MA PATCH Act Compliance Assessment

Do you maintain perpetual inventory for all Schedule II controlled substances?*

MA PATCH Act requires comprehensive tracking of all Schedule II drugs

Are controlled substances secured in substantially constructed locked cabinets or vaults?*

DEA security requirements for storage of controlled substances

Do you conduct physical inventory counts of controlled substances at least monthly?*

Reconciliation of perpetual inventory with physical counts

Are discrepancies in controlled substance counts investigated immediately?*

Document investigation and corrective actions for all variances

Do you use automated dispensing systems (ADCs) with user authentication?*

Pyxis, Omnicell, or similar systems recommended for diversion prevention

Have you established a formal controlled substance diversion prevention program?*

Written program required by MA PATCH Act

Is there a designated Diversion Prevention Officer or Committee?*

Responsible for oversight and investigation of suspected diversion

Do you analyze controlled substance usage data for diversion indicators?*

Statistical analysis of prescriber and dispenser patterns

Are waste and return processes for controlled substances witnessed and documented?*

Two-person witness for waste; comprehensive documentation

Do you conduct pre-employment background checks for all staff with controlled substance access?*

Criminal history and disciplinary action screening

Are staff monitored for behavioral indicators of substance use disorder?*

Impairment, frequent bathroom breaks, unexplained absences

Do you have a policy for reasonable suspicion drug testing?*

Testing when impairment suspected or diversion investigation

Are employees with controlled substance access subject to random audits?*

Review access logs, prescribing patterns, patient complaints

Do you report suspected controlled substance theft or diversion to DEA and DPH?*

DEA Form 106 within one business day of discovery

Are all diversion investigations documented with findings and actions taken?*

Maintain records for inspection by regulatory authorities

Do you check the MA Prescription Monitoring Program (PMP) for prescribing patterns?*

MassPAT system review for prescriber and patient red flags

Are controlled substance records retained for at least 5 years?*

MA PATCH Act requires 5-year retention (DEA requires 2 years minimum)

Do all staff with controlled substance access receive annual diversion prevention training?*

Training on detection, reporting, and consequences of diversion

Are policies and procedures for controlled substance handling documented and accessible?*

Do you have a non-retaliation policy for employees reporting suspected diversion?*

Whistleblower protections encourage reporting