Purpose Statement

The Custody Exchange feature allows paramedics and EMS personnel to formally transfer possession and responsibility of controlled substance (CS) kits between users during shift changes. This feature ensures DEA compliance by maintaining a complete chain of custody audit trail, preventing unauthorized access to medications, and documenting secure possession transfers with dual-signature authentication. By restricting medication events to only the user who currently possesses the kit, this system prevents accidental medication entries and enhances accountability for all controlled substance handling.

Background Information

Chain of custody documentation is a critical requirement for controlled substance management in EMS operations. The Custody Exchange feature extends First Due's existing medication counting functionality to include formal custody transfer workflows that meet regulatory compliance standards.

Key Concepts:

• Exclusive Possession Access: Only the user who currently possesses a CS kit can access its medication events (usage, transfer, remove, receive, count, or exchange)
• Dual-Signature Authentication: Both the transferring and receiving personnel must authenticate the custody exchange
• Automatic Possession Transfer: Upon completion of the exchange, the system immediately transfers kit access from the off-going to oncoming user
• Override Custody: Supervisors and administrators can take possession of kits when the current possessor is unavailable due to emergency, illness, or administrative needs
• Location Tracking: The system maintains current kit location and displays possession status in a prominent white banner

Common Use Cases:

• Standard shift change handoffs between different paramedics
• Unit reassignments requiring CS kit transfers between different personnel
• Scheduled custody exchanges per agency accountability periods
• Emergency personnel rotations
• Supervisor intervention when an employee leaves unexpectedly
• Administrative custody transfers for operational needs
• Holdover and overtime documentation when the same person retains the kit
• Shift trades where the same person continues with the kit

Prerequisites:

• Both users must be authorized for controlled substance handling in First Due
• The off-going user must have current active assignment to the CS kit (for standard exchanges)
• The CS kit must be configured for custody exchange tracking
• Supervisors/administrators must have Override Custody permissions (for override scenarios)

Required Permissions

To complete a custody exchange for controlled substances kits, users need the following permissions:

Required for Both Transferring and Receiving Users (Standard Exchange):

• Medications - Access: Ability to access the Medications module
• Medications - Count Medications: Permission to perform inventory counts
• Medications - Custody Exchange: Authorization to participate in custody transfer events
• Controlled Substance Handler Authorization: User must be designated as authorized to handle controlled substances

Required for Supervisors/Administrators (Override Custody):

• Medications - Access: Ability to access the Medications module
• Medications - Count Medications: Permission to perform inventory counts
• Medications - Override Custody: Special permission to take possession of kits without the current possessor present
• Controlled Substance Handler Authorization: User must be designated as authorized to handle controlled substances

Note: System administrators should verify that all personnel who handle CS kits have these permissions configured in their user profiles under the Medications module permissions section. Override Custody permissions should be granted only to supervisors and administrators who have the authority to intervene in chain of custody situations.

Video

Step-by-Step Guide

Step 1: Determine the Type of Custody Exchange Needed

Before beginning the custody exchange process, determine which type of custody documentation is required based on the operational situation.

Two Types of Custody Events:

Retain Custody:

• Use when the current possessor will continue holding the kit (no transfer of possession occurs)
• Common situations:
  • Employee is holding over to work overtime
  • Employee is working a shift trade and keeping the same kit
  • Employee continues custody during extended shift operations
  • Documentation of continued possession for compliance tracking
    

Custody Exchange:

• Use when transferring possession from one person to another
• Common situations:
  • Standard shift change between different personnel
  • Unit reassignment requiring kit transfer
  • Supervisor override when current possessor is unavailable

Decision Point:

• If retaining custody (same person keeps the kit): Proceed to Step 1A: Retain Custody
• If transferring custody (new person receives the kit): Proceed to Step 1B: Initiate the Custody Exchange

Step 1A: Retain Custody (Current Possessor)

Use this procedure when you will continue to possess the controlled substance kit but need to document retention for compliance tracking.

