February 6, 2012 

Michael Fine, M.D., Director 

Rhode Island Department of Health 

3 Capitol Hill 

Providence, RI 02908 

Dear Dr. Fine: 

On January 17, 2012, 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 program adequate, but needs 

improvement, and compatible with the U.S. Nuclear Regulatory Commission=s (NRC) program. 

Section 5.0, page 13, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. Based on the results of the current IMPEP review, the next 

IMPEP review will take place in approximately 4 years from the current review, with an early 

periodic meeting scheduled in 1 year from the date of current review. The MRB determined that 

a period of monitoring should be initiated for Rhode Island. Monitoring is implemented when 

weaknesses in a program result in a less than fully satisfactory performance for one or more 

performance indicators. 

The MRB acknowledged your response, dated January 6, 2012, to the draft report and the 

review team’s recommendations. Your response did not fully respond to all recommendations. 

We would appreciate additional information from you in that regard along with further 

development of your action plan for the recommendations. If you wish, Monica Orendi, your 

Regional State Agreement Officer, can assist with the development of the action plan. Your 

action plan will be reviewed during the quarterly calls conducted under monitoring and 

subsequent reviews. 

The MRB noted that due to State budget matters the Program Supervisor position has been 

vacant since 2008. The position has not been allowed to be filled and is not expected to be 

filled in Rhode Island during the current fiscal year. The MRB recognizes the challenges facing 

the Program including those identified by the IMPEP team, and that filling the vacant position 

may help to address those challenges. 

 
M. Fine -2- 

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/ 

 Michael F. Weber

 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/encl: Raymond Rusin, Chief 

 Office of Facilities Regulation 

 Edward W. Johnson, Deputy Director 

 RI Emergency Management Agency 

 State Liaison Officer 
M. Fine -2- 

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/ 

 Michael F. Weber

 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/encl: Raymond Rusin, Chief 

 Office of Facilities Regulation 

 Edward W. Johnson, Deputy Director 

 RI Emergency Management Agency 

 State Liaison Officer 

 

DISTRIBUTION: EDATS: FSME-2012-0004 

See next page 

ML120240375 

OFFICE FSME/MSSA FSME/MSSA FSME/MSSA FSME/MSSA 

NAME LDimmick DWhite PHenderson BMcDermott 

DATE 01/25/12 01/25/12 01/ /12 01/30/12 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland MSatorius MWeber 

DATE 02/2/12 02/02/12 02/6/12 

OFFICIAL RECORD COPY 
Letter to Michael Fine from Michael F. Weber dated: February 6, 2012 

SUBJECT: RHODE ISLAND 2012 FINAL IMPEP REPORT 

DISTRIBUTION: EDATS: FSME-2012-0004 

MSSA_Technical_Asst_Resource DCD (SP01) 

RidsEdoMailCenter 

RidsFsmeOd 

RidsOgcMailCenter 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

JKatanic, FSME Commissioner Svinicki 

MOrendi, RI/RSAO Commissioner Apostolakis 

MLight, OH Commissioner Magwood 

RidsRgn1MailCenter Commissioner Ostendorff 

MBeardsley, FSME SECY 

GVinson, IL 

DMerzke, OEDO 

BJones, OGC 

TRothschild, OGC 

JBiggins, OGC 

JWeil, OCA (2 copies) 
Enclosure 1 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE RHODE ISLAND AGREEMENT STATE PROGRAM 

OCTOBER 24-28, 2011 

FINAL REPORT 
 

EXECUTIVE SUMMARY 

This report presents the results of the Integrated Materials Performance Evaluation Program 

(IMPEP) review of the Rhode Island Agreement State Program. The review was conducted 

during the period of October 24-28, 2011, by a review team composed of technical staff 

members from the U.S. Nuclear Regulatory Commission (NRC) and the State of Ohio. 

Based on the results of this review, the review team recommended, and the MRB agreed, that 

Rhode Island’s performance be found unsatisfactory for the performance indicator Status of the 

Materials Inspection Program; satisfactory, but needs improvement, for the performance 

indicators Technical Quality of Inspections and Compatibility Requirements; and satisfactory for 

the three other indicators reviewed. The review team made six recommendations regarding the 

performance of the Rhode Island Agreement State Program. These recommendations include 

areas for improvement to correct identified performance deficiencies and weaknesses in Rhode 

Island’s Agreement State Program. One of these recommendations remains open from the 

2007 IMPEP review. The recommendations address: (1) documentation of the State’s training 

and qualification program for license reviewers and inspectors, including the reimplementation, 

use, and update of licensing and inspection qualification cards for each staff member; (2) taking 

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

accordance with the inspection priority in NRC’s Inspection Manual Chapter 2800, “Materials 

Inspection Program”; (3) taking measures to ensure that inspection records and narrative 

reports are documented in accordance with the Program’s Inspection Manual; (4) ensuring that 

a Program supervisor or other appropriately qualified senior staff member accompany each 

inspector, at least annually, to ensure quality and consistency in the inspection program; (5) 

conducting initial and subsequent security-related inspections in a manner that provides for 

verification of licensee compliance with the requirements; and (6) adoption of all currently 

overdue regulations required for compatibility and adopt future regulation amendments within 

their required three year time frame. 

The review team recommended, and the MRB agreed, that the Rhode Island Agreement State 

Program be found adequate, but needs improvement, and compatible with NRC's program. 

Based on the results of the current IMPEP review, and in accordance with the criteria in NRC 

Management Directive 5.6, the review team recommended, and the MRB agreed, that NRC 

initiate a period of Monitoring for Rhode Island. The review team further recommended, and the 

MRB agreed, that a Periodic Meeting be held within one year of the current review and that a 

full IMPEP review take place in four years from the date of the current review. 
Rhode Island Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

The onsite portion of the review was conducted during the period of October 24-28, 2011, by a 

review team composed of technical staff members from the U.S. Nuclear Regulatory 

Commission (NRC) and the State of Ohio. 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 NRC Management Directive 5.6, 

“Integrated Materials Performance Evaluation Program (IMPEP),” dated February 26, 2004. 

