ML20010B880
| ML20010B880 | |
| Person / Time | |
|---|---|
| Issue date: | 08/07/1981 |
| From: | Wiedeman D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20010B873 | List: |
| References | |
| NUDOCS 8108180429 | |
| Download: ML20010B880 (2) | |
Text
l Appendix A i
l St. Mary's Hospital License No. 12-09869-02 License No. 12-09869-03 As a result of the inspection conducted on July 28, 1981, and in accordance with the Interim Enforcement Policy, 45 FR 66754 (October 7,1980), the following violations were identified:
License No. 12-09869-02 1
1.
License Condition No. 14 states that licensed material shall be possessed and used in accordance with statements, representations, i -
and procedures contained in application dated January 23, 1978.
The above referenced application states, the procedures described in Appendix I of the draft " Guide for Preparation of Applications for Medical Programs" will ba followed. Appendix I states all elution, preparatic : and injection areas will be surveyed daily for-contamin-ation.
Contrary to the above requirement, it was determined through state-ments by licensee representatives and the NRC inspectors review of records that this condition is not being met..Specifically, the elution, preparation and injection areas of the Nuclear Medicine Department are surveyed weekly.
This is a Severity Level V violation (Supplement VII).
2.
License Condition Nc. 14 states that licensed material shall be possessed and used in accordance with statements, representations, and procedures contained in application dated September 18, 1978.
Item No. 21 of the above referenced application states the charcoal i
trap effluent contained in the Pulmonex Xenon System will be sampled weekly and checked with a scintillation camera.
Contrary to the above requirement, it was determined through statements by licensee representatives that this condition is not being met.
~ Specifically, weekly sampling has not been performed since the inception of this license.
1 This is a Severity Level V violation (Supplement VII).
3.
10 CFR 35.14(f)(2) states each licensee who possesses and uses calibration or reference; sources shall ennduct a quarterly physical inventory to account for all sources received and. possessed.
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NMS LIC30 12-09869-02 J
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7 Appendix A Contrary to the above requirement, a licensee representative stated quarterly physical inventories have not been performed since the inception of this license.
Thia is a Severity Level V violation (Supplement VII).
License No. 12-09869-03 4.
10 CFR.35.25 states the licensee shall maintain, for inspection by the Commission, records of instrument calibrations and records of the licensec's evaluation of the qualified experts training and experience.
Contrary to the above requirement, it was determined through statements by licensee representatives and the NRC inspectors review of records that this condition is not being met.
Specifically, on the day of this inspection, the above records were not available for review.
1 This is a Severity Level VI violation (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. written state-ment or explanation in reply, including for each item of noncompliance:
(1) corrective act'an taken and the results achieved; (2) corrective action to be taken to avoid further noncompliance; and (3) the date when full compliance 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 offirmation.
Consideration may be given to extending your response time for good cause shown.
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.c, Dated D. G. Wiedeman, Acting Chief Materials Radiation l'rotection Section 1 l
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