DRUG DIVERSION POLICY

GOAL
To support the health and safety of its employees, patients, and visitors, Cottage Health System (CHS) maintains a drug free workplace.

POLICY
Drug diversion (theft) is prohibited. Suspected drug diversion will be investigated and in the event that substantial evidence supports a belief that diversion has occurred, appropriate disciplinary and reporting actions will be taken.

DEFINITIONS

Drug: A substance used in the diagnosis, treatment, or prevention of a disease or as a component of a medication. Such a substance as recognized or defined by the United States Food, Drug, and Cosmetic Act.

Diversion: Theft of hospital drugs, including use, unauthorized possession or removal from CHS premises of any amount of drugs, including unused amounts of drugs provided to patients or other drugs that have been discarded.

PROCEDURE
If a drug diversion is suspected, the Manager/Director or other responsible party immediately notifies the Pharmacy Director and Human Resources Consultant and provides the relevant information.

If possible, the Pharmacy Director runs activity reports on the individual(s) suspected of diverting the scheduled medications.

The Human Resources Consultant, with support from Security, conducts an investigation of the suspected diversion. During the investigation, the employee(s) suspected of participation in the diversion will be suspended without pay pending the outcome of the investigation; such suspension is classified as an administrative leave of absence.

If, upon completion of the investigation, there is substantial evidence indicating that a drug diversion has occurred:

1. The employee is disciplined up to and including termination. Rehabilitation leave or accommodation will generally not be offered to employees who are determined to have engaged in diversion.
2. A determination will be made if the period of time that the employee was relieved of duty pending investigation is or is not paid or if PTO can be utilized, if hours are available. If the employee is found to have diverted drugs, the administrative leave time is generally unpaid and it is generally the rule that PTO may not be used to fill such time.
3. The employee is offered assistance through the Employee Assistance Program.
4. The Human Resource Consultant notifies the appropriate licensing board, appropriate law enforcement, and the CHS Chief Executive Officer. It is the policy of CHS to make reports to licensing agencies and law enforcement if it is determined that drug diversion has occurred.
5. The Pharmacy Director reports the diversion of significant quantities of controlled medications to the DEA (DEA Form 106) and the California State Board of Pharmacy.

If, upon completion of the investigation, the evidence supporting the suspicion of drug diversion is deemed insufficiently “substantial” to support a finding that diversion has occurred:

1. The facts of the investigation will be documented.
2. A record will be made in the employee's personnel file indicating that substantial evidence does not support the allegations or suspicion of diversion.
3. Monitoring of the individual and the patient care area will continue per the “Control of Scheduled Medications” policy.
4. A determination will be made if the period of time that the employee was on administrative leave pending investigation is or is not paid, or if PTO can be utilized, if hours are available. Such determination will be made on a case-by-case basis and it is possible that an unpaid leave will be deemed a disciplinary measure for violations of policy even if drug diversion cannot be substantiated in the investigation.