What is CMS QSO-17-30 water management?
QSO-17-30 is the CMS survey memo requiring Medicare-certified hospitals, critical access hospitals and long-term care facilities to keep policies and plans that reduce Legionella risk in building water systems.
Who it covers and the legal basis
The memo applies to hospitals, critical access hospitals and long-term care facilities, and CMS adds that it is meant as general awareness for all healthcare organizations. It rests on existing infection control rules: 42 CFR 482.42 for hospitals, 485.635 for critical access hospitals and 483.80 for nursing facilities.
Dates and survey expectations
CMS issued the memo on 2 June 2017 and revised it on 6 July 2018. Facilities must have water management plans and documentation. CMS does not require water cultures for Legionella and leaves testing protocols to the provider.
Long-term care surveyors expect to review the plan, including its risk assessment and testing protocols, but will not cite a facility for the specific protocols it chose.
A continuous record behind the plan
Surveyors want proof the plan runs as written. Aqueduct logs hot water loop temperature, tank levels and branch flow on the water twin around the clock and raises an alert when a reading leaves its set range, so the documentation file is built from recorded data instead of clipboard rounds.