EXECUTIVE SUMMARY:

Our objective was to determine whether Santa Fe Indian Hospital (Santa Fe) complied with applicable requirements to secure and account for its Schedule II substances.

Santa Fe complied with applicable requirements to secure its Schedule II substances. However, Santa Fe did not institute all recommended security precautions or have adequate internal controls over these substances at its outpatient and inpatient pharmacies. In addition, Santa Fe did not always comply with applicable requirements to account for Schedule II substances at its outpatient pharmacy and automated dispensing units in the outpatient department and inpatient ward. As a result, Schedule II substances at Santa Fe were vulnerable to theft and mismanagement.

We recommend that IHS direct Santa Fe to enforce the security, internal, and accountability controls detailed in our report.

IHS concurred with our findings and recommendations and stated that Santa Fe had implemented, or was currently implementing, all recommended corrective actions.