WARNING LETTER
Ideal Implant Incorporated
MARCS-CMS 606103 —
May 14, 2020
Delivery Method:
VIA Electronic Mail
Product:
Medical Devices
Recipient:
Recipient Name
Robert S. Hamas, M.D.
Recipient Title
CEO and President
Ideal Implant Incorporated
14881 Quorum Drive, Suite 925
Dallas
,
TX
75254
United States
Issuing Office:
Center for Devices and Radiological Health
United States
WARNING LETTER
CMS 606103
May 14, 2020
Dear Dr. Hamas:
The United States Food and Drug Administration (FDA) conducted inspection of your medical device operations at 14881 Quorum Drive, Suite 925, Dallas, Texas from January 27, 2020 through February 3, 2020, investigators from the United States Food and Drug Administration (FDA) determined that your firm manufactures the IDEAL IMPLANT Saline-Filled Breast Implant.  Under section 201(h) of the Federal Food, Drug, and Cosmetic Act (the Act), 21 U.S.C. § 321(h), these products are devices because they are intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease, or to affect the structure or function of the body.
This inspection revealed that the IDEAL IMPLANT Saline-Filled Breast Implant device is adulterated within the meaning of section 501(h) of the Act, 21 U.S.C. § 351(h), in that the methods used in, or the facilities or controls used for, their manufacture, packing, storage, or installation are not in conformity with the current good manufacturing practice requirements of the Quality System regulation found at Title 21, Code of Federal Regulations (CFR), Part 820. We received two responses dated February 24, 2020 and April 30, 2020 concerning our investigator’s observations noted on the Form FDA 483, List of Inspectional Observations (FDA 483) that was issued on February 3, 2020.  We address the responses below, in relation to each of the noted violations.  These violations include, but are not limited to, the following:
1.Failure to maintain complaint files and establish and maintain procedures for receiving, reviewing, and evaluating complaints by a formally designated unit, as required by 21 CFR 820.198(a).
Specifically, our inspection identified your firm did not document complaint investigations and medical device reportability evaluations for complaints 19-0233 and 18-0095, as required by your “Complaint Files” procedure dated September 28, 2017, Revision 4.
We have reviewed your responses dated February 24, 2020 and April 30, 2020 and the adequacy of your responses cannot be determined at this time.  Your response dated February 24, 2020 states for complaint 18-0095, multiple attempts were made to obtain the information from the customer and the customer requested to cancel this complaint on June 11, 2019.  Your response indicates when a customer cancels a complaint, this is justification for limited investigation.  However, your revised “Complaint Files” procedure dated February 24, 2020 Revision 5, does not address how your firm should handle investigations associated with “cancelled” complaints.  In response to this letter, please describe and clarify the impact of a cancelled complaint on your complaint handling process and if a revision to your “Complaint Files” procedure is required, please provide the revised procedure.
Further, your responses state your firm completed a full retrospective review of all complaints received since launch of the IDEAL IMPLANT.  It further states, the results of this review will be subject to a risk assessment of revised complaint trend data to evaluate the need for any corrective actions.  However, your responses did not include evidence or results of this review.  Please provide a summary of the results of this review including the complaint numbers of any complaint records identified as deficient from your review and the results of the risk analysis you reported as completed.
2.Failure to establish and maintain procedures for implementing corrective and preventive action, as required by 21 CFR 820.100(a).
A.Your “Corrective and Preventive Action” procedure SOP 12, Rev. 07 dated  August 29, 2017, states, "***The Quality Manager is responsible for analyzing supplier quality data, internal and external audit results, and nonconformances encountered by Ideal Implants***". Your firm’s contract manufacturer had reported rejection of several sterilization loads in 2019
(b)(4)
due to ‘failures’. Your firm has not documented corrective actions taken in response to these nonconformances.
B.Your “Corrective and Preventive Action” procedure SOP 12, Rev. 07 dated  August 29, 2017, requires verification or validation of CAPA to ensure that it is effective and does not create other actual or potential nonconformances. However, a review of your firm’s CAPA initiated in 2018 and 2019 were observed to be ineffective and closed without investigating the cause of nonconformities. Your firm did not investigate the cause of nonconformities and did not identify the actions needed to correct and prevent the recurrence of nonconforming products and other quality problems. A review of 7 CAPAs found that at least 4 CAPAs
(b)(4)
were observed to be voided without any analysis or investigation.
We have reviewed your responses dated February 24, 2020 and April 30, 2020 and have determined they are inadequate.  In your response, you included a revised “Supplier Selection and Control” procedure SOP 006, February 24, 2020, revision 11.  This procedure now requires a supplier corrective action to be generated for nonconformities that may reasonably be attributable to a supplier.  However, your response does not address how your firm addressed recent or ongoing supplier nonconformances generated prior to February 24, 2020.  In response to this letter please provide results from a retrospective review of any open supplier nonconformances, ongoing supplier CAPAs, and your evaluation on if previously received supplier nonconformances were adequately handled.
