Deficient Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to fully develop and implement a comprehensive water management program aimed at preventing the growth and spread of legionella and other water-borne pathogens. During a review of the facility's Water Management Program policy and related documentation, it was found that the program did not include evidence of specific control measures to prevent the growth of opportunistic waterborne pathogens, nor did it outline how these measures would be monitored. Additionally, there was no documentation of testing protocols for these control measures, including details on monitoring frequency, acceptable control limits, required interventions if limits were exceeded, or criteria for when water testing for legionella should occur. This deficiency was confirmed during an interview with the facility's maintenance staff.