Report Summary

Title: Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities
Report Number: 13-01189-267
Issue Date: 8/1/2013
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
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.