IR 05000202/2010001: Difference between revisions

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{{Adams
{{Adams
| number = ML22258A099
| number = ML23024A024
| issue date = 09/15/2022
| issue date = 01/24/2023
| title = EA-22-050: Public: the Hospital of Central Connecticut (Hocc) - NRC Inspection Report 03001250/2021001 and NRC Office of Investigations Report No. 1-2021-010
| title = Hospital of Central Connecticut NRC Inspection Report 03001250/2021001 and Notice of Violation
| author name = Welling B
| author name = Lorson R
| author affiliation = NRC/RGN-I/DRSS
| author affiliation = NRC/RGN-I/ORA
| addressee name = Edwards J
| addressee name = Edwards J
| addressee affiliation = Hospital of Central Connecticut
| addressee affiliation = Hospital of Central Connecticut
| docket = 03001250
| docket = 03001250
| license number = 06-02380-01
| license number = 06-02388-01
| contact person =  
| contact person =  
| case reference number = EA-22-050, OI-2021-010
| case reference number = EA-22-050
| document report number = 2021-001, IR 2021010
| document report number = IR 2021001
| document type = Inspection Report, Letter
| document type = Letter
| page count = 4
| page count = 4
}}
}}
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=Text=
=Text=
{{#Wiki_filter:UNITED STATES NUCLEAR REGULATORY COMMISSION
{{#Wiki_filter:January 24, 2023


==REGION I==
==SUBJECT:==
475 Allendale Road, Suite 102 KING OF PRUSSIA, PA 19406-1415 September 15, 2022 EA-22-050 Jeanette Edwards, VP Operations The Hospital of Central Connecticut 100 Grand Street New Britain, CT 06050 SUBJECT: THE HOSPITAL OF CENTRAL CONNECTICUT (HOCC) - NRC INSPECTION REPORT 03001250/2021001 AND NRC OFFICE OF INVESTIGATIONS REPORT NO. 1-2021-010
NOTICE OF VIOLATION - THE HOSPITAL OF CENTRAL CONNECTICUT -
NRC INSPECTION REPORT NO. 03001250/2021001


==Dear Ms. Edwards:==
==Dear Jeanette Edwards:==
On March 5, 2021, Shawn Seeley and Robert Gallaghar, inspectors of the Nuclear Regulatory Commission (NRC), conducted a routine announced inspection remotely, with an on-site inspection for the safety and security portions from March 21-23, 2021, and continued in-office review through August 19, 2022. This inspection was performed under your NRC License No.
This letter refers to the routine inspection conducted on March 5, 2021, with on-site inspection from March 21-23, 2021, and with continued in-office review through August 19, 2022, of activities performed under the U.S. Nuclear Regulatory Commission (NRC) license issued to the Hospital of Central Connecticut (HOCC). The purpose of the inspection was to examine the HOCCs licensed activities as they relate to radiation safety, compliance with the NRCs regulations, and the conditions in the license. Based on the results of the inspection, the NRC staff identified apparent violations (AVs) of NRC requirements. NRC staff discussed the AVs with you during a telephonic exit meeting on [[Exit meeting date::August 19, 2022]], and described the AVs in the NRC inspection report sent to you in a letter dated September 15, 2022 (ML22258A099). 1 The inspection report, and the AVs described therein, concern Security-Related Information in accordance with 10 CFR 2.390(d)(1), and disclosure to unauthorized individuals could present a security vulnerability. Therefore, the inspection report enclosed with the September 15, 2022, letter was not publicly available, and details regarding the AVs were provided in a non-public enclosure.


06-02388-01.
In the letter transmitting the inspection report, we informed you that the AVs identified in the report were being considered for escalated enforcement action. In a telephone conversation on September 22, 2022, Anne DeFrancisco of my staff informed you that we had sufficient information regarding the AVs and your corrective actions to make an enforcement decision without the need for a pre-decisional enforcement conference or a written response from you.


During this inspection, the NRC staff examined activities conducted under your license related to public health and safety. Additionally, the staff reviewed your compliance with the NRCs rules and regulations as well as the conditions of your license. Within these areas, the inspection consisted of selected examination of procedures and representative records, observations of activities and interviews with personnel.
Enclosure transmitted herewith contains Sensitive, Unclassified, Non-Safeguards Information. When separated from the Enclosure, the transmittal document is decontrolled.


