Susan LaGrange

One timely topic that is both difficult to comprehend and discuss is drug diversion in long-term care. Long-term care leaders must have a solid system in place with policies and procedures, education, oversight and monitoring on an ongoing basis, as shift-to-shift counting alone will not suffice in identification of diversion.

When a licensed professional diverts medications, there are multiple significant concerns the facility needs to address, starting with quality of care for the resident, legal and ethical concerns for the facility, as well as concerns for the impaired professional — each with their own unique problems to address.

“There are no reliable statistics about diversion by healthcare providers. This is because diversion is done covertly, and methods in place in many institutions leave cases undetected or unreported,” states a June 2014 piece by the Centers for Disease Control and Prevention.1

According to the National Institute on Drug Abuse (NIDA) and Drug Enforcement Administration[1], drugs that have the highest potential for diversion include:

  • Anabolic steroids
  • Central nervous system depressants
  • Hallucinogens
  • Opioids
  • Stimulants

A good, solid system will have policies and procedures to address screening, ongoing monitoring (including the ability to recognize the signs of an impaired worker), documentation reconciliation, auditing, handling reports for suspicion of diversion, investigation steps, involvement of other people/entities (i.e. pharmacy consultant, police, State Licensing Board, State Agency, Medical Director, families, etc.), billing concerns, etc. It may also be helpful to educate all nurse managers on identification and auditing.

F-431 Labeling of Drugs and Biologicals3, which has popped up in the top 10 most frequently cited deficiencies, addresses the storage of drugs and biologicals to include safe and secure storage, “limited access” and “mechanisms to minimize loss or diversion.”  F-431 also addresses the requirement that the facility will need to have a good system for “receipt, usage, disposition, and reconciliation of all controlled medications.”

A review of the facility system may be needed to ensure policies and procedures (including facility attorney and Human Resources review), staff education and a system for ongoing compliance monitoring are in place! Facilities cannot rely on shift-to-shift counting as the means for identification of potential missing medications or potential diversion of drugs.  An active proactive system is necessary in the long-term care setting today.

Sue LaGrange, RN, BSN, NHA, is the director of education at Pathway Health.

1Centers for Disease Control and Prevention. (June 20, 2014).  Drug Diversion Defined:  Steps to Prevent, Detect, and Respond to Drug Diversion in Facilities. Retrieved from

2 Department of Health and Human Services, Centers for Medicare & Medicaid Services. (March 2014).   What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs? Medicaid Program Integrity. Retrieved from

3Centers for Medicare & Medicaid Services. (April 14, 2014). State Operations Manual, Appendix PP-Guidance to Surveyors for Long Term Care Facilities. Retrieved from