February 6, 2008 

David R. Gifford, M.D. 

Director 

Department of Health 

3 Capitol Hill, Room 206 

Providence, RI 02908 

Dear Dr. Gifford: 

On January 15, 2008, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Rhode Island 

Agreement State Program. The MRB found the Rhode Island Agreement State Program 

adequate to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s program. 

Section 5.0, page 10, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. We request your evaluation and response to the 

recommendations within 30 days from receipt of this letter. 

Based on the results of the current IMPEP review, the next full review of the Rhode Island 

Agreement State Program will take place in approximately 4 years, with a periodic meeting 

tentatively scheduled for October 2009. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. 

I also wish to acknowledge your continued support for the Agreement State Program. I look 

forward to our agencies continuing to work cooperatively in the future. 

Sincerely, 

 /RA/ 

Martin J. Virgilio 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Rhode Island Final IMPEP Report 

cc w/enclosure: 

John Ferruolo, Supervisor 

Rhode Island Radioactive Materials 

 and X-Ray Programs 

Thomas Conley, Kansas 

Organization of Agreement States 

 Liaison to the MRB
February 6, 2008 

David R. Gifford, M.D. 

Director 

Department of Health 

3 Capitol Hill, Room 206 

Providence, RI 02908 

Dear Dr. Gifford: 

On January 15, 2008, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Rhode Island 

Agreement State Program. The MRB found the Rhode Island Agreement State Program 

adequate to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s program. 

Section 5.0, page 10, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. We request your evaluation and response to the 

recommendations within 30 days from receipt of this letter. 

Based on the results of the current IMPEP review, the next full review of the Rhode Island 

Agreement State Program will take place in approximately 4 years, with a periodic meeting 

tentatively scheduled for October 2009. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. 

I also wish to acknowledge your continued support for the Agreement State Program. I look 

forward to our agencies continuing to work cooperatively in the future. 

Sincerely, 

 /RA/ 

Martin J. Virgilio 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Rhode Island Final IMPEP Report 

cc w/enclosure: 

John Ferruolo, Supervisor 

Rhode Island Radioactive Materials 

 and X-Ray Programs 

Thomas Conley, Kansas 

Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: EDATS: FSME-2008-0004 

See next page. 

 ML080230238 EDATS: FSME-2008-0004 

OFFICE FSME/DMSSA FSME/DMSSA FSME/DMSSA Tech Editor 

NAME ATMcCraw:kk ADWhite RJLewis CPoland 

DATE 1/22/08 1/23/08 1/24/08 1/25/08 

OFFICE FSME DEDMRT 

NAME GCPangburn MJVirgilio 

DATE 1/28/08 2/6/08 

 OFFICIAL RECORD COPY
LETTER TO DAVID R. GIFFORD FROM MARTIN J. VIRGILIO DATED: February 6, 2008 

DISTRIBUTION: EDATS: FSME-2008-0004 

DMSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Klein 

KLukes, FSME/DMSSA Commissioner Jaczko 

AJones, FSME/DILR Commissioner Lyons 

JKottan, RI/RSAO SECY 

DJanda, RI/RSAO 

Frieda Taylor, CA 

KSchneider, FSME/DMSSA 

MOrendi, FSME/DMSSA 

DDiaz-Toro, OEDO 

KCyr, OGC 

JGray, OGC 

BJones, OGC 

ECollins, RIV 

CLMiller, FSME 

APowell, OCA (2 copies) 
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE RHODE ISLAND AGREEMENT STATE PROGRAM 

October 22-25, 2007 

FINAL REPORT

ENCLOSURE
Rhode Island Final Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the review of the Rhode Island Agreement State Program. 

The review was conducted during the period of October 22-25, 2007, by a review team 

comprised of technical staff members from the U.S. Nuclear Regulatory Commission (NRC) and 

the State of California. Team members are identified in Appendix A. The review was conducted 

in accordance with the “Implementation of the Integrated Materials Performance Evaluation 

Program and Rescission of Final General Statement of Policy,” published in the Federal Register

on October 16, 1997, and the February 26, 2004, NRC Management Directive 5.6, “Integrated 

Materials Performance Evaluation Program (IMPEP).” Preliminary results of the review, which 

covered the period of November 18, 2003, to October 25, 2007, for the performance indicator, 

Status of Materials Inspection Program, and period of November 23, 2002, to October 25, 2007, 

for the other performance indicators were discussed with Rhode Island’s Department of Health 

managers on the last day of the review. 

A draft of this report was issued to Rhode Island for factual comment on November 28, 2007. 

The State responded by e-mail on December 5, 2007, from John Ferruolo, Supervisor, 

Radioactive Materials and X-ray Program (the Program). A copy of the State’s response is 

included as the Attachment to this report. The Management Review Board (MRB) met on 

January 15, 2008, to consider the proposed final report. The MRB found the Rhode Island 

Agreement State Program to be adequate to protect public health and safety and compatible 

with NRC’s program. 

