Failure to Implement Comprehensive Water Safety Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella and other opportunistic waterborne pathogens. The deficiency was identified after a resident, who had been transferred to a local hospital, tested positive for Legionella pneumophila. Following this, the facility was instructed by the local Public Health Department (PHD) to test residents with respiratory symptoms and to conduct water testing for Legionella. Initial water testing was deemed inadequate by the PHD, as it was not performed by a certified company, and the facility did not have a contracted provider for certified water testing or maintenance at the time. The facility subsequently arranged for a certified company to collect water samples, but this was only after the PHD's intervention. Further review revealed that the facility's Water Safety Management Program policy and procedure (P&P) was insufficient and lacked critical components required by the CDC's Legionella Toolkit and public health guidance. The policy did not include a full facility-wide assessment of potential Legionella growth areas, a flow chart or diagram of the water system, or documentation of all water sources and their inlets and outlets. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that a comprehensive risk assessment had not been conducted, and the policy did not specify procedures for handling waterborne pathogen outbreaks or include a contract with a certified testing company. Observations and interviews with the Maintenance Director (MTD) further indicated that while some preventative measures, such as installing specialized filters, were being implemented, there was no established process for decontaminating the water system or a contracted provider for such services prior to the Legionella case. The local Public Health Officer confirmed that the facility's water management plan was essentially a copy of the CDC toolkit and lacked the required building-specific details, such as a mapped diagram of the water system and an actionable intervention plan. These deficiencies were present for a census of 54 residents.