URMC Compliance Program Policy Manual:
Controlled Substances

Any URMC entity having a pharmacy is registered to purchase, acquire, compound and dispense narcotics and other controlled substances. Improper use of these substances is illegal and extremely dangerous. Accordingly, the entities must comply with federal laws and regulations administered by the Drug Enforcement Administration (DEA) and New York State laws and regulations administered by the Department of Health.

All employees, as well as affiliated physicians who maintain DEA registration, must comply with all federal and state laws regulating controlled substances. Access to controlled substances is limited to persons who are properly licensed and who have express authority to handle them. No health care practitioner may dispense controlled substances except in conformity with state and federal laws and the terms of the practitioner's license. Employees should carefully follow record keeping procedures established by their departments and the pharmacy. Unauthorized manufacture, distribution, use, or possession of controlled substances by staff employees working in the Strong Health System is strictly prohibited, and will be prosecuted to the full extent of the law. Any person who knows of unauthorized handling of controlled substances is to provide the information immediately to his or her supervisor or the Compliance Officer.

Federal law may impose sentences of up to twenty years in prison and fines of up to $1,000,000. If an organization or its employee is convicted under federal or state law of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance, the organization or employee can be excluded from the Medicare or Medicaid programs.