The Rhode Island Agreement State Program is administered by the Program, within the Division 

of Environmental and Health Regulation Services (the Division). The Division is part of the 

Department of Health (the Department). The Director of Health, who heads the Department, is 

appointed by and reports directly to the Governor. Organization charts for the Department, the 

Division, and the Program are included as Appendix B. 

At the time of the IMPEP review, the Rhode Island Agreement State Program regulated 

approximately 60 specific licenses authorizing Agreement materials. The review focused on the 

radioactive materials program as it is carried out under the Section 274b. (of the Atomic Energy 

Act of 1954, as amended) Agreement between the NRC and the State of Rhode Island and 

Providence Plantations. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Program on August 3, 2007. The Program 

provided its response to the questionnaire on September 20, 2007. A copy of the questionnaire 

response can be found in the NRC’s Agencywide Documents Access and Management System 

(ADAMS) using the Accession Number ML073180728. 

The review team's general approach for conduct of this review consisted of: (1) examination of 

the Program’s response to the questionnaire; (2) review of applicable Rhode Island statutes and 

regulations; (3) analysis of quantitative information from the Program’s database; (4) technical 

review of selected regulatory actions; (5) one field accompaniment of one Rhode Island 

inspector; and (6) interviews with staff and managers to answer questions or clarify issues. The 

review team evaluated the information gathered against the established criteria for each 

common and applicable non-common performance indicator and made a preliminary 

assessment of the Agreement State program’s performance. 
Rhode Island Final Report Page 2 

The review team also evaluated the State’s budgetary and associated staffing issues 

surrounding Rhode Island’s proposed return of its Agreement State program. Due to budget 

issues in October 2006, the State placed the Program under review for possible return to the 

NRC. Specifically, by letter dated April 1, 2007, Governor Donald Carcieri advised the NRC of 

Rhode Island’s proposed decision to return the “Section 274b Agreement,” to the NRC. On July 

19, 2007, after the State legislation vetoed the Governor’s proposal, Rhode Island informed the 

NRC that they would retain their Agreement State program. Section 3.1 contains more 

information on the budget and staffing issues surrounding Rhode Island’s proposed return of its 

Agreement State program. 

Section 2.0 of this report covers the State’s actions in response to recommendations made 

during previous reviews. Results of the current review for the common performance indicators 

are presented in Section 3.0. Section 4.0 details the results of the review of the applicable noncommon performance indicators, and Section 5.0 summarizes the review team's findings and 

recommendations. Recommendations made by the review team are comments that relate 

directly to program performance by the State. A response is requested from the State to all 

recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on November 18, 2002, five 

recommendations were made and the results were transmitted to Patricia A. Nolan, M.D., former 

Director of the Department on February 28, 2003. During the followup IMPEP review which 

concluded on November 18, 2003, four recommendations were closed. The final followup 

report was transmitted to Dr. Nolan on March 2, 2004. The review team’s evaluation of the 

current status of the open recommendation from previous reviews is as follows: 

 The review team recommends that the State adopt overdue regulations required for 

compatibility. (Section 4.1.2 of the 2003 IMPEP report) 

Current Status: Since the 2003 IMPEP followup review, the Program has consistently 

adopted regulations required for compatibility in a timely manner. This recommendation 

is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

IMPEP identifies five common performance indicators to be used in reviewing NRC Regional 

and Agreement State radioactive materials programs. These indicators are: (1) Technical 

Staffing and Training, (2) Status of Materials Inspection Program, (3) Technical Quality of 

Inspections, (4) Technical Quality of Licensing Actions, and (5) Technical Quality of Incident and 

Allegation Activities. 

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Program’s staffing level and staff 

turnover, as well as the technical qualifications and training histories of the staff. To evaluate 

these issues, the review team examined the Program’s questionnaire response relative to this 
Rhode Island Final Report Page 3 

indicator; interviewed managers and staff; and reviewed job descriptions, training plans, and 

training records. The review team also considered any possible workload backlogs in evaluating 

this indicator. 

The Program consists of five technical staff positions and a supervising radiological health 

specialist (the Supervisor). The Program’s responsibilities include mammography, X-ray, 

radioactive materials and emergency preparedness/response. One staff member is dedicated to 

X-ray and mammography, one to the radioactive materials program, and the remaining three 

staff members, along with the Supervisor, provide partial support to the radioactive materials 

program. One of the supporting staff positions has been vacant since May 2007. Efforts to fill 

the vacancy are still ongoing. Based on discussions and information provided in response to the 

questionnaire, 1.75 full-time equivalents are allocated to the radioactive materials program, 

including the contribution from the vacant position. With a total of 60 licenses, the level of 

staffing appeared adequate to perform the Program’s licensing and inspections and did not 

present any performance issues affecting implementation of the Agreement State program. 

