CPA TOOL - Imaging Services - Revision 7/13

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Previous Findings

• Are there any previous CPA findings?<br>

  Yes

  No

  NA

• If yes, have they been corrected?<br>

  Yes

  No

  N/A

• If not corrected, is there a status update?

  Yes

  No

  N/A

• Are their previous RHB findings?

  Yes

  No

  NA

• If yes, have they been corrected?

  Yes

  No

  N/A

• If not corrected, is there a status update?

  Yes

  No

  N/A

• Are there previous TJC findings?

  Yes

  No

  NA

• If yes, have they been corrected?

  Yes

  No

  N/A

• If not corrected, is there a status update?

  Yes

  No

  N/A

Documents

• Is there a cone exemption policy?

  Yes

  No

  N/A

• Is there a P&P for CT radiation dose monitoring?

  Yes

  No

  N/A

• Is there a P&P for monitoring lead protective devices?

  Yes

  No

  N/A

• Do the CT, IR & MRI staff have injector competences?

  Yes

  No

  N/A

• Do all technologists who perform venipuncture have venipuncture certification?

  Yes

  No

  N/A

• Documentation of initial and annual competencies (CT, Amrit, & NM Techs).

  Yes

  No

  N/A

• Does the facility have quarterly Radiation Safety Committee meetings?

  Yes

  No

  N/A

• Are there minutes?

  Yes

  No

  N/A

• Is there a quorum?

  Yes

  No

  N/A

• Are all protocols (CT, MRI, NM, US) approved by P&T?

  Yes

  No

  N/A

• Have the department's policies and procedures been reviewed annually and approved by the MEC?

  Yes

  No

  N/A

• Does the department have evidence of quality improvement projects?

  Yes

  No

  N/A

• Can staff speak to the QI projects?

  Yes

  No

  N/A

• Are there any contract staff being used?

  Yes

  No

  N/A

• If yes, can the site provide their HR files?

  Yes

  No

  N/A

• If yes, is their documentation of department specific orientation?

  Yes

  No

  N/A

• Is there a P&P for administration of IV contrast?

  Yes

  No

  N/A

• Do staff follow the P&P?

  Yes

  No

  N/A

• Is there a P&P for MRI safety?

  Yes

  No

  N/A

• Is there a P&P for monitoring dosimetry badges?<br><br>

  Yes

  No

  N/A

• Can the facility provide 12 months of dosimetry reports?

  Yes

  No

  N/A

• We're the reports reviewed and signed by the RSO?<br><br>

  Yes

  No

  N/A

• Is there follow-up on any discrepancies?

  Yes

  No

  N/A

• Is there a tracking mechanism to ensure all badges are distributed and collected each month?

  Yes

  No

  N/A

• Is there documentation in the RS Mtg Minutes?

  Yes

  No

  N/A

• Is there a P&P for weekly fluoroscopy checks?

  Yes

  No

  N/A

• Can the facility provide 12 months of documentation for all fluoroscopy units?

  Yes

  No

  N/A

• Is each fluoroscopy unit being checked weekly?

  Yes

  No

  N/A

• Are the weekly log sheets current?

  Yes

  No

  N/A

• Are the NM JD'S approved by the MEC?

  Yes

  No

  N/A

• Have all JD's been approved by the MEC?

  Yes

  No

  N/A

• Can the facility provide two weeks (14 days, including weekends) of finalized CT reports - 2 for each day of the week?

  Yes

  No

  N/A

• SB1237: Does every CT report include in the body of the report the CTDIvol & DLP?

  Yes

  No

  N/A

• Is there a P&P for checking eyewash logs?

  Yes

  No

  N/A

General Information - All Imaging Areas

• Is there a valid and current PM sticker for all equipment maintained by Clinical Technology?

  Yes

  No

  N/A

• Are PM's performed on-time?

  Yes

  No

  N/A

• Are actions taken for any discrepancy on a PM or Physicist Report?

  Yes

  No

  N/A

• Any issues that haven't been resolved in a timely manner?

  Yes

  No

  N/A

• Can staff demonstrate how they access the department P&Ps?

  Yes

  No

  N/A

• Are mock codes routinely scheduled in all Imaging areas?

  Yes

  No

  N/A

• Are registry staff, including Staffing Partners, being used?

  Yes

  No

  N/A

• If yes, what modalities and need to review all HR files.

  Yes

  No

  N/A

• Are there good infection control procedures in place?

  Yes

  No

  N/A

• Is there a Cleaning process for cleaning x-ray table or upright stand between patients?

