Inadequate Legionella Water Management Program and Lack of Staff Awareness
Penalty
Summary
The facility failed to develop and implement an adequate Legionella Water Management Program (LWMP) to minimize the risk of Legionella bacteria in the building's water system. Record review of the LWMP, last revised in August 2024, revealed that the policy lacked procedures for using control measures to prevent the introduction and spread of Legionella. Additionally, the policy did not specify control limits or parameters, nor did it include monitoring procedures such as documented testing protocols for Legionella or established control limits for the measures being monitored. There were also no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case in the facility. During interviews with the Administrator, Regional Corporate Nurse, DON, Maintenance Director, and Environmental Services Manager, it was confirmed that facility leadership was unaware of the inadequacies in the LWMP. They stated they did not know the plan was missing essential procedures, acceptable control limits and parameters, monitoring protocols, or intervention strategies for non-compliance or legionellosis cases. This lack of awareness and incomplete policy had the potential to affect all residents in the facility.