Drug Diversion Checklist

Staff Behavioral Indicators

• Staff accessing controlled substances outside of assigned duties or shifts without valid clinical reason
• Frequent failure to document medication waste or shift counts accurately
• Signs of impairment such as slurred speech, drowsiness, pinpoint or dilated pupils, unsteady gait, frequent bathroom breaks
• Rapid mood swings–irritability, agitation, or euphoria followed by withdrawal or fatigue
• Excessive or unexplained medication wastage claims with or without proper witness documentation
• Reluctance to cooperate with audits or inventory checks
• Repeated discrepancies linked to individual staff members during reconciliation
• Frequently volunteers for unit assignments with greater access to controlled substances (i.e., ED, ICU, PACU, oncology)
• Increased absenteeism, tardiness, or leaving the work area abruptly without explanation

Documentation and Administrative Red Flags

• Frequent or unexplained negative balances in controlled substance inventories
• Altered or backdated entries in medication logs or electronic records
• Missing or incomplete witness signatures
• Frequent overrides of automated dispensing cabinet restrictions or bypassing secure storage
• Discrepancies between supplier invoices and receiving logs
• Failure to complete scheduled inventory reconciliations
• Charting medication administration for patients who deny receiving it

Medication Handling and Process Issues

• Storage of narcotics in unsecured or inconsistent locations
• Single person handling of tasks requiring dual verification such as medication waste
• Unexplained returns of unused controlled substances without appropriate documentation
• Use of shared login credentials to access dispensing systems
• Frequently administering PRN medications as soon as due for a patient that hasn’t required that dose/frequency for other healthcare providers

Patient-Related Indicators

• Reports from patients or families regarding missing medications
• Early refill requests for controlled substances
• Symptoms of unrelieved pain or withdrawal inconsistent with prescribed dosages
• Pattern of patients under their care often reporting inadequate pain relief despite medication being charted as given.
• Reports from patient or families that medication safety processes were not followed (i.e., barcode scanning patient and medication, drawing up medication at bedside)

Systemic and Organizational Clues

• Lack of segregation of duties in controlled substance management roles
• Absence of regular diversion training and education for staff
• No implementation of diversion detection technology or analytics
• Infrequent or superficial controlled substance audits
• A workplace culture that discourages reporting of suspicious activities
• Delays or failures in reporting discrepancies to compliance or leadership
• Absence of clear and concise controlled substance medication policies and procedures

Policies and Procedures

• Identify an executive leader to sponsor drug diversion prevention efforts
• Establish clear policies regarding controlled substance medication handling aligned with DEA regulations and accreditation standards
• Require two-person verification for all controlled substance wasting, returning, and disposal activities
• Mandate prompt reporting of diversion suspicions to designated compliance personnel
• Conduct annual diversion prevention training with competency assessments for all relevant staff and be sure to include agency staff (as needed)
• Conduct unannounced surveillance rounds regularly by diversion team to identify areas for improvement and educational opportunities
• Enforce non-retaliation policies to protect individuals who report concerns

Access Controls and Inventory Management

• Use biometric or badge access controls for narcotic storage and automated dispensing cabinets
• Ensure each user has a unique login with no shared or generic accounts allowed
• Perform inventory counts and reconciliations per policies with documented signatures
• Maintain signed chain-of-custody documentation for medication deliveries and returns
• Program usage limits and inventory thresholds in dispensing systems to detect anomalies

Technology and Monitoring

• Implement automated diversion detection software that integrates data feeds from EMRs, Automated Dispensing Cabinets (ADCs), and timekeeping systems
• Use real-time dashboards to monitor controlled substance usage by department and individuals
• Configure scoring or alerts for unusual activities such as activity by a user or witness that is off-shift, whole dose wastes and returns, unreconciled doses and activity on a discharged patient
• Maintain video surveillance focused on narcotic storage and waste disposal areas
• Ensure electronic records are tamper-evident and securely archived

Investigation and Incident Response

• Define procedures for responding to suspected diversion including inventory freezes and evidence preservation
• Involve multidisciplinary teams including pharmacy, nursing, medical staff, compliance, safety, security, human resources, employee health, and legal counsel
• Document all investigative steps and maintain audit trails
• Coordinate with regulatory authorities such as DEA, the local law enforcement, pharmacy board, nursing board when required
• Use findings to inform corrective actions and improve diversion prevention controls

Leadership and Culture

• Demonstrate leadership commitment to diversion prevention with visible support and resource allocation
• Promote an open reporting culture with anonymous hotlines and protection from retaliation
• Review diversion control program effectiveness regularly with executive oversight
• Encourage collaboration across teams including pharmacy, nursing, medical staff, compliance, safety, security, human resources, employee health, and legal counsel

Essential Documentation for Regulatory and DEA Inspections

• Become familiar with policies and requirements of the DEA, Joint Commission, FDA, EPA and your state’s regulatory agencies (pharmacy and nursing boards, local law enforcement)
• Complete controlled substance inventory logs with signatures for each count and reconciliation with frequency required by state and federal agencies
• Complete record of DEA required biennial physical inventory count of all controlled substances on hand
• Detailed medication administration records showing all whole doses are accounted for with timestamps correlating dispensing, wasting, administration and/or returns
• Dual-witnessed medication waste and disposal logs with quantities and signatures
• Access logs documenting all entries to narcotic storage or automated dispensing cabinets
• Current policies and procedures related to controlled substance management and diversion prevention
• Training records demonstrating diversion prevention education for all relevant personnel
• Investigation reports and documentation related to any diversion suspicions or confirmed incidents
• Incident and discrepancy reports including follow-up and resolution documentation
• Records of supplier invoices, packing slips, receiving logs, and reverse distributor receipts
• Records of documentation if inventory loss or theft is identified
• Security and surveillance records relevant to controlled substance areas

Audit Readiness Recommendations

• Become educated with the DEA audit process, what constitutes non-compliance, and the fines associated with non-compliance
• Maintain accurate, current, and organized documentation for auditors which is readily accessible by multiple responsible staff (records must be available at time of unannounced audit)
• Centralize diversion-related records securely to streamline audit response including list of staff or diversion team members that have access to the records that auditors will expect to review
• Prepare summary reports outlining diversion prevention programs, training completion, and audit outcomes
• Conduct mock inspections to identify vulnerabilities and train staff on audit procedures
• Keep updated contact information for regulatory agencies and legal advisors