Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement a water management program aimed at the prevention, detection, and control of waterborne contaminants such as Legionella. This deficiency was identified through observation, policy review, and staff interviews, which revealed that the facility did not have a water management plan in place as required by CDC guidelines and CMS policy memoranda. Specifically, the facility did not conduct a facility risk assessment to identify potential areas where Legionella and other waterborne pathogens could grow and spread within the water system. Further, the facility was unable to provide documented evidence that water testing had been completed, and staff confirmed that water testing and compliance with a water management plan were not ensured. The absence of a documented water management program and lack of water testing protocols meant that the facility did not meet federal, state, and local requirements for inhibiting microbial growth in the building water system.