Since the last IMPEP review, Rhode Island considered returning its Agreement State program to 

the NRC. The Rhode Island Fiscal Year 2008 Budget Act, which became effective July 1, 2007, 

created a restricted receipts account for deposit of the Program’s licensing fees. The creation of 

a dedicated fund for the Program allows the radioactive materials program to be financially selfsufficient, recovering associated costs through licensing fees. 

The review team determined the qualifications of Program staff from the Program’s response to 

the questionnaire, training records, and discussions with staff. Staff training and qualifications 

are maintained in a training matrix that documents staff training history and personnel file 

memoranda. The personnel file memoranda, which are generated on an annual basis, identify 

the inspection categories for which a staff member is qualified. The training matrix is used to 

monitor the status of core, supplemental, and other training. The qualified staff attended the 

core training courses as prescribed by the NRC’s Inspection Manual Chapter (IMC) 1246, 

“Formal Qualification Programs in the Nuclear Material Safety and Safeguards Program Area." Staff members that had not completed the core training courses but had established 

competency in some inspection categories were given interim qualification and were permitted to 

perform inspections for those categories. Staff was familiar with Rhode Island regulations, 

procedures, and policies. At the time of the review, the Program had two staff members that had 

attended the NRC’s Security Systems and Principles Course. Managers were supportive of staff 

training within the budget constraints of the Program. 

Rhode Island statute Title 23, Chapter 23, Section 23-1.3-13 provided for the creation of an 

11-member State Radiation Advisory Commission (the Commission), whose members have 

expertise in radiation protection and radiation health. The Commission provides advice on 

radiation protection issues and regulations to the Program and meets on an as needed basis. 

The review team identified no potential conflicts of interest. 

Based on the IMPEP evaluation criteria, the review team recommended, and the MRB agreed, 

that Rhode Island’s performance with respect to the indicator, Technical Staffing and Training, 

was satisfactory. 
Rhode Island Final Report Page 4 

3.2 Status of Materials Inspection Program

The review team focused on five factors in reviewing this indicator: inspection frequency, 

overdue inspections, initial inspections of new licenses, timely dispatch of inspection findings to 

licensees, and performance of reciprocity inspections. The review team’s evaluation was based 

on the Program’s questionnaire response relative to this indicator, the data gathered from the 

Program’s inspection data tracking system, the examination of completed inspection casework, 

and the interviews with managers and staff. 

The review team verified that the Program’s inspection frequencies for various license types 

were at least as frequent as similar license types listed in IMC 2800, “Materials Inspection 

Program.” 

In analyzing the Program’s inspection tracking data, the review team observed that routine 

inspections of Priority 1, 2, and 3 (1, 2 and 3-year inspection interval, respectively) licenses and 

initial inspections of new licenses were often being conducted at frequencies exceeding those 

prescribed in IMC 2800. The 2002 IMPEP review team identified previous issues in the Program 

with the timeliness of inspections, which led to the State being put on Heightened Oversight. 

During that review period, the Program failed to perform routine inspections for a period of 22 

months. The 2003 followup IMPEP review team found that the Program had scheduled all 

routine Priority 1, 2, and 3 inspections and initial inspections at the appropriate frequency, and 

the State was taken off of Heightened Oversight. Based on the evaluation of current inspection 

tracking data, the review team determined that 19 out of 56 Priority 1, 2, and 3 initial inspections 

were completed overdue during the review period. The review team attributed the root cause of 

the overdue inspections to the Program’s performance of the 2000-2003 backlog inspections, 

wherein overdue inspections are carried over to the next year; maternity leave of inspection staff; 

competing training requirements in other program areas; and the loss of the previous Program 

Chief within this review period. Additionally, the prospect of elimination of the program, 

proposed in October 2006, may have disrupted the Program’s completing inspections due to 

considerations concerning loss of staff. The review team recommends that the State take 

appropriate measures to conduct Priority 1, 2, and 3 inspections and initial inspections in 

accordance with the inspection priority schedule in IMC 2800. 

The review team sampled a cross-section of inspections reports to supplement its analysis of 

the Program’s timeliness of inspections. The review team determined that all but one inspection, 

an inspection of a Priority 5 (5-year interval) licensee, was performed in a timely manner. 

Through the evaluation of casework, the review also determined that inspection findings were 

consistently communicated to licensees less than 30 days after the respective inspection. 

To further evaluate Rhode Island’s performance under this indicator, the review team evaluated 

the Program’s efforts in reducing its inspection backlog. The review team noted the Program’s 

continued success in reducing its backlog since the November 2003 followup IMPEP review. 

The review team determined that in 2004, the Program had 11 overdue Priority 1, 2, and 3 and 

initial inspections. During the review period, the Program reduced its backlog to 6 overdue 

inspections at the time of the review. 

