Joint Commission Looking for Legionella Water Plans

December 20th, 2018

By Gary Evans, Medical Writer

Does your facility have a water management program to protect patients from Legionella infections? In light of continuing outbreaks linked to hospital water systems, the CMS and its accreditation authorities are looking for evidence corrective measures are being taken.

The Joint Commission is reminding healthcare facilities that it can use current accreditation standards to enforce a 2017 CMS memo that called for such water management plans to be put in place – effective immediately.

“The Joint Commission did not need to develop new standards to survey to this requirement because existing standards already required an accredited organization to plan, implement, and evaluate programs to protect the health and safety of patients,” Sylvia Garcia-Houchins, MSN, RN, CIC, director of infection prevention and control at TJC, noted in a recent blog post.

The existing standards that can be used to cite for the lack of water plan include the following, she said.

EC.01.01.01: The hospital has a written plan for managing its utility systems.

EC.02.05.01: The organization manages risks associated with its utility systems.

EC.02.05.05: The organization inspects, tests, and maintains utility systems.

IC.01.03.01: The organization identifies risks for acquiring and transmitting infections.

“In addition, surveyors may ask about situations that could put a facility’s water system at risk and what the facility has done or would do to mitigate the risk,” she said.

For more on this story, see the January 2019 issue of Hospital Infection Control & Prevention.