Deficiency in Legionella Water Management Program
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Legionella bacteria management. The water management plan was not reviewed in 2024 and lacked a water sampling plan and control measures. The facility's policy, 'Water Management Program to Reduce Legionella,' was undated and did not specify the number or location of samples to be collected. There was no documented evidence of an annual review of the Legionella program in 2024. During an interview, the Director of Maintenance revealed that they ordered testing kits from an outside agency and collected samples annually but did not have a sampling plan or control measures in place. The Director was unaware of the need for such a plan.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 The Water Management Program to Reduce Legionella was reviewed and updated. The Policy now reflects that an outside vendor will maintain the facility’s water testing and report and assist with any findings. The vendor will test samples from 6 locations of the facility for analysis and provide a certificate of Legionella Analysis on an annual basis. The Director of Environmental Services will report the Legionella report to the Quality Assurance and Performance Improvement Committee annually with each sampling result. The Director of Environmental Services will review the Water Management Program to Reduce Legionella annually with the Quality Assurance and Performance Improvement Committee to ensure update compliance. Date of Correction: 3/7/2025 Person Responsible for Correction: Director of Facilities
Penalty
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