ML18204A117
| ML18204A117 | |
| Person / Time | |
|---|---|
| Site: | 03008599 |
| Issue date: | 07/09/2018 |
| From: | Piskura D A NRC/RGN-III |
| To: | Cyriac G SSM Audrain Health Care, SSM Health St. Mary's Hospital-Audrain |
| References | |
| IR 2018001 | |
| Download: ML18204A117 (2) | |
Text
NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012) 10CFR2.201 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEE/LOCATION INSPECTED:
SSM Audrain Health Care, Inc, d/b/a SSM Health St. Mary's Hospital-Audrain 620 E. Monroe Street Mexico, MO 65265 REPORT NUMBER(S) 2018001 3. DOCKET NUMBER(S) 030-08599 LICENSEE:
- 2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER(S) 24-15122-01 Region III U. S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 5. DATE(S) OF INSPECTION July 9 , 2018 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 (NRG) 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.
D 2. Previous violation(s) closed. D 3. D 4. 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):
During this inspection, certain of your activities, as described below and/or attached, were in violation of NRG 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 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 NRG will be required, unless specifically requested.
TITLE PRINTED NAME SIGNATURE DA TE LICENSEE'S REPRESENTATIVE NRG INSPECTOR BRANCH CHIEF Deborah A. Piskura, Senior Health Physicist Aaron T. McCraw, Chief, :MIB NRC FORM 591M PART 1 (07-2012)
I I U.S. NUCLEAR REGULA TORY COMMISSION NRC FORM 591M PART 3 (07-2012) 10 CFR2.201 Docket File Information SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEE/LOCATION INSPECTED:
SSM Audrain Health Care, Inc, d/b/a SSM Health St. Mary's Hospital-Audrain 620 E. Monroe Street Mexico, MO 65265 REPORT NUMBER(S) 2018001 3. DOCKET NUMBER(S) 030-08599
- 6. INSPECTION PROCEDURES USED 87130 & 87131 2. NRC/REGIONAL OFFICE 4. LICENSE NUMBER(S) 24-15122-0 I Region III U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 5. DATE(S) OF INSPECTION July 9, 2018 7. INSPECTION FOCUS AREAS 03.01 -03.07 SUPPLEMENTAL INSPECTION INFORMATION
- 1. PROGRAM CODE(S) 02120 2. PRIORITY 3 [{] Main Office Inspection D Field Office Inspection D Temporary Job Site Inspection
- 3. LICENSEE CONTACT 4. TELEPHONE NUMBER George Cyriac, M.D., RSO (573) 582-8000 Next Inspection Date: July 9, 2021 --------------------
PROGRAM SCOPE This was routine inspection of a small hospital authorized to use licensed material permitted by IO CFR 35.100, 35.200, and 35.300. Nuclear medicine studies were performed as needed, with the workload decreasing from previous years. The nuclear medicine department was staffed with one technologist, supported by a PRN, who performed approximately 20-30 diagnostic procedures per month (these numbers were trending down). The licensee received unit doses only; the department administered a full spectrum of diagnostic studies. The hospital administered 1-2 I-131 dosages (capsules only) for hyperthyroid treatments annually.
The licensee had not administered beta-emitting radiopharmaceuticals since the previous inspection.
All patients were released in accordance with 10 CFR 35.75. The licensee retained a consultant who audited the radiation safety program on a quarterly basis (last 4/3/2018, with no findings).
This inspection consisted of interviews with licensee personnel, a review of select records, a tour of the nuclear medicine department, and independent measurements.
All patient studies were completed at the time of the inspector's arrival therefore, the inspector could not observe any patient studies. The inspector observed licensee personnel perform dose calibrator QA tests, inventory of sealed sources, security of byproduct material, and use of personnel monitoring.
No violations ofNRC requirements were identified during this inspection.
NRC FORM 591M PART 3 (07-2012)