ML25134A194
| ML25134A194 | |
| Person / Time | |
|---|---|
| Site: | 03011072 |
| Issue date: | 04/01/2025 |
| From: | Nieves L NRC/RGN-III/DRSS/MIB |
| To: | Howe K Union Hospital |
| References | |
| IR 2025001 | |
| Download: ML25134A194 (1) | |
See also: IR 07200202/1950001
Text
(10-04-2022)
U.S. NUCLEAR REGULATORY COMMISSION
Materials Inspection Record
Page 1 of 2
NRC Form 592M (10-04-2022)
1. Licensee Name:
Union Hospital, Inc.
2. Docket Number(s):
030-11072
3. License Number(s)
13-16457-01
4. Report Number(s):
2025-001
5. Date(s) of Inspection:
4/1/2025 - 4/22/2025
6. Inspector(s):
Luis Nieves
7. Program Code(s):
02230
8. Priority:
2
9. Inspection Guidance Used:
10. Licensee Contact Name(s):
Kristie Howe CNMT, Supervisor
Nuclear Cardiology
11. Licensee E-mail Address:
khowe@union.health
12. Licensee Telephone Number(s):
812-238-4922
13. Inspection Type:
Initial
Routine
Announced
Non-Routine
Unannounced
14. Locations Inspected:
Hybrid
Main Office
Field Office
Temporary Job Site
Remote
15. Next Inspection Date (MM/DD/YYYY):
4/1/2027
Normal
Reduced
Extended
No change
16. Location(s) Inspected List:
1606 N 7th St., Terre Haute, Indiana, 47804
1711 N 6 1/2 St., Terre Haute, Indiana, 47807
17. Scope and Observations:
This was an unannounced, 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, 35.200, 35.300, 35.400, 35.600, and
35.1000(Y-90). At the N 7th St. location, the licensee operated two areas of use for its nuclear medicine activities
(main hospital nuclear medicine and PET, and Heart Institute). The main hospital nuclear medicine department was
staffed with one full-time technologists (NMTs) and three PRN, who performed approximately 8-10 diagnostic
procedures daily and approximately 7-11 PET using FDG daily. The licensee administered a full spectrum of
diagnostic studies. The department also administered approximately 6 iodine-131 (I-131) dosages (capsules only)
for whole body follow up studies, hyperthyroid, and cancer ablation treatments annually. The department also
administered one Ra-223 Xofigo treatments annually, and seven Lutetium-177 pluvicto annually. The licensee also
performed approximately two Y-90 SIR-Spheres permanent manual brachytherapy procedures in 2024.
The heart and vascular institute nuclear medicine department was staffed with six full-time NMTs, who performed
approximately 3-5 cardiac PET using a Sr-82/Ru-82 generator (cardiogen-82 infusion system, Model 1700) and
approximately 12 cardiac stress test daily.
At the 6 1/2 St. location the radiation oncology department was staffed with an oncologist and one authorized
medical physicists (AMP). The licensee performed approximately 10 high-dose rate remote afterloader treatments
for mostly OBGYN, but will expand to skin and prostate treatments in the future. The licensee has not performed any
manual brachytherapy since the last inspection. The licensee still possessed their cesium-137 seeds which are
inventoried and kept secure. They also have some iodine-125 seeds that are decaying in storage.
The inspector toured the nuclear medicine department, heart and vascular institute, oncology department, and
discussed with the NMT package receipt, surveys, and instrument quality control checks. The inspector observed the
preparation and administration of Tc-99m for imaging, FDG for a PET scan, and a cardiac study utilizing a Sr/Rb
generator. Through interviews, the NMT demonstrated adequate knowledge of radiation safety principles and
(10-04-2022)
U.S. NUCLEAR REGULATORY COMMISSION
Materials Inspection Record (Continued)
Page 2 of 2
NRC Form 592M (10-04-2022)
practices. The inspector performed independent surveys of the hot lab and other areas of the nuclear medicine
department and found no contamination or exposure to members of the public distinguishable from background. The
inspector reviewed annual audit reports, instrument quality control, inventory, waste disposal records, leak test
results, dose calibrator linearity and accuracy, written directives and HDR treatment plans, Sr/Rb procedures and
daily QC, and training records. The inspector also reviewed monthly dosimetry reports, which indicated that annual
whole-body and extremity doses were below regulatory limits.
A violation of 10 CFR 35.60 and 10 CFR 35.63 was identified during this inspection. In accordance with the
Enforcement Policy, this violation would normally be categorized at Severity Level IV. However, in accordance with
NRC Enforcement Guidance Memorandum (EGM) 13-003, issued April 18, 2013, the NRC is exercising enforcement
discretion and not pursuing any enforcement action for this violation (EAF-RIII-2025-0098).
No additional violations of NRC requirements were identified during this inspection.
Signature and Date - Branch Chief
Digitally signed by RHEX EDWARDS
Date: 2025.05.14 07:15:08 -05'00'