|Title:||Healthcare Inspection – Testing for Legionella, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania|
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Healthcare Inspections
|Report Type:||Healthcare Inspection
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.