Form CMS-1882 Portable X-Ray Survey Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0027

provider number

date surveyed

portable x-ray survey report
H1
WH2
name of supplier

address of supplier

name of surveyor

professional qualifications of surveyor

CODE
H5

STANDARDS
§486.100 compliance with federal, state, and local
laws and regulations
The supplier of portable X-ray services is in conformity with all

applicable Federal, State, and local laws and regulations.

MET NOT N/A
MET

initial
(1)

i

survey

(2)

resurvey

EXPLANATORY STATEMENT

H6

(a) Licensure or Registration of Supplier
In any state in which State or applicable local law provides for

the licensure or registration of suppliers of X-ray services, the

supplier is (1) licensed or registered pursuant to such law,

or (2) approved by the agency of the State or locality

responsible for licensure or registration as meeting the

standards established for such licensure or registration.
licensed

approved for licensure

n/a

name of agency:
H7

(b) Licensure or Registration of Personnel
All personnel engaged in operating portable X-ray equipment

are currently licensed or registered in accordance with all

applicable State and local laws.

H8

No. of Personnel

H9

No. licensed or approved

H10

No. NOT licensed or approved

H11

(c) Licensure or Registration of Equipment
All portable X-ray equipment used in providing portable X-ray

services is licensed or registered in accordance with all

applicable State and local laws.

Form CMS-1882 (02/09)

Name of Licensing Agency

Page 1

NAME OF FACILITY
STANDARDS

CODE

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

List all portable X-ray equipment (indicate if licensed or registered)

H12

equipment

yes

no

H13
H14

H15
H16

(d) Conformity with Other Federal, State and Local Laws and
Regulations
The supplier of portable X-ray services agrees to render such

services in conformity with Federal, State and local laws

relating to safety standards.

H17

§486.102 supervision by a qualified physician
Portable X-ray services are provided under the supervision of a

qualified physician.

H18

(a) Physician Supervision
The performance of the roentgenologic procedures is subject

to the supervision of a physician who meets the requirements

of paragraph (b) of this section and one of the following

requirements is met:

H19

(1) The supervising physician owns the equipment and it is
operated only by his employees, or

(2) The supervising physician certifies annually that he
periodically checks the procedural manuals and observes

the operators’ performance, that he has verified that
equipment and personnel meet applicable Federal, State,
and local licensure and registration requirements and that
safe operating procedures are used.

Physician’s Name

State in which licensed

Form CMS-1882 (02/09)

2

NAME OF FACILITY
STANDARDS

CODE

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(b) Qualifications of the Physician Supervisor
Portable X-ray services are provided under the supervision of

a licensed doctor of medicine or licensed doctor of osteopathy

who is qualified by advanced training and experience in the

use of X-rays for diagnostic purposes, i.e., he

(1) is certified in radiology by the American Board of Radiology
or by the American Osteopathic Board of Radiology or
possesses qualifications which are equivalent to those

required for such certification, or

(2) is certified or meets the requirements for certification in a
medical specialty in which he has become qualified by

experience and training in the use of X-rays for diagnostic
purposes, or

(3) specializes in radiology and is recognized by the medical
community as a specialist in radiology.

Name of Board

Date
Certification
Certified
No.

Specialization

Other Qualifications (specify)

H20

§486.104 QualificationS, orientation, AND HEALTH of

technIcal personnel (405.1413)

Portable X-ray services are provided by qualified technologists.

H21

(a) Qualifications of Technologists
All operators of the portable X-ray equipment meet the

requirements of paragraph (a)(1), (2), (3), or (4) of this section:
(1) Successful completion of a program of formal training
in x-ray technology in a school approved by the Join
Review Committee on Education in Radiologic Technology
(JRCERT), or have earned a bachelor’s or associate degree
in radiologic technology from an accredited college or
university

Form CMS-1882 (02/09)

