Common Facility Inspection Issues
As part of its facility inspection process, the College and the Accreditation Committee monitor the types of deficiencies that are most commonly identified during an inspection. This data is used to identify risk areas where facility directors and veterinarians working from a facility can direct their attention to ensure adherence to the Minimum Standards for Veterinary Facilities in Ontario (MSVFO). The College also uses this data to direct resources to assist veterinarians in meeting standards.
The most commonly identified deficiencies include:
Absent Controlled Drug Log
The maintenance of an accurate controlled substances log is mandated, not only by the MSVFO, but also by the Controlled Drugs and Substances Act and the Veterinarians Act. The controlled drug log must contain an accurate accounting of the addition to inventory and dispensing of all controlled substances managed by a facility. A sample controlled substances log is available at www.cvo.org/Sample-Controlled-Substances-Log.
Further information regarding management of controlled substances, including the keeping of a log, can be found in the Professional Practice Standard: Management and Disposal of Controlled Substances and the Guide to the Standard. Both documents are at www.cvo.org/ Veterinary-Prescribing-and-Dispensing.
No Evidence of Weekly Controlled Drug Audits
To further assist with the accuracy of a controlled drug log and to increase the vigilance around controlled substances management, most facilities are required to demonstrate that a controlled drug audit is carried out on a weekly basis. For those facility categories for which a regular controlled drug audit is not mandated by the MSVFO, a regular audit is strongly recommended. Tips for carrying out a Controlled Drug Audit can be found at www.cvo.org/ Tips-for-conducting-audits.
Further information regarding the requirements and process associated with an audit can be found in the Professional Practice Standard: Management and Disposal of Controlled Substances and the Guide to the Standard. Both documents are at www.cvo.org/ Veterinary-Prescribing-and-Dispensing.
Mixing of Expired Drugs and Unexpired Drugs
During facility inspections, inspectors frequently encounter expired drugs that are kept amongst unexpired drugs. Such a practice can increase the risk of inadvertently dispensing an expired drug. Expired drugs must be kept separate from unexpired drugs and disposed of in accordance with the Food and Drug Act and the Controlled Drugs and Substances Act or returned to the manufacturer for disposal. Before destroying any controlled drug, veterinarians must contact Health Canada, Office of Controlled Substances to request the form that must be submitted to obtain permission to destroy controlled drugs.
The amendments to the medical records provision of Regulation 1093 stipulate requirements for maintaining an audit trail for electronic records. The standard now states that the audit trail will:
- Record the date and time of each entry of information for each animal
- Indicate any changes in the recorded information
- Preserve the original content of the recorded information when changed or updated
- Is capable of being printed separately from the recorded information of each animal
Please check with your software vendor to confirm that the above information is being recorded appropriately.
X-ray Sources Not Registered with the Ministry of Labour
Each x-ray source in an accredited facility must be inspected and registered with the Ministry of Labour. Registration numbers for each x-ray source must be made available during a facility accreditation inspection. More information regarding radiation safety can be found at www.cvo.org/Radiation-Safety.
Absent Surgical and Anesthesia Logs
It is a requirement under the MSVFO that Anesthesia and Surgery logs be maintained in accredited facilities. The information required for these two logs need not be separate but can be combined into a single log. Logs can be maintained electronically. The details of the requirements for the Anesthesia and Surgery logs are at www.cvo.org/Sample-Documents.
The College recommends that directors of facilities, particularly for those facilities undergoing inspection, familiarize themselves with the requirements for their facility type(s) as set out in the MSVFO. Sample inspection forms for specific facility categories are also available.