Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.23 Medications Brought from a Non‑CDCR Facility

  • Procedure Overview

    • Medications provided for patients of a California Department of Corrections and Rehabilitation (CDCR) facility by a correctional pharmacy or California Correctional Health Care Services (CCHCS)-contracted pharmacy may be used as long as the medications have been reviewed by a physician or pharmacist employed by or contracted with CDCR, CCHCS or a CDCR, CCHCS-contracted vendor.

  • Purpose

    • To provide continuity of care, while ensuring that all medications administered to patients are correct and appropriate.

  • Procedure

    • Orders for Continuing Medications Dispensed from a Non-CDCR Facility

      • When a patient is brought from a non-CDCR facility (e.g., community hospital, clinic, provider’s office) to a CDCR facility, the provider shall review the appropriateness of all recommended medication orders, determine the availability of formulary alternatives where indicated, and write medication orders when indicated.

      • When a patient has arrived with a supply of the ordered medication in their possession and the ordered medication is unavailable from the CDCR correctional pharmacy during business hours, licensed correctional clinic, or automated drug delivery system at the time of arrival and the provider determines that there is not an alternative available that is suitable for this patient, the medication may be ordered to be continued after the contents of the containers have been examined and positively identified by the patient’s physician or a pharmacist retained by CDCR, CCHCS or a CCHCS-contracted vendor.

      • The medications brought from a non-CDCR facility shall be administered as nurse administered (NA) or direct observed therapy (DOT) until such time as the medication labeling has been reviewed to be compliant as described in (c)(3).

      • For medications prescribed and dispensed from a narcotic treatment program (NTP), the provider shall document in the health record that the patient is receiving the medication from an NTP.

    • Identifying the Medications

      • When medications have been provided by a CDCR, CCHCS-contracted pharmacy and the medications have not been in the  possession of the patient, medications bearing the label of the contracted pharmacy is indication that the medication has been identified and approved by a pharmacist and may be used within the CDCR facility.

      • When medications have been in the possession of the patient and the medications do not bear a CDCR label and the patient is admitted to a CDCR facility, the medication shall not be used unless the contents of the containers have been examined and positively identified by the patient’s physician or a pharmacist retained by CDCR, CCHCS or a CCHCS-contracted vendor  and after a Primary Care Provider, psychiatrist (if it is a psychotropic medication) or dentist (when the medication has been ordered for a dental condition) has approved and ordered their use.

        • During Pharmacy Hours

          • Nursing and pharmacy staff shall coordinate to allow a pharmacist to examine and verify medications brought from non-CDCR sources if the provider orders to continue the medication.

        • After Pharmacy Hours

          • If the medication is ordered to be administered after pharmacy business hours, the provider shall inspect the medication, and when necessary, positively identify and approve the medication, prior to releasing it for administration.

          • If the provider is not available for inspection of the medication, licensed health care staff shall contact the provider on-call for further guidance.

          • When the pharmacy reopens and if the medication is still needed, the pharmacist shall verify the order and, if possible, re-dispense the medication with CDCR stock.

    • Labeling Medications from a Non-CDCR Pharmacy

      • When medications have been provided by a CDCR, CCHCS-contracted pharmacy and comply with labeling requirements pursuant to Health Care Department Operations Manual, Section 3.5.16, Medication Inventory Management, Labeling, and Storage, the institution pharmacy is not required to place an additional label upon the product. If any information is missing, then the medication shall be labeled with a CDCR label and administered NA or DOT until the medication can be provided with an appropriate label.

      • Pharmacy, once available, shall affix a CDCR medication label to all medications dispensed from a non-CDCR-contracted pharmacy to facilitate documentation of administration. Where the medication is to be self-administered by the patient, the CDCR label shall indicate KOP administration. If possible, the original label from the non-CDCR pharmacy shall remain visible for all medications dispensed by a non-CDCR pharmacy but administered within the CDCR facility, including medications for KOP administration.

    • Onsite Administrations of Narcotic Treatment Program Medications during Modified Programming

      • In the event of modified programming or other special circumstance in which an NTP needs to deliver a supply of controlled substances used for substance abuse treatment and detoxification for a patient, a pharmacist shall verify the contents and quantities delivered. The handoff between the NTP and pharmacist shall be documented on the CDCR 7457, Pharmacy Chain of Custody Log – Patient’s Methadone Supply (Delivered by NTP).

      • The patient-specific medications shall be kept locked and separate from the pharmacy’s inventory until the medications can be delivered to a licensed correctional clinic.

      • The medication handoff between pharmacy and nursing staff shall be documented on the CDCR 7457.

      • Nursing staff shall secure the controlled substances in a locked cart, cabinet, or drawer and document the security of the medications in their possession on the CDCR 7456, Nursing Chain of Custody Log – Methadone Supply (Delivered by NTP).

  • References

    • California Code of Regulations, Title 22, Division 5, Chapter 3, Article 3, Section 72367, Pharmaceutical Service – Personal Medications

    • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79661, Pharmaceutical Service – Personal Medications

    • California Business and Professions Code, Chapter 9, Division 2, Article 3, Section 4052.7, Repackage Previously Dispensed Drugs; Requirements

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.5, CCHCS Drug Formulary

    • 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 3.5.16, Medication Inventory Management, Labeling, and Storage

  • Revision History

    • Effective: 05/2008
      Revised: 05/24/2023
      Reviewed: 02/11/2025