Legionella in Health Care Settings
In June 2017, the Center for Medicare and Medicaid Services (CMS) issued a memo outlining requirements for health care facilities to reduce the risk of Legionella infection.
Legionella is a type of bacteria found naturally in freshwater environments, like lakes and streams. It can become a health concern when it grows and spreads in human-made water systems like:
- Showers and faucets
- Cooling towers (air-conditioning units for large buildings)
- Hot tubs
- Decorative fountains and water features
- Hot water tanks and heaters
- Large plumbing systems
Home air-condition units do not use water to cool the air so they are not a risk for Legionella growth.
What Healthcare Facilities Need to Know About Legionella
After Legionella grows and multiplies in a building water system, that contaminated water then spreads in droplets small enough for people to breathe in. People can get Legionnaires’ disease when they breathe in small droplets of water in the air that contain the bacteria.
Less commonly, people can get Legionnaires' disease by aspiration of drinking water. This happens when water “goes down the wrong pipe,” into the trachea (windpipe) and lungs instead of the digestive tract. People at increased risk of aspiration include those with swallowing difficulties.
In general, people do not spread Legionnaires’ Disease and Pontiac Fever to other people. However, this may be possible in rare cases. (Correia AM, GonCalves J, Gomes, JP, et al. Probable Person-to-Person Transmission of Legionnaires’ Disease. N Engl J Med. 2016;374:497-8.)
Factors That Lead to Legionella Growth
A variety of internal and external factors can lead to a Legionella problem in your building, including:
- Water main breaks
- Changes in municipal water quality
- Scale and sediment
- Water temperature fluctuations
- Fluctuations in pH
- Inadequate levels of disinfectant
- Changes in water pressure
- Water stagnation
How to Address Legionella Growth
- Ensure disinfectant amounts are correct
- Maintain correct water temperatures
- Prevent stagnation
- Operate and maintain equipment
- Monitor external factors
Expectations for Healthcare Facilities & Surveyors
CMS expects Medicare-certified healthcare facilities 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. Surveyors from the KDHE Health Facilities program will review policies, procedures, and reports to verify that facilities:
- Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system
- Develop and implement a water management plan that considers the toolkit provided by the Centers for Disease Control and Prevention - The plan should include 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
Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of patients. Those facilities unable to demonstrate measures to minimize the risk of Legionella growth, and ultimately Legionnaires’ disease, are at risk of citation for noncompliance with the CMS Conditions of Participation. The KDHE Health Facilities program will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite non-compliance accordingly.
- Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (PDF)
- CMS Legionella and Other Waterborne Pathogens Webinar
- Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings (PDF)
- Special Considerations for Healthcare Facilities
- List of Laboratories Certified Through the CDC Environmental Legionella Isolation Techniques Evaluation (ELITE) Program
- QSO17-30.Requirement to Reduce Legionella Risk REV.07.06.18 (PDF)
- SC17-30.Legionella_Risks in Healthcare.Revised 6-09-17 (PDF)
- For questions related to the CMS requirements, contact the KDHE Health Facilities program at 785-296-0127.
- For technical assistance with sample collection and questions related to public drinking water, contact your local public water supply system. Sample collection should be as per the directions of a Legionella-certified laboratory. The KDHE Public Water Supply Section can provide contact information for your local water supply system. Please call 785-296-5514.
- For questions related to Legionnaires’ disease and disease reporting, contact the KDHE Epidemiology Hotline at 877-427-7317.