HospitalInspections.org

Based on interview and record review, it was determined that the hospital did not ensure that there was an infection control surveillance program that included specific measures for prevention, early detection, control, education, and investigation of infections and communicable diseases specific to Legionella.

Findings include:

1. On 1/9/19 at 1:16 PM, an interview was completed with the compliance officer (CO) over infection control. When the state surveyor asked the CO to provide information on the hospital's Legionella Water Management Program, the CO stated they did not have a water program for Legionella. When questioned further the CO stated, "we don't do testing for it or have a program." The CO further stated she had talked with the facilities manager, and told him that they needed to create a program but that they hadn't done it yet.

2. On 1/9/19 at 1:51 PM, an interview was conducted with the facilities manager (FM). The FM stated they did not complete any testing for Legionella, or have a program. The FM further stated that the CO would be over that.

3. There was no evidence found of a facility risk assessment to identify Legionella, that a water management program was developed or implemented, that policies and procedures were created to reduce the risk of growth and spread of Legionella, or that testing protocols and acceptable ranges for control measures were documented.