Drug Enforcement Administration (DEA)

I. Purpose of policy

The purpose of this policy is to define the correct circumstances for the use of an Institutional Drug Enforcement Administration (DEA) Registration number by Residents in MHMH’s Accreditation Council for Graduate Medical Education (ACGME)-accredited training program.

II. Policy scope

This policy applies to Mary Hitchcock Memorial Hospital, Dartmouth Hitchcock Clinic (Lebanon), Dartmouth Hitchcock Clinic (Southern CGP) and Cheshire Medical Center/D-H Keene.

III. Definitions

Accreditation Council for Graduate Medical Education (ACGME): The organization responsible for accrediting Sponsoring Institutions and the residency and fellowship program at Mary Hitchcock Memorial Hospital (“MHMH”).

Inbound Rotator: A Resident from an external ACGME-accredited training program rotating through MHMH’s ACGME-accredited graduate medical education program. Also known as a “Visiting Resident”.

Institutional DEA Registration Number: A unique number issued by the U.S. Drug Enforcement Administration (DEA) to a licensed, eligible facility (hospital or clinic) that distributes and dispenses controlled substance medications.

Institutional DEA Registration Number with Suffix: A unique number which is a combination of an Institutional DEA Registration Number and a suffix consisting of numbers, letters, or a combination thereof unique to the applicable Resident. The Institutional DEA Registration Number with Suffix is to be used by Residents when administering, dispensing, or prescribing controlled substances at only the location(s) to which the Institutional DEA Registration Number with Suffix applies and only where such use is authorized by such location(s) through their policies and procedures.

As detailed in Section IV, “Organization Responsibilities,” Part A of this Policy, Residents will be notified of the appropriate Institutional DEA Registration Number(s) with Suffix to use in connection with such Resident’s activities at any Dartmouth Health facility(ies). For the avoidance of doubt, a Resident’s MHMH Institutional DEA Registration Number with Suffix is only authorized to be used at: (i) Dartmouth Hitchcock Medical Center; (ii) Dartmouth Hitchcock Clinics Lyme; (iii) Dartmouth Hitchcock Clinics Heater Road; and (iv) the Dartmouth Hitchcock Cancer Center Nashua, and then only at those locations listed in (i)-(iv) at which such Resident has approval to use the MHMH Institutional DEA Registration Number with Suffix.

Moonlighting: Voluntary, compensated, medically-related work by a Resident that is not part of the required educational program and that is outside the scope of the Resident’s training.

Personal DEA Registration Number: A unique number issued by the DEA to a licensed, eligible practitioner to handle (administer, dispense, or prescribe) controlled substances.

Program Letter of Agreement (PLA): A contract between the Inbound Rotator’s home institution and MHMH.

Resident: Any physician in MHMH’s ACGME-accredited graduate medical education program, including residents and fellows.

Sponsoring Institution: The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of graduate medical education consistent with the ACGME Institutional Requirements.

IV. Policy statement

Summary: As further detailed in this policy, each Resident will be assigned a unique Suffix by the GME Office. Each Dartmouth Health facility at which a Resident trains or through which a Resident rotates has a different Institutional DEA Registration Number or may have no Institutional DEA Registration Number. When a Resident administers, dispenses, or prescribes controlled substances at a Dartmouth Health facility, the Resident must use the applicable facility’s Institutional DEA Registration Number, along with the Resident’s unique Suffix. Institutional DEA Registration Numbers are not interchangeable between Dartmouth Health facilities. If a location through which a Resident rotates does not have an Institutional DEA Registration Number, the Resident is not authorized to prescribe, administer, or dispense controlled substances at such location. Inbound Rotators are not authorized to receive a Suffix from the GME office or to use a Dartmouth Health facility’s Institutional DEA Registration Number and, as such, as not permitted to administer, dispense, or prescribe controlled substances at a Dartmouth Health facility. A Dartmouth Health facility’s Institutional DEA Number shall never be used in the context of Moonlighting or for any of the prohibited uses set forth in this policy.

