Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.20 Medication Continuity with Patient Movement: Transfer/Parole/Discharge/Re‑Entry Program

  • Procedure Overview

    • This procedure provides guidelines for maintaining medication continuity with patient movement. This includes intrafacility transfers, interfacility transfers, transfers to outside facilities, and release.

  • Purpose

    • To ensure continuity of drug therapy as patients transfer between California Department of Corrections and Rehabilitation (CDCR) facilities, to other law enforcement entities, or out-of-state correctional facilities and upon release from the jurisdiction of CDCR.

  • Responsibility

    • The Chief Executive Officer and Warden of each institution have overall responsibility for adherence to this procedure while specific functional responsibilities are outlined below.

  • Procedure

    • Transfer Procedure

      • Transfer Medication(s)

        • When a patient is cleared for transfer, continuity of medications shall be maintained.  

        • Pharmacy and Nursing shall provide all medications necessary to safely transport the patient. In the event that there is a medication missing that may compromise patient safety, staff shall coordinate with the Primary Care Team prior to transport. Best practice guidance on transfer medications shall be maintained and reviewed annually by the Systemwide Medication Management Committee and is available on Lifeline at: BestPractice_TransferMeds.pdf (sharepoint.com).

        • Medications which shall not be packaged for transfer include:

          • Non-patient-specific medications from a licensed correctional clinic (LCC) to a different institution which are included on the Standardized LCC Inventory list.

          • Non-patient-specific medications from an automated drug delivery system (ADDS).

          • Drug Enforcement Administration (DEA) controlled substances. If a transfer supply of a DEA controlled substance is needed:

            • For the pharmacy to dispense a DEA Schedule II controlled substance, the provider is required to enter an order in the Electronic Health Record System (EHRS) which will be automatically routed to the DEA-certified electronic prescription application for approval and signature. Alternatively, the provider may write an order on a California-approved, tamper-resistant prescription blank.

            • For the pharmacy to dispense DEA Schedule III-V controlled substances, the provider is required to enter an order in the EHRS which will be automatically routed to the DEA-certified electronic prescription application. Alternatively, the provider may write an order on a California-approved, tamper-resistant prescription blank or deliver a verbal order for the pharmacist to reduce to writing as pursuant to the Health Care Department Operations Manual (HCDOM), Section 3.5.9, DEA Schedule II-V Controlled Substances.

        • Medications packaged for transfer shall include:

          • Medications that have been issued for a specific patient. These medications may be ordered as Nurse Administered (NA), Directly Observed Therapy (DOT), or Keep-on-Person (KOP).  KOP medications shall be packed separate from the patient’s property prior to transfer.

          • Prescribed rescue medications as specified on the Rescue Medications list shall be kept on the patient’s person during transport. Prescribed naloxone or naloxone kept as personal property may be kept on the patient’s person during transport.  For patients who pose a security risk if allowed to carry medications during transportation, alternate methods may be used to transport the medication while allowing the patient access to it.

          • Medications unlikely to be available (e.g., specialty medications) at the receiving institution. The pharmacy shall dispense a patient-specific supply of such medications for transfer as needed to ensure at least a five-day supply is available for continuity of care.

          • A verbal and/or written report provided by the sending care team for patients needing high-risk medications, complex care, or special handling (e.g., narcotic treatment program [NTP] clinic availability for patients on methadone for substance use disorder [SUD], anti-hemophilia factors) pursuant to the HCDOM, Section 3.1.9, Health Care Transfer.

        • The Chief Medical Executive and the Pharmacist-in-Charge (PIC), or designees, at the receiving institution shall ensure that all active medication orders and medications are available for arriving patients. If the PIC at the receiving institution requires prescription or administration information beyond that which is provided by the sending institution, the PIC shall take action to make medications available including, but not limited to, the following:

          • Clarification from the health record.

          • Obtaining a new medication order.

        • In situations where medications are not available locally, the prescriber or on-call provider shall be contacted for orders to address clinical needs until the pharmacy can provide the required medications pursuant to the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability.

