Non-comprehensive Water Management Plan and Lack of Chlorine Monitoring Logs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive water management plan (WMP) for infection prevention and control, specifically related to Legionella control, as outlined by CDC guidance. The existing undated WMP included a team list, building water system descriptions, diagrams of water flow and potential Legionella growth areas, control measures and monitoring, general interventions when control limits were not met, and a broad validation statement. However, the plan did not specify the exact areas or sources from which water temperatures would be obtained. The validation section lacked defined measurements or processes and only stated that control measures should be followed and records of findings and testing should be kept, without detailing how effectiveness would be evaluated. Further review against the CDC Legionella Control Toolkit showed that the facility’s WMP did not meet key elements recommended for a comprehensive program, such as frequent monitoring of temperatures, disinfectant residuals, and pH, and ensuring a detectable disinfectant residual throughout the potable water system. During interviews, the Administrator was unable to locate WMP chlorine logs and confirmed there were no logs of chlorine testing. The Administrator also acknowledged that the facility’s WMP was not a comprehensive plan that included the key elements according to CDC guidelines. This deficiency had the potential to affect all 59 residents in the facility, as the census at the time was 59.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.