Health Care Department Operations Manual

Chapter 1 – Health Care Governance and Administration

Article 4.5 – Professional Workforce: Pharmacy Services

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1.4.5.2 Pharmacy Responsibilities, Scope of Service, and Supervision

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.
References
- California Code of Regulations, Title 16, Division 17, Article 2, Sections 1707.2, 1707.3, 1709.1, and 1714.1
- California Business and Professions Code, Division 2, Chapter 9, Pharmacy
- California Civil Code, Division 1, Part 2.6, Confidentiality of Medical Information
- California Health and Safety Code, Divison 10, Uniform Controlled Substances Act
- Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.11, CCHCS Systemwide Pharmacy and Therapeutics Committee
- Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.5.1, Pharmacy Staff Onboarding
- Health Care Department Operations Manual, Chapter 2, Article 3, Section 2.3.4, Release of Protected Health Information
- Health Care Department Operations Manual, Chapter 3, Article 2, Section 3.2.1, Disposal of Regulated Waste Generated by Health Care Staff
- Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.3, Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics
- Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.27, Temporary Absence of the Pharmacist
Revision History
Effective: 04/2008
Revised: 01/07/2026