Based on the results of the inspection, apparent violations of NRC requirements were identified.
Designation in parentheses refers to an Agency-wide Documents Access and Management System (ADAMS) accession number. Unless otherwise noted, documents referenced in this letter are publicly-available using the accession number in ADAMS. In a letter dated October 21, 2022 (ML22336A183; non-public), you provided a response to the AVs in which you provide further detail about the violations and the HOCCs corrective actions.


The violations were of a security-related nature; therefore, the details of the violations, as well as the corrective actions that have since been taken to restore compliance with regulatory requirements, are discussed in the non-public enclosure.
A summary of your response, the NRC staffs assessment of the AVs, and the actions taken by the HOCC to correct and prevent reoccurrence of these issues is provided in the non-public Enclosure 1.


Additionally, the NRC Office of Investigations (OI), initiated an investigation (Case No. 1-2021-010)
Based on the information developed during the inspection, the NRC has determined that one or more violations of NRC requirements occurred and have been categorized in accordance with the NRC Enforcement Policy as Severity Level III (SL III) violations, which is escalated enforcement. The NRC Enforcement Policy can be found on the NRCs website at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html. The violations are cited in the Notice of Violation (Notice), provided as non-public Enclosure 2, and the circumstances surrounding them are described in detail in the subject inspection report.
to determine whether your staff deliberately committed security-related violations. Based upon documentary and testimonial evidence developed during the OI investigation, the NRC did not substantiate that the actions of your employees were deliberate.


The apparent violations are being considered for escalated enforcement in accordance with the NRC Enforcement Policy. The current Enforcement Policy is included on the NRCs Web site at https://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html. The circumstances surrounding the apparent violations were discussed with you and additional members of your staff telephonically during the final exit meeting on [[Exit meeting date::August 19, 2022]]. The enclosed inspection report presents the findings of this inspection.
In accordance with the NRC Enforcement Policy, a base civil penalty in the amount of $8,000 is considered for a SL III violation. Because your facility has not been the subject of escalated enforcement actions within the last two inspections, the NRC staff considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process in Section 2.3.4 of the Enforcement Policy. The NRC staff determined that the HOCC took prompt and comprehensive corrective actions, and credit is, therefore, warranted. Enclosure 2 (non-public) provides an explanation of the severity level determinations and a description of the HOCCs corrective actions to address the violations. Therefore, to encourage prompt and comprehensive correction of violations, and in recognition of the absence of previous escalated enforcement action, I have been authorized, after consultation with the Director, Office of Enforcement, not to propose a civil penalty in this case. However, significant violations in the future could result in a civil penalty. In addition, issuance of the SL III violations constitutes escalated enforcement action that may subject you to increased inspection effort.


Since the NRC has not made a final determination in this matter, a Notice of Violation is not being issued at this time. Please be advised that the number and characterization of the apparent violations described in the enclosed inspection report may change as a result of further review. You will be advised by separate correspondence of the results of our deliberations on this matter. The circumstances surrounding the apparent violations, the significance of the issues, and the need for lasting and effective corrective actions were discussed with you during the August 19, 2022, telephone call. As a result, it may not be necessary to conduct a pre-decisional enforcement conference in order to enable the NRC to make an enforcement decision. In addition, since your facility has not been the subject of escalated enforcement actions within the last two inspections, and based on our understanding of your corrective action, a civil penalty may not be warranted in accordance with Section 2.3.4 of the Enforcement Policy.
The NRC has concluded that information regarding: (1) the reason for the violations; (2) the corrective actions that have been taken and the results achieved; and (3) the date when full compliance was achieved is already adequately addressed on the docket in Inspection Report No. 03001250/2021001, your letter dated October 21, 2022, and this letter. Therefore, you are not required to respond to this letter unless the description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to provide additional information, you should follow the instructions specified in the enclosed Notice.