      • Intra-facility Transfer of Medication (Patient Movement within the Institution)

        • Should a change in a patient’s bed assignment cause the patient to receive medications from a different medication administration location, the following procedure shall be followed:

        • Custody staff shall print out the Pending Bed Assignments (IPTR149) report from the Strategic Offender Management System prior to moving the patient and provide a copy of the report to licensed nursing staff. 

        • Licensed nursing staff shall check the patient on the report against the current Medication Administration Record to determine the need to have patient-specific medications relocated with the patient.

          • Licensed nursing staff shall note the number of KOP medications the patient should carry to the new housing assignment and sign the front of the report to indicate it has been reviewed.

          • Licensed nursing staff shall release the medications and the signed report in a labeled, sealed container to the custody officer to deliver to licensed nursing staff at the receiving medication administration location. The transporting custody officer shall ensure the patient’s KOP medications are documented for the bed assignment change. Under no circumstances shall KOP medications be packed with a patient’s property.

        • The custody officer shall transport the signed report and all medications provided by licensed nursing staff to the receiving medication administration location.

          • The licensed nursing staff at the receiving medication administration location shall check their LCC stock to ensure that non-patient-specific NA or DOT medications are available. If not available, Pharmacy staff shall be notified during business hours to stock the LCC (e.g., medication line). If it is after business hours, refer to the HCDOM, Section 3.5.24, After-Hours Pharmacy Services.

          • The custody officer shall notify a nursing supervisor and custody sergeant of barriers to following this procedure.

      • Inter-facility Transfer of Medication (Patient Movement between Institutions)

        • The Classification and Parole Representative (C&PR), or designee, shall provide a transfer list to designated institution health care staff at the sending institution no later than Thursday regarding any patients scheduled for transfer the following week. Any modifications to the transfer list shall be properly communicated by the C&PR office to the designated institution health care staff at the sending institution.

        • Pharmacy staff at the sending institution shall review the transfer list for patients who are on specialty medications or medications not generally stocked by all CDCR pharmacies.

          • The PIC, or designee, at the sending institution shall:

            • Contact the pharmacy at the receiving institution when a transferring patient is identified as receiving specialty or medications not generally stocked.

            • Inform the receiving institution what medications these patients require, how that medication shall be ordered/provided, and determine whether medication(s) need to be shipped to the receiving pharmacy by the sending pharmacy.

          • When medications need to be shipped to the receiving pharmacy, the sending pharmacy shall send the medication via the contracted overnight package vendor with tracking information shared with the receiving pharmacy.

        • In the event that a patient-specific NA or DOT medication order is expiring within five days of transfer, a pharmacist shall notify the provider to renew the order to ensure medication continuity. Medication shall be provided according to established dispensing procedures.

        • The Receiving and Release (R&R)/Transfer Registered Nurse (RN) shall complete the Interfacility Transfer PowerForm pending the anticipated transfer.

        • The custody officer shall ensure that transferring patients do not pack KOP medications in their property prior to transport. Once the custody officer has verified that the patient has all KOP medications outside of the property, the patient shall bring those medications to R&R.

        • Prior to transport, nursing staff shall:

          • Gather any patient-specific NA or DOT medications and place into the transfer envelope. If there is less than a five-day supply remaining, or if the medication is not on the Standardized LCC Inventory list, the pharmacy shall dispense a five-day transfer supply to deliver to R&R nurses.

          • Verify availability of an NTP clinic at the scheduled receiving institution for patients on methadone for SUD.

          • Document their actions in the Pre-Boarding Transfer Screening PowerForm.

          • In the event that the pharmacy is closed and a patient must transfer without a five-day supply of medications (e.g., to a higher level of care), coordinate with the receiving institution to ensure no lapse in medication administration occurs.

        • On the day of transport, the first watch Triage and Treatment Area RN/Transfer RN or R&R RN shall:

          • Administer all medications due to be given after the patient is moved from housing to R&R from the transfer envelope.

          • Administer the next scheduled dose of any unavailable patient-specific NA or DOT medication with clinic or ADDS stock as necessary and provide a verbal and/or written report to the receiving institution regarding missing medications. Refer to the HCDOM, Section 3.1.9, Health Care Transfer.

          • Contact the Primary Care Provider or on-call provider for direction if any high-risk medications (e.g., medications for transplant, chemotherapy, etc.) are missing on the day of transfer, and may place a temporary medical hold. Under no circumstance shall non-patient-specific stock from the clinic or ADDS be placed in the transfer envelope.