Reciprocity, which permits licensees from other regulatory jurisdictions to work in Rhode Island, 

was granted to 15 licensees in 2004; 18 licensees in 2005; 22 licensees in 2006; and 21 
Rhode Island Final Report Page 5 

licensees to date in 2007. During the review period, the Program performed 20 reciprocity 

inspections. The review team determined that the Program met or exceeded the goal of 

annually inspecting 20 percent of all candidate licensees operating under reciprocity, as 

established by IMC 1220, “Processing of NRC Form 241 and Inspection of Agreement State 

Licensees Operating Under 10 CFR 150.20,” during the review period. 

The review team determined that the Program adequately planned for the initial set of Increased 

Controls inspections of affected licensees. The review team evaluated the Program’s 

prioritization methodology and found it acceptable. At the time of the review, the Program had 

16 licensees subject to the Increased Controls. The Program had completed all initial Increased 

Controls inspections of the 16 affected licensees prior to the review.

Based on the IMPEP evaluation in Management Directive 5.6, Rhode Island’s performance for 

this indicator met the criteria for a finding of unsatisfactory. In reviewing this indicator, the review 

team was cognizant of the guidance in the All-Agreement States letter, “Prioritization 

Methodology for Increased Controls,” dated November 4, 2005. This letter documented an 

allowance to defer routine health and safety inspections to ensure that Increased Controls 

inspections are performed in a timely manner. The review team took into account the Program’s 

progress in reducing the backlog of overdue inspections from the previous IMPEP review, as 

well as the Program’s performance of risk-significant reciprocity inspections. Considering the 

Program’s efforts to reduce its inspection backlog, improve its performance of reciprocity 

inspections, and perform its Increased Controls inspections in a timely manner, the review team 

recommended, and the MRB agreed, that Rhode Island’s performance with respect to the 

indicator, Status of Materials Inspection Program, was satisfactory, but needs improvement, 

instead of unsatisfactory. 

3.3 Technical Quality of Inspections

The review team evaluated inspection reports, enforcement documentation, inspection field 

notes, and interviewed inspectors for 13 radioactive materials inspections conducted during the 

review period. The casework examined included a cross-section of inspections conducted by 

two Program inspectors and the Supervisor and covered a variety of license types, including: 

gamma knife, medical private practice, high dose-rate remote afterloader (HDR), teletherapy, 

industrial radiography, and manufacturing and distribution. Appendix C lists the inspection 

casework files reviewed, as well as the results of the inspector accompaniments. 

Based on the evaluation of casework, the review team noted that inspections covered all 

aspects of the licensees’ radiation programs. The review team found that inspection reports 

were thorough, complete, consistent, and of high quality, with sufficient documentation to ensure 

that licensees’ performances with respect to health, safety, and security were acceptable. The 

documentation supported violations and recommendations made to the licensee, unresolved 

safety issues, and discussions held with the licensee during exit interviews. Team inspections 

were performed when appropriate and for training purposes. 

For the casework reviewed, inspection findings were appropriate and prompt regulatory actions 

were taken, as appropriate. The Program issues timely compliance letters to licensees 

explaining inspection findings and violations. The Program does not have the authority to levy 

civil penalties. The Supervisor stated that escalated enforcement action is achieved through 

non-routine inspections which, according to Section I.3.7 of Rhode Island’s regulations, require 
Rhode Island Final Report Page 6 

an inspection fee of one-half the annual licensing fee established in Appendix A to Part I of the 

regulations. 

The inspection procedures utilized by the Program are consistent with the inspection guidance 

found in IMC 2800. Findings were clearly stated and documented. All inspection reports and 

correspondence are reviewed by the Supervisor prior to issuance. The review team noted that 

inspection correspondence involving the Increased Controls was appropriately labeled as 

sensitive information and withheld from public disclosure. 

The review team noted that supervisor accompaniments of the inspection staff were completed 

and consistently performed over the review period. 

The review team confirmed that the Rhode Island program maintains an adequate supply of 

portable radiation detection instruments for use during routine inspections and response to 

incidents. Instrument calibrations are performed annually by the University of Rhode Island’s 

Nuclear Science Center or other vendors appropriately licensed to provide calibration services 

using sources that are traceable to the National Institute of Standards and Technology. The 

State also utilized the Nuclear Science Center for analysis of wipes and environmental samples 

taken during inspections. 

On October 16-17, 2007, a review team member accompanied one of the Program’s inspectors 

on a routine health and safety inspection of a medical facility. The accompaniment is identified 

in Appendix C. During the accompaniment, the inspector demonstrated appropriate inspection 

techniques and knowledge of the regulations. The inspector was trained, prepared, and 

thorough in his audit of the licensee’s radiation safety program. The inspector utilized good 

health physics practices and interviewed licensee personnel in an effective manner. The 

inspection was adequate to assess radiological health and safety at the licensed facility. 

Based on the IMPEP evaluation criteria, the review team recommended, and the MRB agreed, 

that Rhode Island’s performance with respect to the indicator, Technical Quality of Inspections, 

was satisfactory. 

