Objective

To determine the extent of the four recommendations included in our initial audit report, Oversight of Registration, Licensing, and Inspection of Radioactive Materials Facilities and Radiation Equipment Facilities (Report 2019-S-64).

About the Program

When handled correctly, radioactive materials have many beneficial medical, industrial, and academic uses. Radioactive materials can be used safely for diagnostic and therapeutic purposes, to test new drugs, and to study cellular functions. Additionally, in various industrial applications, radioactive materials can be used to protect food and blood supplies, increase the safety of roads and buildings, and locate new energy sources. However, high amounts of radiation exposure can cause injury or death by damaging bodily systems.

DOH is responsible for the supervision and regulation of radiation and radioactive materials in New York State, outside of New York City. To fulfill these responsibilities, DOH has established the Bureau of Environmental Radiation Protection (BERP), whose duties include licensing and inspecting approximately 1,100 radioactive materials facilities (RAM facilities), as well as registering and inspecting approximately 9,900 radiation equipment facilities that use diagnostic, mammography, and stereotactic equipment. Failure to promptly register, license, inspect, or follow up on facilities that use radioactive materials or radiation equipment increases the risk that radioactive materials or equipment may be improperly handled or stored, and may expose employees, patients, and others to increased levels of radiation.

The objective of our initial audit, issued September 23, 2021, was to determine if DOH was ensuring that the registration, licensing, and inspection of radioactive materials facilities and radiation equipment facilities were completed as required. The audit covered licensing and inspection records for the period from January 1, 2017 through February 28, 2020 and other information through March 5, 2021. We found that DOH completed 94% of RAM facility inspections on time. However, it completed 44% of those inspections beyond the established 1- to 5-year inspection time frames by relying on a buffer. The buffer is intended to allow for more flexibility and logical extensions to the inspection intervals, such as for staff time and travel. We also found that, of the 259 RAM facility inspections that needed the buffer to be considered inspected on time, 86 (33%) showed the facilities were, at the time of inspection, not in compliance with established standards. For 33 of those 86 inspections (38%), DOH had also found the facility was not in compliance during the prior inspection. Additionally, of the 2,720 radiation equipment facility inspections that needed the buffer to be considered inspected on time, 249 (9%) showed the facilities were, at the time of inspection, not in compliance with established standards. For 55 of those 249 inspections (22%), the facility was found not in compliance during its prior inspection as well. DOH also did not complete all license actions within its 1-year benchmark. For example, as of July 20, 2020, DOH had not completed 55 licensing actions that were beyond the 1-year benchmark.

Key Findings

DOH has made some progress in addressing the problems we identified in the initial audit report; however, more work needs to be done. Of the initial report’s four recommendations, one was implemented, one was partially implemented, and two were not implemented.

Key Recommendation

DOH officials are requested, but not required, to provide information about any actions planned to address the unresolved issues discussed in this follow-up within 30 days of the report’s issuance.