Mr. Steve Schira
I would like to thank the Subcommittee; we appreciate the opportunity to share what we know, to ensure the truth gets told and most importantly to work together to see that preventable outbreaks of Legionella do not occur in the future.
I think it is important to state that we consider Veterans Administration a proactive organization in regard to its efforts to prevent Legionnaires Disease. In 2008, the VA issued a directive to assess and address Legionella in their facilities water system.
Unfortunately, during our interaction with the Oakland VA Pittsburgh, it was obvious the VA was not performing the maintenance essential to keeping the copper silver ionization systems effective. The lack of regulation and oversight also plays an important role here. Without anyone checking to make sure they are maintaining a safe water environment, this important area of patient safety is the proverbial, “out of sight, out of mind” and all too often gets set aside for seemingly higher priority issues.
In December of 2011, LiquiTech provided a courtesy site visit to the Pittsburgh Oakland VA in an effort to reengage the hospital. Prior to this visit LiquiTech did not have any performance data, the VA was not sharing any copper silver levels, or legionella results. This lack of communication, partnership and most importantly validating data, is a big red flag and cause of concern.
While a walkthrough of the facility found obvious evidence that there were maintenance shortcomings, multiple people at the VA acknowledged and understood that adequate maintenance was not being performed. This also resulted in the first disclosure that the VA was experiencing low levels of Legionella. Additionally, Mr. Goetz brought up that there was an area of the hospital that was left untreated, seemingly because of plumbing renovations that needed to be corrected. The VA staff in attendance, Mr. Rodney Goetz, Patty Harris and Dr. Muder was supportive of the need for maintenance improvements. They requested proposals for service and support what would help solve the issues they were having. The sentiment we took away from this meeting was that the VA was going to take action to correct the maintenance problems.
LiquiTech provided a second courtesy site visit in April of 2012. During this visit LiquiTech service engineers found that no maintenance activities were being performed. The explanation given was that the gentleman put in charge of the systems was out on disability leave. Three LiquiTech representatives also encountered a VA staff member falsifying copper levels.
After these visits, a LiquiTech account manager made multiple attempts to follow up on the proposals provided and follow through on the issues encountered to no avail.
While LiquiTech has improved its technology and services to include remote monitoring and control, in an effort to prevent occurrences such as this, clearly the VA could have prevented the Legionella problem itself with simple maintenance. Had routine maintenance been preformed, had more decisive action been taken by the VA and had the VA communicated or requested help this outbreak could have been avoided.
In our opinion, there needs to be better measures in place to ensure that any disinfection method is being maintained with sufficient third party CDC elite validation that Legionella is not present.