Resident Responsibilities

  1. Institutional DEA Registration Number with Suffix
    1. Authorized Use
      Residents are authorized to use an Institutional DEA Registration Number with Suffix corresponding to a Dartmouth Health facility when administering, dispensing, or prescribing controlled substances, provided that:
      1. The applicable Residents is authorized to practice and prescribe based on their status as a trainee in MHMH’s ACGME-accredited program; and
      2. The activities are done in the usual course of professional practice, including e-prescribing; and
      3. The applicable Resident has received notice of authorization by the applicable facility or GME Office that they are authorized to administer, dispense, or prescribe under the Institutional DEA Registration Number with Suffix applicable to the particular Dartmouth Health facility.
    2. Prohibited Use
      1. Residents are not authorized to use their Institutional DEA Registration Number with Suffix corresponding to a Dartmouth Health facility when the Resident administers, dispenses, or prescribes controlled substances:
        1. Outside the scope of MHMH’s ACGME-accredited program; and/or
        2. At any facility or institution (whether affiliated with Dartmouth Health or not) other than the one that corresponds to the applicable Institutional DEA Registration Number with Suffix. Residents are required to use the appropriate Institutional DEA Number with Suffix assigned to them for that specific location of practice.
      2. Residents are further prohibited from using the Institutional DEA Registration Number with Suffix to prescribe controlled substances:
        1. In violation of federal or state law or institutional policy;
        2. For the Resident’s own use or for the use of the Resident’s immediate family; and/or
        3. For any individual who is not registered as a patient, even if the Resident has a physician-patient relationship and completes documentation of care in the patient’s medical record.
    3. Training at Non-Dartmouth Health Locations
      Residents who are assigned or authorized to train at any non-Dartmouth Health facility must work with their program coordinator to obtain the receiving non-Dartmouth Health facility’s policy and procedure for use of its own Institutional DEA Registration Number and will only utilize the outside facility- assigned Institutional DEA Registration Number with Suffix, and then only as authorized by such outside facility.
    4. Misuse of DEA Number
      Any misuse of the Institutional DEA Registration Number with Suffix by the Resident will be addressed as prescribed by law (including making any necessary reports to law enforcement or applicable agencies), institutional policy, and ACGME-accredited program procedure, with actions that may include, but are not limited to, loss of authority to use the Institutional DEA Registration Number with Suffix and further disciplinary action including, but not limited to, termination
  2. Personal DEA Registration Number
    1. Residents who have obtained a Personal DEA Registration Number cannot use it when participating in ACGME-accredited program activities.
      1. Exception: Residents in the Addiction Psychiatry Fellowship program who have obtained a Personal DEA Registration Number and waiver identification number (“X” number) to administer, dispense, and prescribe buprenorphine may, with the written approval of the GME Office, use such X number for buprenorphine administration, dispensing, and prescribing during the course of that Fellowship Program.
      Residents who Moonlight must obtain a Personal DEA Registration Number for use when Moonlighting. Under no circumstances shall such Residents use a Dartmouth Health facility Institutional DEA Registration Number or Institutional DEA Registration Number with Suffix while Moonlighting.
  3. Inbound Rotators
    1. Inbound Rotators will not be provided with an Institutional DEA Registration Number with Suffix when rotating to Dartmouth Health facilities, and as such are not authorized to administer, dispense, or prescribe controlled substance medications.

Organization Responsibilities

  1. DHMC GME Office
    1. The Graduate Medical Education (GME) Office is responsible for assigning a numerical code (Suffix) to each Resident for use with applicable Dartmouth Health facility Institutional DEA Registration Numbers as part of the Resident onboarding process. The Suffix:
      1. Will be transmitted along with corresponding Resident name from the GME Office to System Pharmacy during Resident onboarding;
      2. Will be documented in the Residency Management System by the GME Office of designee;
      3. Is valid for the duration of the ACGME-accredited program when used in connection with the Institutional DEA Registration Number of the specific location at which the Resident is training or rotating. The authority to use the applicable Institutional DEA Registration Number with Suffix ceases immediately upon the earlier of graduation or termination from the program.
        1. Residents who Moonlight may not use a Dartmouth Health facility’s Institutional Registration Number when Moonlighting.
    2. The Suffix assigned to each Resident:
      1. Will be transmitted by the GME Office or designee along with the corresponding Resident name to the designated individual at each Dartmouth Health facility that has an Institutional DEA Registration Number and within which the Resident will train or complete a rotation; and
      2. Will be used by the applicable Resident, in connection with the applicable facility’s Institutional DEA Registration Number, at each Dartmouth Health facility at which the Resident is authorized to prescribe, administer, or dispense controlled substances.
  2. Dartmouth Health Facilities Other than MHMH
    Any Dartmouth Health facility within which a Resident completes an external (e.g., nonMHMH) rotation and which has its own Institutional DEA Registration Number shall:
    1. Verify that the Resident is permitted to administer, dispense, or prescribe drugs within the jurisdiction in which the practice is located;
    2. Authorize the Resident to administer, dispense, or prescribe under the applicable Institutional DEA Registration Number, adding the Suffix, assigned and transmitted by the GME Office or designee; and
    3. Keep a current list of Institutional DEA Registration Numbers with Suffix and corresponding Resident names that is made available at all times to the System Pharmacy, DEA registrants and law enforcement agencies upon request for the purpose of verifying the authority of the prescribing Resident.
    4. Provide the current Institutional DEA Registration Number with Suffix to the GME office or designee for inclusion in the Residency Management System.
  3. Other Facilities
    Any facility not affiliated with Dartmouth Health at which a Resident rotates will follow its own process to assign each Resident an Institutional DEA Registration Number with Suffix for use when administering, dispensing, or prescribing controlled substances during their rotation. Under no circumstances shall MHMH Residents use a Dartmouth Health facility Institutional DEA Registration Number or Institutional DEA Registration Number with Suffix at any external facilities.

    The receiving institution will transmit the Institutional DEA Registration Number with Suffix for each Resident to the Resident’s program coordinator or to the GME Office as a part of the onboarding and Program Letter of Agreement process for inclusion in the Residency Management System.

    Should the facility be unable to obtain an Institutional DEA Registration Number, the rotation site director or program administrator will communicate with the GME Office and Sponsoring Institution training program’s program director or program coordinator as to the same so that together than can solve the issue.

References

U.S. Code of Federal Regulations, Title 21, Chapter II, Part 1301, §1301.22

U.S. Code of Federal Regulations, Title 21, Chapter II, Part 1301, §1301.28


D-H Policy ID: 27365