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Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities

Report Information

Issue Date
Report Number
13-01189-267
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted a review to assess how Veterans Health Administration (VHA) medical facilities manage prevention of Legionnaires’ Disease (LD) at the request of the VA Secretary, Senator Robert P. Casey, Jr., Congressman Tim Murphy, and the Chairmen and Ranking Members of the House Committee on Veterans’ Affairs and the Senate Committee on Veterans’ Affairs. VHA Directive 2008-010, Prevention of Legionella Disease, outlines specific measures that VA facilities should follow to monitor and reduce Legionella in the water distribution system. We found that compliance with the directive was variable. VHA is currently in the process of revising Directive 2008-010. We recommended that the Under Secretary for Health address the reported compliance issues when revising the directive and provide a plan that simplifies and monitors its implementation. VHA Directive 2008-010’s risk stratification criteria are based at the facility level and focus on transplant facilities. We recommended that the Under Secretary for Health consider re-evaluation of the current stratification of facilities that focuses on transplant status. We also recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease. The Under Secretary for Health concurred with our findings and recommendations and provided an acceptable action plan.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.