Pharmaceutical Operations

Idaho
Department of
Correction

Standard
Operating
Procedure

Division of
Operations

Operational
Services
Control Number:
401.06.03.090
Version:
1.0
Page Number:
1 of 5
Adopted:
12-13-2010
Reviewed:
12-13-2010

Title:
Pharmaceutical Operations

This document was approved by Shane Evans, director of Education, Treatment,
and Reentry on 12/13/10 (signature on file).
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY STATEMENT NUMBER 401
Clinical Services and Treatment
POLICY DOCUMENT NUMBER 401
Clinical Services and Treatment
DEFINITIONS
Standardized Definitions List
Contract Medical Provider: A private company under contract with the department to
provide comprehensive medical, dental, and/or mental health services to the incarcerated
offender population. A contract medical provider may include private prison companies and
other entities under contract with the department to operate the Idaho Correctional Center
(ICC) and other out-of-state facilities housing department offenders.
Facility Health Authority: The contract medical provider employee who is primarily
responsible for overseeing the delivery of medical services in an Idaho Department of
Correction (IDOC) facility.
Facility Medical Director: The highest ranking physician in an Idaho Department of
Correction (IDOC) facility.
Formulary: A listing of drugs, classified by therapeutic category or disease class, that are
considered preferred therapy for a given managed population and that are to be used by the
treating practitioner in prescribing medications.
Health Authority: The department employee who is primarily responsible for overseeing or
managing the department’s medical services. The health authority is commonly referred to
as the health services director.
Medication Room: A room where medications are stored and distributed.
Pharmacy: A place from which prescription medications are prepared and dispensed by a
pharmacist.
Control Number:
401.06.03.090
Version:
1.0
Title:
Pharmaceutical Operations
Page Number:
2 of 5

Qualified Health Professional: A physician, physician assistant, nurse practitioner, nurse,
dentist, mental health professional or others who -- by virtue of their education, training,
credentials, and experience -- are permitted by law (within the scope of their professional
practice) to educate, train, evaluate, provide services, and care for patients.
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures for
ensuring that pharmaceutical services provide (1) medication and associated health devices
to offenders in accordance with State and federal laws and regulations, and (2) for the strict
control and accountability of medications prescribed to offenders.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
offenders, contract medical providers and subcontractors.
RESPONSIBILITY
Health Authority
The health authority is responsible for:
• Monitoring and overseeing all aspects of healthcare services, and
• The implementation and continued practice of the provisions provided in this
SOP.
When healthcare services are privatized, he will also be responsible for:
• Reviewing and approving (prior to implementation) all applicable contract medical
provider policy, procedure, and forms; and
• Monitoring the contract medical provider’s performance, to include but not limited
to reviewing processes, procedures, forms, and protocols employed by the
contract medical provider to ensure compliance with all healthcare-related
requirements provided in respective contractual agreements, this SOP, and in
the following National Commission on Correctional Health Care (NCCHC)
standard P-D-01,Pharmaceutical Operations. (See section 2 of this SOP.)
Contract Medical Provider
When healthcare services are privatized, the contract medical provider is responsible
for:
• Implementing and practicing all provisions of this SOP, unless specifically
exempted by written contractual agreements;
• Ensuring that all aspects of this SOP and NCCHC standard P-D-01 are
addressed by applicable contract medical provider policy and procedure;
• Ensuring facility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educational information to fulfill all healthcare-
related requirements provided in this SOP, NCCHC standard P-D-01, or as
indicated in their respective contractual agreement(s); and
Control Number:
401.06.03.090
Version:
1.0
Title:
Pharmaceutical Operations
Page Number:
3 of 5

