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DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 1 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee  SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory surgery centers, home health centers, home health agencies, physician practices, outpatient imaging centers, service centers and all Corporate departments, Groups, Divisions and Markets where controlled substances are utilized.

PURPOSE: To establish monitoring controls related to ordering, receiving, storing, dispensing and administering controlled substances and documenting such activities. The term “controlled substance” means a drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V (including IIN and IIIN) of the Controlled Substance Act. The facility should continue to follow federal and state controlled substance laws and regulations.

POLICY: In order to detect intentional or unintentional breach of procedure in controlled substance handling, the facility must establish a process for monitoring compliance with its policies and procedures that relate to ordering, receiving, storing, dispensing and administering controlled substances and documenting such activities. Facility Administration must designate a person in writing to be responsible for insuring that the monitoring described herein is performed, monitoring results are collected, and trending data is analyzed to detect variances in practice. The facility must have a procedure to ensure that any discrepancies identified in ordering, receiving, administering, or reconciling the inventory of controlled substances is investigated immediately. Similarly, the manager of the department or designee with such a discrepancy must investigate any situation that indicates a breach in product integrity (e.g., broken or cracked containers, broken seals) or a failure to follow appropriate policies related to controlled substances.

DEFINITION: Outpatient practices, for purposes of this policy, are not hospital-based or included within a hospital or Ambulatory Surgery Center license, certification or accreditation.

PROCEDURE: A. Ordering and Receiving Controlled Substances, Schedule II Ordering and receiving of C-II controlled substance may be completed by either of the two processes outlined in Section 1 (preferred) or Section 2 (immediately below) or a combination of both processes.

Section 1: Use of the Controlled Substance Ordering System to Purchase Controlled 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 2 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

Substances, Schedule II. Effective May 2005, the Drug Enforcement Agency (DEA) implemented the Controlled Substance Ordering System (CSOS) which allows for a secured electronic transmission of controlled substance orders (e222) without the supporting paper DEA Form 222. Company-affiliated facilities are encouraged to adopt the CSOS process for ordering controlled substances. The efficiencies of the electronic ordering system make the system easy to use for most Schedule II (C- II) transactions while maintaining security requirements. Use of the paper DEA Form 222 will continue to be allowed for the foreseeable future and will even be required for certain processes, including the return of C-II controlled substances to the wholesaler. a. The CSOS regulations require the following persons to be identified: 1) DEA Registrant – the person who last signed/renewed a DEA 224 application. HCA affiliates are required to specify the Chief Executive Officer (CEO), Administrator, or Practice Manager of the facility as the DEA registrant. For outpatient practices, an individual practitioner who is an agent or employee of another practitioner (other than a mid-level practitioner) registered to dispense controlled substances may, when acting in the normal course of business or employment, administer or dispense (other than by issuance of prescription) controlled substances if and to the extent that such individual practitioner is authorized or permitted to do so by the jurisdiction in which he or she practices, under the registration of the employer or principal practitioner in lieu of being registered him/herself. Further duties associated with controlled substance ordering/management may be delegated by the CEO, Administrator, or Practice Manager using a Power of Attorney (POA). Facilities may specify the Director of Pharmacy or designee be delegated this duty with a POA in an inpatient setting and the Administrator in an outpatient setting. Outpatient physician practices should have a practice DEA Registrant for ordering controlled substances for use in the practice setting. 2) CSOS Coordinator – each DEA Registrant identifies a person to hold the DEA number, monitor license renewal, designate those employees eligible to order controlled substances electronically, retain all digital certificates, and to manage these activities. The Company recommends that the Director of Pharmacy be the CSOS Coordinator for the facility. The DEA Registrant shall convey this responsibility through a POA. 3) Power of Attorney (POA) Designees –The Company recommends that a named individual be identified as the primary person to order C-II controlled substances for the facility (primary designee). The DEA Registrant or CSOS Coordinator may assume this duty of ordering C-II controlled substances. Alternatively, the CSOS Coordinator may identify another employee as the primary designee. The primary designee must have a POA submitted to the DEA for final authorization to order C-II controlled substances. Additional staff may also be identified to order C-II controlled substances in the absence of the primary designee. Such ‘secondary designees’ must also have a POA submitted to the DEA to be fully authorized to submit orders. 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 3 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

