Chapter 1 – Health Care Governance and Administration

Policy

• California Correctional Health Care Services (CCHCS) shall provide all newly appointed civil service pharmacy staff including Pharmacy Services Manager, Pharmacist II, Pharmacist I, and pharmacy technicians who provide clinical and/or support services in California Department of Corrections and Rehabilitation (CDCR) institutions with relevant and job-specific orientation and training (New Pharmacy Staff Onboarding) during the probationary period. This policy shall not be construed as altering existing laws and regulations governing civil service probationary periods or the provisions of any applicable bargaining unit contract.

Purpose

• To establish a comprehensive and standardized onboarding process for new civil service pharmacy staff that:

• Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new pharmacy staff.

• Supports newly appointed pharmacy staff with relevant orientation and training by experienced subject matter experts during the probationary period.

• Facilitates adherence to applicable scopes of practice, standards of practice, applicable clinical guidelines, and CDCR/CCHCS standards.

• Promotes job satisfaction while enhancing pharmacy staff effectiveness and efficiency.

Responsibility

• The Statewide Chief of Pharmacy Services is responsible for:

  • Statewide planning, implementation, and evaluation of this policy and procedure.

  • Supervising the completion of the onboarding requirements for the Central Pharmacy Services Managers.

• The Chief Executive Officer (CEO) and the institution Pharmacist-in-Charge (PIC) are responsible for the local implementation of this policy and procedure.

• The Central Pharmacy Services Managers and Pharmacist IIs are responsible for supervising the completion of the onboarding requirements for all other Central Pharmacy Services staff.

• Regional Pharmacy Services Managers are responsible for the implementation of this policy and procedure at the subset of institutions within an assigned region.

• New civil service pharmacy staff are responsible for completing all standardized onboarding requirements including working with their supervisor to ensure their understanding in meeting the requirements.

Procedure

• Orientation and On-the-Job Support during the Probationary Period

  • The direct supervisor and appropriate subject matter experts shall use the Pharmacy Staff Onboarding and Competency Checklist, located on the Pharmacy Services Lifeline page under the Forms & Medication Lists tab, to ensure each newly hired employee completes, at a minimum, 12 weeks of formal orientation and training (hereinafter referred to as “onboarding”).

    • The pharmacy staff onboarding shall include, at a minimum, the following:

      • Initial introduction to the institution or work location including:

        • Human Resources and Information Technology departments.

        • Overview of the institution’s or work location’s missions and physical layout.

        • Overview of the new employee’s work space.

        • Issuance of the new employee’s identification card and other essential work items.

      • Institution-based or work-location-based onboarding covering the designated topics specified in the Pharmacy Staff Onboarding and Competency Checklist.

      • Electronic Health Record System (EHRS) training and competency validation including completion of CCHCS Learning Management System (LMS) EHRS Modules consistent with the employee’s duty statement.

      • Orientation and mentoring by pharmacy staff performing specific tasks identified in the Pharmacy Staff Onboarding and Competency Checklist.

    • Staff beginning independent work shall have access to pharmacy staff familiar with their job duties for questions and assistance.

    • Upon completion of onboarding, the direct supervisor shall ensure completion of the Pharmacy Staff Onboarding and Competency Checklist and shall review, sign, and maintain the completed forms in the employee’s supervisory file (proof of practice file).  If the new pharmacy staff member is delayed due to unforeseen circumstances in completing the Pharmacy Staff Onboarding and Competency Checklist, the direct supervisor may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 12th week.

    • Any job-required and job-related training that is not listed in the Pharmacy Onboarding and Competency Checklist nor recorded in the CCHCS LMS shall be recorded on a CDCR 844, Training Participation Sign-In Sheet and be filed in the employee’s supervisory file.

• Re-Orientation of Pharmacy Staff (Re-Entry Training)

  • For staff who are out (e.g., long-term sick):

    • If staff have been out for less than one year, the following is required:

      • The supervisor shall review documentation of previous completion of the Pharmacy Staff Onboarding and Competency Checklist.

