Failure to Implement Legionella Prevention Plan
Penalty
Summary
The facility failed to implement a plan to prevent the growth of Legionella bacteria in its water system, which has the potential to affect all 137 residents residing in the facility. During an interview, the Maintenance Director/Housekeeping Director, who has been working at the facility for approximately five months, admitted that there is no plan in place to check the facility's water system for Legionella. He also stated that he could not find any previous documentation indicating that the facility's water system had been tested for Legionella. Despite having implemented Legionella water testing at his previous employment, he has not done so at this facility. The facility's policy, dated 2023, outlines the need to reduce Legionella risk in the facility water systems to prevent cases and outbreaks of Legionnaires' Disease and other waterborne pathogens. The Centers for Medicare & Medicaid Services (CMS) requires Medicare-certified healthcare facilities to develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella. The facility's failure to have a documented water management program in place is a direct violation of this directive, as it lacks measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems.