UNITED STATES

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

May 30, 2014 

Judson H. Turner, Director 

Georgia Department of Natural Resources 

Environmental Protection Division 

4244 International Parkway, Suite 120 

Atlanta, GA 30354 

Dear Mr. Turner: 

On April 15, 2014, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Georgia 

Agreement State Program (the Program). The MRB found the Georgia program adequate to 

protect public health and safety, but needs improvement, and compatible with the U.S. Nuclear 

Regulatory Commission’s (NRC) program. In addition, the MRB agreed with the team’s 

recommendation to recommend discontinuation of the period of Probation of the Georgia 

Agreement State Program and to place the Program on Heightened Oversight. The NRC staff 

is preparing to transmit this recommendation for Commission consideration by the end of June 

2014. The final decision for the discontinuance of Probation will be made by the Commission 

and will be transmitted to the Governor of Georgia under separate cover. 

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. We request your evaluation and response to the 

recommendations in the report within 30 days from receipt of this letter. Based on the results of 

the current IMPEP review, and subject to the Commission’s review the next full review of the 

Georgia Agreement State Program will take place in approximately 2 years, with a periodic 

meeting tentatively scheduled for January 2015. 

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: 

Georgia Final IMPEP Report 

cc: Lee Cox, North Carolina 

 Organization of Agreement States 

 Liaison to the MRB 

 David Crowley, Program Manager 

 Radiation Control Section 
Judson H. Turner, Director 

Georgia Department of Natural Resources 

Environmental Protection Division 

4244 International Parkway, Suite 120 

Atlanta, GA 30354 

Dear Mr. Turner: 

On April 15, 2014, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Georgia 

Agreement State Program (the Program). The MRB found the Georgia program adequate to 

protect public health and safety, but needs improvement, and compatible with the U.S. Nuclear 

Regulatory Commission’s (NRC) program. In addition, the MRB agreed with the team’s 

recommendation to recommend discontinuation of the period of Probation of the Georgia 

Agreement State Program and to place the Program on Heightened Oversight. The NRC staff 

is preparing to transmit this recommendation for Commission consideration by the end of June 

2014. The final decision for the discontinuance of Probation will be made by the Commission 

and will be transmitted to the Governor of Georgia under separate cover. 

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. We request your evaluation and response to the 

recommendations in the report within 30 days from receipt of this letter. Based on the results of 

the current IMPEP review, and subject to the Commission’s review the next full review of the 

Georgia Agreement State Program will take place in approximately 2 years, with a periodic 

meeting tentatively scheduled for January 2015. 

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: 

Georgia Final IMPEP Report 

cc: Lee Cox, North Carolina 

 Organization of Agreement States 

 Liaison to the MRB 

 David Crowley, Program Manager 

 Radiation Control Section 

DISTRIBUTION: (SP05) 

See next page 

ML14121A602 pkg 

OFC

ASPB/MSSA: 

TL ASPB/MSSA ASPB:BC MSSA: D TechEd FSME:D EDO/DEDMRT 

NAME MBeardsley via 

email w/edits 

LDimmick / adw DWhite w/edits LDudes / jmm CPoland BHolian MWeber 

DATE 05/02/14 05/05/14 05/05/14 05/06/14 05/13/14 05/16/14 05/30/14

OFFICIAL RECORD COPY 
Letter to J. Turner from Michael F. Weber dated: May 30, 2014 

SUBJECT: GEORGIA FY2014 FINAL IMPEP REPORT 

DISTRIBUTION: (SP08) 

RidsEdoMailCenter 

JFoster, OEDO 

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WDean, RI 

DLew, RI 

JClifford, RI 

JMarshall, RI 

RidsRgn3MailCenter 

DRoberts, RIII 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

RidsFsmeMssa Commissioner Svinicki 

JMoses, MSSA Commissioner Apostolakis 

MFord, RI/RSAO Commissioner Magwood 

JCook, RIV Commissioner Ostendorff 

BParker, RIII SECY 

JDaehler, MA 

DJanda, RI 

JWeil, OCA (2 copies)
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE GEORGIA AGREEMENT STATE PROGRAM 

January 27– February 10, 2014 

FINAL REPORT
EXECUTIVE SUMMARY 

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

(IMPEP) review of the Georgia Agreement State Program (the Program). The review was 

conducted during the period of January 27 - February 10, 2014, by a review team composed of 

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

Commonwealth of Massachusetts.

Based on the results of this review, Georgia’s performance was found satisfactory for the 

performance indicators, Technical Staffing and Training, Technical Quality of Licensing Actions, 

Technical Quality of Incidents and Allegation Activities, and Compatibility Requirements. The 

indicator, Technical Quality of Inspections, was found satisfactory, but needs improvement, and 

the indicator, Status of the Materials Inspection Program, was found unsatisfactory. Since the 

last IMPEP review, four of the indicators improved while one indicator, Status of the Materials 

Inspection Program, was downgraded, and one indicator, Compatibility Requirements, stayed 

the same. 

The review team made one new recommendation regarding program performance by the State 

for the indicator, Technical Quality of Inspections. Of the twelve recommendations made during 

the 2012 IMPEP review, the team determined that two recommendations for the indicator, 

Technical Quality of Licensing Actions should remain open since actions to address these are in 

progress; however, the MRB directed that one of the recommendations regarding the 

implementation of pre-licensing procedures be closed as the team determined that the Georgia 

Program is implementing the pre-licensing guidance. The MRB directed instead that a new 

recommendation be added for the State to formally write the pre-licensing guidance into its 

official licensing procedures and provide training to the staff. The team determined, and the 

MRB agreed, that eight of the recommendations from the 2012 IMPEP review regarding 

program performance for the indicators, Status of the Materials Inspection Program, Technical 

Quality of Inspections and Technical Quality of Incident and Allegation Activities, can be closed. 

The two recommendations regarding the Sealed Source and Device program are no longer 

applicable, and are therefore closed, as the authority for this program was returned by the State 

to the NRC in August 2013. 

Accordingly, the review team recommended, and the MRB agreed, that the Program is 

adequate, but needs improvement to protect public health and safety, and is compatible with the 

NRC's program. Due to the State’s significant progress in addressing previous 

recommendations, the noted improvement in staff and management communications, and the 

strong commitment from Program management to continue to improve performance as 

evidenced by the actions taken since the last IMPEP review (including the replacement of the 

Program manager and the additional resources allocated for staffing), the review team 

recommended, and the MRB agreed, that the Program be removed from Probation and placed 

on Heightened Oversight. The MRB noted that the Commission will make the final decision 

regarding discontinuance of probation for the Georgia Program. 

The review team recommended, and the MRB agreed, that the next IMPEP review take place in 

approximately two years from the Management Review Board meeting that was held on April 

15, 2014, and that a periodic meeting be held in approximately one year from this IMPEP review 
to assess the State’s sustained performance and progress. The MRB directed that the periodic 

meeting include a focused review of the State’s inspection program, specifically inspector 

accompaniments and implementation of inspection procedures, and progress in addressing the 

performance issues identified in the report. 
Georgia Final IMPEP Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the review of the Georgia Agreement State Program. The 

review was conducted during the period of January 27 - February 10, 2014, by a review team 

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

the Commonwealth of Massachusetts. 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 26, 2012 to January 31, 

2014, were discussed with Georgia managers on the last day of the review. 

