Does your hospital meet all of the Conditions of Participation (COP) for radiology and nuclear medicine? Because of the health risks involved in working with or being treated with these types of equipment or materials, you must strictly follow all of the COP requirements. If not, you’re at risk of deficiencies when—not if—a CMS surveyor comes calling. And failure to stay in compliance with radiology and nuclear medicine COPs can mean costly penalties (and even exclusion from Medicare) for your hospital. To avoid that, ask yourself the following questions:
- Are your policies and procedures (P&Ps) up to par?
Of course your hospital has written P&Ps covering radiology and nuclear medicine, but are you sure they include everything the surveyor will be looking for? He or she will be checking for several easy-to-miss details. For example:
- You must cite the standards you’ve used to create your P&Ps. For example, have a reference page that cites ACR standards for MRIs.
- You must include how you identify patients with a high-risk of an adverse reaction to radiation (i.e. pregnant women or patients with certain devices.) The steps you take to identify these patients must be clearly documented.
- Be sure your P&Ps are consistent with ALARA (As Low as Reasonably Achievable) principles.
- Have you documented any maintenance or repairs to radiology or nuclear medicine equipment?
Hospital COPs require that radiology and nuclear medicine equipment is properly calibrated and in good working order. Consider using a Qualified Medical Physicist for these tasks. When performing equipment maintenance, you must follow the manufacturers’ instructions and document any modifications or repairs. This includes calibration upon installation.
- Is your documentation complete?
You must maintain radiology and nuclear records for at least five years. These include copies of reports, scans, printouts as well as any image records. Unfortunately, incomplete documentation is often a source of violations of hospital radiology and nuclear medicine COPs. For example:
- The interpretation reports of radiological services must be signed by the radiologist (or other practitioner) who performs the service.
- You must document the safety testing of all staff members working in radiology and nuclear medicine.
- How do you monitor radioactive material in your hospital?
Be sure your P&Ps include a detailed account of how you monitor the use and security of radioactive material from the moment it enters your hospital to the moment it is disposed of. The surveyor will be looking at security of the material at every single stage, point of use, and location. Consider creating a checklist to track the information that must be included, such as:
- Type of radioactive material
- Location and amount received/stored
- Staff member who received it
- How it is prepared for use
- How it is labeled
- Manner of disposal
- Are the same studies being performed on the same patients?
If so, and if performed within a short period of time, this could indicate a problem with the quality of your images/procedures. If a repeat study is performed on a patient, be sure this is clearly documented in the patient record.
- Does your signage meet requirements?
The hospital COPs require that you display clear signage in areas where radiation/radioactive materials may be present. What does this mean? Consider the following guidelines:
- The sign(s) should be placed in a conspicuous area (somewhere where “you can’t miss it.”)
- Be sure the sign displays the radiation symbol
- If the sign contains text, be sure it is large enough to be easily readable and simple enough for a Medicare beneficiary to understand
- Consider using signage that is OSHA/ANSI-compliant.
(This post first appeared in a ProfEd blog)
