The working relationship between Law Enforcement, Regulatory and Healthcare

Institutions

Lorri Hall

(1) “I have no relevant financial relationships to disclose.”

(2) “The information contained within this presentation is based upon my knowledge, training and experience as a sworn law enforcement officer and Healthcare Diversion Specialist and will not be found in any publications.”

After completing this class the participant should be better able to: (1) Understand the benefits of law enforcement and healthcare facility partnerships; (2) Understand how a healthcare facility can “Prevent, Detect, & Report” healthcare diversion; (3) Understand the investigative concerns for law enforcement and healthcare facilities; Understand usual patterns related to diversion; Understand what evidence is related to diversion.

http://www.medscape.com/viewarticle/825801

PreventDetectReport

Bio scans and/or passwords for Drug Dispensing machines (Pyxis, OmniCell)

Card Readers in Controlled Substance areas Guidelines and Standard Operating Procedures

for Controlled Substances Drug Diversion Education Specific drug testing policies Cameras in Controlled Substance areas

Policy for wasting at removal Anesthesia waste coming back to pharmacy for

testing Strict drug testing policy Limiting Pyxis/OmniCell access to work areas Checks and balances for non-controlled

substances (ex. Propofol)

Proactive monitoring Controlled substance audits Make staff feel empowered to report diversion either

in person or anonymously Set up Diversion phone line or use Compliance Hotline Have a specific person staff can contact, Drug Diversion

Investigator, etc. Have policy and procedures set up to cover retaliation

in the workplace

Have a drug diversion team Administration Pharmacy Employee Health Security Nursing Administration Physicians Drug Diversion Investigator Anesthesia personnel

DEA Must report to DEA immediatelyThe registrant shall notify the Field Division Office of the Administration in his area, in writing, of the theft or significant loss of any controlled substances within one business day of discovery of such loss or theft. The registrant shall also complete, and submit to the Field Division Office in his area, DEA Form 106 regarding the loss or theft.

Local Law Enforcement Department of Health

Must report to Local Law Enforcement Florida State Statute: 893.07(5)(b)

In the event of the discovery of the theft or significant loss ofcontrolled substances, report such theft or significant loss to the sheriff of that county within 24 hours after discovery. A person who fails to report a theft or significant loss of a substance listed in s. 893.03(3), (4), or (5) within 24 hours after discovery as required in this paragraph commits a misdemeanor of the second degree, punishable as provided in s. 775.082 or s.775.083. A person who fails to report a theft or significant loss of a substance listed in s. 893.03(2) within 24 hours after discovery as required in this paragraph commits a misdemeanor of the first degree, punishable asprovided in s. 775.082 or s. 775.083.

We are only as good as our

contacts!

Both sides need to realize that there are two separate entities looking at the same issue.

Law Enforcement needs to understand that the healthcare institute has to do the primary investigation. Diversion has to be proven or there is reasonable

suspicion that it has occurred

There are different concerns for each side

Safety of patients Safety of staff Legal ramifications (lawsuits) Law enforcement involvement Report to Medical Boards Report to DEA Tainted reputation Health Insurance Portability & Accountability

Act (HIPAA)

Tampering cases Replacing a medication with something else

Know that these can be individuals that cannot access the OmniCell/Pyxis/AccudoseMachines. Radiologic Technologist Surgical Technicians Certified Nursing Assistants Knowing that

Infectious disease testing (ex. Hep C)

Hydromorphone Morphine Fentanyl Oxycodone Hydrocodone Lorazepam Midazolam Propofol (controlled in some states) Benadryl Lomotil

Different hospitals and facilities have different personnel assigned to investigate drug diversion Pharmacy Security Drug Diversion Investigator Compliance Officer Risk

Impairment of employee

Suspicious activity report

Pyxis/OmniCell discrepancies

Missing Controlled Substance

Diversion reported

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• Discrepancy reports – off in counts

• Audit manual documentation non-Pyxis

• Confirm daily custody chain for pharmacy

• Use diversion analytical tool: High usage, user, patient, waste, cancel reports

• Review documentation for trends and diversion patterns

• Review waste retrieval and assay testing

• Audits documented for trending of areas, users, drugs, waste and discrepancies

In order to find diversion you have to be proactive. This entails setting up monthly, weekly, daily etc.

High risk areasPRN nurses/TravelersNursing floors

Comparative audits. auditing more than one nurse/anesthesia staff member in the same area

Having good relationships with nursing, anesthesia etc. Making frequent visits

Education Trending

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Audit/monitor non-controlled substances` - High dollar items

- Patterns of discrepancies- weekly review of removals over 5

Pharmacy audits Daily follow-up on discrepancy resolutions Trending discrepancies

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Proactive Controlled substance audits

High Risk Areas Emergency roomAnesthesia/Surgery Post Anesthesia Care Unit (PACU) Intensive Care Unit (ICU) Pharmacy

Controlled substance audits High Users Routine audits of anyone removing controlled

substances CRNA Students

What are they looking for in the audits?