A draft of this report was issued to Georgia for factual comment on March 5, 2014. The State 

responded by letter dated April 2, 2014 (included as an Attachment to this report). The 

Management Review Board (MRB) met on April 15, 2014, to consider the proposed final report. 

The MRB found the Georgia Agreement State Program adequate to protect public health and 

safety, but needs improvement and compatible with the NRC’s program. 

The Radioactive Materials Program (the Program) is administered by the Air Protection Branch 

(the Branch) which is located within the Environmental Protection Division (the Division). 

The Division is part of the Department of Natural Resources (the Department). Organization 

charts for the Department, Division, and the Branch are included as Appendix B. 

At the time of the review, the Program regulated 471 specific licenses authorizing possession 

and use of radioactive 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 Georgia. 

In preparation for the review, a questionnaire addressing the common and applicable 

non-common performance indicators was sent to the Program on June 20, 2013. The Program 

provided its response to the questionnaire by email dated January 10, 2014. A copy of the 

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

Management System (ADAMS) using the Accession Number ML14014A159. 

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 Georgia statutes and 

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

review of selected regulatory actions, (5) field accompaniments of six Program 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 Georgia Agreement State Program’s 

performance. 

 
Georgia Final IMPEP Report Page 2 

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

during previous reviews. 

Results of the current review of 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 

indicators, and Section 5.0 summarizes the review team's findings. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on October 26, 2012, the review team 

made 12 recommendations regarding the Georgia Agreement State Program’s performance. 

The status of each recommendation is as follows: 

1. “The review team recommends that the State develop and implement a plan to complete 

higher priority and initial inspections in accordance with the inspection frequencies 

specified in IMC 2800. (Section 3.2)” 

Status: To initially address this recommendation, the Program developed and 

implemented a plan to complete higher priority and initial inspections in January 2013. 

This plan involved creating a spreadsheet of all known overdue inspections and 

organizing them by priority code. The inspections were then assigned to staff with the 

focus being on completing the most safety significant inspections first. The spreadsheet 

was discussed at each weekly staff meeting in order to monitor the progress of 

completing the overdue inspections. In November 2013 the Program implemented a 

new database which is being used to track inspections and licensing actions. This 

system is utilized in the license writing process as well. This database was a copy of a 

database being used by another Agreement State Program. The manager of that 

Agreement State Program helped the Program install and populate the database for 

their use. In populating the new database the program uncovered additional inspections 

that were overdue for inspection. At the time of the onsite review, the Program was in 

the process of completing these overdue Priority 1, 2, 3 and initial inspections. During 

the April 2014 MRB meeting, the Program reported it had completed all overdue 

inspections. This recommendation is closed. 

2. “The review team recommends that the State update its inspection procedures to include 

the most recent revisions to Inspection Manual Chapter 2800, including the 

implementation of inspection guidance for NSTS reviews. (Section 3.3)” 

Status: The Program completed the update of its inspection procedures in May 2013 to 

include the most recent revisions to Inspection Manual Chapter 2800, including the 

implementation of inspection guidance for NSTS reviews. This recommendation is 

closed. 

3. “The review team recommends that the State perform Increased Controls security 

inspections at least as frequently as the priority of the license being inspected. (Section 

3.3)” 

 
Georgia Final IMPEP Report Page 3 

Status: The Program updated its inspection procedures to address performance of 

Increased Controls security inspections to be at least as frequent as the priority of the 

license being inspected. The team determined that the Program successfully 

implemented its procedure related to Increased Controls security inspection frequency 

and performs Increased Controls security inspections at least as frequently as the 

priority of the license being inspected. This recommendation is closed. 

4. “The review team recommends that the State perform a causal analysis regarding the 

deficiencies identified during the NRC accompaniments of the Program inspectors, as 

documented in this section as well as Appendix C of this report, and formulate corrective 

actions for the causes identified during this analysis. (Section 3.3)” 

Status: The Program performed a causal analysis regarding the deficiencies identified 

during the NRC accompaniments of the Program inspectors, as documented in Section 

3.3 as well as Appendix C of the 2012 IMPEP report dated February 5, 2013. The team 

verified that the Program formulated corrective actions for the causes identified during 

this analysis which included completion by inspectors of inspection preparation 

checklists that are discussed upon and reviewed by management before performance of 

inspections; and knowledge transfer and discussions of inspection performance and 

activities amongst staff and management during weekly staff meetings. This 

recommendation is closed. 

5. “The review team recommends that the State update its medical licensing guidance 

documents to be consistent with Georgia regulations. (Section 3.4)” 

Status: In August 2013 the Program completed actions to update their medical licensing 

guidance to include the new regulatory requirements regarding authorized user training 

and experience, including the need for preceptor attestation. The review team confirmed 

that license reviewers are implementing the updated guidance. This recommendation is 

closed. 

6. “The review team recommends that the State verify that all previously approved medical 

authorized users have proper documentation of their qualifications, since the new 

requirements were initiated in 2008. (Section 3.4)” 

Status: Since the previous review, the State devoted two full time employees over two 

months to identify how many authorized users (AUs), radiation safety officers (RSOs), 

authorized nuclear pharmacists (ANPs), and/or authorized medical physicists (AMPs) 

may have been added to a license prior to receiving all necessary credentialing 

documentation. In addition, the Program performed a search of the Nuclear Materials 

Events Database (NMED) for any medical events involving the identified authorized 

users; no events were found. However, due to a prioritization of more immediate health 

and safety issues within the State, program management decided to collect the 

appropriate documentation during future amendment, renewal, or notification actions for 

those licenses listing the identified authorized users. The State’s proposed actions for 

completion of this activity were submitted in their Program Improvement Plan in 

response to the 2012 IMPEP report on March 7, 2013 (ML13070A161). The NRC staff 

approved the Plan and responded to the Georgia Agreement State Program on April 4, 
Georgia Final IMPEP Report Page 4 

2013 (ML13084A029). In addition, bimonthly calls are being held between the Program 

and the NRC staff which monitor the State’s progress in addressing this and the other 

recommendations from the previous IMPEP review. The State plans to actively pursue 

the appropriate credentialing documentation for AUs, RSOs, ANPs, and/or AMPs 

beginning May 2014. From the casework reviewed, the team confirmed that preceptor 

attestation statements were reviewed as appropriate for licenses issued during the 

review period; however the Program is in the process of addressing this on applicable 

licenses issued since 2008 and at the time of this review, actions have not been 

completed. This recommendation remains open. 

