Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to establish and implement a comprehensive water management program (WMP) to minimize the risk of Legionella, as required by its own policy. The policy outlined specific steps, including forming a WMP team, describing the building's water systems, identifying potential Legionella growth areas, determining control measures and monitoring, establishing interventions for unmet control limits, and ensuring the program's effectiveness. However, during interviews, the DON was only able to provide water testing results for the activities room and an empty resident room, with no evidence of a facility-wide evaluation or a formal water management program in place. The DON admitted that the facility had not established a WMP team, described the building's water systems, identified all potential Legionella growth areas, determined where and how to monitor control measures, or established interventions for when control limits are not met. Additionally, there was no evidence that the program was being run as designed or evaluated for effectiveness. The DON confirmed responsibility for the program but acknowledged that these critical steps had not been implemented.