Controlled Substances Inventory (Ordering and Receiving)

Scope: Applies to controlled drug inventory managed within the Medication Dispensary. 

Definition(s):
Controlled Substance: A drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V of part B of Title 21 USC Controlled Substances Act. This term does not include distilled spirits, wine, malt beverages, or tobacco.

PAR level: minimum amount of inventory needed to meet the demand from customers while providing a cushion in case of unexpected demand

Equipment:
• Cubex

Background:
Controlled substances will be stored in the Dispensary Cubex. (This does not apply to controlled substances that have already been prescribed and filled for a prescription.) Inventory will be managed by Cubex cycle counts, reorder reports, and upcoming expiration reports. Controlled substances will have a set a PAR level (minimum/maximum) to assist in determining when a drug is needed. These PAR levels are determined by the average use of that drug. Any foreseeable events (i.e. potential shortages, backorders, increase in cost, deer season, etc) may be cause to order more than the standard PAR levels.

Procedure:

1. Once the inventory has hit the minimum PAR level, a Cubex Purchase Order report will print. This prompts the dispensary staff to place an order for the drug and amount needed to reach the high PAR level. 
2. For any controlled substances ordered by the dispensary, these vendors will have the Hospital Director’s DEA License on file. Additionally, the DEA’s CSOS program allows any Schedule II controlled substance orders to be done securely and electronically done without filling out and mailing the paper DEA Form 222. 
3. When controlled substances are ordered, these will ship to the default DEA address that is on the license (1008 W. Hazelwood Dr. Urbana, IL 61802). This address cannot be changed unless first changing the State Controlled Substance Registration and the DEA License addresses. 
4. Shipments are delivered to the VTH Storeroom and then sorted based on the recipient. The Storeroom supervisor is a Pharmacy Technician allowing him to handle medications. Vendors will pack and seal controlled substance orders in a box with a visible tamper seal. When tamper seal is seen, and is addressed to Dr.Whittington, Storeroom staff will not open the sealed package and will leave for Dispensary staff. If Storeroom staff opens an unmarked box and finds any controlled substances, they will bring directly to the dispensary. 
5. Technicians unpacking shipments will sort through orders, and any controlled substances are left for a Pharmacist to verify and receive in by checking off and signing the packing slip. Pharmacist will verify drug amount received is matched to the quantity on the packing slip. If partial order is filled, i.e., #10 ordered, #4 received and #6 is on backorder, then the Pharmacist will document quantity received, date and sign on the packing slip/invoice. These invoices will be filed based on Schedule II, or Schedule III-V, and saved for seven years. Inventory will be restocked into the Cubex by a technician immediately after the Pharmacist has completed verification.

Last Updated: 11/22/2021