ML18220A823
| ML18220A823 | |
| Person / Time | |
|---|---|
| Site: | 03001580 |
| Issue date: | 07/24/2018 |
| From: | Nieves Folch L A NRC/RGN-III |
| To: | Sutkowski J P Deaconess Hosp, Midwest Radiologic Imaging |
| References | |
| IR 2018001 | |
| Download: ML18220A823 (3) | |
Text
NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012) 10CFR 2 , 201 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEE/LOCATION INSPECTED:
Deaconess Hospital c/o Midwest Radiologic Imaging 4087 Gateway Blvd. Newburgh, IN 47630 REPORT NUMBER(S) 2018001 3. DOCKET NUMBER(S) 030-01580 LICENSEE:
- 2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER(S) 13-00142-02 Region III U. S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 5. DATE(S) OF INSPECTION July 24, 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 (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. D 2. D 3. D 4. Based on the inspection findings, no violations were identified.
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 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 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 NRCINSPECTOR BRANCH CHIEF Luis Nieves Folch Aaron T. Mccraw NRC FORM 591M PART 1 (07-2012)
/ ~V-V NRC FORM 591M PART 3 (07-2012) 10 CFR2.201 U.S. NUCLEAR REGULATORY COMMISSION Docket File Information SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION
- 1. LICENSEE/LOCATION INSPECTED:
Deaconess Hospital c/o Midwest Radiologic Imaging 4087 Gateway Blvd. Newburgh, IN 47630 REPORT NUMBER(S) 2018001 3. DOCKET NUMBER(S) 030-01580
- 6. INSPECTION PROCEDURES USED 87130,87131, 87132 2. NRG/REGIONAL OFFICE 4. LICENSE NUMBER(S) 13-00142-02 Region Ill U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
- 5. DATE(S) OF INSPECTION July 24, 2018 7. INSPECTION FOCUS AREAS 03.01-03.08 SUPPLEMENTAL INSPECTION INFORMATION
- 1. PROGRAM CODE(S) 02230 2. PRIORITY 3. LICENSEE CONTACT 4. TELEPHONE NUMBER 2 John P. Sutkowski, RSO D Main Office Inspection Next Inspection Date: [l] Field Office Inspection 600 Mary Street, 4087 Gateway Boulevard, D Temporary Job Site Inspection 4055 Gateway Boulevard July 24, 2020 --------------------
PROGRAM SCOPE (812) 858-3051 This was an unannounced, routine inspection of a large hospital authorized by its NRC license to use unsealed byproduct material for diagnostic and therapeutic procedures under 10 CFR 35.100, 35.200, 35.300, and 35.600 as well as a blood irradiator.
The nuclear medicine department at 600 Mary Street was staffed with four full-time nuclear medicine technologists (NMT) who performed approximately 50 diagnostic nuclear medicine procedures weekly, primarily Hida, bone scan, thyroid, gastric emptying, heart studies, and approximately four 1-131 hyperthyroidis treatments per year. At the 4087 Gateway Boulevard the nuclear medicine department was staff with two NMT who performed approximately 40 diagnostic procedures similar to the ones performed at the Mary Street location but also including PET. At the 4055 Gateway Boulevard the licensee conducted approximately ten high dose-rate brachytherapy (HOR) patient treatments per week. The majority of treatments conducted were for gynecological and some skin legions. PERFORMANCE OBSERVATIONS The inspector toured the nuclear medicine laboratory and observed the nuclear medicine technologist demonstrate package receipt surveys and instrument quality control checks. The inspector observed the preparation and administration of one heart rest study, and one HOR treatment.
The inspector performed independent surveys of the hot lab and other areas of the nuclear medicine department and found no contamination or exposures to members of the public distinguishable from background.
The nuclear medicine technologist demonstrated adequate knowledge of radiation safety principles and practices through interviews.
The inspector reviewed quarterly audit reports, spill reports, and documentation of package receipt, area surveys, instrument quality control, waste disposal, and employee training.
The inspector also reviewed monthly dosimetry reports which indicated annual whole-body and extremity doses below regulatory limits. At the 4055 location the inspector had the AMP and therapist demonstrate the HOR unit's security of licensed material, daily spot check, emergency equipment and procedures,safety procedures and instructions, door interlock system, and radiation monitoring equipment.
The inspector reviewed ten HOR written directives and treatment plans, with no issues noted. No violations ofNRC requirements were identified as a result of this inspection.
NRC FORM 591M PART 3 (07-2012)
Nieves Folch, Luis From: Sent: To:
Subject:
Attachments:
Dear Mrs. Brumley,
Nieves Felch, Luis Tuesday, August 07, 2018 10:16 AM 'Susan Brumley' NRC Clear 591M SKM_C45818080711120.pdf Attach is the clear 591 report for the inspection conducted on July 24, 2018. 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 NRC's "Rules of Practice," a copy of this message will be available electronically for public inspection in the NRC's Public Document Room or from the NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC's website at http://www.nrc.gov/
reading-rm/ad a ms. htm I. 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 1