Challenge
After experiencing several issues with record-keeping and inventory reconciliation, Rossmoyne needed a compliance solution to evaluate the management and oversight of controlled substances within its facility. “We have a total of 16 controlled substances to manage,” says Co-Owner and President, Sabrena Hartley. “When you operate a 24/7 veterinary hospital, emergency situations arise at any moment and can often lead to details slipping through the cracks. We needed a compliance expert to assess our facility weaknesses and develop an ongoing compliance plan that would be easy to implement moving forward.”
Prior to TITAN’s solution, Rossmoyne’s compliance protocols consisted of intermittent inventories with no reconciliation and complete lack of oversight. Discrepancies were seldom if ever rectified. There were no standard operating procedures (“SOPs”) in place as they pertain to inventory or the safe keeping of controlled substances.
TITAN Group DEA Gap Assessment™
Initially, Rossmoyne enlisted TITAN Group to perform a DEA Gap Assessment. A Gap Assessment is a cursory review of the policies and procedures currently in place including a review of inventory and record-keeping to take the core temperature of the compliance elements that they should be adhering to. Gap Assessment objectives included:
Evaluate facility-controlled substances processes and controls
Review of controls for controlled substances wasting and disposal
Assess effectiveness of controls for monitoring/detecting controlled substance diversion including security protocols.
Determine the level of compliance of Rossmoyne’s current policies and procedures against the regulations found in the Controlled Substances Act and applicable state laws
Test existing controls against key controls required by DEA policies and procedures
Preliminary interviews were conducted with key personnel, specific to individuals involved in the ordering, dispensing, record-keeping, and administration of controlled substances throughout the facility. A cursory examination of relevant records was also performed.
The Gap Assessment took approximately six hours to complete. Following the assessment, TITAN provided Rossmoyne with a report representing the facility’s current state of compliancy that included both areas requiring further review/remediation as well as areas where Rossymone met the required compliance standards. Based on the results, TITAN recommended Rossmoyne undergo an end-to-end DEA Diversion Audit and Compliance Inspection to rectify areas requiring improvement and bring the facility into full compliance.
Benefits from TITAN Group Audit
The entire TITAN audit was conducted over a two day period. TITAN Investigators identified and remediated issues with care during their visit.
Cost Avoidance
Annual Revenue Protection
Ongoing Support
Streamlined Operations
Rapid Detection Times
Rossmoyne is now executing facility-wide compliance, supported by a comprehensive plan customized to their needs and operations. Implementing TITAN’s solution has allowed Rossmoyne’s staff to work more accurately and efficiently throughout day-to-day operations. Optimized SOP’s have rectified internal recordkeeping issues, ensuring that nothing slips through the cracks. A ready and retrievable file is now available and on-hand in the event a surprise audit were to take place.
About TITAN Group
Founded by retired DEA Supervisory Special Agent, Jack Teitelman, TITAN Group is a full-service regulatory compliance, drug security and anti-diversion solutions provider. TITAN’s team of experts have extensive law enforcement backgrounds at local, state and federal level which allows us to offer a full-suite of services audits, mock inspections, development and implementation of robust procedures to meet DEA requirements, security protocols, and training.
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