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed the staff and 

discussed 14 licensing actions related to 12 specific licenses. Licensing actions were reviewed 

for completeness, consistency, proper radioisotopes and quantities, qualifications of authorized 

users, adequate facilities and equipment, adherence to good health physics practices, operating 

and emergency procedures, appropriateness of the license conditions, Increased Controls, and 

overall technical quality. The casework was also reviewed for timeliness, use of appropriate 

deficiency letters and cover letters, reference to appropriate regulations, supporting 

documentation, consideration of enforcement history, pre-licensing visits, peer/supervisory 

review, and proper signatures. The casework was checked for retention of necessary 

documents and supporting data. 

The licensing casework was selected to provide a representative sample of licensing actions 

completed during the review period. Licensing actions selected for evaluation included 2 new 

licenses, 1 renewal, 8 amendments, and 3 terminations. The sampling included the following 

license types: industrial radiography; broadscope medical; veterinary non-human; stereostatic 
Rhode Island Final Report Page 7 

radiosurgery; broadscope academic; broadscope manufacturing and distribution; teletherapy; 

portable and fixed gauges; medical private practice; and research and development. A listing of 

the licensing casework evaluated can be found in Appendix D. 

The review team found that the licensing actions were thorough, complete, consistent, and of 

high quality, with health, safety, and security issues properly addressed. License tie-down 

conditions were stated clearly, backed by information contained in the file, and auditable. 

Licensees’ compliance histories were taken into account when reviewing all renewal applications 

and major amendments. 

Each licensing action is given a technical review by a license evaluator. The Supervisor 

performs the majority of the licensing actions and additionally performs a technical and 

supervisory review on licensing actions performed by other reviewers before issuance. Effective 

August 2006, the Program extended its license expiration dates from a 5-year period to a 

10-year period in an effort to reduce the licensing backlog. The Program currently has 60 

specific licensees. At the time of the review, there were 16 overdue renewals (a 27 percent 

backlog). All overdue licenses are under timely renewal and will remain in timely renewal until 

such time as a technical review can be performed. Although the expiration periods ranged from 

the year 2000 through 2006, the review team identified no apparent impact on public health and 

safety due to either ongoing and/or relatively recent licensing actions (amendments). 

The review team observed a thorough and complete documentation of the termination process, 

which included records of an on-site inspection and observance of material transfer. The review 

team found that terminated licensing actions were well documented, showing appropriate 

material transfer and survey records. The review team noted that confirmatory surveys were 

conducted, when appropriate. 

The review team observed the Program’s implementation of the pre-licensing guidance in the 

issuance of two new licenses. Although the Program appeared to have implemented the prelicensing guidance, discussions with Program staff and managers revealed that staff was not 

fully aware that the pre-licensing guidance is also applicable to other licensing actions (renewals 

and amendments). Additionally, although staff routinely used the appropriate NRC guidance 

documents for license reviews, the Program has no formal documentation of the radioactive 

materials licensing program, and thus, no formal documentation as to how the pre-licensing 

guidance will be integrated into the radioactive materials licensing program. 

The review team examined the list of licensees that the Program determined to meet the criteria 

for the Increased Controls, per COMSECY-05-0028, “Staff Response to Staff Requirements 

Memorandum for COMSECY-05-0015: Initiatives for Increasing Agreement State Participation 

in the Control of Sources,” dated July 25, 2005. The review team determined that the Program 

had correctly identified the licensees that require the Increased Controls based on the criteria. 

Each licensee was issued a license amendment, requiring the Increased Controls, in 

accordance with the time lines established by the NRC in the Staff Requirements Memorandum 

for COMSECY-05-0028. Although the Program appeared to have identified all licensees that 

meet the criteria for Increased Controls, at the time of the review, the Program had not 

documented the process used to determine which licensees meet the criteria for the Increased 

Controls, and thus, determination for future licensees and/or licensing actions. 
Rhode Island Final Report Page 8 

The review team noted the depth of experience of the current staff, but had concerns with the 

Program’s ability to transfer historical knowledge and maintain program consistency without a 

fully-documented radioactive materials licensing program to include the Increased Controls 

criteria and the pre-licensing guidance. The review team recommends that the State develop a 

written documentation of its radioactive materials licensing program to ensure that a 

memorialized program exists to train and transfer knowledge to future, as well as current, staff. 

Based on the IMPEP evaluation criteria, the review team recommended, and the MRB agreed, 

that Rhode Island’s performance with respect to the indicator, Technical Quality of Licensing 

Actions, was satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities

To evaluate the effectiveness of the Program’s actions in responding to incidents and 

allegations, the review team examined the Program’s response to the questionnaire relative to 

this indicator, evaluated selected incidents reported for Rhode Island in the Nuclear Material 

Events Database (NMED) against those contained in the Program’s files, and evaluated the 

casework for six radioactive materials incidents. A listing of the incident casework examined can 

be found in Appendix E. The review team also evaluated the Program’s response to four 

allegations. 