Before the NRC makes its enforcement decision regarding the apparent violations, we are providing you an opportunity to (1) respond to the apparent violations addressed in this inspection report within 30 days of the date of this letter or (2) request a Pre-decisional Enforcement Conference (PEC). If a PEC is held, it will be closed to public observation because it would involve security-related information; however, the time and date of the PEC would be publicly announced. A PEC should be held within 30 days of the date of this letter.
Separately, in your October 21, 2022, letter, you identified an error in NRC Inspection Report No. 03001250/2021001. A corrected copy of the inspection report was provided to you with a letter dated January 23, 2023 (ML23023A111, ML23023A106; non-public).


If you choose to provide a written response, it should be clearly marked as a Response to An Apparent Violation in NRC Inspection Report 03001250/2021001; EA-22-050 and should include for each apparent violation: (1) the reason for the apparent violation or, if contested, the basis for disputing the apparent violation; (2) the corrective steps that have been taken and the results achieved; (3) the corrective steps that will be taken; and (4) the date when full compliance will be achieved. Your response may reference or include previously docketed correspondence if the correspondence adequately addresses the required response. Additionally, your response should be sent to the NRCs Document Control Center, with a copy mailed to Regional Administrator, NRC Region I, 475 Allendale Road, Suite 102, King of Prussia, PA 19406, within 30 days of the date of this letter. If an adequate response is not received within the time specified or an extension of time has not been granted by the NRC, the NRC will proceed with its enforcement decision or schedule a PEC.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter will be made available electronically for public inspection in the NRC Public Document Room or from the NRCs document system (ADAMS), accessible from the NRC Website at http://www.nrc.gov/reading-rm/adams.html. However, the material enclosed herewith contains Security-Related Information as described above. Therefore, the material in the enclosure will not be made available electronically for public inspection in the NRC Public Document Room or from the NRCs document system (ADAMS). If you choose to respond and Security-Related Information is necessary to provide an acceptable response, please mark your entire response Security-Related Information in accordance with 10 CFR 2.390(d)(1) and follow the instructions for withholding in 10 CFR 2.390(b)(1). The NRC also includes significant enforcement actions on its Web site at http://www.nrc.gov/reading-rm/doc-collections/enforcement/actions/. If you have any questions concerning this matter, please contact Anne DeFrancisco of my staff at 610-337-5078 or Anne.DeFrancisco@nrc.gov.


If you choose to request a PEC, the conference will afford you the opportunity to provide your perspective on these matters and any other information that you believe the NRC should take into consideration before making an enforcement decision. The decision to hold a PEC does not mean that the NRC has determined that a violation has occurred or that enforcement action will be taken. This conference would be conducted to obtain information to assist the NRC in making an enforcement decision. The topics discussed during the conference may include information to determine whether a violation occurred, information to determine the significance of a violation, information related to the identification of a violation, and information related to any corrective actions taken or planned. In presenting your corrective action, you should be aware that the promptness and comprehensiveness of your actions will be considered in assessing any civil penalty for the apparent violations. The guidance in the enclosed excerpt from NRC Information Notice 96-28, Suggested Guidance Relating to Development and Implementation of Corrective Action, may be helpful.
Sincerely, Raymond Digitally signed by Raymond K. Lorson K. Lorson Date: 2023.01.24 11:01:04 -05'00'
 
Raymond K. Lorson Regional Administrator Docket No. 03001250 License No. 06-02388-01 Enclosures:
Please contact Ms. DeFrancisco at anne.defrancisco@nrc.gov within 10 days of the date of this letter to notify the NRC which of the above options you choose. If you do not contact the NRC within the time specified, and an extension of time has not been granted by the NRC, the NRC will proceed with its enforcement decision.
1. Summary of licensee response, assessment of violations and corrective actions (non-public)
 
2. Notice of Violation (non-public)
Please note that final NRC investigation documents, such as the OI report described above, may be made available to the public under the Freedom of Information Act (FOIA) subject to redaction of information appropriate under the FOIA. Requests under the FOIA should be made in accordance with Title 10 of the Code of Federal Regulations (10 CFR) 9.23, Requests for Records. Additional information is available on the NRC website at http://www.nrc.gov/reading-rm/foia/foia-privacy.html.
cc w/encl:
 
