UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001

 

 July 14, 2016 

Nicole Alexander-Scott, Director 

Rhode Island Department of Health 

Three Capitol Hill 

Providence, RI 02908-5097 

Dear Ms. Alexander-Scott: 

On June 16, 2016, a Management Review Board (MRB), which consists of U.S. Nuclear 

Regulatory Commission (NRC) senior managers and an Organization of Agreement States 

liaison to the 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 to protect public health and safety, but needs 

improvement, and compatible with the NRC’s 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 full 

review of the Rhode Island Agreement State Program will take place in approximately four 

years, with a periodic meeting tentatively scheduled for March 2017. The MRB also determined 

that Rhode Island should remain in the monitoring process. Monitoring is an informal process 

that allows the NRC to maintain an increased level of communication with an Agreement State 

program, and is a useful tool in assessing program improvements. 

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 by Patricia K. Holahan for/ 

Glenn M. Tracy 

Deputy Executive Director for Materials, Waste, 

 Research, State, Tribal, Compliance, Administration, 

 and Human Capital Programs 

Office of the Executive Director for Operations 

Enclosure: 

Rhode Island IMPEP Final Report 

cc: See next page 
N. Alexander-Scott 2 

 

Letter to Nicole Alexander-Scott from Glenn Tracy, Dated July 14, 2016 

SUBJECT: RHODE ISLAND 2016 FINAL IMPEP REPORT 

cc: Seema Dixit, Chief 

 Center for Health Facilities and Regulations 

Angela Leek, IA 

Organization of Agreement States 

 Liaison to the MRB 
July 14, 2016 

Nicole Alexander-Scott, Director 

Rhode Island Department of Health 

Three Capitol Hill 

Providence, RI 02908-5097 

Dear Ms. Alexander-Scott: 

On June 16, 2016, a Management Review Board (MRB), which consists of U.S. Nuclear 

Regulatory Commission (NRC) senior managers and an Organization of Agreement States 

liaison to the 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 to protect public health and safety, but needs 

improvement, and compatible with the NRC’s 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 full 

review of the Rhode Island Agreement State Program will take place in approximately four 

years, with a periodic meeting tentatively scheduled for March 2017. The MRB also determined 

that Rhode Island should remain in the monitoring process. Monitoring is an informal process 

that allows the NRC to maintain an increased level of communication with an Agreement State 

program, and is a useful tool in assessing program improvements. 

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 by Patricia K. Holahan for/ 

Glenn M. Tracy 

Deputy Executive Director for Materials, Waste, 

 Research, State, Tribal, Compliance, Administration, 

 and Human Capital Programs 

Office of the Executive Director for Operations 

Enclosure: 

Rhode Island IMPEP Final Report 

cc: See Next Page 

DISTRIBUTION: (SP05) 

See Next Page 

ADAMS Accession Number: ML16174A024 *Concurred via email 

OFFICE NMSS MSTR/ASPB MSTR/ASPB NMSS/MSTR NMSS/Tech 

Editor 

NMSS DEDM 

NAME MBeardsley* LDimmick PMichalak DCollins WMoore SMoore 

DCollins for 

GTracy 

PHolahan for

DATE 06/22/16 06/27/16 06/27/16 07/05/16 07/06/16 07/08/16 0714/16

OFFICIAL RECORD COPY 
N. Alexander-Scott 2 

 

Letter to Nicole Alexander-Scott from Glenn Tracy, Dated July 14, 2016 

SUBJECT: RHODE ISLAND FY2016 FINAL IMPEP REPORT 

DISTRIBUTION: (SP05) 

Chairman Burns 

Commissioner Svinicki 

Commissioner Baran 

SECY 

RidsEdoMailCenter 

MSampson, OEDO 

RidsSecyCorrespondenceMailCenter 

RidsOgcMailCenter 

JOlmstead, OGC 

RidsRgn1MailCenter 

JTrapp, RI 

JNick, RI 

JGiessner, RIII 

RidsNmssOD 

DCollins, NMSS 

PHenderson, NMSS 

MFord, RI/RSAO 

BSchilke, VA 

LRoldan-Otero, NMSS 

OAS Board 

State of RI 

JWeil, OCA 
 

Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE RHODE ISLAND AGREEMENT STATE PROGRAM 

MARCH 7 - 10, 2016 

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 March 7–10, 2016, by a review team composed of technical staff members 

from the U.S. Nuclear Regulatory Commission (NRC) and the Commonwealth of Virginia. This 

IMPEP review was originally scheduled for October 2015; however, the Rhode Island 

Agreement State Program requested that its review be moved back due to a competing priority 

investigation being conducted with another agency.

Based on the results of this review, Rhode Island’s performance was found satisfactory for four 

of the performance indicators reviewed; satisfactory, but needs improvement for the indicator, 

Technical Staffing and Training; and unsatisfactory for the performance indicator, Status of the 

Materials Inspection Program. The indicator Technical Quality of Inspections was improved 

from the 2011 review (from satisfactory, but needs improvement to satisfactory). The team 

determined that the Rhode Island Agreement State Program took actions to correct the issues 

identified during the 2011 review regarding performance of annual supervisory 

accompaniments, improving inspection documentation, and conducting initial and subsequent 

security inspections to verify licensee compliance with the regulations. The Technical Staffing 

and Training indicator declined from the 2011 IMPEP review (from satisfactory, to satisfactory, 

but needs improvement). The team determined that staff turnover affected the staffing balance 

for inspection and licensing, and vacancies were not filled promptly. While the team notes that 

the Rhode Island Agreement State Program was given approval to hire additional staff in March 

2016, hiring actions were not expected to occur until May 2016 which was out of the period of 

this IMPEP review. The status of the indicator Materials Inspection Program remained 

unsatisfactory from the 2011 review due to overdue inspections. Poor inspection tracking and 

staff vacancies were the main contributors to the overdue inspections. 

The review team did not make any recommendations and determined that one recommendation 

from the 2011 IMPEP review, regarding the performance of Priority 1, 2, and 3 inspections in 

accordance with the inspection priority stated in Inspection Manual Chapter 2800, “Materials 

Inspection Program” should remain open (Section 2.0). Upon its deliberations, the Management 

Review Board (MRB) issued two recommendations to Rhode Island. Both recommendations 

are attributed to the long standing staffing vacancies—one concerns the Program’s 

documentation of its inspection and licensing activities, the second, concerns the timeliness of 

license renewals (Sections 3.1 and 3.4). 

Accordingly, the review team recommended, and the MRB agreed, that the Rhode Island 

Agreement State Program is adequate to protect public health and safety, but needs 

improvement, and is compatible with the NRC’s program. Based on the results of the current 

IMPEP review, the review team recommended, and the MRB agreed, that the next full IMPEP 

review take place in approximately 4 years. Additionally, the team recommended, and the MRB 

agreed, that the period of monitoring continue, and further that periodic meetings be held 1 year 

from this review with a second meeting approximately 18 months after the first periodic meeting 

in lieu of a followup IMPEP review for the two indicators found satisfactory, but needs 

improvement, and unsatisfactory. 
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’s radioactive materials safety program. The review was conducted during the 

period of March 7–10, 2016, by a review team composed of technical staff members 

from the U.S. Nuclear Regulatory Commission (NRC) and the Commonwealth of 

Virginia. 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 (MD 5.6), 

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

2004. Preliminary results of the review, which covered the period of October 29, 2011, 

to March 10, 2016, were discussed with Rhode Island managers on the last day of the 

review. 

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

non-common performance indicators was sent to Rhode Island on December 24, 2015. 

Rhode Island provided its response to the questionnaire on March 25, 2016. A copy of 

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

and Management System (ADAMS) using the Accession Number ML16089A393. 

A draft of this report was issued to Rhode Island on April 11, 2016, for factual comment. 

Rhode Island responded to the findings and conclusions of the review by letter dated 

May 10, 2016. A copy of Rhode Island’s response can be found in ADAMS using the 

Accession Number ML16133A029. A Management Review Board (MRB), which 

consists of NRC senior managers and an Organization of Agreement States liaison to 

the MRB, met on June 16, 2016, to consider the proposed final report. The MRB found 

the Rhode Island Agreement State Program adequate to protect public health and 

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

The Rhode Island Agreement State Program is administered by the Radiation Control 

Program (the Program) which is located within the Center for Health Facilities and 

Regulations (the Center). The Center is part of the Rhode Island Department of Health 

(the Department). Organization charts for the State can be found in ADAMS using the 

Accession Number ML16089A390. 

At the time of the review, the Rhode Island Agreement State Program regulated 45 

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 Rhode Island. 

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 Rhode Island Agreement State Program’s performance. 

2.0 PREVIOUS IMPEP REVIEW AND STATUS OF RECOMMENDATIONS 

The previous IMPEP review concluded on October 28, 2011. The final report is 

available in ADAMS (Accession Number ML120240375). The results of the 2011 review 

and the status of the recommendations are as follows: 
Rhode Island Final IMPEP Report Page 2 

Technical Staffing and Training: Satisfactory 

Recommendation (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 of the 2011 IMPEP report) 

Status: 

The Program developed a new procedure “Rhode Island Department of Health 

Qualification Program for Radioactive Material’s Inspectors and License Reviewers 

(March 2016)” which is compatible to the NRC’s Inspection Manual Chapter (IMC) 1248 

and has provided it to staff going through the qualification process. Additionally, the 

Program has updated inspector and license reviewer qualification cards (memos) to 

document what items each inspector/license reviewer is qualified to perform. The review 

team recommended, and the MRB agreed, that this recommendation be closed.

Status of Materials Inspection Program: Unsatisfactory 

Recommendation (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 of the 2011 IMPEP report) 

Status: 

The Program conducted a total of 41 Priority 1, 2, and 3 and initial inspections during the 

current review period. Of those 41 inspections, 11 inspections were completed overdue. 

The review team calculated that the Program performed 27 percent of its inspections 

overdue during the review period. The review team determined that poor inspection 

tracking was a main contributor to the Program performing inspections overdue, along 

with the staffing vacancies. As discussed in Section 3.2 of this report, the review team 

recommended that the indicator Status of Materials Inspection Program be again found 

unsatisfactory. Accordingly, the review team recommended, and the MRB agreed, that 

this recommendation remain open. 

Technical Quality of Inspections: Satisfactory, but needs improvement 

Recommendation (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 of the 2011 IMPEP report) 

Status: 

The review team’s evaluation of the quality of inspection casework demonstrated that 

inspection records and narrative reports were documented in accordance with the 

Program’s inspection manual. Inspection records and reports now include the focus 

areas examined, sufficient information to support cited violations, identification of 

non-cited violations, closed violations that were identified during the previous inspection, 

and succinct description of the scope of the program. The review team recommended, 

and the MRB agreed, that this recommendation be closed. 
Rhode Island Final IMPEP Report Page 3 

Note: The MRB acknowledged the improved quality of inspection documentation since 

the 2011 IMPEP review with the closure of this recommendation, but also noted some 

missing licensing and inspection documentation attributed to staffing vacancies. As 

discussed in Section 3.1 of this report, the MRB recommended that the Program 

management take measures to ensure proper documentation of inspection tracking 

dates and ensure the Program’s licensing and inspection files are complete. 

Recommendation (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 of the 2011 IMPEP report) 

Status: 

The review team determined that the Program supervisor or designated senior staff 

member performed an accompaniment of each inspector, at least annually, for each year 

of the review period. The review team recommended, and the MRB agreed, that this 

recommendation be closed. 

Recommendation (5): 

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. (Section 3.3 of the 2011 IMPEP report) 

Status: 

The review team determined through observations of inspector performance and 

examination of inspection casework that the State conducted initial and subsequent 

security related inspections which verified licensee compliance with the requirements. 

The review team recommended, and the MRB agreed, that this recommendation be 

closed. 

Technical Quality of Licensing Actions: Satisfactory 

Recommendation: None 

Technical Quality of Incident and Allegation Activities: Satisfactory 

Recommendation: None 

Compatibility: Satisfactory, but needs improvement 

Recommendation (6): 

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

required for compatibility and adopt future regulation amendments within their required 

3-year time frame. (Section 4.1 of the 2011 IMPEP report) 

Status: 

The Program has adopted all regulations that are currently due for purposes of 

compatibility. At the time of the review, there were no regulation amendments overdue 

for adoption. Additionally, the Program adopted all regulation changes that were required 

to be adopted during the review period within the required 3-year time frame. The review 

team recommended, and the MRB agreed, that this recommendation be closed. 
Rhode Island Final IMPEP Report Page 4 

Overall finding from 2011: Adequate to protect public health and safety, but needs 

improvement, and compatible with the NRC’s program. Implement a period of 

monitoring. 