Actions:

1. Open the First Due Medications module
   
2. Select Med Kits from the Medications module menu
   
3. Find the CS kit you currently possess
   

1. Authenticate your identity in the system using your credentials
2. Select "Custody Exchange" from the medication event options

1. The custody exchange confirmation modal appears with two options:
   • "Retain Custody" - Select this to continue possession
   • "Custody Exchange" - Do not select this option
2. Select "Retain Custody"

1. The Retain Custody modal will display
2. Select a reason for retention from the dropdown menu:
• Operational - Operational needs requiring continued custody
• Shift / Staffing - Holdover for overtime, shift trade, or staffing coverage
• Administrative - Administrative decisions requiring retention
• Emergency / Contingency - Emergency situations requiring continued possession
• Other - Any other reason for custody retention
  
3. Add any relevant comments in the Comments field (optional but recommended)

1. Enter your password and input your signature
2. Select "Retain Custody" to confirm
   

System Actions:

• The retention event is officially recorded with timestamp, reason, and location
• You remain the current possessor with continued exclusive access
• The retention is logged in the audit trail for compliance documentation
• A count is NOT performed during retention (unlike custody exchange)

Best Practice: Use the Comments field to document specific details such as "Working 12-hour holdover for staffing shortage" or "Shift trade with Station 2 - continuing 24-hour shift."

Note: Retain Custody does not perform a count. The system simply documents that you are continuing in possession of the kit for compliance tracking purposes.

Step 1B: Initiate the Custody Exchange

Upon reporting for duty, the oncoming Paramedic meets with the off-going Paramedic who currently possesses the controlled substance kit.

Actions:

1. The oncoming Paramedic opens the First Due Medications module
   
2. Navigate to the Med Kits and find the CS kit that needs to be transferred

1. Select "Custody Exchange" from the medication event options
2. The custody exchange confirmation modal appears with two options:
   • "Retain Custody" - Do not select this option
   • "Custody Exchange" - Select this to transfer possession
3. Select "Custody Exchange" to proceed

1. Verify the physical seal is intact and the seal number listed matches what is in the system
   
2. Enter the seal number into the text box and select the "Plus" sign 
3. If the seal number doesn't match, the system will prompt the possessor to Break and Count
   
1. If the seal numbers do not match the kit possessor can Report an Occurrence
   

1. To report an occurrence, select the appropriate user to elevate the occurrence to within your organization
   
2. Add in any comments about the occurrence found
   
3. Select Send to create the occurrence in the system and notify the selected Administrator

1. If the seal number matches, the system will give the option to Sign over possession or Break and Count
   
2. Continue to Step 2 for completing a count, or Step 3 to complete the dual signature transfer process

Note: If the off-going Paramedic is not available, see Step 1C: Override Custody (Supervisor/Administrator Only) below.

Step 1C: Override Custody (Supervisor/Administrator Only)

Use this procedure when the current kit possessor is unavailable due to emergency, illness/injury, or other administrative reasons.

When to Use Override Custody:

• Employee leaves mid-shift due to medical emergency or personal emergency
• Employee becomes ill or injured and cannot complete their shift
• Unexpected personnel changes requiring immediate custody transfer
• Administrative reassignments where dual-signature is not possible
• Operational needs requiring supervisor intervention

Actions:

1. The Supervisor or Administrator opens the First Due Medications module
2. Navigate to the Med Kits and find the CS kit that needs custody transfer

1. Select "Custody Exchange" from the medication event options
2. When the custody exchange confirmation modal appears, select "Override Custody"
3. The Override Custody modal will display

1. Select a reason for the override from the dropdown menu:
   • Medical / Emergency - Employee medical emergency or personal emergency requiring immediate departure
   • Operational / Duty - Operational needs, unit reassignment, or duty-related changes
   • Administrative - Administrative decisions, disciplinary actions, or policy-driven changes
   • Other - Any other reason requiring supervisor custody intervention
2. The system documents your override reason and proceeds to the count function (continue to Step 2)

Important Custody Transfer Notes:

• The override creates a complete audit trail documenting who took custody, when, and why
• You (the supervisor/administrator) will become the current possessor after completing the count and signing
• The previous possessor will immediately lose access to the kit
• You can then transfer custody to an oncoming employee once the shift vacancy is filled by completing a standard custody exchange (Steps 1-4)

Best Practice: Document the circumstances of the override in your agency's incident log or supervisor notes to maintain complete operational records alongside the system's audit trail.

