Inspections, Compliance, Enforcement, and Criminal Investigations

Health Innovations Pharmacy, Inc 7/8/16

  

Department of Health and Human Services logoDepartment of Health and Human Services

Public Health Service
Food and Drug Administration
 Atlanta District Office
60 Eighth Street, NE
Atlanta, GA 30309
Telephone: (404) 253-1161
FAX: (404) 253-1202

 

VIA UNITED PARCEL SERVICE
RETURN RECEIPT REQUESTED
 
WARNING LETTER
16-ATL-16
 
July 8, 2016
 
Timothy H. Clark, Owner/Pharmacist-In-Charge
Health Innovations Pharmacy, Inc.
295 Pinehurst Avenue
Southern Pines, NC 28387-7051
 
Dear Mr. Clark:
 
From February 23, 2015, to February 27, 2015, U.S. Food and Drug Administration (FDA) investigators conducted an inspection of your facility, Health Innovations Pharmacy, Inc., located at 295 Pinehurst Avenue, Southern Pines, North Carolina.
 
During the inspection, the investigators noted that you were not receiving valid prescriptions for individually-identified patients for a portion of the drug products you were producing. In addition, the investigators observed serious deficiencies in your practices for producing sterile drug products, which put patients at risk. For example, your firm failed to conduct personnel monitoring, and did not use a sporicidal agent as part of the disinfection program for the cleanroom and ISO 5 area. In addition, your facility lacked magnehelic gauges to monitor pressure differentials between the ISO 7 cleanroom and the anteroom. Furthermore, your firm failed to demonstrate through appropriate studies that the hoods are able to provide adequate protection of the ISO 5 area in which sterile products are being produced. Therefore, your products were produced in an environment that poses a significant contamination risk.
 
FDA issued a Form FDA 483 to your firm on February 27, 2015. FDA acknowledges receipt of your firm's response to the Form FDA 483 dated March 1, 2015. Based on this inspection, it appears that you produced drugs that violate the Federal Food, Drug, and Cosmetic Act (FDCA).
 
A. Compounded Drugs Under the FDCA
 
Section 503A of the FDCA [21 U.S.C. § 353a] describes the conditions under which certain compounded human drug products qualify for exemptions from three sections of the FDCA: compliance with current good manufacturing practice (CGMP), section 501(a)(2)(B) of the FDCA [21 U.S.C. § 351(a)(2)(B)]; labeling with adequate directions for use, section 502(f)(1)) Of the FDCA [21 U.S.C. § 352(f)(1)]; and FDA approval prior to marketing, section 505 of the FDCA [21 U.S.C. § 355]. Receipt of valid prescriptions for individually-identified patients is one of the conditions for the exemptions under section 503A of the FDCA. During our inspection, investigators observed that your firm does not receive valid prescriptions for individually-identified patients for a portion of the drug products you produce.
 
Accordingly, the drugs you compound without valid prescriptions for individually identified patients are not entitled to the exemptions in section 503A of the FDCA.
 
In addition, we remind you that there are a number of other conditions that must be satisfied to qualify for the exemptions in section 503A of the FDCA.1
 
B. Violations of the FDCA
 
The drug products that you manufacture and distribute without valid prescriptions for individually-identified patients are misbranded drugs in violation of section 502(f)(1) of the FDCA.
 
In addition, drug products that are intended or expected to be sterile were prepared, packed, or held under insanitary conditions whereby they may have been contaminated with filth, or whereby they may have been rendered injurious to health, causing them to be adulterated within the meaning of section 501(a)(2)(A) of the FDCA [21 U.S.C. § 351(a)(2)(A)]. Furthermore, because you manufacture and distribute a portion of your drugs without valid prescriptions for individually-identified patients, the manufacture of those drugs is subject to FDA's CGMP regulations for Finished Pharmaceuticals, Title 21, Code of Federal Regulations (CFR), Parts 210 and 211. FDA investigators observed significant CGMP violations at your facility, causing such drug products to be adulterated within the meaning of section 501(a)(2)(B) of the FDCA.
 
Misbranded Drug Products
 
You compound drug products for which you have not obtained valid prescriptions for individually-identified patients that are intended for conditions that are not amenable to self-diagnosis and treatment by individuals who are not medical practitioners; therefore, adequate directions for use cannot be written so that a layman can use these products safely for their intended uses. Consequently, their labeling fails to bear adequate directions for their intended uses, causing them to be misbranded under section 502(f)(l) of the FDCA, and they are not exempt from the requirements of section 502(f)(1) of the FDCA [see, e.g., 21 CFR § 201.115].
 
It is a prohibited act under section 301(k) of the FDCA [21 U.S.C. § 331(k)] to do any act with respect to a drug, if such act is done while the drug is held for sale after shipment in interstate commerce and results in the drug being misbranded.
 
