(a) Radiology services shall be provided or made available when appropriate to meet the needs of the patients and adequately support the ambulatory surgical center's (ASC's) clinical capabilities. Policy and procedures shall be available for emergency and/or routine radiological procedures.
(b) A radiologist shall authenticate all examination reports, except reports of specific procedures that may be authenticated by physicians who are not radiologists, but who have been granted privileges by the governing body or its designee to authenticate such reports.
(c) Services shall be provided either directly within or through a Medicare-approved facility, and the contracts shall be available for review.
(d) If X-ray services are performed within the ASC, the X-ray department shall be surveyed according to 42 Code of Federal Regulations §482.26 or §§486.100 - 486.110.
(e) Procedure manuals shall include procedures for all examinations performed, infection control in the ASC and operating rooms to include dress code of personnel and cleaning of equipment.
(f) Policies shall address the quality aspects of radiology services, including, but not limited to:
  (1) performing radiology services only upon the written order of a physician, dentist, advanced practice registered nurse, or other authorized health care practitioner (such orders shall be accompanied by a concise statement of the reason for the examination); and
  (2) limiting the use of any radioactive sources in the ASC to physicians who have been granted privileges for such use on the basis of their training, experience, and current competence.
(g) Policies shall address the safety aspects of radiology services, including, but not limited to:
  (1) regulation of the use, removal, handling, and storage of any radioactive material which is required to be licensed by the Department of State Health Services, Radiation Safety Licensing Branch;
  (2) precautions against electrical, mechanical, and radiation hazards;
  (3) proper shielding where radiation sources are used;
  (4) acceptable monitoring devices for all personnel who might be exposed to radiation (monitoring devices shall be worn by such personnel in any area with a radiation hazard);
  (5) maintenance of radiation exposure records on personnel; and
  (6) authenticated, dated reports of all examinations performed shall be made a part of the patient's medical record.
(h) Laser equipment shall be licensed as required by the Department of State Health Services, Radiation Safety Licensing Branch. Policies and procedures shall be established and implemented for laser technology which include laser safety programs, education and training of laser personnel, credentialing for each specific laser, and a requirement for all personnel working with lasers to be adequately trained in the safety and use of each type of laser utilized.

Source Note: The provisions of this §135.14 adopted to be effective June 18, 2009, 34 TexReg 3948