Step 2: Perform the Inventory Count

The Custody Exchange automatically includes a medication count to verify kit contents before transfer.

Actions:

1. The standard "Count" function appears automatically upon initiating the exchange
2. Perform a complete physical inventory of all controlled substance kit contents
3. Enter the count for each medication item in the kit
4. Verify that all contents match the expected inventory quantities
   
1. Failing any CS medication will prompt the user to create an Occurrence for the agency Administrator
5. Document any discrepancies or issues discovered during the count
   
1. NOTE - The Add Action is not available for use during a custody exchange
   
6. After entering all count data, select Sign and Finish
   
1. The Save as Draft feature will save the progress if both users cannot sign at that moment
   
2. Note - both users must be present to submit any change of custody

Best Practice:

• Standard Exchange: Both the oncoming and off-going personnel should physically verify the count together to ensure accuracy and agreement before proceeding
• Override Custody: The supervisor/administrator should perform the count with another authorized witness when possible to verify accuracy
  

Step 3: Complete the Dual-Signature Authentication

Upon completing the inventory verification, both parties must authenticate the custody transfer.

Standard Exchange Actions:

1. The signature authentication modal will display requiring two authorized signatures
2. The system clearly identifies two signature fields:
   • "Receiving Provider" (second signature position) - This will be the oncoming Paramedic who will become the new assigned user
   • "Transferring Provider" (first signature position) - This is the off-going Paramedic who currently has kit assignment
3. The Transferring Provider (off-going Paramedic) inputs their system password and signs first
4. The Receiving Provider (oncoming Paramedic) inputs their system password and signs second
5. The system validates that both users are authorized for controlled substance handling

Override Custody Actions:

1. After entering all count data, select either "Sign" or "Seal and Sign" to proceed
2. A signature authentication modal will display requiring your signature only
3. The Supervisor/Administrator signs to take possession of the kit
4. The system validates you are authorized for controlled substance handling and have Override Custody permissions
5. The system documents the override event with reason, timestamp, and your identity

Important:

• Standard exchanges require both signatures to complete the transfer
• Override custody requires only the supervisor/administrator signature to take possession
• All override events are logged in the audit trail for compliance review

Step 4: Confirm Possession Transfer

After signatures are authenticated, the system completes the custody transfer.

System Actions:

1. The custody exchange is officially recorded with timestamp and location
2. Kit possession automatically transfers to the new possessor (oncoming Paramedic or Supervisor/Administrator)
3. The controlled substance kit status updates in the interface
4. A white banner displays "Current Possession" followed by the new possessor's name and current kit location
5. Previous possession is logged with complete transfer details
6. The previous possessor immediately loses access to the kit and all its medication events
7. The new possessor gains exclusive access to all kit medication events

Verification:

• Confirm that the white banner shows your name as the current possessor
• Verify the kit location is correct
• Ensure you can now access medication event options for the kit
• The previous possessor should verify they no longer see medication event options for this kit

For Supervisors After Override: Once you have taken possession via override custody, you can transfer the kit to an oncoming employee by completing a standard custody exchange (repeat Steps 1-4) when the shift vacancy is filled.

