CMS SOM App. H, Tag V274

Water testing results including, but not limited to,

chemical, microbial, and endotoxin levels which meet AAMI action levels or deviate from

the AAMI standards must be addressed with a corrective action plan that ensures patient

safety.

Interpretive Guidance § 494.40(c)

Facility policy must include requirements to develop and implement a corrective action plan that

ensures patient safety when water testing results exceed acceptable limits or action levels.

A corrective action plan must be developed and implemented to ensure patient safety if any of the

results of water chemical analysis or microbial and endotoxin testing for water and dialysate

exceed the AAMI action levels or fall outside the AAMI standards. Water and dialysate

monitoring must be reported in the QAPI materials, and the medical director must be involved in

analyzing and addressing test results outside of expected parameters.