Preliminary results of the review, which covered the period of October 27, 2007, to October 28, 

2011, were discussed with Rhode Island managers on the last day of the review. 

A draft of this report was provided to Rhode Island for factual comment on November 17, 2011. 

The State responded by electronic mail dated January 6, 2012. A copy of the State’s response 

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

January 17, 2012, to consider the proposed final report. The MRB found the Rhode Island 

Agreement State Program adequate, but needs improvement, and compatible with the NRC’s 

program. 

The Rhode Island Agreement State Program (the Program) is administered by the Office of 

Facilities Regulation (the Office), in the Division of Environmental and Health Services 

Regulation (the Division). The Division is part of the Rhode Island Department of Health (the 

Department). Organizational charts for the Program, the Office, the Division, and the 

Department are included as Appendix B. 

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

49 specific licenses authorizing byproduct, source, and certain special nuclear 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. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Program on June 27, 2011. The Program 

provided its response to the questionnaire via email on October 7, 2011, with supplemental 

information provided on October 11, 2011 and October 20, 2011. A publicly available version of 

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

Management System (ADAMS) using the Accession Number ML112840079. 

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 databases; (4) technical 

review of selected regulatory actions; (5) field accompaniments of two inspectors; and 

(6) interviews with staff and managers. The review team evaluated the information gathered 

against the established criteria for each common and the applicable non-common performance 

indicator and made a preliminary assessment of the Program’s performance. 
Rhode Island Final IMPEP Report Page 2 

Section 2.0 provides the status of recommendations from the previous IMPEP. The results of 

the review for the common performance indicators are presented in Section 3.0. Section 4.0 

details the results of the review of the applicable non-common performance indicator, and 

Section 5.0 summarizes the review team's findings and recommendations. The review team’s 

recommendations are comments that relate directly to the Program’s performance. 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 covered the period of November 18, 2003, to October 

25, 2007, the review team made two recommendations regarding program performance. The 

current status of the recommendations is as follows: 

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 NRC Inspection Manual Chapter (IMC) 2800. (Section 3.2 of the 2007 IMPEP 

report) 

Status: The review team calculated that the Program performed 28 percent of its Priority 1, 

2, and 3, and initial inspections overdue during the review period. The review team found 

no Priority 1, 2, and 3 inspections were overdue at the time of the review. Although no initial 

inspections were conducted overdue during the review period, one initial inspection was 

overdue at the time of the review. Based on the results from the current review, the review 

team is unable to close this recommendation and determined that the actions taken by the 

State to address the recommendation have not been effective. This recommendation 

remains open. 

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 of the 2007 

IMPEP report) 

Status: On October 26, 2011, the Program Manager published a memo to document the 

specific guidance to be used by Program staff when performing licensing actions. The 

memo documented: (1) the conditions under which the NRC NUREG-1556 series will be 

used; (2) the specific circumstances where Rhode Island requires submission and 

verification in addition to the information requested in the NRC NUREG-1556 series; and (3) 

the use of Rhode Island specific pre-licensing guidance. This recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review 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. 

 
Rhode Island Final IMPEP Report Page 3 

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 

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 four technical staff positions and a vacant Supervising Radiological 

Health Specialist (Program Supervisor) position. The four technical staff positions consist of 

three license reviewers/inspectors, whose roles vary in support of the Program, and an 

individual that provides support to emergency response and equipment maintenance. During 

the review period, one license reviewer/inspector left in January 2009 and then returned to the 

Program in June 2010. All four technical staff members provide partial support to the 

radioactive materials program ranging from 0.2 full-time equivalents (FTE) to 0.9 FTE. Based 

on discussions and information provided in response to the questionnaire, the team determined 

that 1.8 FTE are allocated to the radioactive materials program. This does not include the 

contribution from the vacant Program Supervisor position. With a total of 49 licenses, the level 

of staffing appeared adequate to perform the Program’s licensing and inspection activities. 

The Program Supervisor position has been vacant since October 2008. Efforts to fill the 

vacancy are ongoing; however, due to current State budget matters the position has not been 

allowed to be filled and is not expected to be approved to be filled in Rhode Island fiscal year 

2012. 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 dedicated 

fund for the Program allows the radioactive materials program to be financially self-sufficient, 

recovering associated costs through licensing fees. Even though this dedicated fund is in place, 

since the State as a whole currently has budget issues, the Program has not been approved to 

use these dedicated funds to fill the vacant position. 

The review team found that the Program trains its technical staff in a manner that is consistent 

with the requirements in the NRC/Organization of Agreement States Training Working Group 

Report and NRC’s Inspection Manual Chapter (IMC) 1246, “Formal Qualification Programs in 

the Nuclear Material Safety and Safeguards Program Area”, however this training and 

qualification program is not formally documented. The technical staff members have degrees in 

a physical or life science and have several years of professional experience in radiation 

protection. The Program uses on-the-job training to supplement formal coursework. Staff 

members are typically assigned increasingly complex duties as they progress through the 

qualification process. The review team found that while personnel file memoranda qualification 

cards were in place during the last IMPEP review, they have not been updated to reflect the 

current qualifications of the technical staff. At the time of the review, one technical staff member 

was a fully qualified license reviewer/inspector, and the other technical staff member was still 

completing the qualification process. As a result of the lack of formal documentation of the 

State’s training program and the lack of current or updated technical staff qualification cards, it 

was difficult to determine what was necessary for the one technical staff member to become 

fully qualified for licensing and inspection activities. The review team recommends that the 

State document its training and qualification program for license reviewers and inspectors, 
Rhode Island Final IMPEP Report Page 4 

including the reimplementation, use, and update of licensing and inspection qualification cards 

for each staff member. 

