Failure to Implement and Document Water Management Controls for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program specifically related to the management of Legionella and other opportunistic waterborne pathogens in its water system. According to a review of facility policy and CMS guidance, the facility was required to conduct a risk assessment, implement a water management program with control measures such as flushing, and document these activities. However, documentation revealed that while the policy called for quarterly flushing of the water system, there was no evidence that this had been performed or recorded. The Director of Maintenance, who had been in the role for six months, confirmed that he had not conducted any water system flushing during his tenure and could not provide documentation of previous flushing activities. Further review of the facility's water management program materials, including schematics and diagrams, showed no reference to a flushing schedule or evidence of completed control measures. Interviews with both the Regional Director of Maintenance and the Director of Maintenance confirmed the lack of documentation and uncertainty about when, if ever, the water system was last flushed. As a result, the facility did not meet the requirements to implement and document control measures to prevent the growth and spread of Legionella and other waterborne pathogens.