7. “The review team recommends that the State implement pre-licensing guidance for all 

licensing actions to provide assurance that radioactive material will be used as specified 

on the license. (Section 3.4)” 

Status: After the last IMPEP review, the NRC conducted training on the proper 

completion of pre-licensing activities. Since this training, it has been the State’s internal 

policy to complete this pre-licensing basis for confidence. The review team confirmed 

that license reviewers are evaluating new license applications and license amendments 

using a program which incorporates the essential elements of the NRC’s revised prelicensing guidance to verify that the applicant will use requested radioactive materials as 

intended. This recommendation is closed. 

 

8. “The review team recommends that the State develop, document, provide training to the 

Program staff on, and implement a procedure to notify the NRC of reportable incidents in 

a complete, timely and accurate manner in accordance with Office of Federal and State 

Materials and Environmental Management Programs Procedure SA-300 “Reporting 

Material Events. (Section 3.5)” 

Status: The team found that the State developed a procedure for the proper reporting of 

events to the NRC. Training on this procedure was given to the staff in August 2013. 

From the casework reviewed, the team determined that the State provided notification to 

the NRC for all events requiring reporting. This recommendation is closed. 

9. “The review team recommends that the State strengthen its incident response program 

and take measures to (1) develop, document, implement, and provide training to the 

Program on the incident response procedure; (2) ensure that reported incidents are 

promptly evaluated to determine the appropriate type and level of Program response, 

including providing for Program management notification and review; (3) ensure that 

incidents are responded to with an appropriate level of effort and in a timeframe 

commensurate with the potential health and safety and/or security consequences of the 

incident; (4) ensure that licensee written reports are reviewed for completeness and 

appropriate corrective actions; and (5) ensure that the Program’s evaluation of licensee 

incidents, whether based on a review of licensee reports, on-site reviews, or inspection 

followup, is properly documented to facilitate future followup. (Section 3.5)” 

Status: The team found that the State had developed a comprehensive program which 

addresses all aspects of incident evaluation, handling, response and documentation. 

Training on this procedure was given to the staff in August 2013. From the files 
Georgia Final IMPEP Report Page 5 

reviewed, the team determined that the staff is implementing the procedure and taking 

actions appropriate to the type of incident. The team confirmed that management 

reviews each case and provides feedback as to whether the action can be closed or if 

additional action or information is needed. This recommendation is closed. 

10. “The review team recommends that the State revise, enhance, implement, and provide 

training to the staff on its Allegation Procedure, including providing additional written 

guidance on (1) recognizing and identifying allegations; (2) notifying Program 

management of all received allegations; (3) promptly evaluating allegations for safety 

and security significance; (4) ensuring that the level of effort and timeliness in 

responding to allegations is commensurate with the potential significance of the 

allegation; and (5) tracking all allegations to ensure timely review and closure and timely 

feedback to allegers. (Section 3.5)” 

Status: The team found that the State has revised its Allegation procedure to include the 

proper identification, response and reporting of allegations. Training on this procedure 

was given to the staff in August 2013. From the files reviewed, the team determined that 

all three allegations received by the State were properly documented, responded to and 

reported to the Program manager for further followup actions and closure. This 

recommendation is closed. 

11. “The review team recommends that the State qualify one additional reviewer in SS&D 

evaluations to provide backup for the principal reviewer. This is in addition to a qualified 

reviewer or supervisor performing concurrence reviews. (Section 4.2 of the 2004 IMPEP 

report and 2012 IMPEP report).” 

Status: Georgia returned its authority for the Sealed Source and Device Program in 

August 2013; therefore this recommendation is closed. 

12. “The review team recommends that the State develop and implement a plan to inactivate 

SS&D registrations for devices and sources that are no longer being made or distributed. 

(Section 4.2.2)” 

Status: Georgia returned its authority for the Sealed Source and Device Program in 

August 2013; therefore 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. 

3.1 Technical Staffing and Training

Considerations 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 
Georgia Final IMPEP Report Page 6 

to this indicator, interviewed managers and staff, reviewed job descriptions and training records, 

and considered workload backlogs. 

At the time of the review, there were nine technical staff members and a program manager 

totaling approximately 10 full-time equivalents (FTE); this was increased from the 2012 IMPEP 

review where the staffing plan was 6 technical staff members and a program manager. Five of 

the nine technical staff members are fully qualified to perform inspection and licensing 

activities. The other four technical staff members are at various points in the qualification 

process and program management expects that all staff will be fully qualified by August 2015. 

Each technical staff member has at least a Bachelor’s degree in a physical science and has 

between 6 months and 18 years of experience with the Program. There were four new hires 

during the review period. At the time of the last IMPEP review, there were two vacant 

technical staff positions and one technical staff position was removed. The Program manager 

left the Program during the current review period and one of the new hires was appointed to 

this position. There were no vacant positions at the time of the review; however, the team was 

informed by program management that one technical staff member resigned the week after the 

IMPEP review. The technical staff who resigned had only been with the program for six 

months and was not yet a fully qualified inspector or license reviewer. Program management 

will begin the process to post and fill the vacant position. 

The Program updated its formal training and qualification process in June 2013. The new 

training plan for technical staff is consistent with the requirements in the NRC/Organization of 

Agreement States Training Working Group Report and the NRC’s Inspection Manual Chapter 

(IMC) 1248, “Formal Qualifications Programs for Federal and State Materials and Environmental 

Management Programs.” Two technical staff members were hired since the process was put 

into place and both are being trained utilizing the new process. The review team concluded that 

the Program’s documented training program is adequate to carry out its regulatory duties and 

noted that program management supports the training program. 

During the previous IMPEP review, the review team noted significant communication issues 

between staff and management which affected the ability of the program to manage its health 

and safety responsibilities. During the current IMPEP review, the team noted that the 

communication between program management and staff had greatly improved. Several 

changes were made during the 15 months since the October 2012 IMPEP review, including the 

appointment of a new program manager and the addition of weekly staff meetings. Program 

staff consistently stated to the team that they felt more comfortable discussing licensing and 

inspection questions with fellow staff and program management, and that they felt more like a 

team instead of individuals. 

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

that Georgia’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 while 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 
Georgia Final IMPEP Report Page 7 

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

Program’s database, examination of completed inspection casework, and interviews with 

management and staff. 

The review team verified that the Program’s inspection frequencies for all types of radioactive 

material licenses are at least as frequent as similar license types listed in IMC 2800, “Materials 

Inspection Program.” In addition, the review team confirmed the Program is conducting 

Increased Controls inspections in conjunction with routine health and safety inspections. 

