WIXLIB

-EIRMCEASTERN IDAHOREGIONAL MEDICAL CENTER030-32290/2020-001; EA-21-019proper dosimeter use and not being aware of, or accounting for, occupational radiation dosesreceived by Individuals at other facilities.(2) Corrective Steps That Have Been Taken and the Results Achieved: Made request for AUl dosimetry reports from outside facilities. AUl Is badged at oneadditional facility outside of EIRMC. Report was obtained; data is incomplete.Estimated dose for CY 2016-2020 for AU1 has been completed by Adam Arndt, acontracted medical physicist. Complete dose estimate is included with this submission(see Appendix S).Dosimetry badge return rates are monitored by Directors in radiation areas; theRadiation Safety Officer exchanges returned badges for new monthly/quarterly badges.{3) Corrective Steps That Will Be Taken: In the process of moving all badged participants to a monthly cycle for dosimeters."Request for Radiation Dose History'' form will be completed by department directorsfor respective physician groups.Dose reports for concurrent employment will be reviewed by the Radiation SafetyCoordinator, the contracted medical physicist and/or the RSO.The RSO will determine if action is warranted when investigation levels are exceeded.This will be a line item in Radiation Safety Committee meetings and the RSO will sign offquarterly.Beginning In 2022, "Request for Radiation Dose History'' form will be included in annualphysician credentialing packets for those physicians working in radiation areas.(4) Date When full Compliance Will Be Achieved: Full compliance will be achieved by 8/31/21, to coincide with the Radiation Safetytraining requirements.Apparent Violation 030-32290/2020-001-04 Failure to provide instruction to occupationallyexposed individuals (10 CFR 19.12(alf3)):(1) Reason for the Apparent Violation:The licensee's radiation safety training did not include any topics related to provisions orinstructions regarding the proper use of personnel dosimeters. Additionally, the licensee wasunable to provide any records indicating that AU1 had participated in the licensee's personnel6

-EIRMCEASTERN IDAHOREGIONAL MEDICAL CENTER030-32290/2020-001; EA-21-019radiation safety training program or received relevant education in maintaining doses ALARAand managing occupational exposure. It appeared that as part of an independent radiologygroup, AUl was inadvertently not included in the licensee's radiation safety training programand therefore did not receive any initial or refresher radiation safety training from the licenseeor any specific instruction regarding the proper use of dosimeters.(2) Corrective Steps That Have Been Taken and the Results Achieved: Revised policy "Guidelines for Radiation Safety, Ref #1425, Ver. 9" was approved byJeffrey Sollis, CEO on December 3, 2020. Revisions include proper wear and use ofdosimetry badges, education on dosimetry badges, and information in regards toLandauer and the report system, ALARA limits, grounds for investigation, expectationsof the investigation and RSO duties if ALARA limits are exceeded.Revised participant TLD EIRMC Badge Request Form to include education on dosimeterwear and use with staff signature stating proper education and Instruction did occur.Revised Investigation Form to identify when dosimeters are unused, not returned orhave inappropriate exposure levels.(3) Corrective Steps That Will Be Taken: Initial and annual Radiation Safety Training course for all physicians performing licensedand unlicensed radiation procedures.(4) Date When Full Compliance Will Be Achieved: Revised EIRMC TLO Badge Request Form with education and instruction is in use. EIRMCis fully compliant.Initial and annual Radiation Safety Training course for all physicians performing licensedand unlicensed radiation procedures. Full compliance for radiation safety training will beachieved by August 31, 2021.7