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

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

have expertise in radiation protection and radiation health. The Advisory Commission provides 

advice on radiation protection issues and regulations to the Program and meets on an asneeded basis. Since the Advisory Commission functions in a purely advisory capacity, the 

Program has the discretion to accept or reject direction it receives from the Advisory 

Commission. 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, 

be found satisfactory. 

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 all types of radioactive 

material licenses are at least the same frequency as NRC’s inspection frequencies, listed in 

NRC IMC 2800, “Materials Inspection Program.” The review team determined that the Program 

conducted a total of 42 inspections of Priority 1, 2, and 3 licensees during the review period. Of 

the 42 Priority 1, 2, and 3 inspections, the review team determined that 12 inspections were 

completed overdue during the review period by more than 25 percent of the inspection 

frequency prescribed by IMC 2800. The review team identified that at the time of the review, no 

Priority 1, 2, and 3 inspections were overdue by more than 25 percent of the inspection 

frequency prescribed by IMC 2800. Although inspections were conducted overdue throughout 

the review period, the number of inspections conducted overdue was higher at the beginning of 

the review period. After the December 2, 2009, Periodic Meeting with NRC, the Program 

increased its efforts to conduct inspections in a timely manner, resulting in fewer inspections 

being conducted overdue during the latter part of the review period. 

The review team determined that the Program issued four new licenses during the review 

period. Three of the initial inspections were conducted within one year of license issuance in 

accordance with Rhode Island’s equivalent inspection manual to NRC’s IMC 2800. The review 

team identified that one new license had not been inspected within one year of license issuance 

and was still overdue at the time of the review. As required by IMC 2800 and by Rhode Island’s 

equivalent inspection manual, initial inspections should be conducted within 12 months of 

license issuance. This applies even if the licensee still has not received licensed material. This 

criterion was discussed with Program management and staff and the review team determined 

that the reason this initial inspection had not been conducted was due to a misunderstanding of 
Rhode Island Final IMPEP Report Page 5 

the criteria for initial inspections of licensees that have not possessed licensed material or 

performed licensed activities. The Program committed to conducting this overdue initial 

inspection. Overall, the review team calculated that the Program performed 28 percent of its 

Priority 1, 2, and 3, and initial inspections overdue during the review period. 

The timely conduct of inspections has been an ongoing issue for the State. Specifically, the 

2002 IMPEP also identified issues with inspection timeliness, which led to the State being 

placed on Heightened Oversight. A follow-up IMPEP performed in 2003 found improvement in 

this area, which resulted in the State being taken off Heightened Oversight. During the 2007 

IMPEP review, the State was found satisfactory, but needs improvement for this indicator. The 

2007 IMPEP review did not make a determination as to the percent of overdue inspections 

during the review period, but noted that many inspections had been conducted overdue during 

the review period and several were overdue at the time of the review. The 2007 IMPEP made a 

recommendation that the State take appropriate measures to conduct Priority 1, 2, and 3 

inspections and initial inspections in accordance with the inspection priority in IMC 2800 

(Section 3.2 of the 2007 IMPEP report). Based on the results from the current review, the 

review team determined that the recommendation regarding conducting inspections in 

accordance with NRC’s IMC 2800 should remain open. 

The review team evaluated the Program’s timeliness of issuance of inspection reports. The 

Program has a policy of issuing the inspection findings to licensees within 30 days from the date 

of the inspection. Inspection reports were generally issued to the licensee within 30 days. Of 

the 42 inspection files reviewed, the review team identified five inspection findings that were 

issued beyond the 30-day goal. 

During the review period, the Program granted 49 reciprocity requests to candidate licensees 

based upon the criteria in IMC 1220, “Processing of NRC Form 241 and Inspection of 

Agreement State Licensees Operating under 10 CFR 150.20”. The review team determined 

that the Program was unable to consistently perform inspections of 20 percent of the reciprocity 

licensees annually. During calendar years 2008 and 2009, the Program inspected less than 20 

percent of candidate licensees operating under reciprocity. However, during calendar year 

2010 and for January thru October 2011 the Program inspected greater than 20 percent of 

candidate licensees operating under reciprocity. 

 

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

that Rhode Island’s performance with respect to the indicator, Status of Materials Inspection 

Program, be found unsatisfactory.

3.3 Technical Quality of Inspections

The review team evaluated 13 inspection reports that included inspection records, enforcement 

documentation and letters to licensees. The review team also interviewed the Program 

Manager as well as technical staff members who were responsible for radioactive materials 

inspections conducted during the review period. The casework reviewed covered a wide variety 

of inspection types, including academic broad scope, industrial radiography, nuclear pharmacy, 

self-shielded irradiators, and medical-written directives required. The casework reviewed 

represented inspections conducted by the two current members of the technical staff. Appendix 
Rhode Island Final IMPEP Report Page 6 

C lists the inspection casework files reviewed as well as the results of the inspector 

accompaniments performed by the review team. 

Based on the review of casework, the review team noted that the methodology for documenting 

inspections was based on the Program’s Radiation Control Agency Inspection Manual, dated 

May 18, 2002. The Program’s Inspection Manual directs the staff to document inspections in an 

inspection record or a narrative report. The review team found that it was the practice of the 

inspectors that for routine health and safety inspections, the inspectors duplicated the previous 

inspection record or narrative report and, if no violations were found during the current 

inspection, the current inspection record or narrative report largely remained the same with no 

additional documentation. However, if the inspectors identified a violation, they would document 

it in an inspection record or narrative report. The review team identified several casework files 

where the current inspection record or narrative report had been duplicated and was nearly 

identical to several previous inspection records or narrative reports. Because each inspection is 

a snapshot in time, it is unlikely that the snapshot remains the same from inspection to 

inspection. Furthermore, inspection observations of licensed activities are likely to vary from 

inspection to inspection. The duplication of the previous inspection record can result in a static 

inspection record that is fixed at a point in time several inspections prior to the current 

inspection. The review team found that although the inspection records and narrative reports 

were completely filled in by the inspectors, the technical quality of the information contained 

therein was lacking. For Increased Controls inspections, the review team found that it was the 

practice of the inspectors that if the previous inspection did not result in any violations, the 

current inspection was not documented in an inspection record or a narrative report. 

The Program’s Inspection Manual provides instructions to staff regarding methods to document 

inspection results. As described above, the review team found that the Program’s inspection 

documentation practices for inspection records and narrative reports often did not follow the 

Program’s Inspection Manual. As a result, inspection records and narrative reports did not 

contain sufficient detail to: describe the inspection that was conducted, areas inspected, or 

observations made; contain sufficient documentation to ensure that licensees’ performance with 

respect to health, safety and security were acceptable; provide the status of violations from 

previous inspections; or provide sufficient information to support identified violations. The 

issues with respect to inspection report or narrative report technical quality were compounded 

due to a lack of appropriate management review resulting from the vacancy of the Program 

Supervisor. The review team recommends that the State take measures to ensure that 

inspection records and narrative reports are documented in accordance with the Program’s 

Inspection Manual. 

The review team found that during the review period, the two inspectors had not been 

accompanied annually by a supervisor or other senior staff member during any year of the 

review period. The lack of supervisory accompaniments was due, in part, to the vacant 

Program Supervisor position. As noted in Office of Federal and State Materials and 

Environmental Management Programs (FSME) Procedure SA-102, “Reviewing the Common 

Performance Indicator, Technical Quality of Inspections,” in an Agreement State where there is 

a vacancy in a supervisory position, the accompaniments may be performed by an experienced 

senior staff member until the vacancy is filled. The review team recommends that a Program 

supervisor or other appropriately qualified senior staff member accompany each inspector, at 

least annually, to ensure quality and consistency in the inspection program. 
Rhode Island Final IMPEP Report Page 7 

The review team noted that the Program maintained appropriately calibrated survey instruments 

to support the inspection program. The instrumentation is calibrated by an outside vendor 

according to the manufacturer’s recommendations. The vendor utilizes National Institute of 

Standards and Technology traceable sources to perform calibrations. The Program uses a 

database to track each instrument, its current location, and next calibration date. 

 

A review team member accompanied the two inspectors during the week of September 26, 

2011. One inspector was a fully qualified inspector and the other inspector was qualified to 

independently inspect the license type selected for the accompaniment inspection. The license 

types inspected as part of the accompaniments included industrial radiography and veterinary 

therapeutic non-human use. Two of the inspections included a review of the licensee’s 

implementation of the Increased Controls. The accompaniments and associated comments are 

identified in Appendix C. 

The Program’s Radiation Control Agency Inspection Manual, dated May 18, 2002, as well as 

the recent revision dated October 2011, describes the approach to be taken by Program 

inspectors while conducting inspections. Both of these documents describe that inspector 

emphasis should be placed on observing licensee performance, and that the review of licensee 

records should be directed toward verifying that current operations are in compliance rather 

than a review of historical records, which should only occur if the inspector believes it is 

necessary to determine the presence of a persistent problem. During the inspector 

accompaniments, the review team member observed both inspectors spend the majority of their 

inspection time directed toward a review of historical records rather than observing licensed 

activities and licensee performance or interviewing workers. This matter was discussed with the 

inspectors, who indicated that they performed the inspections in this manner because this is the 

way they were trained and has become a normal practice for them. The review team member 

discussed this with the Program manager, who indicated that the Department is very focused on 

performance objectives and that he would begin taking measures to instill these practices on the 

Program technical staff. 

During the observed inspections of the Increased Controls and Fingerprinting requirements, the 

inspectors did not review or verify licensee compliance with many of the requirements. This 

matter was discussed with the inspectors, who indicated that the practice was that if the 

previous inspection did not result in any violations then the matter did not require review during 

future inspections. The practice of not verifying licensee compliance with many of the Increased 

Controls requirements is contrary to the purpose of performing an inspection. The Program 

may wish to review NRC’s inspection guidance related to initial Increased Controls inspections 

found in NRC Temporary Instruction 2800/038, “Inspection of the Implementation of Increased 

Controls for Licensees Authorized to Possess Risk Significant Radioactive Material,” dated 

March 30, 2006, and inspection guidance for subsequent inspections of Increased Controls 

licensees which was transmitted to the Agreement States in RCPD 07-006,”Continuing 

Inspections of Increased Controls Licensees,” dated September 27, 2007. The review team 

recommends that the State conduct initial and subsequent security-related inspections in a 

manner that provides for verification of licensee compliance with the requirements. 

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, 

be found satisfactory, but needs improvement. 
Rhode Island Final IMPEP Report Page 8 

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed the staff for 15 

licensing actions. 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 use of appropriate deficiency 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 five new 

licenses, one renewal, five amendments, and four terminations. Casework reviewed included a 

cross-section of license types, including: industrial radiography; medical broad scope; 

veterinary non-human use; stereotactic radiosurgery; academic broad scope; nuclear pharmacy; 

manufacturing and distribution; portable gauges; medical institution-written directive required; 

medical private practice; and research and development. A listing of the licensing casework 

reviewed can be found in Appendix D. 