The Program reported that it conducted approximately 70 high priority (Priority 1, 2, and 3) 

inspections during the review period, based on the inspection frequencies established in IMC 

2800. Thirty of these inspections were conducted overdue by more than 25 percent of the 

inspection frequency prescribed in IMC 2800. In addition, the Program performed 21 initial 

inspections during the review period, 13 of which were conducted overdue. As required by IMC 

2800, initial inspections need to be conducted within 12 months of license issuance. Twelve 

inspections, both high priority and initial, were overdue at the time of the review. The Program 

is in the process of working off an inspection backlog that was identified during the previous 

IMPEP review. Based on a recommendation from the previous IMPEP review the Program 

installed a new database to help track inspections to ensure that they are not conducted past 

their due date. In populating this database, the Program discovered additional inspections that 

were overdue which added to the backlog. The Program manager stated that the Program 

would be caught up on all overdue inspections by the MRB meeting, and reported at the April 

2014 MRB meeting that the Program was current on inspections. Overall, the review team 

calculated that the Program performed 53 percent of its inspections overdue during the review 

period. The review team evaluated the Program’s timeliness in providing inspection findings to 

licensees. A sampling of 15 inspection reports indicated that 2 inspection findings were 

communicated to the licensees greater than the Program’s goal of 30 days after the inspection. 

One report had violations associated with the inspection and was sent out two months after the 

inspection, and the other report had no violations associated with the inspection and was sent 

out four months after the inspection. 

During the review period, the Program granted 26 reciprocity permits. The review team 

determined that the Program inspected approximately 19 percent of candidate licensees 

operating under reciprocity in the year covered by the review period. This is below the NRC’s 

criteria of inspecting 20 percent of candidate licensees operating under reciprocity as stated in 

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

Operating under 10 CFR 150.20.” 

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

that Georgia’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 the inspection reports, enforcement documentation, inspection field 

notes, and interviewed 5 of the 10 inspectors for 15 radioactive materials inspections conducted 

during the review period. The casework reviewed covered inspections of various license types: 

medical broad scope, medical institutions-therapy including high dose rate remote afterloader 
Georgia Final IMPEP Report Page 8 

(HDR), unsealed radioiodine therapy, permanent implant brachytherapy, radionuclide 

production (cyclotron), medical-diagnostic, portable gauges, industrial radiography, self-shielded 

irradiators, gamma knife, nuclear pharmacy, HDR mobile medical services, nuclear laundry, 

academic broad scope, manufacturing and distribution and Increased Security Controls for 

Large Quantities of Radioactive Materials (Increased Controls). 

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

outlined in IMC 2800. An inspection report is completed by the inspectors which is then 

discussed and reviewed by the Program Manager prior to the issuance of inspection results to 

the licensee. 

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

aspects of the licensee’s radiation safety programs, the documentation supported 

recommendations made to licensees, unresolved safety issues, the effectiveness of corrective 

actions taken to resolve previous violations and discussions held with licensees during exit 

interviews. The team found that inspection findings were appropriate, clearly stated and 

documented, and prompt regulatory actions were taken, as necessary. Inspection findings were 

documented in the reports and sent to the licensees with the appropriate letter detailing the 

results of the inspection in 9 of the 15 files. In 6 of the 15 case files reviewed, the team 

determined that the inspectors did not follow the Program’s procedures for the classification and 

documentation of violations including the determination of the frequency of the next inspection, 

the reason for not inspecting temporary job sites, and specifics of the violations cited. Although 

the Program’s inspection procedures discuss what action to take for different severity level 

violations, the Program had not completed or fully utilized its procedure for assigning severity 

level or seriousness of violations. Appendix C lists the inspection casework files reviewed, with 

case-specific comments, as well as the results of the inspector accompaniments. The Program 

has been working on revising its enforcement policy and procedure that includes how severity 

levels may be assigned and additional actions necessary dependent on the severity level. The 

Program issues to the licensee, either a letter indicating a clear inspection or a Notice of 

Violation (NOV), in letter format, which details the results of the inspection. When the Program 

issues an NOV, the licensee is asked by the Program to provide a written corrective action plan 

based on the violations cited, within 30 days. All findings are reviewed by the Program 

Manager. 

The Program made considerable efforts to develop and update its inspection procedures in May 

2013 to be equivalent to IMC 2800. The Program provided training to staff on the updated 

inspection procedures on July 23, 2013, and plans to review its inspection procedures at six 

month intervals. From discussions with Program management, the team determined that the 

Program has not had enough time to address complete implementation of its inspection 

procedures, including ensuring that inspectors conduct performance-based inspections and 

other performance issues that were identified during the inspector accompaniments detailed 

later in this section of the report. Program management discussed the results of the causal 

analysis performed in response to the previous IMPEP recommendation. The team verified that 

the Program formulated corrective actions for the causes identified during this analysis which 

included completion by inspectors of inspection preparation checklists that are discussed upon 

and reviewed by management before performance of inspections; and knowledge transfer and 

discussions of inspection performance and activities amongst staff and management during 

weekly staff meetings. 
Georgia Final IMPEP Report Page 9 

Accompaniments of six Program inspectors were conducted by an IMPEP team member during 

the weeks of August 5 and December 16, 2013. A re-accompaniment of one inspector was 

performed by another team member on November 6, 2013. The inspectors were accompanied 

during health and safety and security inspections of medical institutions with therapy [high dose 

rate remote afterloader (HDR) and permanent brachytherapy], industrial radiography, 

self-shielded irradiator, nuclear laundry and PET production and distribution 

(cyclotron-pharmacy). The accompaniments, with case specific comments, are identified in 

Appendix C. During the accompaniments, three of the six inspectors demonstrated appropriate 

inspection techniques. During two of the three medical inspection accompaniments, the team 

member found that the inspectors did not verify whether the licensee had any medical events 

through examination of the written directives (prescribed vs. administered dose). The 

inspectors were unaware of the revised IMC 2800 Inspection Procedure (IP) 87132 issued in 

April 2012 which addresses this issue. One of the inspectors had just been qualified to perform 

brachytherapy inspections. In addition, when one of the inspectors questioned the authorized 

medical physicist (AMP) about how he verifies if any medical events occurred, he stated that he 

was unaware of this requirement, and further added that he had never been inspected on this 

before. This AMP is authorized on multiple licenses which perform brachytherapy treatments. 

The team member determined that this inspector did not possess the training and experience 

necessary to be qualified to perform brachytherapy inspections. It was noted during the MRB 

meeting that this inspector had left the Program after the review. During an accompaniment of 

the other medical-therapy inspection (HDR remote afterloader), the inspector failed to respond 

immediately to a security breach in which it appeared that the licensee had allowed unescorted 

access to personnel who did not have the appropriate trustworthy and reliability clearance. The 