b. The CSOS Coordinator must submit all required documents to the DEA for issuance of digital signatures to the individuals granted POAs and maintain a copy of each document submitted in a secure area in the Pharmacy or a secured location in areas without a Pharmacy. c. Each individual granted a POA will be e-mailed his or her access code and delivered by U.S. mail the password. POA access codes and passwords must not be shared with any other persons. d. With the digital signatures, the CSOS Coordinator must download the Digital Certificates from the DEA website to the facility-based computer. One computer should be used for placing and receiving all CSOS orders. This is important as records will be downloaded from the wholesale vendor website to the facility-based computer that will include the order placed for the C-II controlled substances and the receipt acknowledgment of the order. The digital certificate files, order acknowledgment files and receipt acknowledgment files must be copied to an external CD, floppy disk, or flash drive after each order receipt occurs. This file copy must be maintained in a secure area with limited access as defined by the CSOS Coordinator. e. The CSOS Coordinator is responsible for notifying the facility’s wholesale vendor that the facility will place orders electronically for C-II controlled substances. This includes account setup for CSOS ordering at the wholesale vendor website. It includes the creation of access to the wholesale vendor website for all staff with POA privileges. f. Separation of Ordering/Receiving Functions – Ordering and receiving of C-II controlled substances must be performed by different individuals unless mitigating circumstances prevent this from occurring. In such instances, compensating controls should be implemented (e.g., additional independent reviews, outside audits). The facility should consider limiting the ordering and receiving authority of any Controlled Substance product to designated staff members, not all Pharmacy Department Staff members. As part of CSOS use, both ordering and receiving must be done in the wholesale vendor website program. g. The receiving process must include a reconciliation of controlled substances received against the packing slip or invoice. The printed invoice must be signed and dated by the receiver indicating completion of this phase of receipt of product. With the invoice signed and dated, the receiver or another staff member with POA access must receive the C-II controlled substances in the wholesale vendor website system. Completion of this activity will allow downloading of the receipt record into the facility personal computer for permanent storage. A backup must be performed after each C-II controlled substance receipt into the facility pharmacy. Note: The receiver’s signature and dating of the invoice and receipt into the wholesale vendor software system must be a separate action from the signing of the invoice by the Director or authorized person approving payment for Accounts Payable. 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 4 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

Section 2: Use of DEA Form 222 to Purchase Controlled Substances, Schedule II a. Authority to Purchase Controlled Substances. Company-affiliated facilities are required to specify the Chief Executive Officer (CEO), Administrator, or Practice Manager of the facility as the DEA registrant. For outpatient practices, an individual practitioner who is an agent or employee of another practitioner (other than a mid-level practitioner) registered to dispense controlled substances may, when acting in the normal course of business or employment, administer or dispense (other than by issuance of prescription) controlled substances if and to the extent that such individual practitioner is authorized or permitted to do so by the jurisdiction in which he or she practices, under the registration of the employer or principal practitioner in lieu of being registered him/herself. Further duties associated with controlled substance ordering/management may be delegated by the CEO, Administrator, or Practice Manager using a Power of Attorney (POA). Facilities may specify the Director of Pharmacy or designee be delegated this duty with a POA in an inpatient setting and the Administrator in an outpatient setting. Outpatient physician practices should have a practice DEA Registrant for ordering controlled substances for use in the practice setting. b. Each pharmacy director should have a duly executed POA, signed by the CEO of the facility, to order all controlled substances in schedules II, II-N III, III-N, IV, and V for the institution. DEA 222 forms are used for ordering Schedule II and II-N. It is not required for lower schedule controlled substances. The POA should be permanently kept with other controlled substance records. Additional powers of attorney may be required if another individual, e.g., a Pharmacy Supervisor, is to be able to order (sign) DEA Form 222 order forms in the Pharmacy Director’s absence.

c. Control of and Access to DEA Form 222 (Schedule I & II Order Forms). DEA Form 222 is the official form used to order controlled substances in Schedules I & II from manufacturers, wholesalers, or other sources. Upon receipt of DEA Form 222 ordering forms from the Drug Enforcement Agency, the Pharmacy Director or designee must record each DEA Form 222 number onto a control log to document all forms received into the facility. Unused DEA 222 forms should be stored in a secured area, e.g., in the controlled substances vault or a locked drawer, accessible only by those individuals authorized to order controlled substances in Schedules I & II. By Federal regulation, Controlled Substances in the Schedules III, III-N, IV, and V do not require a DEA Form 222 for ordering. However, for the purposes of this Controlled Substance Monitoring Policy, controlled substances in the Schedule III, III-N, IV, and V must be included in the audit process.

d. Pre-Signing DEA Form 222. DEA Form 222 should be signed by the authorized agent/attorney only as orders are placed. Blank forms should never be pre-signed in anticipation of future use.

