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Ohio Administrative Code (Last Updated: January 12, 2021) |
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3701 Department of Health - Administration and Director |
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Chapter3701-84. Quality Standards for Providers of Health Care Service (HCS) |
3701-84-68. Personnel/staffing - radiation therapy and stereostatic radiosurgery service
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(A) Each radiation therapy service shall have an administrator.
(B) Each stereotactic radiosurgery service and/or each gamma knife service shall have as a medical director either a radiation oncologist as defined in rule 3701-84-01 of the Administrative Code or a board- certified neurosurgeon certified by the American board of neurological surgery.
(C) All radiation therapy services not covered by paragraph (B) of this rule shall have a radiation oncologist as medical director.
(D) The medical director of each radiation therapy and/or stereotactic radiosurgery service shall:
(1) Approve the specific clinical duties that may be performed by each member of the physics staff as established by the medical physicist under paragraph (G) of this rule; and
(2) Ensure appropriate coverage of the radiation therapy service and/or stereotactic radiosurgery service by radiation oncologists, neurosurgeons, and staff.
(3) Ensure that calculation discrepancies identified in rule 3701-84-70 of the Administrative Code are resolved and documented.
(E) A radiation oncologist shall be available for direct care and quality review on a daily basis. If the radiation oncologist is not on-site, the radiation oncologist shall be accessible by phone, pager, or other designated mechanism.
(F) Each radiation therapy service or dedicated stereotactic radiosurgery service shall have a medical physicist who meets the requirements of:
(1) Paragraph (D) of rule 3701:1-67-02 of the Administrative Code for radiation therapy using radiation-generating equipment; or
(2) Rule 3701:1-58-19 of the Administrative Code for radiation therapy using radioactive materials.
(G) The medical physicist shall be available for consultation with the radiation oncologist or neurosurgeon and provide advice or direction to staff when a patient's treatments are being planned or patients are being treated. Radiation therapy services and stereotactic radiosurgery services shall have regular on-site physics support during hours of clinical activity. The on-site support shall, at a minimum, be provided on a weekly basis. When a medical physicist is not available on-site, other physics duties shall be established and documented in writing by the medical physicist. The medical physicist shall specify the specific physics duties that shall be performed by each member of the physics staff in accordance with their qualification and competence.
(H) Each radiation therapy service shall have available a sufficient number of qualified staff for the radiation therapy services provided, including individuals licensed as a radiation therapist under Chapter 4773. of the Revised Code, who are able to supervise and conduct the radiation therapy services as appropriate for the services being offered. A radiation oncologist and support staff shall be available to initiate urgent treatment with a medically appropriate response time on a twenty-four hour a day, seven days a week basis.
(I) Each stereotactic radiosurgery service shall have available a sufficient number of qualified staff for the stereotactic radiosurgery services provided, including individuals licensed as a radiation therapist under Chapter 4773. of the Revised Code, who are able to supervise and conduct the radiosurgery services as appropriate for the services being offered. A radiation oncologist and/or a neurosurgeon and support staff shall be available to initiate urgent treatment with a medically appropriate response time on a twenty-four hour a day, seven days a week response basis.
(J) In addition to the requirement of paragraph (B) of rule 3701-84-08 of the Administrative Code, each radiation therapy service and radiosurgery service shall establish personnel files for all individuals who provide radiation therapy services and shall maintain files for each individual that specify the types of procedures or services the individual is permitted to perform. All files shall be updated at least every twelve months.