Building a Diversion Prevention Program That Works

Introduction: Prevention Is Better Than Investigation

Controlled substance diversion is a serious threat to patient safety, community safety, staff integrity, and regulatory compliance.

A well-designed diversion prevention program doesn’t just react to problems—it stops them before they start.  The objective is to detect and correct aberrant behavior.

An ounce of prevention is worth far more than the cost and chaos of a diversion investigation.

Step 1: Establish Written Policies

Your program must be anchored in clear, accessible policies that cover:

• Access Control – Who is authorized to handle controlled substances and under what conditions.
  
• Inventory Management – Frequency and method of counts, reconciliation, and documentation.
  
• Monitoring Procedures – Urine drug testing, pill counts, and PMP checks.
  
• Incident Response – Steps to take when discrepancies or suspicious activity occur.
  

Ensure all staff receive, read, and sign these policies annually.

Step 2: Control Physical Access

• Store controlled substances in locked, substantially constructed cabinets or safes.
  
• Limit keys or access codes to essential personnel only.
  
• Track access with key logs or electronic audit trails.
  
• Change locks or codes immediately if a staff member leaves or is reassigned.
  

Step 3: Maintain Tight Inventory Controls

• Conduct two-person counts whenever possible.
  
• Reconcile logs daily for high-risk medications.
  
• Separate receiving, storing, and dispensing duties when staffing allows to reduce opportunities for diversion.
  

Step 4: Train Staff to Recognize Red Flags

• Missing or altered documentation.
  
• Unexplained discrepancies in counts.
  
• Staff frequently volunteering for medication-handling tasks outside their usual role.
  
• Patients reporting “lost” prescriptions or requesting early refills.
  

Training should be scenario-based so staff can practice spotting and responding to suspicious behavior.

Step 5: Conduct Random Audits

• Randomize audit timing to make patterns harder to exploit.
  
• Include both scheduled and surprise counts.
  
• Document all audit results, including zero findings.
  

Step 6: Foster a Speak-Up Culture

• Encourage staff to report concerns without fear of retaliation.
  
• Provide multiple reporting channels—anonymous options help.
  
• Investigate all reports thoroughly and discreetly.
  

Step 7: Respond Quickly to Suspected Diversion

• Remove the suspected individual from controlled substance access immediately.
  
• Conduct a formal investigation in line with policy.
  
• Notify DEA, state authorities, and law enforcement when required.
  
• Document every step of the process.
  

Step 8: Review and Improve Annually

• Reassess policies in light of new regulations or incidents.
  
• Incorporate lessons learned from past audits, inspections, or investigations.
  
• Update staff training with real-world case studies.
  

Common Mistakes to Avoid

• Overtrusting Without Verification – Even trusted staff must be held to the same monitoring standards.
  
• Poor Documentation – Without clear records, you can’t prove compliance or detect problems.
  
• One-Time Training – Diversion prevention requires ongoing reinforcement.
  
• Ignoring “Minor” Issues – Small red flags can signal larger problems.
  

Benefits of a Strong Diversion Prevention Program

• Protects patients from harm.
  
• Preserves the integrity and reputation of your practice.
  
• Reduces regulatory and legal risks.
  
• Promotes a culture of compliance and safety.
  

Final Thoughts: Build It Before You Need It

A diversion prevention program is like insurance—you hope you never need it, but if you do, it’s invaluable.

By combining strict access controls, continuous training, and prompt response protocols, you greatly reduce the risk of diversion in your practice.

The best diversion prevention program is one that makes diversion nearly impossible.

About the Author

Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP

Dr. Doug is a physician, consultant, and national educator on healthcare compliance, controlled substance management, and diversion prevention. He helps practices create proactive programs that protect patients, staff, and providers.