ML18229A251
| ML18229A251 | |
| Person / Time | |
|---|---|
| Site: | 03011427 |
| Issue date: | 07/13/2018 |
| From: | Craffey R J NRC/RGN-III |
| To: | Conn D J Beaumont Hospital - Trenton |
| References | |
| IR 2018001 | |
| Download: ML18229A251 (2) | |
Text
NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012) 10 CFR 2.2 o1 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEE/LOCATION INSPECTED.
Beaumont Hospital Trenton 5450 Fort Street Trenton, MI 48183 REPORTNUMBER(S) 2018001 2. NRC/REGIONAL OFFICE Region III U. S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 3. DOCKET NUMBER(S) 030-11427
- 4. LICENSE NUMBER(S)
- 5. DATE(S) OF INSPECTION 21-16656-01 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 lnspectQr.
The inspection findings are as follows: [3' 1. Based on the ii:ispection findings, no violations were identified.
- 2. Previous vlolatlon(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 fonn is a NOTICE OF VIOLATION, which may be subject to posting In accordance with 10CFR 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 BRANCH CHIEF Ryan Craffey Aaron McCraw NRC FORM 591M PART 1 107-2012) -v_, ("'_J _ .. .. -. -I ~/z/J(,.
NRC FORM 591M PART 3 (07-2012) 10CFR2.201 U.S. NUCLEAR REGULATORY COMMISSION Docket File Information SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION 1 LICENSEE/LOCATION INSPECTED:
Beaumont Hospital Trenton 5450 Fort Street Trenton, MI 48183 REPORT NUMBER($)
2018001 3. DOCKET NUMBER($)
030-11427
- 6. INSPECTION PROCEDURES USED 87131 2. NRCIREGIONAL OFFICE Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 4. LICENSE NUMBER($)
21-16656-0]
- 7. INSPECTION FOCUS AREAS All 5. DATE(S) OF INSPECTION July 13, 2018 SUPPLEMENTAL INSPECTION INFORMATION
- 1. PROGRAM CODE(S) 02120 2. PRIORITY 3 1./ 1 Main Office Inspection . I Field Office Inspection D Temporary Job Site Inspection
- 3. LICENSEE CONTACT Donald Conn, MD -RSO Next Inspection Date: PROGRAM SCOPE 4. TELEPHONE NUMBER (313) 593-7295 07/13/2021 This was an unannounced routine inspection of a community hospital in Trenton, Michigan, authorized to use byproduct material for diagnostic and therapeutic medical purposes.
At the time of the inspection, two full-time and three part-time nuclear medicine technologists performed around 10 diagnostic administrations per day, seven days a week, using unit and bulk doses from a local radiopharmacy.
The licensee has not performed any therapeutic administrations since before the last inspection.
The licensee retained the services of a medical physics consultant to perform instrument calibrations and to review the content and implementation of the program quarterly.
PERFORMANCE OBSERVATIONS The inspector toured the facility in Trenton to evaluate the licensee's measures for materials security, hazard communication, and exposure control. The inspector conducted independent surveys throughout the facility, and found no evidence of residual contamination nor any exposures to members of the public above background in unrestricted areas. The inspector observed the preparation and administration of numerous diagnostic administrations, as well as a selection of activities conducted by the licensee's consultant as part of her quarterly audit. The inspector interviewed the licensee's staff, including management and the consultant, to discuss procedures the safe use of licensed material, emergency response measures, and oversight of the radiation safety program. Through these observations and interviews, the inspector found the licensee's staff to be knowledgeable ofradiation protection principles, licensee procedures, and regulatory requirements.
The inspector also reviewed a selection ofrecords, including quarterly program audits, hazmat refresher training, routine survey records, and personnel dosimetry reports, which indicated that exposures to staff were well below regulatory limits for occupational exposure.
No violations ofNRC requirements were identified as a result of this inspection.
NRC FORM 691 M PART 3 (07-2012)