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review the 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 

The ability to conduct effective licensing and inspection programs is largely dependent 

on having a sufficient number of experienced, knowledgeable, well-trained technical 

personnel. Under certain conditions, staff turnover could have an adverse effect on the 

implementation of these programs, and thus could affect public health and safety. 

Apparent trends in staffing must be explored. Review of staffing also requires a 

consideration and evaluation of the levels of training and qualification. The evaluation 

standard measures the overall quality of training available to, and taken by, materials 

program personnel. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-103, “Reviewing 

the Common Performance Indicator: Technical Staffing and Training,” and evaluated 

Rhode Island’s performance with respect to the following performance indicator 

objectives: 

• A well-conceived and balanced staffing strategy has been implemented throughout 

the review period. 

• Agreement State training and qualification program is equivalent to the NRC IMC 

1248, “Formal Qualifications Program for Federal and State Materials and 

Environmental Management Programs.” 

• Qualification criteria for new technical staff are established and are being followed or 

that qualification criteria will be established if new staff members are hired. 

• Any vacancies, especially senior-level positions, are filled in a timely manner. 

• There is a balance in staffing of the licensing and inspection programs. 

• Management is committed to training and staff qualification. 

• Individuals performing materials licensing and inspection activities are adequately 

qualified and trained to perform their duties. 

• License reviewers and inspectors are trained and qualified in a reasonable period of 

time. 

b. Discussion 

The Program is composed of five technical staff members and a program manager who 

are all partially allocated to support the Program. The total effort allocated by all six 

employees is approximately three full-time equivalents for the radioactive materials 
Rhode Island Final IMPEP Report Page 5 

program. These numbers include the two technical staff vacancies present in the 

program at the time of the review. During the review period, one of the staff members 

left the program and one staff member was hired. The two open positions have been 

vacant since September of 2012 and July of 2013, respectively. The Program has a 

training and qualification manual compatible with the NRC’s IMC 1248. Staff going 

through the qualification process have been assigned the Program’s training and 

qualification journal to complete. Qualification cards for qualified staff have been 

updated and the Program is tracking refresher training for qualified staff. 

c. Evaluation 

The team determined that during the review period Rhode Island did not fully meet the 

performance indicator objectives listed in Section 3.1.a. The staff vacancies have 

resulted in a backlog of licensing renewal actions, poor tracking of inspection due dates 

leading to 27 percent of inspections being performed overdue during the review period, 

and missing documentation in the Program’s licensing and inspection files. A letter of 

support dated January 14, 2016, was sent to the Governor of Rhode Island. This letter 

stressed the importance of addressing staffing vacancies to ensure the long term 

success and viability of the Program. The Rhode Island Department of Health 

management responded to the NRC in a letter dated February 1, 2016. The response 

letter described the State’s path forward to address the staffing vacancies. On March 3, 

2016, Rhode Island posted two positions that will directly support the Program: one 

technical staff position and the other a licensing aide. The Program filled these 

vacancies on May 29, 2016, and June 12, 2016, respectively. 

The review team identified several instances of missing licensing and inspection 

documents as well as errors in the inspection tracking system which were determined to 

be attributed to the long standing staffing vacancies. The MRB recommended that the 

Program management take measures to ensure proper documentation of inspection 

tracking dates and ensure the Program’s licensing and inspection files are complete. 

d. Results 

The review team considered the criteria in MD 5.6 and concluded that because (1) some 

staff turnover could adversely affect the program, (2) some vacant positions were not 

readily filled during the review period, and (3) there was some evidence of a lack of 

management attention or actions to deal with staffing problems, a rating of satisfactory, 

but needs improvement should be recommended for this indicator.

Based on the IMPEP evaluation criteria in MD 5.6, 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, but needs improvement. 

