Chapter 3 – Health Care Operations

3.5.10 CCHCS Pharmacy Policy and Procedure Review, Revisions, and Additions

• Policy

  • California Correctional Health Care Services shall ensure that pharmacy policies and procedures (P&Ps) are reviewed and approved by all stakeholders and published in the Health Care Department Operations Manual (HCDOM).  Pharmacy P&Ps shall be implemented as written within California Department of Corrections and Rehabilitation (CDCR) and made readily available to health care staff.

• Purpose

  • To ensure that the pharmacy operates in accordance with the HCDOM; and that revisions and additions to the HCDOM, Chapter 3, Article 5, Pharmacy are made and approved, as needed.

• Procedure

  • Chapter 3, Article 5, Pharmacy and Medication Services and pharmacy-related sections of the HCDOM shall be reviewed and revised as follows:

    • The Statewide Chief of Pharmacy Services, or designee, shall initiate the biennial review to ensure the P&Ps reflect current federal and state laws and regulations, applicable accreditation requirements, and standards of pharmacy practice.  The review process shall be initiated at least six months, prior to the biennial due date.

    • The Statewide Chief of Pharmacy Services, or designee, shall initiate interim revisions and additions, as needed to update or improve pharmacy services.

    • Health care staff shall forward suggested changes via email to Pharmacyreports@cdcr.ca.gov for consideration by the Statewide Chief of Pharmacy Services or designee.

    • P&Ps involving therapeutics or relevant to other disciplines shall be presented to the Systemwide Pharmacy and Therapeutics Committee, and to the Systemwide Medication Management Subcommittee as appropriate.  Members of both committees shall obtain input from their corresponding disciplines (e.g., medical, dental, mental health, nursing, and pharmacy) on proposed changes to ensure they are not in conflict with any corresponding disciplines’ P&Ps.  Input shall also include operational perspective from frontline staff, which shall be shared with the rest of the committee members for consideration.

    • Once approved by the necessary committee(s), the Statewide Chief of Pharmacy Services, or designee, shall submit the P&Ps to the CCHCS Health Care Regulation and Policy Section, HCDOM Team, to route the P&Ps through the Clinical Policy and Procedure Review and Approval Process located on Lifeline at:
      RPS Clinical HCDOM Approval Process.pdf (sharepoint.com)

  • Pharmacy P&Ps in the HCDOM, Chapter 3, Article 5 apply to all CDCR institutions and shall be implemented as published.  Institutions may establish local operating procedures (LOPs) to specify how they will implement statewide P&Ps.

  • The Pharmacist-in-Charge (PIC) is responsible for ensuring that pharmacy staff have knowledge of and access to pharmacy P&Ps in the HCDOM and LOPs. The Statewide Chief of Pharmacy Services, or designee, is responsible for ensuring all headquarters and regional pharmacy staff have knowledge and access to pharmacy P&Ps in the HCDOM.

  • If an institution has a licensed health care facility, the PIC shall ensure that a complete set of pharmacy P&Ps is reviewed and accepted through the institution Medication Management Subcommittee annually.

  • Central Fill Pharmacy shall establish and maintain a set of LOPs relating to the repackaging process and central fill functions.

• References

  • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79647, Pharmaceutical Service -General Requirements

  • 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 5, Article 1, Section 5.1.1, Implementation and Review of Health Care Regulations, HCDOM, and Health Care Forms

• Revision History

• Effective: 04/2009
  Reviewed: 10/11/2022, 04/21/2026
  Revised: 07/01/2024