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Healthcare Inspection – Testing for Legionella, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania

Report Information

Issue Date
Report Number
14-03688-399
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
0
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to complaints about delayed reporting of positive Legionella test results in 2012, potentially delaying treatment and causing death for patients at the VA Pittsburgh Healthcare System, Pittsburgh, PA. The complainant also alleged that water samples for Legionella monitoring were collected improperly by excessively flushing the water line prior to collection in order to obtain false negative results. We substantiated that reporting of positive Legionella test results was occasionally delayed but found no evidence of delays in treatment for patients with Legionnaires’ disease, either for those who died or for those who survived. We did not substantiate that water samples collected for environmental cultures of Legionella were collected improperly. We made no recommendations.
Recommendations (0)