24-Hour Emergency Veterinary Hospital Realizes A Cost Savings Of $400,000 In Potential Fines Plus An Increase Of 25-35% Operational Efficiency As A Result Of A DEA Gap Assessment And Compliance Inspection By TITAN Group.
Rossmoyne Animal Emergency Trauma Center is a leading emergency veterinary hospital located in Mechanicsburg, Pennsylvania. Rossmoyne provides 24-hour emergency veterinary care services to small companion animals throughout South Central, Pennsylvania. Rossmoyne serves as Harrisburg’s regional critical care center, and its facility provides emergency services for over 50 primary care veterinary hospitals. Rossmoyne employs nine veterinarians, several relief veterinarians and a staff of approximately 55 personnel classified as follows on either a full or part-time basis:
- Veterinarian Technicians (certified)
- Veterinarian Assistants (certified)
- Practice Manager
- Office Manager
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.
Rossmoyne Co-Owner, Sabrena Hartley, was introduced to TITAN Group Founder and CEO, Jack Teitelman, during the 2017 NY Vet Show. “It was clear from our initial conversation that Jack’s compliance expertise far-exceeded other solutions we were exploring,” says Hartley.
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. “The gap assessment was an easy process, so we decided to move forward with a full audit inspection.” notes Hartley.
DEA Diversion Audit and Compliance Inspection
A full audit and compliance inspection is a more detailed undertaking including a complete inventory and audit of all recordkeeping relating to the controlled substances ordered, used and/or dispensed by the facility. In addition, a full review of security protocols is executed as well as review of all the necessary paperwork required by the CFR.
On February 19, 2018, TITAN performed a DEA Diversion Audit and Compliance Inspection at Rossmoyne. TITAN executed a team of three experts to conduct the audit, which consisted of eight key areas of inspection, including:
- Waste/Disposal of Inventory
- Employee Background Check
- Policies and Procedures
- Training and Education
A report detailing the audit findings and recommended corrective action was presented to Rossmoyne. “To streamline the process, our team worked directly with Rossmoyne personnel assisting with implementation,” says TITAN Founder and CEO, Jack Teitelman. “We provided a detailed action plan to ensure that Rossmoyne’s compliance strategy was both easy to implement and maintain going forward.”
Following TITAN’s DEA Gap Assessment and DEA Diversion Audit & Compliance Inspection, Rossmoyne realized the following benefits:
- Cost-Effective Compliance Management Solution
- $60K-$400K Cost Savings (no fines from failed inspection)
- Between a 25-35% increase in efficiency including areas of record keeping, staff onboarding, education and training, inventory
- Streamlined Operations which reduced errors and redundancy in record keeping
- 100% Visibility into the entire process
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. “Now if the DEA comes knocking at our door, we will be 100% complaint,” says Hartley.
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.