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.
Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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Department of Veterans Affairs | VHA Should Continue to Improve Water Safety and Oversight of Prevention Practices to Minimize the Effects of Legionella | Audit | Agency-Wide | View Report | |
Federal Deposit Insurance Corporation | DOJ Press Release: Leader of $20M COVID-19 Relief Fraud Ring Sentenced to 15 Years | Investigation |
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View Report | |
Internal Revenue Service | Thousands of Tax Exempt and Government Entities Taxpayers May Not Have Received Satisfactory Responses to Their Questions | Audit | Agency-Wide | View Report | |
Internal Revenue Service | Inflation Reduction Act: Assessment of Implementation of Processing Year 2023 Tax Provisions | Audit | Agency-Wide | View Report | |
U.S. Postal Service | Louisiana District: Delivery Unit Operations | Audit | Agency-Wide | View Report | |
U.S. International Development Finance Corporation | DFC Compliance with FISMA in FY 2023 | Audit | Agency-Wide | View Report | |
Department of Health & Human Services | Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Aetna, Inc. (Contract H5521) Submitted to CMS | Audit | Agency-Wide | View Report | |
Federal Deposit Insurance Corporation | DOJ Press Release: Five Men Plead Guilty to Roles in Multimillion-Dollar COVID-19 Relief Fraud Conspiracy | Investigation |
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View Report | |
Internal Revenue Service | The Innocent Spouse Program Needs Improved Guidance for Employees and Increased Communication With Taxpayers | Audit | Agency-Wide | View Report | |
Internal Revenue Service | Inflation Reduction Act: Assessment of a Free and Electronic Direct Filing Tax Return System | Audit | Agency-Wide | View Report | |