The VA Pittsburgh Healthcare System experienced systemic problems during a 2011 and 2012 outbreak of Legionnaires' disease, including a "lack of clarity" about how to manage the water-treatment system designed to keep Legionella in check, according to a report by the Veterans Affairs Office of Inspector General. The hospital system also neglected to test all suspected pneumonia patients for the disease, and facilities-management and infection-control personnel failed to communicate adequately, the report said.

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