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    344 views55 pages

    Controlled Substances SOP

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    Doctor Motrin

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    © All Rights Reserved
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    of 55
    2 Ape lt COMNAVAIRFOR/COMNAVSURFPAC/COMNAVSURFLANT STANDARD ‘OPERATING PROCEDURES From: (1) Foree Surgeon, Commander Naval Air Forces @) Force Surgeon, Naval Surface Forces, U.S, Pacific Feet (G) Force Surgeon, Naval Surface Forees Atlantic Subj: CONTROLLED SUBSTANCES STANDARD OPERATING PROCEDURES Ref (@) COMNAVAIRFORCES 6000.1 series (b) COMNAVSURFLANTINST/COMNAVSURFPACINST 6000.1 series (©) BUMEDINST 6710.704, (@) Manual of Medicine P-117; Chapter 21(S Mae 18) Encl: (1) Contolled Substances Standard Operating Manuel 1. Purpose. To promulgete standardized operating procedures (SOP) for managing controlled sutstances in Medical and Dental Departments. Commands shal use this SOP asthe controlled substance directive and as amplifying guidance to references (a) through (@). This SOP should be reviewed in its entirety. 2, Scope, This SOP applies to all Commander, Naval Air Forees (COMNAVAIRFOR), (Commander, Naval Surface Foree, U.S, Pacific Flet (COMNAVSURFPAC), and Commander, prccedures, board composition, and tining requirements for controlled substances. Senior “Medical Department Representatives and Senior Medical Offices shall forward change ‘recommendations to ther applicable Type Commander (TYCOM) Surgeon's Office for further discussion and approval 4. Action, This SOP is promulgated for action by all (COMNAVAIRFOR/COMNAVSURFPACICOMNAVSURFLANT ships and unis with Medical ‘or Dental Departments and is effetive upon receipt. The information in enclosures need not be reproduced in local instructions. 5. Records Management, Records created as a result of this instruction, regardless of media, and format, shall be managed in accordance with SECNAV Manual $210.1 series. ed Agi A Force Surgeon, Force Surgeon, Force Surgeon, ‘COMNAVSURELANT ‘COMNAVSURFP: COMNAVAIRFOR Distbution: Electronic only, via COMNAVAIRFOR Directive Website and COMNAVSURFOR Directive Website CONTROLLED SUBSTANCES STANDARD OPERATING PROCEDURES PUBLISHED BY: COMMANDER, NAVAL AIR FORCES COMMANDER, NAVAL SURFACE FORCE, US. PACIFIC FLEET ‘COMMANDER, NAVAL SURFACE FORCE, US, ATLANTIC FORCE HEALTH OFFICES RECORD OF CHANGES ‘Change Nomber | Date of Change | Date Entered SIGNATURE PAGE Date. Signature ‘Signature and date required aftr reviewing SOP TABLE OF CONTENTS, ‘Chapter 1 ~ Administration and Security Roles and Responsibilities... 1.2. Physical Security Requirements, ‘Chapter 2 ~ Material Management 2.1 Authorized Medical Allowance List Requirements 2.2 Procurement, Purchasing and Requistioning of Controlled Substances. 23 Receipt of Controlled Substances 24 Procedures for Transfer om Bulk Stock to Working Stock 25 Procedures for Transfer fom Working Stock to Bulk Stock. 2.6 Procedures for Transfer fom Unit t9 Unit.s.ssnnnunnnnnnnn 2.7 Destruction. 28 Dispensing ‘Chapter 3 ~ Controlled Substance Inventory Board 5.1 Controlled Substance Inventory Bord 3.2 Training, 3.3 Periodicity of Inventories. 3.4 Reporting Requirements 3.5 Procedure for Theft or Loss 3.6 ArchiVES.c.rrssesnntnnntnnneseane eee Forms, Enelosu: Enclosure | ~ CSIB Training Power Point Enclosure 2 - CSIB Test HAI R 1.1 ROLES AND RESPONSIRILE @, Commanding Officer (CO) (1) The CO is responsible for the operation ofthe pharmacy. (2) The CO in conjunction with the Senior Medical Officer (SMO) of Senior Medical Department Representative (SMDR) mus establish policies to ensure rational preseribing, to ensure quantities of rugs presribed are not excessive and to ensue drug dispensing i based on 1 formulary system. The CO is responsible forthe oversight ofthe controlled substance program and must review and sign all controlled substance inventories. (3) COs may designate other substances as drugs of abuse and require security measures similar to controled substances, (4) The CO must ensure thatthe Medical Department funding is aligned to meet the ‘mission requirements, Medical Departments are required to maintain emergency medical supplies at 100% at al times to include controlled substances. . Authorized Prescribing Providers. May prescribe and administer only those controlled substances listed inthe ativity’s Authorized Medical Allowance List (AMAL) and within their scope of practice. Only the applicable Type Commander (TYCOM) Force Surgeon may approve «revision or augmentation of controlled substances in AALS. ©. Bulk Stock Custodian. The Bulk Stock Custodian willbe a commissioned officer ppoinied in welling with responsibilities delineated by the eurent CO. The Bulk Stock Custodian must not be the Working Stock Custodian or a member ofthe Controlled Substance Inventory Board (CSIB). The