Audit finds access, inventory and disposal gaps for controlled substances in Garland Fire Department; chiefs commit to controls and follow‑up

An internal audit presented Sept. 30 found that the Garland Fire Department needs tighter controls and clearer procedures for storage, access, inventory, disposal and documentation of controlled substances used in emergency medical services.

Auditors said controlled substances are held in a bolted safe at the administration inventory room and in med‑vaults inside each of the department’s 11 ambulances. The department’s in‑house inventory system and a separate patient care system record usage and transfers; auditors compared user lists and system activity across those platforms and flagged several issues with access rights and usage logging.

The audit found 245 employees had PIN access to ambulance med‑vaults; auditors found instances in which PINs assigned to terminated or retired personnel were used to open med‑vaults, and cases where one paramedic used another paramedic’s PIN. The med‑vault opening/closing report showed prolonged open durations in some cases — 125 instances where a vault was left open for more than one hour, and a sample of 59 such events produced 43 instances without adequate documentation to justify the extended openings. Auditors recommended reviewing and reducing access lists, strengthening PIN complexity (the vendor allows up to eight digits), resetting PINs and creating onboarding/offboarding checklists; department leaders agreed and set target dates beginning November 2025 for access review and February 2026 for PIN resets.

Inventory and reconciliation issues also emerged. Auditors compared patient-care system records with the inventory ledger and identified macro‑level volume differences for several controlled substances (reported in the audit as specific microgram/milligram deltas for the period reviewed). They found incidents recorded in the patient-care system with no corresponding inventory-system entry, and vice versa. The auditors reported only 263 recorded morning inventory counts over the audit scope where roughly 6,000 would have been expected (11 ambulances times daily counts), reflecting either missing documentation or failure to enter counts into the system. Auditors recommended evaluating system modules or other options to reduce duplicate manual entries and to develop formal reconciliation policies; management concurred and will pursue system changes and documented procedures through 2026.

Disposal and destruction of controlled substances raised policy questions. The audit reported varied disposal practices observed or described by paramedics, including placing unused contents in biohazard containers, sinks or other ad hoc methods. Auditors noted the DEA requires wastage and destruction to render substances “non‑retrievable,” and found expired vials that had not been returned for destruction; the most recent documented destruction in the records was January 2022. The department agreed to evaluate DEA‑compliant disposal best practices and consider commercially available products that render controlled substances non‑retrievable; management set target completion for initial evaluation and return of expired vials beginning November 2025 and into early 2026.

The audit also reviewed policy, segregation of duties and camera access. It found large numbers of employees with access to the inventory room and a long list of camera‑system operators (some listed were retired personnel or otherwise not clearly justified). Auditors recommended narrowing access to a business‑necessity list, performing periodic reviews of access rights, and exploring safe configurations that support electronic logging. Management concurred and identified January–March 2026 target dates for several items, with some earlier corrections already made for expired vials and access rights during the audit.

Fire Chief Mark Lee responded to the audit by acknowledging the department’s progress since prior reviews, noting the department has developed an in‑house tracking system and that leadership will explore commercial narcotics‑tracking modules to improve electronic reporting. Chief Lee said he will work with vendors on PIN length and system configurations and welcomed a follow‑up review; he also said the department will engage wastewater or product‑neutralizing options before adopting any single disposal method to satisfy both EPA and FDA guidance concerns.

Ending: Audit staff and department leaders agreed to follow up. Committee members requested management updates in approximately six months to review progress on access lists, reconciliation procedures and disposal policies.