All licensing actions received by the Program are assigned a log number in the Radiation 

Control Program computer tracking system. The licensing action is then assigned for review to 

one of two license reviewers for their action. The assigned license reviewer is responsible for 

reviews, deficiency letters, coordination with the licensee/applicant, and finalizing the licensing 

action. When a licensing action is completed, a senior staff member reviews the licensing 

action for quality and the Program manager signs and issues the licensing action. The review 

team noted that the licensing actions were consistent with the licensing guidance found in the 

State’s regulations as well as the NRC NUREG-1556 series “Consolidated Guidance About 

Materials Licensees.” 

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. 

The review team evaluated a license termination that was found to be a thorough and complete 

documentation of the termination process, to include an on-site inspection and verification of 

material transfer. The review team found that terminated licensing actions were welldocumented, showing appropriate material transfer and survey records. The review team noted 

that confirmatory surveys were conducted, when appropriate. 

 

The review team found that the Program addressed maximum possession limits on all active 

radioactive materials licenses as requested by the FSME Letter RCPD-10-007, “Requesting 

Implementation of a Policy on Maximum Possession Limits for Radioactive Materials Licenses” 

dated June 21, 2010. The review team noted that the licensing casework files examined had 

maximum possession limits in accordance with the guidance provided by NRC. 
Rhode Island Final IMPEP Report Page 9 

The review team assessed the Program’s implementation of NRC’s pre-licensing guidance 

issued on September 22, 2008, and transmitted to the Agreement States via FSME Letter 

RCPD-08-020, “Requesting Implementation of the Checklist to Provide a Basis for Confidence 

That Radioactive Material Will Be Used as Specified on a License and the Checklist for RiskSignificant Radioactive Material.” The Program had incorporated the NRC pre-licensing 

guidance into its own Rhode Island specific “Enhanced Pre-Licensing Guidance.” The review 

team found that the Program determined and documented the basis of confidence, through 

consistent use of the pre-licensing checklist and guidance, that radioactive materials will be 

used as intended and as described in the application or amendment request, prior to authorizing 

the material on the license. 

The review team verified that the Program used license conditions to require licensees to follow 

Increased Controls and Fingerprinting requirements. The review team determined that 

documents containing sensitive security-related information were appropriately controlled and 

maintained in a manner to limit access. The Program reviews documents requested under 

Rhode Island Code, Chapter 38-2, “Rhode Island-Access to Public Records” to determine 

whether the document should be withheld from public disclosure. 

Section 3.4 of the 2007 IMPEP report recommended 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. The review 

team found that when processing licensing actions, the Program consistently used the licensing 

guidance in the NRC NUREG-1556 series “Consolidated Guidance About Materials Licensees.” 

However, use of these licensing guidance documents was not a formalized policy within the 

Program. This matter was discussed with the Program Manager. Although the Program’s 

process was to follow the licensing guidance, the process had not been documented to ensure 

that a memorialized program exists to train and transfer knowledge to current and future staff. 

During the review, the Program manager held a staff meeting with the Program staff to discuss 

this issue. Following the meeting, on October 26, 2011, the Program Manager published a 

memo to document the Rhode Island specific guidance to be used by Program staff when 

performing licensing actions. The memo documented: (1) the conditions under which the NRC 

NUREG-1556 series will be used; (2) the specific circumstances where Rhode Island requires 

the submission and verification in addition to the information requested in the NRC NUREG1556 series; and (3) the use of Rhode Island specific pre-licensing guidance. This memo 

satisfies the recommendation from the 2007 IMPEP and the recommendation is considered 

closed. 

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, be found satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities

In evaluating 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 against those contained in the Program’s files, and evaluated the casework for 

four radioactive materials incidents. A listing of the casework examined, with case-specific 
Rhode Island Final IMPEP Report Page 10 

comments, can be found in Appendix E. The review team also evaluated the Program’s 

response to one allegation that was referred to the Program during the review period. The 

Program reported that it did not receive any other allegations during the review period. 

In evaluating the effectiveness of the Program's response to incidents and events, the review 

team evaluated the program’s response to four incidents. The incidents selected for review 

included incidents related to: contamination/transportation events, release of radioactive 

material, and a reported medical event. When incidents were reported to the Program by 

licensees, the Program in turn took actions consistent with the potential health and safety 

significance of the incident. For minor incidents, the Program typically followed up on the event 

through phone calls and emails for the licensee. In the case of the potential medical event, the 

Program conducted an onsite review that was performed by one of the members of the 

Program’s technical staff as well as an individual from outside of Program staff that had 

extensive training and experience in conducting investigations related to the medical arena. 

In evaluating the effectiveness of the Program's response to allegations, the review team 

identified one allegation that had been referred to the Program by NRC during the review 

period. The Program reported that they did not receive any other allegations during the review 

period. The review team found that the Program’s review of the allegation referred by NRC 

included an on-site inspection by a member of the Program staff and was appropriate with the 

potential health and safety significance of the allegation. 

When notification of an allegation or complaint is received, the Office’s Incident Response 

Coordinator enters the information into the Office-wide Aspen Complaints Tracking System 

(ACTS). The Office Incident Response Coordinator will review the allegation and contact the 

appropriate State program responsible for the allegation. The Office Incident Response 

Coordinator, working in consultation with the Program staff, determines the appropriate initial 

response to an allegation or complaint. As appropriate, the pertinent information is forwarded to 

the Program for investigation and follow-up and/or enforcement actions. The allegations are 

tracked to completion in ACTS. The review team noted that Rhode Island law requires that 

certain documents be made available upon request from a member of the public. The Program 

makes every effort to protect an alleger’s identity, but cannot guarantee that an alleger’s 

identification would not be released under applicable State laws or in the event of legal 

proceedings. 

