3701:1-66-04 Quality assurance program.

(A) In accordance with Chapter 3748. of the Revised Code, each registrant shall develop and maintain a written quality assurance program. For purposes of this chapter quality assurance program means a program providing for verification by written procedures such as testing, auditing, and inspection to ensure that deficiencies, deviations, defective equipment, or unsafe practices, or a combination thereof, relating to the use, disposal, management, or manufacture of radiation devices are identified, promptly corrected, and reported to the appropriate regulatory authorities.

(B) The quality assurance program of each registrant shall address and document at least the following:

(1) The intervals of and procedures for the evaluation of all radiation-generating equipment to ensure compliance with all applicable rules of this chapter;

(2) Radiation monitoring requirements such as, surveys, occupational exposure limits, maintenance of records, and procedures regarding the use of area and personnel monitoring;

(3) Procedures for notifying the director when individuals are occupationally over-exposed to radiation, pursuant to Chapter 3701:1-38 of the Administrative Code;

(4) Radiation safety procedures for each type of radiation-generating equipment to be handled;

(5) Training of operators of each type of radiation-generating equipment to be handled in order to assure competency in the operating procedures;

(6) In addition to the requirements of paragraph (B)(1) of rule 3701:1-38-10 of the Administrative Code, individuals likely to be working in a restricted area or to receive an annual occupational dose in excess of one mSv(one hundred mrem) shall be instructed in the potential hazards of being present in such an area, to include the following:

(a) The location, boundaries, and purpose of restricted areas;

(b) A description of the radiation-generating equipment and its location;

(7) The quality control tests to be performed, and the frequency of the quality control tests to be performed as applicable to the radiation-generating equipment type and use;

(8) Policies regarding the state license of each person operating radiation-generating equipment as required by Chapters 4773. and 4715. of the Revised Code;

(9) Quality assurance policies and a method to educate the workers on any policy changes;

(10) Radiation workers' role and responsibility for following and supporting the quality assurance program;

(11) Policies regarding personnel protection, including time, distance, and shielding;

(12) Policies regarding prenatal exposure;

(13) Policies regarding radiation training for ancillary personnel;

(14) Policies regarding training for personnel with quality control responsibilities;

(15) Policies regarding patient protection, including screening for pregnancy, patient shielding, patient protection, patient identity verification; and

(16) Policies regarding protection of public to include identification of all radiation areas, warning signs, warning lights, and interlocks.

(C) In addition to the requirements of paragraphs (A) and (B) of this rule the quality assurance program of hospital registrants shall be maintained in the form of a readily available quality assurance manual and shall comply with the following:

(1) A certified radiation expert shall conduct oversight and maintenance of quality assurance programs for hospital registrants, by:

(a) Auditing the quality assurance program on an annual basis;

(b) Performing quarterly reviews;

(c) Completing and submitting all required information with the annual audit form in accordance with paragraph (C)(6) of this rule, and;

(d) Serving on the quality assurance committee.

(2) Employees working in the radiation areas shall be made aware of the identity, scope of authority, and a method for contacting the certified radiation expert and the individual responsible for radiation protection. This information, or a specific location where this information may be obtained, shall be conspicuously posted in each area where radiation-generating equipment is used.

(3) Each hospital registrant shall establish a quality assurance committee for the management of the quality assurance program. Membership to the committee may include an appointed member and a similarly qualified alternate. If an appointed member cannot attend a quarterly meeting, the appointed alternate is authorized to attend in his/her place. The quality assurance committee shall include at least the following appointed members:

(a) A radiologist;

(b) An administrative director of radiology;

(c) A certified radiation expert representing each of the following as applicable in each hospital;

(i) Radiation therapy services,

(ii) Mammography, or

(iii) Diagnostic radiography other than mammography;

(d) A member of the hospital's executive administration;

(e) The individual responsible for radiation protection; and

(f) A representative of each department of the hospital which has responsibilities involving the handling of radiation-generating equipment.

(4) The quality assurance committee shall meet as often as is deemed necessary to carry out its duties, but at least on a quarterly basis. To establish a quorum at least one-half of the committee's membership must be present, and must include the individual responsible for radiation protection for the hospital, and the member of the executive administration of the hospital. A record of each meeting shall be maintained and distributed to each appointed member which shall include the following:

(a) The date of the meeting;

(b) An indication of members present and absent; and

(c) A summary of meeting including any recommended actions and ALARA reviews.

(5) Each quarter, the certified radiation expert shall submit, to each appointed quality assurance committee member, a review of the quality assurance plan which shall contain, as applicable:

(a) Proposed radiation safety policy revisions;

(b) Occupational exposure record reviews;

(c) Radiation safety incidents;

(d) Equipment performance evaluation summaries; and

(e) Any recommended corrective actions necessary to comply with the requirements of this chapter.

(6) The quality assurance program shall be audited at least annually as defined in paragraph (A)(17) of rule 3701:1-38-01 of the Administrative Code by a certified radiation expert. The certified radiation expert shall develop a written report of the audit findings on forms prescribed by the director and submit the report to the quality assurance committee within thirty days of completing the audit. The quality assurance committee shall review the audit report and implement any corrective actions determined to be necessary. The certified radiation expert shall file the audit report with the director, within ninety days of completing the audit. Every audit report shall include a determination of whether the quality assurance program properly addresses the matters described in this rule and whether it is being carried out in accordance with the written quality assurance program, and any corrective actions to be taken to comply with the requirements of this chapter. The audit report shall become a part of the inspection record.

(D) At the time of the state inspection the following items shall be readily available for review:

(1) A complete listing of the inventory of radiation-generating equipment, including the location and description of each unit;

(2) All quality assurance documents as required under this rule;

(3) Data and test results of the evaluation of each unit of radiation-generating equipment and its shielding and surroundings;

(4) Maintenance logs and incident reports for each radiation-generating equipment system;

(5) Current copies of department's licensure verification web page for each individual who is required to possess a license at the facility; and

(6) Records required for each type of radiation-generating equipment indicating the following:

(a) Personnel responsible for monitoring and performing quality control tests;

(b) A brief description of the procedures to be used for each quality control test to be performed;

(c) A list of the equipment to be used for each quality control test;

(d) The manner in which the performance of quality control tests will be documented; and

(e) Instrumentation used to perform area radiation surveys, calibrations and evaluations, as appropriate for each type of radiation-generating equipment, including at least biennial calibration certificates or cross-calibration documentation done within the biennium.

Effective: 12/22/2008
R.C. 119.032 review dates: 09/15/2008 and 12/01/2013
Promulgated Under: 119.03
Statutory Authority: 3748.04
Rule Amplifies: 3748.04
Prior Effective Dates: 6/1/1998, 12/1/03