Program requested that this inspector be re-accompanied. Another team member performed an 

accompaniment of this inspector during an HDR inspection in November 2013. The team 

member found that the inspector examined appropriate records to confirm that no medical 

events had occurred; however, the team member noted that the inspector would benefit from 

additional brachytherapy training. During an accompaniment of a PET production pharmacy, 

the team member found that the inspector missed valuable opportunities to evaluate the 

licensee’s performance while activities were ongoing. The inspector instead focused on the 

inspection checklist. As stated previously, the Program revised its inspection procedures in 

accordance with IMC 2800 which requires performance-based inspections. The team 

determined that the inspectors need to implement IMC 2800 which requires performance-based 

inspections. The team also advised program management that these inspectors would benefit 

from attending the newly revised brachytherapy training course. Overall, the team did not 

identify any missed health and safety issues during the accompaniments, and determined that 

the inspections were adequate to assess radiological health and safety and security at the 

licensed facilities. The review team recommends that the State: (1) implement its inspection 

procedures to ensure that inspectors document the reason for missing temporary job site 

inspections; document details and circumstances of violations in inspection reports and NOVs; 

consider an increase in inspection frequency for serious violations and conduct performance 

based inspections; and (2) complete its enforcement procedure for assigning severity levels of 

violations. The team discussed with Program managers the effectiveness of the corrective 

actions taken as a result of the previous causal analysis, as performance issues with inspectors 

were also identified as part of this review. The managers believe that constant reinforcement of 

procedures and expectations through training and the weekly staff meetings will, over time, 

result in improved performance. 
Georgia Final IMPEP Report Page 10 

The review team found that accompaniments of inspectors by supervisors were not conducted 

annually for all inspectors during the review period. Two of the six qualified inspectors were not 

accompanied; these included one inspector for whom an NRC inspector performed an 

accompaniment and an inspector who had briefly left and subsequently returned to the 

Program. The review team discussed with Program management the importance of performing 

annual supervisory accompaniments systematically to assess performance and assure 

application of appropriate and consistent policies and guides. The Program Manager committed 

to perform supervisory accompaniments beginning in 2014, of all qualified inspection staff. 

The review team noted that the Program has an adequate supply of survey instruments to 

support its inspection program. Appropriate, calibrated survey instrumentation, such as 

Geiger-Mueller (GM) meters, scintillation detectors, ion chambers, micro-R meters, and neutron 

detectors, was observed to be available. The Program also has portable multi-channel 

analyzers and a mobile laboratory having a liquid scintillation counter, high purity germanium 

detectors, and gas proportional alpha/beta counters. Instruments are calibrated at least 

annually, or as needed, by persons specifically licensed to perform instrument calibrations that 

use National Institute of Standards and Technology traceable sources. 

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

that Georgia’s performance with respect to the indicator, Technical Quality of Inspections, be 

found satisfactory, but needs improvement. 

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed license reviewers for 

18 specific licenses. Licensing actions were reviewed for completeness, consistency, proper 

radioisotopes and quantities, qualifications of authorized users, adequacy of facilities and 

equipment, adherence to good health physics practices, financial assurance, operating and 

emergency procedures, appropriateness of license conditions, 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 signature 

authority. 

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

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

new licenses, six amendments, six renewals, and two termination actions. Files reviewed 

included a cross-section of license types: medical with and without written directive required, 

industrial radiography, mobile nuclear medicine, gamma stereotactic radiosurgery, research 

and development, nuclear pharmacy, fixed and portable gauges, manufacturer and distributor 

generally licensed devices, and brachytherapy. The casework sample represented work from 

all current license reviewers. A list of the licensing casework evaluated is provided in 

Appendix D. 

The Program has nine full time license reviewer staff positions. Currently there are seven 

license reviewers with signature authority. New license reviewers who are working on getting 

signature authority for licensing casework utilize a qualification journal and are assigned a 

mentor who eventually provides signature on the action. Mentored work is subject to an 
Georgia Final IMPEP Report Page 11 

independent secondary review by someone else with signature authority. Licensing actions 

are assigned by administrative and managerial staff directly to the license reviewer. After the 

initial technical review is completed, the action will undergo a peer review. The action is then 

processed and logged into an electronic tracking system. Since the last IMPEP review the 

Program has installed and is implementing a new system/database to process its licenses 

which the Program reports has improved the transparency of licensing work and is proving to 

be extremely useful in holding staff accountable for their work products. 

The Program’s licensing metric for new and renewal licensing actions is that they be 

completed within six weeks of receipt; amendments and terminations are to be completed 

within four weeks of receipt; and notifications are to be completed within two weeks of receipt. 

License tie-down conditions, including security requirements, were stated clearly and were 

inspectable. Deficiency letters were usually sent via email and follow-up telephone calls were 

made and documented, as appropriate. Both deficiency letters and follow-up telephone calls 

clearly stated regulatory positions, were used at the proper time, and identified substantive 

deficiencies in the licensees’ documents. Licenses are issued for a five year period under a 

timely renewal system. 

License reviewers use the Program’s licensing guides that are similar to the NUREG-1556 

Series. As of August 2013, the Program has completed actions to update its medical licensing 

guidance to include the new regulatory requirements regarding authorized user training and 

experience, including the need for preceptor attestation. In response to the recommendation 

made during the last IMPEP review regarding licensing actions which authorized physician 

users on the license without proper documentation to verify the training, experience, and 

preceptor attestation, the State devoted two full time employees over two months to identify how 

many authorized users (AUs), radiation safety officers (RSOs), authorized nuclear pharmacists 

(ANPs), and/or authorized medical physicists (AMPs) may have been added to a license prior to 

receiving all necessary credentialing documentation. In addition, the Program performed a 

search of the NMED database for any medical events involving the identified authorized users; 

no events were found. However, due to a prioritization of more immediate health and safety 

issues within the State, program management decided to collect the appropriate documentation 

during future amendment, renewal, or notification actions for those licenses listing the identified 

authorized users. The State’s proposed actions for completion of this activity were submitted in 

their Program Improvement Plan in response to the 2012 IMPEP report, on March 7, 2013 

(ML13070A161). The NRC staff approved the Plan and responded to the Georgia Agreement 

State Program on April 4, 2013 (ML13084A029). In addition, bimonthly calls are being held 

between the Program and the NRC staff which monitor the State’s progress in addressing this 

and the other recommendations from the previous IMPEP review. The State plans to actively 

pursue the appropriate credentialing documentation for AUs, RSOs, ANPs, and/or AMPs 

beginning May 2014. The review team noted that the casework reviewed demonstrated that 

license reviewers were implementing this requirement currently. 

The review team confirmed that license reviewers are evaluating new license applications and 

license amendments using a three-step program which incorporates the essential elements of 

the NRC’s revised pre-licensing guidance to verify that the applicant will use requested 

radioactive materials as intended. The team reviewed four new licenses and confirmed that all 

received a pre-licensing visit. In addition, as specified in its Performance Improvement Plan and 

Progress Report, the Program has updated its procedures and implemented the pre-licensing 
Georgia Final IMPEP Report Page 12 

guidance for all licensing actions to ensure consistency with RCPD 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.” As the Program has not completed all actions to address the 

previous recommendation regarding the implementation of pre-licensing guidance for all 

licensing actions, the team, as directed by the MRB, recommends that the Georgia Program 

finalize the pre-licensing procedure and provide training to staff on the revised procedure. 

The review team found that the program’s licensing procedures covering “Additional Information 

Requests and Timely Filed Notices” and “Identifying, Marking, and Securing of Increased 

Controls (IC) Documents” have been instituted and licenses are being reviewed to ensure these 

licensing procedures are being followed accordingly. The team found examples of 

administrative errors (typos, incorrect dates, missing cover letters, etc.) in half of the licenses 

reviewed; however, these were of minor health and safety significance. As noted previously, 

the Program has installed a new licensing system which, once implemented, will help to reduce 

the amount of errors in the licenses. 