          • Ensure patients have self-administered KOP medications prior to placing the KOP medications in the transfer envelope.

            • In the event that KOP medications are not accounted for (i.e., a patient did not bring their KOPs), custody shall search the patient’s housing unit or property for KOPs.

            • If none are found, the nurse shall provide a verbal and/or written report to the receiving institution regarding the missing medications. Refer to the HCDOM, Section 3.1.9, Health Care Transfer.

          • Document the above actions in the Pre-Boarding Transfer Screening PowerForm.

          • Seal the transfer envelopes once all scheduled medication doses are administered to the transferring patients.

          • Give the envelopes to the R&R custody staff to seal the transfer envelopes within the transport container. Medications shall be packed and transported in the same vehicle as the patient and shall be made immediately available to the nurse at the layover or receiving institution(s) upon the patient’s arrival.

        • At the receiving institution, licensed nursing staff shall:

          • Return prescribed KOP medication to the patient for self-administration.

          • Document the medication administration in the KOP section of the Initial Health Care Screening PowerForm.

          • Request refill any KOP medications that did not arrive in the patient’s envelope following the usual pharmacy medication request process. 

          • Confiscate and appropriately dispose of any medication no longer in the original container, which cannot be identified, pursuant to the HCDOM, Section 3.2.1, Disposal of Regulated Waste Generated by Health Care Staff.

          • Check the EHRS for an open patient encounter at the receiving institution, and follow the transfer process in the EHRS Workflow 500-40 Integrated Medication History, to ensure that medication orders are reconciled into the open encounter to allow for timely administration of NA or DOT orders and pharmacy dispensing of KOP medications where needed.

          • Administer any medications necessary from the transfer supply provided by the sending institution or from an ADDS or LCC within the institution. Refer to the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability, Section (e)(13) for more information.

          • Contact a provider for medications with additional prescribing requirements, when necessary.  The provider shall issue a bridge order to ensure continuity of care. Patients requiring NTP services shall have a medical hold and an order for consult at an NTP within four calendar days.

      • Transfers to Non-CDCR Facilities including Hospital Visits

        • Licensed nursing staff from the sending institution shall collect the patient-specific NA or DOT medications and return them to the pharmacy.

        • When the patient is admitted to an outside facility and custody staff has retrieved KOP medications from a patient’s assigned housing unit, custody staff shall ensure delivery to health care staff for appropriate pharmaceutical waste disposal pursuant to HCDOM, Section 3.2.1, Disposal of Regulated Waste Generated by Health Care Staff.

        • Under no circumstances shall KOP medications be packed with a patient’s property.

        • A verbal and/or written report with any specific high-risk medication information shall be provided to the outside facility pursuant to HCDOM, Section 3.1.9, Health Care Transfer. This shall include the licensed health care staff coordinating continuity of care for medications that cannot be dispensed to the patient (e.g., Medication Assisted Treatment [MAT], oncology infusions, long-acting injectable antipsychotics).

        • On rare occasions when the outside facility cannot provide specific medications, refer to the established best practice guidance available on Lifeline at:  CCHCS-Admitted-to-Non-CDCR-Facilities.pdf (sharepoint.com).

      • Transfers to Non-CDCR Facilities including Out-to-Court

        • CDCR shall provide medications for continuity of care if requested by the receiving law enforcement jurisdiction.

    • Release: Parole/Probation/Discharge/Re-Entry Program

      • Pre-Release Planning

        • To assist the patient with continuity of medications after release (e.g., MAT, infusions, long-acting injectable antipsychotics), the licensed nursing staff shall connect the patient with external clinics based on the patient’s medical needs and expected relocation.

      • Release Medications

        • Prescription medications shall be prescribed and dispensed at the time of release to patients leaving directly from a CDCR institution or community correctional facility to a re-entry program or to the community through parole, probation, or discharge. 

        • Providers shall prescribe a 60-day supply of authorized medications for the purpose of continuity of care; refer to Section (d)(2)(C) for details.

