{"ref":"OH-HSP-QA-02","title":"Investigating and Reporting Suspected Drug Diversion","category":"Quality","summary":"Sets the Agency's drug diversion investigation and reporting program required by ORC 3712.062 and OAC 3701-19-06(C)(3)(f): every staff member reports any sign of suspected diversion at once; the Administrator or the Administrator's designee investigates within twenty-four hours of receiving the report; and, when the investigation substantiates diversion or is inconclusive, reports the results to the law enforcement agency with jurisdiction over the patient's home no later than ten days after receipt of the report or upon conclusion of the investigation. It also covers protecting the patient's comfort, related reports to ODH and others, and use of the results in QAPI.","inShort":["If counts are short, refills come early or drugs look tampered with, report it at once by phone to the Administrator or the designee.","Do not accuse or confront anyone; just report what you saw.","The Administrator or designee must investigate within 24 hours of receiving your report.","If diversion is confirmed or unclear, the Agency reports to the local police for the patient's home within ten days.","Make sure the patient's pain is still controlled and call the prescriber the same day."],"primaryCitation":"OAC 3701-19-06(C)(3)(f)","citations":["OAC 3701-19-06(C)(3)(f)","ORC 3712.062(B)(5)-(6), (B)(9), (F)","ORC 3712.03(A)(5)-(6)","OAC 3701-19-03(C)(7), (H)","OAC 3701-19-11(D)"],"federalCitations":["42 CFR §418.106(e)(2)-(3)","42 CFR §418.52(b)(4)","21 CFR §1301.76(b)","45 CFR §164.512(a), (f)"],"surveyorAsks":["Who receives reports of suspected drug diversion, and how do staff reach that person after hours?","Walk me through your last diversion investigation. When did you receive the report, when did the investigation start, and when did you report to law enforcement?"],"forms":[{"ref":"OH-HSP-QA-02-A","title":"Suspected Drug Diversion Investigation Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (ORC 3712.062(B)(5)-(6); OAC 3701-19-06(C)(3)(f))","5. Signs of Suspected Diversion","6. Report at Once","7. Investigate Within Twenty-Four Hours","7.1 Inpatient unit discrepancies","8. Reaching a Conclusion","9. Reporting to Law Enforcement","10. Other Reports That May Be Required","11. Protecting the Patient's Comfort","12. Monitoring and License Renewal","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"oh-hospice","state":"Ohio","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}