Water Management: Why Identifying Potential Risks Supersedes Testing



With everything we touch, our philosophy is to minimize all waste, which includes material waste, excess/unnecessary time and money expenditures, medical waste, etc. (Interested in revolutionizing medical waste management, check out our BETA WasteCare Calculator.)

We believe in doing what is most efficient and effective and nothing more (minimal waste). Effective water sustainability and infection prevention are both attainable. For purposes of this article, we’ll focus on the water infection prevention piece, while addressing what you need to know regarding the CMS memo and offer the least-burdensome suggestions for compliance.

By now you’ve likely seen the recent memo from the Department of Health and Human Service CMS re Legionella Risk. (For those of you who are familiar, feel free to skip over the next section.)

Snapshot of the CMS Memo Read entirety here.

 “Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations.”

Essentially, the CMS is requiring Medicare-certified healthcare facilities to implement water management policies and procedures to reduce the potential risk of Legionella (and other waterborne pathogens). The water management program should consider the ASHRAE 188 Standard and the CDC Toolkit.

AND, healthcare facilities that are unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance with the CMS Conditions of Participation.

This is really not new! Rather, CMS has added ASHRAE-188 to their list of “Examples of organizations that promulgate nationally recognized infection and communicable disease control guidelines, and/or recommendations” and clarified survey procedures.


Don’t sell yourself short! You likely have many, if not all, of the component already in place. The following are the seven things you need to know about the new CMS requirement:

1. Establish a DESIGNATED TEAM
2. If not in existence, develop water flow diagram for building(s)
3. Identify “at risk” areas/systems/equipment and populations
4. Develop and implement risk mitigation strategies
5. Monitor, review and document results
6. Appropriately respond to outlier conditions
7. Review Program periodically

(If you read CMS §482.42 Condition of Participation: Infection Control , you will find each of the items above except TEAM. All they have done on the ‘TEAM’ front was to specifically include others outside of Infection Control.)


The 188 process is not a testing process; it is a risk management process. (Several of my colleagues and I have been actively involved in providing Healthcare facilities better information re Legionella and how to manage it, along with other water pathogens. You can discover more in the ASHE Water Management Monograph, that we co-authored, here.

Standard 188 does ask each facility to assess its risk based on a number of factors and to effectively manage that risk. Testing water for Legionella is one way to manage but so is adequately maintaining your water systems and equipment…. so is testing for residual levels of chlorine… so is IP surveillance.

According to Steve Cutter, Director of Dartmouth-Hitchcock Engineering Services, “The decision to conduct legionella testing is to be made by the organization based on a risk assessment… There are documented cases of Legionellosis where Legionella is not found in the potable water supply, as well as cases where Legionella was detected in the water, but no disease. Until limits are established, finding a single CFU in a test result can expose the organization to significant costs.”


Our IP Consultant Enid Eck preaches, “Prevention is key”. This is applicable for any risk management plan, including water. The key is to understand your patient population, your water quality, your water systems and equipment, and to scrupulously maintain the latter.


Later this month, we are hosting two live events to further address your questions on this topic.


Related Content


Interested in what you see? Subscribe to receive monthly news and information
more tailored to what you need.

    This site uses cookies to ensure you have the best experience and to analyze our traffic. Read more in out Privacy Policy.