"Deficiency Free" Those were the magic words heard on Wednesday by staff and residents at Broadwater Health Center Nursing Home, in Townsend. Only 1% of the nursing homes nationwide ever achieve a deficiency free status. Two state surveyors had been at BHC for the past three days and it was 4:30 pm on Wednesday during the exit interview that the staff got the good news.

"This is an incredible accomplishment by our staff. Everyone in this organization made this happen" exclaimed Kyle Hopstad, BHC Administrator.

The surveyors were both nurses with years of experience. They were sent to Broadwater Health Center Nursing Home because it was time for the facility's yearly compliance inspection for the Federal Medicare/Medicaid programs. The state had also received a complaint from someone about the facility. The surveyor said "the complaint was unsubstantiated."

He went on to review that the survey was to make sure BHC was meeting their conditions for participation. While the surveyors were at BHC they conducted interviews with the residents, their families and the staff. They interviewed staff about policies and procedures for care and they observed staff caring for the residents. After the surveyors reviewed the process that happens following the survey and the responsibilities BHC has to follow up with the survey he said, "Now I am here to report to you what deficiencies we found if any".

Then he said "We find Broadwater Health Center Nursing Home to be deficiency free" the room exploded with cheers that quickly turned to tears of joy! "We talked with several residents and they told us that if they had to choose a place to live again they would come here" the surveyor reported.

Several residents attended the report from the surveyors. After the joy in the room calmed, one resident shared, "I have lived in a number of nursing home facilities and none of them have ever come close to this experience. Every day I am amazed. I have never found staff here who didn't smile! And the kitchen's broccoli cheese soup is a cup of heaven."

Another resident shared that because of an illness he would be living at BHC Nursing Home for the rest of his life. He said, "This place is a family. You are my second family. I love it here."

With this deficiency free survey BHC Nursing Home staff can breathe a little easier until the next survey comes around in 9 to 15 months. In closing the surveyor gave some very good advice, he said "Just keep showing up every day like you mean it and continue the good work."

Drug Supply Chain Security Act (DSCSA)

Submitted by Deb Anczak, Livingston Healthcare  

Note: Deb provided a sample policy and a wealth of drug information.   These documents can be found on the PIN Website HERE or by going to the PIN Website>CAH Document Library and searching DSCSA. 

For dispensers, the follow are key dates for implementation of elements of the DSCSA.

As of January 1, 2015,

1. Dispensers should know how to identify and handle suspect and illegitimate products. Suspect products are products where there is reason to believe them to be fraudulent, counterfeit, stolen, adulterated or harmful for human use. Suspect products may be identified though a visual inspection. The appearance may be suspicious, be missing information, labeled in a foreign language. Some warning signals include the products are in high demand, have been purchased from secondary or unknown sellers, experienced recent shortage, previously reported as counterfeit or fraudulent or have unusual pricing.
2. Establish a system for verification and handlingsuspect and illegitimate product.
3. Establish systems to quarantine these products.
4. Know how to notify FDA and immediate trading partners, if illegitimate product is found.
5. Confirm authorized trading partners, which can be done several ways:

• Check with your trading partner directly
• Check FDA's drug establishment registration database for registration of manufacturers and repackagers
• For wholesale distributors, third-party logistic providers and dispensers, you can check with your respective state authority to confirm licensure.

As of July 1, 2015, lot level product tracing information is required. Dispensers should only accept products with applicable transaction information, transaction history, and transaction statements. These records must be retained must be retained for six years. Check with your drug wholesalers as many have developed electronic record keeping systems.

For more information please refer to the following:

http://www.fda.gov/Drugs/DrugSafety/DrugIntegrityandSupplyChainSecurity/DrugSupplyChainSecurityAct/ 

http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm