Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.24 After‑Hours Pharmacy Services

  • Procedure Overview

    • After-hours pharmacy services shall be available whenever the local pharmacy is closed and shall be consistent with options approved by the Systemwide Pharmacy and Therapeutics Committee or the Systemwide Medication Management Subcommittee.  The most cost-effective option shall be prioritized, provided it is conducive to the needs of the patient.  Proper stocking and inventory control, as required in the Health Care Department Operations Manual (HCDOM), Section 3.5.4, Automated Drug Delivery System, will provide more timely access and mitigate the need for other, more costly processes to be utilized to meet the immediate needs of the patient. For purposes of this policy, pharmacy services shall be deemed available when California Department of Corrections and Rehabilitation (CDCR) processes, with respect to after-hours services, have been followed or a CDCR pharmacist was consulted for clinical or after-hours assistance.

  • Purpose

    • To ensure that pharmacy services are available for consultation and medication needs on a 24-hour basis.

  • Responsibilities

    • Statewide

      • The CDCR and California Correctional Health Care Services departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative and clinical systems are in place and appropriate tools, training, technical assistance, and resources are available to:

      • Ensure the furnishing or dispensing of medication from the Correctional Pharmacy and the CDCR-Central Fill Pharmacy comply with federal and state requirements and community standards of practice.

      • Provide the availability of specific medication to authorized personnel and health care treatment areas when necessary to address the most common medication needs when providing after-hours treatment for CDCR patients in compliance with federal and state requirements.

    • Regional

      • Regional Health Care Executives and Regional Pharmacy Services Managers are responsible for operationalizing this policy and compliance with federal and state requirements at the subset of institutions within an assigned region.

    • Institutional

      • The Chief Executive Officer (CEO) has overall responsibility for ensuring the implementation and enforcement of this procedure, compliance with federal and state requirements, and maintaining a local operating procedure (LOP).

      • The Pharmacist-in-Charge (PIC) shall be responsible for:

        • Compliance with federal and state requirements concerning medication provision.

        • Maintaining adequate quantities of essential and commonly used medications in a licensed correctional clinic (LCC) or automated drug delivery system (ADDS).

        • Providing a list of pharmacists to contact in a specified order to respond when the PIC is unavailable as described in Section (e)(1)(A)5.

        • Reviewing after-hours medication needs and optimizing medication availability to meet clinical needs.

      • Each institution shall maintain an LOP to be reviewed and approved by the institution Medication Management Subcommittee annually.

      • The medications available in the ADDS and LCC shall be determined as described in HCDOM, Section 3.5.4, Automated Drug Delivery System, and Section 3.5.3, Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics, respectively.

  • Local Operating Procedure Addendum

    • When an institution has pharmacists who volunteer for callback, an addendum to the LOP is required to outline:

    • Implementation and processes related to the maintenance of a voluntary list.

    • Steps that shall be followed before an SRN can contact the voluntary callback pharmacist to dispense a medication if the medication is available within the institution’s pharmacy.

  • Procedure

    • Access to After-Hours Pharmacy Services

      • The institution shall complete the following steps to access after-hours pharmacy services:

        • Implement the procedures indicated in the HCDOM, Section 3.5.4, Automated Drug Delivery System and HCDOM, Section 3.5.3, Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics, to properly manage and monitor medication use and needs. These procedures include, but are not limited to:

          • Establishing and maintaining:

            • A floor stock medication supply for each health care location licensed pursuant to California Health and Safety Code, Title 22.

            • A floor stock medication supply for each LCC pursuant to California Business and Professions Code (BPC), Division 2, Chapter 9, Article 13.5, Section 4187.

            • Medication par levels within each ADDS pursuant to BPC, Division 2, Chapter 9, Article 13.5, Section 4187.5.

          • Following the procedure in Section (e)(1)(A)2., when the institution demonstrates an inability to meet patient needs following full implementation and adherence with the above.

        • Local institution staff shall follow the procedures outlined in their LOP to locate required medications in other medication storage areas when a single location is unable to meet the needs of a patient. Staff shall have access to medications located at any LCC using the following process:

          • Use personal access to remove medications from an ADDS, or

          • Complete an electronic requisition to move a medication between two LCCs within the same institution.

          • Follow the procedure in Section (e)(1)(A)3. if the institution demonstrates an inability to meet patient needs following full implementation and adherence with the above.

        • The Supervising Registered Nurse (SRN) on duty shall contact the on-call provider if it is determined that the medication is not readily available and may be held until obtained or an order for an available alternative is provided. If necessary, the SRN shall notify the PIC, or designee, that a medication is needed. If the institution cannot reach the PIC, follow the procedure in Section (e)(1)(A)4.

        • When an institution has access to a contracted pharmacy vendor (e.g., retail pharmacy, hospital discharge pharmacy) that can supply patient-specific prescription coverage, a prescription shall be provided for a quantity not to exceed a one-week supply. Institution staff shall be responsible for transporting the prescription from the contracted vendor to the institution.  The patient-specific prescription shall be administered as Nurse Administered (NA) or under Directly Observed Therapy (DOT). Pharmacy shall dispense an appropriate medication supply on the next business day pursuant to HCDOM, Section 3.5.23, Medications Brought from a Non-CDCR Facility.  If the institution demonstrates an inability to meet the patient needs following attempts to obtain a supply from a contracted pharmacy vendor, follow the procedure in Section (e)(1)(A)5. 

        • Voluntary callback of a pharmacist may be attempted if the procedure in Section (e)(1)(A)4. has failed to meet patient needs.

          • The institution shall develop an LOP to determine how voluntary callback shall be authorized, if available, to meet patient needs.

          • Voluntary callback is a request for staff to report to the institution during off-duty hours that do not run contiguously with a scheduled shift or meal break. Pharmacists are not required to participate in voluntary callback.

            • The PIC shall generate a voluntary callback list following written requests from the pharmacists for inclusion as defined by the LOP. If no pharmacist wishes to be included, then this option shall not be utilized.

            • The PIC shall place the names of all pharmacists requesting inclusion onto this list based on seniority with the most senior pharmacist first and provide to all locations as specified within the LOP.

            • The institution staff utilizing the voluntary callback list shall be instructed to start with the first name on the list at each occurrence and work their way down.

          • Compensation for voluntary callback is pursuant to the current Bargaining Unit 19, Memorandum of Understanding.

        • If all the steps above have failed to meet patient needs and in the on-call provider’s professional judgment, a delay in therapy may cause potential harm, consider transitioning the patient to a higher level of care.

    • Callback Reporting

      • Each month, the PIC shall submit the CDCR 7531, After-hours Medication Call Log, to the institution management team and the Statewide Chief of Pharmacy Services.

      • The PIC shall also analyze the CDCR 7531 for the purpose of adjusting the after-hours inventory to better meet patient needs, institution and statewide process improvement changes, and practitioner education.

  • References

  • Revision History

  • Effective: 06/2008
    Revised: 12/16/2024