Part 2: How To Conduct A Self-audit Of Your Practice’s Controlled Substances

As mentioned in Part 1 of this series, one of the ways you can reduce your risk and better ensure your practice is ready for a DEA audit is to conduct a self-audit. By auditing the controlled substances in your practice before an audit happens, you can identify and fix many issues that could come up during the accountability portion of the inspection.

The basic equation at work here is that the number of received controlled substances minus the number dispensed or destroyed should equal the number of controlled substances you have on hand that day.

Here are the steps to audit your controlled substances:

  1. First, total up all of the controlled substances your practice has received:
  • Start with your most recent physical inventory that you’re required to do every 2 years.
  • To that list, add all of the controlled substances that you’ve received since the last inventory.
    • Note: use your 222 forms for Schedule 2 drugs and your controlled substance purchase invoices for Schedule 3, 4, and 5 drugs
  1. Next, calculate how much you have dispensed and destroyed:
  • Pull together your dispensing records, log books, patient files, and destruction records for the period of time since the last inventory and calculate the total of dispensed and destroyed drugs
  1. Subtract the records of dispensed and destroyed drugs from the records of received drugs. This is your documented amount of controlled substances.
  2. Finally, find out how much controlled substances you actually have on hand that day.

If the amount you have on hand equals the documented amount, then congratulations on passing your self-audit. As an added bonus, you can count this as your new biennial inventory and won’t have to do another for 2 more years, unless you choose to self-audit again before then.

If you find out these numbers don’t match up, here are some options:

  • If you have fewer controlled substances on record than you have on hand, it’s probably a recordkeeping problem, so start double-checking your order receipts and your math. Check the documentation on your orders to make sure it matches your logs. Do another physical count. Double-check your math and make sure the balance at the top of each page matches the final balance on the previous page.
  • If you have more controlled substances on record than you have on hand, first try to figure out if the problem can be found in your records. Double-check the math, order forms, balances, etc. Check patient medical records to ensure the quantities there match your logs. If you find the problem, make an entry to correct the balance.
    • However, if you cannot explain the shortage through a recordkeeping error or you have reason to believe there was a theft or burglary, then you need to:
      • Report it to your DEA field office immediately. Reporting this won’t automatically cause you to get audited, but you will need to follow the instructions and form(s) the DEA agent gives you.
      • Contact your local police as well, and don’t assume they’ll contact the DEA for you. 

If you do have a discrepancy, it’s time to address any issues that caused the error(s), including adjusting any standard operating procedures that might have failed or weren’t correctly followed by staff. Furthermore, if you do get audited, you’ll know what to expect, and having taken corrective measures will have minimized the extent of the damage by catching the problem earlier. Furthermore, your proactive efforts should reflect well upon you in the eyes of your auditors, possibly minimizing any consequences of the error(s).

If you want an objective third-party to conduct your self-audit or help correct any problems that are found in your self-audit, OMS Consulting Firm has the expertise to help improve your practice’s compliance procedures, train staff on best practices, and reduce your risk exposure for non-compliance. Contact OMS Consulting Firm for more information.

The next (and final) article in this series covers what to expect during an audit if the DEA shows up at your door. Continue reading Part 3 of the DEA compliance series.

OMS Consulting Firm’s team of experts can offer guidance and hands-on improvements for your practice’s compliance program. Contact us for more information.