didn't think we needed the [biannual] audit."
But sure enough, when he read the law the surveyor cited from the
DEA's Diversion Control Division (osmag.net/ eSrTQ5), there was
mention of the need for a biannual inventory of controlled substances.
The surveyor didn't suggest the audit to meet his accreditation
agency's standards, but to keep Dr. Greene's facility safe in the event
it ever had an unexpected visit from the DEA.
"We do the bi-annual narcotics audits on a specific date every 2
years," says Dr. Greene. "We simply write down the drugs, amounts,
strengths, number of tablets and number of vials."
On top of giving your facility an extra layer of documentation to
prove what it did or had in the event there was a narcotics theft or a
diverter made off with some controlled substances, it also ensures
you don't get hit with a significant federal fine.
"If the DEA shows up and you have the narcotics inventory info,
you're in good shape. If not, you wind up $14,000 lighter," says Dr.
Greene.
2. Pending board approval
While surveyors often cite deficiencies you need to correct, some-
times they'll also point out things that, while not technically ding-wor-
thy, you could do better. That's what Joyce Mackler, RN, MSN, CASC,
the manager at Seaford (Del.) Endoscopy Center, learned during a
recent survey.
While reviewing the minutes of Seaford's board meetings, a surveyor
noticed that some meetings were held just to approve new or revised
policies and procedures. This led to having more board meetings than
necessary and also led to important policy change delays — some-
times for months at a time. The surveyor pointed out that the govern-
ing board can designate the medical director or president of the med-
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