Failure in Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program specifically related to water management for Legionella. The deficiency was identified through a review of the facility's Legionella policy, documentation, and staff interviews. The facility's policy, dated January 9, 2025, outlined specific actions for the prevention and investigation of Legionella cases. However, the facility did not adhere to these guidelines, as evidenced by the lack of a comprehensive water management program to monitor and control the potential development and spread of Legionella for the entire year from December 2023 to December 2024. The facility's water management plan lacked essential elements such as a log for Point of Use Disinfectant to measure and record chlorine concentration levels in the water. Additionally, there were no logs for the flushing of hot water and storage tanks or for minimum water temperature testing in all tanks. These omissions were confirmed during an interview with the Maintenance Director, who acknowledged the absence of documentation for water or temperature testing as per the Legionella policy. Further interviews revealed that the facility had recently terminated the Maintenance Director, which contributed to the failure in maintaining a comprehensive water management program. The Nursing Home Administrator confirmed the facility's inability to implement control measures for Legionella, which is a requirement under the Department of Health and Human Services and CMS guidelines. This deficiency highlights the facility's non-compliance with federal, state, and local requirements for infection control and prevention.
Plan Of Correction
-The facility will implement an effective Water Management Program and Infection Control Program that, at a minimum, will have a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. -A Water Management Program will be developed based on the framework outlined in ASHRAE standards. -The Maintenance Director/Designee will be educated on the development of the Water Management Program and its implementation by the Administrator/Designee. -Water samples will be taken in-house and sent to a certified lab for testing. -Audits will be completed by the Administrator/Designee on compliance with the Water Management system. These audits will be completed weekly for 8 weeks. -The Infection Control Program will be revised so that documentation is present for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. -The Infection Preventionist will be educated on the revised process by the Director of Nursing/Designee. -These audits will be forwarded to the monthly Quality Assurance Performance Improvement Committee for review and frequency of audits.