ML20052B205
| ML20052B205 | |
| Person / Time | |
|---|---|
| Issue date: | 04/27/1982 |
| From: | Wiedeman D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20052B202 | List: |
| References | |
| NUDOCS 8204300161 | |
| Download: ML20052B205 (2) | |
Text
a d
Appendix NOTICE OF VIOLATION Lutheran Deaconess Hospital License No. 22-18001-01 As a result of the inspection conducted on April 6,1982, and in accordance with the NRC Enforcement Policy, 47 FR 9987 (March 9, 1982), the following violations were identified:
1.
License Condition No. 15 requires that all licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated January 11, 1978.
Item 7 of the applica-tion states that Medical Isotope Committee meetings will be held not less than once each calendar quarter.
Contrary to the above requirement, the NRC inspectors learned through statements by licensee representatives and review of records, that quarterly meeting requirement of your Medical Isotopes Committee were not being met.
Specifically, no meetings were held between April 22, 1980 and October 30, 1980 and between December 18, 1981 and April 5, 1982. These intervals are in excess of the quarterly frequency requirement.
This is a Severity Level V violation (Supplement VI).
2.
License Condition No. 15 requires that all licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated January 11, 1978,.
Item 10a of the application states survey meters used in the radiation safety program will be calibrated at least annually and following repair.
Contrary to the above, the NRC inspectors learned from statements of licensee representatives, that this requirement was not being met.
Specifically, intervals during February 1980, November 1980, May 1981, and February 1982, a Dosimeter Corporation of America, survey meter (Model No. 3700, Serial No. 004617) was out for calibration and an uncalibrated survey meter was used.
This is a Severity Level V violation (Supplement VI).
M 820430
e d
Appendix 2
3.
10 CFR 35.14(c)(1)(1) requires that sealed sources used as calibration or reference sources be tested for leakage and/or contamination at inter-vals not to exceed six months.
Contrary to this requirement, a 190 microcurie cesium-137 and a 194 microcurie barium-133 sealed source was not leak tested since January 16, 1978 and June 28, 1978, respectively.
This is a Severity Level V violation (Supplement VI).
4.
License Condition No. 15 requires that all licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated January 11, 1978.
Item 10b of the applica-tion states that the procedures described in Appendix D, Section 2, of the NRC Medical Licensing Guide will be used for calibration of the dose calibrator. Appendix D, Section 2, requires quarterly linearity tests.
Contrary to the above, the NRC inspectors learned from statements of licensee representatives, that this requirement was not met.
Specifi-cally, between August 14, 1978 and February 12, 1982, quarterly line-arity tests were not performed.
This is a Severity Level V violation (Supplement VI).
t 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 statement or explanation in reply, including for each item of noncompliance:
(1) corrective action 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.
Consideration may be given to extending your response time for good cause shown.
o 2
Dated D. G. Wiedeman, Acting Chief Materials Radiation Protection Section 1
__