Bulk Stock Custodian must complete CSIB training and test in Enclosure (1) end 2) prior to be appointed by the CO. Bulk Stock Custodian responsibilities ae a follows: (1) Responsibility for main the bulk stock, ining custody of ll unissued controlled substances within (2) Familiarization with and observance of spplicable potions of Chapter 21 of | MANMED relating to receipt, custody, and security of controled substances. (@) Maintaining the necessary accounting records and documents to substantiate proper receipt and expenditure of controled substances in custody, (4) Ensuring that a SF 700 as been placed inthe custody ofthe CO or their designee. (5) Reporting directly to the CO in the performance of he above duties. NOTE: Due tothe crew size, DDG 1000, LCS, MCM, and PC class ships are exemps from the equirement to assign @ Bulk Stock Custodian, On these platforms, the Bulk Stock Custodian's duties will be performed by the Working Stock Custodian. 4. Working Stock Custodian. The Working Stock Custodian willbe the Pharmacy ‘Technizian (NEC 122A) if one is assigned to the ship/unit. Inthe absence ofa Pharmacy’ Technician, the Working Stock Custodian will be the Independent Duty Corpsman (NEC L10A). “The Working Stock Custodian will be appointed in writing with responsibilities delineated by the CO. The Working Stock Custodian must not be the Bulk Stock Custodian or a member of the csi. (1) The duties, responsibilities, and authority ofthe Working Stock Custodian willbe the same as those of the Bulk Stock Custodian, but applied tothe working stock. (2) The Working Stock Custodian shall maintains minimum of one unit of issue ofeach authorized controlled substance inthe working stock sfe at all times (3) The Working Stock Custodian is responsible to provide the Bulk Stock Custodian and all CSIB members prior to appointme ing with Enclosure (I) 0 (4) The Working Stock Custodian is responsible for administering the CSIB test in Enclosure (2) to the Bulk Stock Custodian and all CSIB members prior to appointment. The ‘Working Stock Custodian is responsible for maintaining positive control over the CSIB tes and answers. This tet shall not be distributed, (5) The Working Stock Custodian shall report directly tothe CO in the performance of the above duties. ¢, Senior CSIB Member. The most senior officer on the CSIB will be designated as the Senior CSIB Member and is responsible forthe management, coordination and execution ofthe CSIB Program on behalf ofthe CO in accordance with this Standard Operating Procedure (SOP) and references (a) thru (d). The Senior CSIB Member is responsible for the completion of all required CSIB forms, inventories and report. £ CSIB Members. All CSIB members ae responsible forthe following: (1) Must be paygrades £-7 to £9 for enlisted and O-1 0 0-6 for officers. (2) CSIB members shall nt be involved inthe diret procurement af controled substances. (3) Must receive training defined in Enclosure (I). (4) Must score 90% or above on the CSIB test provided in Enclosure (2. (3) Must be appointed in writing by the CO with completion of taining annotated inthe sppoiniment letter. (©)CSIB members mus fariliarize themselves with references (a) thru (8), 1.2. PHYSICAL SECURITY REQUIREMENTS 1. A minimum of two safes are required for security of controlled substances. The only ‘exceptions are DDG 1000, LCS, MCM and PC platforms. Combinations of safes will be safeguarded as follows: (1) Bulk Safe. Only the Bulk Stock Custodian shall hod the combination. A. ‘combination change envelope (SF 700) shall be used and placed inthe custody ofthe CO or an officer designated in writing by the CO. (2) Working Stock Safe. Only the Working Stock Custodian shall hold the combination. ‘A combination change envelope (SF 700) shall be used and placed inthe custody ofthe CO or an officer designated in writing by the CO. (G) Safe combinations. The Bulk Safe and Working Stock Safe sll have their combination changed immediately upon turnover, suspicion of eompromise, and periodically every six months in accordance with eference (d), (4) Pharmacy Door combinations. For ships with dedicated pharmacies, a log must be ‘maintained inthe Medical Department fo record combination changes to the pharmacy door. ‘The door combination must be changed if compromise is suspected or upon turnover oF personnel with acess tothe pharmacy in accordance with reference (2. HAL : iT 2.1 AUTHORIZED MEDICAL ALLOWANCE LIST REQUIREMENTS 2. Alcohol, barbiturate, hypnotic, stimulant, narcotic and sedative medications requiring special custodial are (hereafter referred to as “controled substances”) are those designated by the symbols “C",“R”, and “Q” appearing in the “NOTES” coluran of the Mentfication list of the Federal Supply Catalog, b. The AMAL quantity isthe authorized quantity of material required onboard a all times and for controlled substances iis the total of the bulk