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, be found satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

Four non-common performance indicators are used to review Agreement State Programs: 

(1) Compatibility Requirements, (2) Sealed Source and Device Evaluation Program, (3) Lowlevel Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. The NRC’s 

Agreement with the State of Rhode Island does not relinquish authority to regulate a sealed 

source and device evaluation program, or a uranium recovery program, so only the first and 

third non-common performance indicators were applicable to this review. 
Rhode Island Final IMPEP Report Page 11 

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 and Providence Plantations 

Department of Health Rules and Regulations for the Control of Radiation, Title 23, Chapter 23-

1.3. 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 Rhode Island General Laws-42-35-4.1, requiring all 

regulations promulgated by State agencies to be re-filed every five years to remain effective. 

The radiation control regulations were last filed in January 2007 and are due to be re-filed in 

January 2012. 

4.1.2 Program Elements Required for Compatibility 

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

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

compatibility policy, and verified the adoption of regulations with data obtained from the State 

Regulation Status Sheet that is maintained by FSME. 

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 initial timeframe for promulgation of a proposed regulation can vary depending on the 

complexity and number of regulations amended. The review team examined the State’s 

administrative rulemaking process and found that the process takes between four and 12 

months once the Program prepares a proposed regulation. This variance is due in part to the 

document being presented to the Rhode Island Radiation Advisory Commission for review and 

comment. Per Rhode Island statute Title 23, Chapter 23-1.3 the Advisory Commission is strictly 

consultative in nature and the Program has the discretion to accept or reject any 

recommendations that are made. After being reviewed by the Advisory Commission, the 

proposed regulations go through a Regulations Subcommittee for further review and 

modification to produce a final document. Once the regulations are adopted in final, the 

regulations are then filed with the Secretary of State and become effective 20 days after filing. 

Discussions with the staff indicated that there are no outside factors which affect the adoption of 

regulations within NRC’s three year time requirement. The State has the authority to issue 

legally-binding requirements (e.g., license conditions) in lieu of regulations until compatible 

regulations become effective. 
Rhode Island Final IMPEP Report Page 12 

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

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

team identified the following six amendments as overdue at the time of the review, including one 

that was identified as overdue during the previous IMPEP 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. 

• “Minor Amendments,” 10 CFR Parts 20, 30, 32, 35, 40, and 70 amendment (71 

FR 15005), that became effective March 27, 2006 and was due for Agreement 

State adoption on March 27, 2009. 

• “Medical Use of Byproduct Material – Minor Corrections and Clarifications,” 10 

CFR Parts 32 and 35 amendment (72 FR 45147 and 72 FR 54207), that became 

effective October 29, 2007 and was due for Agreement State adoption by 

October 29, 2010. 

• “Requirements for Expanded Definition of Byproduct Material,” 10 CFR Parts 20, 

30, 31, 32, 33, 35, 61, and 150 amendment (72 FR 55864), that became effective 

on November 30, 2007 and was due for Agreement State adoption by November 

30, 2010. 

• “Exemptions from Licensing, General Licenses, and Distribution of Byproduct 

Material: Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32, and 

150 amendment (72 FR 58473), that became effective December 17, 2007 and 

was due for Agreement State adoption by December 17, 2010. 

• “Occupational Dose Records, Labeling, Containers, and Total Effective Dose 

Equivalent,” 10 CFR Parts 19 and 20 amendment (72 FR 68043), that became 

effective on February 15, 2008 and was due for Agreement State adoption by 

February 15, 2011. 

Through discussions with the Program, the team determined that Rhode Island does have a 

plan in place to adopt the six currently overdue regulations which includes submission of final 

regulations to the NRC by the second calendar quarter of 2012. 

The State will need to address the following three amendments in upcoming rulemakings or by 

adopting alternate legally binding requirements: 

• “Medical Use of Byproduct Material – Authorized User Clarification,” 10 CFR Part 

35 amendment (74 FR 33901), that became effective on September 28, 2009 

and is due for Agreement State adoption by September 28, 2012. 

• “Licenses, Certifications, and Approvals for Materials Licensees,” 10 CFR Parts 

30, 36, 39, 40, 51, 70, and 150 amendment (76 FR 56951), that became effective 
Rhode Island Final IMPEP Report Page 13 

on November 14, 2011 and is due for Agreement State adoption by November 

14, 2014. 

• “Decommissioning Planning,” Parts 20, 30, 40, and 70 amendment (76 FR 

35512) that will become effective on December 17, 2012, and is due for 

Agreement State adoption by December 17, 2015. 

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

compatibility and adopt future regulation amendments within their required three year time 

frame. 

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, be 

found satisfactory, but needs improvement. 

4.2 Low-Level Radioactive Waste (LLRW) Disposal Program

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

Discontinuance of NRC 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 existing Agreements prior to 1981 were determined to have continued LLRW 

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

authority to regulate a LLRW disposal facility, NRC has not required States to have a program 

for licensing a disposal facility until such time as the State has been designated as a host State 

for a LLRW disposal facility. When an Agreement State has been 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 program. There are no plans 

for a commercial 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 above, the review team recommended, and the MRB agreed, 

that Rhode Island’s performance be found unsatisfactory for the performance indicator Status of 

the Materials Inspection Program; satisfactory, but needs improvement for the performance 

indicators Technical Quality of Inspections and Compatibility Requirements; and satisfactory for 

the three other indicators reviewed. The review team made six recommendations regarding the 

performance of the State. 

Overall, the review team recommended, and the MRB agreed, that the Rhode Island Agreement 

State Program be found adequate, but needs improvement, and compatible with NRC's 

program. 

Based on the results of the current IMPEP review, and in accordance with the criteria in NRC 

Management Directive 5.6, the review team recommended, and the MRB agreed, that a period 

of Monitoring be initiated for Rhode Island. Monitoring may be used in cases where 

weaknesses in a program result in a less than fully satisfactory performance for one or more 

performance indicators. Monitoring is an informal process that allows the NRC to maintain an 
Rhode Island Final IMPEP Report Page 14 

increased level of communication with an Agreement State program. The review team believes 

that Monitoring will be a useful tool in assessing the State’s progress toward addressing the 

programmatic issues and deficiencies identified during the review.

