Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.2 Pharmacy Licensing Requirements

  • Policy

    • Each Correctional Pharmacy shall have a valid, current pharmacy permit issued by the California State Board of Pharmacy (BOP).  Pharmacies preparing intravenous admixtures shall have an additional valid Sterile Compounding Permit issued by the BOP.

  • Procedure

    • Pharmacy

      • California State Board of Pharmacy

        • The institution’s Chief Executive Officer (CEO) shall be designated as the Administrator or Corporate Officer on the pharmacy permit.

        • The Pharmacist II shall be designated as the Pharmacist-in-Charge (PIC) on the permit in accordance with California statutory and regulatory requirements.

        • When a CEO vacancy occurs, the PIC, in coordination with Central Pharmacy Services, is responsible for updating the licenses by submitting the applicable Change of Permit applications within 30 days of the last effective date served as the CEO.

        • In the case of a PIC vacancy, the outgoing PIC shall notify the BOP of their departure within 30 days of the date of that change in status.  The CEO as the hiring authority, in coordination with Central Pharmacy Services, shall submit a Change of PIC application to place a new PIC or acting PIC on the license within 30 days of the last effective date served as the PIC.

          • Prior to assuming the PIC role, the incoming PIC shall have completed the BOP-provided Pharmacist-in-Charge Overview and Responsibility training course, available on the BOP’s website, within two years prior to the date of application and an attestation statement in compliance with California Code of Regulations, Title 16, Section 1709.1, Designation of Pharmacist-In-Charge.

          • Once the incoming PIC has completed the BOP-provided training course, the incoming PIC is responsible for completing an application to replace the previous PIC pursuant to Business and Professions Code, Section 4113, Pharmacist-in-Charge: Notification to Board; Responsibilities.

        • The Regional Health Care Executives and Regional Pharmacy Services Managers shall facilitate the timely notifications and renewals of each pharmacy permit to ensure that vacancies and license expirations do not compromise the validity of a pharmacy permit.

        • The current permit shall be posted in the pharmacy in conspicuous view.

        • The Statewide Chief of Pharmacy Services, as the liaison to the BOP and as the deciding authority on behalf of CCHCS, holds the authority to decide and to take any action regarding BOP licenses, including applying for, renewing, or deactivating any license. Any change to the individual holding the position of the Statewide Chief of Pharmacy Services shall be communicated to the BOP.

        • All licenses issued by the BOP are aligned to expire on November 1 of each year for the Central Pharmacy Services to pay any renewal fees collectively.

        • All changes in CCHCS licensing permits issued by the BOP shall be coordinated through Central Pharmacy Services, who shall coordinate the processing of all fees.

      • National Council for Prescription Drug Programs (NCPDP)

        • The Statewide Chief of Pharmacy Services, or designee, shall be designated as the Authorized Official on the NCPDP provider identification number, who shall ensure the organization’s compliance with Medicare statutes, regulations, and instructions.

      • Drug Enforcement Administration (DEA)

    • For information on licensing automated drug delivery systems, see the HCDOM, Section 3.5.4, Automated Drug Delivery System.

    • For information on licensing correctional clinics, see the HCDOM, Section 3.5.3, Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics.

  • References

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4021.5

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4036.5

    • California Business and Professions Code, Division 2, Chapter 9, Article 6, Section 4101

    • California Business and Professions Code, Division 2, Chapter 9, Article 7, Section 4113

    • California Business and Professions Code, Division 2, Chapter 9, Article 13.5, Section 4187

    • California Business and Professions Code, Division 2, Chapter 9, Article 19, Section 4305

    • California Code of Regulations, Title 16, Division 17, Article 2, Section 1709.1

    • 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 3.5.4, Automated Drug Delivery System

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.9, DEA Schedule II-V Controlled Substances

  • Revision History

    • Effective: 02/2008

    • Revised: 08/11/2025