IR 015000026/2021001
| ML21022A159 | |
| Person / Time | |
|---|---|
| Site: | 15000026, 015000026 |
| Issue date: | 01/21/2021 |
| From: | Kevin Null Division of Nuclear Materials Safety III |
| To: | Matthes D Bryan Medical Center-Mobile Imaging |
| References | |
| IR 2021001 | |
| Download: ML21022A159 (2) | |
Text
U.S. NUCLEAR REGULATORY COMMISSION SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION NRC FORM 591M PART 1 (07-2012)
10 CFR 2.201 LICENSEE/LOCATION INSPECTED:
2. NRC/REGIONAL OFFICE REPORT NUMBER(S)
3. DOCKET NUMBER(S)
4. LICENSE NUMBER(S)
5. DATE(S) OF INSPECTION The inspection was an examination of the activities conducted under your license as they relate to radiation safety and to compliance with the Nuclear Regulatory Commission (NRC) rules and regulations and the conditions of your licens The inspection consisted of selective examinations of procedures and representative records, interviews with personnel, and observations by the inspecto The inspection findings are as follows:
LICENSEE:
1.
Based on the inspection findings, no violations were identified.
2.
Previous violation(s) closed.
The violations(s), specifically described to you by the inspector as non-cited violations, are not being cited because they were self-identified, non-repetitive, and corrective action was or is being taken, and the remaining criteria in the NRC Enforcement Policy, to exercise discretion, were satisfied.
3.
Non-cited violation(s) were discussed involving the following requirement(s):
4.
(Violations and Corrective Actions)
During this inspection, certain of your activities, as described below and/or attached, were in violation of NRC requirements and are being cited in accordance with NRC Enforcement Policy. This form is a NOTICE OF VIOLATION, which may be subject to posting in accordance with 10 CFR 19.11.
I hereby state that, within 30 days, the actions described by me to the Inspector will be taken to correct the violations identifie This statement of corrective actions is made in accordance with the requirements of 10 CFR 2.201 (corrective steps already taken, corrective steps which will be taken, date when full compliance will be achieved). I understand that no further written response to NRC will be required, unless specifically requested.
Statement of Corrective Actions DATE SIGNATURE PRINTED NAME TITLE LICENSEE'S REPRESENTATIVE NRC INSPECTOR BRANCH CHIEF NRC FORM 591M PART 1 (07-2012)
Bryan Medical Center 1600 South 48th Street Lincoln, NE 68506 2021001 Region III U. S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352 150-00026 NE 02-52-01 GL under 150.20 January 21, 2021
Kevin G. Null Michael Kunowski
Kevin G. Null Digitally signed by Kevin G. Null Date: 2021.01.21 14:11:31 -07'00'
Michael A. Kunowski Digitally signed by Michael A. Kunowski Date: 2021.01.22 05:26:39 -06'00'
NRC FORM 592M (10-2020)
U.S. NUCLEAR REGULATORY COMMISSION Materials Inspection Record Page 1 of 1 NRC Form 592M (10-2020) Licensee Name:
Bryan Medical Center Docket Number(s):
150-00026 License Number(s)
Nebraska 02-52-01; GL 150.20 Report Number(s):
2021001 Date(s) of Inspection:
January 21, 2021 Inspector(s):
Kevin Null Program Code(s):
02220 Priority:
3 Inspection Guidance Used:
87130 1 Licensee Contact Name(s):
Daniel Matthes 1 Licensee E-mail Address:
daniel.matthes@bryanhealth.org 1 Licensee Telephone Number(s):
402-481-3879 1 Inspection Type:
Initial Routine
Announced
Non-Routine Unannounced Temporary Job Site
Field Office Main Office 1 Locations Inspected:
Remote
1 Next Inspection Date (MM/DD/YYYY):
N/A Normal Reduced Extended No change 1 Scope and Observations:
This was an announced, remote inspection of Bryan Medical Center (BMC), a mobile nuclear medicine service licensed by the State of Nebraska to provide diagnostic nuclear medicine studies at temporary job site The inspection was conducted using video/audio conferencin The licensee submitted an NRC Form 241 on 10/18/2020, to report that they would be conducting licensed activities at Community Hospital in Fairfax, Missouri, a state under NRC jurisdictio BMC was staffed by 8 certified nuclear medicine technologists (CNMT's) who performed diagnostic nuclear medicine procedures in 5 mobile unit BMC conducted diagnostic studies 2 - 3 times per month at Community Hospita Procedures were typically performed by 1 CNMT at the Missouri location, and included cardiac, bone, renal, parathyroid, lung, and liver scan Unit dosages were supplied by a radiopharmacy located in Lincoln, Nebraska, and were delivered directly to a space in Lincoln that was leased by BM Performance Observations The inspector observed 2 CNMT's: 1) perform radiation level and removable contamination surveys on a package containing unit doses; 2) perform daily QA/QC of the licensee's dose calibrator; 3) prepare and inject a unit dose for a cardiac study; 4) demonstrate security measures within the mobile van for sealed sources, unit doses, and radioactive waste; and 5) demonstrate daily radiation level surveys and weekly smears for contamination inside the van. The inspector observed the CNMT's lock all licensed material within the van, and lock the van before transporting a dose into the client's facility for a diagnostic procedur The inspector noted that the CNMT's maintained constant surveillance of the dose before it was injected for the stud The CNMT's also described radiation surveys that were performed in the client's facility at the end of the da The inspector noted that the CNMT's wore appropriate protective clothing, were assigned whole body and extremity dosimetry, and utilized protective equipment including syringe shields and tongs when handling licensed materia Prior to conducting the remote inspection, the inspector obtained and reviewed the following records: 1) dosimetry for calendar years (CY) 2019 and 2020; 2) sealed source inventory and leak test results; 3) dose calibrator QA/QC for CY 2020; 3) survey meter calibration records; 4) dose calibrator linearity and accuracy records; 5) records of radioactive waste disposal; and 5) the letter of agreement between Bryan Medical Center and Community Hospital to provide licensed service Through interviews with the CNMT's and observations of work practices implemented to maintain security and surveillance of licensed material, the inspector confirmed that the licensee effectively implemented corrective actions to prevent the recurrence of a violation against 10 CFR 20.1801 cited in 2013, and 20.1802 that was cited in 201 No violations of NRC requirements were identified.