3

NAME OF FACILITY
STANDARDS

CODE

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(2) For those whose training was completed prior to
July 1,1966, but on or after July 1, 1960: Successful
completion of 24 full months of training and/or experience
under the direct supervision of a physician who is certified
in radiology by the American Board of Radiology or who
possesses qualifications which are equivalent to those
required for such certification, and at least 12 full months of
pertinent portable X-ray equipment operation experience in
the 5 years prior to January 1, 1968.
(3) For those whose training was completed prior to
July 1, 1960: Successful completion of 24 full months of
training and/or experience of which at least 12 full months
were under the direct supervision of a physician who is
certified in radiology by the American Board of Radiology or
who possesses qualifications which are equivalent to those
required for such certification, and at least 12 full months of
pertinent portable X-ray equipment operation experience in
the 5 years prior to January 1, 1968.
(4) For those whose training was completed prior to
January 1, 1993, successful completion of a program of
formal training in X-ray technology in a school approved
by the Council on Education of the American Medical
Association, or by the American Osteopathic Association
is acceptable.
H22

No. of Technologists meeting: 1.___ 2.___ 3.___
License required?

yes

no

H23

(b) Personnel Orientation
The supplier of portable X-ray services has an orientation

program for personnel based on a procedural manual which

is: Available to all members of the staff, incorporates relevant

portions of professionally recognized documents, and includes

instruction in all of the following:

H24

H25

(2) Precautions to be followed to protect an individual
supporting the patient during X-ray procedures from

unnecessary exposure to radiation;

(1) Precautions to be followed to protect the patient from
unnecessary exposure to radiation;

Form CMS-1882 (02/09)

4

NAME OF FACILITY
STANDARDS

CODE

MET

H26

(3) Precautions to be followed to protect other individuals in
the surrounding environment from exposure to radiation;

H27

(4) Precautions to be followed to protect the operator of
portable X-ray equipment from unnecessary exposure to
radiation;

H28

(5) Considerations in determining the area which will receive
the primary beam;

H29

(6) Determination of the time interval at which to check
personnel radiation monitors;

H30

(7) Use of the personnel radiation monitor in providing an
additional check on safety of equipment;

H31

(8) Proper use and maintenance of equipment;

H32

(9) Proper maintenance of records;

H33

(10) Technical problems which may arise and methods
of solution;

H34

(11) Protection against electrical hazards;

H35

(12) Hazards of excessive exposure to radiation.

H36

(c) Employee Records
Records are maintained and include evidence that—

(1) Each employee is qualified for his or her position by
means of training and experience; and

NOT
N/A
MET

EXPLANATORY STATEMENT

(2) Employees receive adequate health supervision.

Form CMS-1882 (02/09)

5

NAME OF FACILITY
STANDARDS

CODE
H37

§486.106 referral for service and preservation of

records
All portable X-ray services performed for Medicare
beneficiaries are ordered by a doctor of medicine or doctor of
osteopathy and records are properly preserved.

H38

(a) Referral by a Physician

Portable X-ray examinations are performed only on the order

of a doctor of medicine or doctor of osteopathy licensed to

practice in the State. The supplier’s records show that:

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(1) The X-ray test was ordered by a licensed doctor of
medicine or doctor of osteopathy, and

(2) Such physician’s written, signed order specifies the reason
an X-ray test is required, the area of the body to be

exposed, the number of radiographs to be obtained, and

the views needed; it also includes a statement concerning
the condition of the patient which indicates why portable
X-ray services are necessary.
H39

(b) Records of Examinations Performed
The supplier makes for each patient a record of the date of the

X-ray examination, the name of the patient, a description of the

procedures ordered and performed, the referring physician, the

operator(s) of the portable X-ray equipment who performed the

examination, the physician to whom the radiograph was sent,

and the date it was sent.

H40

(c) Preservation of Records
Such reports are maintained for a period of at least 2 years, or

for the period of time required by State law for such records

(as distinguished from requirements as to the radiograph

itself), whichever is longer.
Number of physicians’ orders reviewed

H41

Physicians’ justification for portable X-rays recorded.

1.

yes

2.

no

Form CMS-1882 (02/09)

6

NAME OF FACILITY
STANDARDS

CODE
H42

§486.108 safety standards
X-ray examinations are conducted through the use of
equipment which is free of unnecessary hazards for patients,
personnel, and other persons in the immediate environment,
and through operating procedures which provide minimum
radiation exposure to patients, personnel, and other persons
in the immediate environment.

