CMS Memo S&C17-30 Updated 06 July 2018 

The Centers for Medicare and Medicaid Services (CMS) released an update to their 02 June 2017 memorandum that states: "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." 

The 2018 update "...clarifies expectations for providers, accrediting organizations, and surveyors, and does not impose any new expectations or requirements for hospitals, CAHs and surveyors of hospitals and CAHs."

The original and updated memos references ASHRAE 188-2015 and the CDC Toolkit and states that facilities unable to demonstrate measures to minimize the risk of Legionnaires' Disease are at risk of citation for non-compliance with the CMS Condition of Participation.  The revised memo (09 June 2017) clariified that the memo applied to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC) facilities.

Facilities must:

  • Conduct a facility risk assessment to identify where Legionella and other opportunisitic waterborne pathogens could grow and spread in the facility water system
  • Implement a water management program that considers ASHRAE 188-2015 and the CDC Toolkit, and includes control measures
  • Specify testing protocols and acceptable ranges for control measures, and document results of testing and corrective actions taken when control limits are not maintained.

ASI can help by providing independent, third-party Legionella testing services.

Incorporated in 1993, ASI is a nationally recognized, full service environmental microbiology laboratory and has been CDC ELITE certifed since 2009 (the first year of the ELITE program).  ASI is also NYS-DOH-ELAP certified for Legionella (Lab #12021 for ISO11731).  ASI provides reliable, defensible Legionella data to clients throughout the U.S. for regulatory compliance or as part of ASHRAE 188-2015 water safety plans. 

 Located in Williston, Vermont, ASI is part of the Institute for Environmental Health (IEH) Laboratory and Consulting Group, with corporate headquarters in Lake Forest Park, WA.