by Glenn Panzer, MD

Recently the DEA fined a pharmacy for prepopulating prescriptions for controlled substances.

It seems to have all started when a “whistle blower” from a Midwestern state reported that a pharmacy company was going too far in assisting doctors with phone orders for C-II medications by sending the physician a fax prescription with all the data, patient's name, address, date, Rx, amount dispensed and the sig filled in. Then all the doctor had to do was review, sign and fax back to the pharmacy company.  As the story goes the DEA found fault with this practice stating that the prescribing physician had to be the primary source of the information and that the pharmacy could only remind the doctor that a hard copy was required and doctor had to "populate all the fields."

Pharmacies that supply SNF and hospice patients have been converting to a new process, one by one.  Many of them are faxing a refill request to the physician with all the information needed.  If the physician agrees, he or she is to fill out the prescription, sign it and send it back.

2 years ago the DEA reinterpreted the Controlled Substances Act to indicate that SNF nurses cannot act as the agent of the prescriber for controlled substances.  Institutional pharmacies serving skilled nursing facilities (SNFs) in the Midwest received fines in the millions of dollars for violating the CSA (Controlled Substances Act) by accepting prescriptions that did not meet all the criteria and/or were communicated by people who were not agents of the physician.  In October 2010 the DEA clarified policy regarding prescriptions for controlled substances in SNFs and for hospices.. Prescriptions will need to meet all the criteria spelled out in the CSA, every time.  Physicians needed written agreements with individuals who were not their employees to be their agents, when communicating prescriptions to pharmacies.

The agents could call in Class III-V prescriptions and fill out for signature Class II.

The CSA and California law require these specific criteria for a paper prescription to be valid:

• Date written
• Name and address of patient
• Name, address and telephone number of prescriber
• Name of medication
• Quantity to be dispensed
• Instruction for use and indication
• Wet signature of prescriber (in ink)
• DEA and license number of prescriber
• Refill information (if any)

Prescriptions may be prepared for review and signature by a secretary or authorized agent, but no one other than the physician may make medical determinations, or can sign or date the prescription.  An agent of a prescriber (for simplicity we will say physician) is “an authorized person(s) who acts on behalf of or at the direction” of a prescriber. The agent could be a nurse or medical assistant in the office, but the agent does not necessarily have to be employed by the physician. The decision to designate an agent lies solely with the physician.

At The Elizabeth Hospice where I have been Chief Medical Officer, we have devised Nurse as Agent Contracts that our nurses sign as agents and our contracted physicians/ nurse practitioners sign as practitioner or registrant.  It has allowed nurses to call in class III- V prescriptions.  Based on the guidelines above It seems reasonable to utilize an assigned administrative assistant as agent to fill in the patient and prescriber information on Class II prescriptions and then to pass on to the prescriber for class II drug dosing information and signature.