June 15, 2017 zacherlaw 0 Comments

The Centers for Medicare and Medicaid Services (CMS) issued a requirement to all healthcare facilities on June 2, 2017 to reduce the risk of the Legionella bacteria in their water systems. This bacteria is the cause of Legionnaires’ disease. CMS issued this requirement because of numerous recent Legionnaires’ disease outbreaks in hospitals and long-term care facilities.

As stated in the regulation;

The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control and investigation of infections and communicable diseases[i]

The same type of regulation applies to skilled nursing facilities and nursing facilities[ii], and critical access hospitals[iii].

The essence of the requirement for all Medicare certified healthcare facilities is “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[iv] by following the industry standard developed by ASHRAE[v]. Most importantly, even though ASHRAE 188 does not require it, testing for the presence of legionella in a healthcare facilities water system must also be done. This is a monumental change and the CMS should be applauded for it.

Finally, the new requirement carries a stiff penalty for non-compliance. The CMS requirement states “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance with the CMS Conditions of Participation.”




[i] 42 CFR § 482.42

[ii] 42 CFR § 483.80

[iii] 42 CFR § 485.653(a)(3)(vi)

[iv] S&C 17-30-Hosptals/CAHs/NHs Revised 6-9-17

[v] ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta. www.ashrae.org

New CMS Requirement for Healthcare Facilites was last modified: June 15th, 2017 by zacherlaw

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