ML18241A334
| ML18241A334 | |
| Person / Time | |
|---|---|
| Site: | 03017616 |
| Issue date: | 08/13/2018 |
| From: | Null K G NRC/RGN-III |
| To: | Hassien J D Hannibal Regional Hosp |
| References | |
| IR 2018001 | |
| Download: ML18241A334 (2) | |
Text
NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012) 1ocFR2.201 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEEILOCATlON INSPECTED:
Hannibal Regional Hospital 6000 Hospital Drive Hannibal, MO 63401 REPORT NUMBER(S) 2018001 2. NRC/REGIONAL OFFICE Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 3. DOCKET NUMBER(S) 030-17616
- 4. LICENSE NUMBER(S)
- 5. DATE(S) OF INSPECTION 24-18988-01 LICENSEE:
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 license. The inspection consisted of selective examinations of procedures and representative records, interviews with personnel, and observations by the inspector.
The inspection findings are as follows: [~~* Based on the inspection findings, no violations were identified.
- 2. f: 3. L._! I__J 4. 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 . . Non-cited violation(s) were discussed involving the following requirement(s):
During this inspection, certain of your activities, as described below and/or attached, were in violation of NRG 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. (Violations and Corrective Actions) Statement of Corrective Actions I hereby state that, within 30 days, the actions described by me to the Inspector will be taken to correct the vlolations identified.
This statement of corrective actions ls 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.
TITLE PRINTED NAME SIGNATURE DATE LICENSEE'S REPRESENTATIVE NRC INSPECTOR Kevin G. Null BRANCH CHIEF G N w A \ ' e:o'trr c,y c. r re." c:..,. ;II\'\ NRC FORM 591M PART 1 {07-2012) f / lJ/Jr ~V-NRC FORM 591 M PART 3 (07-2012) 10 CFR 2.201 U.S. NUCLEAR REGULATORY COMMISSION Docket File Information SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEE/LOCATION INSPECTED:
Hannibal Regional Hospital 6000 Hospital Drive Hannibal, MO 63401 REPORT NUMBER(S) 2018001 3. DOCKET NUMBER(S) 030-17616
- 6. INSPECTION PROCEDURES USED 87130 and 87131 2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER(S) 24-18988-01 Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 5. DATE(S) OF INSPECTION August 13, 2018 7. INSPECTION FOCUS AREAS 03-01 -03.07 SUPPLEMENTAL INSPECTION INFORMATION
- 1. PROGRAM CODE(S) 2120 2. PRIORITY 3. LICENSEE CONTACT 4. TELEPHONE NUMBER 3 Joel Hassien, M.D., RSO (618) 406-6558 [{] Main Office Inspection Next Inspection Date: 08/13/2021 D Field Office Inspection
*--*
D Temporary Job Site Inspection
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PROGRAM SCOPE This was a routine, unannounced inspection of a 100 bed regional hospital authorized for material described in 10 CFR Part 35, Sections 35.100, 200 and 300. The licensee employed two full-time certified nuclear medicine technologists (CNMT's), and performed 4 -5 diagnostic studies per week, using unit doses provided by a local radiopharmacy.
The licensee also performed 30 -50 iodine-131 ( capsule only) procedures requiring a written directives each year. The nuclear medicine department included one imaging room and a hot lab. The licensee contracted with a health physics consultant who audited the nuclear medicine department on a quarterly basis. PERFORMANCE OBSERVATIONS The inspector observed the CNMT's prepare and administer diagnostic doses of technetium-99m, and noted the use of lab coats, gloves, syringe shields, and personal dosimetry.
A CNMT demonstrated procedures implemented for the receipt and survey of packages, and thresholds for notifying the radiopharmacy and NRC if a package had removable contamination exceeding threshold values. The CNMT also described daily calibration of the dose calibrator, handling and processing of radioactive waste for decay in storage, and daily and weekly surveys for radiation levels and removable contamination.
The inspector noted that the licensee's survey instrumentation was calibrated at the required frequency.
The inspector reviewed package survey results, a random selection of written directives, records of sealed source leak test and physical inventory, daily and weekly surveys, and results of the licensee's annual program review for calendar year 2017. A CNMT showed the inspector where the sealed sources were secured and stored, and performed a physical inventory accounting for each sealed source The inspector performed independent surveys of the hot lab and imaging room with a Canberra model RadEyeG gamma survey meter calibrated on 9/12/17. Radiation levels ranged from 0.05 mrem/hr (background)-
0.10 mrem/hr in the hot lab. No violations or NRC requirements were identified.
NRG FORM 591M PART 3 (07-2012)