The incidents selected for review included medical events, lost/stolen radioactive material, and 

overexposure. Upon receipt, the Supervisor reviews the report, decides on the appropriate 

response, assigns the report a specific identification number, and then logs it into the Program’s 

incident tracking system. Written documentation related to each incident is placed in an incident 

file. The review team determined that the Program’s response to incidents was complete and 

comprehensive. Initial responses were prompt and well coordinated, and the level of effort was 

commensurate with the health and safety significance. The Program dispatched inspectors for 

on-site investigations in appropriate situations and took suitable enforcement and followup 

actions when necessary. 

The Supervisor provides information electronically to the NRC’s contractor responsible for 

maintaining NMED. The NMED information is updated as needed. The review team found that 

incident information in NMED provided by the Program was up to date and complete. 

During the review period, the Program received four allegations involving radioactive material. 

All were reported directly to the Program. The review team evaluated the casework for all four 

allegations. The review team noted that the Program promptly responded to all allegations with 

appropriate investigations and followup and close-out actions. All of the allegations were 

appropriately closed, and appropriate parties were notified of the actions taken. 

The Program has complete written guidance for handling incidents and allegations in their 

inspection procedures. The review team noted that Rhode Island law requires that public 

documents be made available upon request. The State makes every effort to protect an 

alleger’s identity, but protection cannot be guaranteed. 

Based on the IMPEP evaluation criteria, the review team recommended, and the MRB agreed, 

that Rhode Island’s performance with respect to the indicator, Technical Quality of Incident and 

Allegation Activities, was satisfactory. 
Rhode Island Final Report Page 9 

4.0 NON-COMMON PERFORMANCE INDICATORS 

IMPEP identifies four non-common performance indicators to be used in reviewing Agreement 

State Programs: (1) Compatibility Requirements; (2) Sealed Source and Device Evaluation 

Program; (3) Low-Level Radioactive Waste Disposal Program; and (4) Uranium Recovery 

Program. Only the non-common performance indicators, Compatibility Requirements and LowLevel Radioactive Waste Disposal Program, were applicable to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Rhode Island became an Agreement State on January 1, 1980. The currently effective statutory 

authority for the Program is contained in the State of Rhode Island’s enabling statute Title 23, 

Chapter 1.3 (Radiation Control) of the Rhode Island General Laws [RIGL]. as amended. The 

current implementing regulations are titled Rules and Regulations for the Control of Radiation 

[R-23-1.3-RAD] and are dated September 2007. In addition to their response to the 

questionnaire, the State provided the review team with the opportunity to review copies of 

legislation that affect the radiation control program. The review team noted that no legislation 

affecting the Program was passed during the review period. Rhode Island Regulations are 

subject to RIGL-42-35-4.1, requiring all regulations promulgated by State agencies to be refiled 

every 5 years to remain effective. The radiation control regulations were last filed in January 

2007. 

4.1.2 Program Elements Required for Compatibility 

The Rhode Island Rules and Regulations for the Control of Radiation (R23-1.3-RAD) apply to all 

sources of ionizing radiation. Rhode Island requires a license for possession and use of all 

radioactive material including naturally occurring materials, such as radium, and acceleratorproduced radionuclides. Rhode Island also requires registration of all equipment designed to 

produce x-rays or other ionizing radiation, as well as non-ionizing radiation from tanning 

equipment. 

The review team examined the State’s administrative rulemaking process and found that the 

process takes approximately 4 to 6 months after the Program prepares a proposed regulation 

and submits it to the NRC. The proposed regulation is sent to the Department’s legal counsel 

concurrently with (or slightly before) submission to the NRC, the public, other agencies, and all 

potentially impacted licensees and registrants for comment. There is a required formal public 

hearing as part of the public comment process. The Director of Health gives final approval and 

signs the final regulations. The regulations are then filed with the Secretary of State and 

become effective 21 days later. The State can adopt other agency regulations by reference and 

has the authority to issue legally-binding requirements (e.g., license conditions) in lieu of 

regulations until compatible regulations become effective. 

The review team evaluated the Program’s response to the questionnaire, reviewed the status of 

regulations required to be adopted by the State under the NRC’s adequacy and compatibility 

policy, and verified the adoption of regulations with data obtained from the NRC’s Office of 

Federal and State Materials and Environmental Management Programs’ State Regulation Status 

Sheet. 
Rhode Island Final Report Page 10 

Current NRC policy requires that Agreement States adopt certain equivalent regulations or 

legally-binding requirements no later than 3 years after they become effective. The review team 

identified the following amendment as overdue at the time of the review: 

• “Compatibility with IAEA Transportation Safety Standards (TS-R-1) and Other 

Transportation Safety Amendments,” 10 CFR Part 71 amendment (69 FR 3697, 58038), 

that became effective October 1, 2004, and was due for Agreement State adoption by 

October 1, 2007. 