        • If no documentation of previous completion of the Pharmacy Staff Onboarding and Competency Checklist, then the supervisor and staff member shall work together to complete any portion of onboarding they did not previously complete within 12 weeks of re-entry.

      • Staff shall review all classes, updates, and mandatory training missed.

      • Skills competency validations shall be completed for the areas in which staff will be working.

    • Staff who are out more than one year shall complete the onboarding process in its entirety upon return.

• Transferring Between Institutions Without a Break in Service or Performing Duties at More Than One Institution

  • The direct supervisor is responsible to ensure that all pharmacy staff working at that institution are competent to perform all the duties of the position for which the pharmacy employee has been hired.

  • The direct supervisor may develop an abbreviated Pharmacy Staff Onboarding and Competency Checklist for pharmacy staff who have already completed onboarding at another institution, taking into account the staff member’s clinical competency and professional performance at any other CDCR location.

  • Proof of completion of the onboarding process, clinical competencies, and professional performance shall be maintained at each CDCR location.  This does not absolve the direct supervisor at each CDCR location from ensuring that annual performance evaluations are conducted or that pharmacy staff are competent to perform the duties required in their position.

Procedure Overview

• California Correctional Health Care Services (CCHCS) Pharmacy Services shall provide medically necessary medications to patients within California Department of Corrections and Rehabilitation (CDCR).

• Pharmacy staff shall perform duties consistent with CCHCS policies and procedures and federal and state laws and regulations.  All aspects of pharmacy services shall comply with federal and state requirements.

• Pharmacy Services shall provide medication information for patients and health care staff.

• Each institution shall have a Medication Management Subcommittee to provide professional, multidisciplinary oversight of the clinical aspects of pharmacy services and to implement policies and procedures as well as other therapeutic initiatives approved by the CCHCS Systemwide Pharmacy and Therapeutics (P&T) Committee.

Purpose

• To define the scope of services, supervision, and clinical oversight of pharmacy services, to ensure access to medication information for patients and health care staff, and to ensure that pharmacy services comply with federal and state requirements governing pharmacy practice and applicable standards of care.

Procedure

• Scope of Pharmacy Services

  • Pharmacies operating within CDCR institutions provide services to:

    • Patients who are housed within the institution.

    • Patients transferring to another institution or upon release.

    • Patients in community correctional facilities or camps for which the institution is the hub facility.

    • Licensed correctional clinics (LCCs).

  • Pharmacies shall:

    • Manage the automated drug delivery system (ADDS) licensure and pharmaceutical inventory.

    • Procure, compound (if applicable), dispense, distribute, furnish,  and store pharmaceuticals pursuant to federal and state requirements and applicable standards of care.

    • Manage medication reverse distribution and disposal of pharmaceutical waste generated by pharmacy staff.

    • Provide cost-effective pharmacotherapy management, medication information, and surveillance programs as appropriate.

    • Promote evidence-based use of medications.

  • A pharmacist on the premises  shall be directly responsible for ensuring that all activities of ancillary staff are performed completely, safely, and without risk of harm to patients at all times. Ancillary staff may perform their duties as outlined in Sections (c)(4) and (c)(5) during the temporary absence of a pharmacist; however, a pharmacist must check all completed work before it leaves the pharmacy.

• Pharmacy Services

  • Pharmacy services include, but are not limited to, the following:

  • Procuring, compounding (if applicable), dispensing, distributing, furnishing, and storing of pharmaceuticals pursuant to federal and state requirements and applicable standards of practice.

  • Conducting routine inspections of all medication storage areas.

  • Overseeing all medication storage areas for the Department of Public Health licensed facilities in collaboration with Nursing Services.

  • Consulting with the institution’s Chief Executive Officer (CEO), nursing staff, and other health care staff as applicable to ensure compliance with LCC medication management policies and procedures and federal and state requirements.

  • Establishing and maintaining appropriate pharmaceutical inventory to meet patient and clinic needs.

