Failure to Implement Active Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. During a tour, surveyors observed that on the third floor, the soiled utility room had active water lines remaining after the removal of a hopper basin, and the Maintenance Director (MD) was unsure if these lines were being flushed. On the second floor, a tub room was found full of equipment with the tub removed, but water lines previously connected to the tub were still active and connected to the domestic water supply, despite being believed inactive by the MD. The surveyor confirmed the lines were still active after moving equipment to access the shut-off valves. Further interviews with the MD revealed that while vacant rooms are flushed weekly, only a couple of free chlorine samples are taken each year, and there was uncertainty regarding the facility's control limits for free chlorine. A review of the facility's Water Management Program policy indicated requirements for preventing water stagnation, ensuring adequate disinfection, and monitoring controls, but the observed practices did not align with these policy requirements.