Failure to Implement Comprehensive Legionella Water Management Program
Penalty
Summary
The facility failed to implement a comprehensive water management program for Legionella disease as part of its infection prevention and control program for a census of 60 residents. During an observation and interview, the maintenance staff reported that the facility relied on a single Legionella testing kit performed on kitchen water in late December, which showed no Legionella detected. However, the maintenance staff verified there was no documentation of a map showing the facility’s incoming water source, no flow diagram of the facility’s water distribution system, and no identification of dead-end water areas where water could stagnate. The facility’s written Water Management, Legionella Testing policy, dated October 2022, stated that approaches to controlling waterborne microorganisms, including water systems decontamination, would be consistent with CDC, HICPAC, FDA, and state and local health department requirements, but the lack of these key documents demonstrated the policy was not fully implemented. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
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.