The Department of Veterans Affairs Office of the Inspector General (VAOIG) released a report Aug. 1 on the prevention of Legionnaires’ Disease (caused by Legionella bacteria) in Veterans Health Administration (VHA) facilities.
The impetus for the report was the death of five veterans in 2011-2012 at the Pittsburgh VA Medical Center, caused by Legionella. In a separate report, VAOIG concluded the deaths were caused by mismanagement and leadership failures at the facility.
In the aftermath of those fatalities, several members of Congress asked VAOIG to conduct an investigation on how to prevent future Legionella outbreaks at the Pittsburgh hospital, as well as at other VHA facilities. Sen. Robert Casey, D-Pa., and Rep. Tim Murphy, R-Pa., were among those who urged the investigation.
Sen. Bernie Sanders, I-Vt., and Rep. Jeff Miller, R-Fla., also expressed great concern over conditions at the Pittsburgh facility. Sanders and Miller are chairs of the Senate and House committees on veterans affairs.
The report’s recommendations to VA for preventing Legionnaires’ Disease and improving management at VA hospitals included:
• Address reported compliance issues when revising the current Prevention of Legionnaires’ Disease directive.
• Provide a plan that simplifies implementation of the directive, and that provides guidance, education and monitoring of the implementation of the revised Prevention of Legionnaires’ Disease directive when issued.
• Consider reevaluation of the current stratification plan that identifies risk of Legionnaires’ Disease based on transplant status.
• Institute a national water safety committee that will provide expert and technical assistance for collaborative decision-making, at the local level, in the control and prevention of waterborne disease.
VA concurred with the recommendations and has developed action plans to address VAOIG’s concerns.
The American Legion’s Veterans Affairs and Rehabilitation Commission will meet with staff from VAOIG’s Office of Health Care Inspections next week to learn more about the report, and provide steps VA can take to prevent future patient exposure to Legionella at its 152 medical centers nationwide.