CMS SOM App. A, Tag A-0538

meters or badge tests, for amount of radiation exposure.

Interpretive Guidelines §482.26(b)(3)

This requirement applies to radiologic services personnel, as well as other hospital employees

who may be regularly exposed to radiation due to working near radiation sources. This could

include certain nursing and maintenance staff. The types or locations of employees who require

monitoring for radiation exposure must be identified in the policies and procedures for the

radiologic services developed or approved by the radiologist who supervises the services, in

conjunction with the appropriately qualified radiation safety personnel. The monitoring of staff

exposure must be documented by qualified personnel.

Hospitals are expected to educate staff who are monitored for radiation exposure about the

appropriate use of the monitoring meters or badges (or through use of a “personal radiation

monitoring device,” which employs modern technology for the same measurement purpose).

Hospitals must educate staff on the importance of tracking their radiation exposure over various

timeframes, such as the most recent month and year, as well as their cumulative exposure

through work. Staff also must be educated about the appropriate storage of the meters and/or

badges as well as the procedures to follow if the exposure device exceeds cumulative dosage

parameters specified per hospital policy. The hospital is expected to proactively monitor staff

cumulative dosage and take appropriate steps if an individual staff member’s cumulative dosage

level exceeds parameters specified per hospital policy.

For Information Only – Not Required/Not to be Cited

The Occupational Safety and Health Administration (OSHA) has requirements for protecting

hospital staff from radiation exposure, some of which are summarized below:

• “For information about exposure limits see: 29 CFR 1910.1096, Ionizing Radiation

Standard. The standard also requires:

• …Every employer shall supply appropriate personnel monitoring equipment, such as

film badges, pocket chambers, pocket dosimeters, or film rings, and shall require the

use of such equipment [29 CFR 1910.1096(d)(2)]

• Employers shall maintain records of the radiation exposure of all employees for whom

personnel monitoring is required under paragraph (d) of this section and advise each

employee of his individual exposure at least yearly…

See: https://www.osha.gov/SLTC/etools/hospital/clinical/radiology/radiology.html#Radiation

As a reminder, although hospitals are required to comply with applicable OSHA

requirements, surveyors conducting surveys on behalf of CMS do not interpret or assess

compliance with the requirements of OSHA or other Federal Agencies. Surveyors do

assess compliance with Medicare requirements that may overlap or duplicate OSHA

requirements.

Survey Procedures §482.26(b)(3)

• Verify that staff being monitored have been trained about the appropriate use and storage of

their badges/meters. Are staff knowledgeable about their personal radiation exposure over

various timeframes?

• Observe whether staff in categories or locations identified for monitoring have radiation-detecting meters or badges and that they appropriately wear and store them.

• Review records to verify that monitoring of staff exposure is documented.

• Ask the hospital what steps it takes if staff exposure exceeds parameters established per

hospital policy. Can the hospital provide examples, or, if it asserts there have been no

cases in the prior 12 – 24 months, do its records support this?