The review team identified the following NRC amendment that needs to be addressed: 

• “Minor Amendments,” 10 CFR Part 20, 30, 32, 35, 40 and 70 amendments (71 FR 

15005) that became effective March 27, 2006, and is due for Agreement State adoption 

by March 27, 2009. 

Based on the IMPEP evaluation criteria, the review team recommended, and the MRB agreed, 

that Rhode Island’s performance with respect to the indicator, Compatibility Requirements, was 

satisfactory. 

4.2 Low-Level Radioactive Waste (LLRW) Disposal Program

In 1981, the NRC amended its Policy Statement “Criteria for Guidance of States and NRC in 

Discontinuance of NRC Regulatory Authority and Assumption Thereof by States Through 

Agreement” to allow a State to seek an amendment for the regulation of LLRW as a separate 

category. Those States with Agreements prior to 1981 were determined to have continued 

LLRW disposal authority without the need of an amendment. Although the Rhode Island 

Agreement State Program has LLRW disposal authority, NRC does not require States to have a 

program for licensing a LLRW disposal facility until the State is designated as a host State for a 

LLRW disposal facility. When an Agreement State is notified or becomes aware of the need to 

regulate a LLRW disposal facility, it is expected to put in place a regulatory program that will 

meet the criteria for an adequate and compatible LLRW disposal program. There are no plans 

for a LLRW disposal facility in Rhode Island. Accordingly, the review team did not review this 

indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Rhode Island’s performance was found satisfactory, but needs 

improvement, for the performance indicator, Status of Materials Inspection Program, and 

satisfactory for all other performance indicators reviewed. The review team made two 

recommendations regarding program performance. Accordingly, the review team 

recommended, and the MRB agreed, that the Rhode Island Agreement State Program was 

adequate to protect public health and safety and compatible with NRC's program. Based on the 

results of the current IMPEP review, the review team recommended, and the MRB agreed, that 

the next full IMPEP review take place in approximately 4 years. 

Below are the recommendations, as mentioned earlier in the report, for evaluation and 

implementation, as appropriate, by the State. 
Rhode Island Final Report Page 11 

1. The review team recommends that the State take appropriate measures to conduct 

Priority 1, 2, and 3 inspections and initial inspections in accordance with the inspection 

priority schedule in IMC 2800. (Section 3.2) 

2. The review team recommends that the State develop a written documentation of its 

radioactive materials licensing program to ensure that a memorialized program exists to 

train and transfer knowledge to future, as well as current, staff. (Section 3.4) 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Rhode Island Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Attachment December 5, 2007, Letter from John L. Ferruolo 

 Rhode Island’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Andrea Jones, FSME Team Leader 

 Status of Materials Inspection Program 

 Technical Quality of Inspections 

Technical Quality of Incident and Allegation 

 Activities 

James Kottan, Region I Technical Staffing and Training 

Frieda Taylor, California Technical Quality of Licensing Actions 

Monica Orendi, FSME Compatibility Requirements 

Donna Janda, Region I Inspector Accompaniment 
APPENDIX B 

RHODE ISLAND ORGANIZATION CHART 

ADAMS ACCESSION NO.: ML073190195 

PAGES 1-3 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Rhode Island Hospital License No.: 7D-051-02 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 9/4/07 Inspector: DK 

File No.: 2 

Licensee: Paul D. Aldinger License No.: 3L-107-01 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 3/31/04 Inspector: CW 

File No.: 3 

Licensee: Kent County Hospital License No.: 7B-020-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/27/03 Inspector: JF 

File No.: 4 

Licensee: GZA Geotechnical Inc. License No.: 3L-079-01 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 9/15/05 Inspector: CW 

File No.: 5 

Licensee: Jaworski Geotech License No.: 3L-119-01 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 9/11/02 Inspector: DK 

File No.: 6 

Licensee: Cardiology Specialist License No.: 7B-134-01 

Inspection Type: Initial, Unannounced Priority: 5 

Inspection Date: 12/27/05 Inspector: DW 

File No.: 7 

Licensee: Digirad License No.: 7B-133-01 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 9/6/05 Inspector: JF 

File No.: 8 

Licensee: Enviroscience Consultants, Inc. License No.: 3L-118-01 

Inspection Type: Initial, Unannounced Priority: 5 

Inspection Date: 4/30/04 Inspector: CW 
Rhode Island Final Report Page C.2 

Inspection Casework Reviews 

File No.: 9 

Licensee: Geisser Engineering License No.: 3L-050-01 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 6/13/05 Inspector: CW 

File No.: 10 

Licensee: South County Cardiology Associates License No.: 7B-129-01 

Inspection Type: Initial, Unannounced Priority: 3 

Inspection Date: 6/24/04 Inspector: DK 

File No.: 11 

Licensee: Cardinal Health License No.: 3B-114-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 10/7/02 Inspector: DK 

File No.: 12 

Licensee: Niton Corporation License No.: 3G-105-02 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 12/4/03 Inspector: DK 

