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

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.