Deficient Water Management and Legionella Control
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. During a facility tour, surveyors observed that several water fixtures, including hoppers in soiled utility rooms and capped water lines in a spa room, were not being regularly flushed or maintained. Some fixtures had missing handles, were zip-tied shut, or were otherwise inaccessible for flushing, and discolored water was observed from one faucet. The Director of Facilities was unable to provide documentation or a list of fixtures being regularly flushed, and was unsure about the control limits for free chlorine in the domestic hot water supply. Although the facility had a written Legionella Control/Water Management Plan, it was not being fully implemented as described, particularly regarding the flushing of minimally used or unused fixtures. Interviews revealed that while housekeeping staff flushed water in vacant rooms weekly, there was no comprehensive system in place for ensuring all low-use or unused fixtures were included. The Director of Facilities also stated that quarterly Legionella testing and some free chlorine sampling were being performed, but no results were available for review. The facility's policy assigned responsibility for standard operating procedures to the Facility Director, but the lack of documentation and uncertainty about procedures contributed to the deficiency.
Plan Of Correction
Element 1: All residents/patients can be affected by the deficient practice of failing to reduce risk of Legionella and other opportunistic pathogens of premise plumbing. Element 2: The water management team initiated facility-wide water sampling for free chlorine and Legionella. Free chlorine meter was purchased to monitor levels when needed. All hopper faucet handles were replaced or reinstalled by plumber. The zip ties restricting hopper spray hose were removed. Water lines in spa room were assessed for flushing function and fixture accessibility. The Environmental Services team was retrained on flushing protocols. Element 3: All residents/patients can be affected by failing to reduce the risk of Legionella and other opportunistic pathogens of premise plumbing. All unused or low-use fixtures, including hoppers and spa room lines, will be flushed weekly. Vacant or unoccupied rooms will have showers, faucets flushed for at least one minute on a weekly basis. Testing for free chlorine will be monthly. Water testing policy reviewed and updated as necessary. Element 4: Audits for flushing will be performed weekly by EVS Manager or designee(s). Audits for hopper functionality checks will be completed monthly. Free chlorine levels and flushing compliance data will be reviewed, and findings of all audits will be reported to the Quality Assurance and Process Improvement committee monthly for 3 months. Administrator is responsible for compliance.