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U.S. Department of Health and Human Services

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Enforcement Actions

Swope Parkway Health Center 18-Jul-01

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

 

Food and Drug Administration
SOUTHWEST REGION
Office of the Regional
Food and Drug Director
7920 Elmbrook Drive, Suite 102
Dallas, TX 75247-4982
TELEPHONE: 214-655-8100
FACSIMILE: 214-655-8130

July 18, 2001

WARNING LETTER

CERTIFIED MAIL

RETURN RECEIPT REQUESTED 01-SWR-WL-6310

Ralph Caro
Administrator/COO
Swope Parkway Health Center
3801 Blue Parkway
Kansas City, MO 64030

RE: Inspection ID -1540620007

Dear Ralph Care,

On July 11,2001, a representative of the State of Missouri acting in behalf of the Food and Drug Administration (FDA) inspected your facility. This inspection revealed a serious regulatory problem involving the mammography at your facility.

The Mammography Quality Standards Act of 1992 requires your facility to meet specific standards. These requirements help protect the health of women by assuring that a facility can perform quality mammography. The inspection revealed the following level 1 and repeated level 2 findings at your facility:

Level 1: Failed to produce documents verifying that the interpreting physician [redacted] met the initial requirement of holding a valid state license to practice medicine.

Level 2 repeat: Processor QC records in the month of 02/2001 were missing for at least 10% but less than 30% of operating days, for processor 1, Kodak, X-OMAT.

The specific problems noted above appeared on your MQSA Facility Inspection Report, which was issued to your facility at the close of the inspection.

[A finding is considered a repeat finding if the same type of violation was cited during the previous inspection, whether or not the finding is associated with the same piece of equipment (x-ray unit, processor, or darkroom) or the same personnel in a given category.]

Level 1 and repeated level 2 findings maybe symptomatic of serious underlying problems that could compromise the quality of mammography at your facility. They represent a serious violation of the law which may result in FDA taking regulatory action without further notice to you. These actions include, but are not limited to:

  • Placing your facility under a Directed Plan of Correction.
  • Charging your facility for the cost of on-site monitoring.
  • Assessing civil money penalties up to $10,000 for each failure to substantially comply with, or each day of failure to substantially comply with, the Standards.
  • Suspension or revocation of your facility?s FDA certificate, or obtaining a court injunction against further mammography.

In addition, your response should address the level 2 finding that was listed on the inspection report provided to you at the close of the inspection. The inspection revealed the following level 2 findings:

Level 2: Processor QC records were missing at least 2 but less than 5 consecutive days for processor 1, Kodak, X-OMAT.

Level 2: Failed to produce documents verifying that the radiologic technologist [redacted] (12 CEU? s in 36 months) met the continuing education requirement of having taught or completed at least 15 continuing education units in mammography in 36 months.

Level 2: Failed to produce documents verifying that the radiologic technologist [redacted], (12 CEU?S in 36 months) met the continuing education requirement of having taught or completed at least 15 continuing education units in mammography in 36 months.

Level 2: Failed to produce documents verifying that the radiologic technologist [redacted] met the continuing experience requirement of having performed 200 mammography examinations in 24 months.

Level 2: Failed to produce documents verifying that the radiologic technologist [redacted], met the continuing experience requirement of having performed 200 mammography examinations in 24 months.

Level 2: Failed to produce documents verifying that the medical physicist [redacted]

(2 CME?S in 36 months) met the continuing education requirement of having taught or completed at least 15 continuing education units in mammography in 36 months.

Level 2: Failed to produce documents verifying that the medical physicist [redacted], met the continuing experience requirement of having surveyed at least 2 mammography facilities and a total of at least 6 mammography units in 24 months.

Level 2: 1 of 5 random reports reviewed did not contain an assessment category.

Level 2: There were no examples of, nor attempts, to get biopsy results.

It is necessary for you to act on this matter immediately. You are required to respond to this office in writing within fifteen (15) working days from receipt of this letter. Please address the following:

  • The specific steps you have taken to correct all of the violations noted in this letter.
  • Each step your facility is taking to prevent the recurrence of similar violations.
  • Equipment settings (including technique factors), raw test data, and calculated final results, where appropriate.
  • Sample records that demonstrate proper record keeping procedures, if the findings relate to quality control or other records (Note: Patient names or identification should be deleted from any copies submitted).

Please submit your response to:

Deborah M. McGee, Radiation Specialist

Food and Drug Administration

7920 Elmbrook Drive, Suite 102

Dallas, TX 75247-4982

This letter pertains only to findings of your inspection and does not necessarily address other obligations you have under the law. You may obtain general information about all of FDA?s requirements for mammography facilities by contacting the Mammography Quality Assurance Program, Food and Drug Administration, P.O. Box 6057, Columbia, MD 21045-6057 (1-800-838-7715) or through the Internet at http: //www.fda.gov.

If you have more specific questions about mammography facility requirements, or about the content of this letter, please feel free to contact Deborah M. McGee at (214) 655-8100 ext. 138.

Sincerely yours,

/s/

Gary L. Pierce

Regional Food and Drug Director