Failure to Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the management of water systems to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of facility policies and CMS guidance revealed requirements for a comprehensive water management plan, including risk assessments, temperature controls, routine maintenance, and protocols for testing and responding to positive Legionella results. However, the facility's water management plan did not identify areas at risk for Legionella growth or outline mitigation strategies in the event of positive test results. Laboratory testing of the facility's water system detected L. pneumophila in two locations, with results of 47 MPN/ml and 10 MPN/ml, which are considered cause for concern according to CDC guidelines. Despite these findings, there was no evidence that the facility took any mitigation actions or conducted further testing in response to the positive results. The Director of Maintenance was unaware of the positive Legionella results and did not implement any temperature controls or other measures specifically aimed at preventing Legionella growth in the resident water supply. Interviews with facility leadership, including the Administrator and Director of Maintenance, confirmed a lack of awareness regarding the positive Legionella test results and the absence of any follow-up actions or environmental assessments. The facility's water temperature logs indicated that hot water in resident areas was maintained between 109.9°F and 111.4°F, below the recommended levels for Legionella control. The facility's water management plan and practices did not align with federal and industry standards for Legionella prevention, contributing to the identified deficiency.