Chapter 1 – Health Care Governance and Administration

1.4.5.4 Impaired Pharmacy Personnel

• 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.

• References

  • California Business and Professions Code, Division 2, Chapter 9, Article 6, Section 4104

  • California Code of Regulations, Title 2, Division 1, Chapter 3, Subchapter 1, Article 29, Substance Abuse

  • California Correctional Health Care Services, Fitness for Duty Evaluation memorandum located on Lifeline at: https://cdcr.sharepoint.com/sites/cchcs_lifeline_pharmacy/SiteAssets/SitePages/Forms-&-Medication-Lists/Fitness-For-Duty-Evaluations.pdf

  • California Correctional Health Care Services, Disability Management Unit Assignment Roster located on Lifeline at: https://cdcr.sharepoint.com/sites/cchcs_lifeline_hr/SitePages/Disability-Management-Support-Services(2).aspx

  • California Department of Corrections and Rehabilitation, Reasonable Suspicion Policy located on the CDCR Hub under Health & Safety in the Substance Abuse Testing Section

  • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.26, Break-In, Theft/Loss From Pharmacy or Medication Storage Areas

  • Health Care Department Operations Manual, Chapter 5, Article 1, Section 5.1.4, Reporting of Actual or Suspected Incidents of Fraud, Errors, and Improper Governmental Activities

• Revision History

  • Effective: 05/2008

  • Revised: 04/05/2023

  • Reviewed: 01/14/2025