Failure to Maintain Facility-Specific Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding its water management program intended to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of the facility's Legionella Water Management Program policy and related documentation revealed that the written description of the building's water system and devices was not specific to the actual facility. The water system flow diagram included features, such as a trellis fountain and references to water supplied by the town, that did not exist in the facility. Additionally, the diagram did not clearly identify or classify hazardous areas or conditions that could encourage bacterial growth, such as stagnation, permissive temperatures, lack of disinfectant, or external hazards. Interviews with the Director of Maintenance and the Administrator confirmed that the water management program and assessment were not tailored to the facility and did not meet all required criteria. The Director of Maintenance acknowledged that the documentation was not specific to the facility and that the flow diagram failed to depict hazardous concerns. The Administrator also confirmed that the program should have been facility-specific and comprehensive, as required by policy.