing you would look at in the program —and this is a vulnerability for many hospitals who have not been surveyed in the last year — would be [to determine whether] you have a document or documents that describes the plan,” says Connors.

What those documents would look like is up to you. However, “you are required to have a risk assessment, done by a multidisciplinary team, to identify your hospital’s risk for Legionella bacteria growth relative to the [hospital] population in general, and then specifically relative to at-risk populations,” Connors notes.

You might have a written Legionella plan or a water management plan. Those terms are used interchangeably, but are different, he notes.

CMS is clear that Legionella is just one — an important one — but just one of several waterborne pathogens to be managing for, Connors emphasizes. To satisfy CMS, you must manage the risk from the other waterborne pathogens too. But in general, says Connors, “if you are controlling for Legionella, you’re controlling for a lot of the other pathogens.”

The written plan should have a description of the water management team, and what their roles and responsibilities are. The plan also should outline what the risks are within the organization regarding your water systems, mitigating factors and how you are monitoring the system.

The plan should include process flow diagrams of the water system, including “incoming water, potable water and non-potable water, and distribution systems throughout the facility including water storage, and water treatment tanks — as well as a narrative associated with those.”

It should also identify problem areas and how those areas are being mitigated.

For instance, how are you identifying and eliminating dead legs of plumbing where water can sit still and allow pathogens to grow? What, how and when are you sampling for in cooling towers? Every hospital has some type of renovation or repair, Connors notes. How are you flushing pipes during renovation and ensuring that your redesign doesn’t result in water stagnating?

How do you monitor water temperatures, and what parameters do you use? What is the schedule for cleaning and maintenance of your water towers or other systems?

When assessing risk, you need to have someone who knows the plumbing system design and configuration, who can look at things like hot water tanks, dead leg plumbing, and cross connects, he says.

“You do have to get out and walk around. If you don’t have someone who knows your plumbing system, you’re not doing it right.”

Legionella not always required

While the CMS memo requires a documented water plan, it also emphasizes that periodic testing for Legionella bacteria is not required, notes Connors. “The most important point [of the update] being that the plan does not have to include Legionella bacteria sampling as a part of it,” though most hospitals should at least monitor their cooling towers.

What it must have, says Connors, is a narrative of what type of monitoring (such for residual disinfectants like free chlorine) is being done, when Legionella sampling would be required, and how you manage that data, he says.

The plan should include what kind of monitoring you do of your water system, but measurements can include residual disinfectants, pH and chlorine — it’s all about the risk assessment for your hospital’s population and risks, he says. However, the CMS memo “is not prescriptive about testing.”

The materials to outline your water management program need to show that the plan is an effective and implemented document, “not just a binder on a shelf. Typically, what we’re talking about here are committee minutes and action plans from water management committee meetings.”

That multidisciplinary committee should include your infection preventionist, a nurse manager, a representative from clinical labs and other areas with a key stake in the use of water at your facility.

The frequency of the committee meetings is up to you. “But you do have to show that this plan is being implemented.”

One tactic would be to use the committee meetings as a continuing way to implement and manage the plan, Connors suggests.

In the first meeting, go through roles and responsibilities of the water management committee and team. Have all those people in the room and discuss what they will be doing. Document changes to the plan suggested during the meeting.

In subsequent meetings, review a different section of the plan. “Make the committee meeting a time to review the effectiveness of the plan,” suggests Connors.

Show your progress

The process must remain dynamic. Surveyors “want to see that action is being taken.”

The plan should also include input from the clinical side, including what steps must be taken if Legionella is either identified in the building water or in a patient.

That will require strong communication between clinical and facilities management teams, he notes.

Legionnaire’s disease as well as the less severe Pontiac fever present as similar to pneumonia, notes Connors. There should be appropriate screening of patients and staff, and a plan for the steps to take both clinically and within the facility system once Legionella is suspected or confirmed.

Your water management plan should outline both the proactive and reactive parts of pathogen management from a facilities and clinical perspective, Connors says. That should include whatever triggers your facility sets to activate that algorithm — concentrations of Legionella bacteria, patient diagnoses or other “screen parameters out of tolerance that might be of concern.”

“If you are going to come up for survey in the next 12 months, you want to make sure … you or one of your consultants has done a risk assessment, and that risk assessment was done by a multidisciplinary team,” and you have a written water management plan. The document should include process flow diagrams, screen parameters and other such elements, as well as “things like committee minutes and committee rosters to show that this plan is being implemented,” says Connors.

Originally published in Environment of Care Leader.