  Yes

  No

  N/A

• Is there dust on equipment?

  Yes

  No

  N/A

• Is linen stored properly? Title 22 70825

  Yes

  No

  N/A

• Have the Crash carts been checked per policy?

  Yes

  No

  N/A

• Are any dated supplies expired?

  Yes

  No

  N/A

• Are the crash carts clean?

  Yes

  No

  N/A

• Are the medical gas manifolds being used as hooks to hang supplies?

  Yes

  No

  NA

• Are all staff and MD's wearing their ID badges with their photo ID facing outward?

  Yes

  No

  N/A

Radiology

• Are patient fluoro logs being kept?

  Yes

  No

  N/A

• Are weekly fluoroscopy checks being performed? <br>

  Yes

  No

  N/A

• Are the weekly fluoro checks log sheets current?

  Yes

  No

  N/A

• Are the completed weekly fluoro log sheets signed after fully completed?

  Yes

  No

  N/A

• If there are any discrepancies, is their documentation?

  Yes

  No

  N/A

• Are dosimetry badges being managed?

  Yes

  No

  N/A

• Are occupational radiation staff, who work in areas where ionizing radiation can be generated, wearing dosimetry badges?

  Yes

  No

  N/A

• Can the site prove that all badges have monthly oversight?

  Yes

  No

  N/A

• Are staff wearing their dosimetry badges?

  Yes

  No

  N/A

• Are the dosimetry badges worn properly?

  Yes

  No

  N/A

• Caution X-ray signs posted?

  Yes

  No

  N/A

• Notice to Employees signs posted (5/09)?

  Yes

  No

  N/A

• Radiation Safety Operating Procedures sign posted?

  Yes

  No

  N/A

• Pregnancy Warning sign posted?

  Yes

  No

  N/A

• Emergency procedures posted?

  Yes

  No

  N/A

• X-ray generator affixed?

  Yes

  No

  N/A

• X-ray exposure switch affixed?

  Yes

  No

  N/A

• Student agreement approval letter from RHB posted?

  Yes

  No

  N/A

• Is the information noted on agreement followed by the site (Days of week or hours of operation, etc.)?

  Yes

  No

  N/A

• Lead apron checks performed prior to use and annually?

  Yes

  No

  N/A

• Are the lead aprons easily identified?

  Yes

  No

  N/A

• Are the lead skirts on fluoro towers checked prior to first use and annually?

  Yes

  No

  N/A

• Can staff discuss where and why portable units are stored?

  Yes

  No

  N/A

• Dose charts posted on all x-ray units?

  Yes

  No

  N/A

• Technique charts posted on all x-ray units?

  Yes

  No

  N/A

• Physician S&O permits posted & current?

  Yes

  No

  N/A

• Technologists licenses posted and current?

  Yes

  No

  N/A

• Is there notification as to where copies of the tech certifications and S&O permits are located and in 20 font?

  Yes

  No

  N/A

• Are the MD S&O Permits kept on the mobile C-arms, including the mini c-arms?

  Yes

  No

  N/A

• Are spacer cones affixed to all mobile c-arms?

  Yes

  No

  N/A

• Are the vendor's radiation safety procedures posted on each unit?

  Yes

  No

  N/A

• Does the mini c-arm have a label stating "For Extremity Use Only" ?

  Yes

  No

  N/A

• Repeat Rates - can Staff identify their or the department's overall repeat rate?<br>

  Yes

  No

  N/A

• Is there any escalation process if a repeat rate is higher than acceptable?

  Yes

  No

  N/A

• Do staff know how to find MD privileges?

  Yes

  No

  N/A

• Is Contrast media secured and accessible only to authorized staff?

  Yes

  No

  N/A

• Is there documentation that all staff have had Radiation Safety Training?

  Yes

  No

  N/A

CT

• Were the current CT Protocols approved by P&T?

  Yes

  No

  N/A

• Are the CT techs following the most recent CT protocols approved by P&T?

  Yes

  No

  N/A

• Are the current CT protocols signed the Chief of the department, Section Chief, Lead Tech, and Management?

  Yes

  No

  N/A

• Was a CT physicist report completed annually and were any failures resolved? Is there documentation?

  Yes

  No

  N/A

• Are Emergency procedures posted?

  Yes

  No

  N/A

• Do staff know where the Emergency Stop buttons are located?

  Yes

  No

  N/A

• Do staff know if the Emergency Stop buttons work?

