Community Pharmacy / Clinic Drug Diversion Checklist

Governance & Program Oversight 0 / 6

Designated responsible person / PIC with defined diversion prevention duties (w:3)

Written controlled substance diversion prevention policy (w:3)

Policy reviewed and updated within the past 12 months (w:2)

All staff have read and signed diversion prevention policy acknowledgment (w:2)

Annual self-assessment of diversion prevention controls completed (w:3)

Non-punitive reporting culture actively promoted (w:2)

Inventory & Recordkeeping 0 / 7

Controlled substance perpetual inventory maintained and current (w:3)

DEA 222 forms / CSOS records complete and auditable (w:3)

Physical inventory of C-II performed every 24 hours or as required by policy (w:3)

Receiving discrepancies documented and reported within 24 hours (w:2)

Controlled substance return to reverse distributor tracked and reconciled (w:2)

Power outage / temperature excursion log maintained for CS storage (w:1)

Out-of-date controlled substance disposal documented per DEA requirements (w:2)

Dispensing & Workflow Controls 0 / 8

Two-person verification for C-II dispensing (no sole practitioner dispensing) (w:3)

Controlled substance counts verified at each shift change (w:3)

Prescription hard copies audited for DEA-required elements (w:2)

Electronic prescriptions of record tracked (EPCS) (w:2)

Red flag screening performed on every controlled substance prescription (w:3)

State PMP / PDMP queried before dispensing (where required) (w:3)

Early refill / partial fill documentation compliant (w:2)

Delivery and mail-order CS shipments have signature and chain-of-custody (w:2)

Physical Security 0 / 6

Controlled substances stored in locked cabinet or safe (Schedule II separate) (w:3)

CS storage area alarmed and/or monitored by security camera (w:2)

Safe combination / key access limited to essential personnel only (w:2)

Alarm system tested and logged monthly (w:2)

After-hours access to controlled substances logged and reviewed (w:3)

Outside delivery drop-off area secured from public access (w:1)

Personnel & Training 0 / 6

Pre-employment background check for all employees with CS access (w:2)

All staff trained on red flag identification and reporting obligations (w:3)

Annual diversion prevention training completed by all CS-touching staff (w:2)

Controlled substance access revoked immediately on separation (w:3)

Behavioral observation / impairment awareness training provided (w:2)

Employee theft reporting procedure documented and communicated (w:2)

Monitoring & Surveillance 0 / 6

Pharmacy management system CS usage reports reviewed monthly (w:2)

Discrepancy log maintained and reviewed by PIC monthly (w:3)

Chargebacks and insurance rejection patterns reviewed for red flags (w:1)

Prescriber pattern analysis — unusual prescribing by any provider (w:2)

Patient-level patterns — multiple providers, cash-only, distance traveled (w:2)

DEA 106 losses trended over 12-month period (w:2)

Incident Reporting & Investigation 0 / 6

Documented investigation protocol for suspected theft or loss (w:3)

DEA Form 106 filed within 1 business day of significant loss (w:3)

Local field division DEA office contact information readily available (w:2)

State board of pharmacy notified as required (w:3)

Investigation findings documented with corrective action plan (w:2)

Inventory and security controls reassessed after any confirmed diversion (w:2)

Assessment Summary

Overall Score

Governance & Program Oversight 0%

Inventory & Recordkeeping 0%

Dispensing & Workflow Controls 0%

Physical Security 0%

Personnel & Training 0%

Monitoring & Surveillance 0%

Incident Reporting & Investigation 0%

Select items above to see your score.

Program Assessment Checklist

Assessment Summary