IR 07200201/1990001
| ML19219B042 | |
| Person / Time | |
|---|---|
| Site: | 07200201, 03031172 |
| Issue date: | 07/15/2019 |
| From: | O'Dowd D NRC/RGN-III |
| To: | Breeden W Union Hospital |
| References | |
| IR 2019001 | |
| Download: ML19219B042 (3) | |
Text
NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012)
1 ocFR2.20 1 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION 1. LICENSEE/LOCATION INSPECTED:
Union Hospital, Inc. 1606 N. 7th St. Terre Haute, IN 47804 REPORT NUMBER(S)
2019001 3. DOCKET NUMBER(S)
030-11072 LICENSEE:
2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER(S)
13-16457-01 Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352 5. DATE(S)OF INSPECTION JS-July J ID, 2019 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 inspecto The inspection findings are as follows: 1. D 2. D 3. D 4. Based on the inspection findings, no violations were identifie Previous violation(s)
closed. 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 satisfie Non-cited violation(s)
were discussed involving the following requirement(s):
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 identifie 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 requeste TITLE PRINTED NAME SIGNATURE DA TE LICENSEE'S REPRESENTATIVE NRC INSPECTOR Dennis P. O'Dowd BRANCH CHIEF Aaron T. Mccraw NRC FORM 591M PART 1 (07-2012)
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NRC FORM 591M PART 3 (07-2012)
10 CFR2.201 U.S. NUCLEAR REGULA TORY COMMISSION Docket File Information SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION 1. LICENSEE/LOCATION INSPECTED:
Union Hospital, Inc. 1606 N. 7th St. Terre Haute, IN 47804 REPORT NUMBER(S)
2019001 3. DOCKET NUMBER($)
030-11072 6. INSPECTION PROCEDURES USED 87130, 87131, & 87132 2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER($)
13-16457-01 Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite210 Lisle, IL 60532-4352 5. DATE(S) OF INSPECTION July 15-16, 2019 7. INSPECTION FOCUS AREAS 03.01-03.09 SUPPLEMENTAL INSPECTION INFORMATION 1. PROGRAM CODE(S) 02200 2. PRIORITY 3 [l] Main Office Inspection 3. LICENSEE CONTACT 4. TELEPHONE NUMBER William K. Breeden, III, MS, DABR (765) 447-7447 Next Inspection Date: 07/15/2022
[l] Field Office Inspection 1711 N_ 6 1/2 St., Terre Haute, and D Temporary Job Site Inspection 801 S. Main St. Clinton, IN ---------------------
PROGRAM SCOPE This was a routine inspection of a large medical institution (350+ beds) authorized to use licensed material permitted by 10 CFR 35.100, 35-200 (including PET), 35.300, 35.400, and 35.500. The licensee was authorized for three areas of use for its nuclear medicine activities; however, only two of these areas, both on the main campus, were currently active, as the Clinton, IN location was temporarily without nuclear medicine staff. Collectively, the nuclear medicine department was staffed with four full-time technologists who performed approximately 300-350 diagnostic procedures monthly. The licensee received unit doses and bulk Tc-99m for kit preparation; the licensee administered a full spectrum of diagnostic studies. The department also administered occasional 1-131 dosages (capsules only) for whole body follow-up studies, hyperthyroid, and CA treatment The department also administered 2-3 Ra-223 Xofigo treatments annuall The nuclear cardiology department recently was authorized for cardiac PET using of a Sr-82/Ru-82 generator, with receipt and initial utilization expected within the next two to three months. The radiation oncology department was staffed with two medical physicists, two dosimetrists, and three authorized physician users. The licensee used Cs-137 to administer approximately 10-12 temporary implants per year; these treatments were limited to gynecological and lung cancers. The licensee administered 1-2 1-125 permanent prostate implants annuall Performance Observations The inspection consisted of tours of the nuclear medicine and radiation oncology departments, interviews with licensee personnel, a review of select records, and independent measurement All radioactive material was properly secured from unauthorized access and not readily accessible to members of the general public. The inspector verified that the nuclear medicine hot lab at the Clinton, Indiana location was locked and secured. The inspector observed licensee personnel perform and/or demonstrate dose calibrator QA tests, surveys, source inventories, security of byproduct material and use of personnel monitorin The inspector observed the licensee staff administer several diagnostic nuclear medicine and PET doses. These observations, combined with interviews with available staff, revealed an adequate level of understanding of emergency and material handling procedures and technique No therapeutic procedures were conducted at the time of the inspectio The inspector reviewed written directives for all therapeutic uses, licensee (cont'd on next page) NRG FORM 591 M PART 3 (07-2012)
NRC FORM 591M PART 3 (07-2012)
10 CFR 2.201 U.S. NUCLEAR REGULATORY COMMISSION Docket File Information SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION 1. LICENSEE/LOCATION INSPECTED:
Union Hospital, Inc. 1606 N. 7th St. Terre Haute, IN 4 7804 REPORT NUMBER(S)
2019001 3. DOCKET NUMBER($)
030-11072 6. INSPECTION PROCEDURES USED 87130, 87131, & 87132 2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER($}
13-16457-01 Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352 5. DATE(S) OF INSPECTION July 15-16, 2019 7. INSPECTION FOCUS AREAS 03.01-03.09 SUPPLEMENTAL INSPECTION INFORMATION 1. PROGRAM CODE(S) 02200 2. PRIORITY 3. LICENSEE CONTACT 4. TELEPHONE NUMBER 3 William K. Breeden, III, MS, DABR (765) 447-7447 [ZJ Main Office Inspection Next Inspection Date: [ZJ Field Office Inspection 1711 N. 6 1/2 St., Terre Haute, and D Temporary Job Site Inspection 801 S. Main St. Clinton, IN PROGRAM SCOPE (cont'd from previous page) 07/15/2022 calculations for compliance with patient release requirements, and other pertinent records relative to therapeutic uses, including those for permanent and temporary implant cases, with no issues noted. Review of licensee dosimetry and survey record& indicated no concerns with exposures to radiation workers or general public. The inspector performed independent and confirmatory radiation measurements which indicated results consistent with licensee survey records and posting No violations ofNRC requirements were identified during this inspectio NRC FORM 591M PART 3 (07-2012}