Inspections, Compliance, Enforcement, and Criminal Investigations
Saint Dominic's Hospital 05-Nov-01
DEPARTMENT OF HEALTH & HUMAN SERVICES
Food and Drug Administration
San Francisco District
1431 Harbor Bay Parkway
Alameda, CA 94502-7070
November 5, 2001
Via Federal Express
FDA Reference #: 2951828
MQSA Facility ID: 138172
Inspection ID: 1381720008
Saint Dominic?s Hospital
1777 W. Yosemite
Manteca, CA 95337
Dear Kim Ham:
We are writing to you because on September 25, 2001, your facility was inspected by a representative of the State of California, acting on behalf of the Food and Drug Administration (FDA). This inspection revealed a serious regulatory problem involving the mammography at your facility.
Under a United States Federal law, the Mammography Quality Standards Act of 1992, your facility must meet specific requirements for mammography. These requirements help protect the health of women by assuring that a facility can perform quality mammography. The inspection revealed the following Level 1 findings at your facility:
1. Processor QC records in the month of 12/2000 were missing for at least 30% of operating days, for processor 0000000001, [redacted] room DARKROOM at site Saint Dominic?s Hospital.
2. Processor QC ere missing at least 5 consecutive days for processor 0000000001, [redacted] room DARKROOM at site Saint Dominic?s Hospital
The specific problems noted above appeared on your MQSA Facility Inspection Report, which was issued to your facility at the close of the inspection. These problems are identified as Level 1, because they identify a failure to meet a significant MQSA requirement.
Because these conditions may be 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, MQSA 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 findings that were listed on the inspection report provided to you at the close of the inspection. These Level 2 findings are:
1. Corrective actions for processor QC failures were not documented at least once for 0000000001, [redacted] room DARKROOM at site Saint Dominic?s Hospital.
2. Failure to produce documents verifying that the radiologic technologist [redacted] (9 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.
It is necessary for you to act on this matter immediately. Please explain to this office in writing within fifteen (15) working days horn the date you received this letter:
- 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; and
- 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).*
*This note is not applicable for letters which also address patient notification.
Please submit your response to:Russell A. Campbell, Compliance Officer
San Francisco District
U.S. Food and Drug Administration
1431 Harbor Bay Parkway
Alameda, CA 94502
Finally, you should understand that there are many FDA requirements pertaining to mammography. 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 Russell A. Campbell at 510-337-6861.Sincerely yours,
Dennis K. Linsley