Failure to Review and Implement Waterborne Pathogen Prevention Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several deficiencies. The infection prevention coordinator and administrator confirmed that infection prevention and control policies and procedures, including those related to Legionella surveillance, had not been reviewed or updated annually, with no documentation of any recent reviews. Additionally, there was no facility assessment or evaluation in place to identify locations where Legionella or other waterborne pathogens could grow and spread, nor were there measures implemented to prevent the growth of such pathogens. The facility also lacked a monitoring process to evaluate the effectiveness of any water pathogen prevention program. At the time of the survey, 64 residents resided in the facility.