S02 VISN 23 SPS Water Quarterly Report Template.pdf

Facility: Date:

Confirm Conformity (Yes/No)

Target Date to close (if No):

Responsible Party(s)

1st location (please indicate location) Required Frequency

Confirm Conformity (Yes/No)

Responsible Party

(SPS/FMS/etc.)

Visual inspection of Spry arms/inside chambers walls/ inside or interior of machines Daily Color or Turbidity Daily Temperature Daily

Filters Daily

Visual inspection of Spry arms/inside chambers walls/ inside or interior of machines Daily Color or Turbidity Daily Temperature Daily

Filters Daily 3rd Location (please indicate location)

FY23 Q3 (Apr‐ Jun) VISN 23 CRITICAL WATER TESTING REPORT AT POINT OF USE

FMS POC: SPS POC:

For all required testing locations, refer to AAMI TIR34 recommendations and Facility SOP/Policy

List the specific actions needed to close this item (if applicable)

Critical Water SOP Evaluation: (Can be a combined SOP with Utility water)

1. does the SOP address all tests needing completed (based on site specific requirements) and are the responsible parties identified for each test/inspection

2. does the SOP address how and to whom testing and/or inspection results are reported

Method of Inspection/ Testing (e.g., installed meter, visual inspection, etc.)

Method of Documentation

(e.g., log book, automated records, etc.)

3. does the SOP address anticipated action plans to take if test and/or inspection results out of range

4. does the SOP address/include a flushing program for potential low water use in SPS, including responsible party and reporting requirements

5. does the SOP address the Facility's reporting structure from testing to leadership (e.g., SPS/FMS reports to Water Safety Committee (or Sterile Processing Committee) to EOC to Healthcare Operations Board)

2nd Location (please indicate location)

Visual inspection of Spry arms/inside chambers walls/ inside or interior of machines Daily Color or Turbidity Daily Temperature Daily

Filters Daily 4th Location (please indicate location)

Visual inspection of Spry arms/inside chambers walls/ inside or interior of machines Daily Color or Turbidity Daily Temperature Daily

Filters Daily Continue to add locations if more than 4 sites for sample collection

Month 1 Month 2 Month 3 pH Monthly

Resistivity Meter/Conductivity meter Monthly Total Alkalinity Monthly Total Hardness Monthly

Bacteria Monthly Endotoxin Monthly pH Monthly

Resistivity Meter/Conductivity meter Monthly Total Alkalinity Monthly Total Hardness Monthly

Bacteria Monthly Endotoxin Monthly

3rd Location (please indicate location) pH Monthly

Resistivity Meter/Conductivity meter Monthly Total Alkalinity Monthly

1st location (please indicate location) Required Frequency Confirm

Conformity Responsible

Party Provide Last 3 Month's Results

Certifying Conformity indicates that your facility is in fact conducting the required test and/or inspection at the required frequency and has documentation to that fact. Note that there may be more that one testing point depending upon the size and complexity of a Facility's SPS systems.

Action Plan: for each item that does not conform, provide an action plan for coming into compliance for that element. Conforming items need not be addressed.

1)

2) as applicable

Total Hardness Monthly Bacteria Monthly Endotoxin Monthly

4th Location (please indicate location) pH Monthly

Resistivity Meter/Conductivity meter Monthly Total Alkalinity Monthly Total Hardness Monthly

Bacteria Monthly Endotoxin Monthly

Comments Result Date

Ionic Contaminants Annually

Ionic Contaminants Annually 3rd Location (please indicate location)

Ionic Contaminants Annually 4th Location (please indicate location)

Ionic Contaminants Annually

If Yes, Provide the Latest Test Results (only one result required;

additional may be entered at the Facility's

Result

1st location (please indicate location) Required Frequency Confirm

Conformity Responsible

Party Provide Latest Test

Certifying Conformity indicates that your facility is in fact conducting the required tests and/or inspections at the required frequency and has documentation to that fact. Note that there may be more that one testing point depending upon the size and complexity of a Facility's SPS systems.

Continue to add locations if more than 4 sites for sample collection

2nd Location (please indicate location)

Continue to add locations if more than 4 sites for sample collection

1st location (please indicate location) Required Frequency

Confirm Conformity (Yes/No)

Responsible Party

(SPS/FMS/etc.)

Have One or More Tests

Been Required in the Last

Year (Yes/No)

Certifying Conformity indicates that your facility is in fact conducting the required test and/or inspection at the required frequency and has Action Plan: for any items that do not conform, provide your action plan for coming into compliance for each applicable element.

Action Plan: for any items that do not conform, provide your action plan for coming into compliance for each applicable element.

1)

Endotoxins

Upon installation, modification, or repair of the critical water treatment system, or when persistent increased microbial

Endotoxins See above 3rd Location (please indicate location) Date

Endotoxins See above 4th Location (please indicate location)

Endotoxins See above

Continue to add locations if more than 4 sites for sample collection

Certifying Conformity indicates that your facility understands the requirement and has a plan in place to conduct endotoxin tests if and when they are required. It further indicates that your facility did in fact conduct this testing if and when you had an event that required it (i.e., a "triggering" event). You can be in compliance if you did not conduct a test due to the fact that there were no "triggering" events in the past 12‐ months.

Action Plan: for any items that do not conform, provide your action plan for coming into compliance for each applicable element.

1)