        • The patient shall also be provided with a list of the medications and be advised to retain the copy for their provider in the community to reference. A pharmacist can also be reached at the toll-free number listed in the consultation flyer for a replacement copy or for questions related to their medication record; refer to Section (d)(2)(F).

        • The pharmacy shall:

          • Prepare a supply of prescribed legend medication(s), prescribed as needed (PRN) medications which pharmacy has dispensed in the last 30 days, and medications necessary to protect life, prevent significant illness or disability, alleviate severe pain, or mitigate side effects of other essential medications, unless clinically contraindicated, pursuant to an appropriately licensed provider’s order. Each institution shall ensure that the patient receives their medication(s) at the time of release with a list of the medication(s) provided.

          • Provide CDCR patients up to a 60-day supply of authorized medications (if within the confines of legal, clinical, and safe practices) when released from a CDCR institution or community correctional facility.

          • Provide PRN medications, not to exceed 50 percent of a 60-day supply.

          • Furnish an opioid reversal agent at the time of release.

          • Furnish condoms at the time of release.

          • Provide the medications to the receiving institution in cases of courtesy parole, where the patient transfers to an institution more convenient to their community.   

          • Be limited to the same rules set forth in policies and procedures, guidelines, and laws regarding medications with dispensing restrictions (e.g., DEA controlled substances, medications under a Risk Evaluation and Mitigation Strategy program).

        • Patients to be released to an inpatient facility outside of CDCR’s administrative authority (e.g., those under authority of the Department of State Hospitals) shall not be provided a supply of medications authorized by CDCR upon transfer. The sending institution shall provide a list of the patient’s currently prescribed medications for the receiving inpatient facility to order, fill, and dispense as appropriate.

        • Methadone for SUD treatment shall be administered within an NTP clinic. Prior to release, nursing shall provide a warm handoff of the patient to the NTP clinic, which the patient will be consulting upon release to mitigate any disruption in continuity of care upon release.

        • Health care and pharmacy staff shall be notified by the C&PR office at least seven days prior to a patient scheduled release date when possible. 

        • C&PR and/or staff shall promptly communicate to the pharmacy any additions or deletions made to the release list after it is sent to health care and pharmacy staff.

      • Authorized Medications

        • Authorized medications are those necessary to protect life, prevent significant illness or disability, alleviate severe pain, or mitigate side effects of other essential medications. This includes medications prescribed to treat chronic or acute illness which are scheduled to be taken on a routine or PRN basis and may occasionally include prescribed over-the-counter (OTC) medications.

        • Examples of prescribed OTC medications which may be provided include, but are not limited to:

          • Aspirin 81 mg

          • Proton pump inhibitors

          • Histamine-2 receptor antagonists

        • Medications that shall NOT be provided include:

          • OTC medications for minor ailments such as seasonal allergies, dandruff, and acne.

          • Items such as shampoos, moisturizing lotions, antacids, and sunscreen.

        • Exceptions to a full 60-day supply of medications are available on Lifeline and the CCHCS/CDCR publicly-accessible website.

      • Prescription Requirements

        • Release medications shall be prescribed via computerized provider order entry or, if unavailable, utilizing the CDC 7221, Physician’s Orders.  Refer to the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability, for the required elements of a prescription.

        • An electronic prescription from the DEA-certified electronic prescription application or a completed and signed California approved tamper-resistant prescription shall accompany any order for a DEA Schedule II controlled substance as required by state law. Refer to the HCDOM, Section 3.5.9, DEA Schedule II-V Controlled Substances, for additional requirements for DEA Schedule II, III, IV, or V controlled substances.

          • All prescriptions for DEA controlled substances for patients being released are considered outpatient prescriptions and require the individual DEA number of the prescribing provider. 

          • Reporting to the Controlled Substance Utilization, Review and Evaluation System shall be completed electronically as required by the State of California Department of Justice.

        • Syringes and needles necessary for prescribed chronic subcutaneous medications shall be prescribed and dispensed in the same manner as medications. A licensed health care staff member performing within their scope of practice shall instruct the patient on the use of syringes.

        • Intramuscular injections, with the exception of auto-injectors and where patients have been trained to self-administer, shall not be dispensed.

        • Long-acting injectable psychotropic medications shall not be dispensed. The patient shall receive an injection just prior to release if deemed appropriate by the prescribing psychiatrist.

