Report Summary

Title: Combined Assessment Program Summary Report – Evaluation of the Controlled Substances Inspection Program at Veterans Health Administration Facilities
Report Number: 14-01785-184
Issue Date: 6/10/2014
City/State:
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: The purpose of the review was to determine whether Veterans Health Administration (VHA) facilities complied with requirements related to controlled substances (CS) security and inspections and to follow up on the OIG report Healthcare Inspection – Review of Selected Pharmacy Operations in Veterans Health Administration Facilities (Report No. 07-03524-40, December 3, 2009). OIG performed this review in conjunction with 58 Combined Assessment Program reviews of VHA medical facilities conducted from October 1, 2012, through September 30, 2013. OIG identified opportunities for improvement in: conducting annual physical security surveys and correcting identified deficiencies; completing quarterly trend reports and providing them to facility Directors; conducting monthly CS inspections of non-pharmacy areas; completing non-pharmacy inspection activities; performing emergency drug cache quarterly physical counts and monthly verification of seals; validating completion of required drug destruction activities, accountability of prescription pads stored in the pharmacy, and outpatient pharmacy written prescriptions for schedule II drugs; providing annual CS inspector training.
VHA can strengthen policy by defining acceptable reasons for missed CS area inspections and providing guidance on CS Coordinator performance of monthly inspections. OIG made 10 recommendations.