Additionally, in your response you reference supplier CAPA
(b)(4)
, which is related to finished product testing.  Please include a description and appropriate supporting documentation of the current status of this supplier CAPA in relation to your quality system and supplier oversight activities.  Please describe any activities you have retroactively completed for this supplier CAPA in relation to the changes made to your supplier control activities.
In response to item B, your response explains you have opened several new CAPAs to address the previous CAPA which have been deemed ineffective.  In response to this letter, please provide your firm’s remediation plans to complete and resolve these CAPAs in a reasonable timeframe as they involve deficiencies that have been ongoing for up to 1 ½ years without correction.
3.Failure to establish and maintain adequate procedures for finished device acceptance to ensure that each production run, lot, or batch of finished devices meets acceptance criteria, as required by 21 CFR 820.80(d).
Specifically, your firm has not established your procedure for finished device acceptance. Your firm’s “Finished Device Specification” for IDEAL IMPLANT Structured Breast Implant, FP 001, Rev 13, dated November 29, 2018 requires
(b)(4)
for
(b)(4)
testing for finished implant lot release. Your finished device test data from
(b)(4)
, for Sterilization Load #
(b)(4)
, dated January 8, 2019, shows failure of
(b)(4)
out of
(b)(4)
samples. Your sampling plan is based on
(b)(4)
with AQL of
(b)(4)
. However, your firm released the lot on January 9, 2019, after conducting additional sampling.
We have reviewed your responses and determined they are inadequate.
We acknowledge in response to these failures your firm conducted additionally sampling documented in your firm’s “Memo to File – Quality #26" dated January 9, 2019.  However, the justification provided in this memo is inadequate.  In the “Justification and Conclusion” section of the memo you state you met an acceptance quality level (AQL) of
(b)(4)
based on your sampling plan.  It further states, the sampling plan used allows the lot to be accepted at
(b)(4)
and rejected at
(b)(4)
.  As described in the memo, the testing conducted resulted in
(b)(4)
with inconclusive investigations into the root cause.  As such, these failures have no conclusive basis to be invalidated.  Further, we recommend your firm consider revising your draft “Finished Product Specification” provided in your response to better define “inconclusive results” to ensure proper application of the other sections of this procedure.
Please include in your response to this letter how your firm ensured the validity and robustness of your
(b)(4)
testing, as your records and response assert some of your failures are believed to be associated with test method failures.
Additionally, the draft revision to your “Finished Product Specification” now define
specific criteria for handling out of specification results and resampling. However, your draft specification does not include any limitations to the number of times any specific set of products can be retested.  In response to this letter, please include if your firm intends to limit the number of retests permitted.
Lastly, section 5.3.2(a) of your draft “Finished Product Specification” states " If a root cause for the Out of Specification (OOS) mechanical test measurement(s) is determined upon investigation to be an aberration isolated to the implant for which the OOS mechanical test measurement(s) was measured, then the OOS mechanical test measurement(s) is invalidated... ". Please explain a situation this would apply that would invalidate the statistical sampling and outlier analysis proposed in the revised "Finished Product Specification".
Please provide evidence of implementation of the new procedure, including verification of effectiveness and indicate if a retrospective review of production records was performed to determine if there were other instances where retesting was done that could have resulted in distribution of nonconforming product.
Our inspection also revealed that your firm’s IDEAL IMPLANT devices are misbranded under section 502(t)(2) of the Act, 21 U.S.C. § 352(t)(2), in that your firm failed or refused to furnish material or information respecting the device that is required by or under section 519 of the Act, 21 U.S.C. § 360i, and 21 CFR Part 803 - Medical Device Reporting. Significant violations include, but are not limited to, the following:
1.Failure to submit a report to FDA no later than 30 calendar days after the day that the firm received or otherwise became aware of information, from any source, that reasonably suggests that a device that the firm markets has malfunctioned and this device or a similar device that it markets would be likely to cause or contribute to a death or serious injury, if the malfunction were to recur, as required by 21 CFR 803.50(a)(2).
For example, the information included for Complaints 18-0016, 18-0014, 19-0006, 19-0175, 19-0015, 19-0017, 18-0077, 19-0074, 19-0183, 19-0121, 19-0099, 18-0051, 19-0142, 18-0109, 19-0227, 19-0172, 19-0229, 19-0075, 10-0088, 19-0051, 18-0115, 19-0256, 18-0113, 19-0262, 18-0099,, 18-0118, 18-0119, 19-0292, 19-0310 ad 19-0328 describes adverse events occurring as a result of malfunctions of the firm's breast Implants (e.g. rupturing or deflation)
Your firm initiated a recall (i.e. Z-2219-2019), for the referenced deflation malfunctions. In addition, the device involved in the referenced events is a long-term implant. The 1995 preamble states that a malfunction is reportable if the manufacturer takes or would be required to take an action under sections 518 or 519(f) of the act as a result of the malfunction of the device or other similar devices and that the malfunction of a long-term implantable device is reportable. There is no information included in the firm’s complaint files that justifies that the malfunction of the subject device would not be likely to cause or contribute to a death or serious injury if it were to recur. As such, the referenced complaints meet the definition of a reportable malfunction, as defined in 21 CFR 803.3. An MDR for each of the above referenced complaints was not submitted within the 30-calendar day timeframe.
