VHA Should Continue to Improve Water Safety and Oversight of Prevention Practices to Minimize the Effects of Legionella

Report Information

Issue Date
Report Number
22-03247-198
VISN
1
State
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Audit
Major Management Challenges
Benefits for Veterans
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

Legionnaires’ disease is caused by Legionella bacteria, found naturally in freshwater environments. The bacteria can become a health concern when spread through showerheads, faucets, ice machines, and hot water tanks in the water systems of large buildings. A 2017 CDC report concluded that one in every four people with healthcare associated Legionnaires’ disease dies. Veterans Health Administration (VHA) Directive 1061 establishes standards to prevent and control healthcare associated Legionnaires’ disease at VHA owned buildings where patients, residents, visitors, or staff stay overnight. The VA Office of Inspector General (OIG) audited whether VHA is complying with the directive and effectively addressing the prevention and control of Legionella for potable water distribution systems. The OIG determined that the four VA medical facilities reviewed—in Salem, Virginia; Brooklyn, New York; Pittsburgh, Pennsylvania, and Dublin, Georgia—did not fully comply with VHA requirements on components of their healthcare-associated Legionella disease prevention plans, water safety testing validation collection, remediation actions, and reporting practices. VHA leaders also did not receive complete water safety test results needed for effective oversight. Additionally, VA medical facility leaders responsible for notifying clinical staff of Legionella conditions did not communicate positive test results to staff to ensure awareness of elevated diagnostic levels. Specifically, the OIG found incomplete healthcare associated Legionella disease prevention plans; inconsistent water sampling; noncompliance with remediation actions; and inconsistent test result reporting. The OIG made eight recommendations to improve oversight of Legionella water sampling, fix identified problems, and ensure Directive 1061 is followed.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The assistant under secretary for health for support should establish certification procedures for Veterans Integrated Service Networks to ensure medical facilities’ healthcare-associated Legionella disease prevention plans for buildings comply with Veterans Health Administration Directive 1061 requirements.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The assistant under secretary for health for support should develop and ensure Veterans Integrated Service Networks perform and document quality control and quality assurance checks of their requirements for oversight and enforcement of the Veterans Health Administration Directive 1061 quarterly Legionella water testing procedures conducted by the facility.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The assistant under secretary for health for operations should monitor Veterans Integrated Service Network officials fulfillment of their oversight responsibilities found in Veterans Health Administration Directive 1061 regarding Legionella water sampling, testing, remediation efforts, and reporting of Legionella water testing data, including the post-remediation test results.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The director of the Office of Healthcare Engineering should consider alternative measures, such as adding dedicated resources, to provide expertise and support for medical facilities experiencing persistent positive Legionella in facility water supply systems after applying the remediation efforts prescribed by Veterans Health Administration Directive 1061.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The director of the Office of Healthcare Engineering should assist the Salem VA medical center with their persistent positive Legionella in the facility water supply system, and, with consideration of the ongoing water supply system renovations, develop an action plan to mitigate remediation challenges.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The director of the Office of Healthcare Engineering should clarify the responsibility section of Veterans Health Administration Directive 1061 to clearly define oversight responsibilities for ensuring required remediation steps are completed when facilities received positive Legionella water test results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The director of the Office of Healthcare Engineering should revise the Water Safety Management Tool to alert Veterans Integrated Service Network and medical facility oversight officials when quarterly testing data is not posted.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The assistant under secretary for health for operations should take actions to confirm that Veterans Integrated Service Network officials are ensuring front-line staff are routinely notified by responsible medical facility officials when elevated Legionella water sample levels require diagnostic awareness and additional clinical surveillance of veterans to detect Legionnaires’ disease.