  Yes

  No

  N/A

• Is there Contrast Media administration documentation?

  Yes

  No

  N/A

• Are Reduced technique factors for pediatric and small patients in use?

  Yes

  No

  N/A

• Have the CT techs had their original and annual Competencies?

  Yes

  No

  N/A

• Does each CT tech have a vendor specific Injector Competency completed?

  Yes

  No

  N/A

• Has the crash Crash Cart been checked daily?

  Yes

  No

  N/A

• Can the CT techs discuss SAS 916 - CT Radiation Dose Monitoring?

  Yes

  No

  N/A

• Can the CT techs discuss SB 1237?

  Yes

  No

  N/A

• Can the CT techs describe the Stroke Alert process?

  Yes

  No

  N/A

• Can the CT techs describe the Code Blue workflow?

  Yes

  No

  N/A

• Is there documentation of Critical Results?

  Yes

  No

  N/A

• Are there MD Contrast Orders?

  Yes

  No

  N/A

• Is there Contrast media security?

  Yes

  No

  N/A

• Are injector syringes secured?

  Yes

  No

  N/A

• Are the Dose rates posted for 8, 16, or 64 slice CT?

  Yes

  No

  N/A

• Is Medication labeling occurring?

  Yes

  No

  N/A

• Is there a blanket warmer?

  Yes

  No

  N/A

• Is yes, is it checked daily and following P&P?

  Yes

  No

  N/A

• Is there a Contrast Warmer?

  Yes

  No

  N/A

• Is yes, is it checked daily and following P&P?

  Yes

  No

  N/A

• Are Caution X-ray signs posted on all entrances to rooms with x-ray equipment?

  Yes

  No

  N/A

MRI

• Are there Emergency procedures?

  Yes

  No

  N/A

• Are they posted?

  Yes

  No

  N/A

• Can staff verbalize their process?

  Yes

  No

  N/A

• Can MRI staff describe the Code Blue process in MRI?

  Yes

  No

  N/A

• Were the MRI Protocols approved by P&T?

  Yes

  No

  N/A

• Are there MRI Safety Screening procedures?

  Yes

  No

  N/A

• Are all MRI Safety Zones posted?

  Yes

  No

  N/A

• Do all staff complete MRI Safety Training?

  Yes

  No

  N/A

• Is there a list of employees who completed MRI Safety Training?

  Yes

  No

  N/A

• Are the O2 tanks non-ferrous?

  Yes

  No

  N/A

• Is there a current MRI physicist report?

  Yes

  No

  N/A

• Are there MRI Tech Competencies, including vendor specific injector competencies?

  Yes

  No

  N/A

• Do the MRI techs have the correct Venipuncture (10/10) documentation?

  Yes

  No

  N/A

• Is there documented MRI QC?

  Yes

  No

  N/A

• Is the MRI Crash Cart checked daily?

  Yes

  No

  N/A

• Can the MRI staff discuss the MRI Safety - SAS 910 process?

  Yes

  No

  N/A

• Is there a List of employees with access?

  Yes

  No

  N/A

• Is procedural sedation performed in MRI?

  Yes

  No

  N/A

IR/CCL

• Are there patient fluoro logs?

  Yes

  No

  N/A

• Are weekly fluoro checks performed each week?

  Yes

  No

  N/A

• Is there a dosimetry badge P&P?

  Yes

  No

  N/A

• Is the dosimetry badge P&P followed?

  Yes

  No

  N/A

• Are the dosimetry badge reports being monitored, signed, and actions taken when there are discrepancies such as over exposures or missing badges?

  Yes

  No

  N/A

• Are staff and MDs wearing there dosimetry badges?

  Yes

  No

  N/A

• Is the control badge kept with the dosimetry badge mailing envelope?

  Yes

  No

  N/A

• Is there a lead apron P&P?

  Yes

  No

  N/A

• Are the lead aprons identified?

  Yes

  No

  N/A

• Are the lead aprons checked prior to use and annually?

  Yes

  No

  N/A

• Are the lead apron skirts on fluoro unit checked annually?

  Yes

  No

  N/A

• Are current S&O Permits and Tech state certifications posted?

  Yes

  No

  N/A

• Is there an injection competency for the IR Tech and specific to the manufacturer used?

  Yes

  No

  N/A

• Are time-outs used?

  Yes

  No

  N/A

• Are two-patient identifiers used?

  Yes

  No

  N/A

• Is side-site verification practiced and the area to be examined marked?

  Yes

  No

  N/A

• Are secondary containers labelled appropriately?