3.2 Status of the Materials Inspection Program 

Periodic inspections of licensed operations are essential to ensure that activities are 

being conducted in compliance with regulatory requirements and consistent with good 

safety practices. The frequency of inspections is specified in IMC 2800, “Materials 

Inspection Program” and is dependent on the amount and kind of material, the type of 

operation licensed, and the results of previous inspections. There must be a capability 

for maintaining and retrieving statistical data on the status of the inspection program. 
Rhode Island Final IMPEP Report Page 6 

a. Scope 

The review team used the guidance in State Agreements procedure SA-101, “Reviewing 

the Common Performance Indicator: Status of the Materials Inspection Program,” and 

evaluated Rhode Island’s performance with respect to the following performance 

indicator objectives: 

• Initial inspections and inspections of Priority 1, 2, and 3, licensees are performed at 

the frequency prescribed in IMC 2800. 

• Candidate licensees working under reciprocity are inspected in accordance with the 

criteria prescribed in IMC 1220, “Processing of NRC Form 241, Report of Proposed 

Activities in Non-Agreement States, Areas of Exclusive Federal Jurisdiction, and 

Offshore Waters, and Inspection of Agreement State Licensees Operating Under 10 

CFR 150.20.” 

• Deviations from inspection schedules are normally coordinated between technical 

staff and management. 

• There is a plan to perform any overdue inspections and reschedule any missed or 

deferred inspections; or a basis has been established for not performing any overdue 

inspections or rescheduling any missed or deferred inspections. 

• Inspection findings are communicated to licensees in a timely manner (30 calendar 

days, or 45 days for a team inspection, as specified in IMC 0610, “Nuclear Material 

Safety and Safeguards Inspection Reports”). 

b. Discussion 

The Program’s inspection frequency is the same for similar license types in IMC 2800. 

The Program performed 41 Priority 1, 2, 3, and initial inspections during the review 

period. Rhode Island conducted 27 percent of Priority 1, 2, 3, and initial inspections 

overdue. Eleven of 37 Priority 1, 2, and 3 inspections were conducted overdue during 

the review period. The four initial inspections of new licenses were performed within 12 

months of license issuance. 

In 3 of the 4 years of the review period, the Program performed greater than 20 percent 

of candidate reciprocity inspections. The Program could not find any records of 

reciprocity inspections conducted in calendar year 2014. Additionally, poor tracking of 

reciprocity inspections contributed to the Program being unable to produce any 

measureable data for the 2014 calendar year. 

c. Evaluation 

The team determined that during the review period Rhode Island did not meet all of the 

performance indicator objectives listed in Section 3.2.a. Specifically, Rhode Island 

inspected 27 percent of Priority 1, 2, and 3 inspections overdue during the review period. 

According to MD 5.6, the threshold for an unsatisfactory performance of this indicator is 

more than 25 percent of higher priority licensees are inspected at intervals that exceed 

the tolerance allotted for the inspection interval. Additionally, the Program could not 

produce any documentation to support completing reciprocity inspections in calendar 

year 2014. Therefore, Rhode Island did not meet the criteria of inspecting greater than 

20 percent of candidate licensees for reciprocity. 
Rhode Island Final IMPEP Report Page 7 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

the MRB agreed, that Rhode Island’s performance with respect to the indicator, Status of 

the Materials Inspection Program, be found unsatisfactory. 

3.3 Technical Quality of Inspections 

Inspections, both routine and reactive, provide assurance that licensee activities are 

carried out in a safe and secure manner. Accompaniments of inspectors performing 

inspections, and the critical evaluation of inspection records are used to assess the 

technical quality of a program’s inspection capability. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-102, “Reviewing 

the Common Performance Indicator: Technical Quality of Inspections,” and evaluated 

Rhode Island’s performance with respect to the following performance indicator 

objectives: 

• Inspections of licensed activities focus on health, safety, and security. 

• Inspection findings are well-founded and properly documented in reports. 

• Management promptly reviews inspection results. 

• Procedures are in place and used to help identify root causes and poor licensee 

performance. 

• Inspections address previously identified open items and violations. 

• Inspection findings lead to appropriate and prompt regulatory action. 

• Supervisors conduct annual accompaniments of each inspector to assess 

performance and assure consistent application of inspection policies. 

• For programs with separate licensing and inspection staffs, to verify that procedures 

are established and followed to provide feedback information to license reviewers. 

• For Agreement States, to determine if inspection guides are consistent with NRC 

guidance. 

• An adequate supply of calibrated survey instruments is available to support the 

inspection program. 

b. Discussion 

The review team evaluated the inspection reports, enforcement documentation, and 

interviewed inspectors for 13 materials inspections conducted during the review period. 

