Texas State Auditor's Office - Summary of Report 25-004

A Performance Audit

An Audit Report on Controlled Substances Management at The University of Texas at Tyler

October 2024

Overview

Background

Audit Objective

The University of Texas at Tyler Health Science Center’s (UT Tyler HSC) Inpatient and Outpatient Pharmacies had adequate processes to ensure that controlled substances were properly tracked and secured from ordering through dispensing and, as applicable, disposal. They also implemented safeguards to appropriately limit access to controlled substances.

In addition, UT Tyler HSC ensured that the annual inventory of controlled substances was conducted as required; however, it should strengthen its monitoring over the weekly inventories.

LOW

ORDERING, ADMINISTERING, AND DISPENSING CONTROLLED SUBSTANCES

UT Tyler HSC had effective processes to track the receipt, administration, and dispensing of controlled substances.

Jump to Chapter 1

MEDIUM

INVENTORY COUNTS

UT Tyler HSC’s pharmacies conducted the required annual inventory. However, required weekly inventories were not consistently conducted.

Jump to Chapter 2

LOW

DRUG DISPOSAL AND RETURNS

UT Tyler HSC established processes to help ensure that the risk of drug loss or diversion is minimized during the drug disposal and return processes.

Jump to Chapter 3

LOW

SECURITY AND ACCESS CONTROLS

UT Tyler HSC implemented physical and user access controls to safeguard and prevent diversion of its controlled substances.

Jump to Chapter 4

Internal Audit

Audit Services

Manuals & Guides

Tools

Forms