Multi-Hospital Assessment

How It Works

1. Add each facility in your health system using the form above.
2. Complete the checklist for each facility — items are organized by site with per-site scoring.
3. View consolidated results including a system-wide average score alongside individual facility performance.
4. Export data to CSV for reporting and gap analysis across your system.

Running One Reconciliation Across Sites

A health system gets comparable numbers only if every site reconciles the same way. These steps are practice, not regulation. The regulatory points are in the section below.

1. Fix one cut-off time. Pull dispensing-cabinet, pharmacy and anesthesia records for the same 24-hour window at every site, so a discrepancy at one site is not a timing artifact at another.
2. Use one discrepancy definition. Decide what counts as open, who may resolve it, and how many hours it may stay open before it goes to the pharmacy lead, then apply that at every site.
3. Reconcile in the same order. Purchases and receipts, then vault and satellite stock, then cabinet counts, then administration against waste, then returns and destruction.
4. Report the same measures. Open discrepancies, waste not witnessed, overrides, and unresolved counts per site, on one template, so the system view is a sum and not a translation.
5. Review outliers together. A site far from the system pattern gets a joint review by a pharmacist and a nurse leader from another site.

Standardise or Keep Local

Standardise across the system:

• Written policy for counts, waste witnessing, discrepancy resolution and escalation.
• The definition of a reportable loss and who decides it.
• Surveillance reports, thresholds and review frequency.
• Training content and the investigation workflow.

Leave local:

• Physical storage layout, cabinet configuration and par levels.
• Staffing patterns and who performs the witness step on nights.
• Service-specific workflows such as the operating room, the emergency department and the pharmacy satellite.
• State rules that differ between locations. A system that spans states cannot assume one state's rule applies everywhere.

Where a local variation exists, write it down as an approved exception to the system policy. An unwritten difference is hard to defend in an audit.

What DEA Expects of a Multi-Location Registrant

• One registration per location. "A separate registration is required for each principal place of business or professional practice." Some sites are deemed not to be places where controlled substances are manufactured, distributed or dispensed, such as certain warehouses and agent offices. Check each site against the full list. 21 CFR 1301.12
• Changes go through modification. A registrant may apply to modify a registration to add controlled substances or to change a name or address. There is no fee for modification, and approval brings a new certificate (DEA Form 223). 21 CFR 1301.51
• Closing or selling a site. A registration ends when a registrant discontinues business or surrenders it. It cannot be transferred without DEA's written consent. When the business passes to another person, notice goes to the Special Agent in Charge at least 14 days before the transfer unless that period is waived, and a complete inventory is taken on the transfer date. 21 CFR 1301.52
• Inventory is per location. Each registered location needs its own inventory, kept at that location, and a new one at least every two years. Stock at an unregistered site counts in the inventory of the registered location that controls it. 21 CFR 1304.11
• Records stay at each location. Records are kept at each registered and designated location and held for at least 2 years from the date of the inventory or record, available for inspection and copying by DEA. Records may be kept at a central location only if the registrant has notified DEA of its intention to do so. Executed order forms and inventories are not part of the central set, and the registrant must deliver central records to the registered location within two business days when asked. Records on an in-house computer system need no such notice. 21 CFR 1304.04
• Loss reporting has a short clock. Theft or significant loss goes to the DEA Field Division Office in writing within one business day of discovery. DEA Form 106 follows within 45 days. Build that clock into your system escalation path. 21 CFR 1301.76

This summarises the sections linked above and is not legal advice. Confirm the current text and your state's rules with counsel or your DEA Field Division before you change a registration or a record location.