  • Maintaining pharmacy records pursuant to federal and state requirements.

  • Obtaining and maintaining pharmacy-related registrations and licensure.

  • Furnishing medication information to:

    • Medical, dental, mental health, and nursing staff as applicable.

    • Patients pursuant to federal and state requirements and upon request by the patient.

  • Implementing the Systemwide P&T Committee and institution Medication Management Subcommittee decisions in collaboration with the CEO and health care leadership.

  • Maintaining a system for after-hours availability of medications.

  • Managing pharmaceutical reverse distribution.

  • Managing disposal of pharmaceutical waste generated by pharmacy staff.

• Supervision

  • A Pharmacist-in-Charge (PIC) shall:

    • Be a licensed pharmacist in the State of California.

    • Have completed the California Board of Pharmacy (BOP)-provided Pharmacist-in-Charge Overview and Responsibility training course as described in the Health Care Department Operations Manual (HCDOM), Section 3.5.2, Pharmacy Licensing Requirements.

    • Ensure that any person employed as a pharmacist or pharmacy technician possesses a valid license that is in good standing at all times and issued by the California State Board of Pharmacy.

    • Oversee all functions of the pharmacy staff at the institution to ensure compliance with applicable policies and procedures and federal and state laws.

    • Serve as the consultant pharmacist for each of the correctional clinic licenses for that institution to ensure implementation of the policies and procedures developed and approved by the Systemwide Pharmacy and Therapeutics Committee and the HCDOM.

    • Fulfill the role of Primary Vaccine Coordinator for the institution and managing vaccine inventory.

    • Have responsibility for the daily operation of the pharmacy and be vested with adequate authority to assure compliance with the laws governing the operation of the pharmacy.

    • Report to the CEO and receive program guidance from Pharmacy Services leadership.

    • Serve as a co-chairperson of the institution Medication Management Subcommittee and be responsible for:

      • The professional direction of pharmacy-related clinical functions and decisions.

      • Implementation of CCHCS Systemwide P&T Committee policies and procedures, the CCHCS Drug Formulary, and other programs approved by the Systemwide P&T Committee.  Refer to the HCDOM, Section 1.2.11, CCHCS Systemwide Pharmacy and Therapeutics Committee, for more details.

    • Provide ADDS training to pharmacy staff and all users on an annual basis.

    • Ensure staff fulfill training requirements upon hire and annually in accordance with the HCDOM, Section 1.4.5.1, Pharmacy Staff Onboarding, and training is documented on the CDCR 844, Training Participation Sign-in Sheet, or through the electronic Learning Management System.

    • Notify the Regional Pharmacy Services Manager (PSM) and the Statewide Chief of Pharmacy Services of any telework agreements and alternate work schedules.

    • In coordination with the CEO, provide notification to the Regional PSM and the Statewide Chief of Pharmacy Services whenever they are to be absent from the institution, excluding regular days off, along with the statement of the designee.

  • The PIC participates in:

    • The development of health care policies and procedures relevant to pharmacy services such as the prescribing and administering of medication.

    • Appropriate in-service and continuing education activities.

    • Committees as necessary or as requested.

• Pharmacy Technicians

  • Non-discretionary duties

    • Pharmacy technicians may perform non-discretionary duties including, but not limited to, the following:

    • Packaging and repackaging medications.

    • Distributing and delivering medications to appropriate medication storage areas.

    • Tracking and managing inventory in the pharmacy and LCCs.

    • Stocking and removing medications in the pharmacy and LCCs.

    • Maintaining inventory in the ADDS to include, but not limited to:

      • Stocking and destocking of medication after delivery.

      • Performing cycle counts.

      • Reviewing and electronically maintaining medication expiration dates.

      • Removing expiring medications.

      • Managing the return bin.

      • Reporting ADDS issues or concerns to a pharmacist.

    • Counting or pouring pharmaceuticals.

    • Labeling prescription containers.

    • Mixing pharmaceuticals in a pharmacy licensed for compounding.

    • Preparing parenteral products in a pharmacy licensed for sterile compounding.

    • Entering prescriptions into the Electronic Health Record System (EHRS).

    • Requesting and receiving refill authorizations.

    • Maintaining appropriate records.

    • Completing other non-discretionary tasks as assigned.

  • Other requirements:

    • Pharmacy technicians shall:

    • Be responsible to ensure that their duties are performed under the supervision and control of a pharmacist at all times.

    • Not perform any act requiring the exercise of professional judgment by a pharmacist.

    • Wear a name badge clearly identifying them as pharmacy technicians per the California State Board of Pharmacy regulations.

• Other Ancillary Staff

  • Other ancillary staff working in a CCHCS pharmacy may perform duties consistent with their EHRS or ADDS access which do not involve the dispensing of prescriptions.  These include, but are not limited to:

  • Entering medication orders.

  • Entering patient information into the EHRS.

  • Requesting and receiving refill authorizations at the direction of a pharmacist.

  • Picking up prescription orders.

  • Delivering medications to nursing units.

  • Printing patient profiles and other reports.

  • Ordering pharmacy stock.

  • Stocking pharmacy shelves.

  • Completing other non-discretionary tasks not requiring a pharmacist or a technician license as allowed by federal or state law.

• Medication Information Services

  • The pharmacy shall have access to electronic medication information resources.  These resources can be accessed on the Pharmacy Lifeline page.

  • Under the direction of the PIC, or designee, pharmacists provide medication information and when necessary in-service training related to the safety, proper use, and handling of medications by health care staff.

  • Pharmacists provide consultation or medication information to medical, dental, and mental health staff and patients when requested and as required by federal and state laws.

  • Patient requests shall be handled by Central Pharmacy Services for release counseling or the endorsed institution for current patients.

  • The pharmacist shall document pharmacy interventions in the health record.

• Hours of Operation and Staff Scheduling

  • The pharmacy shall be open a minimum of five days per week (Monday through Friday, except for holidays) for at least eight hours per day.

  • The PIC, in collaboration with the Statewide Chief of Pharmacy Services, Regional PSM, and the CEO, shall determine the hours of pharmacy operation based on pharmacy service needs.  Final determination of pharmacy operating hours shall be made by the Statewide Chief of Pharmacy Services.

  • The PIC, or designee, shall be expected to work a schedule during the primary operating hours of the pharmacy.  This schedule is subject to approval by the CEO.

• Reporting

  • The PIC shall be responsible for reporting information related to operational and clinical aspects of pharmacy services to the institution CEO; institutional medical, dental, mental health, and nursing leadership; and statewide pharmacy leadership as appropriate.

• Maintenance of Records

  • The PIC shall ensure that:

  • Pharmacy-related records are maintained pursuant to federal and state requirements.

  • All records are shredded after the applicable federal and state required retention periods have lapsed.

• Record and Information Requests

  • When requested by an authorized officer of the law or authorized representative of the Medical Board or BOP, the PIC shall provide the board or its authorized representative with the requested records within three business days of the time the request was made.  The PIC may request in writing an extension of this timeframe for a period not to exceed 14 calendar days from the date the records were requested.  A request for an extension of time is subject to the approval of the board. An extension shall be deemed approved if the board fails to deny the extension request within two business days of the time the extension request was made directly to the board.

  • Record requests made by licensing, registering, or accreditation agencies shall be handled in consultation with the Statewide Chief of Pharmacy Services or designee via email at m_rxpolicytraining@cdcr.ca.gov, Regional PSM, and CCHCS Office of Legal Affairs.

  • Any court order, administrative order, or subpoena requesting medical records related to gender affirming health care shall be processed by Health Information Management in accordance with the HCDOM, Section 2.3.4, Release of Protected Health Information.

  • CCHCS and CDCR shall not cooperate with any inquiry or investigation by, or provide medical information to, any individual, agency, or department from another state or, to the extent permitted by federal law, to a federal law enforcement agency that would identify an individual and that is related to an individual seeking or obtaining gender-affirming health care or gender-affirming mental health care that is lawful under the laws of this state.

  • CCHCS and CDCR are not prohibited from disclosing medical information of an individual upon request to a health care facility that is run by an agency or department from another state, or to a federal law enforcement agency, for treatment purposes and direct medical care for the specified individual if the information disclosed is narrowly limited to the request.

• Drug Enforcement Administration or Board of Pharmacy Inspections

  • An authorized officer of the law or authorized representative of the board is entitled to remove copies of documents reviewed during an inspection with the condition that they provide an itemized receipt for all documents taken.  Where documents are not readily retrievable at the time of inspection or request, the PIC shall produce the documents within the timeframe specified in the request unless otherwise agreed in writing by the authorized officer of the law or authorized representative of the board.

  • The PIC shall forward a copy of all Drug Enforcement Administration or BOP inspection reports and any additional requests to the Statewide Chief of Pharmacy Services or designee via email at m_rxpolicytraining@cdcr.ca.gov and Regional PSM.

Policy

• California Correctional Health Care Services (CCHCS) shall recruit, train, evaluate, develop, and integrate a team of centrally based clinical pharmacists.  Clinical pharmacists shall practice under protocol, approved by the Systemwide Pharmacy and Therapeutics (P&T) Committee, once they have achieved training and completed the provisioning process.  When providing health care services to patients through telehealth services, clinical pharmacists shall provide only those services specified in Systemwide P&T Committee-approved protocols for which they are deemed competent.  Incorporating clinical pharmacists into collaborative drug therapy management allows all providers to practice to the fullest extent of their licenses.

Purpose

• To establish the roles, responsibilities, and scope of practice for clinical pharmacists communicating and collaborating with other health care professionals to provide patient care; to define standardized procedures to maintain competency and performance of each participating clinical pharmacist; and to ensure the pharmacy-managed drug therapy process complies with federal and state laws requirements as it strives to improve the quality of medication management and health outcomes.

Responsibility

• Statewide

  • California Department of Corrections and Rehabilitation and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative and clinical systems are in place and appropriate tools, training, technical assistance, and resources are available to:

    • Ensure clinical operations are in compliance with federal and state requirements; and

    • Ensure the safety and quality of pharmacist-provided patient care.

  • Medical Deputy Director and Statewide Chief of Pharmacy Services are responsible for:

    • Implementing, monitoring, and evaluating of this procedure.

    • Onboarding, training and clinical supervision of clinical pharmacists.

    • Monitoring and evaluating clinical pharmacist interventions.

    • Designating physician mentors to support the clinical pharmacy program.

  • The physician mentor is responsible for:

    • Providing physician direction, supervision, and support to the clinical pharmacist.

    • Providing case consultation on individual patients as needed.

• The Systemwide P&T Committee

  • The Systemwide P&T Committee is responsible for approval of policies, procedures, protocols, and performance standards pertaining to clinical pharmacists’ management of disease states.

• Performance Improvement Plan

  • Designated medical and pharmacy leadership shall monitor and evaluate central clinical pharmacy services using key performance indicators that correlate to potential problems or opportunities for improved patient outcomes.  Findings shall be reported to the Systemwide P&T Committee at least annually.

  • Documentations of medication errors shall be detailed in the pharmacy’s quality assurance program pursuant to Health Care Department Operations Manual (HCDOM), Sections 1.2.6, Statewide Patient Safety Program; Section 1.2.7 Institution Patient Safety Program; and 3.5.11, Pharmacy Quality Assurance Program.

Procedure

• Experience

  • All clinical pharmacists shall possess the following:

    • Active licensure as a Registered Pharmacist in California without restrictions.

    • Completion of a clinical residency or documentation of clinical experience in direct patient care delivery to meet California Business and Professions Code, Section 4052.2, Scope of Practice and Exemptions.  The Systemwide P&T Committee shall maintain a Direct Patient Care Experience Form for the documentation of clinical experience in direct patient care delivery.

