What is CMS QSO-17-30 water management?
CMS QSO-17-30 is a Centers for Medicare and Medicaid Services memorandum, first issued in 2017 and revised in 2018, that expects hospitals, critical access hospitals and nursing homes to have water management policies and procedures that reduce the risk of Legionella and other waterborne pathogens, considering ASHRAE 188 and the CDC toolkit.
What it is
The memo tells surveyors what to look for when assessing whether a facility manages waterborne pathogen risk. Facilities are expected to assess where Legionella and other opportunistic pathogens could grow and spread in their water systems.
They must then implement a water management program that considers ASHRAE 188 and the CDC toolkit, specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions.
CMS can cite facilities that cannot show a program or its records during a survey.
Who it applies to
Hospitals, critical access hospitals and long-term care facilities that participate in Medicare and Medicaid. Check the current CMS memo and survey guidance for the exact expectations.
In practice the program is usually run by a multidisciplinary team that includes facilities, infection prevention, clinical leadership and sometimes outside water treatment specialists.
What evidence it needs
Surveyors look for documented program elements and evidence they are carried out.
- A facility risk assessment of water systems
- Control measures and acceptable ranges
- Testing and monitoring results
- Corrective actions when results are out of range
How Aqueduct helps
Aqueduct supplies the monitoring records and corrective action trail the program must document. The facility owns the program.
- aQ WaterGuard temperature and flow records at named control points
- Out of range readings flagged and routed into your CMMS
- A time-stamped record of each excursion and its closure
- aQ Assurance exports ready for surveys and program review