The casework reviewed included inspections conducted by both of Rhode Island’s 

inspectors and covered medical, industrial, commercial, academic, research, blood 

irradiators, and medical and academic broadscope licensees. 

A review team member accompanied the two program inspectors on 

February 18 and 19, 2016. The inspector accompaniments are identified in Appendix B. 

Supervisory accompaniments were conducted annually for all inspectors by the Program 

Supervisor or senior staff member. 
Rhode Island Final IMPEP Report Page 8 

c. Evaluation 

The team determined that during the review period Rhode Island met the performance 

indicator objectives listed in Section 3.3.a. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, 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. 

3.4 Technical Quality of Licensing Actions 

The quality, thoroughness, and timeliness of licensing actions can have a direct bearing 

on public health and safety, and security. An assessment of licensing procedures, 

actual implementation of these procedures, and documentation of communications and 

associated actions between the Rhode Island licensing staff and regulated community 

will be a significant indicator of the overall quality of the program. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-104, “Reviewing 

the Common Performance Indicator: Technical Quality of Licensing Actions,” and 

evaluated Rhode Island’s performance with respect to the following performance 

indicator objectives: 

• Licensing action reviews are thorough, complete, consistent, and of acceptable 

technical quality with health, safety, and security issues properly addressed. 

• Essential elements of license applications have been submitted and elements meet 

current regulatory guidance (e.g., financial assurance, increased controls, 

pre-licensing guidance). 

• License reviewers, if applicable, have the proper signature authority for the cases 

they review independently. 

• License conditions are stated clearly and are inspectable. 

• Deficiency letters clearly state regulatory positions and are used at the proper time. 

• Reviews of renewal applications demonstrate a thorough analysis of a licensee’s 

inspection and enforcement history. 

• Applicable guidance documents are available to reviewers and are followed (e.g., 

NUREG-1556 series, pre-licensing guidance, regulatory guides, etc.). 

• Licensing practices for risk significant radioactive materials are appropriately 

implemented including increased controls and fingerprinting orders (Part 37 

equivalent). 

• Documents containing sensitive security information are properly marked, handled, 

controlled and secured. 

b. Discussion 

The review team evaluated 15 radioactive materials licensing actions. The licensing 

actions selected for review included three new applications, eight amendments, three 

renewals, and one termination. The review team evaluated casework which included the 
Rhode Island Final IMPEP Report Page 9 

following license types and actions: medical broad scope, medical diagnostic, medical 

therapy, industrial radiography, research and development, academic broad scope, 

gauges, stereotactic radiosurgery, and decommissioning actions. The team verified that 

no Rhode Island licensees were subject to financial assurance requirements. The 

casework sample represented work from two license reviewers. The team determined 

that all licensing actions were of high quality using a thorough, concise, and easily 

understood process prior to issuing any licensing action, no matter how minor or 

complex. 

The team noted that the Program has 13 overdue renewals, ranging from 1 month to 14 

years overdue. Interviews with the staff confirmed that these renewals were evaluated 

for any health and safety concerns upon receipt. Further, contact with the licensees is 

maintained on an annual basis, and confirmation of the applicability of the material 

submitted would be acquired from the licensees prior to completing the renewal requests 

to ensure the information is current. 

Given that 28 percent of the licenses are under timely renewal ranging from several 

months to 14 years, and the Program attributes the backlog to staffing vacancies, the 

MRB recommended that Program management develop and implement an action plan 

to reduce the licensing renewal backlog. 

Interviews with license reviewers revealed a performance-based application of the 

Pre-Licensing guidance; however, documentation was not completed in some cases, 

and for cases in which the reviewer completed a checklist, it could not be located to 

record this use. The team discussed the need to record and retain this document. The 

team also noted that some documents and files containing sensitive information were 

not marked as such and were not secured. The team brought this to the attention of the 

Program. The Program took immediate action to correct this by labeling all applicable 

documents and folders, and securing them in a locked cabinet. 

c. Evaluation 

The team determined that during the review period Rhode Island met the performance 

indicator objectives listed in Section 3.4.a. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, 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 

The quality, thoroughness, and timeliness of response to incidents and allegations of 

safety concerns can have a direct bearing on public health and safety. An assessment 

of incident response and allegation investigation procedures, actual implementation of 

these procedures, internal and external coordination, and investigative and follow-up 

procedures and actions will be a significant indicator of the overall quality of the 

program. 