We reviewed your firm’s responses dated February 24, 2020 and April 30, 2020 and concluded they are not adequate. Your firm’s response noted that it had completed a 100% review of complaints since product launch and revised its MDR decision process. However, your firm did not provide evidence of the systemic correction actions, including a retrospective review of all complaints in accordance with its revised MDR process.
2.Failure to adequately develop, maintain and implement written MDR procedures, as required by 21 CFR 803.17(a). For example, the following document was collected during the inspection and reviewed as your firm’s MDR procedure:
Document “Medical Device Reporting", SOP 025, Rev. 05, dated December 11, 2017.
After reviewing your firm’s MDR procedure, the following deficiencies were noted:
(1) The procedure does not establish internal systems that provide for timely and effective identification, communication, and evaluation of events that may be subject to MDR requirements, as required by 21 CFR 803.17(a)(1). For example, the procedure includes definitions from 21 CFR 803.3 for the terms “serious injury” and “MDR reportable event”, “become aware”, “caused or contributed” and the definition for the term “reasonably suggests” found in 803.20(c)(1). However, the procedure omits the definition of the term “malfunction” found in 21 CFR 803.3. The exclusion of the definition for this term from the procedure may lead your firm to make an incorrect reportability decision when evaluating a complaint that may meet the criteria for reporting under 21 CFR 803.50(a).
(2) The procedure does not establish internal systems that provide for timely transmission of complete medical device reports, as required by 21 CFR 803.17(a)(3). For example, the procedure failed to address how your firm will submit all information reasonably known to it for each event. Specifically, which sections of the 3500A will need to be completed to include all information found in your firm’s possession and any information that becomes available as a result of a reasonable follow up within your firm.
Your firm’s response dated February 24, 2020, appears to be adequate. Your firm’s response included its revised procedure titled “Adverse Event Reporting”, SOP 025, Rev: 06, dated February 24, 2020. As written, the revised document addresses the noted deficiencies and will allow your firm to meet its reporting requirements.
Your firm should take prompt action to correct the violations addressed in this letter.  Failure to promptly correct these violations may result in regulatory action being initiated by the FDA without further notice.  These actions include, but are not limited to, seizure, injunction, and civil money penalties.  Also, federal agencies may be advised of the issuance of Warning Letters about devices so that they may take this information into account when considering the award of contracts.  Additionally, should FDA determine that you have Quality System regulation violations that are reasonably related to premarket approval applications for Class III devices, such devices will not be approved until the violations have been corrected.  Also, should FDA determine that your devices do not meet the requirements of the Act, requests for Certificates to Foreign Governments (CFG) may not be granted. If you believe that your products are not in violation of the Act, please respond to FDA with your reasoning and any supporting information for our consideration.
Please notify this office in writing within fifteen business days from the date you receive this letter of the specific steps your firm has taken to correct the noted violations, including an explanation of how your firm plans to prevent these violations, or similar violations, from occurring again.  Include documentation of the corrections and/or corrective action (which must address systemic problems) that your firm has taken.  If your firm’s planned corrections and/or corrective actions will occur over time, please include a timetable for implementation of those activities.  If corrections and/or corrective actions cannot be completed within fifteen business days, state the reason for the delay and the time within which these activities will be completed.  Please provide a translation of documentation not in English to facilitate our review.  We will notify you regarding the adequacy of your firm’s response(s) and the need to re-inspect your firm’s facility to verify that the appropriate corrections and/or corrective actions have been made.
Your firm’s response should be sent to: US Food and Drug Administration, Division 3/West, Office of Medical Device and Radiological Health Operations at
ORADevices3FirmResponse@fda.hhs.gov
.  Please identify your response with FEI 3008342021.
If you have any questions about the contents of this letter, please contact Compliance Officer Jeff R. Wooley at
214-253-5251
, or via e-mail at
Jeffrey.wooley@fda.hhs.gov
.
Finally, you should know that this letter is not intended to be an all-inclusive list of the violations at your firm’s facility.  It is your firm’s responsibility to ensure compliance with applicable laws and regulations administered by FDA.  The specific violations noted in this letter and in the Inspectional Observations, FDA 483, issued at the close of the inspection may be symptomatic of serious problems in your firm’s manufacturing and quality management systems.  Your firm should investigate and determine the causes of the violations, and take prompt actions to correct the violations and bring the products into compliance.
Sincerely,
/S/
Shari J. Shambaugh
Program Division Director
Office of Medical Devices and Radiological
Health, Division III
And
Binita S. Ashar, MD, MBA, F.A.C.S.
Director
OHT4: Office of Surgical and Infection Control
Devices
Office of Product Evaluation and Quality
Center for Devices and Radiological Health
Content current as of:
05/14/2020
Regulated Product(s)
Medical Devices