• Ensuring that all applicable contract medical provider policy, procedure, and
forms are submitted to the health authority for review and approval prior to
implementation.
Note: Nothing in this SOP shall be construed to relieve the contract medical provider(s)
of any obligation and/or responsibility stipulated in respective contractual agreements.
Facility Health Authority
The facility health authority will be responsible for:
• Ensuring the presence of an adequate number of appropriately trained staff and
materials are available to meet the requirements of this SOP;
• Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-D-01
are accomplished as required;
• Ensuring that all Drug Enforcement Agency (DEA)-controlled substances are
procured, dispensed, administered, distributed, accounted for, and disposed of in
accordance with State and federal laws and regulations; and
Note: DEA-controlled substances come under the jurisdiction of the federal
Controlled Substance Act (United States Code, Title 21, Chapter 13).
• Ensuring that pharmaceutical services are included in the continuous quality
improvement (CQI) process, with emphasis upon addressing trends noted in
offender concerns and grievances. (See SOP 401.06.03.006, Continuous Quality
Improvement Program.)
Qualified Health Professional
The qualified health professional will be responsible for:
• Ensuring that orders are processed and completed in a timely manner;
• Conducting a two (2)-person, face-to-face inventory count of DEA-controlled
substances; and
• Immediately reporting inventory count discrepancies to the facility health
authority and the shift commander.
Table of Contents
General Requirements ......................................................................................................... 4
1. Guidelines ...................................................................................................................... 4
General ..................................................................................................................... 4
Poison Control Information and Antidotes ................................................................. 4
Medication Room Inspections ................................................................................... 5
2. Compliance .................................................................................................................... 5
References ........................................................................................................................... 5
Control Number:
401.06.03.090
Version:
1.0
Title:
Pharmaceutical Operations
Page Number:
4 of 5

GENERAL REQUIREMENTS
1. Guidelines
General
• For the purposes of this SOP only, the following terms shall be defined as:
Procuring – The act of ordering medications for the facility.
Distributing – The system of delivering, storing, and accounting for medications
from the source of supply to the nursing station or point where they will be
administered to the patient.
Dispensing – The act of a pharmacist placing one (1) or more doses of a
prescribed medication into a container(s) that is/are correctly labeled to indicate
the name of the patient, the contents of the container, and all other vital
information.
Administering – The act in which a single dose of an identified drug is given to a
patient.
Accounting – The act of recording, summarizing, analyzing, verifying, and
reporting medication usage.
Disposing – The act of getting rid of medication on its expiration date or when
retention is no longer necessary or suitable (e.g., upon the discharge of the
patient from the facility).
• All pharmacy services shall be provided by pharmacies that are licensed in the state
where they are located and staffed by licensed pharmacists.
• Each IDOC facility shall comply with all applicable State and federal laws and
regulations regarding procuring, distributing, prescribing, dispensing, administering,
accounting, and disposing of pharmaceuticals.
• A closed formulary shall be used for medication prescribing. A practitioner may
request that an item be included in the formulary. A practitioner may request a non-
formulary medication for an offender.
• Typically, all patients with ongoing or chronic conditions are rescheduled to see their
assigned practitioner before the expiration of their medication order. However, if a
patient cannot be seen by his assigned practitioner before the expiration of his
medication order, the qualified healthcare professional shall refer to treatment
protocol for information regarding the extension of medication orders.
Note: Doors to medication rooms shall remain locked at all times. Under no
circumstance shall the doors to medication rooms be left ajar, propped open, or blocked
in any way to prevent closing.
Poison Control Information and Antidotes
Poison control information, inclusive of the Poison Control Center’s telephone number,
shall be posted in each facility's medication room.
Note: The Poison Control Center will only provide the name of the antidote, not the
antidote itself.
Control Number:
401.06.03.090
Version:
1.0
Title:
Pharmaceutical Operations
Page Number:
5 of 5

Adequate and appropriate antidotes shall be stored on-site in the medication room. The
antidotes stored shall be decided by the supervising pharmacist and shall be pertinent to
the narcotics utilized on-site.
Medication Room Inspections
A licensed pharmacist will inspect all medication rooms in each facility at least quarterly
(or more frequently if required by the Idaho Board of Pharmacy). Included in the
inspection will be storage, records, orders, and expired or discontinued medications. The
inspection shall be documented on forms that are approved by the Idaho Board of
Pharmacy. Copies of inspections shall be forwarded to the health authority immediately
upon completion.
2. Compliance
Compliance with this SOP and all related Department-approved protocols will be monitored
by the health authority (or designee) by using various sources to include: this SOP, clinical
practice guidelines, routine reports, program reviews, and record reviews.
The health authority (or designee) must conduct two (2) audits per year (or more frequently
as desired based on prior audit results). The audits must consist of monitoring applicable
contract medical provider and IDOC policy and procedures, applicable NCCHC standards,
and the review of a minimum of 15 individual records.
REFERENCES
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-D-01, Pharmaceutical Operations
Standard Operating Procedure 401.06.03.006, Continuous Quality Improvement Program
United States Code, Title 21, Chapter 13, Parts A thru F, Drug Abuse Prevention and
Control
– End of Document –