Limit Litigation Liabilities – Healthcare Facilities

Every administrator in a health care environment is interested in limiting litigation and liability. When it comes to potable water and the minimization of Legionella in this water system – there are some very definite steps that every institution can take to limit the liability and litigation potentials.

The Center for Medicare and Medicaid Services (CMS) released a document in June of 2017 that outlined expectations for Healthcare Facilities. These expectations follow closely the directives that New York State adopted in July of 2016 and the Standard 188 issued by American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE), released in June of 2015. The Center for Disease Control (CDC) has also offered a toolkit to assist with facilitating implementation of a Water Compliance Program. CMS expects Medicare certified healthcare facilities to implement water management policies and procedures to minimize the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Systems include: hot water systems, ice machines, decorative fountains, cooling towers, showerheads, eyewash stations, hot tubs, saunas, humidifiers, air washers.

The basic components of a Water Compliance Program will be:

Conduct a facility risk assessment. NYS DOH Form 5222 – Environmental Assessment of Water Systems in Healthcare Settings – is a valuable tool for identifying where Legionella and other waterborne pathogens could grow and spread in a facility water system.

  • Implement a Water Compliance Program that considers the ASHRAE Standard 188 and the CDC toolkit – to include control measures, temperature management, secondary disinfectant level control (if appropriate), visual inspections and environmental testing for pathogens and Legionella. NYS asks for quarterly testing initially (4 sample collection – 90 days apart. A minimum of 10 samples for a location with <500 beds. These samples are from “unique distal sites throughout the facility”).
  • Documentation of specific testing protocols and acceptable ranges for control measures and any necessary corrective actions that must be taken if an “actionable level” is detected.

Failure to comply with this directive to protect the health and safety of residents will greatly increase the potential for liability issues and litigation. In addition, the healthcare facility may be cited for non-compliance with the CMS Conditions of Participation and risk losing reimbursement from CMS.

Do the right thing to protect the residents of the facility and prevent unnecessary litigation and liability. – develop your Water Compliance Program today.

Mark Botsford, CWT

District Manager




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