• Goal #7: Reduce the risk of health-care-associated infections.
• Requirement #7B: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health-care-associated infection.
• Full compliance required as of January 1, 2005

• Controlling the Spread of Waterborne Microorganisms

“Eliminate contaminated water or fluid environmental reservoirs (e.g. in equipment or solutions) wherever possible"

• Preventing Legionnaires Disease in Protective Environments and Transplant Units

“If Legionella spp. are determined to be present in the water of a transplant unit, implement certain measures until Legionella spp. are no longer detected by culture.

Decontaminate the water supply.

Do not use water from the faucets in patient-care rooms to avoid creating infectious aerosols.

Restrict severely immunocompromised patients from taking showers…”

• Prevention and Control of Health-Care-Associated Legionnaires Disease

“Health-care facilities with hematopoietic stem cell or solid-organ transplantation programs. If Legionellae are detected in the potable water supply of a transplant unit, and until Legionellae are no longer detected by culture:

Restrict severely immunocompromised patients from taking showers.
Do not use water from faucets with Legionella-contaminated water in patients’ rooms to avoid creating infectious aerosols.”

• Control of Specific Nosocomial Infections/Recommendations Regarding Legionella Species:

“…conduct a thorough epidemiologic and environmental investigation to determine the likely environmental source(s) of Legionella species (e.g. showers, tap water faucets, cooling towers and hot water tanks.)”

• Control of Specific Nosocomial Infections/Recommendations Regarding Legionella Species:

“The source of Legionella infection should be identified and decontaminated or removed.”

 “…the goal, if environmental surveillance for Legionellae is undertaken, should be to maintain water systems with no detectable organisms.”