Inspections, Compliance, Enforcement, and Criminal Investigations
Bi-County Community Hospital 20-Jun-02
1580 East Jefferson Avenue
Detroit, MI 46207-3179
June 20, 2002
RETURN RECEIPT REQUESTED
Bi-County Community Hospital
13355 East Ten Mile Road
Warren, MI 48089
Dear Ms. Turner:
We are writing you because on May 17, 2002, your facility was inspected by a representative of the State of Michigan acting on behalf of the Food & Drug Administration (FDA). The inspection revealed a serious compromise in the quality of the mammography services offered by your facility.
Under the Mammography Quality Standards Act of 1992 (MQSA), 42 U.S.C. 263b, 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 recent inspection at your facility revealed the following Repeat Level 2 finding:
1. Corrective actions for processor quality control (QC) failures were not documented at least once for your [redacted] mammography film processor. This is a violation of Title 21 Code of Federal Regulations section 900.12(e) (8).
The specific problem noted above appeared on your MQSA Facility Inspection Report which your facility received at the close of the inspection. This problem is identified as a Repeat Level 2 because it identifies a failure to meet a significant MQSA requirement and indicates failure by your facility to implement permanent correction of the same problem found during your previous inspection.
Since this condition may be symptomatic of serious underlying problems that could compromise the quality of mammography at your facility, it represents a 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, suspension or revocation of your facility?s FDA certificate, or obtaining a court injunction against performing further mammography.
In addition, you should also address the following Level 2 findings that were listed on the inspection report provided to you at the close of the inspection:
1. Corrective actions, before further exams, for a failing phantom image score, or a phantom background optical density or density difference outside of the regulatory limit, were not documented for your [redacted] mammography x-ray system. This is in violation of Title 21 Code of Federal Regulations 900.12 (e)(8).
2. There was no documentation available at the time of the inspection to show that Dr. [redacted], met the requirement of having obtain a minimum of 15 hours of category 1 continuing medical education in mammography within the previous 36 month period. This is in violation of Title 21 Code of Federal Regulations 900.12 (a) (1) (ii) (8).
It is necessary for you to act on this matter immediately. Please explain to this office in writing within fifteen (15) working days from the date you receive this letter:
- the specific steps you have taken to correct the Level 1 and 2 violations noted in this letter;
- each step your facility is taking to prevent the recurrence of similar violations;
- the 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).
Mr. David M. Kaszubski
Director Compliance Branch
U. S. Food & Drug Administration
1580 East Jefferson Ave.
Detroit, MI 48207-3179
Please note that FDA regulations do not preclude a State from enforcing its own State mammography laws and regulations. In some cases, these requirements may be more stringent than FDA?s. When you plan your corrective actions, you should consider the more stringent State requirements, if any. You should also send a copy of your response to the State of Michigan radiation control office that conducted the inspection referenced in this letter. You may choose to address both the FDA and any additional State requirements in your response.
There are many FDA requirements pertaining to mammography. This letter only concerns the findings of your recent 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 21045-8057 (1-800-638-7715) or through the Internet at http://www.fda.gov/crdh/mammography.html
If you have any questions regarding this letter or how to ensure that you are meeting MQSA standards, please call Mr. Dennis E. Swartz, Radiological Health Expert, at 313-226-6260 Ext. 155.
John P. Dempster for Joann M. Givens
Detroit District Office