File No.: 13 

Licensee: Brown University License No.: 3K-036-01 

Inspection Type: Routine/Special, Unannounced Priority: 3 

Inspection Date: 10/27/03 Inspector: DK 

INSPECTOR ACCOMPANIMENT 

The following inspector accompaniment was performed prior to the on-site IMPEP review: 

Licensee: Rhode Island Hospital License No.: 7D-051-01 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 10/16-17/07 Inspector: DK 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: ANVIL International, Inc. License No.: 3D-064-01 

Type of Action: Termination Amendment No.: 15 

Date Issued: 11/3/06 License Reviewer: JF 

File No.: 2 

Licensee: ANVIL International, Inc. License No.: 3D-064-01 

Type of Action: Amendment Amendment No.: 13 

Date Issued: 10/14/05 License Reviewer: JF 

File No.: 3 

Licensee: Rhode Island Hospital License No.: 7D-051-01 

Type of Action: Amendment Amendment No.: 31 

Date Issued: 10/14/05 License Reviewer: JF 

File No.: 4 

Licensee: Ocean State Veterinary Specialists License No.: 3K-126-01 

Type of Action: Renewal Amendment No.: 1 

Date Issued: 4/17/07 License Reviewer: CW 

File No.: 5 

Licensee: Rhode Island Hospital License No.: 7A-051-02 

Type of Action: Amendment Amendment No.: 21 

Date Issued: 10/24/05 License Reviewer: JF 

File No.: 6 

Licensee: Brown University License No.: 3K-036-01 

Type of Action: Amendment Amendment No.: 30 

Date Issued: 10/14/05 License Reviewer: JF 

File No.: 7 

Licensee: Thermo Niton Analyzers LLC License No.: 3A-105-01 

Type of Action: Amendment Amendment No.: 15 

Date Issued: 1/19/06 License Reviewers: DK, WD 

File No.: 8 

Licensee: Rhode Island Hospital License No.: 7D-051-01 

Type of Action: Amendment Amendment No.: 37 

Date Issued: 6/8/07 License Reviewer: JF 
Rhode Island Final Report Page D.2 

License Casework Reviews 

File No.: 9 

Licensee: Radiation Oncology Services of Rhode Island License No.: 7A-053-01 

Type of Action: Termination Amendment No.: 15 

Date Issued: 5/21/07 License Reviewer: JF 

File No.: 10 

Licensee: Northeast Engineers & Consultants, Inc. License No.: 3L-115-01 

Type of Action: Amendment Amendment No.: 4 

Date Issued: 2/3/05 License Reviewer: JF 

File No.: 11 

Licensee: Rhode Island Cardiovascular Group, Inc. License No.: 7B-137-01 

Type of Action: New Amendment No.: N/A 

Date Issued: 2/2/07 License Reviewer: JF 

File No.: 12 

Licensee: Rhode Island Psychiatric Research Center License No.: 3K-023-01 

Type of Action: Termination Amendment No.: 10 

Date Issued: 10/30/03 License Reviewer: JF 

File No.: 13 

Licensee: VeroScience, LLC License No.: 3K-136-01 

Type of Action: New Amendment No.: 1 

Date Issued: 4/27/07 License Reviewer: JF 

File No.: 14 

Licensee: Electric Boat Corporation License No.: 3D-005-01 

Type of Action: Amendment Amendment No.: 17 

Date Issued: 12/4/06 License Reviewer: JF 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Rhode Island Hospital 

(Miriam Campus) No.: 7D-051-01 

Date of Incident: 2/16/05 NMED No.: 050195 

Investigation Date: 4/11/05 Type of Incident: Lost/stolen RAM 

 Type of Investigation: Telephone 

File No.: 2 

Licensee: Rhode Island Hospital License No.: 7A-051-02 

Date of Incident: 5/9/07 NMED No.: 050529 

Investigation Date: 5/25/07 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 3 

Licensee: Cardinal Health License No.: 3B-114-01 

Date of Incident: 3/8/07 NMED No.: 050139 

Investigation Date: 3/9/07 Type of Incident: Lost/stolen RAM 

 Type of Investigation: Telephone 

File No.: 4 

Licensee: Rhode Island Hospital License No.: 7A-051-02 

Date of Incident: 5/9/07 NMED No.: 070309 

Investigation Dates: 5/25/07 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

File No.: 5 

Licensee: Rhode Island Hospital License No.: 7A-051-02 

Date of Incident: 7/18/05 NMED No.: 050529 

Investigation Date: 8/19/05 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

File No.: 6 

Licensee: Anvil International License No.: 3D-064-01 

Date of Incident: 3/3/06 NMED No.: 060163 

Investigation Dates: 3/3/06, 3/8/06, 3/16/06 Type of Incident: Overexposure 

 Type of Investigation: Site 
ATTACHMENT 

December 5, 2007, Letter from John L. Ferruolo 

Rhode Island’s Response to Draft IMPEP Report 

ADAMS: ML073400218