Failure to Conduct Legionella Risk Assessment in Water Management Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program specifically related to Legionella prevention. Record review revealed that the facility's water management program did not include a risk assessment to identify areas within the building where Legionella bacteria could potentially grow and spread. The facility's own Legionella Water Management Program policy requires identification of such areas, including storage tanks, water heaters, filters, aerators, showerheads, hoses, and other equipment, as well as specific control measures, monitoring systems, and documentation. However, these steps were not completed as required by the policy. During an interview, both the Administrator and the Director of Maintenance confirmed that a risk assessment had not been conducted, and areas in the building where Legionella could reside had not been identified. The Director of Maintenance stated that they did not believe there were any areas in the facility where Legionella could grow, further confirming the lack of compliance with the facility's policy and regulatory expectations.