Failure to Document and Implement Water Flushing per Water Management Plan
Penalty
Summary
The facility failed to maintain records of monthly water flushes as required by its water management plan. An environmental assessment identified risk areas for opportunistic pathogens and recommended flushing uncommonly used tubs, showers, and faucets for 3 to 5 minutes, with documentation to be kept in the service records. The water management plan also required monthly flushing of eyewash stations. Despite these requirements, a review of facility documents revealed that the last documented water flushing occurred several months prior, and there was no consistent documentation of flushing activities for tubs, sinks, or showers. The Director of Physical Plant acknowledged performing the flushes but admitted to not always documenting them due to other responsibilities and periods of extended leave. During the Director's absence, the Special Projects Supervisor covered some duties but did not consistently document or recall all required flushing activities. Additionally, the facility's water management plan policy lacked specific preventative measures to prevent the growth of opportunistic pathogens, and meeting minutes indicated that flushing documentation was not reviewed during water plan meetings. While water testing for opportunistic pathogens was completed and results were negative, the facility did not have a reliable system in place to ensure and document that all required water flushing tasks were performed according to the plan. This lack of documentation and inconsistent implementation of the water management plan's requirements led to the identified deficiency.