Practice Assessment – Utilizing The Compliance Health Score Chart

Courtney on March, 2025

Introducing the Compliance Health Checklist

In this module, we will be using VetSnap’s DEA Compliance Health Score Checklist to evaluate your practice’s current standing in relation to controlled substance compliance. Think of it like a regular physical exam for your practice’s compliance.  

The checklist is divided into sections, each addressing essential aspects of controlled substance handling. These sections cover various components of record-keeping, security protocols, and staff training.  

To use the checklist effectively, carefully review each item within each section. For each item, indicate whether it accurately reflects your current practice by checking the corresponding box. It is important to answer honestly and accurately to obtain a true representation of your practice’s current compliance health.

Using the Compliance Health Checklist: Record-Keeping

Let’s walk through an example of how to use the checklist by focusing on the Record-Keeping section. This section is designed to assess the accuracy, completeness, and organization of your practice’s controlled substance records.

The Record-Keeping section covers several key areas:

  • Acquisition Records: This part of the checklist focuses on ensuring proper documentation of all received controlled substances. It includes verifying that purchase records are signed and stored appropriately, inventory shipments are processed promptly, and acquisition logbook records are maintained according to DEA requirements.  
  • Dispensing Records: This section verifies that accurate and detailed logs are maintained for all dispensed or administered controlled substances. It assesses whether logbook records are DEA compliant, retained for the minimum required period, created in real-time, reconciled daily, and current, complete, and accurate.
  • Inventory Records: This section checks the maintenance of accurate inventory records, including the retention of inventory records, performance of biennial inventory counts, regular inventory counts, container weight tracking (if applicable), and proper disposal of expired/unwanted medications.  
  • Required Forms: This part of the checklist confirms that all required DEA forms are maintained and executed properly. It includes items such as maintaining and executing Form 222, signing receipt of CII drugs on Form 222, submitting Form 106 for theft/loss of controlled drugs, filling out Form 41 for wasted/destroyed controlled drugs, and securely storing unexecuted/void 222s.

For each item within the Record-Keeping section, carefully review your practice’s procedures and documentation practices. Then, check the box that corresponds to your current practice.

Understanding Your Findings

Once you have completed the checklist, you will use the DEA Compliance Practice Health Score to check your practice’s compliance health condition results.

The score chart categorizes your practice’s compliance health into one of four conditions:

  • Critical Condition (0-40%): This indicates significant deficiencies in your compliance program.
  • Serious Condition (41-60%): This suggests that your compliance program requires substantial improvement.
  • Fair Condition (61-80%): This indicates that your compliance program has some areas of strength but needs further development.
  • Excellent Condition (81-100%): This signifies that your compliance program is well-managed and demonstrates a strong commitment to compliance.

This categorization provides you with a clear understanding of the overall health of your practice’s DEA compliance.

Actionable Steps for Improvement

Based on your results, here are the actionable steps for improvement:

  1. Attend Live Webinars with VetSnap: Regularly participate in live webinars to stay current with compliance knowledge and best practices.
  2. Enroll in Free On-Demand Compliance Courses: Utilize available educational resources to test your knowledge and explore new compliance topics.
  3. Download & Implement Ready-To-Use Resources: Take advantage of resources such as SOP templates and audit readiness checklists to enhance your compliance efforts.
  4. Schedule a VetSnap Demo: Explore comprehensive compliance management solutions to improve your record-keeping and storage compliance.
  5. Assign a Compliance Officer and Implement a Controlled Substance Management Plan: Establish a system for regularly auditing and improving your compliance.
  6. Book a Personalized Compliance Consultation: Seek expert guidance from regulatory advisors for tailored advice and support.

Implementing a Controlled Substance Management Plan

In this course, we will be focusing on step 5: Assign a Compliance Officer and Implement a Controlled Substance Management Plan to regularly audit and improve your compliance.

A Controlled Substance Management Plan is a comprehensive strategy that outlines your practice’s policies and procedures for handling controlled substances. It serves as a roadmap for ensuring compliance with DEA regulations and preventing diversion or misuse.

Key components of a Controlled Substance Management Plan typically include:

  • Clearly defined roles and responsibilities: Designating a compliance officer and outlining the responsibilities of all staff members involved in controlled substance handling.
  • Standard Operating Procedures (SOPs): Establishing detailed procedures for ordering, receiving, storing, dispensing, administering, and disposing of controlled substances.
  • Inventory management protocols: Implementing systems for tracking inventory, conducting regular audits, and reconciling discrepancies.
  • Security measures: Defining protocols for secure storage, access control, and monitoring to prevent diversion or theft.
  • Record-keeping practices: Establishing procedures for maintaining accurate and complete records of all controlled substance transactions.
  • Training and education: Providing regular training to staff on DEA regulations, proper handling procedures, and diversion prevention.
  • Diversion prevention strategies: Implementing measures to detect and prevent the diversion of controlled substances, such as regular audits, monitoring for red flags, and establishing reporting mechanisms.

By implementing a well-designed Controlled Substance Management Plan, your practice can create a culture of compliance, minimize risks, and ensure the safe and responsible handling of controlled substances. This course will provide you with the knowledge and tools necessary to develop and implement such a plan effectively.