Adulterated Drug Products
 
Additionally, FDA investigators observed that the drug products in your facility that were intended or expected to be sterile were prepared, packed, or held under insanitary conditions, whereby they may have become contaminated with filth or rendered injurious to health, causing your drug products to be adulterated under section 501(a)(2)(A) of the FDCA. For example, your firm failed to conduct personnel monitoring, and did not use a sporicidal agent as part of the disinfection program for the cleanroom and ISO 5 area. In addition, your facility lacked magnehelic gauges to monitor pressure differentials between the ISO 7 cleanroom and the anteroom. Furthermore, your firm failed to demonstrate through appropriate studies that the hoods are able to provide adequate protection of the ISO 5 area in which sterile products are being produced. Therefore, your products were produced in an environment that poses a significant contamination risk.
 
The FDA investigators also observed CGMP violations at your facility, causing the drug products for which you have not obtained valid prescriptions for individually-identified patients to be adulterated under section 501(a)(2)(B) of the FDCA. The violations include, for example:
 
1.  Your firm failed to ensure the system for cleaning and disinfecting equipment is adequate to produce aseptic conditions. (21 CFR 211.42(c)(10)(v))
 
2.  Your firm failed to establish and follow appropriate written procedures that are designed to prevent microbiological contamination of drug products purporting to be sterile, and that include validation of all aseptic and sterilization processes. (21 CFR 211.113(b ))
 
3.  Your firm failed to laboratory test each batch of drug product purporting to be sterile and pyrogen-free in order to determine conformance to such requirements. (21 CFR 211.167(a))
 
4.  Your firm failed to establish a written testing program designed to assess the stability characteristics of your drug products. (21 CFR 211.166(a))
 
5.  Your firm failed to establish an adequate system for monitoring environmental conditions in aseptic processing areas. (21 CFR 211.42(c)(10)(iv))
 
It is a prohibited act under section 301(k) of the FDCA to do any act with respect to a drug, if such act is done while the drug is held for sale after shipment in interstate commerce and results in the drug being adulterated.
 
D. Corrective Actions
 
FDA acknowledges your voluntary recall of all sterile products within a six-month expiry, initiated on February 12, 2015, following the North Carolina Board of Pharmacy's order directing your firm to cease production of all compounded preparations. FDA further acknowledges your response to the Form FDA 483, dated March 1, 2015, in which you stated that your firm ceased all sterile and non-sterile compounding operations at your Southern Pines facility as of February 12, 2015, and will "never do sterile compounding ever again ... in any of [your] pharmacies or any other location."
 
If you decide to resume production of sterile drugs, FDA strongly recommends that your management undertake a comprehensive assessment of your operations, including facility design, procedures, personnel, processes, materials, and systems. In particular, this review should assess your aseptic processing operations. A third party consultant with relevant sterile drug manufacturing expertise could be useful in conducting this comprehensive evaluation.
 
Please be aware that section 501(a)(2)(A) of the FDCA concerning insanitary conditions applies regardless of whether the drugs are compounded and distributed after receipt of a prescription for an identified individual patient.
 
Furthermore, should you continue to manufacture and distribute drug products without valid prescriptions for individually-identified patients, the manufacture of such drugs would be subject to FDA's drug CGMP regulations (21 CFR Parts 210 and 211), among other requirements described above, and, before doing so, you should fully implement corrections that meet the minimum requirements of 21 CFR Part 211 in order to provide assurance that the drug products produced by your firm conform to the basic quality standards regarding safety, identity, strength, quality, and purity.
 
E. Conclusion
 
The violations cited in this letter are not intended to be an all-inclusive statement of violations at your facility. You are responsible for investigating and determining the causes of the violations identified above and for preventing their recurrence or the occurrence of other violations. It is your responsibility to ensure that your firm complies with all requirements of federal law, including FDA regulations.
 
You should take prompt action to correct the violations cited in this letter. Failure to promptly correct these violations may result in legal action without further notice, including, without limitation, seizure and injunction.
 
Within fifteen (15) working days of receipt of this letter, please notify this office in writing if you have taken any specific steps to correct violations, or you may inform us that you do not intend to resume production of sterile drugs. If you intend to resume production of sterile drugs in the future, please include an explanation of each step being taken to prevent the recurrence of violations, as well as copies of related documentation. If you do not believe that the products discussed above are in violation of the FDCA, include your reasoning and any supporting information for our consideration. In addition to taking appropriate corrective actions, you should notify this office prior to resuming production of any sterile drugs in the future.
 
Your written notification should be addressed to:
 
Marie Mathews, Compliance Officer
FDA Atlanta District Office
U.S. Food and Drug Administration
60 Eighth Street, NE
Atlanta, GA 30309
 
If you have questions regarding any issues in this letter, please contact Ms. Mathews via email at marie.mathews@fda.hhs.gov or by phone at 404-253-1279.
 
Sincerely,
/S/
lngrid Zambrana
District Director
Atlanta District
 
 
cc:
Jack W. Campbell IV
Executive Director
North Carolina Board of Pharmacy
6015 Farrington Rd., Suite 201
Chapel Hill, NC 27517
___________________________________________
1 For example, section 503A also addresses anticipatory compounding, which includes compounding (not distribution) before receipt of a valid prescription order for an individual patient. We are not addressing anticipatory compounding here.

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