Behavioral Health Services, Inc.
Subject: Detoxification – Chemical Dependency Recovery Hospitals Policy#: 4.5.14.3
Title: Protection from Theft, Diversion or Self Use of Dangerous Drugs
Effective Date of This Revision: September 25, 2014
Contact: Chief Executive Officer 310-679-9126
Executive Office Applies to:
Officers
Other agents
Staff
Visitors
Student clinicians
Contractors
Volunteers
Subcontractors / Business Associates
BACKGROUND:
The Chemical Dependency Recovery Hospitals of BHS use medications as part of the treatment of dependencies in accordance with generally accepted standards of medical practice and upon the order of the Medical Director or the alternate physician. All activities involving storage, preparation, distribution and administration of medications must be in accordance with
applicable federal, state and local laws and regulations. Chapter 9, Division 2, Section 4104 of the CA Business and Professions Code requires every pharmacy to have procedures for taking action to protect the public when a licensed individual employed by or with the pharmacy is discovered or known to have engaged in the theft, diversion, or self use of dangerous drugs.
PURPOSE:
This document outlines Behavioral Health Services, Inc.’s policies and procedures to ensure that the public is protected from any individual employed by or working in any of the BHS Pharmacies or Drug Rooms who is discovered or known to have engaged in the theft, diversion or self use of dangerous drugs.
POLICY:
No theft, diversion or self use of dangerous drugs by any licensed or non licensed individual employed or contracted to work in any of the Behavioral Health Services, Inc. (BHS) Pharmacies or Drug Rooms shall be tolerated.
PROCEDURE:
1. Any employee or contracted personnel working in any of the BHS Pharmacies or Drug
Rooms who is discovered or known to be engaged in theft, diversion, or self use of
dangerous drugs will be terminated immediately.
2. Any licensed employee terminated for any of the above causes will be reported to the
California Pharmacy Board within 14 days of the termination.
3. The report to the Pharmacy Board shall include the following evidence:
a. Any admission by the licensed individual of theft, diversion or self use of dangerous drugs.
b. Any video or documentary evidence demonstrating theft, diversion or self use of
dangerous drugs by the licensed individual.
c. Any audit showing type and quantity of all the dangerous drugs suspected to be involved or missing, the time frame over which the losses are suspected and the date of the last controlled substances inventory.
4. Additionally, a separate report will be submitted to the Drug Enforcement Agency (DEA) if the theft or diversion involves controlled substance or scheduled drug.