George Pavlonnis, Radiation Safety Officer State of Connecticut SUBJECT: NOTICE OF VIOLATION - THE HOSPITAL OF CENTRAL CONNECTICUT -
However, the material enclosed herewith contains Security-Related Information in accordance with 10 CFR 2.390(d)(1) and its disclosure to unauthorized individuals could present a security vulnerability. Therefore, the material in the enclosure will not be made available electronically for public inspection in the NRC Public Document Room or from the NRCs Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html. If Security Related Information is necessary to provide an acceptable response, please mark your entire response Security-Related Information in accordance with 10 CFR 2.390(d)(1) and follow the instructions for withholding in 10 CFR 2.390(b)(1). In accordance with 10 CFR 2.390(b)(1)(ii), the NRC is waiving the affidavit requirements for your response.]
NRC INSPECTION REPORT NO. 03001250/2021001: DATED January 24, 2023 DISTRIBUTION w/encl:
If you have any questions concerning this matter, please contact Anne DeFrancisco of my staff at anne.defrancisco@nrc.gov.
ADAMS SECY    RIDSSECYMAILCENTER OEMAIL OEWEB D Dorman, EDO  RIDSEDOMAILCENTER C Haney, DEDM D Pelton, OE  RIDSOEMAILCENTER T Martinez-Navedo, OE J Peralta, OE N Hasan, OE L Sreenivas, OE J Lubinski, NMSS  RIDSNMSSOD RESOURCE R Lewis, NMSS K Williams, NMSS M Burgess, NMSS Enforcement Coordinators RII, RIII, RIV (M Kowal; D Betancourt-Roldan; J Groom)
 
L Baer, OGC  RIDSOGCMAILCENTER T Steinfeldt, OGC H Harrington, OPA  RIDSOPAMAILCENTER R Feitel, OIG  RIDSOIGMAILCENTER D DAbate, OCFO  RIDSOCFOMAILCENTER R Lorson, RA  R1ORAMAIL RESOURCE D Collins, DRA  R1ORAMAIL RESOURCE B Welling, DRSS, RI  R1DRSSMAILRESOURCE T Bloomer, DRSS, RI A DeFrancisco, DRSS, RI R Elliott, DRSS, RI H Ahmed, DRSS, RI D Screnci, PAO-RI / N Sheehan, PAO-RI F Gaskins, SAO-RI/ L Hanson, SAO-RI B Klukan, ORA, RI R McKinley, ORA, RI ML23024A024 Public Non-Sensitive DOCUMENT NAME: S:\Enf-allg\Enforcement\Proposed-Actions\Region1\HOCC PUBLIC NOV EA-22-050_ML22314A103.docx X Non-Sensitive  X Publicly Available X SUNSI Review/ MMM Sensitive  Non-Publicly Available OFFICE RI/ORA RI/DRSS RI/ORA RI/ORA OE NAME M McLaughlin A DeFrancisco B Klukan NLO R McKinley L Sreenivas DATE 11/10/22 12/02/22 12/05/22 12/12/22 1/09/23 OFFICE     RI/DRSS RA NAME     B Welling R Lorson DATE     1/18/23 1/24/23 OFFICIAL RECORD COPY
Sincerely, Digitally signed by Blake Blake D. D. Welling Welling Date: 2022.09.15 16:06:58 -04'00'
Blake Welling, Director Division of Radiological Safety and Security Region I Docket No. 030-01250 License No. 06-02388-01 Enclosures:
1. Inspection Report No. 03001250/2021001 (non-public)
2. NRC Information Notice 96-28 cc w/Encl:
Mohammed Aljallad, Ph.D., RSO State of Connecticut ML22258A099 Cvr Ltr & Encl: Non-Publicly Available Sensitive A.3.
 
