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  1. Mammography Quality Standards Act and Program

Mammography Facility Adverse Event and Action Report - October 5, 2017: Jack County Hospital District dba Faith Community Hospital

Mammography Facility Adverse Event and Action Report - October 5, 2017: Jack County Hospital District dba Faith Community Hospital

Background
As part of the Mammography Quality Standards Act (MQSA), Congress mandated there be annual reporting of adverse actions taken against mammography facilities. Congress stipulated that the report be made available to physicians and the general public and that it should include information that is useful in evaluating the performance of mammography facilities nationwide. In order to provide this information in the timeliest manner, we now post the following information in "real time," as actions taken against mammography facilities are concluded:

Mammography Facility Against Which There Was An Adverse Action

The State of Texas

Facility Name and Address:
Jack County Hospital District
dba Faith Community Hospital
215 Chisholm Trail
Mammography
Jacksboro, TX 76458

Facility ID Number:
242613

Adverse Event:
In April 2017, the State of Texas Accreditation Body (STX AB) initiated an Additional Mammography Review (AMR) of mammograms performed by this facility due to serious image quality problems identified during a review of clinical images submitted to it for accreditation of a new unit.

On June 30, 2017, STX AB notified the facility that it failed the AMR because the images reviewed did not meet the STX AB’s criteria for clinical image quality and that it believed the deficiencies posed a serious risk to human health.

Action Taken:
Under State authority the facility was allowed to voluntarily suspend its accreditation, effective June 30, 2017. After evaluating the information leading up to serious risk to human health determination, the State of Texas Certification Agency (STX CA) suspended the facility’s MQSA certificate until such time as the facility’s accreditation was reinstated and the facility complied with all requirements under the MQSA.

Corrective Action:
On July 12, 2017, the STX CA Agency required the facility to perform a Patient and Referring Healthcare Provider Notification (PPN) to alert all at-risk patients and their providers of the mammography quality problems at the facility.

The facility completed the PPN and was notified of such by the STX CA on October 3, 2017.

Status of the Facility:
The facility’s accreditation and MQSA certificate were reinstated and the facility is currently performing mammography.