• New Medical Provider Onboarding

  • Prior to performing any duties under protocol, a clinical pharmacist shall complete the New Medical Provider Onboarding (NMPO) program.  NMPO shall include pertinent information regarding the work environment, institution and headquarters resources, as well as job expectations.  NMPO shall be completed pursuant to HCDOM, Section 1.4.2.1, New Medical Provider Onboarding.

• Scope of Practice Authority

  • Clinical pharmacists must request and be granted provisional privileges prior to beginning patient care duties and shall follow all CCHCS policies and procedures.  Clinical pharmacists shall follow Systemwide P&T Committee-approved protocols that are within their scope of practice based on their education and training and are consistent with their experience, credentialing, and privileging.

  • Protocols

    • The Systemwide P&T Committee shall define the parameters and clinical pharmacists’ role in a protocol.

    • In accordance with policies, procedures, and protocols, a clinical pharmacist may:

      • Order or perform routine drug therapy-related patient assessment procedures.

      • Order drug therapy-related laboratory tests.

      • Administer drugs pursuant to a primary care provider (PCP) or other appropriate authorized provider’s order.

      • Initiate or adjust the drug regimen of a patient pursuant to an order or authorization made by the patient’s PCP or other appropriate authorized provider.

  • A clinical pharmacist shall not select a different drug than prescribed, except as authorized by protocols.

  • The clinical pharmacist shall consult with a physician prior to performing drug therapy management outside the parameters of the protocol.  The consultation shall be documented in the health record.

  • Clinical pharmacists shall not provide direct patient care for the treatment of psychiatric conditions.

• Physician Referral to the Clinical Pharmacist

  • A patient’s PCP or other appropriate authorized provider shall complete a referral form to the pharmacy in the electronic health record system (EHRS) to express authorization for a patient to be managed by a clinical pharmacist.

  • The protocol for which the clinical pharmacist is to follow shall be related to a condition for which the patient has first been evaluated by a physician.

  • A patient’s PCP or other appropriate authorized provider may prohibit, by written instructions, any adjustment or change in the patient’s drug regimen by the clinical pharmacist.

• Patient Health Records

  • A clinical pharmacist shall be responsible for the preparation of a complete health record for each patient interaction.  All information relevant to patient care shall be documented in the patient’s EHRS profile including, but not limited to:

    • Pertinent subjective and objective data.

    • Assessment.

    • Details of therapy, responses, and reactions.

    • Interventions and the rationale for a particular treatment plan.

    • Consultation notes.

    • Dispensing records.

  • Within 24 hours of initiating a new drug regimen, a clinical pharmacist shall enter the appropriate information into EHRS.

  • A clinical pharmacist shall communicate in writing any change, adjustment, or modification of an approved preexisting treatment of drug therapy to the treating provider or physician mentor within 24 hours.

• Supervision of Clinical Pharmacists

  • Designated medical and pharmacy leadership shall ensure that the clinical pharmacist:

    • Receives adequate supervision and support.

    • Be properly credentialed and receives appropriate privileges.

    • Receives onboarding and training in accordance with CCHCS policy and management directions.

    • Complies with all departmental policies, procedures, and protocols.

  • Physician consultation shall be available at all times either onsite, by telephone, or via electronic device. 

• Evaluation of Clinical Competence

  • The Statewide Clinical Pharmacy Services Manager shall establish competency assessment documentation and tools to establish a minimum level of competency.

  • Clinical and practical experience and skills shall be documented and the records maintained in the pharmacy.  The location of  these records shall be documented in the California Board of Pharmacy compliance binder under the On-Site Records Storage Location Log.

  • Competency, defined by knowledge and the application of knowledge and skills, shall be assessed through annual performance evaluations, a structured or written assessment, and direct observation during the probationary period and ongoing.

  • Designated pharmacy leadership shall conduct ongoing professional practice evaluations annually for each clinical pharmacist and retain these documents for each clinical pharmacist.

