California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 1 - General Acute Care Hospitals
Article 6 - Supplemental Services
Section 70587 - Radiation Therapy Service General Requirements

(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(b) The responsibility and the accountability of the radiation therapy service to the medical staff and administration shall be defined.

(c) Radiation therapy shall be given only under the direction of a radiation therapist.

(d) All cancer cases accepted for curative radiation shall have adequate histologic substantiation of diagnosis unless convincing alternative evidence for diagnosis is presented.

(e) Documentation of the initial evaluation, treatment plan, dosimetry, and clinical, technical and follow-up notes shall be maintained.

(f) Adequate communication shall be maintained with referring physicians.

(g) There should be periodic review of case management, complications and treatment results.

(h) There shall be a tumor board, a tumor registry, and/or cancer committee in which the radiation therapy staff shall participate.

(i) There shall be provided:

(j) Periodic follow-up of patients following completion of treatment shall be coordinated with the referring physician.

(k) The hospital shall have on file and open to inspection by the Department evidence of any and all affiliations currently in effect. These may include but are not limited to:

(l) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.