The review team found that the Program is in the process of marking licenses or documents 

containing security-related information as recommended in RCPD-11-005 “Additional Guidance 

and Clarification Regarding the Review of the Control of Sensitive Information during Integrated 

Materials Performance Evaluation Program Reviews”. 

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

that Georgia’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 incidents reported for Georgia in the Nuclear Material Events Database 

(NMED) against those contained in the Program’s files, and evaluated the casework for 

radioactive materials incidents. A list of the incident casework examined, with case specific 

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

response to three allegations involving radioactive materials, none of which were referred to the 

State by the NRC during the review period. 

The review team identified 11 radioactive material incidents in NMED for Georgia during the 

review period; one of which was incorrectly categorized and did not require reporting. The team 

examined the Program’s non-reportable incidents and found them to be correctly categorized as 

non-reportable. The review team evaluated all 10 radioactive material incidents. The incidents 

included several categories: lost/stolen radioactive material, potential overexposure, medical 

event, damaged equipment and leaking sources. 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 three of the 

cases reviewed and took suitable enforcement and follow-up actions. If the incident met the 

reportability thresholds, as established in the Office of Federal and State Materials and 
Georgia Final IMPEP Report Page 13 

Environmental Management Programs (FSME) Procedure SA-300 “Reporting Material Events,” 

the State notified the NRC Headquarters Operations Center and entered the information into 

NMED, in a prompt manner in all but two of the incidents that required reporting; both of these 

incidents involved leaking sources (i.e. 4 and 26 days late). Program management 

acknowledged this oversight and committed to reporting all events involving leaking sources in a 

timely manner. 

The review team examined the Program’s implementation of its incident and allegation 

processes, including written procedures for handling allegations and incident response, file 

documentation, notification of incidents to the NRC Headquarters Operations Center, and the 

use of NMED software. The team found that the Program developed comprehensive 

procedures which address all aspects of incident and allegation evaluation, handling, response 

and documentation. Training on this procedure was given to the staff in August 2013. From the 

files reviewed, the team determined that the staff is implementing the procedure and taking 

actions appropriate to the type of incident. The team confirmed that management reviews each 

case and provides feedback as to whether the action can be closed or if additional action or 

information is needed. When notification of an incident or an allegation is received, the 

procedure requires staff to complete a Complaint Tracking System (CTS) Form with details 

describing the incident/allegation and to notify the Program manager who determines the 

appropriate level of response. 

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

evaluated the completed casework for all three allegations received during the review period. 

The review team concluded that the Program took prompt and appropriate actions in response 

to concerns raised. The review team noted that the Program documented the investigations of 

concerns and retained all necessary documentation to appropriately close the allegations. The 

Program notified the concerned individuals of the conclusion of their investigations. The 

Georgia Open Records Act does not permit the Program to protect alleger’s identities; staff is 

instructed to advise concerned individuals not to provide their name or contact information if 

they wish to remain anonymous. 

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

that Georgia’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) Low-Level Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. The 

NRC’s Agreement with Georgia does not relinquish regulatory authority for a low level 

radioactive waste disposal or uranium recovery program. In addition, the State returned its 

authority for the Sealed Source and Device Program in August 2013; therefore, only the first 

non-common performance indicator applied to this review. 
Georgia Final IMPEP Report Page 14 

4.1 Compatibility Requirements

4.1.1 Legislation

Georgia became an Agreement State on December 15, 1969. The current effective statutory 

authority is contained in the Official Code of Georgia Annotated, Title 31 Chapter 13. The 

Department is designated as the State’s radiation control agency. The Branch implements the 

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

radiation control program was passed during the review period. 

4.1.2 Program Elements Required for Compatibility

The Georgia regulations governing radiation protection requirements are located in Chapter 

391 of the Georgia Administrative Code and apply to all ionizing radiation. Georgia requires a 

license for possession and use of all radioactive material. 

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

process takes approximately one year from the development stage to the final approval by the 

Board of Natural Resources. The public, the NRC, other agencies, and potentially impacted 

licensees and registrants are offered an opportunity to comment during the process. 

Comments are considered and incorporated, as appropriate, before the regulations are 

finalized and approved. The review team noted that the State’s rules and regulations are not 

subject to sunset laws. 

The review team evaluated the Program’s response to the questionnaire relative to this 

indicator, 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 FSME maintains. During the 

review period, the Program submitted five final regulation amendments to the NRC for a 

compatibility review. Four of the five amendments were adopted overdue. Those four 

amendments were overdue at the time of the last IMPEP review and the Program adopted 

them during this review period as part of its corrective actions from the last IMPEP review. 

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

legally-binding requirements no later than three years after they become effective. At the 

time of this review, there were no amendments overdue for adoption. A complete list of 

regulation amendments can be found on the NRC website at the following address: 

http://nrc-stp.ornl.gov/rss_regamendents.html. 

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

that Georgia’s performance with respect to the indicator, Compatibility Requirements, be found 

satisfactory. 

 
Georgia Final IMPEP Report Page 15 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0 above, Georgia’s performance was found satisfactory for the 

performance indicators Technical Staffing and Training, Technical Quality of Licensing Actions, 

Technical Quality of Incident and Allegation Activities and Compatibility Requirements; 

satisfactory, but needs improvement for the indicator, Technical Quality of Inspections; and 

unsatisfactory for the indicator, Status of the Materials Inspection Program. Since the last 

IMPEP review, four of the indicators have improved; one indicator has been downgraded, 

Status of the Materials Inspection Program; and one indicator has stayed the same, 

Compatibility Requirements. 

The review team made one new recommendation regarding program performance by the State 

for the indicator, Technical Quality of Inspections. Of the twelve recommendations made during 

the 2012 IMPEP review, the team determined that two recommendations for the indicator 

Technical Quality of Licensing Actions should remain open since actions to address these 

recommendations are in progress; however, the MRB directed that one of the recommendations 

regarding the implementation of pre-licensing procedures be closed as the team determined 

that the Georgia Program is implementing the pre-licensing guidance. The MRB directed 

instead that a new recommendation be added for the State to formally write the pre-licensing 

guidance into its official licensing procedures and provide training to the staff. The team 

determined, and the MRB agreed, that eight of the recommendations from the 2012 IMPEP 

review regarding program performance for the indicators, Status of the Materials Inspection 

Program, Technical Quality of Inspections and Technical Quality of Incident and Allegation 

Activities, can be closed. The two recommendations regarding the Sealed Source and Device 

program are no longer applicable, and are closed, as the authority for this program was returned 

by the State to the NRC in August 2013. 

