Matt Freije
Matt Freije

How you go about complying with the June 2 Centers for Medicare & Medicaid Services “requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ disease” could have a major impact on your facility—and possibly your job.

Here are four ways to avoiding citations and protecting your residents’ health with minimal time, money, and legal risk:

1. Smart Control Measures

Control measures are the most important part of a water management program (WMP) because what you do to your water is what reduces the risk of disease. Other parts of your WMP—flow diagrams, water systems descriptions, hazard analysis, sampling—are important but in themselves do not reduce risk.

To avoid a CMS citation for non-compliance, facilities must “demonstrate measures to minimize the risk of LD.” Which measures you implement to accomplish that objective CMS is leaving largely up to you.

CMS provided only a framework, simply referring to ANSI/ASHRAE Standard 188-2015 and the CDC’s publication (toolkit), “Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards.”

What you put inside that framework is crucial. Answer these questions to find out if you are on the right track with your control measures:

  • Are measures included for all water systems? CMS requires policies and procedures (control measures) for all building water systems that can harbor and spread Legionella and other opportunistic pathogens including plumbing (domestic water) systems and devices connected to them, whirlpool spas, humidifiers, decorative fountains and cooling towers.
  • For each control measure, have you (per ASHRAE 188) listed a performance limit, monitoring for that limit and corrective action if the limit is exceeded?
  • Have you included measures for design and construction as well as operation and maintenance?
  • Are all applicable measures included for each water system type? Many WMPs omit procedures that cost little or nothing but are crucial to reducing risk, simply because the facility or the company they hire to provide their WMP is unaware of them. Look at a WMP known to be comprehensive and see how your facility measures up.
  • Are your measures specific? Vague policies like “reduce stagnation” or “avoid dead-legs” are ineffective. Each control measure should be written such that a maintenance person could go do it (e.g., “Open the valve on the North Tower backflow preventer bypass for 30 seconds once a month.”).
  • Are you providing training? Your personnel must know how to perform the control measures well. Also knowing why is even better.
  • Are your measures evidence-based? Doing what is unnecessary or ineffective wastes time and money and sometimes water, energy and chemicals as well.

2. Smart Execution

How you manage the development and implementation of your plan will affect your cost and risk.

Facilities that execute their WMPs well seem to have certain habits in common, one of which is striking the right balance between in-house personnel and outside services. If you attempt to write a WMP on your own from scratch, you will fool yourself into thinking you are saving money only to find you wasted countless hours on a WMP that is vague, incomplete and indefensible.

Most make the opposite mistake—attempting to rely entirely on a vendor to develop and implement their WMP. That does not work, in part because many control measures will be performed better and much less expensively by your own maintenance personnel.

Some facilities can develop an excellent WMP inexpensively on their own if they use a well-recognized, comprehensive and defensible cloud application or template. Other facilities will be better off hiring a company to provide the WMP for them if they thoroughly research options—the differences among vendors are significant. Don’t be fooled into thinking the more expensive options are better.

Developing the WMP is only the start. Two facilities with the same WMP content can have quite different outcomes if one executes their WMP better than the other.

In implementing the WMP, you need to have in-house personnel as well as vendors involved. Facilities that attempt to carry out the WMP with only one or the other either fail to adequately reduce risk, spend too much money or both.

In September 2016, the facilities director, infection control director and risk management director at UCSF Medical Center were interviewed in a live webcast about the execution of their WMP because they have done it so extraordinarily well. Their success could be for several reasons but two stood out in the interview: They work hard at communication (e.g., scheduling regular conference calls with all parties to discuss the progress of implementing control measures) and they plan and monitor repair and construction projects thoroughly and vigilantly (e.g., to ensure minimal stagnation and biofilm disruption).

3. Smart Validation

Validation procedures measure the effectiveness of a WMP in accomplishing its main objective, i.e., to reduce the hazard (e.g., Legionella).

Although a good WMP will include control measures to reduce the risk of many waterborne pathogens, Legionella is the best pathogen by which to define the scope and objective of a WMP because Legionella it is almost entirely waterborne, several commercial laboratories in the United States can test for it in water samples and numerous scientific studies provide an abundance of data on which to base control measures and remediation methods.

Testing water samples for Legionella provides the most reliable feedback on Legionella control. Chlorine measurements, temperate readings and total bacteria counts can provide good information for water system management, but in most water systems they will not reliably indicate Legionella. However, for Legionella tests to provide good validation of a WMP, the sampling, laboratory analysis and interpretation of results must be performed properly. Success depends on these six factors:

  • Collect the optimum number of samples. Too many samples results in overspending. Too few provide data insufficient for decision making—a total waste of money and time.
  • Plan samples strategically. Hot versus cold water. Pre- versus post-flush. The right locations.
  • Collect samples properly. It is easy to fill a bottle with water, but the details are crucial.
  • Record data to maximize useful information. You get more for your money if you collect the right data.
  • Use a proven laboratory. Don’t skimp here. Use the best you can find. At a minimum, ensure it has CDC ELITE certification for Legionella testing.
  • Interpret results from multiple angles, not just one. If you interpret results based on a simple grid of Legionella concentrations or positivity (percentage of plumbing system samples in which Legionella is found), you will miss opportunities to prevent disease, spend too much money on remediation, harm the environment unnecessarily or all the above.

4. Smart Remediation

Too many facilities and consultants take an all or nothing approach to domestic water remediation, responding to Legionella test results by either doing nothing or disinfecting the entire system. Rarely is either extreme the best action.

Don’t be like the facilities that have responded inadequately or too late to test results—deciding instead to just retest and hoping the results get better. And don’t waste money on ineffective changes, like facilities that have replaced all domestic water piping at the advice of an engineering firm—and still failed to fix a Legionella problem that could have been solved for $30,000.

Thorough and properly interpreted analytics are the key to smart remediation. Instead of making decisions on a simple Legionella threshold, compare results for hot versus cold water, buildings and outlet types. The facility with the results shown in the image below should consider replacing shower hoses more often, since they had higher positivity than showerheads over several sampling rounds, and either discontinuing the piped-in water dispensers or replacing them with a different model.

Using analytics to pinpoint the root of problems allows you to remediate with a rifle instead of a shotgun — solving problems faster, more effectively and at much lower cost.


In the long run, the CMS requirement will reduce health risk at reasonable costs if facilities implement smart water management programs — ones with smart control measures, execution, validation, and remediation.

Matt Freije is the founder and CEO of and the content manager for LAMPS, a cloud application for water management plans and training.