ADAMS ACCESSION NUMBER: ML22258A097 OFFICE RI:DRSS RI:DRSS RI:DRSS RI:ORA NAME SSeeley  RGallaghar ADeFrancisco MMcLaughlin DATE 9/9/22 9/1/22 8/31/22 8/31/22 OFFICE OE  RI:DRSS NAME LSreenivas  BWelling DATE 9/13 /22  9/15/22
}}
}}

Latest revision as of 15:28, 7 February 2023

Hospital of Central Connecticut NRC Inspection Report 03001250/2021001 and Notice of Violation
ML23024A024
Person / Time
Site: 03001250, 05000202
Issue date: 01/24/2023
From: Ray Lorson
Region 1 Administrator
To: Edwards J
Hospital of Central Connecticut
References
EA-22-050 IR 2021001
Download: ML23024A024 (4)
v • d • e


Text

January 24, 2023

SUBJECT:

NOTICE OF VIOLATION - THE HOSPITAL OF CENTRAL CONNECTICUT -

NRC INSPECTION REPORT NO. 03001250/2021001

Dear Jeanette Edwards:

This letter refers to the routine inspection conducted on March 5, 2021, with on-site inspection from March 21-23, 2021, and with continued in-office review through August 19, 2022, of activities performed under the U.S. Nuclear Regulatory Commission (NRC) license issued to the Hospital of Central Connecticut (HOCC). The purpose of the inspection was to examine the HOCCs licensed activities as they relate to radiation safety, compliance with the NRCs regulations, and the conditions in the license. Based on the results of the inspection, the NRC staff identified apparent violations (AVs) of NRC requirements. NRC staff discussed the AVs with you during a telephonic exit meeting on August 19, 2022, and described the AVs in the NRC inspection report sent to you in a letter dated September 15, 2022 (ML22258A099). 1 The inspection report, and the AVs described therein, concern Security-Related Information in accordance with 10 CFR 2.390(d)(1), and disclosure to unauthorized individuals could present a security vulnerability. Therefore, the inspection report enclosed with the September 15, 2022, letter was not publicly available, and details regarding the AVs were provided in a non-public enclosure.

In the letter transmitting the inspection report, we informed you that the AVs identified in the report were being considered for escalated enforcement action. In a telephone conversation on September 22, 2022, Anne DeFrancisco of my staff informed you that we had sufficient information regarding the AVs and your corrective actions to make an enforcement decision without the need for a pre-decisional enforcement conference or a written response from you.

Enclosure transmitted herewith contains Sensitive, Unclassified, Non-Safeguards Information. When separated from the Enclosure, the transmittal document is decontrolled.

Designation in parentheses refers to an Agency-wide Documents Access and Management System (ADAMS) accession number. Unless otherwise noted, documents referenced in this letter are publicly-available using the accession number in ADAMS. In a letter dated October 21, 2022 (ML22336A183; non-public), you provided a response to the AVs in which you provide further detail about the violations and the HOCCs corrective actions.

A summary of your response, the NRC staffs assessment of the AVs, and the actions taken by the HOCC to correct and prevent reoccurrence of these issues is provided in the non-public Enclosure 1.

Based on the information developed during the inspection, the NRC has determined that one or more violations of NRC requirements occurred and have been categorized in accordance with the NRC Enforcement Policy as Severity Level III (SL III) violations, which is escalated enforcement. The NRC Enforcement Policy can be found on the NRCs website at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html. The violations are cited in the Notice of Violation (Notice), provided as non-public Enclosure 2, and the circumstances surrounding them are described in detail in the subject inspection report.

In accordance with the NRC Enforcement Policy, a base civil penalty in the amount of $8,000 is considered for a SL III violation. Because your facility has not been the subject of escalated enforcement actions within the last two inspections, the NRC staff considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process in Section 2.3.4 of the Enforcement Policy. The NRC staff determined that the HOCC took prompt and comprehensive corrective actions, and credit is, therefore, warranted. Enclosure 2 (non-public) provides an explanation of the severity level determinations and a description of the HOCCs corrective actions to address the violations. Therefore, to encourage prompt and comprehensive correction of violations, and in recognition of the absence of previous escalated enforcement action, I have been authorized, after consultation with the Director, Office of Enforcement, not to propose a civil penalty in this case. However, significant violations in the future could result in a civil penalty. In addition, issuance of the SL III violations constitutes escalated enforcement action that may subject you to increased inspection effort.