Procedure Overview

• California Correctional Health Care Services’ (CCHCS) pharmacy personnel are required to report to work physically and mentally able to perform their duties to avoid endangering the safety of themselves and others.

• Impairment shall be reported to the Statewide Chief of Pharmacy Services and the California State Board of Pharmacy (BOP) in accordance with applicable regulations. 

• This procedure describes the process of taking action to protect the public when a licensed individual employed by or with the pharmacy is discovered or known to:

  • Be chemically, mentally, or physically impaired to the extent it affects his or her ability to practice the profession or occupation authorized by his or her license; or

  • Have engaged in the theft, diversion, or self-use of dangerous drugs.

• Incidents of actual or suspected fraud, theft, loss, or irregularities of medications shall be reported immediately pursuant to the Health Care Department Operations Manual (HCDOM), Section 5.1.4, Reporting of Actual or Suspected Incidents of Fraud, Errors, and Improper Governmental Activities; and the HCDOM, Section 3.5.26, Break-In, Theft/Loss From Pharmacy or Medication Storage Areas.

Purpose

• To protect the public by ensuring that pharmacy personnel reporting to work are physically and mentally able to perform their duties.

Procedure

• The Chief Executive Officer (CEO) and the Pharmacist-in-Charge (PIC), or their respective designees, shall be responsible for taking action in compliance with California Department of Corrections and Rehabilitation (CDCR) policies and state regulatory mandates to protect the public whenever pharmacy personnel is discovered or is known to be chemically, mentally, or physically impaired to the extent that the impairment affects job performance.

• It is the professional responsibility of pharmacy personnel to immediately report suspected chemical, mental, or physical impairment to a supervisor.

  • Impaired pharmacy personnel shall be reported to the PIC.  If the PIC is absent or suspected to be impaired, the report shall be made to the CEO (or designee) or, if at the Central Fill Pharmacy, to the Statewide Chief of Pharmacy Services.

  • If the CEO, or designee, is not available, contact the Regional Health Care Executive, the Regional Pharmacy Services Manager or the Chief of Pharmacy Services.

  • Impaired pharmacy personnel at the Elk Grove campus shall be reported to the Statewide Chief of Pharmacy Services or designee.

• The PIC, or aforementioned leadership, shall arrange to immediately remove an employee who is suspected of being impaired or under the influence of alcohol or drugs from pharmacy duties.  If warranted, contact the Investigative Services Unit or, if at the Central Fill Pharmacy or Elk Grove campus, the California Highway Patrol.

• Any pharmacy personnel suspected of being chemically impaired on the job may be subject to substance testing according to CDCR’s Reasonable Suspicion Policy.  Positive test results may result in disciplinary action up to and including termination.

• The PIC, or designee, shall notify the Statewide Chief of Pharmacy Services, or designee, via telephone and in writing via electronic mail as soon as possible regarding any suspected impairment of pharmacy personnel.

• Any pharmacy personnel suspected of being physically or mentally impaired on the job may be subject to a medical evaluation according to CCHCS’ Fitness for Duty Evaluation process.

• The PIC shall notify the BOP in writing of any employee’s admission of impairment, documented evidence of impairment, or termination as a result of impairment within 14 calendar days of discovery of impairment or termination.

  • The required report shall include sufficient detail to inform the BOP of the facts upon which the report is based including an estimate of the type and quantity of all dangerous drugs involved, the timeframe over which the losses are suspected, and the date of the last controlled substances inventory.

  • Upon request of the BOP, the pharmacy shall prepare and submit an audit involving the dangerous drugs suspected to be missing.

  • All correspondence with the BOP shall be sent via certified mail.

  • A scanned copy of the notification to the BOP shall be sent via electronic mail to the Statewide Chief of Pharmacy Services.

• When the facts include theft, diversion, or self-use of dangerous drugs, refer to HCDOM, Section 3.5.26, Break-In, Theft/Loss from Pharmacy or Medication Storage Areas, for additional procedures.