CMS SOM App. A, Tag A-0547

radiologic equipment and administer procedures.

Interpretive Guidelines §482.26(c)(2)

The medical staff must develop policies, consistent with State law, that govern the designation of

all personnel who are qualified to use the radiologic equipment and perform diagnostic or

therapeutic studies or procedures. Qualifications must include appropriate training and

demonstrated competence in the use of equipment and administration of procedures prior to

being designated as qualified. Only designated individuals may use the equipment and perform

studies or procedures.

The use of the radiologic equipment includes, but is not limited to, functions such as operating

the equipment according to the manufacturer’s instructions and hospital policy, and interfacing

with specialized technology as needed.

In addition to a radiologist, and although not specifically mentioned in the regulations, radiologic

technologists are typically involved in the delivery of radiologic services in a hospital.

Radiologic technologists are medical personnel who typically perform diagnostic imaging

examinations and administer radiation therapy treatments, as permitted under State law. They are

educated in anatomy, patient positioning, examination techniques, equipment protocols, radiation

safety, radiation protection, and basic patient care. All radiologic technologists using radiologic

equipment or performing studies/procedures must be designated to do so.

Personnel also need to know how to respond to adverse events that may occur during a

radiologic study or procedure.

Hospitals are expected to regularly reassess staff competency and to provide periodic training

needed to keep staff skills up-to-date. The hospital must document training completion dates and

evidence of satisfactory competence. Staff that complete training but cannot demonstrate

satisfactory competence must not be permitted to use radiologic equipment and/or administer

procedures.

Survey Procedures §482.26(c)(2)

• Verify that the medical staff established criteria for personnel who use radiologic services

equipment and perform studies or procedures.

• Determine which staff are using which pieces of radiological equipment. Review their

personnel folders to determine if they meet the qualifications established by the medical staff

for the tasks they perform.

• Verify that radiologic services staff are periodically trained and reassessed for competence to

ensure that they are operating the equipment according to manufacturer instructions and

hospital policy and know how to respond to adverse events related to their use of the

equipment.