The NRC has concluded that information regarding: (1) the reason for the violations; (2) the corrective actions that have been taken and the results achieved; and (3) the date when full compliance was achieved is already adequately addressed on the docket in Inspection Report No. 03001250/2021001, your letter dated October 21, 2022, and this letter. Therefore, you are not required to respond to this letter unless the description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to provide additional information, you should follow the instructions specified in the enclosed Notice.

Separately, in your October 21, 2022, letter, you identified an error in NRC Inspection Report No. 03001250/2021001. A corrected copy of the inspection report was provided to you with a letter dated January 23, 2023 (ML23023A111, ML23023A106; non-public).

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter will be made available electronically for public inspection in the NRC Public Document Room or from the NRCs document system (ADAMS), accessible from the NRC Website at http://www.nrc.gov/reading-rm/adams.html. However, the material enclosed herewith contains Security-Related Information as described above. Therefore, the material in the enclosure will not be made available electronically for public inspection in the NRC Public Document Room or from the NRCs document system (ADAMS). If you choose to respond and Security-Related Information is necessary to provide an acceptable response, please mark your entire response Security-Related Information in accordance with 10 CFR 2.390(d)(1) and follow the instructions for withholding in 10 CFR 2.390(b)(1). The NRC also includes significant enforcement actions on its Web site at http://www.nrc.gov/reading-rm/doc-collections/enforcement/actions/. If you have any questions concerning this matter, please contact Anne DeFrancisco of my staff at 610-337-5078 or Anne.DeFrancisco@nrc.gov.

Sincerely, Raymond Digitally signed by Raymond K. Lorson K. Lorson Date: 2023.01.24 11:01:04 -05'00'

Raymond K. Lorson Regional Administrator Docket No. 03001250 License No. 06-02388-01 Enclosures:

1. Summary of licensee response, assessment of violations and corrective actions (non-public)

2. Notice of Violation (non-public)

cc w/encl:

George Pavlonnis, Radiation Safety Officer State of Connecticut SUBJECT: NOTICE OF VIOLATION - THE HOSPITAL OF CENTRAL CONNECTICUT -

NRC INSPECTION REPORT NO. 03001250/2021001: DATED January 24, 2023 DISTRIBUTION w/encl:

ADAMS SECY RIDSSECYMAILCENTER OEMAIL OEWEB D Dorman, EDO RIDSEDOMAILCENTER C Haney, DEDM D Pelton, OE RIDSOEMAILCENTER T Martinez-Navedo, OE J Peralta, OE N Hasan, OE L Sreenivas, OE J Lubinski, NMSS RIDSNMSSOD RESOURCE R Lewis, NMSS K Williams, NMSS M Burgess, NMSS Enforcement Coordinators RII, RIII, RIV (M Kowal; D Betancourt-Roldan; J Groom)

L Baer, OGC RIDSOGCMAILCENTER T Steinfeldt, OGC H Harrington, OPA RIDSOPAMAILCENTER R Feitel, OIG RIDSOIGMAILCENTER D DAbate, OCFO RIDSOCFOMAILCENTER R Lorson, RA R1ORAMAIL RESOURCE D Collins, DRA R1ORAMAIL RESOURCE B Welling, DRSS, RI R1DRSSMAILRESOURCE T Bloomer, DRSS, RI A DeFrancisco, DRSS, RI R Elliott, DRSS, RI H Ahmed, DRSS, RI D Screnci, PAO-RI / N Sheehan, PAO-RI F Gaskins, SAO-RI/ L Hanson, SAO-RI B Klukan, ORA, RI R McKinley, ORA, RI ML23024A024 Public Non-Sensitive DOCUMENT NAME: S:\Enf-allg\Enforcement\Proposed-Actions\Region1\HOCC PUBLIC NOV EA-22-050_ML22314A103.docx X Non-Sensitive X Publicly Available X SUNSI Review/ MMM Sensitive Non-Publicly Available OFFICE RI/ORA RI/DRSS RI/ORA RI/ORA OE NAME M McLaughlin A DeFrancisco B Klukan NLO R McKinley L Sreenivas DATE 11/10/22 12/02/22 12/05/22 12/12/22 1/09/23 OFFICE RI/DRSS RA NAME B Welling R Lorson DATE 1/18/23 1/24/23 OFFICIAL RECORD COPY

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