Failure to Implement Comprehensive Water Management Program for Legionella Control
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program specifically for water management to monitor and control the potential development and spread of Legionella bacteria. This deficiency was identified through a review of the facility's policy, documentation, and staff interviews. The facility's Legionella Assessment and Prevention Program, dated January 13, 2025, indicated the use of water management practices to reduce the risk of Legionella growth. However, the facility did not implement these practices effectively for ten out of twelve months, from April 2024 through January 2025. The facility's water management information lacked specific testing protocols, acceptable ranges for control measures, and a description of the water system using a flow diagram. The facility also failed to maintain a log for Point of Use Disinfectant to measure and record chlorine concentration levels in the water, which are critical for controlling Legionella. During an interview, the Nursing Home Administrator confirmed the absence of a Maintenance Director and acknowledged the facility's failure to maintain a comprehensive water management program. This deficiency was in violation of the Department of Health and Human Services, CMS memo requirements, and ASHRAE guidance, which emphasize the need for a water management plan to prevent Legionella outbreaks in healthcare facilities.
Plan Of Correction
Annual Legionella testing was completed in the facility on March 25, 2024, and no legionella species were detected. To prevent recurrence, the NHA will be educated on the Legionella Assessment and Prevention Program by the RVPO/designee. To prevent recurrence, the NHA will assign persons responsible to complete the required Legionella assessment. A text and flow diagram will be formulated to describe the facility's water system. A risk assessment with control methods including physical controls, temperature management, and disinfection level control if a cooling tower or evaporative condenser is present, visual inspection/environmental testing for pathogens, and corrective actions will be completed by the assigned persons. After the assessment is completed, the assessment team will develop a plan for any areas identified that require a plan. To maintain and monitor compliance, annual legionella testing will be conducted in March 2025. Additional risk assessment will be completed if new equipment meeting assessment criteria has been placed or replaced, local authorities and/or utility providers announce a boil water order, there is loss of service, or there is a service main break immediately adjacent to the center.