ML19219B042
| ML19219B042 | |
| Person / Time | |
|---|---|
| Site: | 03011072 |
| Issue date: | 07/15/2019 |
| From: | O'Dowd D NRC/RGN-III |
| To: | Breeden W Union Hospital |
| References | |
| IR 2019001 | |
| Download: ML19219B042 (3) | |
See also: IR 07200201/1990001
Text
NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION
(07-2012)
1ocFR2.201 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
1. LICENSEE/LOCATION INSPECTED: 2. NRG/REGIONAL OFFICE
Union Hospital, Inc. Region III
1606 N. 7th St. U.S. Nuclear Regulatory Commission
Terre Haute, IN 47804 2443 Warrenville Road, Suite 210
Lisle, IL 60532-4352
REPORT NUMBER(S) 2019001
3. DOCKET NUMBER(S) 4. LICENSE NUMBER(S) 5. DATE(S)OF INSPECTION
JS-
030-11072 13-16457-01 July JID, 2019
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:
~ 1. Based on the inspection findings, no violations were identified.
D 2. Previous violation(s) closed.
D 3. 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):
D 4. 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.
(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 violations identified. 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.
TITLE PRINTED NAME SIGNATURE DA TE
LICENSEE'S
REPRESENTATIVE
NRC INSPECTOR Dennis P. O'Dowd
o~<?t9*~c- !
BRANCH CHIEF Aaron T. Mccraw
NRC FORM 591M PART 1 (07-2012) ' '
NRC FORM 591M PART 3 U.S. NUCLEAR REGULA TORY COMMISSION
(07-2012)
10 CFR2.201 Docket File Information
SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
1. LICENSEE/LOCATION INSPECTED: 2. NRG/REGIONAL OFFICE
Union Hospital, Inc. Region III
1606 N. 7th St. U.S. Nuclear Regulatory Commission
Terre Haute, IN 47804 2443 Warrenville Road, Suite210
Lisle, IL 60532-4352
REPORT NUMBER(S) 2019001
3. DOCKET NUMBER($) 4. LICENSE NUMBER($) 5. DATE(S) OF INSPECTION
030-11072 13-16457-01 July 15-16, 2019
6. INSPECTION PROCEDURES USED 7. INSPECTION FOCUS AREAS
87130, 87131, & 87132 03.01- 03.09
SUPPLEMENTAL INSPECTION INFORMATION
1. PROGRAM CODE(S) 2. PRIORITY 3. LICENSEE CONTACT 4. TELEPHONE NUMBER
02200 3 William K. Breeden, III, MS, DABR (765) 447-7447
[l] Main Office Inspection Next Inspection Date: 07/15/2022
[l] Field Office Inspection 1711 N_ 6 1/2 St., Terre Haute, and
D Temporary Job Site Inspection -801-S.-Main St. Clinton, IN
PROGRAM SCOPE
This was a routine inspection of a large medical institution (350+ beds) authorized to use licensed material permitted by
10 CFR 35.100, 35-200 (including PET), 35.300, 35.400, and 35.500. The licensee was authorized for three areas of use
for its nuclear medicine activities; however, only two of these areas, both on the main campus, were currently active, as
the Clinton, IN location was temporarily without nuclear medicine staff. Collectively, the nuclear medicine department
was staffed with four full-time technologists who performed approximately 300-350 diagnostic procedures monthly. The
licensee received unit doses and bulk Tc-99m for kit preparation; the licensee administered a full spectrum of diagnostic
studies. The department also administered occasional 1-131 dosages (capsules only) for whole body follow-up studies,
hyperthyroid, and CA treatments. The department also administered 2-3 Ra-223 Xofigo treatments annually. The nuclear
cardiology department recently was authorized for cardiac PET using of a Sr-82/Ru-82 generator, with receipt and initial
utilization expected within the next two to three months. The radiation oncology department was staffed with two
medical physicists, two dosimetrists, and three authorized physician users. The licensee used Cs-137 to administer
approximately 10-12 temporary implants per year; these treatments were limited to gynecological and lung cancers. The
licensee administered 1-2 1-125 permanent prostate implants annually.
Performance Observations
The inspection consisted of tours of the nuclear medicine and radiation oncology departments, interviews with licensee
personnel, a review of select records, and independent measurements. All radioactive material was properly secured from
unauthorized access and not readily accessible to members of the general public. The inspector verified that the nuclear
medicine hot lab at the Clinton, Indiana location was locked and secured. The inspector observed licensee personnel
perform and/or demonstrate dose calibrator QA tests, surveys, source inventories, security of byproduct material and use
of personnel monitoring. The inspector observed the licensee staff administer several diagnostic nuclear medicine and
PET doses. These observations, combined with interviews with available staff, revealed an adequate level of
understanding of emergency and material handling procedures and techniques. No therapeutic procedures were
conducted at the time of the inspection. The inspector reviewed written directives for all therapeutic uses, licensee
(cont'd on next page)
NRG FORM 591 M PART 3 (07-2012)
NRC FORM 591M PART 3 U.S. NUCLEAR REGULATORY COMMISSION
(07-2012)
10 CFR 2.201 Docket File Information
SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
1. LICENSEE/LOCATION INSPECTED: 2. NRG/REGIONAL OFFICE
Union Hospital, Inc. Region III
1606 N. 7th St. U.S. Nuclear Regulatory Commission
Terre Haute, IN 4 7804 2443 Warrenville Road, Suite 210
Lisle, IL 60532-4352
REPORT NUMBER(S) 2019001
3. DOCKET NUMBER($) 4. LICENSE NUMBER($} 5. DATE(S) OF INSPECTION
030-11072 13-16457-01 July 15-16, 2019
6. INSPECTION PROCEDURES USED 7. INSPECTION FOCUS AREAS
87130, 87131, & 87132 03.01- 03.09
SUPPLEMENTAL INSPECTION INFORMATION
1. PROGRAM CODE(S) 2. PRIORITY 3. LICENSEE CONTACT 4. TELEPHONE NUMBER
02200 3 William K. Breeden, III, MS, DABR (765) 447-7447
[ZJ Main Office Inspection Next Inspection Date: 07/15/2022
[ZJ Field Office Inspection 1711 N. 6 1/2 St., Terre Haute, and
D Temporary Job Site Inspection 801 S. Main St. Clinton, IN
PROGRAM SCOPE
(cont'd from previous page)
calculations for compliance with patient release requirements, and other pertinent records relative to therapeutic uses,
including those for permanent and temporary implant cases, with no issues noted.
Review of licensee dosimetry and survey record& indicated no concerns with exposures to radiation workers or general
public. The inspector performed independent and confirmatory radiation measurements which indicated results
consistent with licensee survey records and postings.
No violations ofNRC requirements were identified during this inspection.
NRC FORM 591M PART 3 (07-2012}