The review team further recommended, and the MRB agreed, that a Periodic Meeting be held 

within one year to assess the State’s progress in addressing the open recommendations. The 

team recommends that the next IMPEP review take place in approximately four years from the 

date of the current IMPEP. The review team believes that the performance of a Periodic 

Meeting within one year will provide time to assess the State’s progress and that if progress is 

not apparent, the timing of the next IMPEP review can be reassessed at that time. 

Below are the review team’s recommendations, as mentioned in the report, for evaluation and 

implementation by the State: 

1. The review team recommends that the State document its training and qualification 

program for license reviewers and inspectors, including the reimplementation, use, and 

update of licensing and inspection qualification cards for each staff member. (Section 

3.1) 

2. 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 in IMC 2800. (Section 3.2) 

3. The review team recommends that the State take measures to ensure that inspection 

records and narrative reports are documented in accordance with the Program’s 

Inspection Manual. (Section 3.3) 

4. The review team recommends that a Program supervisor or other appropriately qualified 

senior staff member accompany each inspector, at least annually, to ensure quality and 

consistency in the inspection program. (Section 3.3) 

5. The review team recommends that the State conduct initial and subsequent securityrelated inspections in a manner that provides for verification of licensee compliance with 

the requirements. (Section 3.3) 

6. The review team recommends that the State adopt all currently overdue regulations 

required for compatibility and adopt future regulation amendments within their required 

three year time frame. (Section 4.1) 
 

LIST OF APPENDICES 

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 

 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Janine Katanic, FSME Team Leader 

 Inspector Accompaniments 

Technical Quality of Inspections 

Technical Quality of Incident and 

 Allegation Activities 

 

Monica Orendi, Region I Technical Staffing and Training 

Status of Materials Inspection Program 

Compatibility Requirements 

Mark Light, Ohio Technical Quality of Licensing Actions 

 Technical Quality of Incident and 

 Allegation Activities 
APPENDIX B 

RHODE ISLAND ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML112840093
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Primary Flow Signal, Inc. License No.: 3D-140-01 

Inspection Type: Routine, Initial, Announced Priority: 1 

Inspection Date: 4/27/10 Inspector: DK 

File No.: 2 

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

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Dates: 6/14, 20/11 Inspector: DK 

Comments: 

1) The inspection report, which identified issues related to security as well as health 

and safety, was issued to the licensee on 10/7/2011, approximately 109 days after 

the date of the inspection. 

2) Based on the information contained in the inspection records, some of the violations 

issued to the licensee were not well developed or well documented. 

File No.: 3 

Licensee: Primary Flow Signal, Inc. License No.: 3D-140-01 

Inspection Type: Special, Initial, Announced Priority: 1 

Inspection Date: 4/27/10 Inspector: DK 

Comment: 

The special inspection record did not contain sufficient information related to the 

inspection findings and observations. 

File No.: 4 

Licensee: Rhode Island Blood Center License No.: 3E-100-01 

Inspection Type: Special Priority: 5 

Inspection Date: 7/28/10 Inspector: CW 

Comment: 

The special inspection observations were not formally documented because no 

violations were identified. 

 
Rhode Island Final IMPEP Report Page C.2 

Inspection Casework Reviews 

File No.: 5 

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

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 1/27/10 Inspector: DK 

Comment: 

The inspection was performed overdue (greater than 25% of the due date) by 

approximately 30 days. 

File No.: 6 

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

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Dates: 6/14, 15, 22/10 Inspector: DK 

Comment: 

The note to file dated 06/26/08 mentioned 3 specific areas that warranted review and 

verification during the next inspection. The inspection record did not document the 

inspector’s review of these 3 specific items. 

File No.: 7 

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

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 6/22/10 Inspector: DK 

File No.: 8 

Licensee: DiPrete Engineering, Inc. License No.: 3L-141-01 

Inspection Type: Initial, Unannounced Priority: 5 

Inspection Date: 3/2/11 Inspector: CW 

File No.: 9 

Licensee: Baker Testing Services, Inc. License No.: RMRA-08-011 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 5/12/08 Inspector: CW 

File No.: 10 

Licensee: St. Joseph Health Services License No.: 7B-025-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 4/2/08 Inspector: DK 

Comment: 

The inspection was performed overdue (greater than 25% of the due date) by 

approximately 30 days. 
Rhode Island Final IMPEP Report Page C.3 

Inspection Casework Reviews 

File No.: 11 

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

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/2/10 Inspector: DK 

Comments: 

1) The inspection was performed overdue (greater than 25% of the due date) by 

approximately 177 days. 

2) The inspection record refers to the inspector’s review of license conditions that were 

no longer part of the license at the time of the inspection. 

3) The inspection report was issued to the licensee on 11/16/10, approximately 106 

days after the date of the inspection. 

File No.: 12 

Licensee: Rhode Island Emergency Management Agency License No.: 8A-009-01 

Inspection Type: Routine and Special, Announced Priority: 5 

Inspection Date: 3/4/10 Inspector: DK 

Comments: 

1) The inspection reports, which identified issues related to security and health and 

safety, was issued to the licensee on 6/4/10, approximately 92 days after the date of 

the inspection. 

2) Some of the violations issued to the licensee were not well developed based on the 

information contained in the inspection records. 

File No.: 13 

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

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 1/NR/10-8/17/10 Inspector: DK 

Comments: 

1) The inspection report was issued to the licensee on 11/17/10, approximately 92 days 

after the date of the inspection. 

2) The inspection record did not document if a review was performed related to items of 

non-compliance that were identified during the previous inspection. 

