Diversion Control Plan

(1) Each clinic shall develop policies and procedures for a Diversion Control Plan that contains specific measures to reduce the possibility of diversion of controlled substances and that assigns specific responsibility to the medical and administrative staff of the Facility for carrying out the diversion control functions described in the Diversion Control Plan. The Diversion Control Plan shall contain, at a minimum, a random call-back program with mandatory compliance. (a) This call-back shall be in addition to the regular schedule of clinic visits. (b) Each service recipient receiving three (3) or more consecutive take-home medications per week shall be called back randomly within the three (3)-month period immediately following the previous call-back. (c) Upon call back a service recipient shall report to the clinic within twenty-four (24) hours of notification, with all take-home medications. If a service recipient call-back displays treatment instability, such as absence from the scheduled call-back, not having the appropriate quantity of take-homes, or the packaging shows signs of tampering, the service recipient shall be required to attend the clinic at least three (3) nonconsecutive days per week for a minimum of twenty-eight (28) days prior to returning to regular clinic attendance schedule, in accordance with Subpart 0940-05-42-.15(1)(c)1.(iii). (d) Service recipients shall be informed of the above requirements and the Facility’s policies and procedures regarding call-backs and receiving take-homes, including follow-up actions for any call-back results that demonstrate treatment instability. (e) The Facility shall document individual call-back results in the service recipient medical record. (2) The Facility’s policies and procedures for the Diversion Control Plans shall include the method for which the Facility will prevent the diversion of controlled substances from within the Facility. The plan shall include, at a minimum: maintaining a perpetual inventory, procedures for ordering and receiving controlled substances, and conducting investigations if theft or diversion is suspected.