Health Facility Licensure Procedures
Prepare for Inspection of an X-ray Facility
X-ray personnel may dread hearing that the state inspector is coming to their department to survey. According to the Administrative Rules of South Dakota, x-ray facilities must be surveyed by a state inspector or physicist every three years. With some minor preparation, this survey can be quite easy.
There are four items that the inspectors will ask the technologist to see:
- Film badge report
- Technique chart
- Darkroom/processor QA records
- Patient examination record
The inspectors will check over these items and make suggestions on ways to improve these records. If everything is in order, they will move on to the next part of the survey.
The main part of the survey is checking machine accuracy. KVp, timer, collimation, and linearity are the areas checked. Timer and kVp accuracy must be within ten percent to meet state regulations. Collimation accuracy must be within two percent of the SID to meet state regulations. For linearity, the output of each mA station must be within ten percent of the average output of all mA stations.
Machine and patient safety are the next area checked into. All locks must be in good working order. Inspectors will make sure that the facility has gonadal shields and lead aprons. These protective devices must be in good condition. They will make sure that there is adequate shielding for the control booth and the areas surrounding the x-ray room.
Shielding may not be checked every time. If the shielding was adequate on the previous inspection and no changes to the room have been made, the shielding may not be checked. If there is any new construction in the x-ray department, plans must be submitted to the Department of Health (DOH) for review of the lead requirements. The facility may elect to have a health physicist design the shielding and the DOH will accept their recommendations.
The darkroom is the last area checked. Inspectors will check the condition of the safelight filter, the bulb wattage, and the distance the safelight is from the work area. DOH recommends using a fifteen watt or less bulb. The safelight filter should have no tears and shouldn’t be faded. The safelighting should prevent a pre-exposed film from increasing 0.10 in density when exposed to the darkroom conditions for two minutes.
If everything in your department meets state regulations, DOH will send you a letter stating that you are in-compliance. If your department doesn’t meet regulations, we will give you thirty days to have the problem. After the problem has been fixed, DOH requests that you send a copy of the work order.