Controlled substance audit questionnaire by 9oZ5rM

VIEWS: 24 PAGES: 3

									                                                             CONTROLLED SUBSTANCES AUDIT

                                                     Rutgers, The State University of New Jersey


REGISTRANT:          ..........................................................      DATE OF AUDIT:           .......................................................
LOCATION:            ..........................................................      AUDIT BY:                .......................................................
DEA#:                ..........................................................      CDS#:                    .......................................................
APPROVED DRUGS: ................................................................................................................................................


Note: Additional supporting information is included as “Hidden Text”. Hidden text must be set to visible for viewing on
screen or printing in order to see this information.

     1. Current DEA registration?                                                                                                        [ ] YES       [ ] NO
     2. Current NJ CDS registration?                                                                                                     [ ] YES       [ ] NO
     3. DEA and CDS registrations prominently displayed at approved site location?                                                       [ ] YES       [ ] NO

     4. Do you have a copy of your original DEA and NJ CDS applications with a list of                                                   [ ] YES       [ ] NO
        approved drugs?
     5. List of authorized users?                                                                                                        [ ] YES       [ ] NO
                a. Do you maintain a written list of authorized users under your registration?                                           [ ] YES       [ ] NO
                b. Have any of your authorized users been convicted of a drug offense? Ever?                                             [ ] YES       [ ] NO

                c. Are RU forms in use for Registrant Information and Authorized Site                                                    [ ] YES       [ ] NO
                   Registration?
                d. Authorized users have access to federal and state regulations?                                                        [ ] YES       [ ] NO


     6. Controlled substances securely locked in a secure cabinet or safe?                                                               [ ] YES       [ ] NO

                a. Cabinet/safe locked at time of inspection?                                                                            [ ] YES       [ ] NO
                b. If secure cabinet or safe weighs less than 700 lb, is it securely fastened to the                                     [ ] YES       [ ] NO
                   floor?
                c. Locked by key?                                                                                                        [ ] YES       [ ] NO
                            i. Location of key _______________
                d. Locked by combination?                                                                                                [ ] YES       [ ] NO
     7. Blank DEA Form 222 (triplicate prescription form) for Schedule II drugs in a secure                                              [ ] YES [ ] NO
        location?                                                                                                                             [ ] N/A
     8. Biennial (every 2 year) inventory within the last 24 months? Date: _____________                                                 [ ] YES       [ ] NO

     9. Are records maintained for 24 months?


b6c5b765-3e10-4991-aebc-492955730dce.doc                                      [Type text]                                                                      1 of 3
                                            CONTROLLED SUBSTANCES AUDIT

                                      Rutgers, The State University of New Jersey


   10. Using last biennial inventory as a starting point, if usage subtracted from inventory,       [ ] YES   [ ] NO
       does this agree with current inventory within a 1% error? Attach calculations.

   11. For all drugs in current inventory, and for all drugs used since last biennial inventory,    [ ] YES   [ ] NO
       is there a record of purchase (P.O. number, shipping label, invoice, Form 222)?
           a. Is the record of purchase readily available for inspection?                           [ ] YES   [ ] NO
           b. Is the RU form Drugs Received Form is use?                                            [ ] YES   [ ] NO
           c. Can every container you have purchased be accounted for?                              [ ] YES   [ ] NO
   12. For Schedule I or Schedule II drugs, has drug receipt been recorded on Researcher            [ ] YES   [ ] NO
       copy of Form 222?

   13. Is each use of controlled substances recorded?                                               [ ] YES   [ ] NO

           a. Is there a separate record (page) for each container?                                 [ ] YES   [ ] NO
           b. Is the RU Controlled Substance Log Form in use?                                       [ ] YES   [ ] NO
           c. Is each container of controlled substances consecutively numbered?                    [ ] YES   [ ] NO
           d. Is each container weighed on arrival and then after each day’s use?                   [ ] YES   [ ] NO
   14. Are expired drugs clearly labeled and segregated from non-expired drugs? Use of              [ ] YES   [ ] NO
       expired drugs in animals will be reported by federal agencies as “inadequate
       veterinary care”.
           a. Is someone in the lab assigned the duty of checking expiration dates on a             [ ] YES   [ ] NO
              regular (monthly) basis? The “registrant” of record has ultimate
              responsibility for record keeping, but this duty can be delegated.
   15. Are expired drugs secured in a suitable cabinet or safe?                                     [ ] YES   [ ] NO
   16. Are proper procedures followed for disposal of expired and unwanted drugs?                   [ ] YES   [ ] NO
           a. Is DEA Form 41 submitted to DEA with a cover letter prior to disposal?                [ ] YES   [ ] NO
           b. Is disposal documented by signature of one or more witnesses?                         [ ] YES   [ ] NO
           c. Is disposal witnessed by a Rutgers Police officer?                                    [ ] YES   [ ] NO
           d. Is a copy of Form 41 returned to DEA?                                                 [ ] YES   [ ] NO
           e. Are records of disposal retained for 24 months?                                       [ ] YES   [ ] NO



                                                  AUDIT PARTICIPANTS

               NAME                                    SIGNATURE                                   EMAIL




b6c5b765-3e10-4991-aebc-492955730dce.doc                [Type text]                                               2 of 3
                                    CONTROLLED SUBSTANCES AUDIT

                                Rutgers, The State University of New Jersey




b6c5b765-3e10-4991-aebc-492955730dce.doc        [Type text]                   3 of 3

								
To top