Best Practices

Do:

• Determine the correct custody event type (Retain vs Exchange) before starting
• Use "Retain Custody" when working overtime, holdovers, or shift trades where you keep the kit
• Use "Custody Exchange" when transferring possession to a different person
• Complete custody exchanges at the beginning of each shift as part of your standard checkout procedure
• Perform the physical count together with both personnel present whenever possible
• Verify all signatures are captured correctly before finalizing
• Document the exact location where the exchange takes place
• Review the possession banner immediately after transfer to confirm accuracy
• Complete exchanges promptly to avoid gaps in custody documentation
• Use Override Custody only when the current possessor is truly unavailable
• Document override situations in both the system and agency incident logs
• Transfer custody from supervisor to oncoming employee as soon as the vacancy is filled

Don't:

• Attempt to access medication events for kits not in your possession - the system will prevent this
• Rush through the inventory count process
• Skip verification of the possession banner after transfer
• Leave custody exchanges incomplete or pending
• Transfer custody without both parties physically present (unless using Override Custody)
• Delay exchanges beyond your agency's configured accountability periods
• Use Override Custody for routine shift changes when both parties are available
• Forget to complete the second custody exchange when supervisors transfer to oncoming personnel

Tips:

• Understand the difference between Retain Custody (no transfer, no count) and Custody Exchange (transfer with count)
• Always document holdover and overtime situations using Retain Custody for compliance tracking
• Use the Comments field in Retain Custody to provide context for audit purposes
• Schedule custody exchanges to align with shift change times
• Use the location field to document the specific apparatus, station, or area where the exchange occurred
• If discrepancies are found during the count, resolve them before completing the custody exchange
• Familiarize yourself with your agency's specific custody exchange requirements and timeframes
• Ensure supervisors understand when Override Custody is appropriate versus waiting for the current possessor
• Train all personnel on both standard and override custody procedures

Troubleshooting & FAQs

Q: When should I use "Retain Custody" versus "Custody Exchange"?

A: Use Retain Custody when:

• You're holding over to work overtime
• You're working a shift trade and keeping the same kit
• You need to document continued possession for compliance
• You're staying on duty but the shift is changing around you

Use Custody Exchange when:

• You're transferring the kit to a different person
• A new person is taking over possession
• Standard shift change with different personnel

Q: Does "Retain Custody" perform a medication count?

A: No. Retain Custody only documents that you are continuing in possession of the kit. It does NOT perform a count. If you need to perform a count while retaining custody, use the standard "Count" function separately from the Retain Custody event.

Q: I'm working overtime - do I need to do anything with custody?

A: Yes, for compliance tracking purposes, you should document your continued possession by using the "Retain Custody" option. Select "Shift / Staffing" as the reason and add a comment explaining the holdover situation (e.g., "12-hour holdover for staffing coverage").

Q: I can't see the medication events for a CS kit I need to use. What's wrong?

A: You likely don't have current possession of that kit. Only the user who currently possesses a CS kit can access its medication events. You must complete a custody exchange with the current possessor to gain access, or contact your supervisor to use Override Custody if the current possessor is unavailable.

Q: What happens if we discover a medication discrepancy during the custody exchange count?

A: Document the discrepancy in the count as you normally would. Address the issue according to your agency's controlled substance variance protocol before finalizing the custody exchange. Both parties should agree on the documented count before signing.

Q: Can I complete a custody exchange if the off-going user is not physically present?

A: No, not for a standard custody exchange. However, if the off-going user is unavailable due to emergency, illness, or administrative reasons, a supervisor or administrator with Override Custody permissions can take possession of the kit. The supervisor then completes a standard custody exchange with an oncoming employee once the vacancy is filled.

Q: When should I use Override Custody versus waiting for the current possessor?

A: Use Override Custody when:

• The current possessor leaves unexpectedly due to medical or personal emergency
• An employee becomes ill or injured mid-shift
• Operational needs require immediate custody transfer
• Administrative decisions require supervisor intervention
• The current possessor is unavailable and the kit needs to be deployed

Do NOT use Override Custody for routine shift changes when both parties are available.

Q: What happens to the audit trail when Override Custody is used?

A: The system creates a complete audit trail including:

• Who initiated the override (supervisor/administrator name)
• Date and timestamp of the override
• Reason selected for the override
• Complete count documentation
• Previous possessor information
• New possessor information
• Location of the override event

This ensures full DEA compliance and accountability even when standard dual-signature is not possible.

Q: After I take custody via override, how do I transfer it to the oncoming employee?

