Deficient Infection Control Program and Water Management Oversight
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program in accordance with current standards of practice, specifically regarding its Water Management Plan (WMP) and laundry dryer ventilation. The WMP did not include the infection preventionist (IP) as a member of the water management committee, and there was no evidence of collaboration or communication between the IP and the maintenance department regarding water system infection risks. The WMP also lacked documentation of corrective actions to be taken when water control limits, such as temperature ranges, were not met. The facility's policy indicated that the Safety Committee, which oversees the WMP, consisted of administrative and maintenance personnel, but meeting participants were not listed, and the IP was not involved in discussions or decision-making related to waterborne pathogen prevention. Interviews with facility staff revealed that the maintenance department was primarily responsible for water system monitoring and that the IP was not included in WMP discussions or safety committee meetings. The maintenance director was uncertain about specific protocols for addressing out-of-range control limits and indicated that administration would be contacted if issues arose, but no formal procedures were in place for additional testing or water use restrictions. The IP confirmed a lack of involvement in water risk management and stated that, in the event of a positive legionella case or other waterborne pathogen concern, they would refer to CDC guidance but had no established process at the facility. Additionally, the facility did not monitor the dryer ventilation system in the basement laundry room to ensure that the vent leading outside remained clear and free of debris. The maintenance director acknowledged that the dryer vent was not included in routine inspections by an external company and was unsure of its condition or location. This lack of monitoring was confirmed during a tour of the laundry area, and facility leadership was made aware of the concern.