New York City Department of Health and Mental Hygiene


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NYS Comptroller


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New York City Department of Health and Mental Hygiene
Selected Aspects of Inspecting and Licensing Radioactive Materials and Radiation Equipment

Issued: August 21, 2018
Link to full audit report 2016-N-4

To determine whether the New York City Department of Health and Mental Hygiene (DoHMH) ensured that facilities using or possessing radioactive materials were appropriately licensed and inspected; facilities with radiation equipment were registered and inspected; facilities complied with selected licensing and registration regulations; and identified violations were followed up on in a timely manner. The audit covered the period July 1, 2014 to June 27, 2017.

Radioactive materials are commonly used for a variety of purposes in medicine and other industries. Under an agreement between New York State and the U.S. Nuclear Regulatory Commission, DoHMH has regulatory authority pertaining to the use and possession of radioactive materials and equipment in New York City, and is responsible for the scientific review and approval of applications for new, renewed, and amended radioactive material licenses and the registration of facilities with radiation equipment.

To ensure compliance with applicable rules, regulations, and license conditions, DoHMH is required to inspect all licensed and registered facilities. Licensing, registration, and inspection helps to protect and safeguard the public health from the misuse or abuse of such materials and equipment.

Key Findings
DoHMH did not always ensure that facilities which use radioactive material or radiation equipment were licensed or registered, inspect such facilities in a timely manner, or follow up on violations.

Of the 67 randomly sampled facilities with radioactive materials, 5 were not licensed and 4 were not inspected, as required. Similarly, of the 53 sampled hospitals with radiation equipment, 5 did not have registration certificates for the current and the prior registration period, 4 had gaps in their registration periods, and 2 had no registration records. Moreover, 6 were not inspected. Similar results were found when we reviewed a random sample of 80 other facilities, including dental facilities (the most prevalent type of facility requiring registration), urgent care facilities, research centers, diagnostic centers, and small medical, podiatry, and veterinary facilities using radiation equipment. Additionally, even when non-compliance was identified in the sample of hospitals, DoHMH did not always follow up on violations to ensure that a facility took action to correct the identified condition.

Not licensing, registering, inspecting, or following up on violations in facilities with radioactive materials or radiation equipment increases the risk that radioactive material may be improperly handled or stored at such facilities, and may expose employees, patients, and others to increased levels of radiation.

Key Recommendations

  • Take steps to comply with the regulations to license and register all facilities with radioactive materials and radiation equipment.
  • Inspect dental facilities before they commence operations.
  • Re-inspect facilities with violations within 60 days, as required.

Other Related Audit/Report of Interest

State Government Accountability Contact Information:
Audit Director: Carmen Maldonado
Phone: (212) 417-5200; Email:
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236