12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 5 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

e. Execution of DEA Form 222. In completing DEA Form 222, care should be taken so that no erasures or alterations are made anywhere on the form. If a mistake is made, void all copies of the form and maintain the voided copy in your records. Only one item should be ordered on a single line and the number of different items ordered should always correspond to the “number of items ordered” entry on the form. The Supplier’s Copy 1 and DEA Copy 2 are sent to the drug wholesaler/supplier and Purchaser’s Copy 3 retained in the pharmacy.

f. Separation of Ordering/Receiving Functions. Check and balance systems should be in place so that the ordering and receiving of controlled substances are performed by different individuals unless mitigating circumstances prevent this from occurring. In such instances, compensating controls should be implemented (e.g., additional independent reviews, outside audits). The facility should consider limiting the ordering and receiving authority of any Controlled Substance product to designated staff members, not all staff members.

g. Direct Delivery of Controlled Substances. All controlled substances should be delivered directly to the Pharmacy Department (or designated location in facilities without a pharmacy) and never through an intermediary, such as the Purchasing Department. Only authorized personnel should be allowed to “receive” such orders. h. Reconciliation of Invoices/Packing Slips for Controlled Substances. The receiving process must include a reconciliation of controlled substances received against the packing slip or invoice accompanying the order as well as the DEA 222 ordering form. On the “blue” copy (Purchaser’s Copy 3) of the DEA Form 222, the number of packages received and date received must be filled in. Both the DEA Form 222 and the invoice must be signed and dated by the receiver. The Director must not be precluded from stapling the DEA 222 form to the invoice or packing slip. If stapled together, the attached documents must be stored together in a different location from all other DEA 222 ordering forms. If the DEA 222 form is not affixed to the invoice or packing slip, the Director should store the DEA Form 222 in a separate and independent location from the invoice copy signed and dated by the receiver, and the packing slip signed by the receiver for Schedule II controlled substances. Note: The receiver’s signature and dating of the invoice must be a separate action from the signing of the invoice by the Director or authorized person approving payment for Accounts Payable.

i. Immediate Resolution of Order Discrepancies/Shortages/Breakage. In case of any order discrepancy, shortage or breakage, the wholesaler must be notified immediately and the incident documented on the packing slip/invoice.

j. Inventory System for Controlled Substances. An inventory system that assures accuracy of all controlled substances is required. For all Schedule II, II-N, III, III-N controlled substances, a 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 6 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

perpetual inventory system must be maintained. The inventory system may be either manual or computerized as long as the disposition of all controlled substances (e.g., all controlled substances received, dispensed to nursing units, or returned to reverse wholesalers) is accurately tracked.

k. Monthly Record of Controlled Substance Purchases. The Pharmacy Director or Administrator must maintain the “Monthly Customer Record of Controlled Substances” purchasing summary available from drug wholesalers, or a written history of all controlled substance purchases made by the facility for the month, sorted by date.

l. Monitoring Procedure for Ordering and Receiving Controlled Substances. The Pharmacy Director or Administrator must employ the following methods for monitoring the ordering and receipt of controlled substances. 1) Check off all DEA 222 numbers on Wholesaler Customer Narcotic Purchase Record against master log book or computer log; and 2) Randomly select 3 deliveries per month and confirm the presence of proper documentation on the DEA 222 form, match units received as documented by invoice and receiving personnel notation on the DEA 222 form, and match units received against the master log book or computer log.

B. Controlled Substance Dispensing Ordering and dispensing controlled substances must conform to all facility Policies and Procedures as well as all State and Federal regulatory requirements.

1. Manual System Monitoring a. Controlled substances must be dispensed to match the items requested. Changes to items/units dispensed versus items requested must be noted on the requisition sheet. Monitoring must be performed on all requisition sheets submitted for two random days selected each month to determine that items/units dispensed match items requested or exceptions are documented on the requisition form. Monitoring must also confirm that items/units dispensed match the Master Control Dispensing Log documentation for the withdrawals. b. There must be signed documentation of the receipt of controlled substances by the receiving personnel. Monitoring must be performed on all receipts signed on two random days selected each month to confirm that items/units received match the items dispensed as documented on the Master Control Dispensing Log. 2. Automated Dispensing Cabinet (ADC) System Monitoring. A process must exist for matching controlled substances distributed to the automated dispensing cabinets with the 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 7 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

Master Control Dispensing Log . For example, the quantity of controlled substance distributed to each automated dispensing cabinet as documented in the cabinet system reports shall be reconciled with the amount signed out on the Controlled Substance Perpetual Log in the Pharmacy vault. Monitoring of this process must be performed on two randomly selected days each month.