H43

(a) Tube Housing and Devices to Restrict the Useful Beam
The tube housing is of diagnostic type. Diaphragms, cones,

or adjustable collimators capable of restricting the useful

beam to the area of clinical interest are used and provide the

same degree of protection as is required of the housing.

H44

(b) Total Filtration

(1) The aluminum equivalent of the total filtration in the

primary beam is not less than that shown in the following

table except when contraindicated for a particular
diagnostic procedure:

Operating kVp

Total filtration
(Inherent plus added)

Below 50 kVp
50 – 70 kVp
Above 70 kVp

0.5 millimeters aluminum
1.5 millimeters aluminum
2.5 millimeters aluminum

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(2) If the filter in the machine is not accessible for examination

or the total filtration is unknown, it can be assumed that
the requirements are met if the half-value layer is not less
than that shown in the following table:
Operating kVp

Half-value layer

0.6 millimeters aluminum
1.6 millimeters aluminum
2.6 millimeters aluminum
2.8 millimeters aluminum
3.0 millimeters aluminum
3.3 millimeters aluminum

50 kVp
70 kVp
90 kVp
100 kVp
110 kVp
120 kVp

Form CMS-1882 (02/09)

7

NAME OF FACILITY
STANDARDS

CODE

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

List and indicate for each piece of equipment
name or
serial number

kVp

total
filtration

half-value
layer

H45

H46

(d) Control Panel
The control panel provides a device (usually a milliammeter or

a means for an audible signal) to give positive indication of the

production of X-rays whenever the X-ray tube is energized.
The control panel includes appropriate indicators (labelled

control settings and/or meters) which show the physical factors

(such as kVp, mA, exposure time or whether timing is

automatic) used for the exposure.

H47

(e) Exposure Control Switch

The exposure control switch is of the dead-man type and is so

arranged that the operator can stand at least 6 feet from the

patient and well away from the useful beam.

H48

(f) Protection Against Electrical Hazards
Only shockproof equipment is used. All electrical equipment is

grounded.

H49

(g) Mechanical Supporting or Restraining Devices
Mechanical supporting or restraining devices are provided so

that such devices can be used when a patient must be held in

position for radiography.

(c) Termination of Exposure

A device is provided to terminate the exposure after a preset

time or exposure.

Form CMS-1882 (02/09)

8

NAME OF FACILITY
STANDARDS

CODE
H50

H51

(i) Restriction of the Useful Beam
Diaphragms, cones, or adjustable collimators are used to

restrict the useful beam to the area of clinical interest.

H52

(j) Personnel Monitoring

A device which can be worn to monitor radiation exposure

(e.g., a film badge) is provided to each individual who operates

portable X-ray equipment. The device is evaluated for

radiation exposure to the operator at least monthly and

appropriate records are maintained by the supplier of portable

X-ray services of radiation exposure measured by such a

device for each individual.

H53

(k) Personnel and Public Protection

No individual occupationally exposed to radiation is permitted

to hold patients during exposures except during emergencies,

nor is any other individual regularly used for this service. Care

is taken to assure that pregnant women do not assist in

portable X-ray examinations.

H54

§486.110 inspection of equipment
Inspections of all X-ray equipment and shielding are made by

qualified individuals at intervals not greater than every 24

months.

H55

(a) Qualified Inspectors
Inspections are made at least every 24 months by a radiation

health specialist who is on the staff of or approved by an

appropriate State or local government agency.

H56

(b) Records of Inspection and Scope of Inspection
The supplier maintains records of current inspections which

include the extent to which equipment and shielding are in

compliance with the safety standards outlined in 486.108.

MET

NOT
N/A
MET

EXPLANATORY STATEMENT

(h) Protective Gloves and Aprons
Protective gloves and aprons are provided so that when the
patient must be held by an individual, that individual is protected with these shielding devices.

Form CMS-1882 (02/09)

9

NAME OF FACILITY

H57

MET NOT N/A
MET

STANDARDS

CODE

EXPLANATORY STATEMENT

Date of Last Inspecting Agency Inspector’s Statement
Inspection
Maintained

yes

no

Inspector’s Qualifications

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0027. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, Attn: PRA Reports Clearance, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-1882 (02/09)

10