IR 015000202/2010001
| ML21239A247 | |
| Person / Time | |
|---|---|
| Site: | 015000202, 03035150 |
| Issue date: | 08/18/2021 |
| From: | Folch L NRC/RGN-III |
| To: | Plankey L Northwest Health - Porter |
| References | |
| IR 2021001 | |
| Download: ML21239A247 (3) | |
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