On October 21, 2009, the NRC issued a Notice of Violation to Virtua Health System - West Jersey Hospital (Virtua) for a Severity Level III violation involving the failure to develop, implement, and maintain written procedures to provide high confidence that each administration is in accordance with the written directive, as required by 10 CFR 35.41(a)(2). Specifically, during patient setup on January 19, 2009, Virtua staff raised questions concerning the visualization and positioning of seeds in the prostate and there were no procedures to ensure resolution of the questions. As a result, all seeds were implanted outside the prostate.