3. Security of Automated Dispensing Cabinets. Automated dispensing cabinets (i.e., AcuDose, Omnicell, Pyxis) can be accessed electronically through logon and passwords and also physically through traditional locks and keys. a. Electronic Access –Only patient care staff members who have completed an authorization/access form and have had the form approved by the individual designated to approve such forms may remove controlled medications from the ADC. The following healthcare providers may request access to controlled substances based on their job description and competencies: LIPs, APPs, RNs, LPNs/LVNs, Anesthesia Assistants, Registered Pharmacists, Pharmacy Technicians, and other qualified staff as authorized by the facility. Contracted staff will only receive access to the ADC on the unit in which they are scheduled to work. Access should be limited to areas that are needed to perform assigned duties and for the designated time period of the contract. Access for staff working on a shift-to-shift basis is limited to the shift assigned. A staff member’s, LIP’s or APP’s access to medications may be terminated at any time if policy infractions occur. A physician may request access to controlled substances for a qualified staff member who will work under his/her direction (e.g., RN, LPN/LVN, radiology technologist, medical assistant) when working in an outpatient imaging center or physician office practice. All staff, LIPs, and APPs will protect their access to ADCs. ADC pin numbers should be changed every 90/180 days, as appropriate, or when the user suspects the integrity of their access has been compromised. Other locking mechanisms will be changed routinely based on the facility policy. This does not apply to facilities using bioID.

b. Physical Key Access – Pharmacy shall review automated dispensing cabinet lock status with the manufacturer to document the status of the current physical locks with respect to lock duplication in the same cabinets or other cabinets within the facility. The existence and current location of all physical keys including master keys shall be determined. If an inventory of all keys cannot be determined, the facility shall institute steps to replace the automated dispensing cabinet locks as soon as possible. 1) Pharmacy Management team shall retain all physical keys to the automated dispensing cabinets in a locked/secured location within the Pharmacy. 2) The physical keys shall only be issued to a staff member of the Pharmacy Department at the time of need for the purpose of opening the automated dispensing cabinet for Department use or maintenance by authorized personnel.

12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 8 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

3) Pharmacy Staff shall remain with the automated dispensing cabinet during the entire time the cabinet is unlocked, unless all medications have been removed. At no time is the Pharmacy Staff to relinquish possession of the key(s) to any other person outside of those staff within the Pharmacy authorized to use the key. Keys shall not be given to maintenance/service personnel. 4) Pharmacy shall take appropriate action to take possession of any automated dispensing cabinet keys found to be in the possession of anyone other than authorized Pharmacy personnel immediately.

4. Patients’ Medications Brought from Home: Each facility should have a policy that addresses how the facility will handle a patient’s own medication that is a controlled substance brought from home. A patient’s own medication will only be used for cases where the medication is not available from the local wholesaler and continuation is imperative for patient care. Patient-owned controlled substances, which are sent to the pharmacy to be stored, will be logged and kept in the vaulted room or the pharmacy ADC.

C. Controlled Substance Administration

1. Count Verification. Count verification will be performed any time a controlled substance medication is accessed AND per facility policy.

2. Wastage Documentation. a. Any controlled substance packaged in an amount larger than the dose being administered must be wasted immediately after administration.

b. Wastage documentation will be performed by two (2) licensed individuals, one of whom must be an employee of HCA.

c. Signatures of each individual involved with the wastage of a controlled substance medication must be performed electronically or ascribed on the manual documentation form.

3. Order Verification on Chart. All controlled substance medication administration must be validated by a physician order contained in the patient’s medical record. STAT or NOW verbal orders issued by the physician during emergency situations, operative or other procedures (e.g., Endoscopy, cardiac cath) must be documented in the patient’s medical record as soon as possible after the procedure. In such cases, it is recommended that the medication orders be documented as separate events with individual dose orders rather than one event with a totaled dose. 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 9 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

4. Administration Documentation. Documentation of administration of a controlled substance must occur immediately after administration by the administering individual.

