Policy Templates

Purpose

Establish a comprehensive, system-wide program to prevent, detect, and respond to the diversion of controlled substances and other medications. Define roles, responsibilities, surveillance methods, and investigatory procedures.

Scope

All departments, employees, contractors, and volunteers with access to controlled substances. All controlled substances (C-II through C-V) and high-alert non-controlled drugs. All locations where medications are stored, prepared, dispensed, or administered.

Key Requirements

• Designated Diversion Prevention Officer with defined authority
• Interdisciplinary committee meets quarterly
• Annual program effectiveness review with documented improvements
• Non-punitive reporting culture — confidential reporting mechanism
• Executive dashboard with diversion metrics reviewed monthly

Purpose

Ensure all controlled substance waste is accurately documented, witnessed by an appropriate second person, and disposed of per DEA and state requirements. Eliminate the practice of falsified waste witness signatures.

Scope

All controlled substance waste in any care setting — inpatient, perioperative, ED, ICU, procedural areas. Wastage includes partial doses, expired medications, returned unused medications, and patient-administered pump residuals.

Key Requirements

• Two-person witness verification for ALL CS waste — witness must physically observe the destruction
• Witness must be a licensed healthcare professional (RN, PharmD, MD, DO)
• Waste documentation completed within 15 minutes of administration
• Exception process for emergent situations (documented and reviewed within 24 hours)
• Monthly waste audit — flag any nurse with > 20% waste rate vs. unit average

Purpose

Establish controls for accepting, storing, verifying, and administering patient-owned medications to ensure safety, prevent diversion, and limit liability. POMs bypass normal pharmacy receiving and dispensing controls.

Scope

All medications brought into the facility by patients or families, including controlled substances, non-controlled prescriptions, OTC medications, and supplements.

Key Requirements

• Pharmacy verification of ALL POMs before administration — visual ID, expiry check, entry into medication record
• Controlled substance POMs default to pharmacy-dispensed only; documented exception process
• POMs stored in locked container at bedside (not in patient's personal bag)
• POM administration charted in MAR with barcode scanning
• Return of POMs to patient/family on discharge with documented chain

Purpose

Define the use, placement, retention, access, and oversight of video surveillance for controlled substance diversion prevention, balancing security needs with patient and staff privacy rights.

Scope

All fixed and mobile cameras used for medication security and diversion surveillance in medication storage, dispensing, preparation, and disposal areas. Does not cover general security cameras in public areas.

Key Requirements

• Cameras positioned to show hands during medication handling — over-the-shoulder angle preferred
• Minimum 45-day retention (90 preferred)
• Continuous recording at medication access points (not motion-activated)
• NTP time sync verified weekly — must match ADC/EHR time source
• Video access restricted to authorized personnel only with audit log
• Digital privacy masking for patient care areas (OR surgical field)

Purpose

Establish a clear process for identifying, documenting, and responding to suspected impairment in healthcare personnel who handle controlled substances, balancing patient safety, employee rights, and regulatory obligations.

Scope

All employees, medical staff, trainees, and contractors with direct patient care or CS access responsibilities. Covers impairment from any substance (alcohol, controlled substances, non-controlled drugs, cannabis).

Key Requirements

• Behavioral observation training for all supervisors — what to look for, how to document
• Low-threshold reporting mechanism for concerns about a colleague's fitness for duty
• Objective documentation standards — observations, not opinions
• Removal from patient care duties during evaluation
• Referral pathway to state Practitioner Health Program (PHP)
• Return-to-work agreement with monitoring requirements