  Yes

  No

  N/A

• Are there contrast media orders?

  Yes

  No

  N/A

NM

• Is the RML current?

  Yes

  No

  N/A

• Are initial and annual venipuncture competencies performed on NM techs?

  Yes

  No

  N/A

• Is there evidence of annual live stick competencies?

  Yes

  No

  N/A

• Is there a Hot Lab Security plan?

  Yes

  No

  N/A

• Is there a P&P for stolen radiopharmaceuticals?

  Yes

  No

  N/A

• Are personal belongings stored in the Hot Lab or Waste areas?

  Yes

  No

  NA

• Is there a Pregnancy warning sign where patients are being injected?

  Yes

  No

  N/A

• Is I131 used?

  Yes

  No

  N/A

• If yes, what post procedure information given to the patient and by whom?

  Yes

  No

  N/A

• Can the staff identify the RSO?

  Yes

  No

  N/A

• Are the NM contacts ICE posted?

  Yes

  No

  N/A

• Can staff explain the radiopharmaceutical delivery process?

  Yes

  No

  N/A

• Is the Microwave approved by engineering?

  Yes

  No

  N/A

• Is the Microwave oven labeled "For patient use only"!

  Yes

  No

  N/A

• Is the refrigerator approved by engineering?

  Yes

  No

  N/A

• Is the refrigerator marked for patient use only?

  Yes

  No

  N/A

• Is the eyewash checked routinely?

  Yes

  No

  N/A

• Is there a eyewash log?

  Yes

  No

  N/A

• NM Protocols approved by P&T?

  Yes

  No

  N/A

• Are medications placed in a secondary container?<br>Are they labeled?

  Yes

  No

  N/A

• Is waste storage secure?

  Yes

  No

  N/A

• Is access to the Hot Lab limited to authorized personnel only?

  Yes

  No

  N/A

• Can NM Techs describe the process for reinjecting blood?

  Yes

  No

  N/A

• Is PPE used?

  Yes

  No

  N/A

• Can staff identify where the PPE are located?

  Yes

  No

  N/A

• Are both Ring & Body dosimeters used?

  Yes

  No

  N/A

• Is waived testing performed?

  Yes

  No

  N/A

• Is informed consent used?

  Yes

  No

  N/A

• Was the Vent Hood Inspected?

  Yes

  No

  N/A

• For Facility a services: Are there radiation hazardous waste signs on the vent stacks from NM, including the trefoil sign?

  Yes

  No

  N/A

• Are there quarterlyRadiation Safety Committee Meeting minutes with a quorum?

  Yes

  No

  N/A

• Is there documentation of weekly Radiation Detector testing and exit routes?

  Yes

  No

  N/A

• Is there documentation of Radiation Safety Training?

  Yes

  No

  N/A

• Is there Correct RHB signage?

  Yes

  No

  N/A

• Is Regadenosn (Lexiscan) used? If yes, who administers and where is the NM MD?

  Yes

  No

  N/A

Mammography

• Has the RHB Inspected Mammography for ACR accreditation?

  Yes

  No

  N/A

• Is there a documented QA program for Interpreting MDs?

  Yes

  No

  N/A

• Is there an annual Physicist report?

  Yes

  No

  N/A

• Can Mammo Techs discuss their Repeat Rate?

  Yes

  No

  N/A

• Is there state Information for breast implant patients?

  Yes

  No

  N/A

• Is there side site verification for Interventional procedures?

  Yes

  No

  N/A

• Can staff discuss Mammo QC?

  Yes

  No

  N/A

• Is there a Technique chart?

  Yes

  No

  N/A

• Can staff access department P&Ps?

  Yes

  No

  N/A

• Is there a Dose chart?

  Yes

  No

  N/A

• Is there a Cleaning procedure for Mammo unit between patients?

  Yes

  No

  N/A

• Does each Mammo Tech have a documented Mammo competency?

  Yes

  No

  N/A

US

• Does the US department clean their probes or does the SPD?

  Yes

  No

  N/A

• If performed by the US department, is there daily QC of the Cidex?

  Yes

  No

  N/A

• Can US staff accurately describe and demonstrate the probe cleaning process?

  Yes

  No

  N/A

• Is the Cidex temperature monitored?

  Yes

  No

  N/A

• Is there a Time-out for IR procedures?

  Yes

  No

  N/A

• Is there Side-site verification for an IR procedure?

  Yes

  No

  N/A

• Is there a Secondary container labeling practice?

  Yes

  No

  N/A