Nicholas H Noyes Memorial Hospital

“RADIOLOGIC SERVICES CFR(s): 482.26 The hospital must maintain, or have available, diagnostic radiological services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. This Condition is not met as evidenced by: 49420 Based on policy review, medical record review, document review, and interview, in one of two Nuclear Medicine/PET (Positron Emission Tomography) Technologist’s, the facility failed to meet professionally approved standards for safety and personnel qualifications as evidenced by lack of required certification, and the lack of facility policy consistent with state laws and establishing criteria governing designation and the qualifications for personnel that perform PET/CT scans (Staff (A). Reference: 482.26(c)(2): Qualified Staff.”

“QUALIFIED STAFF CFR(s): 482.26(c)(2) Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer procedures. This Standard is not met as evidenced by: 49420 Based on observation, medical record review, policy review, document review, and interview, in one of two nuclear medicine technologists (Staff (A)) were performing PET/CT scans (Positron Emission Tomography [a medical imaging test that uses radioactive tracers to create detailed images of the inside of the body, showing how well organs and tissues are functioning]) without required certification. There is no clinical policy consistent with state laws and established criteria governing designation and the qualifications for staff that perform PET/CT scans. Findings Include: Review of “Plan for Providing Diagnostic Imaging Services and Staffing”, last revised 07/01/23, revealed the qualifications and scope of practice for each role. The policy does not include the qualification and scope of practice for PET/CT technicians. Review of the job description for “Nuclear Medicine PET Technologist”, last reviewed August 2024, revealed the education needed to be qualified for the position included, “bachelor’s degree or certification in nuclear medicine technology; New York State Department of Health license in the practice of nuclear medicine; nuclear medicine computed tomography registry certification and NMTCB/ARRT (Nuclear Medicine Technology Certification Board/American Registry of Radiologic Technologists) must be obtained within six months of hire. “ Review of Staff (A), Nuclear Medicine/PET Technologist’s license and certifications revealed Staff (A) is licensed until 05/14/28 as a nuclear medicine technologist with the New York State Department of Health and is certified with the ARRT through May 2025 for nuclear medicine technology. Staff (A) lacks certification of nuclear medicine CT registry certification for NMTCB. Review of Staff (A), Nuclear Medicine/PET Technologist, leased employee contract signed on 08/26/24, revealed Staff (A) was leased from another hospital within the hospital system to help perform and administer PET/CT studies to increase patient access. The start date of the contract was 09/09/24 and the contract has been extended through 05/31/25. Review of the PET/CT meeting on 08/20/24, revealed Staff (A), Nuclear Medicine/PET Technologist, Staff (B), Supervisor Nuclear Medicine/PET Technologist, Staff (E), Vice President of Operations, and Staff (M), Regional Imaging Administrator, were present for the meeting. The meeting included a discussion that Staff (A) was not certified in computed tomography and would require Staff (B) to “push the computed tomography scan button” if Staff (A) was scanning the patient. Review of Staff (B), Supervisor Nuclear Medicine/PET Technologist, timecards revealed that Staff (B) did not work on 11/15/24 and 02/07/25 when PET/CT scans were performed. Review of the PET/CT patient log revealed on 11/15/24 there were three PET/CT scans completed by Staff (A), Nuclear Medicine/PET Technologist when Staff (B), Supervisor Nuclear Medicine/PET Technologist was not present and on 02/07/25 there were four PET/CT scans completed by Staff (A), Nuclear Medicine/PET Technologist when Staff (B), Supervisor Nuclear Medicine/PET Technologist was not present. In 3 out of 13 patient medical records reviewed Staff (A), Nuclear Medicine/PET Technologist, completed PET/CT scans out of their scope of practice. (Patient #1, #2, and #3). The medical record for Patient #1, dated 01/03/25, revealed the following: -At 08:00 AM, the imaging exam information flowsheet, revealed that Patient #1’s PET/CT scan was started by Staff (A), Nuclear Medicine/PET Technologist. -At 09:50 AM, the imaging exam information flowsheet, revealed that Patient #1’s PET/CT scan was completed by Staff (A), Nuclear Medicine/PET Technologist. The medical record for Patient #2, dated 01/07/25, revealed the following: -At 09:30 AM, the imaging exam information flowsheet, revealed that Patient #2’s PET/CT scan was started by Staff (A), Nuclear Medicine/PET Technologist. -At 11:55 AM, the imaging exam information flowsheet, revealed that Patient #2’s PET/CT scan was completed by Staff (A), Nuclear Medicine/PET Technologist. The medical record for Patient #3, dated 03/05/25, revealed the following: -At 09:30 AM, the imaging exam information flowsheet, revealed that Patient #2’s PET/CT scan was started by Staff (A), Nuclear Medicine/PET Technologist. -At 11:10 AM, the imaging exam information flowsheet, revealed that Patient #2’s PET/CT scan was completed by Staff (A), Nuclear Medicine/PET Technologist. Interview on 04/28/25 at 11:50 AM with Staff (G), Director of Imaging and Rehab Services, revealed the hospital has two Nuclear Medicine/PET Technologists that perform PET/CT scans Staff (A), Nuclear Medicine/PET Technologist and Staff (B), Supervisor Nuclear Medicine/PET Technologist. If there is a call off, the facility would cancel all scheduled PET/CT scans. PET/CT scans are performed Tuesday, Wednesday and Fridays, with an average of 30 completed per week. To be able to perform a PET/CT scan the employee would need to be licensed in New York State in nuclear medicine and would need to take a credentialing exam to perform the PET/CT scans. Staff (A) can only administer the nuclear pharmaceuticals (a type of medication that uses radioactive materials for diagnostic or therapeutic purposes in nuclear medicine) and Staff (B) can perform the entire PET/CT scan. Interview on 04/28/25 at 12:06 PM with Staff (J), Vice President of Human Resources, revealed when they hire a new employee, they use the job description to ensure the employee is licensed and credentialed for that position. Interview on 04/28/25 at 02:30 PM with Staff (K), Computed Tomography Technician, revealed Staff (A), Nuclear Medicine/PET Technologist would need someone in the room with them when completing the scans for the PET/CT, as Staff (A) is only licensed as a nuclear medicine technologist. Staff (K) revealed they cannot perform the scans for a PET/CT due to not being trained or credentialed to do so. Interview on 04/28/25 at 03:00 PM with Staff (H), Radiologist and Radiation Safety Officer, revealed they oversee the nuclear pharmaceuticals at the hospital and are one of the radiologists onsite at the hospital while PET/CT scans are completed. If Staff (H) is not at the hospital while PET/CT scans are completed there is another radiologist at the hospital available if there are any issues. For an individual to be qualified to perform PET/CT scans they must possess a license as a computed tomography technologist to run the procedure as well as a license in nuclear medicine to administer the nuclear pharmaceuticals. For the PET/CT scan procedure there are either two staff members involved which include one with the nuclear medicine license and one with the computed tomography technologist license or one staff member that has both licenses. Staff (H) has worked with both Staff (A), Nuclear Medicine/PET Technologist and Staff (B), Supervisor Nuclear Medicine/PET Technologist and has not had any issues while they have performed PET/CT scans. Staff (H) revealed Staff (A), and Staff (B) have never worked alone while completing PET/CT scans and are both qualified to perform PET/CT scans. Staff (H) revealed they were aware Staff (A) did not have their computed tomography license but was under the impression they never worked alone when performing PET/CT scans. Interview on 04/29/25 at 09:02 AM with Staff (A), Nuclear Medicine/PET Technologist, revealed they were a leased employee on a contract to assist with PET/CT scans. There was a backlog of patients that needed PET/CT scans completed and Staff (A) volunteered to assist with the procedures to increase patient access. Staff (A) started training with Staff (B), Supervisor Nuclear Medicine/PET Technologist, in October 2024. Staff (A) would do the prepping including administering the nuclear pharmaceuticals. When the patient is ready to be scanned, Staff (A) assists the patient onto the scanner. When asked if Staff (A) performed PET/CT scans independently, Staff (A) responded there was two days when staff (B) was not working, and they completed the scans. Staff (A) revealed they do not have the Nuclear Medicine Technology Certification Board (NMTCB) computed tomography certification needed to complete the PET/CT scans. Staff (A) revealed on 04/10/25 they started to track diagnostic computed tomography scans they have completed. To meet the NMTCB criteria to take the exam for the computed tomography certification Staff (A) must complete 50 diagnostic computed tomography studies. Interview on 04/29/25 at 09:50 am with staff (B), Supervisor Nuclear Medicine/PET, revealed at the time of opening the PET/CT scan in April 2021 they were the only employee certified to complete the scans. The hospital could only perform six procedures per day and other imaging centers had patients waiting a long time be able to get the scan completed. There was a PET/CT meeting on 08/20/24 with Staff (B), Supervisor Nuclear Medicine/PET Technologist, Staff (A), Nuclear Medicine/PET Technologist, Staff (E) Vice President of Operations, and Staff (M), Regional Imaging Administrator, to increase patient volume to enable patients to get their scans completed in a timely manner. At the meeting, Staff (B) was told Staff (A) was only nuclear medicine certified and could not do the PET/CT scanning portion of the exam. Staff (B) or other qualified staff member would need to perform the computed tomography portion of the exam for the PET/CT scan when Staff (A) was working. Staff (B) revealed there were two days where they were not on the schedule and Staff (A) worked without them. Interview on 04/29/25 at 10:27 AM with Staff (E), Vice President of Operations, revealed Staff (A), Nuclear Medicine/PET Technologist, has a limited license for PET/CT scans and could only perform the nuclear medicine aspect of the procedure. Staff (A) was aware they needed to have a PET/CT certified technician to assist them. Staff (E) stated Staff (A) worked without Staff (B), Supervisor Nuclear Medicine/PET Technologist, on two different days. Interview on 04/29/25 at 05:00 PM with Staff (G), Director of Imaging and Rehab Services, verified Staff (A), Nuclear Medicine/PET Technologist, worked alone on two separate days (11/15/24 and 02/07/25) as Staff (B), Supervisor Nuclear Medicine/PET Technologist, had planned time off per their timecard.”