Text

Forwards Amend 7 to License 50-17686-01
	ML20141E375
Person / Time
Site:	03013158
Issue date:	12/02/1985
From:	Riedlinger B; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:	Burns J; BARTLETT MEMORIAL HOSP., JUNEAU, AK
Shared Package
ML20141E361	List: ML20141E356; ML20141E375;
References
	70278, NUDOCS 8601070670
	Download: ML20141E375 (1)
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DEC 2

1I85

Docket No. : 030-13158

License No.:

50-17686-01

Control No.:

70278

Bartlett Memorial Hospital

3260 Hospital Drive

Juneau, Alaska 99801

Attention:

Mr. James R. Burns

Administrator

Gentlemen:

Enclosed is the NRC license amendment which you requested.

Please review the enclosed document carefully and be sure that you understand

all conditions. If there are any errors or questions, please notify us so

that we can provide appropriate corrections and answers.

Any future correspondence relating to your license should specifically

reference your license and docket numbers to expedite your inquiry.

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Sincerely,

Beth A. Riedlinger

Health Physicist (Licensing)

Nuclear Materials Safety Section

Enclosure: Attachment A

Amendment No. 7 to License No. 50-17686-01

8601070670 851202

REG 5 LIC30

50-17686-01

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3260 HOSPITAL DRIVE o JUNEAU, ALASKA 99801 e TELEPHONE (907) 586:2611

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October 21, 1985

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Docket No: 030-13158

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License No: 50-17686-01

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NOTICE OF VIOLATION - CORRECTIVE ACTION

This ackncwledges receipt of your cover letter and NOTICE OF VIOLATION dated

October 1, lo85.

We have reviewed our management controls and a corrected effort is being made to

assure full compliance. We are proposing some changes in our license

application that more realistically fit our operation.

We have averaged about

26/28 nuclear exams per month over the past few years.

At the regular meetings of-the Nuclear Medicine Committee we plan to develop and

implement a -heck list to assure regular review of procedures.

Replies to the violations are as follows:

A.

DISPOSAL: Separate trash containers labeled " RADIOACTIVE" and

"NON-RADIOACTIVE" have been placed in the Nuclear Medicine room.

The

" RADIOACTIVE" container is kept in a locked cabinet to preclude

handling by untrained personnel.

B.

VISITING PHYSICIANS: We checked Dr. Greening's credentials and find

that he does not meet the criteria.

Therefore, we have developed the following policy:

" Nuclear medicine testing shall be carried out only when the

regular authorized radiologist (s) or a visiting radiologist who

is currently authorized on a NRC license for human use is in

charge of the department."

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AN AGENCY OF THE CITY AND BOROUGH OF JUNEAU gg

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U. S. Nuclear Regulatory Commission

October 21, 1985

Page 2

C.

DAILY SURVEYS & TRAINING:

1.

We do not perform nuclear medicine studies on a daily basis.

Presently ITEM 17. AREA SURVEY PROCEDURES reads as follows:

"A.

All elution, preparation and injection areas will be

surveyed whenever radioactive materials are eluted, transported

or prepared on a daily basis with a S-M Survey meter and

decontaminated if necessary."

a

We request that the following wording be placed into effect:

"A.

All elution, preparation and injection areas will be

surveyed whenever radioactive materials are eluted, transported

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or prepared. This will be done with a G-M Survey meter and

decontaminated if necessary.

Additionally, we requested that the word " DAILY" be stricken from the

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note on that page.

It will then read:

" Note:

For surveys where no

abnormal exposures are found, only the date, the identification

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of the person performing the survey and the survey reporter will

be recorded."

2. We request that the first two paragraphs of ITEM 12.

PERSONNEL

TRAINING PROGRAM read as follows:

"A training program will be provided for all personnel who work

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with or in the area of radioactive materials. This program will

be given within the first thirty (30) days of employment and

annually thereafter.

The_ program will consist of lectures given by the RSO or his

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designate and shall cover the folowing subjects:"

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'We have held a training program on Thursday, September 19, 1985. We

have arranged for the Personnel Office to notify pertinent department

heads who might require the above training so that it is carried out

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as scheduled above.

The above actions should correct the deficiencies.

@

JAMES R. BURNS, ADMINISTRATOR

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Maintenance

Housekeeping

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ML20141E375

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