A: Once you have possession as a supervisor/administrator, simply complete a standard custody exchange (Steps 1-4) with the oncoming employee. They will select "Custody Exchange," perform the count together, and both parties will sign. This transfers possession from you to the oncoming employee.

Q: The system won't let me initiate a custody exchange. What should I check?

A: Verify the following:

• You have the required permissions (Medications - Custody Exchange, or Medications - Override Custody for supervisors)
• You are authorized as a controlled substance handler
• The off-going user still has active assignment to the kit (for standard exchanges)
• The kit is configured for custody exchange tracking
• You are authenticated in the system with your credentials

Q: What if I need to access a kit for an emergency but don't have possession and I'm not a supervisor?

A: Contact your supervisor immediately. They can use Override Custody to take possession and then transfer it to you. Never attempt to bypass the possession controls without proper authorization.

Q: How long does a custody exchange take to process?

A: The exchange is completed in real-time. Once signatures are authenticated, possession transfers immediately. The previous user loses access and the new possessor gains access within seconds.

Q: Will I receive notifications about required custody exchanges?

A: Yes. The system generates compliance notifications for:

• Missed or overdue custody exchanges based on your agency's configured timeframes
• Upcoming required exchanges based on accountability periods
• Possession irregularities or gaps in custody

Q: Can I see the history of who has possessed a kit, including override events?

A: Yes. The possession history is maintained in the medication logs and chain of custody reports. System administrators can access detailed custody transfer documentation including timestamps, locations, all transfer participants, and any override events with documented reasons.

Additional Sections

Related Medication Events

The Custody Exchange integrates with other medication events in First Due:

• Count Medications: The custody exchange automatically includes a count function
• Usage Events: Only available to the user with current possession
• Transfer Events: Can only be initiated by the current kit possessor
• Remove/Receive Events: Restricted to users with active kit possession

Override Custody Scenarios

Common Override Situations:

1. Medical Emergency: Employee experiences medical emergency requiring immediate hospital transport
2. Family Emergency: Employee receives notification of family emergency and must leave immediately
3. Illness/Injury: Employee becomes ill or injured during shift and cannot continue duties
4. Disciplinary Action: Administrative decision requires immediate removal of employee from duties
5. Operational Reassignment: Command staff decision requires immediate kit redeployment
6. Equipment Failure: Vehicle or equipment failure requires kit transfer to operational unit

Override Best Practices:

• Always document the circumstances in agency logs in addition to the system audit trail
• Use the most specific override reason available from the dropdown menu
• Complete the count thoroughly even when the previous possessor is absent
• Transfer custody to an oncoming employee as soon as operationally feasible
• Brief the oncoming employee on any circumstances related to the override
• Review override events regularly for pattern identification and policy compliance

Compliance & Security Features

Audit Trail Components:

• Complete timestamp documentation for all exchanges
• Dual-signature authentication records for standard exchanges
• Single-signature with override reason documentation for supervisor custody transfers
• Location tracking for each custody transfer
• Possession history with user identification
• Access attempt logging for security monitoring
• Override justification tracking for compliance review

DEA Compliance: The Custody Exchange feature supports DEA requirements for controlled substance accountability by:

• Maintaining unbroken chain of custody documentation
• Preventing unauthorized access to controlled substances
• Creating comprehensive audit trails for regulatory review
• Enforcing exclusive possession-based access controls
• Documenting emergency custody transfers with administrative oversight
• Providing complete override event tracking with justification

Reporting & Analytics

Available Reports:

• Enhanced Med Logs: Include all custody exchange events (standard and override) with possession history and location tracking
• Chain of Custody Reports: Detailed custody transfer documentation for regulatory compliance, including override events
• Security Audit Reports: Possession history, location changes, access patterns, compliance metrics, and override frequency analysis
• Override Custody Report: Dedicated report showing all override events, reasons, supervisors involved, and resolution status

System administrators can generate these reports to monitor custody exchange compliance, identify patterns, track override usage, and support regulatory audits.