Failure to Implement and Review Water Management Program for Infection Control
Penalty
Summary
The facility failed to implement and annually review its water management program, which is required for infection prevention and control. A review of the facility's Water Management Program revealed that multiple at-risk areas were identified, including water heaters, expansion tanks, pipes, valves, fittings, faucets, shower heads, air washers, humidifiers, eyewash stations, ice machines, CPAP machines, oxygen bubblers, nebulizers, hydrotherapy equipment, heater-cooler units, and water filters. However, the program did not specify what control measures would be applied or monitored for these at-risk areas. Interviews with the Maintenance Director and Infection Preventionist confirmed that there was no documentation of control measures for the identified areas, and neither staff member could identify the nationally-recognized standard used to develop the water management program. Further review showed that the facility's Legionella Policy had not been reviewed or updated since 2018, and there was no documentation that the Water Management Plan had been discussed at a committee meeting. The Administrator confirmed the absence of documentation regarding the application and monitoring of control measures and acknowledged that the policy had not been reviewed since 2018. The deficiency had the potential to affect all 69 residents residing in the facility.