Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.28 Pharmacy Services Business Continuity Plan

  • Procedure Overview

    • The California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) shall maintain a contingency plan for correctional institutions in the event of a disruption of local institution pharmacy services.

  • Purpose

    • To identify the facility level procedures, including a post-disruption recovery plan, that shall be followed in the event of a disaster or network degradation causing an interruption to local institution pharmacy services.

  • Responsibilities

    • CDCR and CCHCS departmental leadership, at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available.

    • In the event of any network slowdown or outage, lack of electrical power, significant reduction in workforce, or other immediate negative impact to pharmacy operations, the institution’s pharmacist-in-charge (PIC) or designee shall:

      • Report the situation to the CCHCS Information Technology Services Division via the CCHCS Service Portal.

      • Notify their Regional Pharmacy Services Manager and the Statewide Chief, Pharmacy Services, or designees.

      • Be the local liaison between the Central Pharmacy Services and institutional pharmacy staff to assist with the continued function and recovery of pharmacy operations.

  • Procedure

    • Pharmacy Emergency Team

      • The Pharmacy Emergency Team shall include the following staff:

      • Statewide Chief, Pharmacy Services or designee

      • Any Regional or Central Pharmacy Services Managers or designees

      • Local PIC or designee

    • Emergency Preparedness

      • The pharmacy shall have the CCHCS Electronic Health Record System (EHRS) Interdisciplinary Downtime Procedures & Downtime Viewer Guide available and a sufficient number of blank forms to account for a week of downtime, including:

        • Downtime Medication Administration Records (MAR) form

        • Downtime prescription labels

        • Downtime Filled Medications Log

      • The pharmacy shall maintain a 96-hour reserve of medications, especially essential medications including, but not limited to, analgesics, antibiotics, anti-emetics, anti-psychotics, and insulins, for use in the event of a disaster that constrains the institution’s ability to contact or access external resources.

    • Network Slowdown

      • A network slowdown occurs when pharmacy software is impacted, causing pharmacy operations to be reduced or available at limited capacity.

      • When a network slowdown is identified, the institution pharmacy staff shall complete an Information Technology (IT) ticket online via the CCHCS Service Portal, by calling 1-888-735-3470, or by calling the extension to the local IT department. 

      • The pharmacy staff shall notify the PIC or designee.

      • The PIC, or designee, shall:

        • Send an email with system issues to CDCRPharmacyEmergencyTeam@cdcr.ca.gov.

        • Notify local health care staff, including the Chief Executive Officer (CEO), Chief Medical Executive, Chief Nurse Executive, and Chief Psychiatrist, of the system slowdown and potential impact on patient care.

      • Upon notification of a network slowdown, members of the Pharmacy Emergency Team shall:

        • Coordinate with the pharmacy software vendor and CCHCS IT to determine the nature and extent of the network issue and a proposed course of action.

        • Determine a frequency for contact between relevant parties for updates regarding the network issue, operational impact, and course of action.  Relevant parties may include the following:

          • Pharmacy Emergency Team

          • Local clinical leadership

          • Institution CEO(s)

          • Institution Health Care IT (HCIT) staff

        • Determine a course of action consistent with the function of the institution and nature of the issue. Remediation may include, but is not limited to:

          • Prioritizing STAT (immediate) and same-day prescriptions for local fill.

          • Employing and recording verification and fill functions using paper methods and forms.

          • Moving verification functions to an alternate site (e.g., central pharmacy) with fill function performed by the local institution.

          • Moving all essential pharmacy functions to an alternate site with an arrangement for delivery to the impacted institution.

    • Network Outage, Lack of Electrical Power, or Other Immediate Negative Impact To Pharmacy Operations

      • In the event local institution pharmacy operations are impacted by an inability to access pharmacy software or meet the immediate pharmaceutical needs of the institution, the following shall occur:

      • The local PIC shall determine operational status and notify the Pharmacy Emergency Team.

      • When necessary to obtain further details of the network issue and operational impacts and to determine a course of action, the Pharmacy Emergency Team shall conduct a conference call with all relevant parties, which may include:

        • Local clinical leadership

        • Institution CEO(s)

        • Institution HCIT staff

        • Regional HCIT manager(s)

      • Remediation shall be individualized with consideration of the following:

        • The institution(s) impacted

        • Projected outage duration

        • Volume of prescriptions

        • Nearest facility with operational pharmacy software

        • Emergent needs

      • The course of action may include, but is not limited to:

        • Dispensing medications from a nearby facility.

        • Printing labels from a nearby facility.

        • Delivering medications, labels, or MAR from a nearby facility.

        • Moving verification and all essential functions to an alternate site (e.g., central pharmacy) to reduce recovery time.

        • Accessing information from a system attached to an unaffected network (e.g., CDCR Enterprise Information Services Network, CCHCS Health Care Network).

      • Refer to the Health Care Department Operations Manual, Section 3.5.4, Automated Drug Delivery System, for automated drug delivery system downtime procedures, if applicable.

    • Recovery

      • A recovery plan shall be developed by the Pharmacy Emergency Team based upon the nature of the failure and the time involved to reestablish normal operations. The Pharmacy Emergency Team shall communicate this plan to interested parties, which may include, but is not limited to:

        • File maintenance.

        • Notification to institutions once recovery is complete.

  • References

    • State Administrative Manual, Section 5325

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.4, Automated Drug Delivery System

    • California Correctional Health Care Services Electronic Health Record System (EHRS) Interdisciplinary Downtime Procedures & Downtime Viewer Guide

  • Revision History

  • Effective: 11/2011
    Revised: 02/24/2025