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

Portable X-Ray Survey Report

H1
ADDRESS OF S UPPLIER

NAME OF S URVEYOR

PROFESSIONAL QUALIFICATIONS OF

H5

STANARDS

INITIAL
SURVEY

H2

NAME OF S UPPLIER

CODE

(1)

DATE SURVEYED

MET

NOT
MET

N/A

RESURVEY

SURVEYOR

EXPLANATORY STATEMENT

§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.
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 LICNESURE

N/A

NAME OF AGENCY:

H7

H8
H9

H10
H11

(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.
No. of Personnel

No. licensed or approved

No.

NOT

Name of Licensing Agency

licensed or approved

(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 (06/2012)

Page 1

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

N/ A

EXPLANTORY STATEMENT

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

YES

NO

H12
H13
H14
H15
H16

H17

H18
H19

(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.
§486.102 SUPERVISION BY A QUALIFIED PHYSICIAN
Portable X-ray services are provided under the supervision of a
qualified physician.
(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:
(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

Form CMS-1882 (06/2012)

State in which licensed

2

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

N/ A

EXPLANATORY STATMENT

(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
Certified

Certification
no.

Specialization

Other Qualifications (specify)

H20

§486.104 QUALIFICATIONS,

ORIENTATION, AND HEALTH
OF TECHNICAL PERSONNEL

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 Joint
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.
(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

Form CMS-1882 (06/2012)

3

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

N/ A

EXPLANATORY STATMENT

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.
License required?

yes

2.

3.

4.___

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

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

H25

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

Form CMS-1882 (06/2012)

4

NAME OF FACILITY

STANDARDS

CODE

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—

MET NOT
MET

N/ A

EXPLANATORY STATMENT

(1) Each employee is qualified for his or her position by
means of training and experience; and
(2) Employees receive adequate health supervision.

Form CMS-1882 (06/2012)

5

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

H37

N/ A

EXPLANATORY STATMENT

§486.106 REFERRAL FOR SERVICE AND PRESERVATION
OF RECORDS

All portable X-ray services performed for Medicare beneficiaries
are ordered by a physician or a nonphysician practitioner as
provided in 410.32(a) of this chapter or by a nonphysician
practitioner as provided in 410.32(a)(2) and records are properly
preserved.
H38

(a) Referral by a Physician
Portable X-ray examinations are performed only on the order of a
physician licensed to practice in the State or by a nonphysician
practitioner acting within the scope of State law. Such
nonphysician practitioners may be treated the same as physicians
treating beneficiaries for the purpose of this paragraph. The
supplier’s records show that: (1) the portable X-ray test was
ordered by physician or nonphysician practitioner acting with the
State scope of law, and (2) Such physician or nonphysician
practitioner’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 Xray examination, the name of the patient, a description of the
procedures ordered and performed, the referring physician or
nonphysician practitioner, 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.
YES 2.
NO
1.

Form CMS-1882 (06/2012)

6

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

H42

N/ A

EXPLANATORY STATMENT

§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

(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

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

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

Form CMS-1882 (06/2012)

7

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

N/ A

EXPLANATORY STATMENT

List and indicate for each piece of equipment
NAME OR
SERIAL NUMBER

kVP

TOTAL
FILTRATION

HALF-VALUE
LAYER

H45

(c) Termination of Exposure
A device is provided to terminate the exposure after a
preset time or exposure.

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)

H49

(g) Mechanical Supporting or Restraining Devices

Protection Against Electrical Hazards
Only shockproof equipment is used. All electrical equipment
is grounded.

Mechanical supporting or restraining devices are provided so
that such devices can be used when a patient must be held in
position for radiography.

Form CMS-1882 (06/2012)

8

NAME OF FACILITY

STANDARDS

CODE

MET

NOT
MET

H50

(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.

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.

Form CMS-1882 (06/2012)

N/ A

EXPLANATORY STATMENT

9

NAME OF FACILITY

MET

STANDARDS

CODE

NOT

N/ A

EXPLANATORY STATMENT

MET

H57

Date of Last
Inspection

Inspecting Agency

Inspector’s Statement
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
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improving this form, please write to: CMS, ATTN: PRA Reports Clearance, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-1882 (06/2012)

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