Report Summary

Title: Healthcare Inspection - Legionnaires’ Disease at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
Report Number: 13-00994-180
Issue Date: 4/23/2013
City/State: Pittsburgh, PA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted a review of Legionnaires’ disease (LD) at the VA Pittsburgh Healthcare System (VAPHS). VAPHS has a long history of comprehensive mitigation efforts for LD, and following a recent outbreak, VAPHS instituted numerous additional measures. However, we found that VAPHS inadequately managed its water treatment systems during 2011–12. We also found that VAPHS did not conduct routine flushing of hot water faucets and showers as recommended by the manufacturer of the water treatment systems.
We found that VAPHS conducted environmental surveillance in accordance with Veterans Health Administration (VHA) guidance. However, VAPHS responded to positive cultures with corrective actions inconsistent with VHA or Centers for Disease Control and Prevention guidance. In addition, VAPHS did not test all healthcare-associated pneumonia patients for Legionella as required by VHA for transplant centers with a history of healthcare-associated LD.
We recommended that the VAPHS Director ensure that any disinfectant system in use for Legionella prevention is monitored and maintained in accordance with manufacturer’s instructions, that hot-water faucets and showerheads are routinely flushed, and that close coordination between the Infection Prevention Team and Facilities Management Service staff occurs. Additionally, we recommended that the VAPHS Director ensure that when environmental cultures are positive, actions taken comply with VHA guidelines, and that all healthcare-associated pneumonia patients are tested for Legionella infection.