        • Intravenous medications shall not be dispensed.

      • Packaging and Labeling

        • All parole and discharge prescriptions for oral medications shall be dispensed in containers with secure child-resistant closures that protect medication from contamination, moisture, and light (e.g., plastic amber medication vials), with the exceptions of those exempted from Code of Federal Regulations, Chapter II, Subchapter E, Part 1700, Section 1700.14(a)(10) (e.g., birth control, sublingual nitroglycerin).

        • Medication shall be dispensed and placed in a stapled or sealed opaque bag by pharmacy staff with the patient’s name affixed. Medication shall be delivered to the nursing supervisor, or designee, prior to the day of release.

        • During the processing of release medications, three extra prescription labels for each medication shall be printed:

          • A label shall be affixed to each of the three copies of the CDCR 7533, Patient Release Medication Receipt.

          • The three copies of the CDCR 7533 shall be attached to the package containing the medication.

        • When a patient reports to R&R for release, all medication in their possession shall be confiscated and disposed of in accordance with the HCDOM, Section 3.2.1, Disposal of Regulated Waste Generated by Health Care Staff. Medications packaged for use within CDCR are not packaged in child resistant containers and therefore do not meet federal and state regulations for use outside of a CDCR facility.

        • At the time of release, health care staff shall scan the medication delivered to the patient in the health care record and have the patient sign two of the three copies of the CDCR 7533 to acknowledge receipt or refusal of the medication.

          • One signed copy of the CDCR 7533 shall be returned to the Health Records Department to be scanned to the health record.

          • The second signed copy of the CDCR 7533 shall be returned to Pharmacy to be saved for pharmacy records.

          • The third copy is given to the patient at the time of release.

        • If release medications are refused or not delivered to the patient for any reason, the medication shall be returned to the pharmacy before the end of the pharmacy’s business day with the CDCR 7533 indicating refusal or the reason for its return (e.g., release date changed).

          • If the patient’s release date is postponed to a time within five calendar days of the original planned release date, the pharmacist shall update its release list and re-issue the same medications to R&R.

          • If the patient’s release date is postponed beyond five calendar days of the original planned release date, the pharmacist shall void-cancel-credit the dispense and, if a DEA controlled substance, return the medication to the Controlled Substances Manager using the “return to stock of patient-specific dispense” function.

        • Missing or non-delivered medication shall be immediately reported (and documented) to the PIC and Supervising RN on duty for resolution prior to the patient’s release from the institution.

        • If release medications are not delivered to the patient at the time of discharge for any reason, all efforts shall be made by nursing, pharmacy, and custody staff to ensure delivery of medication to the patient.

          • To ensure continuity of care if medications are not sent with the patient upon release, staff shall follow best practice guidance available on Lifeline at: BestPractice_PBM.pdf (sharepoint.com).

      • Consultation

        • Patient consultation shall be made available in accordance with federal and state statutory and regulatory requirements. Included with each bag containing patient medication for release, the pharmacy shall include:

          • A patient drug information leaflet (also known as discharge information) for each medication supplied. Note: discharge information can be found in all required languages using the state-supplied drug information service.

          • A patient consultation flyer which shall contain:

            • Notification that drug information has been included.

            • Instructions to the patient specifying the phone number where a pharmacist can be reached during regular business hours and a list of the business hours the pharmacist is available. Central Pharmacy Services shall be available six days a week and no less than 40 hours per week.

        • The pharmacist checking the release packet shall document that the discharge information has been provided to the patient on the CDCR 7533.

  • References

    • Code of Federal Regulations, Chapter II, Subchapter E, Part 1700, Section 1700.14(a)(10) Prescription Drugs

    • California Code of Regulations, Title 16, Division 17, Article 2, Section 1707.2, Duty to Consult

    • California Business and Professions Code, Division 2, Chapter 9, Article 4, Section 4076

    • California Business and Professions Code, Division 2, Chapter 9, Article 7, Section 4112

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.9, Health Care Transfer

    • 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 3.5.8, Prescription/Order Requirements and Medication Availability

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

  • Revision History

    • Effective: 09/2008
      Revised: 11/18/2025