Long Term Care Facility Component—Annual Facility Survey □ □ Temperature Yes No If Yes, do you have a plan for corrective actions when □ □ temperatures are not within acceptable limits as determined by Yes No your water management program? □ □ Heterotrophic plate counts Yes No If Yes, do you have a plan for corrective actions when □ □ heterotrophic plate counts are not within acceptable limits as Yes No determined by your water management program? □ □ Specific tests for Legionella Yes No If Yes, do you have a plan for corrective actions when specific □ □ tests for Legionella are not within acceptable limits as determined Yes No by your water management program?
Long Term Care Facility Component—Annual Facility Survey Temperature □ Yes □ No If Yes, do you have a plan for corrective actions when temperatures are not within acceptable limits as determined by your water management program? □ Yes □ No Heterotrophic plate counts □ Yes □ No If Yes, do you have a plan for corrective actions when heterotrophic plate counts are not within acceptable limits as determined by your water management program? □ Yes □ No Specific tests for Legionella □ Yes □ No If Yes, do you have a plan for corrective actions when specific tests for Legionella are not within acceptable limits as determined by your water management program? □ Yes □ No