Accordingly, the review team recommended, and the MRB agreed, that the Program is 

adequate to protect public health and safety, but needs improvement, and is compatible with the 

NRC's program. Due to the State’s significant progress in addressing previous 

recommendations, the noted improvement in staff and management communications, and the 

strong commitment from Program management to continue to improve performance as 

evidenced by the actions taken since the last IMPEP review including the replacement of the 

Program manager and the additional resources allocated for staffing, the review team 

recommended, and the MRB agreed, that the Program be removed from Probation and placed 

on Heightened Oversight. The MRB noted that the Commission will make the final decision 

regarding discontinuance of probation for the Georgia Program. 

The review team recommended, and the MRB agreed, that the next IMPEP review take place in 

approximately two years from the Management Review Board meeting, and that a periodic 

meeting be held in approximately one year from this IMPEP review to assess the State’s 

sustained performance and progress. The MRB directed that the periodic meeting include a 

focused review of the State’s inspection program, specifically inspector accompaniments and 

implementation of inspection procedures, and progress in addressing the performance issues 

identified in the report. 

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

implementation by the State: 
Georgia Final IMPEP Report Page 16 

RECOMMENDATIONS: 

1. The review team recommends that the State: (1) implement its inspection procedures to 

ensure that inspectors document the reason for missing temporary job site inspections; 

document details and circumstances of violations in inspection reports and NOVs; 

consider a reduction in inspection frequency for serious violations and conduct 

performance based inspections; and (2) complete its enforcement procedure for 

assigning severity levels of violations. (Section 3.3) 

2. The review team recommends that the State verify that all previously approved medical 

authorized users have proper documentation of their qualifications, since the new 

requirements were initiated in 2008. (Section 3.4, kept open from 2012 IMPEP) 

3. The review team recommends that the State finalize its procedure for pre-licensing 

requirements and provide training to the staff on the revised procedure. (Section 3.4) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Georgia 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

Michelle Beardsley, FSME Team Leader 

Technical Quality of Incident and Allegation 

Activities 

Inspection accompaniments 

Monica Ford, Region I Technical Staffing and Training 

 Status of Materials Inspection Program 

 Compatibility Requirements 

Joshua Daehler, Massachusetts Technical Quality of Inspections 

Jackie Cook, Region IV Technical Quality of Licensing Actions 

Bryan Parker, Region III Inspection accompaniment 
APPENDIX B 

GEORGIA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML14014A075
 

 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Unitech Services Group, Inc. License No.: 894-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/8/13 Inspectors: KR; TC 

Comments: 

a.) The violation cited a commitment made by the licensee that was misinterpreted by the 

Program. 

b.) The details of violation documented by inspectors did not match the licensee’s 

commitment cited. 

File No.: 2 

Licensee: PETNET Solutions, Inc. License No.: 1475-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 12/18/13 Inspectors: JM; KR 

Comments: 

a.) Contrary to Program’s inspection procedures and IMC 2800, inspectors did not 

document details and circumstances of violation, when violation occurred and who was 

involved. 

b.) Violation transmitted to licensee identified problem related to bill of lading whereas 

Inspectors documented problem related to emergency procedures without identification 

of any bill of lading. It is not clear how the documented problem of the emergency 

procedures evolved to a violation involving the bill of lading. 

File No.: 3 

Licensee: Monroe HMA, Inc. d/b/a Clearview Regional Medical Center License No.: 648-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 12/17/13 Inspectors: TC; JO 

File No.: 4 

Licensee: Atlanta Outpatient Surgery Center License No.: 1325-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 12/19/13 Inspector: QT 

Comments: 

a.) Contrary to Program’s inspection procedures and IMC 2800, inspector did not document 

details and circumstances of the cited violation, when requirement was violated and who 

was involved. 

b.) The non-cited violation identified a reporting requirement whereas problem resulted from 

the licensee’s lack of knowledge of reporting requirement.
Georgia Final IMPEP Report Page C.2 

Inspection Casework Reviews 

 

File No.: 5 

Licensee: Metals & Materials Engineers, LLC License No.: 1643-1 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 8/7/13 Inspectors: EJ; IB 

Comment: Contrary to Program’s inspection procedures and IMC 2800, inspectors did not 

document explanation for missing temporary job site inspection. 

File No.: 6 

Licensee: Metals & Materials Engineers, LLC License No.: 1643-1 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 2/22/13 Inspector: IB 

File No.: 7 

Licensee: St. Joseph’s Hospital License No.: 296-4 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 8/9/13; 9/5/13 Inspectors: IB; DC; AM 

Comment: Inspection letter was issued 60 days after inspection was completed. 

File No.: 8 

Licensee: St. Joseph’s Hospital License No.: 296-6 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 7/10/13 Inspectors: KR; QT 

File No.: 9 

Licensee: Harbin Clinic Radiation Oncology License No.: 1411-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 11/6/13 Inspectors: IB; QT 

File No.: 10 

Licensee: Radiotherapy Clinics of Georgia License No.: 848-5 

Inspection Type: Special, Unannounced Priority: 2 

Inspection Date: 12/18/13 Inspector: TC 

File No.: 11 

Licensee: Professional Service Industries, Inc. License No.: 629-1 

Inspection Type: Special, Announced Priority: 5 

Inspection Date: 6/14/13 Inspector: DC 

Comment: Contrary to Program’s inspection procedures, the Program did not schedule and 

conduct another inspection within six months of the escalated enforcement action, issuance of 

severity level II violation. 
Georgia Final IMPEP Report Page C.3 

Inspection Casework Reviews 

 

File No.: 12 

Licensee: H & H X-Ray Services, Inc. License No.: LA-2970-L01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 10/25/13 Inspector: KR 

File No.: 13 

Licensee: Georgia Institute of Technology License No.: 147-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/27/13; 2/28/13 Inspectors: IB; DC 

File No.: 14 

Licensee: Acuren Inspection, Inc. License No.: 1115-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/31/13 Inspectors: EJ; TC 

Comment: Contrary to Program’s inspection procedures and IMC 2800, inspectors did not 

document explanation for missing temporary job site inspection. 

File No.: 15 

Licensee: Honeywell International, Inc. License No.: 832-1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 2/15/13 Inspectors: EJ; FN 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Metals and Materials Engineers License No.: 1643-1 

Inspection Type: Initial, Unannounced, Special Priority: 1 

Inspection Date: 8/7/13 Inspectors: EJ, IB 

Accompaniment No.: 2 

Licensee: Unitech Services Group, Inc. License No.: 894-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/8/13 Inspectors: KR, IB 

Accompaniment No.: 3 

Licensee: St. Joseph’s Regional Medical Ctr. License No.: 296-4 

Inspection Type: Routine, Unannounced, Special Priority: 2 

Inspection Date: 8/9/13 Inspectors: IB, DC 

Comment: Inspector was not knowledgeable of revised inspection procedure IP 87132.
Georgia Final IMPEP Report Page C.4 

Inspection Casework Reviews 

 

Accompaniment No.: 4 

Licensee: Clearview Regional Medical Ctr. License No.: 648-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 12/17/13 Inspector: TC 

Accompaniment No.: 5 

Licensee: PETNET Solutions, Inc. License No.: 1475-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 12/18/13 Inspectors: JM, KR 

Comment: Inspector did not perform a performance-based inspection as required by IMC 2800 

and the Program’s inspection procedures. 

