Report Summary

Title: Healthcare Inspection – Testing for Legionella, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
Report Number: 14-03688-399 Download
Report
Issue Date: 7/6/2015
City/State: Pittsburgh, PA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted
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.