Controlled Substance Diversion Activities in SNF

Nancy Leveille and Karen Morris in Clinical & Quality

Over the last couple years and most recently, NYSHFA has heard of a number of SNF discovering that they have had controlled substance diversion occurring in their facilities. Per the Bureau of Narcotic Enforcement, BNE, and the State Education Department, Board of Nursing, these activities have risen sharply over the last 5 or more years due to a reduction of illegal street drugs and a turn to diversion of prescription medications. NYSHFA has worked closely with the BNE to bring educational events to our members via our conferences and classes. We will again plan for another event this fall. However, we encourage all of you to check on your controlled substance systems at this time and then establish an ongoing monitoring plan. Unfortunately, some of the diverters have been long standing nurses that the facility would never suspect. So the prototype for drug diverter may be different that you might expect. Here are a couple things to help you evaluate your system:

  1. Do you have a strong policy and procedure for overall maintenance of controlled substances in your facility.
    • Do your policies and procedures follow New York State Code, Rules and Regulations? NYCRR Title 10 Part 910.5 and 415.18
    • Has your pharmacy consultant been involved in the development and the review process of these policies and procedures
    • Do the policies outline who can accept controlled substances into your facility; how they enter them into your documentation system; and how they need to be locked in a secure spot.
    • Do they also include how to secure prescription pads in a locked cabinet with documentation of the number of pads ordered and documentation recording distribution of the pads to the physician. (NYCRR title 10, 910.5)
    • Does it include how to handle discontinued controlled substances and where to store and control those.

  2. Do you have a specific procedure for shift to shift counting of controlled substances that identifies which nurse is counting the actual substances and which nurse is reviewing the documentation sheets as they do this procedure together in a quiet place.

  3. Do you have a procedure for how the nurse documents administration of each controlled substance and documents the number or amount left after that dose is given and then the effects the resident has after consumption?
    • Does this include how to waste unused or contaminated controlled substances and who must be present to do this per regulation/law.
  4. Is your pharmacy consultant helping you to monitor this process per unit on a regular basis.

  5. Do you have an unannounced system for spot checking the nurses shift to shift counting procedure.

  6. Do you have a system for evaluating the controlled substances administration to look for unusual patterns, i.e. one nurse always gives out a lot of controlled substances on her shift, but residents rarely ask for them on another shift; residents are complaining of little pain relief from their pain medications; nurses “borrowing the keys for just a few minutes,” (even if they are the supervisor) there still needs to be a complete controlled substances count done with both nurses signing off; nurses not understanding the significant/need for following a protocol to count controlled substances at various times.

  7. Do you know who to call if you suspect a problem? The BNE and your pharmacy can assist you with any questions as to how to have a tight secure system and monitoring process in your facility. The BNE investigators can give guidance if you suspect diversion. The DOH and Attorney General’s Office will/may get involved if diversion is suspected or has occurred.

This information is not all inclusive, but should assist you in checking your system and current practices in your facility. If you have any questions, please contact Nancy Leveille or Karen Morris.



Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20
  Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15