Appendix 1Guidelines for Radiation Safety, Ref# 1425, Ver: 9

Document Owner: Kade Price (Dir Dia nostlc Imaging)Manual: Medical Imaging Medical ImagingRef#: 142S Ver: 9Date Approved: 05/17/2021Next Review: 1/23/2024Approved: Kade Price (Dir Diagnostic Imaging)Page: 1 of4Title: Guidelines for Radiation SafetyI.RADIATION SAFETY RULESLead aprons should be worn during all fluoroscopic examinations. Whenever it becomes necessaryfor a technologist to hold a patient during x-ray exposure, lead gloves and lead aprons should beworn. Lead Aprons/Thyroid Shield integrity is done through proper QC procedures performedannually. QC ls performed on all new aprons.During an x-ray exposure the door to the hall must be closed to eliminate the possibility of exposureto any passerby as well as for privacy. The technologist should remain within the shielded area of thecontrol panel while making an exposure.When performing portable x-ray procedures, a lead apron should be worn by the technologist. Thetechnologist must also remove him/herself as far as possible from the source of the radiation. Prior tothe exposure, the technologists will inform those present in the room, and allow time for those notrequired to remain in the room during the exposure to either leave or increase their distance andlocation from the radiation source. Lead aprons should be worn if remaining in the room during theexposureAnyone accompanying a patient to a room where ionizing radiations are used, a lead apron will beworn or the individual will stand behind the shielded area. This applies to any accompanying personsor assisting personnel.Cancer Center - The patient is the only one allowed in the treatment vault during treatment.Nuclear Medicine - Those accompanying the patient will be discouraged from remaining in theNuclear Medicine rooms during image acquisition to decrease potential exposure. Those who wish toremain in the Nuclear Medicine rooms during Imaging acquisition will be instructed on how to reducepotential exposure.Coning to film size or less will be carried out on every exposure; this includes portable procedures.Proper gonadal shielding is required for all patients where it is reasonable to do so.All patients who are not responsible for their actions are not to be left alone in the x-ray rooms orwaiting areas. Should any incident occur either to the patient, personnel or visitor, an occurrencereport should be documented by the individual who discovered the incident. The Radiation SafetyOfficer (RSO) and department director are also to be informed of the incident immediately.Should any malfunction of equipment occur either electrically or mechanically, use of that room isdiscontinued until repaired by maintenance or service vendor. Ali weights and counterbalance cablesare checked periodically by service vendor for wear and replaced as needed. In case of electricalproblem. the machine is turned off.Technologists must report to supervising technologist any notice of wear, malfunction or irregularity inequipment.In case of fire, a carbon dioxide extinguisher is located in several locations for quick access from anyequipment area, and the fire alarm given according to the hospital fire rules.

Title: Guidelines for Radiation SafetyDocument Owner: Kade Price (Dir Diagnostic Imaging)Manual: Medical Imaging Medical ImagingRef#: 1425 Ver: 9Date Approved: 0S/17/2021Next Review: 1/23/2024Approved: Kade Price (Dir Diagnostic Imaging)Page: 2 of4Should any employee become pregnant who works where routine ionizing radiation is used, theRadiation Safety Coordinator (RSC) will be notified by the employee and the policy Gujde!ines onPregnant Females Wor1 ing in Medical Imaging will be observed.All female patients of reproductive age (12YO- 50YO) are to complete and sign the Pre-ExaminationPregnancy Determination form prior to any exam. The age range is from menses to menopause. Ifthe question arises to the possibility of pregnancy, or it has been more than 10 days since thepatient's last period, a radiologist will be consulted prior to the examination being done. The PreExamination Pregnancy Determination form will be sent to HIM and Is part of the permanent medicalrecord.II. DOSIMETRY BADGESAll personnel having direct contact with patients who have been injected with a radioisotope or whoconduct the duties and functions of their job in areas of radiation exposure will be required to wear aradiation dosimetry badge while on duty. This includes technologists, radiologists, physicians,contract workers, and all staff that assist in radiological procedures or procedures where radiationexposure occurs. Dosimetry badges for monitoring of radiation exposures are provided for personnelin medical imaging, interventional radiology, the cancer center, cardiology, biomedical services, theOR, endoscopy and others as requested.Education on proper dosimeter badge wear-and-handling will be given to all participants upon hire.Every effort will be made to determine occupational dose by requesting exposure reports from prior orconcurrent employer.Facility radiation film badges will be monitored monthly by Landauer, Inc. Dosimetry badges will becollected at the end of each month with replacement badges available. It is the responsibility of thestaff member or physician to switch out their film badges at the time of collection. Monthly andquarterly reports will be available to all monitored staff.Whole body dosimeters (that is, when one dosimeter is worn) must be worn on the portion of the bodywhich is likely to receive the highest dose. If a lead apron is worn, the dosimeter should be wornoutside the lead apron at the collar or neck.If two dosimeters are worn at the same time (e.g. one at the collar and one at the chest or waist underthe lead apron), care must be taken to always wear the dosimeters in their correct locations. That is,the "collar" badge must always be wom at the collar and the "waist badge must always be worn atthe waist. Verify the date of use and badge-type designation when inserting into the plastic coloredholders.If a worker wears a lead apron and a thyroid shield, the badge is worn outside the apron and theshield and the dose is an "eye dose". If a wor1 er wears a lead apron, thyroid shield and lead glasses,then the dosimeter is wom under the lead apron or thyroid shield.A second dosimetry badge will be provided to technologists wor1 ing In the interventional suite due topotential risk of receiving higher doses. The second badge is to be worn at the collar, underneath thethyroid shield. The holder is to be clipped at the proper location with printed side out.

