ML20005A864
| ML20005A864 | |
| Person / Time | |
|---|---|
| Issue date: | 06/22/1981 |
| From: | Wiedeman D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20005A860 | List: |
| References | |
| NUDOCS 8107010399 | |
| Download: ML20005A864 (2) | |
Text
O a
O Appendix A NOTICE OF VIOLATION St. Francis Mercy Hospital License No. 24-15097-01 As a result of the inspection conducted on June 3, 1981, and in accordance with the Interim Fnforcement Policy, 45 FR 66754 (October 7,1980), the following violations were identified:
1.
License Condition No. 14 requires that licensed material be possessed and used in accordance with statements, representations, and procedures 4
contained in application dated July 20, 1977.
License application dated July 20, 1977, states that the procedures described in Appendix C of the NRC medical licensing guide dated February 1976, will be followed for calibration of the dose calibrator.
Appendix C states that a geometrical variation check of the dose calibrator shall be performed.
Contrary to this requirement, it was learned through statements of licensee representatives that a geometrical variation check of the dose calibrator nas not been performed since the date of license issuance.
This is a Severity Level V violation (Supplement VII).
2.
License Condition No. 14 requires that licensed material be possessed and used in accordance with statements, representation, <.nd procedures contained in application dated July 20, 1977.
License application dated July 20, 1977, states that the procedures described in Appendix C of the NRC medical licensing guide dated February 1976, will be followed for performing surveys. Appendix C states that the method used to analyze wipe tests shall be capable of detecting 200 dpm.
Contrary to this requirement, it was learned through statements of licensee representatives and a review of records that the method used to analyze wipe tests was not sufficiently sensitive to detect 200 dpm. Specifically, wipe tests have been analyzed using a portable G-M meter which is incapable of detecting contamination levels as l
low as 200 dpm.
This is a Eeverity Leval V violation (Supplement VII).
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8M7010397
s Appendix A,
3.
10 CFR Section 20.401(a), requires each licensee maintain film badge records on Form NRC-5 or a record containing all information required in Form NRC-5.
Contrary to this requirement, film badge records did not show social security numbers and birthdates of individuals for which film badge monitoring is required.
This is a Severity Level VI violation (Supplement IV) and a repeat item of noncomplia:ce.
'4.
10 CFR 50.61(a), states that conditions of each license issued shall be subject to ammendments, revision or modification by reason of amendments to the Act or by reason of rules, regulaticas and orders issued in accordance with the terms of the Act.
Byproduct Material License No. 24-15097-01 was amended by an NRC Order issued March 12, 1979, which states: " Effective immediately, any license which author-izes possession and use of molybdenum-99/ technetium-99m generators and any license which autho.2zes extraction or separation of technetium-99m from molybdenuu-99 not contained in generators is amended to add the following ccnditions:" These specific conditions require that the licensee establish written procedures for personnel performing molybdenum-99 breakthrough tests including all calculations and steps to be taken if molybdenum-99 in excess of the specified limits are de?.ected, personnel performing these breakthrough tests shall be given specific training and records of the training provided shall be e.aintained for two years following performance of the test.
Contrary to these requirements, it was learned through statements of licensee representatives that records of training given to personnel who perform molybdenum-99 breakthrough tests were not maintained.
This is a Severity Level VI (Supplement VII).
Pursuant to the provisions of 10 CFR 2.201, you are required to submit to this office within thirty days of the date of this Notice a written state-ment or explanation in reply, including for each item of noncompliance:
(1) corrective action taken tad the results achieved; (2) corrective action to be taken to avoid further noncompliance; and (3) the date when full com-pliance will be achieved. Under the authority of Section 182 of the Atomic Energy Act of 1954, as amended, this response shall be submitted under oath or affirmation. Consideration may be given to extending your response time for good cause shown.
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D. G. Wiedeman, Acting Chief j
Dated
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Materials Radiation Protection Section 1 l