Compliance Partners With Pharmacy to Audit CSA Compliance at Health System’s Clinics

By Nina Youngstrom

When the University of Michigan Health System (UMHS) settled alleged violations of the Controlled Substances Act (CSA) in 2018, it lit a fire under pharmacy leaders halfway across the country at UNC Health in North Carolina. They advocated for reviews of CSA compliance at UNC’s off-campus clinics because they didn’t want to end up in the same boat as UMHS and because drug diversion generally is a risk for health care organizations that dispense controlled substances.

The pharmacists’ wish was granted. Pharmacy and compliance have been collaborating on audits of CSA compliance at outpatient clinics for years, said Patrick Kennedy, executive system director of hospital compliance at UNC Health. “We have a great pharmacy team and they partnered with us in compliance to look at our off-campus clinics with controlled substances,” Kennedy said. “This is one piece of many we have in place to ensure an environment of surveillance of controlled substances aimed at preventing diversion.”

The pharmacy and compliance departments also developed a guidebook to help the clinics monitor their own compliance moving forward.

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