3) The inspection record did not document a review of an incident that occurred in April 

2010. 

 
Rhode Island Final IMPEP Report Page C.4 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

The following inspector accompaniments were performed prior to the on-site IMPEP review: 

Accompaniment No.: 1 

Licensee: Ocean State Technical Services License No.: 3D-117-01 

Inspection Type: Routine and Special, Announced Priority: 1 

Inspection Date: 9/27/11 Inspector: CW 

Comments: 

1) The inspection of licensee implementation of security requirements warranted a 

more detailed review and verification of licensee implementation than what was 

performed by the inspector, especially considering that the facility layout had 

changed from the last inspection. 

2) The inspection was not in accordance with Program’s inspection guidance which 

directs the inspector to focus on observations rather than a review of records. Also, 

the inspector’s methodology for asking questions of the licensee did not facilitate 

verification of licensee compliance. 

Accompaniment No.: 2 

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

Inspection Type: Routine and Special, Announced Priority: 1 

Inspection Date: 9/28/11 Inspector: DK 

Comments: 

1) The inspection of licensee implementation of security requirements warranted a 

more detailed review and verification of licensee implementation than what was 

performed by the inspector. 

2) The inspector’s methodology for asking questions of the licensee did not facilitate 

verification of licensee compliance. 

Accompaniment No.: 3 

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

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 9/29/11 Inspector: DK 

Comments: 

1) The inspector’s methodology for asking questions of the licensee did not facilitate 

verification of licensee compliance. 

2) The inspector did not have a thorough understanding of the proper use and 

operation of radiation survey and measurement instrumentation and the concept of 

instrument efficiency. 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Primary Flow Signal, Inc. License No.: 3D-140-01 

Type of Action: New Amendment No.: 0 

Date Issued: 10/15/09 License Reviewer: DK 

File No.: 2 

Licensee: Roger Williams Radiation Therapy, LLC License No.: 7B-139-01 

Type of Action: New Amendment No.: 0 

Date Issued: 10/29/08 License Reviewer: WD 

File No.: 3 

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

Type of Action: Amendment Amendment No.: 38 

Date Issued: 07/12/10 License Reviewer: JF 

File No.: 4 

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

Type of Action: Renewal Amendment No.: 17 

Date Issued: 02/14/11 License Reviewers: JF, DK 

File No.: 5 

Licensee: DiPrete Engineering Associates License No.: 3L-141-01 

Type of Action: New Amendment No.: 0 

Date Issued: 05/20/10 License Reviewer: CW 

File No.: 6 

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

Type of Action: Termination Amendment No.: 21 

Date Issued: 07/31/09 License Reviewer: DK 

File No.: 7 

Licensee: Thermo Niton Analyzers, LLC License No.: 3G-105-02 

Type of Action: Termination Amendment No.: 14 

Date Issued: 07/31/09 License Reviewer: DK 

 
Rhode Island Final IMPEP Report Page D.2 

License Casework Reviews 

File No.: 8 

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

Type of Action: Amendment Amendment No.: 40 

Date Issued: 10/11/11 License Reviewer: DK 

Comment: 

The additional safety considerations for the specific model of irradiator (Standard 

License Condition 75, from NUREG-1556, Volume 20, “Consolidated Guidance About 

Materials Licenses: Guidance About Administrative Licensing Procedures”) were not 

included in the license conditions or alternately in tie-down documents to the license. 

File No.: 9 

Licensee: Navix Diagnostics License No.: 7B-109-01 

Type of Action: Termination Amendment No.: 07 

Date Issued: 7/12/10 License Reviewer: CW 

File No.: 10 

Licensee: Rhode Island Atomic Energy Commission License No.: 3K-063-01 

Type of Action: Termination Amendment No.: 25 

Date Issued: 04/13/09 License Reviewer: DK 

File No.: 11 

Licensee: Women’s and Infant’s Hospital of Rhode Island License No.: 1D-045-02 

Type of Action: Amendment Amendment No.: 17 

Date Issued: 03/14/08 License Reviewer: JF 

File No.: 12 

Licensee: Cardiovascular Institute of New England License No.: 7B-137-01 

Type of Action: New Amendment No.: 0 

Date Issued: 10/20/10 License Reviewer: CW 

File No.: 13 

Licensee: St. Joseph Health Services License No.: 7B-025-01 

Type of Action: Amendment Amendment No.: 20 

Date Issued: 07/20/2010 License Reviewer: CW 

File No.: 14 

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

Type of Action: Amendment Amendment No.: 3 

Date Issued: 09/24/10 License Reviewer: CW 

File No.: 15 

Licensee: ATC Associates License No.: 3L-142-01 

Type of Action: New Amendment No.: 0 

Date Issued: 04/15/11 License Reviewer: CW 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

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

Date of Incident: 12/22/2009 NMED No.: NA 

Investigation Date: 12/23/2009 Type of Incident: Contamination/Transportation 

Type of Investigation: Phone/email 

File No.: 2 

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

Date of Incident: 12/22/09 NMED No.: NA 

Investigation Date: 12/24/2009 Type of Incident: Contamination/Transportation 

Type of Investigation: Phone/email 

File No.: 3 

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

Date of Incident: 9/2/10 NMED No.: NA 

Investigation Date: 9/2/10 Type of Incident: Release of Radioactive Material 

Type of Investigation: Phone/email 

File No.: 4 

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

Date of Incident: 4/21/10 NMED No.: 100388 

Investigation Date: 5/11-20/10 Type of Incident: Medical 

Type of Investigation: Licensee Report, Site Visit 
ATTACHMENT(S) 

January 6, 2012 Letter from Raymond Rusin 

Rhode Island’s Response to the Draft Report 

ADAMS Accession No.: ML120090074