Arutoo WMEDICAL CENTERTitle: Guidelines for Radiation SafetvDocument Owner: Kade Price (Dir Diagnostic lmagln1dManual: Medical Imaging Medical ImagingRef#: 1425 Ver: 9Approved: Kade Price (Dir Diagnostic Imaging)Page: 3 of 4Date Aooroved: 05/17/2021Next Review: 1/23/2024Ring badges are provided for all technologists performing nuclear medicine examinations.All reports are reviewed by the RSO or designee monthly and reported to the Radiation SafetyCommittee quarterly. Reports are maintained in the Nuclear Medicine department. Any unusually highreadings will be investigated immediately by the RSO or designee. Additionally, minimal dosesreported for those working in areas requiring two dosimeters will be investigated.If exposure readings continue to fall out of compliance, specifically those above ALARA Action Level2, the participant will be removed from all fluoroscopic and portable procedures for a time periodrecommended by the RSO. Additional training in radiation safety will be given by the RSO ordesignee and documented prior to their returning to full scope duties.The hospital operates under the ALARA program, and receives monthly and quarterly reports fromthe dosimetry badge company alerting us of any unusual readings.ALARA LIMITS - PERSONNEL DOSIMETRY(mrem I calendar quarter)Badge / Body PartActionLevel1ActionLevel2LimitsWhole Body (ODE)12515005000375500015,00050,000Lens of Eye (LOE)Extremities I Skin (SOE)450015,000Ill. LOST OR DAMAGED DOSIMETRY BADGES OR RINGS In the event of a lost or damaged dosimetry badge or ring dosimeter, the participant willreport it to the RSO or designee. All lost or damaged dosimetry badges will be discussed in Radiation Safety Committee. Adetermination will be made to pursue further investigation and/or further actions. The RSO or designee will average the amount of radiation received by the individual for theprevious 12 months. This average will then be submitted to Landauer, Inc. This informationwill be used by Landauer to update the individual's exposure record.

Arumo wMEDICAi. CENTERTitle: Guidelines for Radiation SafetyDocument Owner: Kade Price (Dir Diagnostic Imaging)Manual: Medical Imaging Medical ImagingRef#: 1425 Ver: 9Date Aooroved: 05/17/2021Next Review: 1/23/2024Approved: Kade Price (Dir Diagnostic Imaging)Page: 4 of 4IV. RADIATION SAFETY OFFICERTO: ALL EMPLOYEESSUBJECT: DELEGATION OF AUTHORITYJames Edlin M.D. has been appointed as the Radiation Safety Officer (RSO) and is responsible forensuring the safe use of radiation. The RSO is responsible for managing the radiation safety program:Identifying radiation safety problems; initiating, recommending or providing corrective actions; verifyingimplementation of corrective actions; and ensuring compliance with regulations. The RSO is herebydelegated the authority necessary to meet those responsibilities.The RSO is also responsible for chairing the Radiation Safety Committee and assisting in theperformance of its duties.IV. PHYSICIST SUPPORTAn offsite Radiation Physicist, (Health Physics Northwest), provides the Main Campus and Women'sImaging Center with all physicist support activities. The Cancer Center contracts with Mountain StatesMedical Physics for physicist support. Radiation Safety surveys of all Imaging equipment is performedannually.The Physicist is available for calculating radiation doses for given exams upon request, providing inservices on radiation and general assistance as needed.Reference:EQUIPMENT CALIBRATIONS/PREVENTATIVE MAINTENANCEHazardous Materials & Waste Management Plan C3QO Series)