 
Rhode Island Final IMPEP Report Page 10 

a. Scope 

The review team used the guidance in State Agreements procedure SA-105, “Reviewing 

the Common Performance Indicator: Technical Quality of Incident and Allegation 

Activities,” and evaluated Rhode Island’s performance with respect to the following 

performance indicator objectives: 

• Incident response, investigation, and allegation procedures are in place and 

followed. 

• Response actions are appropriate, well-coordinated, and timely. 

• On-site responses are performed when incidents have potential health, safety or 

security significance. 

• Appropriate follow-up actions are taken to ensure prompt compliance by licensees. 

• Follow-up inspections are scheduled and completed, as necessary. 

• Notifications are made to the NRC Headquarters Operations Center for incidents 

requiring a 24-hour or immediate notification to the Agreement State or the NRC. 

• Incidents are reported to the Nuclear Material Events Database. 

• Allegations are investigated in a prompt, appropriate manner. 

• Concerned individuals are notified of investigation conclusions. 

• Concerned individuals’ identities are protected, as allowed by law. 

b. Discussion 

During the review period, three radioactive materials incidents were reported to Rhode 

Island. The review team evaluated all three incidents which included two lost/stolen 

radioactive materials, and one medical event (Y-90 microspheres underdose). Rhode 

Island dispatched inspectors for onsite followup for one of the cases reviewed. The 

review team evaluated the Program’s analyses and followup actions for each event, and 

determined that they were adequate for the type of event. 

There was one allegation reported to the Program from the NRC during the review 

period; however, the Program determined after speaking with the concerned individual, 

that the concern was not related to licensed activities. The review team agreed with the 

Program’s assessment. 

c. Evaluation 

The team determined that during the review period Rhode Island met the performance 

indicator objectives listed in Section 3.5.a. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, 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. 

 
Rhode Island Final IMPEP Report Page 11 

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 

(SS&D) Program, (3) Low-Level Radioactive Waste Disposal (LLRW) Program, and (4) 

Uranium Recovery Program. The NRC’s Agreement with Rhode Island does not 

relinquish regulatory authority for a SS&D or uranium recovery program; therefore, only 

the first and third non-common performance indicators applied to this review. 

4.1 Compatibility Requirements 

State statutes should authorize the State to establish a program for the regulation of 

agreement material and provide authority for the assumption of regulatory responsibility 

under the agreement. The statutes must authorize the State to promulgate regulatory 

requirements necessary to provide reasonable assurance of protection of public health, 

safety, and security. The State must be authorized through its legal authority to license, 

inspect, and enforce legally binding requirements, such as regulations and licenses. 

The NRC regulations that should be adopted by an Agreement State for purposes of 

compatibility or health and safety should be adopted in a time frame so that the effective 

date of the State requirement is not later than 3 years after the effective date of the 

NRC's final rule. Other program elements, as defined in Appendix A of State 

Agreements procedure SA-200, “Compatibility Categories and Health and Safety 

Identification for NRC Regulations and Other Program Elements,” that have been 

designated as necessary for maintenance of an adequate and compatible program 

should be adopted and implemented by an Agreement State within 6 months following 

NRC designation. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-107, “Reviewing 

the Non-Common Performance Indicator: Compatibility Requirements,” and evaluated 

Rhode Island’s performance with respect to the following performance indicator 

objectives. A complete list of regulation amendments can be found on the NRC website 

at the following address: https://scp.nrc.gov/rss_regamendents.html. 

• The Agreement State program does not create conflicts, duplications, gaps, or other 

conditions that jeopardize an orderly pattern in the regulation of radioactive materials 

under the Atomic Energy Act, as amended. 

• Regulations adopted by the Agreement State for purposes of compatibility or health 

and safety were adopted no later than 3 years after the effective date of the NRC 

regulation. 

• Other program elements, as defined in SA-200 that have been designated as 

necessary for maintenance of an adequate and compatible program have been 

adopted and implemented within 6 months of NRC designation. 

• The State statutes authorize the State to establish a program for the regulation of 

agreement material and provide authority for the assumption of regulatory 

responsibility under the agreement. 

• The State is authorized through its legal authority to license, inspect, and enforce 

legally binding requirements such as regulations and licenses. 

