CMS Conditions of Participation states, “Abuses and losses of controlled substances must be reported, in accordance with applicable Federal and State laws, to the individual responsible for the pharmaceutical service, and to the chief executive officer, as appropriate.” (482.25(b)(7).
Survey Procedures for this are:
Pharmacy staff need to have an understanding of what policies and procedures are in place for controlled substance security. Not only because they are often the eyes and ears to what is going on within the pharmacy as well as on the nursing units, but they may be interviewed by a surveyor, and they need to be able to speak to the policies. If the staff don’t understand the big picture of why controlled substance security is important and what to do if in the event of an odd occurrence or unaccounted for med, then controlled substance security at the facility is not as tight as you may think it is.