Appendlx2TLD Badge Request Form (Revised)

f.lRMCTLD Badge Request FormEMPLOYEE INFORMATIONName (Last, first}DateDate of BirthDepartmentAre you currently monitored for radiation at another Facility? YesNoHave you previously been monitored for radiation exposure at another lnstlMlon? YesNoIf yes to ether question please complete the exposure hls1ory Information below:Institution Name and AddresslnsHtutlon Name and AddressiDates of EmploymentOates of EmploymentDosimeter LocationDChest (Radiology, CT, US, Cancer Center. OR. Endo. Women's Imaging)DCollar & Waist (Angie, Cardiology. MDs)D Chest & Ring {Nuclear Medicine)D Fetal Badge, Due Date:(Review Policy: Guidelines for Pregnant females Working In MedicalImaging. Ref#: 1424 V.5 Return signed copy to Radiation safety coordinator)I certify that the above information is correct ond complete to the best of my knowledge. I hereby authorize the releose ofmy exposure data to EIRMC. I certify that I have been instructed on the proper wear and use of TLD's.SignatureTLD Ordered By {Name)DoteDate

Appendlx3Investigation Form (Revised)

-EIRMCRADIATION DOSIMETRY INVESTIGATIONName.Date of InvestigationDepartment.Participant NumberDosimeter ReadingMonitor PeriodThis letter is to inform you that you have;DExceeded the ALARA II investigation threshold0Retuned an unused badgeDReturned a badge with minimal exposureBody Part ExposedWhole BodyLens of the EyeExtremitiesAtARA Level II Umlt375 mrem/quarter1125 mrem/quarter3750 mrem/quarterBecause you have returned a TLD Badge that:1. Exceeds the above listed ALARA limits2. Was unused for the listed monitor period3. Has minimal exposure readingsYou must complete and submit the attached questionnaire to the RSO or Medical Imaging Director. This hasbeen noted by the Radiation Safety Officer as required and will be available for outside agency inspections ifrequested. A signature from your department director is required prior to submission to the RSO or Directorof medical Imaging.For ALARA level ti exposures please complete the following;Was the dosimeter placed or stored near radiation?YesNoDid you accidently expose yourself to a beam of radiation?YesNoDid you work significantly more hours or complete moreProcedures during this period?YesNo-- YesNoWere you Involved in procedures requiring unusually high exposure to radiation?YesNoWere you wearing leaded eyewear during your radiation exposure?YesNoWere you wearing a lead apron during your radiation exposure?YesNoDid you perform different work duties which might have increased your exposure?Date reviewed

-EIRMCRADIATION DOSIMETRY INVESTIGATIONPlease describe any unusual incident or provide any additional information that will help explainYour high dose:For return of an unused no badge please complete the following;Please explain why you did not wear your TLD Badge during the noted monitor period :For return of a TLD badge with minimal exposure please complete the following;Please explain why you returned TLD Badge with minimal exposure for the noted monitor period:Print NameDateSignatureDepartment Director SignatureDate reviewedRSO Signature

Appendlx4Request for Radiation Dose History (New)

t lRMCRequest for Radiation Dose :City:State:Zip Code:Attn: Radiation Safety OfficerTo Whom It May Concern:In accordance with state and federal regulations to "Determine Prior Occupational Dose" I amRequesting the occupational radiation dose (current year and lifetime) for the following individual:Name:Date of Birth:SSN:-----------------Radiation Dose for Current Year:Badge Type:Beginning Date: Ending Date: Total mrem:----A copy of this individuals NRC Form S (or equivalent) will be acceptableLifetime Dose:Total Effective Dose Equivalent: Total mrem:------Please send the requested information to:EIRMCMedical Imaging3100 Channing WayIdaho Falls, ID 83404I hereby authorize and request that any person/employer having knowledge of my occupa

inspection, November 2020, AUl was wearing a June 2020 dosimetry badge. Furthermore, inspection revealed that AU1 has not been wearing the dosimetry badge as prescribed by . Landauer and EIRMC policy and procedure. AUl is currently listed on the NRC license as an authorized user of Yttrium-90 (Y90). AUl performs licensed and unlicensed .