5. Controlled Substance Medication Audit. a. Each facility must perform a minimum of two controlled substance audits per month. The medications may be selected randomly but must include one of high volume. The second audit may be for one of high or low volume. Each audit should cover at least a 48 hour period of retrospective review. Facilities may choose to conduct their audit simultaneously for all locations or may conduct the audits at different times for each. Nursing Reviews should include the technique of “Velocity Audits” where the volumes of use of the medication under review are examined for each individual administering the medication to identify individuals with a high administering volume. When variations in the number of doses of the medication administered is found, further investigation should be initiated to determine why the variation occurred. These findings should be documented in the Controlled Substance Medication Audit document.

b. Controlled substances identified in each area must be reviewed for policy compliance in each of the following items: administration documentation, discrepancy resolution, documented medication order, wastage documentation, and verification of current inventory levels of selected controlled substances.

c. Many ancillary patient treatment areas, e.g., Cath Lab, Endoscopy, and Pulmonary Lab, stock controlled substances as well. Staff in these ancillary departments must perform a random audit of controlled substance documentation on all patients being treated in the ancillary department on the day of the audit. These audits must be conducted at least once a month. All requirements for the audit as described in 5.b. (immediately above) should be completed during the audit. The audit results must be forwarded to the facility person retaining all audit records.

d. The facility shall identify all areas with high use of controlled substances (e.g., Surgery, Cath Lab, Endoscopy). In such areas, a concurrent audit and reconciliation process will be established to monitor controlled substance usage on a daily basis. For example, establishment of standardized patient specific ‘kits’ of controlled substances to be issued to each authorized LIP, APP for use during the case is preferred. Each LIP/APP is responsible for documenting controlled substances removed from the ‘kit’ on a ‘kit’ log, including doses administered and wasted on each patient. The controlled substance kit and the designated controlled medication record must be returned to the designated area. The 12/2010 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Controlled Substance Medication Management Monitoring PAGE: 10 of 10 REPLACES POLICY DATED: 3/1/08 EFFECTIVE DATE: May 31, 2010 REFERENCE NUMBER: CSG.MM.001 (formerly QM.003) APPROVED BY: Ethics and Compliance Policy Committee

LIP/APP must verify via signature, date, and time that the contents of the controlled substances kit have been verified and checked against the Controlled Medication Record or Anesthesia Administration Form. Any discrepancy discovered must be resolved during the return process. Failure to do so may result in loss of privileges to sign-out controlled medications. If a discrepancy cannot be resolved (i.e., cause of discrepancy cannot be determined), the nurse manager or designee should be notified and an occurrence report should be initiated.

e. The Pharmacy Department or other designated responsible party must verify that reports and audits carried out by area management are returned to designated storage areas (e.g., Director of Pharmacy Office or Risk Management Office).

f. All monthly medication audits must be documented on the “Institution Audit Log” along with documentation of any discrepancies and their associated resolutions. The “Institution Audit Log” must be either the sample form attached, or a similar form with all fields defined in 5.b. (above) at a minimum. g. All “Institution Audit Log” forms and facility documentation must be stored in a central location as designated in facility policy and be readily retrievable for internal and external audits. See the Corporate Records Management Policy, EC.014, for length of storage requirements.

12/2010 Attachment to CSG.MM.001 HCA CONTROLLED SUBSTANCE

MONITORING AUDIT SHEET

Facility: ______Facility Area: ______

Date of Audit: ______Medication Reviewed: ______

Instructions for Use: Three sections must be completed on the form. Reviewer shall enter Header information for each monitor session above. Reviewer shall “ ” beside the Monitoring Process being performed below. Reviewer shall use the entire Patient, Discrepancies, & Resolution Section for data from the process being monitored. Enter Patient name (as applicable). Details of Identified Discrepancies and the Discrepancy Resolution shall be entered as identified. Enter ‘None” when appropriate.

 IDENTIFIED DISCREPANCY MONITORING PROCESS PATIENT DISCREPANCIES RESOLUTION

Ordering & Receiving:

All DEA 222 forms are recorded into Control Log Ordering and Receipt of C-II drugs are performed by different Staff All completed ‘blue copy’ DEA 222 forms have packages received, date received, and signature of receiver. All received C-II drugs on the ‘blue copy’ match to the Master Control Log or Computer Log entries in Pharmacy.

Dispensing:

Requisition medication matches medication dispensed from Pharmacy and dispensing documents match Master Control Dispensing Log Items dispensed have a signed receipt or the ADC record matches the Master Control Dispensing Log

Administration: Random check of Medical Record confirms a physician order for the medication reviewed. Random check of eMAR matches medication administration documentation with the Narcotic Administration Record or ADC removal record. Wastage documentation is performed by 2 licensed individuals Narcotic Counts and Findings are documented at least once per shift.

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