Go back to the Greeley Insights Blog >

Question: Can you go into more detail about what the regulations require for medication storage. In our facility, pharmacy insists that any and all medications be locked unless under 24/7 observation. This focus has even included pharmacy provided baby formula, eye drops, and other miscellaneous items kept at ambulatory settings that are supplied through the pharmacy.

Medication SecurityOn December 6, 2018 The Greeley Company held its annual “Survey Hot Spots” national webinar. Feel free to view our free “Hot Spots” webinar in case you missed the live session.

Among the questions raised during the webinar was a question about securing eyedrops and infant formula in an ambulatory care clinic.

Return to Hot Spots Q and A post. 


Question: Can you go into more detail about what the regulations require for medication storage. In our facility, pharmacy insists that any and all medications be locked unless under 24/7 observation. This focus has even included pharmacy provided baby formula, eye drops, and other miscellaneous items kept at ambulatory settings that are supplied through the pharmacy.

  • Answer: This is a commonly misunderstood and controversial topic.

Our upcoming series on “Common Medication Management Challenges” will go into detail about medication security, including an analysis of CMS, Joint Commission, DEA and selected state requirements. Materials provided during the session will include a fully-compliant model medication storage/security policy.

Briefly: controlled medications (e.g. narcotics) must be in a locked location. Other medications (e.g. eye drops) must be “secure,” meaning that unsupervised access by unauthorized individuals must be prohibited. However, housekeeping, security and other individuals (whether employed or contracted) can be authorized to be in the unsupervised presence of non-controlled medications. This is very clear in the regulation.

So, unless your ambulatory care setting allows strangers to wander through its hallways during off hours, there would no regulatory reason to take additional security measures (e.g. locking the eye drops away) as long as you have standard security measures in place for the clinic during off hours (e.g. locks on the doors to the clinic) and you “authorize” housekeepers and other employees/contractors to have unsupervised access to non-controlled medications.

PS: There may be valid non-regulatory reasons to secure some of these things at night. It is very understandable that pharmacy will want to limit “shrinkage” of the items it supplies. This makes perfect economic and DEA-responsibility-of-the-pharmacist sense. However, the regulations leave this determination up to the institution.

PPS: Straight infant formula is classified by the FDA as a food, not a medication. So the medication security standard would not apply.

PPPS: We strongly recommend a risk assessment related to medication security (see our response to the contracting query and restraint orders). It would be very handy to have in one’s hip pocket at the time of survey. (We will, of course, provide a model risk assessment for medication storage during our medication management educational session.)


The Greeley Company team looks forward to helping you solve these difficult problems in the months and years to come. For more information about how Greeley can help accelerate solving your challenges with practical solutions, you may contact us at 1.888.749.3054, email us at info@greeley.com or complete the form below to start the conversation.

Let’s start the conversation.

Copyright © 2019 The Greeley Company

Log in with your credentials

Forgot your details?