ML21239A247

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Northwest Health - Porter - NRC Form 591M Part 1, Inspection Report 03012150/2021001
ML21239A247
Person / Time
Site: 03012150
Issue date: 08/18/2021
From: Folch L
NRC/RGN-III
To: Plankey L
Northwest Health - Porter
References
IR 2021001
Download: ML21239A247 (3)


See also: IR 015000202/2010001

Text

NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION

(07-2012)

10 CFR 2.201

SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION

1. LICENSEE/LOCATION INSPECTED: 2. NRC/REGIONAL OFFICE

Northwest Health - Porter Region III

85 E. U.S. Hwy6 U. S. Nuclear Regulatory Commission

Valparaiso, IN 46383 2443 Warrenville Road, Suite 210

Lisle, IL 60532-4352

REPORT NUMBER(S) 202101

3. DOCKET NUMBER(S) 4. LICENSE NUMBER(S) 5. DATE(S) OF INSPECTION

030-12150 13-17073-01 August 18, 2021

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.

2. Previous violation(s) closed.

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):

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 DATE

LICENSEE'S

REPRESENTATIVE

NRC INSPECTOR Luis Nieves Folch Luis A. Nieves Folch Digitally signed by Luis A. Nieves Folch

Date: 2021.08.26 10:19:00 -05'00'

BRANCH CHIEF Michael Kunowski Michael A. Kunowski Digitally signed by Michael A. Kunowski

Date: 2021.08.26 11:16:28 -05'00'

NRC FORM 591M PART 1 (07-2012)

From: Nieves Folch, Luis

To: loriplankey@nwhealthin.com

Subject: Northwest Health Porter 591M NRC report

Date: Friday, August 27, 2021 8:43:00 AM

Attachments: Northwest Health Porter 591M(1)MK.pdf

Dear Mrs. Plankey

Attach is the clear 591 report for the inspection conducted on August 18, 2021. At this

point there is no further actions on your part.

In accordance with Title 10 of the Code of Federal Regulations 2.390 of the NRCs

Rules of Practice, a copy of this message will be available electronically for public

inspection in the NRCs Public Document Room or from the NRC's Agencywide

Documents Access and Management System (ADAMS), accessible from the NRCs

website at http://www.nrc.gov/reading-rm/adams.html.

Please feel free to contact me if you have any questions regarding this correspondence.

Thank you,

Luis Nieves

Health Physicist

U.S. Nuclear Regulatory Commission

Division of Nuclear Materials Safety

Office: (630) 829-9571

Fax: (630) 515-1259

NRC FORM 592M U.S. NUCLEAR REGULATORY COMMISSION

(10-2020)

Materials Inspection Record

1. Licensee Name: 2. Docket Number(s): 3. License Number(s)

Northwest Health - Porter 030-12150 13-17073-01

4. Report Number(s): 5. Date(s) of Inspection:

2021001 August 18, 2021

6. Inspector(s): 7. Program Code(s): 8. Priority: 9. Inspection Guidance Used:

Luis Nieves 02240 2 87132

10. Licensee Contact Name(s): 11. Licensee E-mail Address: 12. Licensee Telephone Number(s):

Lori Plankey, CNMT

loriplankey@nwhealthin.com 219-983-8300

13. Inspection Type: Initial 14. Locations Inspected: 15. Next Inspection Date (MM/DD/YYYY):

Routine Announced Main Office Field Office Normal Extended

August 18, 2023

Non-Routine Unannounced Temporary Job Site Remote Reduced No change

16. Scope and Observations:

This was an announced, routine inspection of a hospital authorized by its NRC license to use unsealed byproduct

material for diagnostic and therapeutic procedures under 10 CFR 35.100, 200, 300, 400, and 1000(Y-90). At the

time of the inspection, the licensee performed a comprehensive spectrum of diagnostic procedures. The nuclear

medicine department was staffed with six full-time nuclear medicine technologists (NMTs) who performed

approximately 80 diagnostic nuclear medicine procedures weekly and 25 PET diagnostic procedures also weekly.

The licensee has two hot labs at their main hospital one for nuclear medicine and one for PET open from Mondays

to Fridays. The licensee has not performed any manual brachytherapy since 2012, they did perform ten I-131, one

complete Xofigo treatment, and five Y-90 treatments in the last year. The licensee retains a consultant health

physicist to perform annual audits of the radiation safety program and calibrations.

PERFOMANCE OBSERVATIONS

The inspector conducted a tour of the nuclear medicine hot labs and discussed with the NMT package receipt,

surveys, and instrument quality control checks. The inspector observed the preparation and administration of one

bone scan. The NMTs demonstrated adequate knowledge of radiation safety principles and practices through

interviews. The inspector reviewed audit reports, instrument quality control, safety committee minutes, written

directives, inventory, dose calibrator linearity and accuracy, leak tests, and training. The inspector also reviewed

monthly dosimetry reports which indicated annual whole-body and extremity doses were below regulatory limits.

No violations of NRC requirements were identified as a result of this inspection.

NRC Form 592M (10-2020) Page 1 of 1