X-ray Inspection: Be Prepared for the Inevitable

If you have an X-ray machine at your medical practice or facility, you can rest assured that the inspector will, at some point, be paying you a visit.

These inspections, conducted by the Department of State Health Services, are random and unannounced. If you’re not ready for them, you can expect to find yourself in a bind.

However, the inspection process does not have to be an unpleasant experience. Knowing the requirements and being prepared at all times for the inspector to pay your facility a visit is the key to a smooth and trouble-free inspection.

A blue X-ray protection device is shown on a white background. Protection equipment is an important part of any X-ray inspection.

X-ray Inspection — What You Need to Prepare

According to the Texas Health and Human Services website, under Texas Department of State Health Services, the paperwork you will need to make available to inspectors includes the following:

  • Current Certificate of Registration
  • Personal Monitoring — records of radiation badge reports
  • Dose to the public surveys
  • Equipment Performance Evaluations (EPE) — the 3 most recent EPE results for each X-ray unit
  • Credentials
  • Status of Radiation Protocol Committee (for CT and fluoroscopy)
  • Posted Notice to Employees
  • Operating and Safety Procedures
  • A copy of applicable 25 TAC 289 Regulations in accordance with your Certificate of Registration
  • Notices of Violation and your response letters to each notice
  • Receipt of Purchase

In addition, records related to the transfer or disposal of all units (if applicable) will need to be made available. Those records include the following:

  • Annual Evaluation of Protective Devices
  • Annual Inventory of X-ray units
  • X-ray Image Processing — records of compliance QA/QC for digital acquisition systems or film

For more information, click to read the full article by the Texas Department of State Health Services.

How Often Does an EPE Need to Be Performed?

When your practice/facility is being inspected, you will need to have the last 3 Equipment Performance Evaluations (EPE) on hand. That said, the more of these reports you have available for the inspector to review, the better.

In the State of Texas, EPEs must be performed on a routine basis, but how often depends on what kind of practice you have or what kind of facility you work for.

The following is a rough outline for different types of medical facilities:

  • Hospitals (CT/Fluoroscopy) — every year
  • Medical clinics (using CT/Fluoroscopy) — every year
  • Medical clinics (not using Fluoroscopy) — every 2 years
  • Chiropractic clinics — every 2 years
  • Podiatry clinics — every 4 years
  • Veterinarian clinics — every 5 years

Most other states require EPEs as well.

Why Is an EPE Required?

There are 2 primary reasons for conducting an EPE.

The 1st reason is to ensure that the X-ray machine is not emitting unnecessary radiation.

The 2nd reason is to ensure the safety of the technologist operating the X-ray machine.

In the state of Texas, the EPE must be performed by a licensed medical physicist.

Although each individual facility is different, an hour is usually sufficient to complete the inspection.

Pictured is a light blue gonad shield, a type of radiation protection device. Proper maintenance of such devices is a mandatory part of an X-ray inspection.

X-ray Inspection — Who’s Involved

When the inspector arrives, they will need the assistance of the Radiation Safety Officer or the person in the highest position of management who is present and available at the time of inspection.

They will also need the assistance of the technologist who normally operates the X-ray unit.

Learn More About X-ray Inspection

Regular inspections of your medical practice’s radiology equipment are both essential and inevitable.

We hope this information helps you in your preparation efforts and that your upcoming X-ray inspection goes as smoothly as possible.

If you have concerns, Southwest X-ray can help. Contact us to set up a maintenance schedule that will help keep your X-ray machine operating in accordance with state regulations and keep you prepared for the next X-ray inspection.


Shad Merchant

Shad Merchant is an industry veteran with experience in every aspect of the X-ray and imaging industry, having spent over 20 years assisting small medical practices, massive hospital systems, and everyone in between, all over the world, to find the right imaging solution for their needs. Contact him at shadm@swxray.com to learn more about what equipment is right for you.

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