and working stock quantities, 2.2 PROCUREMENT, PURCHASING, AND REQUISITIONING OF CONTROLLED IBSTANCES 4. Units shall procure and/or dispense ONLY. the controlled substances onthe AMAL specific to their platform, Exceptions to this provision must be granted in writing by the applicable TYCOM Force Surgeon. The written waiver granting authorization shall be ‘maintained with the bulk stock records, b. Controlled substances shall be ordered through ships supply system (R-Supply). This is the only authorized system for requisitioning of controlled substances. Any other means of requisitioning is strietly prohibited. Navy Medical Logistics Command (NMLC) mottos all issues of controlled substances and forwards reports of discrepancies to TYCOM Surgeons for «. Naval Medical Logistiss Command Notifieation ete. When controlled substances are ‘ordered in excess of AMAL. quantity allowed, NMILC will notify applicable TYCOM. Surgeon via letter. The ship will be notified immediately and will have five business days to provide @ formal response tothe applicable TYCOM Surgeon with plan of action. Options include requesting a letter from TYCOM Surgeon to carry excess, controlled substances maybe transferred to another ship and asa lat resort destruction. Permission to destroy narcotics that ‘are not expired must be granted by the applicable TYCOM Surgeon 2.3 RECEIPT OF CONTROLLED SUBSTANC! normally accompanied with DD Form 134 document the receipt of controlled substances: When narcotics are received they are 'A. The following process must be followed to ‘4, Bulk Stock Custodian (Working Stock Custodian on platforms exempt from assigned a Bulk Stock Custodian) must sign the DD form 1348-1A recording the receipt of controlled substances from the Supply Department, ». Supply Department representative must sign the DD Form 1348-14 recording the ‘controlled substances were turned aver tothe Bulk Stock Custodian and shall be kep on file in the bulk stock binder. «c. NAVMED 67015 shall be completed by the Bulk Custodian for each controlled substance received and transaction shall be annotated accordingly once medication is placed into bulk stock. The item requisition number shall be annotated under the “Rx or Req No.” on the [NAVMED 6710/5 during receipt that are kept in bulk and working stock binders, No other ‘numbers are authorized. 4. A CSIB inventory must be conducted within 30 days of receipt due to receipt of medication being considered a transaction per reference (0) €. In the event a DD Form 1348-1 does not accompany the controlled substance, the ‘Supply Department or Medical Department must generate a NAVSUP Form 1250-1 and follow the procedures outlined above forthe DID Form IS4R-1A. The NAVSUP From 1250ct should be kept on file in the bulk and working stock binders 2.4 PROCEDURES FOR TRANSFER FROM BULK STOCK TO WORKING STOCK 2, Transfers shall be made in whole units only (bottle, box) for bulk stock records and Individual quantity for working stock records. b, A NAVSUP 1250-1 shall be prepared in duplicate, deed, and signed by both the ‘Working Stock Custodian and Bulk Stock Custodian. One copy ofthe completed NAVSUP 1250-1 willbe filed in an envelope attached to the back ofthe Bulk stock NAVMED 6705 for the drug being transferred in whole units (eg. | BTL or I Box). The duplicate copy will be filed inenvelope attached tothe back ofthe working stock NAVMED 6710/5 forthe drug being twansfered in individual units (eg. 100 Tabs or 10 Carpujets). NOTE: Working stock NAVSUP 1250-1 and working stock NAVMED 6710/5 shall aleys reflect individual quantity. Bulk stock NAVSUP 1250-1 and bulk stock NAVMED 6710/5, should always reflect bulk quantities. 2.5 PROCEDURES FOR TRANSFER FROM WORKING STOCK TO BULK STOCK ‘Transfers shall be made in whole units only (e.g. bottle, box) for bulk stock records and individual uantty for working stock records, b. A NAVSUP 1250-1 shall be prepared in duplicate, dated, and signed by both the ‘Working Siock Custodian and Bulk Stock Custodian, One copy ofthe completed NAVSUP. 1250-1 willbe filed in an envelope attached to the back ofthe bulk stock NAVMED 6710/5 for the drug being transferred in whole units (e.g | BTL or 1 Box). ‘The duplicate copy willbe filed inenvelope attached tothe back ofthe working stock NAVMED 6710/5 forthe drug being transfered in individual unis (eg. 1°00 Tabs or 10 Carpujts).. 2.6 PROCEDURES FOR TRANSFER FROM UNIT TO UNIT. ‘a. Transfers shall be made in whole units only e, botte, box), b. ADD form 1149 shall be prepared in duplicate, date, and signed by both custodions fiom each unit. Each unt custodian will maintain a copy ofthe completed DD form 1149 to be filed in an envelope attached tothe back of the NAVMED 6710/5 for the deug being transfered. 2.7 DESTRUCTION 1, Financial Liability of Property Loss (DD Form 200) shall be utilized during a

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