UNUSAL PATTERNS

Removing controlled substances with no “Doctor’s orders”

Removing controlled substances for patients “not assigned” to them

Removing controlled substances for patients that have been discharged from their care

Removing controlled substances and not documenting them on the “MAR” (Medication Adminstration Record)

Patient charting reveals excessive pulls for “PRN” medication compared to other nurses assigned to that patient.

Discrepancies from the OmniCell machines on a regular basis.

Pulling out controlled substances, tablets, in lower dosages in order to obtain more pills, when the exact dosage is available.

Pulling out larger dosages of injectables to obtain more waste.

Patient continuing to complain about pain, even though the nurse has documented the administration of pain medications.

Falsifying records Removing PRN medications to frequently(ex.

Order q 4 hrs, pulls q 2 hrs). Not documenting waste Helpful nurses who only want to help give

your patients their pain medications.

Pyxis Station User Name Patient name & Med ID Medication pulled/date & time Quantity removed/date & time Waste documented/date & time Witness to waste Administration of drug/date & time

Doctor’s order Pain Scale Comments

Highlight suspicious or unusual findings Send to employees supervisor, ex. Nurse

manager, physician etc.

Missing controlled substance Audit results

No documentation Pain score Administration Scan or no scan Only nurse/provider to give controlled substance (PRN) Nurse/provider administers the majority of a specific

controlled substance (PRN)

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Missing waste transactions High use/drug of choice Only subject to give PRN controlled substances

and/or early doses Inflated pain scores/no pain scores No doctor’s orders/patient not assigned/discharged

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Negative Behavior Checklist Negative Witness Statements Reasonable suspicion Patients continually complaining about pain

after administration Impairment Law enforcement reports

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• Know who you need in the room and who you do not

• Have one person designated as the primary interviewer, secondary person should be taking notes

• Set up room so the suspect gets your undivided attention

• If possible the interviewer should not be the employees supervisor or Human Resources

Lockers Desks Bags Coats Pockets Electronic devices if needed

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Evidence from a drug diversion case is crucial, not only to the institution but also to law enforcement.

• Evidence Handling: Maintaining chain of custody Packaging, labeling, securing Court of law admissible Video Capture – covert - overt

The use of evidence bags are imperative. Double signature and date If taken from subject. Place in evidence bag in front of subject

Medications

Empty/broken medication vials or packaging

Syringes

Photographs of the scene

Sharps waste bins

PCA Pumps (secure them)

Subject/Witness Statements

Can be used for sharps

Sharps

Need to reach out before any incidents occur Contact your local law enforcement departments Try and find a detective who understands diversion

cases or is willing to learn Working with a detective a head of time helps both

parties to understand what is needed to prove diversion Have a specific point of contact for the detective Need to understand the need for an arrest verses just

drug rehab

Establish a DEA /DEA Diversion contact in your area

Establish a Department of Health contact Food and Drug Administration (FDA) contact

Tampering cases

Understanding the diversion Interviewing witnesses Interviewing suspect(s) Probable Cause Evidence Presenting case for prosecution Not knowing what is needed to obtain

information from the facility, (ex. Subpoenas, Search Warrants)

Meet with hospital diversion investigators to truly understand why the findings are diversion and not just poor documentation

Covering every base, in other words find out what the defense for these actions might be?

This might entail interviewing numerous staff members Be prepared for the hospital to explain their audit analytics Know you will not get patient information without

subpoena or search warrant

Know what State Statute to use to charge the offender, (ex. Theft, Obtaining Controlled Substance by Fraud, Trafficking)

Learn what evidence is obtainable from the hospital, via subpoena or search warrant. Pyxis/Omni reports Medication removals Bio-scan

Medical records PCA Pump data Drug test results

Interview at the facility, if possible Only law enforcement in the interview Understand the processes surrounding the

diversion This way you know when the subject is not being

truthful

Working together to set up these interviews

Suspect interviews are so much more effective for law enforcement when the suspect is unaware of the criminal allegations prior to the interview.

Need to know that the majority of healthcare drug diverters are addicted to the controlled substance they are stealing

When interviewing these suspects it helps to be sympathetic to the addiction in order for them to open up In the mind of a healthcare diverter the worst thing

they could admit to is stealing drugs from a patient Realize the majority of healthcare diverters will

never admit to using on duty

Need to reach out before any incidents occur Hospital, Pharmacies, Nursing homes, etc. Have a point of contact for each facility Meet with these contacts to understand how

processes work and how they investigate diversion cases

Use a low key approach Conceal weapons and badges while in the facilities

Establish a DEA/DEA Diversion contact in your area

Establish a Department of Health contact Food and Drug Administration (FDA) Contact

Tampering cases

Have a plan of action in place prior to an incident!!!

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