LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 351.01 Controlled Substances
 
  PROCEDURES
  1. Inventories and Records 
     
    1. All purchase orders, invoices, or receipts for controlled substances in Schedules II-V, purchased through a wholesaler, shall be maintained in a readily retrievable file according to federal guidelines.
       
    2. Clinics shall maintain transaction records for at least three (3) years.
       
    3. Inventories and records for Schedule II-V controlled substances shall be filed separately or maintained in a readily retrievable manner that distinguishes them from other ordinary business records.
       
    4. Upon receiving controlled substances delivered, authorized personnel shall sign for receipt to show the type and quantity of controlled substances received.
       
    5. A physical inventory count of Schedule II-V controlled substances shall be performed daily on workdays by two authorized personnel.
       
    6. Biennial inventory reconciliation shall be performed by two authorized personnel, including nurses, psychiatric technicians or psychiatrists other than the professional director.
       
      1. Reconciliation shall be performed by reviewing and reconciling acquisition or purchase records, disposition, and physical count of the current inventory.
         
      2. Records shall be maintained for at least three (3) years. 
         
      3. All persons involved in performing the inventory reconciliation shall sign and date the report which shall be countersigned by the professional director at the clinic. 
         
      4. All inventory reconciliation reports shall be submitted to the Chief of Pharmacy for review.
         
  2. Loss or Theft 
     
    1. Report of loss, theft, or diversion of controlled substances shall be submitted to the California Board of Pharmacy and Drug Enforcement Administration (DEA) within 14 days using DEA Form 106. 
       
    2. Any discrepancy between the receipt and the type or quantity of controlled substances actually received shall be reported to the delivering wholesaler or manufacturer by the next business day after delivery to the clinic.
       
    3. Records of loss and theft shall be maintained for at least three (3) years. 
       
    4. Upon discovery of loss, theft, or diversion of controlled substances, clinic staff shall notify the professional director at the clinic, Chief of Pharmacy, consulting pharmacist, and Chief of Nursing.
       
    5. Clinic staff shall file an incident report in accordance with DMH Suspected Criminal Activity Including Employee Theft and Misappropriation of Funds Policy 605.03.