• Impact of sunset requirements, if any, on the State’s regulations. 
Rhode Island Final IMPEP Report Page 12 

b. Discussion 

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

Agreement State Program‘s current effective statutory authority is contained in Section 

23-1.3 – Radiation Control, of the Rhode Island Statutes. The Department is designated 

as the State’s radiation control agency. No legislation affecting the radiation control 

program was passed during the review period. 

The State’s administrative rulemaking process takes approximately 12-18 months from 

drafting to finalizing a rule. 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 subject to “sunset” laws and need to be administratively refiled every 

5 years. The next administrative refiling for the Program will take place in 2017. 

During the review period, Rhode Island submitted 17 final regulation amendments and 

one legally binding license condition to the NRC for a compatibility review. Eight of the 

amendments were overdue for State adoption at the time of submission. These eight 

amendments were identified as overdue at the time of the 2011 IMPEP review (see 

Section 2.0 for the recommendation made during the 2011 IMPEP review). In order to 

address the previous recommendation the Program adopted final regulations for those 

eight overdue amendments in addition to amendments that were due to be adopted 

during the review period. At the time of this review, no amendments were overdue. 

However, there are outstanding compatibility comments on final regulations that the 

Program is in the process of addressing. The Program expects those changes to be 

promulgated in final by the summer of 2017. 

c. Evaluation 

The team determined that during the review period Rhode Island met the performance 

indicator objectives listed in Section 4.1.a. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

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

Compatibility Requirements, be found satisfactory. 

4.2 Low-Level Radioactive Waste Disposal Program 

In 1981, the 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, the 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 
Rhode Island Final IMPEP Report Page 13 

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 team did not review this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0 above, Rhode Island’s performance was found 

satisfactory for four performance indicators reviewed, satisfactory, but needs 

improvement for the indicator, Technical Staffing and Training, and unsatisfactory for the 

performance indicator, Status of the Materials Inspection Program. The review team did 

not make any recommendations and determined that the recommendations from the 

2011 IMPEP review can be closed with the exception of the recommendation regarding 

Status of the Materials Inspection Program which should remain open. The MRB issued 

two recommendations to the Program both attributed to the long standing staffing 

vacancies—one concerning the Program’s documentation of its inspection and licensing 

activities, the second concerning the timeliness of license renewals. 

Accordingly, the review team recommended, and the MRB agreed, that the Rhode 

Island Agreement State Program be found adequate to protect public health and safety, 

but needs improvement, and compatible with the NRC's program. Based on the results 

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

the next full IMPEP review take place in approximately 4 years. In lieu of a followup 

IMPEP review for the two indicators found satisfactory, but needs improvement, and 

unsatisfactory, the review team recommended, and the MRB agreed, that a periodic 

meeting be held 1 year from this review with a second meeting approximately 18 months 

after the first periodic meeting. Additionally, the review team recommended and the 

MRB agreed, that Rhode Island remain on monitoring. 

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

implementation by the State: 

RECOMMENDATIONS: 

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 in IMC 2800. This recommendation remains open from the 2011 

IMPEP review. (Section 2.0 and 3.2) 

2. The MRB recommends that the Program management take measures to ensure 

proper documentation of inspection tracking dates and ensure the Program’s 

licensing and inspection files are complete. (Section 3.1) 

3. The MRB recommends that Program management develop and implement an action 

plan to reduce the licensing renewal backlog. (Section 3.4) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Inspection Accompaniments 

 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Michelle Beardsley, NMSS Team Leader 

 Technical Quality of Inspections 

 Technical Quality of Incident and Allegation Activities 

 Inspector Accompaniments 

Monica Ford, Region I Technical Staffing and Training 

 Status of the Materials Inspection Program 

 Compatibility Requirements 

Beth Schilke, Virginia Technical Quality of Licensing Actions 
APPENDIX B 

INSPECTION ACCOMPANIMENTS 

The following inspection accompaniments were performed prior to the onsite IMPEP review: 

Accompaniment No.: 1 License No.: 

License Type: Nuclear Pharmacy Priority: 2 

Inspection Date: 02/18/16 Inspector: DK 

Accompaniment No.: 2 License No.: 

License Type: Industrial Radiography Priority: 1 

Inspection Date: 02/19/16 Inspector: CW