Accompaniment No.: 6 

Licensee: Atlanta Outpatient Surgery Ctr. License No.: 1325-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 12/19/13 Inspectors: QT, JM 

Comment: Inspector was not knowledgeable of revised inspection procedure IP 87132. 

Accompaniment No.: 7 

Licensee: Harbin Clinic Radiation Oncology License No.: 1411-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 11/6/13 Inspector: IB 

 

 

 

 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Nuclear Medicine Professionals, Inc. License No.: 1631-1 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 10/18/13 License Reviewer: IB 

File No.: 2 

Licensee: Acuren Inspection, Inc. License No: 1115-1 

Type of Action: Amendment Amendment No.: 17 

Date Issued: 1/7/14 License Reviewer: TC 

File No.: 3 

Licensee: Nuclear Medicine Professionals, Inc. License No.: 1631-1 

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

Date Issued: 11/9/12 License Reviewer: IB 

 File No.: 4 

Licensee: Cemex, Inc. License No.: 433-1 

Type of Action: Amendment Amendment No.: 21 

Date Issued: 12/3/13 License Reviewer: KR 

File No.: 5 

Licensee: Imerys Kaolin, Inc. License No: 903-1 

Type of Action: Renewal Amendment No.: 28 

Date Issued: 12/30/13 License Reviewer: TC 

File No.: 6 

Licensee: Schnabel Engineering South, LLC License No.: 1360-1-1 

Type of Action: Renewal Amendment No.: 08 

Date Issued: 9/24/13 License Reviewer: IB 

File No.: 7 

Licensee: Lewis Hall Singletary Oncology Center License No.: 78-2 

Type of Action: Renewal Amendment No.: 07 

Date Issued: 11/18/13 License Reviewer: KR 

File No.: 8 

Licensee: PETNET Solutions, Inc. License No: 1475-1 

Type of Action: Amendment Amendment No.: 13 

Date Issued: 9/6/13 License Reviewer: JO 

 
Georgia Final IMPEP Report Page D.2 

Licensing Casework Reviews 

File No.: 9 

Licensee: Landis International, Inc. License No.: 941-1 

Type of Action: Renewal Amendment No.: 14 

Date Issued: 11/20/12 License Reviewer: KR 

File No.: 10 

Licensee: St. Joseph’s Hospital License No.: 296-6 

Type of Action: Amendment Amendment No.: 08 

Date Issued: 10/7/13 License Reviewer: JO 

File No.: 11 

Licensee: ECS Southeast, LLC License No: 1335-1 

Type of Action: Renewal Amendment No.: 14 

Date Issued: 12/6/13 License Reviewer: JM 

File No.: 12 

Licensee: Golder Associates, Inc. License No.: 1205-1 

Type of Action: Renewal Amendment No.: 12 

Date Issued: 11/4/13 License Reviewer: QT 

File No.: 13 

Licensee: Havells USA License No.: 1611-1 

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

Date Issued: 6/21/13 License Reviewer: EJ 

File No.: 14 

Licensee: Urology Specialist Surgery Center License No: 1639-1 

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

Date Issued: 7/8/13 License Reviewer: KR 

File No.: 15 

Licensee: Radiotherapy Clinics of GA License No.: 848-4 

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

Date Issued: 11/7/12 License Reviewer: TC 

File No.: 16 

Licensee: Givinette Heart Specialists License No.: 1645-1 

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

Date Issued: 5/1/13 License Reviewer: IB 

File No.: 17 

Licensee: Lewis Hall Singletary Oncology Center License No: 78-2 

Type of Action: Amendment Amendment No.: 07 

Date Issued: 11/18/13 License Reviewer: KR
Georgia Final IMPEP Report Page D.3 

Licensing Casework Reviews 

File No.: 18 

Licensee: Paper Making Controls Services License No.: 1430-1 

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

Date Issued: 10/28/13 License Reviewer: EJ
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Georgia Institute of Technology License No.: 0147-1 

Date of Incident: 12/6/12 NMED No.: 120728 

Investigation Date: 12/19/12 Type of Incident: Leaking source 

 Type of Investigation: Telephone/report 

Comment: The State did not report this event to the NRC within 24 hrs. as required (4 days 

late). 

File No.: 2 

Licensee: Cardinal Health Radiopharmacy License No.: 1609-1 

Date of Incident: 9/23/13 NMED No.: 130459 

Investigation Date: 10/9/13 Type of Incident: Possible overexposure 

 Type of Investigation: Site 

File No.: 3 

Licensee: Professional Services Industries License No.: 0629-1 

Date of Incident: 4/24/13 NMED No.: 130217 

Investigation Date: 5/2/13 Type of Incident: Lost RAM 

 Type of Investigation: Telephone 

File No.: 4 

Licensee: Pet Imaging License No.: 1429-1 

Date of Incident: 3/28/13 NMED No.: 130330 

Investigation Date: 6/20/13 Type of Incident: Leaking source 

 Type of Investigation: Telephone 

Comment: The State did not report this event to the NRC within 24 hrs. as required (26 days 

late). 

File No.: 5 

Licensee: Piedmont Hospital License No.: 0292-1 

Date of Incident: 8/7/13 NMED No.: 130361 

Investigation Date: 8/9/13 Type of Incident: Medical event 

 Type of Investigation: Telephone
Georgia Final IMPEP Report Page E.2 

Incident Casework Reviews 

File No.: 6 

Licensee: Radiotherapy Clinics of Georgia License No.: 848-5 

Date of Incident: 12/16/13 NMED No.: 140002 

Investigation Date: 12/16/13 Type of Incident: Medical event 

 Type of Investigation: Site 

File No.: 7 

Licensee: GE Healthcare License No.: N/A (Illinois licensee) 

Date of Incident: 12/16/13 NMED No.: 140006 

Investigation Date: 12/16/13 Type of Incident: Lost RAM 

 Type of Investigation: Telephone 

File No.: 8 

Licensee: Arizona Chemical License No.: GL 

Date of Incident: 12/9/13 NMED No.: 140039 

Investigation Date: 12/16/13 Type of Incident: Equipment malfunction 

 Type of Investigation: Telephone/report 

File No.: 9 

Licensee: NOVA Engineering and Environmental License No.: 1323-1 

Date of Incident: 1/14/14 NMED No.: 140040 

Investigation Date: 1/14/14 Type of Incident: Stolen RAM 

 Type of Investigation: Telephone 

File No.: 10 

Licensee: The PQ Corporation License No.: 976-1 

Date of Incident: 1/16/14 NMED No.: 140048 

Investigation Date: 1/16/14 Type of Incident: Equipment malfunction 

 Type of Investigation: Telephone 
April 2, 2014 letter from Judson H. Turner 

Georgia’s Response to the Draft Report 

ADAMS Accession No.: ML14093A580